Morphofunctional cardiac changes in singleton and twin pregnancies: a longitudinal cohort study

Background

This study aimed to compare the echocardiographic changes and cardiac biomarkers between women with singleton and twin pregnancies.

Methods

From April 2014 to March 2016, this longitudinal cohort study invited pregnant women who were scheduled to give birth at Hokkaido University Hospital. We analyzed prospectively collected data on simultaneously determined echocardiographic parameters and blood cardiac markers of 44 women with singleton and 22 women with twin pregnancies. Furthermore, we tested the mixed-effect models for echocardiographic parameters and cardiac biomarkers.

Results

During the third trimester and immediately postpartum (within 1 week after childbirth), the mean left atrial volume index and brain natriuretic peptide (BNP) level were significantly higher in women with twin pregnancies than in those with singleton pregnancies. Women with twin pregnancies also had significantly smaller second-trimester inferior vena cava diameters and significantly higher third⁻trimester creatinine levels than those with singleton pregnancies. BNP positively correlated with the left atrial volume index (β = 0.49, p < 0.01) and the ratio of early diastolic transmitral to mitral annular velocity (E/e’) (β = 0.41, p < 0.01). At 1 month after childbirth in women with singleton pregnancies, BNP and N-terminal precursor protein BNP (NT-proBNP) fragments immediately postpartum negatively correlated with the later E/e’ (r = − 0.33, p = 0.02 and r = − 0.36, p < 0.01, respectively).

Conclusions

The intravascular cardiac load reached maximum within 1 week after childbirth and was greater in women with twin pregnancies than in those with singleton pregnancies. BNP/NT-proBNP significantly positively correlated with LA volume index and E/e’. In women with singleton pregnancies, BNP secreted immediately after childbirth might improve the diastolic functions 1 month after childbirth.

[Improvement of QOL by Surgery in Two Patients for Brain Metastasis from Esophageal Carcinoma with Paralysis-A Report of Two Cases]

Brain metastasis from esophageal cancer is rare. Symptoms such as paralysis caused a decline in quality of life(QOL)and activity of daily life(ADL)and required emergency treatment. We report 2 cases in which QOL was improved by emergency resection for brain metastasis from esophageal carcinoma with paralysis. Case 1: A 50's male was diagnosed esophageal carcinoma and underwent esophagectomy(pT3N2M0, Stage Ⅲ). Brain metastasis was detected owing to development of left hemiparesis. Craniotomy and tumorectomy were performed, left hemiparesis was improved. He died 10 months after diagnosis of brain metastasis due to progression of other metastatic lesions. Case 2: A 61-year-old female was diagnosed esophageal carcinoma and underwent esophagectomy(pT3N1M0, Stage Ⅲ). She developed right hemiparesis 5 months after esophagectomy, admitted to our hospital. Brain and lung metastases were detected, craniotomy and tumorectomy and were performed, right hemiparesis was improved. Although systemic chemotherapy was administered, she died 10 months after diagnosis of brain metastasis due to progression of lung metastasis. Conclusion: Aggressive surgical treatments for brain metastasis were one good treatment option to maintain QOL and ADL.

Validation of the HFA-PEFF- and H2FPEF score in Japanese patients with heart failure with preserved ejection fraction

Background

Diagnosing heart failure with preserved ejection fraction (HFpEF) still remains challenging, and simple and reliable diagnostic tools have been required. Recently, novel and evidence-based diagnostic algorithms for HFpEF were proposed, such as H2FPEF score (Circulation. 2018) and HFA-PEFF score (Eur Heart J 2019), and their accuracy was validated in the outside patient group. However, there are regional and ethnic variations in patient characteristics of HFpEF, particularly between Western and Asian countries, and it is not elucidated whether these diagnostic scores are useful in Asian population.

Purpose

To investigate the validity of the HFA-PEFF- and H2FPEF score in Japanese patients with HFpEF.

Methods

We calculated H2FPEF score and the second step of HFA-PEFF score among the registered patients in the PURSUIT-HFpEF (Prospective, Multicenter, Observational Study of Patients with Heart Failure with Preserved Ejection Fraction) study, which is a multicenter registration of patients hospitalized for HFpEF. The obtained scores were compared with the scores of the HFpEF cohort in the previous validation studies. We followed the study patients for median of 360 days (IQR 237–630 days) to observe the major adverse cardiovascular events (MACE; composite of death, heart failure hospitalization and stroke).

Results

We enrolled 757 patients hospitalized for HFpEF between June 2016 and August 2019 for the present study. H2FPEF score was obtained in 588 (77.7%) patients among them. Compared with the HFpEF cohorts in the previously reported sub-analysis of TOPCAT trial, the PURSUIT-HFpEF cohort had lower mean value of HFpEF score (4.0±1.8 points vs. 6.0±2.0 points in Americans or 5.3±1.9 points in Russians). It had significantly higher proportion (40.3%, p&lt;0.001) of patients in the low likelihood of HFpEF category (0–3 points) than the TOPCAT cohorts (8.0% in Americans and 19.6% in Russians).

HFA-PEFF score was obtained in 615 (81.2%) patients, though global longitudinal strain was not available. The mean value of HFA-PEFF score was 5.0±0.8, and all patients had ≥2 points. The proportion of patients in the high likelihood of HFpEF category (5–6 points) was 88.3%, which was significantly higher (p&lt;0.001) than those of the HFpEF cohort from Europe and USA in the previous validation study (Eur J Heart Fail 2019). There was no correlation between H2FPEF score and HFA-PEFF score (R=0.06, p=0.14). Cox proportional hazard model selected HFA-PEFF score as a significant predictor for MACE during follow-up period, whereas H2PEF score was not selected. Kaplan-Meier survival analysis demonstrated that patients with 6 points of HFA-PEFF score had higher incidence rate of MACE than those with ≤5 points (p=0.002).

Conclusion

The HFA-PEFF score could be more useful for the diagnosis and risk stratification for HFpEF than the H2PEF score in the Japanese cohort.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnostics K.K.; Fuji Film Toyama Chemical Co. Ltd.

Comprehensive genomic profiling for patients with chemotherapy-naïve advanced cancer

Comprehensive genomic profiling (CGP) testing by next‐generation sequencing has been introduced into clinical practice as part of precision cancer medicine to select effective targeted therapies. However, whether CGP testing at the time of first‐line chemotherapy could be clinically useful is not clear. We conducted this single‐center, prospective, observational study to investigate the feasibility of CGP testing for chemotherapy‐naïve patients with stage III/IV gastrointestinal cancer, rare cancer, and cancer of unknown primary, using the FoundationOne^® companion diagnostic (F1CDx) assay. The primary outcome was the detection rate of at least one actionable/druggable cancer genomic alteration. Actionable/druggable cancer genomic alterations were determined by the F1CDx report. An institutional molecular tumor board determined the molecular‐based recommended therapies. A total of 197 patients were enrolled from October 2018 to June 2019. CGP success rate was 76.6% (151 of 197 patients), and median turnaround time was 19 days (range: 10‐329 days). Actionable and druggable cancer genomic alterations were reported in 145 (73.6%) and 124 (62.9%) patients, respectively. The highest detection rate of druggable genomic alterations in gastrointestinal cancers was 80% in colorectal cancer (48 of 60 patients). Molecular‐based recommended therapies were determined in 46 patients (23.4%). CGP testing would be a useful tool for the identification of a potentially effective first‐line chemotherapy.

Moisturizing mechanism of glycerol and diglycerol on human stratum corneum studied by synchrotron X-ray diffraction

OBJECTIVE

Polyols are moisturizers used in cosmetics. Using X-ray diffraction, we studied the moisturizingmechanism of polyol solutions in the stratum corneum (SC). We examined whether glycerol disrupts the ordered hydrocarbon chain packing structure in isolated SC, as previously proposed in an SC lipid model.

METHODS

The SC samples were prepared by treatment with water and aqueous solutions of glycerol, diglycerol and glycerol/diglycerol. To examine the differences in the water-retention efficiency of polyols, using a solution cell, we performed dynamic X-ray diffraction to analyse the structural changes that occurred during water removal from the hydrated samples by a stream of dry nitrogen gas. We focused on two structures, the orthorhombic hydrocarbon chain packing structure in the intercellular lipids and the soft keratin in the corneocytes where most of the water is stored.

RESULTS

The spacing formed by the soft keratin in the corneocytes immersed in a solution of water and diglycerol solution decreased rapidly by water removal. In contrast, it decreased gradually in the corneocytes immersed in a solution of glycerol and glycerol/diglycerol, indicating that the glycerol-containing solutions maintained the hydrated state of the corneocytes for longer. Furthermore, the characteristic change of the spacing in the orthorhombic hydrocarbon chain packing structure over time was observed during the drying process. The hydrated state was maintained longer, in water, followed by glycerol, diglycerol and glycerol/diglycerol, in increasing order. This is the first study to report such characteristic properties that could be indicators of the capacity of the SC to regulate water.

