Evaluation of Deep Thermal Rehabilitation System Using Resonant Cavity Applicator During Knee Experiments

This paper evaluates experiments on the knee using a new heating rehabilitation system. For effective thermal rehabilitation of osteoarthritis, it is necessary to heat the deep tissue inside the knee joint. Our new rehabilitation system is based on the re-entrant type resonant cavity applicator which was developed for deep hyperthermia treatment in our previous studies. Our experimental results using agar phantoms showed our heating system is able to heat the deep tissue inside the knee without physically contacting the surface skin. In this study, we developed a prototype applicator and experimented on a healthy human subject's knee under clinical conditions. To evaluate heating performance, we conducted heating experiments with our resonant cavity applicator and a conventional microwave diathermy system and compared the results. The experimental results of temperature increase distributions inside the human body were estimated by ultrasound imaging techniques. The estimated results from our knee experiments show that our heating system is able to heat knee tissue more deeply than microwave diathermy systems can and thus would be effective for deep thermal rehabilitation applications in clinics.

P2817Efficacy and safety of ticagrelor monotherapy in patients with complex percutaneous coronary intervention: insights from the Global Leaders trial

Background/Introduction

Purpose

Methods

The Global Leaders trial recruited 15,991 patients treated by default with a biolimus A9-eluting stent, and randomised in a 1:1 ratio either to the experimental strategy (1-month dual antiplatelet therapy [DAPT] followed by 23-month ticagrelor monotherapy) or to the reference regimen (12-month DAPT followed by 12-month aspirin monotherapy). Complex PCI includes at least one of the following characteristics; left main and/or multivessel PCI, long stenting (defined as total stent length≥46mm), and bifurcation treatment with two stents. The present sub-analysis of the trial evaluated at two years the primary endpoint (composite of all-cause death and new Q-wave myocardial infarction [MI] centrally adjudicated with the Minnesota code). In addition, the patient-oriented composite endpoint (POCE) (composite of all-cause death, any stroke, any MI, and any revascularization) and the net adverse clinical events (NACE) (composite of POCE and Bleeding Academic Research Consortium [BARC] type 3 or 5 bleeding) were also evaluated at two years.

Results

Of 15,450 patients included in the present analysis, 5,188 (26.7%) patients underwent complex PCI. The experimental strategy, when compared with the reference one, had a significantly lower risk of the primary endpoint (3.56% vs. 5.33%, HR: 0.66; 95% CI: 0.51–0.86; p-value= 0.002; p-value for interaction= 0.019) in patients with complex PCI. Similarly, the experimental treatment was associated with a significantly reduced risk of POCE (14.41% vs. 16.88%, HR: 0.84; 95% CI: 0.74–0.97; p=0.016, p-value for interaction= 0.099) and NACE (15.77% vs. 18.37%, HR: 0.85; 95% CI: 0.74–0.97; p=0.014; p-value for interaction= 0.096). The reduction in ischemic events was predominantly observed in patients with 2 or more characteristics of complex PCI (