CONCLUSION

The dynamic X-ray diffraction experiment on the structure of the soft keratin and the orthorhombic hydrocarbon chain packing structure during the drying of the hydrated SC provides an insight into the moisturizing mechanism of the polyol solutions in the SC. The results show that the glycerol/diglycerol solution functions as an effective SC moisturizer at the molecular level. Further, it was confirmed that the behaviour of glycerol in the isolated SC varies from that proposed in the SC lipid model, wherein glycerol was proposed to prevent the formation of a regular hydrocarbon chain packing structure.

A prospective, randomized, comparison of the coronary vasomotion associated with drug-coated balloon versus drug-eluting stent

Background

It is widely known that even new-generation drug-eluting stent (DES) induce coronary vasomotion abnormality. On the other hand, recent studies reported that drug-coated balloon (DCB) for native coronary artery was non-inferior to DES in medium term outcomes. However, there is no available information about vasomotion after treatment with DCB.

Purpose

The aim of this study was to prospectively compare coronary vasomotion in patients treated with DCB versus new-generation DES.

Methods

Twenty-seven patients were randomly treated with angioplasty with DCB (n=12) versus implantation of bioabsorbable polymer everolimus-eluting stent (BP-EES, n=15) after successful predilation. At 8 months after treatment, endothelium-dependent and -independent vasomotion were evaluated by intracoronary infusion of incremental doses of acetylcholine (for right coronary artery: low-dose 5μg, high-dose 50μg and for left coronary artery: low-dose 10μg, high-dose 100μg) and nitroglycerine (200μg). Mean luminal diameter of the distal segments, beginning 5 mm and ending 15 mm distal to the edge of the treated segment was quantitatively measured by angiography.

Results

Clinical and procedural characteristics were not different between two groups. Vasoconstriction after acetylcholine infusion was less pronounced in the DCB group than the BP-EES group (low-dose: 4±13% vs −4±14%, p=0.158, high-dose: −2±14% vs −28±30%, p=0.013). The response to nitroglycerin was not different between two groups (17±13% vs 18±24%, p=0.838).

Conclusion

Vasoconstriction after acetylcholine infusion in the peri-treated region was more pronounced in the BP-EES group than in the DCB group, which suggests that endothelial function of coronary vessel treated by DCB can be more preserved than new-generation DES.

Figure 1

Funding Acknowledgement

Type of funding source: None

Predictors of silent cerebral infarction associated with catheter ablation for atrial fibrillation

Introduction

Cather ablation (CA) has been identified as an effective and safe treatment option for patients with atrial fibrillation (AF). One of the serious complications associated AF is cerebral infarction (CI). Recent studies reported that CA was associated with lower incidence of ischemic stroke in patients with AF. However, CA for AF itself has a potential risk of CI. Several previous studies showed that the incidence of silent CI (SCI) assessed by magnetic resonance imaging (MRI) of the brain occurred 5 to 18% during CA for AF. Recently, CA for AF made a remarkable progress in technology. However, there are few information available that the impact of 3-dimensional electroanatomical mapping system on the incidence of SCI. This study aimed to clarify the prevalence and predictors of SCI during CA for AF.

Methods

We enrolled 893 consecutive patients (male 534, age 71±10 years), who underwent CA for AF and MRI of brain 1 day after the procedure. We collected patients data such as physical examinations, blood sampling, echo cardiography, and CA data. A brain MRI was performed the next day following the procedure to identify any CIs. One-hundred and forty-six of patients used the Rhythmia® mapping system catheter, and the other mapping system such as CARTO or EnSite system used in the remaining 747 patients.

Results

The MRI depicted acute micro-CIs in 144 (16%) patients, but neither symptoms nor abnormal neurological findings were present in these patients. Patients with SCI had significantly higher prevalence of persistent AF (60 vs 43%, p=0.0002), CHADS2 Score (2 (1–3) vs 1 (1–2), p=0.0001), higher prevalence of previous stroke (19 vs 12%, p=0.02), larger left atrial (LA) diameter (43.2±6.4 vs 41.7±6.5mm, p=0.01), lower left ventricular ejection fraction (LVEF) (59.0±13.2 vs 64.2±11.3%, p≤0.0001), higher B-type natriuretic peptide level (221±236 vs 163±225 pg/dl, p≤0.0001), more Rhythmia® mapping system use (30 vs 8%, p&lt;0.0001), and longer procedure time (129±46 vs 108±39 min, p≤0.0001) than those without SCI, while there were no significant differences in age, LA appendage flow velocity, kind of anti-coagulant agent between the two groups. Multivariate regression analysis identified Rhythmia® use [odds ratio (OR) 4.26, (95% CI 2.32–7.84), p=0.0001], LVEF (OR 1.02, p=0.0059), CHADS2 score (OR 1.27, p=0.009), and procedure time (OR 1.005, p=0.04) as independent risk factors of acute SCI during CA for AF.

Conclusion

Acute SCI occurred about 16% after CA for AF. Rhythmia® mapping system use exhibited a higher incidence of acute SCI after catheter ablation for AF than the other mapping system use. Rhythmia® mapping system use, LVEF, CHADS2 score, and procedure time are associated with SCI relating CA for AF.

Funding Acknowledgement

Type of funding source: None

Impact of simple nutrition index on the long-term mortality of acute decompensated heart failure patients with preserved left ventricular ejection fraction: insight from PURSUIT-HFpEF registry

Background

The novel nutrition index; triglyceride (TG) × total cholesterol (TG) × body weight (BW) index (TCBI) has been reported to be an easy and useful predictor for patients with coronary artery disease. However, there is no information available on the prognostic value of TCBI in patients with heart failure with preserved LVEF (HFpEF) who admitted with acute decompensated heart failure (ADHF).

Methods and results

Data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT HFpEF) study. PURSUIT-HFpEF study is a prospective multicenter observational study in which collaborating hospitals recorded clinical, echocardiographic, and outcome data of ADHF pts with HFpEF. We enrolled consecutive 757 HFpEF patients who admitted with ADHF from June 2016 to June 2019. TCBI was calculated by the formula; TG × TC × BW / 1000 at the discharge. After we excluded patients with in-hospital death or without sufficient data, we analyzed 419 patients. The primary endpoint was all-cause mortality. During a median follow up period of 1.1 (0.9–1.9) years, 59 patients died. ROC analysis revealed that TCBI at discharge was a fair discriminator for predicting all-cause mortality (AUC 0.676, sensitivity 53%, specificity 78%). Multivariate Cox proportional analysis showed that TCBI (p=0.002) was an independent predictor for all cause death after adjustment with major confounders such as age, gender, NT-proBNP, hemoglobin and serum creatinine level. We divided patients into 4 groups according to quartiles of TCBI. Kaplan-Meier analysis showed a significantly higher risk of all-cause death in relation to the decrease in TCBI.

Conclusion

TCBI, a simple and novel nutrition index, is a useful and strong long-term prognostic indicator in ADHF patients with HFpEF.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnositics K.K.; Fuji Film Toyoma Chemical Co. Ltd.

Effect of empagliflozin as add-on therapy on transtubular potassium concentration gradient in patients with type 2 diabetes hospitalized for acute decompensated heart failure

Background

The transtubular potassium concentration gradient (TTKG) has been reported to be a marker of renal aldosterone bioactivity, and has been shown to be a surrogate of arterial underfilling in patients with acute decompensated heart failure (ADHF). Moreover, high TTKG at discharge has been shown to be associated with poor prognosis in ADHF patients. Empagliflozin, one of the sodium glucose cotransporter 2 inhibitors, has been shown to reduce the risk of cardiovascular mortality in patients with type 2 diabetes mellitus (T2D) and cardiovascular disease. However, little is known about the effect of empagliflozin as add-on therapy on TTKG in T2D patients with ADHF.

Purpose

We sought to elucidate the effect of empagliflozin as add-on therapy on TTKG in T2D patients with ADHF.

Methods

We enrolled 58 consecutive T2D patients admitted for ADHF. On admission, enrolled patients were randomly assigned in a 1:1 ratio to either empagliflozin add-on therapy (EMPA(+)) or conventional glucose-lowering therapy (EMPA(−)). All patients in EMPA(+) group received empagliflozin (10 mg/day) throughout the study period. Left ventricular ejection fraction (LVEF) was measured at baseline using echocardiography. Body weight and vital signs, such as blood pressure and heart rate, were measured, and blood and urine samples were collected at baseline and 1, 2, 3 and 7 days after randomization. The TTKG was measured using the first morning urine samples collected on each day. TTKG was calculated according to the following equation: TTKG = (Ku/Ks)×(plasma osmolality/urine osmolality), where Ku is urine potassium concentration and Ks is serum potassium concentration, as previously reported.

Results

Thirty patients were assigned to the EMPA(+) group, and 28 patients were assigned to the EMPA(−) group. There were no significant baseline differences in LVEF, plasma B-type natriuretic peptide (BNP) level, body mass index, or serum creatinine level between the EMPA(+) and EMPA(−) groups. TTKG did not significantly differ between the two groups at baseline. However, seven days after randomization, plasma BNP level was significantly lower in the EMPA(+) group than in the EMPA(−) group (median 227 [IQR 114–381] pg/mL vs 362 [227–554] pg/mL, p=0.0294). Furthermore, TTKG of the EMPA(+) group was significantly lower at 2, 3 and 7 days after randomization (Figure).

Conclusions

This study demonstrated that empagliflozin as add-on therapy can lower TTKG in T2D patients with ADHF.

Figure 1

Funding Acknowledgement

Type of funding source: None

Clinical characteristics and prognostic impact of pulmonary hypertension in heart failure with preserved ejection fraction: the PURSUIT HFpEF study

Background

Heart failure (HF) with preserved ejection fraction (HFpEF) can develop pulmonary hypertension (PH), which can result from pre-capillary PH as well as post-capillary PH. However, the prevalence and clinical significance of pre-capillary component of PH in HFpEF remain unknown.

Purpose

We aimed to investigate prevalence, clinical features, and prognostic impact of pre-capillary and/or post capillary PH associated with HFpEF.

Methods

From the PURSUIT-HFpEF (Prospective Multicenter Observational Study of Patients with Heart Failure with Preserved Ejection Fraction) registry, 204 patients (men: 46%, age: 79±9 years) who were hospitalized with HF and underwent right heart catheterization were divided into 4 groups according to the PH guidelines: non-PH, isolated post-capillary PH (Ipc-PH), pre-capillary PH, and combined pre- and post-capillary PH (Cpc-PH). Patients who had been diagnosed with idiopathic pulmonary arterial hypertension were excluded from the analysis.

Results

The prevalence of PH was 31% (Ipc-PH: 22%, pre-capillary PH: 3%, Cpc-PH: 6%). The prevalence of subcategories of PH was significantly different depending on mean right atrial pressure (RAP) (figure). Echocardiography at discharge showed no significant differences in RV diameter or TAPSE, but smaller LV diameter and higher E/e' in pre-capillary PH and Cpc-PH, which resulted in a higher operant diastolic elastance (Ed). Composite endpoint of all-cause mortality and HF hospitalization at 1 year occurred 13% in non-PH, 25% in Ipc-PH, 49% in pre-capillary PH, and 63% in Cpc-PH, respectively (p=0.001 by log-rank test).

Conclusions

Distinct prevalence of PH was observed in the groups with different RAP levels. Pre-capillary component of PH was associated with impaired LV diastolic function and worse outcomes in HFpEF.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnostics K.K.; Fuji Film Toyama Chemical Co. Ltd

Role of diuretics on long-term mortality may differ in volume status in patients with acute myocardial infarction

Background

Diuretics has been reported to have a potential for an activation of the renin-angiotensin-aldosterone system and the sympathetic nervous system, leading to a possibility of poor clinical outcome in patients with cardiovascular disease. However, few data are available on clinical impact of diuretics on long-term outcome in patients with acute myocardial infarction (AMI) based on plasma volume status.

Methods

To address the issue, a total of 3,416 survived patients with AMI who were registered to a large database of the Osaka Acute Coronary Insufficiency Study (OACIS) were studied. Plasma volume status was assessed with the estimated plasma volume status (ePVS) that was calculated at discharge as follows: actual PV = (1 − hematocrit) × [a + (b × body weight)] (a=1530 in males and a=864 in females, b=41.0 in males and b=47.9 in females); ideal PV = c × body weight (c=39 in males and c=40 in females), and ePVS = [(actual PV − ideal PV)/ideal PV] × 100 (%). Multivariable Cox regression analysis and propensity score matching were performed to account for imbalances in covariates. The endpoint was all-cause of death (ACD) within 5 years.

Results

During a median follow-up period of 855±656 days, 193 patients had ACD. In whole population, there was no significant difference in long-term mortality risk between patients with and without diuretics in both multivariate cox regression model and propensity score matching population. When patients were divided into 2 groups according to ePVS with a median value of 4.2%, 46 and 147 patients had ACD in groups with low ePVS and high ePVS, respectively. Multivariate Cox analysis showed that use of diuretics was independently associated with an increased risk of ACD in low ePVS group, (HR: 2.63, 95% confidence interval [CI]: 1.22–5.63, p=0.01), but not in high ePVS group (HR: 0.70, 95% CI: 0.44–1.10, p=0.12). These observations were consistent in the propensity-score matched cohorts; the 5-year mortality rate was significantly higher in patients with diuretics than those without among low ePVS group (4.7% vs 1.7%, p=0.041), but not among high ePVS group (8.0% vs 10.3%, p=0.247).

Conclusion

Prescription of diuretics at discharge was associated with increased risk of 5-year mortality in patients with AMI without PV expansion, but not with PV expansion. The role of diuretics on long-term mortality may differ in plasma volume status. Therefore, prescription of diuretics after AMI may be considered based on plasma volume status.

Funding Acknowledgement

Type of funding source: None

Comparative prognostic impact of ACCI and AHEAD risk score in heart failure with reduced, mid-range and preserved left ventricular ejection fraction admitted for acute decompensated heart failure

Background

Comorbidities are strongly associated with poor clinical outcome in heart failure patients (pts). The Age-adjusted Charlson comorbidity index (ACCI), which is well-known widely used comorbidity index, recently has been used as a robust prognostic model in heart failure pts. On the other hand, AHEAD risk score has been recently reported as a useful long-term risk stratification score in acute decompensated heart failure (ADHF) pts. Recently, a new group of heart failure pts with mid-range ejection fraction (HFmrEF) has been defined, separated from reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). We sought to compare the prognostic value of ACCI and AHEAD score in ADHF pts, relating to HFrEF, HFmrEF and HFpEF.

Methods

We prospectively studied 410 consecutive ADHF pts (HFrEF [n=143], HFmrEF [n=99] and HFpEF [n=168]) with survival discharge. ACCI contains 19 issues which was weighted according to their potential influence on mortality. AHEAD risk score is a simple index, which is range 0–5; atrial fibrillation, hemoglobin &lt;13 mg/dL for men and 12 mg/dL for women, age &gt;70 years, creatinine &gt;130 μmol/L, and diabetes mellitus. The endpoint of this study was all cause death (ACD).

Results

During a follow-up period of 2.4±1.4 years, 119 pts had ACD (42, 29 and 48 pts in HFrEF, HFmrEF and HFpEF, respectively). At univariate Cox analysis, ACCI and AHEAD risk score were significantly associated with ACD in each subgroup. At multivariate Cox analysis, in HFrEF pts, ACCI, but not AHEAD risk score, showed the significant and independent association with ACD. In HFmrEF, both ACCI and AHEAD risk score was significantly and independently associated with ACD and ROC analysis showed AUC of ACCI was greater than that of AHEAD risk score (0.778 [0.683–0.855] vs 0.637 [0.572–0.764], p=0.07). On the other hand, in HFpEF pts, AHEAD risk score, but not ACCI, showed the significant and independent association ACD.

Conclusion

ACCI provides more prognostic value in HFrEF pts, and AHEAD risk score has more prognostic value in HFpEF pts. In HFmrEF pts, both ACCI and AHEAD score might have prognostic values, although ACCI tends to be more associated with ACD than AHEAD score.

Funding Acknowledgement

Type of funding source: None

Prognostic significance of cardiac 123I-MIBG SPECT imaging in patients with acute decompensated heart failure with preserved left ventricular ejection fraction

Background

Cardiac sympathetic nerve dysfunction, which is assessed by I-123 metaiodobenzylguanidine (MIBG) imaging, is associated with the poor outcomes in patients with heart failure (HF). Most of the literature on the use of 123I-MIBG imaging is based on planar images in patients with chronic HF and reduced left ventricular ejection fraction (HFrEF), because It is technically challenging to conduct precise 123I-MIBG SPECT analysis in globally denervated heart, which is frequently observed in HFrEF patients. There was no information available on cardiac sympathetic nerve dysfunction evaluated by cardiac MIBG SPECT imaging in acute decompensated HF (ADHF) patients with preserved left ventricular ejection fraction (HFpEF).

Purpose

We aimed to clarify the prognostic significance of 123I-MIBG SPECT myocardial imaging in ADHF patients with HFpEF.

Methods

We enrolled 183 patients who were admitted for ADHF with HFpEF, discharged with survival. All patients underwent cardiac MIBG imaging at the timing of discharge. The cardiac MIBG heart to mediastinum ratio (H/M) was calculated on the early image and the delayed image (late H/M). We studied 156 patients after excluding 27 patients whose MIBG SPECT reconstruction was difficult due to too low MIBG uptake or extracardiac accumulation interference. SPECT analysis on the delayed image was conducted by using CardioBull, a fully automated software for the quantification of I-123 MIBG SPECT. All of 17 regional tracer uptake were compared with normal control database. A scoring algorithm for the evaluation of low uptake employs a 5-point scoring system as 0–4 for normal, mildly abnormal, moderately abnormal, severe abnormal, and perfusion defect, respectively. The summed severity (SSS) scores were obtained by summing the score for all segments. SSS could range from 0 to 68. The endpoint of this study is cardiac events defined as the composite of unplanned heart failure hospitalization and cardiac death.

Results

During a mean follow up period of 2.4±1.6 years, 60 patients reached cardiac events. SSS was significantly high in patients with than without cardiac events (20 [10–27] vs 7 [4–16], p&lt;0.0001). SSS (p&lt;0.0001) was significantly associated with cardiac events after multivariable Cox adjustment of age, sex, creatinine and log-transformed BNP level, although late H/M showed the significant association with the endpoint at the univariate Cox analysis. Kaplan-Meier analysis showed that patients with high SSS (&gt;10, defined by median) had significantly greater risk of cardiac event (56% vs 21%, Hazard ratio: 3.56 (2.00–6.33, p&lt;0.0001). ROC curve analysis showed that area under the curve (AUC) of SSS was 0.746 [95% CI:0.670, 0.812], which was significantly higher than that of late H/M (0.618 [95% CI:0.537, 0.695]) (p=0.0159).

Conclusion

Cardiac MIBG SPECT imaging was useful for risk stratification in ADHF patients with HFpEF.

Funding Acknowledgement

Type of funding source: None

Impact of comorbidity on the predictive value of cystatin-C in patients admitted for acute decompensated heart failure: insights from a prospective study

Background

Comorbidities are strongly associated with poor clinical outcome in heart failure patients. The Age-adjusted Charlson comorbidity index (ACCI), which is well-known widely used comorbidity index, recently has been used as a robust prognostic model in heart failure patients. On the other hand, Cystatin C, as a novel and important biomarker of renal function, has been recently reported as a useful long-term risk stratification score in heart failure patients. However, there is no information available on the impact of comorbidities on the prognostic value of cystatin-C in patients admitted for acute decompensated heart failure (ADHF).

Methods

We prospectively studied 458 consecutive ADHF patients with survival discharge. Patients with hemodialysis were excluded. Echocardiography and venous blood sampling were performed just before discharge and serum cystatin-C level was measured. Comorbidity was measured with the Age-adjusted Charlson comorbidity index (ACCI). ACCI was commonly used for the evaluation of the comorbid condition which is weighted and scored, with additional points added for age. The endpoint was all-cause death (ACD).

Results

During a follow-up period of 2.8±1.5 years, 132 patients had ACD. At multivariate Cox analysis, ACCI (p=0.0015) and cystatin-C level (p=0.0145) were significantly and independently associated with ACD. Patients with high ACCI (≥6: determined by ROC analysis) had a significantly greater risk of ACD (37.2% vs 17.8%, p&lt;0.0001, HR 2.45 [1.61–3.70]). In the subgroup of higher ACCI, patients with higher cystatin-C level (≥1.56: determined by ROC analysis) had a significantly higher risk of ACD (50.3% vs 23.4%). Furthermore, in the subgroup of lower ACCI, patients with higher cystatin-C level had also significantly higher risk of ACD (34.2% vs 12.1%).

Conclusions

The prognostic value of cystatin-C is not affected by comorbidities and cystatin-C provide prognostic information even in patients admitted for ADHF, irrespective of comorbid burden.

All-cause death-free rate in ADHF pts

Funding Acknowledgement

Type of funding source: None

Prognostic value of nutritional status in patients with heart failure with preserved ejection fraction, with and without atrial fibrillation: insights From PURSUIT-HFpEF Registry

Background

Malnutrition is one of the most important comorbidities among heart failure (HF) patients, and serum cholinesterase (CHE) has been reported to be a prognostic factor in HF patients. On the other hand, atrial fibrillation (AF) is frequently observed in patients with HF with preserved ejection fraction (HFpEF). However, there is little information available on the prognostic value of nutritional status in HFpEF patients, with and without AF. We sought to clarify the prognostic value of CHE in HFpEF with and without AF and compare it with that of other nutrition indices such as gastric nutritional risk index (GNRI), controlling nutritional status (CONUT), and the prognostic nutritional index (PNI).

Methods and results

Patients data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT HFpEF) study, which is a prospective multicenter observational registry for acute decompensated heart failure patients with left ventricular ejection fraction ≥50% in Osaka. We analyzed 380 patients (median age: 80 [75–87] years, male: 46%) after exclusion of patients with in-hospital death, missing follow-up data, or missing data to calculate nutritional indices. On admission, 155 patients had AF. Laboratory data were obtained at discharge. During a mean follow up period of 1.1±0.6 years, 131 patients had a composite endpoint (CE) of all-cause death and hospitalization for worsening heart failure or cerebrovascular disorder. In multivariate Cox analysis, in patients with AF, CHE was significantly associated with CE independently of age, gender and body mass index after the adjustment with serum albumin, total cholesterol levels and total lymphocyte count, while it was not significantly associated with CE in patients without AF. C-index of CHE (0.708) was higher than that of GNRI (0.555, p=0.0028), CONUT (0.651, p=0.208) and PNI (0.635, p=0.208) in AF patients, while there were no significant differences in those nutritional indices in patients without AF. Kaplan-Meier curve analysis revealed that AF patients with lower CHE (&lt;208 U/L = median value) had higher risk of CE than those with higher CHE (44% vs 18%, adjusted HR 3.26 95% CI [1.66–6.67], p=0.0005), while there was no significant difference in the occurrence rate of CE between patients with and without higher CHE in non-AF group (42% vs 31%, adjusted HR 1.28 95% CI [0.78–2.13], p=0.33).

Conclusions

Prognostic value of CHE would be stronger than other nutritional indices in HFpEF patients with AF, while it would be weak in HFpEF patients without AF.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnostics K.K.; Fuji Film Toyama Chemical Co. Ltd.

The impact of frailty and aging on prognosis in patients with heart failure with preserved ejection fraction – insights from PURSUIT-HFpEF registry

Introduction

Frailty and aging are two common conditions both associated with increased vulnerability to stressful events with high risk of adverse outcomes.

Purpose

To evaluate the association between frailty and aging and their impacts on clinical outcome in patients with heart failure with preserved ejection fraction (HFpEF).

Methods

Analysis was performed from a prospective multicenter observational registry for HFpEF (PURSUIT-HFpEF Registry) conducted in the Osaka region of Japan. A total of 757 patients hospitalized for acute heart failure (diagnosed by using Framingham criteria) met the inclusion criteria: a left ventricular ejection fraction ≥50% and brain natriuretic peptide ≥100pg/ml. We included 483 patients (age, 80±9 years; men, 45%; atrial fibrillation, 35%) whose follow-up data after survival discharge were available. Patients' frailty and aging were evaluated using the clinical frailty scale (CFS) and age quartiles (Q1: &lt;76 years (n=122), Q2: 76–82 years (n=111), Q3: 82–87 years (n=127), Q4: &gt;87 years (n=123)), respectively. The primary clinical endpoint was defined as the composite of death, re-hospitalization for heart failure, and cerebrovascular accident.

Results

The median (interquartile range) CFS rating was 3 (2–5), and there was a little correlation between CFS rating and age (r2=0.16, p&lt;0.001). The prevalence of frailty, defined as a CFS rating &gt;4 (n=132), was positively correlated with age quartiles (Q1: 9.0%, Q2: 21.4%, Q3: 29.9%, Q4: 48.0%, p&lt;0.001). During the median follow-up period 396 days (interquartile range, 344–698) after discharge, the clinical endpoint was observed in 172 patients. The incidence was higher in patients with frailty than those without it (49.6% vs. 30.4%, log-rank p&lt;0.001). It was also correlated with age quartiles (Q1: 23.0%, Q2: 34.2%, Q3: 36.2%, Q4: 48.8%, log-rank p=0.001). Multivariate Cox regression analysis revealed that frailty (hazard ratio, 1.52; 95% confidence interval, 1.09–2.10; p=0.013) and age (hazard ratio per quartile increase, 1.24; 95% confidence interval, 1.07–1.43; p=0.004) were both associated with the clinical endpoint. Subgroup analysis in 352 patients without frailty also revealed the significant impact of age on the endpoint (1.26; 1.06–1.51; p=0.008). However, in 131 patients with frailty, there was no significant impact of age on the endpoint (1.16; 0.90–1.51; p=0.25).

Conclusions

Frailty was common and was associated with aging in HFpEF patients. Although they were both associated with unfavorable events, aging was no longer a significant predictor of adverse outcomes under the frailty conditions.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnostics K.K. and Fuji Film Toyama Chemical Co. Ltd.

Clinical usefulness of relative apical sparing pattern for predicting functional recovery after transcatheter aortic valve implantation in patients with severe aortic stenosis

Background

Relative apical sparing pattern (RASP) is thought to be associated with prognosis in patients with cardiac amyloidosis or left ventricular hypertrophy (LVH). Although almost all patients with severe aortic stenosis (AS) have LVH, little is known about the effect of transcatheter aortic valve implantation (TAVI) in patients with severe AS exhibiting a RASP.

Purpose

This study aimed to elucidate the effect of TAVI on left ventricular global longitudinal strain (LS; LVGLS) in patients with severe AS exhibiting a RASP.

Methods

Eighty-four patients who underwent transfemoral or subclavian TAVI were evaluated. They were divided into the RASP and non-RASP groups. The average apical LS divided by the sum of the average mid and basal LS values of &gt;1.0 was defined as the RASP. We analyzed the difference between pre- and post-TAVI LVGLS (ΔGLS = post-TAVI LVGLS − pre-TAVI LVGLS).

Results

Of the 84 patients (mean age, 84.5±3.9 years; 24 men), 15 (17.9%) exhibited a RASP. No significant difference in mean pre-TAVI LVGLS was found between the RASP and non-RASP groups (−16.6% ± 3.8% vs. −15.8% ± 3.9%). The ΔGLS in the RASP group was significantly higher than that in the non-RASP group (−0.97% ± 2.5% vs. −2.6% ± 3.0%; P&lt;0.05). Multivariate analysis revealed that relative apical longitudinal strain was an independent predictor of ΔGLS (β = 0.35, p=0.002).

Conclusion

Relative apical longitudinal strain was associated with LVGLS recovery. The effect of TAVI on LVGLS in patients with a RASP is inferior to that in patients without a RASP.

Funding Acknowledgement

Type of funding source: None

The comparison of clinical significance between atrial and ventricular structural remodeling in patients with heart failure with preserved ejection fraction – insights from PURSUIT-HFpEF registry

Introduction

Structural remodeling is an important aspect of pathophysiology of heart failure (HF). The compensatory mechanism against diastolic dysfunction would be more obvious on the left atrium rather than left ventricle in HF with preserved ejection fraction (HFpEF).

Purpose

To investigate the impact of left atrial (LA) and left ventricular (LV) remodeling on clinical outcomes in HFpEF patients.

Methods

Analysis was performed from a prospective multicenter observational registry for HFpEF (PURSUIT-HFpEF Registry) conducted in the Osaka region of Japan. A total of 757 patients hospitalized for acute HF (diagnosed by using Framingham criteria) met the inclusion criteria: a LV ejection fraction ≥50% and brain natriuretic peptide ≥100pg/ml. We included 381 patients (age, 82±9 years; men, 45%; atrial fibrillation (AF), 34%) whose follow-up data after survival discharge were available and whose LA volume index (LAVI) and left ventricular end-diastolic volume index (LVEDVI) at discharge were measured by the biplane Simpson's method using echocardiography. The primary endpoint was defined as the composite of death, re-hospitalization for HF, and cerebrovascular accident.

Results

The LAVI and LVEDVI at discharge was 54±25 ml/m2 and 55±21 ml/m2, respectively (r2=0.014, p=0.021). When patients were classified into the LAVI tertiles groups (T1: &lt;40ml/m2 (n=124), T2: 41–59ml/m2 (n=127), T3: &gt;60ml/m2 (n=130)), there was a positive correlation between the prevalence of diastolic dysfunction and the LAVI tertiles (T1, 21.0%; T2, 48.8%; T3, 51.5%; p&lt;0.001). On the other hand, significant association was not observed between the prevalence of diastolic dysfunction and the LVEDVI tertile groups (p=0.42). During the median follow-up period of 396 days (IQR, 345–698), the composite endpoint was observed in 131 patients and there was a positive correlation between the endpoint and the LAVI tertiles (T1, 24.2%; T2, 38.6%; T3, 40.3%; p=0.011). On the other hand, no correlation was found between the endpoint and the LVEDVI tertiles (p=0.13). After adjustment for age, gender, and presence of diastolic dysfunction, Cox regression analysis revealed that not LVEDVI but LAVI at discharge was a significant predictor of the composite endpoint in the entire cohort (hazard ratio per 10 ml/m2 increase; 1.09; 95% confidence interval, 1.02–1.16; p=0.009) and in the sinus rhythm subgroup (1.10; 1.01–1.20; p=0.034). However, not LAVI but LVEDVI was a significant predictor for the adverse outcomes in the AF subgroup (1.23; 1.04–1.46; p=0.016).

Conclusions

Increased LAVI at discharge, which was associated with diastolic dysfunction, related to unfavorable prognosis in patients with HFpEF. However, LAVI was no more a predictor for the adverse outcomes but LVEDVI was in the AF subgroup. The clinical significance of atrial and ventricular remodeling may differ between sinus rhythm and AF rhythm in HFpEF population.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnostics K.K. and Fuji Film Toyama Chemical Co. Ltd.

Long-term serial changes of cardiac sympathetic nerve dysfunction in acute decompensated heart failure patients with reduced, mid-range and preserved left ventricular ejection fraction

Background

Cardiac sympathetic nerve dysfunction, which is assessed by I-123 metaiodobenzylguanidine (MIBG) imaging, is associated with the poor outcomes in patients with chronic heart failure (CHF). Serial evaluation of cardiac MIBG imaging was shown to be useful for predicting adverse outcome in CHF. However, there was no information available on long-term serial changes of cardiac sympathetic nerve dysfunction after discharge of acute decompensated heart failure (ADHF) hospitalization.

Purpose

We aimed to clarify the serial change of cardiac MIBG imaging parameter in long-term after discharge of heart failure hospitalization, especially relating to HFrEF (LVEF&lt;40%), HFmrEF (40%≤LVEF&lt;50%) and HFpEF (LVEF≥50%).

Methods

We studied 112 patients (HFrEF; n=44, HFmrEF; n=23 and HFpEF; n=45) who were admitted for ADHF, discharged with survival and without heart failure hospitalization during follow-up period. All patients underwent cardiac MIBG imaging at the timing of discharge, in 6–12 months and in 18–24 months after discharge. The cardiac MIBG heart to mediastinum ratio (H/M) was calculated on the early image and the delayed image (late H/M). The cardiac MIBG washout rate (WR) was calculated from the early and delayed planar images after taking radioactive decay of I-123 into consideration.

Results

In HFrEF patients, late H/M was significantly improved from discharge to 6–12 months data (1.60±0.24 vs 1.75±0.31, p&lt;0.0001). Late H/M of HFmrEF patients was also significantly improved from discharge to 18–24 months data (1.71±0.27 vs 1.84±0.29 p=0.043). On the other hand, late H/M of HFpEF patients was not significantly changed. As for WR, WR in HFrEF and HFmrEF patients was significantly improved from discharge to 18–24 months data, although WR of HFpEF was not significantly changed.

Conclusion

The improvement in cardiac sympathetic nerve dysfunction was observed in patients with HFrEF and HFmrEF, not in HFpEF, after the discharge of acute heart failure hospitalization.

Funding Acknowledgement

Type of funding source: None

Long-term prognostic value of the combination of malnutrition and pulmonary-systemic pressure ratio in patients admitted with acute decompensated heart failure

Background

Malnutrition is associated with increased mortality risk in patients (pts) with acute decompensated heart failure (ADHF). On the other hand, concomitant presence of pulmonary hypertension in heart failure is associated with increased adverse events and may be related to interventricular uncoupling and impaired cardiac efficiency. It has recently been shown that an increased mean pulmonary artery pressure to mean systemic arterial pressure ratio (MPS ratio), a marker of interventricular coupling and efficiency, is associated with worse clinical outcomes in patients with advanced heart failure. However, there is no information available on the long-term prognostic value of the combination of malnutrition and MPS ratio in pts admitted for ADHF.

Methods and results

We studied 248 pts admitted for ADHF, who underwent right heart catheterization at the admission and were discharged with survival. Malnutrition was assessed by geriatric nutritional risk index (GNRI), prognostic nutritional index (PNI) and controlling nutritional status score (CONUT). During a mean follow-up period of 5.2±4.4 yrs, 62 pts had cardiovascular death (CVD). MPS ratio was significantly greater in pts with than without CVD (0.408±0.114 vs 0.347±0.102, p=0.0001). GNRI and PNI were significantly lower, CONUT was significantly greater in pts with than without CVD. At multivariate Cox regression analysis, GNRI and MPS ratio were significantly associated with CVD, independently of prior heart failure hospitalization, eGFR, and serum sodium level and anemia, although PNI and CONUT showed the association with CVD at unvariate analysis. Pts with malnutrition (GNRI≤median value=96.5) and greater MPS ratio (≥median value=0.346) had a significantly higher CVD risk than those with either and none of them (51% vs 20% vs 12%, p&lt;0.0001, respectively).

Conclusions

The combination of malnutrition and MPS ratio might be useful for stratifying pts at risk for CVD in patients with ADHF.

Funding Acknowledgement

Type of funding source: None

Cardiac factors as well as non-cardiac factors were associated with frailty in patients with heart failure with preserved ejection fraction

Background

Frailty is associated with malnutrition and poor prognosis in patients with heart failure with preserved ejection fraction (HFpEF). However, the cardiac factors associated with frailty have not been fully examined in patients with HFpEF.

Purpose

The purpose of this study is to clarify the cardiac factors related to frailty in patients with HFpEF.

Methods

Of the 756 patients who registered prospective, multicenter, observational study of patients with HFpEF (PURSUIT-HFpEF) registry, 481 cases with clinical frailty score (CFS) and prognosis after discharge were examined. Frailty was defined as CFS ≥5. Outcomes were composite endpoint of all-cause death and heart failure readmission, and all-cause mortality. We compared outcomes between patients without and with frailty, and sought to identify factors which were associated with increase in clinical frailty score by the correlation analysis and linear regression analysis.

Results

Of 481 patients, 131 patients (27.2%) were frail. Male gender was less in patients with frailty than those without frailty (26.7% vs 73.3%, P&lt;0.001). Frail patients had higher age (85.2±7.3 vs 78.7±9.4 years, P&lt;0.001). During follow-up period of 396 [343, 697] days, composite endpoint (Kaplan-Meier event rate estimates, 77% vs. 60%; log-rank P&lt;0.001), and all-cause mortality (Kaplan-Meier event rate estimates, 57% vs. 28%; log-rank P&lt;0.001) was higher in patients with frailty than those without frailty. Multivariate Cox regression analysis revealed frailty was significantly and independently associated with mortality (HR=1.40, 95% CI=1.17–1.68, P&lt;0.001). CFS was significantly correlated with age (r=0.401, P&lt;0.001), sex (r=0.223, P&lt;0.001), body mass index (r=−0.146, P=0.001), hemoglobin (r=−0.148, P=0.001), albumin (r=−0.222, P&lt;0.001), left ventricular diastolic diameter (r=−0.184, P&lt;0.001), interventricular septum thickness (r=−0.124, P=0.008), left ventricular mass (r=−0.217, P&lt;0.001), tricuspid annular plane systolic excursion (r=−0.165, P=0.001), and tricuspid regurgitation pressure gradient (TRPG) (r=0.189, P&lt;0.001). Multivariate linear regression analysis using these factors as covariates revealed age (standardized β: 0.337, P&lt;0.001), sex (standardized β: 0.120, P=0.014), albumin (standardized β: −0.151, P=0.003) and TRPG (standardized β: 0.129, P=0.005) were significantly and independently associated with increase in clinical frailty score.

Conclusion

Our results suggest that not only nutritional factors but also a cardiac factor were associated with frailty, and frailty was associated with mortality in patients with HFpEF. Improvement of hemodynamics in HFpEF patients as well as improvement of nutrition might contribute to alleviation of frail in HFpEF patients.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnostics K.K.; Fuji Film Toyama Chemical Co. Ltd.

Current status and legal/ethical problems in the research use of the tissues of aborted human fetuses in Japan

To date, there is no law regulating the research use of human aborted fetuses in Japan. The aim was to review the current status with historical background and legal/ethical problems limiting the research use of the tissues of aborted human fetuses. We reviewed literature via PubMed, Web of Science, Scopus, Japana Centra Revuo Medicina and CiNii, reports from various committees and research groups from Ministry of Health, Labour and Welfare (MHLW), and domestic books. Aborted human fetal tissues used for research purposes were first documented in the 1920s. The first guideline, the Peel Code was released in 1972. Since then, in Western countries, the research use of aborted fetuses has been less restricted compared with that of embryos, due to the following guidelines outlined by expert groups. Currently, aborted fetal tissues are commercially available for research purposes in the United States. In Japan, only four indications are presented in "a public statement permitting research use of deceased fetuses' and 'neonates' organs, etc." (1987). In the 2000s, expert committees of the MHLW concluded that research use of human aborted fetuses should be discontinued, and that comprehensive rules and independent regulations should be implemented. This issue has not been discussed in the Japanese legislature since 2003. Establishment of laws and guidelines for this issue is insufficient not only in Japan but also in other countries. It is important to secure transparency for making laws and guidelines and in obtaining public understanding.

Retrospective details of false-positive and false-negative results in non-invasive prenatal testing for fetal trisomies 21, 18 and 13

OBJECTIVE

Maternal characteristics and neonatal outcomes associated with cell-free DNA (cfDNA) results were analysed retrospectively to assess the details of false-positive and false-negative results after initial blood sampling in non-invasive prenatal testing (NIPT).

STUDY DESIGN

A multicentre retrospective study was performed for women undergoing NIPT who received discordant cfDNA results between April 2013 and March 2018. The NIPT data obtained using massive parallel sequencing were studied in terms of maternal background, fetal fraction, z-scores, invasive procedure results and neonatal outcomes after birth.

RESULTS

Of the 56,545 women who participated in this study, 54 false-positive (0.095 %) and three false-negative (0.006 %) cases were found. Seven of the 54 false-positive cases (13.0 %) had vanishing twin on ultrasonography. Among the 18 false-positive cases of trisomy 18, confined placental mosaicism (CPM) was confirmed in three cases (16.7 %), while CPM was present in one of the three false-negative cases of trisomy 21.

CONCLUSION

These data suggest that the incidence of women with false-positive or false-negative results is relatively low, that such false results can often be explained, and that vanishing twin and CPM are potential causes of NIPT failure. Genetic counselling with regard to false results is important for clients prior to undergoing NIPT.

Mucin-Derived O-Glycans Act as Endogenous Fiber and Sustain Mucosal Immune Homeostasis via Short-Chain Fatty Acid Production in Rat Cecum

BACKGROUND

Intestinal mucins escape digestion and enter the large bowel where they are degraded by the microbiota. To what extent and how mucins impact large-bowel physiology remain unclear.

OBJECTIVE

This study examined the large-bowel fermentation characteristics of mucins and mucin-derived O-glycan sugars and whether they affect gut immunity.

METHODS

Mucin secretion from the terminal ileum was determined from feces of ileorectostomized male Wistar rats (age 6 wk) fed an AIN76-based control diet (CD) for 15 d (experiment 1). Normal male Wistar rats (age 6 wk; 4 wk for experiment 4) were fed CD ± porcine stomach mucin (PM) at 6 or 12 g/kg diet, equivalent to 1.5 and 3 times the daily mucin secretion, for 14 d (experiment 2); CD ± N-acetylglucosamine (GlcNAc), fucose, or N-acetylneuraminic acid at 10 g/kg diet for 14 d (experiment 3); or CD ± PM (15 g/kg diet) or GlcNAc (10 g/kg diet) for 29 d (experiment 4). SCFAs, microbial composition, and cecal O-glycan content were assessed. IgA+ plasma cells and regulatory T cells and inflammatory cytokine expression in the cecum were evaluated (experiment 4).

RESULTS

Daily mucin secretion corresponded to 43.2 μmol of O-glycans. Cecal O-glycan contents were comparable between CD- and PM-fed rats. PM-fed rats harbored more mucin-degrading bacteria. Cecal concentrations of acetate (+37%) and n-butyrate (+73%) were higher in 12-g/kg PM diet-fed rats versus CD (P < 0.05). Among O-glycan sugars, only GlcNAc produced higher n-butyrate concentrations (+68%) versus CD (P < 0.05), with increased numbers of butyrate-producing bacteria. GlcNAc increased the abundance of IgA+ plasma cells (+29%) and regulatory T cells (+33%) versus CD, whereas PM increased IgA+ plasma cells (+25%) (all P < 0.05). GlcNAc and PM decreased expression of Tnfa (-30%, -40%) and Ifng (-30%, -70%) versus CD (all P < 0.05).

CONCLUSIONS

Mucin-derived O-glycans act as endogenous fiber and maintain mucosal immune homeostasis via large-bowel SCFA production in rats.

Thioether Ligand-Enabled Cationic Palladium(II)-Catalyzed Electrophilic C-H Arylation of α,β-Unsaturated Oxime Ethers

The use of the cationic palladium(II) catalyst realized electrophilic C-H arylation of α,β-unsaturated O-SEM oximes with arylboronic acids. This Pd-catalyzed electrophilic C-H arylation is facilitated by employing alkyl aryl thioether ligands, and optimization of the ligand structure greatly improves the yield. The resulting α,β-unsaturated oximes would provide access to multisubstituted heterocyclic compounds.

The short-term mortality and morbidity of very low birth weight infants with trisomy 18 or trisomy 13 in Japan

Trisomy 18 (T18) and trisomy 13 (T13) are major concerns in prenatal genetic testing due to their poor prognosis; very low birth weight (VLBW) is also a concern in neonatology. The aim of this study was to investigate the mortality and morbidity of VLBW infants diagnosed with T18/T13 in Japan, compared with those with no birth defects (BD-). Maternal and neonatal data were collected prospectively from infants weighing <1501 g and were admitted to centers of the Neonatal Research Network of Japan during 2003 to 2016. Among 60,136 infants, 563 and 60 was diagnosed with T18 and T13, respectively. Although the age of mothers of infants with T18/T13 was higher, the frequency of maternal complications was lower than those with BD-. With maternal and neonatal characteristic adjustments, T18/T13 had a higher incidence of each morbidity when compared with BD-. Mortality rates in the NICU were 70, 77, and 5.8% for T18, T13, and BD-, respectively, while the survival discharge rates of T18 and T13 were 29.5 and 23.3%, respectively, which was significantly higher than previous reports. This was the first nationwide survey for VLBW infants with T18/T13 in Japan; this novel data will be relevant and useful for prenatal genetic counseling and perinatal management. Although T18/T13 were considered to be fatal in the past, with proper epidemiological information, discussions with affected families, and compassionate patient care, the mortality rate of T18/T13 can be improved.

Polyamines polarized Th2/Th9 cell-fate decision by regulating GATA3 expression

Polyamines produced by both prokaryotes and eukaryotes are bioactive substances with pleiotropic effects. Accumulating evidence has demonstrated that polyamines contribute to anti-inflammatory responses by suppressing the expression of proinflammatory cytokines in mononuclear cells and macrophages. However, the effects of polyamines on CD4⁺ T cell responses remain to be elucidated. Here, we investigated the effect of polyamines on cell fate decisions of naïve CD4⁺ T cells in vitro. We found that endogenously generated polyamines are essential for the development of T helper 2 (Th2) cells. Treatment with DL-2-difluoromethylornithine (DFMO), an inhibitor of polyamine biosynthesis, diminished GATA3 expression in CD4⁺ T cells under Th2-skewed conditions. Supplementation of exogenous polyamines rescued GATA3 downregulation caused by DFMO treatment in CD4⁺ T cells. Transcriptome analysis revealed that deprivation of endogenous polyamines resulted in upregulated Th9-related genes, such as Il9, Irf4, and Batf3, even under the Th2-skewing conditions. Depletion of intracellular polyamines reduced GATA3 expression but increased IL-9-producing CD4⁺ T cells under both Th2 and Th9-skewing conditions. Furthermore, oral administration of DFMO increased IL-9-producing CD4⁺ T cells in small intestine in mice. Thus, our data indicate that polyamines play a critical role in the regulation of the Th2/Th9 balance.

Clinical impact of a cancer genomic profiling test using an in-house comprehensive targeted sequencing system

Precision medicine is a promising strategy for cancer treatment. In this study, we developed an in‐house clinical sequencing system to perform a comprehensive cancer genomic profiling test as a clinical examination and analyzed the utility of this system. Genomic DNA was extracted from tumor tissues and peripheral blood cells collected from 161 patients with different stages and types of cancer. A comprehensive targeted amplicon exome sequencing for 160 cancer‐related genes was performed using next‐generation sequencing (NGS). The sequencing data were analyzed using an original bioinformatics pipeline, and multiple cancer‐specific gene alterations were identified. The success rate of our test was 99% (160/161), while re‐biopsy was required for 24% (39/161) of the cases. Potentially actionable and actionable gene alterations were detected in 91% (145/160) and 46% (73/160) of the patients, respectively. The actionable gene alterations were frequently detected in PIK3CA (9%), ERBB2 (8%), and EGFR (4%). High tumor mutation burden (TMB) (≥10 mut/Mb) was observed in 12% (19/160) of the patients. The secondary findings in germline variants considered to be associated with hereditary tumors were detected in 9% (15/160) of the patients. Seventeen patients (11%, 17/160) were treated with genotype‐matched therapeutic agents, and the response rate was 47% (8/17). The median turnaround time for physicians was 20 days, and the median survival time after the initial visit was 8.7 months. The results of the present study prove the feasibility of implementing in‐house clinical sequencing as a promising laboratory examination technique for precision cancer medicine.

Microbiota-derived butyrate limits the autoimmune response by promoting the differentiation of follicular regulatory T cells

Background

Rheumatoid arthritis (RA) is a chronic debilitating autoimmune disorder with a high prevalence, especially in industrialized countries. Dysbiosis of the intestinal microbiota has been observed in RA patients. For instance, new-onset untreated RA (NORA) is associated with the underrepresentation of the Clostridium cluster XIVa, including Lachnospiraceae, which are major butyrate producers, although the pathological relevance has remained obscure. Follicular regulatory T (T_FR) cells play critical regulatory roles in the pathogenesis of autoimmune diseases, including RA. Reduced number of circulating T_FR cells has been associated with the elevation of autoantibodies and disease severity in RA. However, the contribution of commensal microbe-derived butyrate in controlling T_FR cell differentiation remains unknown.

Methods

We examined the contribution of microbe-derived butyrate in controlling autoimmune arthritis using collagen-induced arthritis (CIA) and SKG arthritis models. We phenotyped autoimmune responses in the gut-associated lymphoid tissues (GALT) in the colon and joint-draining lymph nodes in the CIA model. We developed an in vitro CXCR5⁺Bcl-6⁺Foxp3⁺ T_FR (iT_FR) cell culture system and examined whether butyrate promotes the differentiation of iT_FR cells.

Findings

Microbe-derived butyrate suppressed the development of autoimmune arthritis. The immunization of type II collagen (CII) caused hypertrophy of the GALT in the colon by amplifying the GC reaction prior to the onset of the CIA. Butyrate mitigated these pathological events by promoting T_FR cell differentiation. Butyrate directly induced the differentiation of functional T_FR cells in vitro by enhancing histone acetylation in T_FR cell marker genes. This effect was attributed to histone deacetylase (HDAC) inhibition by butyrate, leading to histone hyperacetylation in the promoter region of the T_FR-cell marker genes. The adoptive transfer of the butyrate-treated iT_FR cells reduced CII-specific autoantibody production and thus ameliorated the symptoms of arthritis.

Interpretation

Accordingly, microbiota-derived butyrate serves as an environmental cue to enhance T_FR cells, which suppress autoantibody production in the systemic lymphoid tissue, eventually ameliorating RA. Our findings provide mechanistic insights into the link between the gut environment and RA risk.

Funding

This work was supported by 10.13039/100009619AMED-Crest (16gm1010004h0101, 17gm1010004h0102, 18gm1010004h0103, and 19gm1010004s0104 to KH), the Japan Society for the Promotion of Science (JP17KT0055, JP16H01369, and JP18H04680 to KH; JP17K15734 to DT), Keio University Special Grant-in-Aid for Innovative Collaborative Research Projects (KH), Keio Gijuku Fukuzawa Memorial Fund for the Advancement of Education and Research (DT), the SECOM Science and Technology Foundation (KH), the Cell Science Research Foundation (KH), the Mochida Memorial Foundation for Medical and Pharmaceutical Research (DT), the Suzuken Memorial Foundation (KH and DT), the Takeda Science Foundation (KH and DT), The Science Research Promotion Fund, and The Promotion and Mutual Aid Corporation for Private Schools of Japan (KH).

Lactobacillus paracasei KW3110 Suppresses Inflammatory Stress-Induced Premature Cellular Senescence of Human Retinal Pigment Epithelium Cells and Reduces Ocular Disorders in Healthy Humans

Lactobacillus paracasei KW3110 (KW3110) has anti-inflammatory effects and mitigates retinal pigment epithelium (RPE) cell damage caused by blue-light exposure. We investigated whether KW3110 suppresses chronic inflammatory stress-induced RPE cell damage by modulating immune cell activity and whether it improves ocular disorders in healthy humans. First, we showed that KW3110 treatment of mouse macrophages (J774A.1) produced significantly higher levels of interleukin-10 as compared with other lactic acid bacterium strains (all p < 0.01). Transferring supernatant from KW3110- and E. coli 0111:B4 strain and adenosine 5′-triphosphate (LPS/ATP)-stimulated J774A.1 cells to human retinal pigment epithelium (ARPE-19) cells suppressed senescence-associated phenotypes, including proliferation arrest, abnormal appearance, cell cycle arrest, and upregulation of cytokines, and also suppressed expression of tight junction molecule claudin-1. A randomized, double-blind, placebo-controlled parallel-group study of healthy subjects (n = 88; 35 to below 50 years) ingesting placebo or KW3110-containing supplements for 8 weeks showed that changes in critical flicker frequency, an indicator of eye fatigue, from the week-0 value were significantly larger in the KW3110 group at weeks 4 (p = 0.040) and 8 (p = 0.036). These results suggest that KW3110 protects ARPE-19 cells against premature senescence and aberrant expression of tight junction molecules caused by chronic inflammatory stress, and may improve chronic eye disorders including eye fatigue.

Attitudes toward and current status of disclosure of secondary findings from next-generation sequencing: a nation-wide survey of clinical genetics professionals in Japan

The management of secondary findings (SFs), which are beyond the intended purpose of the analysis, from clinical comprehensive genomic analysis using next generation sequencing (NGS) presents challenges. Policy statements regarding their clinical management have been announced in Japan and other countries. In Japan, however, the current status of and attitudes of clinical genetics professionals toward reporting them are unclear. We conducted a questionnaire survey of clinical genetics professionals at two time points (2013 and 2019) to determine the enforcement of the SF management policy in cases of comprehensive genetic analysis of intractable diseases and clinical cancer genome profiling testing. According to the survey findings, 40% and 70% of the respondents stated in the 2013 and 2019 surveys, respectively, that they had an SF policy in the field of intractable diseases, indicating that SF policy awareness in Japan has changed significantly in recent years. Furthermore, a total of 80% of respondents stated that their facility had established a policy for clinical cancer genome profiling testing in the 2019 survey. In both surveys, the policies included the selection criteria for genes to be disclosed and the procedure to return SFs, followed by recommendations and proposals regarding SFs in Japan and other countries. To create a better list of the genes to be disclosed, further examination is needed considering the characteristics of each analysis.

AI approach of cycle-consistent generative adversarial networks to synthesize PET images to train computer-aided diagnosis algorithm for dementia

OBJECTIVE

An artificial intelligence (AI)-based algorithm typically requires a considerable amount of training data; however, few training images are available for dementia with Lewy bodies and frontotemporal lobar degeneration. Therefore, this study aims to present the potential of cycle-consistent generative adversarial networks (CycleGAN) to obtain enough number of training images for AI-based computer-aided diagnosis (CAD) algorithms for diagnosing dementia.

METHODS

We trained CycleGAN using 43 amyloid-negative and 45 positive images in slice-by-slice.

RESULTS

The CycleGAN can be used to synthesize reasonable amyloid-positive images, and the continuity of slices was preserved.

DISCUSSION

Our results show that CycleGAN has the potential to generate a sufficient number of training images for CAD of dementia.

A familial case of alveolar capillary dysplasia with misalignment of the pulmonary veins: the clinicopathological features and unusual glomeruloid endothelial proliferation

Background

Alveolar capillary dysplasia with misalignment of pulmonary veins (ACD/MPV) is a rare disorder of pulmonary vascular abnormality with persistent pulmonary hypertension of the newborn. The symptom usually presents within hours after birth, leading to an early demise. Heterozygous de novo point mutations and genomic deletions of the FOXF1 (forkhead box F1) gene or its upstream enhancer have been identified in most patients with ACD/MPV. Most cases of ACD/MPV are sporadic; however, familial cases are also reported in 10% of patients.

Case presentation

We herein report a case of familial ACD/MPV that showed unusual glomeruloid proliferation of endothelial cells. In this family, three of the four siblings died within two to 3 days after birth because of persistent pulmonary hypertension and respiratory failure. Only the second child remains alive and healthy. An autopsy was performed for the third and fourth children, resulting in a diagnosis of ACD/MPV based on the characteristic features, including misalignment of smaller pulmonary veins and lymphangiectasis. In both of these children, glomeruloid endothelial proliferation of vessels was noted in the interlobular septa. The vessels were immunohistochemically positive for D2–40, CD31, Factor VIII, and ERG, suggestive of differentiation for both lymphatic and blood vessels.

Conclusions

Unusual glomeruloid endothelial proliferation was observed in a familial ACD/MPV case. This histologic feature has not been described previously in ACD/MPV or any other pulmonary disease. Although the histogenesis of this histologic feature is unclear, this finding may suggest that ACD/MPV is a compound vascular and lymphovascular system disorder that exhibits various histologic features.

Traceable point-like 68Ge/68Ga source with a spherically symmetric positron absorber for PET scanners

A novel traceable point-like ⁶⁸Ge/⁶⁸Ga source was developed for calibration of positron emission tomography (PET) scanners. The source was equipped with a spherically symmetric acrylic positron absorber. The physical characteristics of photons emitted from the point-like source were evaluated by Monte Carlo simulation, considering possible geometrical uncertainties. The calibration factor of a clinical PET/CT scanner was evaluated using four manufactured point-like sources as a practical application of the point-like source. The results were consistent with that determined by the conventional cross-calibration method. The traceable point-like ⁶⁸Ge/⁶⁸Ga source is expected to be a simple and practical tool for determining the calibration factor and evaluating the physical characteristics of PET scanners.

Maternal gut microbiota in pregnancy influences offspring metabolic phenotype in mice

Antibiotics and dietary habits can affect the gut microbial community, thus influencing disease susceptibility. Although the effect of microbiota on the postnatal environment has been well documented, much less is known regarding the impact of gut microbiota at the embryonic stage. Here we show that maternal microbiota shapes the metabolic system of offspring in mice. During pregnancy, short-chain fatty acids produced by the maternal microbiota dictate the differentiation of neural, intestinal, and pancreatic cells through embryonic GPR41 and GPR43. This developmental process helps maintain postnatal energy homeostasis, as evidenced by the fact that offspring from germ-free mothers are highly susceptible to metabolic syndrome, even when reared under conventional conditions. Thus, our findings elaborate on a link between the maternal gut environment and the developmental origin of metabolic syndrome.

α-particle discrimination in the measurement of α/β decaying chains by the use of ultra-thin plastic scintillation sheets

We found that problems of α/β pulse-height overlapping can be solved by use of ultra-thin plastic scintillator sheets. In order to determine individual α-counting efficiencies for nuclides in the ²²³Ra decay-chain, the 4πα-γ anti-coincidence spectrometry technique was employed with a 4πα-γ detector configuration composed of a source sandwiched between ultra-thin plastic scintillator sheets and a Ge detector. This technique was applied to the activity measurements of ²²³Ra. This type of sandwich source is useful to prevent possible leakage of ²¹⁹Rn gas.

Effect of high ligation on survival of patients undergoing surgery for primary colorectal cancer and synchronous liver metastases

Background

Although R0 surgery is recommended for stage IV colorectal cancer, the degree of required lymphadenectomy has not been established. The aim of this study was to investigate the prognostic impact of high ligation (HL) of the feeding artery and the number of retrieved lymph nodes after R0 surgery for colorectal cancer and synchronous colorectal cancer liver metastasis (CRLM).

Methods

This was a multi‐institutional retrospective analysis of patients with colorectal cancer and synchronous CRLM who had R0 surgery between January 1997 and December 2007. Clinical and pathological features were compared in patients who underwent HL and those who had a low ligation (LL). Kaplan–Meier analysis was performed to estimate the effect of HL on overall survival (OS). The impact of several risk factors on survival was analysed using the Cox proportional hazards model.

Results

Of 549 patients, 409 (74·5 per cent) had HL. Median follow‐up was 51·4 months. HL significantly improved the 5‐year OS rate (58·2 per cent versus 49·3 per cent for LL; P = 0·017). Multivariable analysis revealed HL to be a significant prognostic factor compared with LL (5‐year mortality: hazard ratio (HR) 0·68, 95 per cent c.i. 0·51 to 0·90; P = 0·007). In subgroup analysis, the positive effect of HL on OS was greatest in patients with lymph node metastasis.

Conclusion

HL of the feeding artery was associated with improved OS in patients with colorectal cancer and synchronous CRLM after R0 surgery.

Tomography system for two-dimensional observation of fluctuation in magnetized plasma

A tomography system is developed for observing local fluctuations, pursuing higher spatial resolution, over the entire plasma of a linear cylindrical plasma. The system is equipped with totally 126 lines-of-sight that are distributed equally to six sets of light guide arrays placed around the plasma. The system has succeeded in measuring the two-dimensional structure of plasma emission and resolving coherent fluctuation structures, with spatial resolution comparable to the ion Larmor radius.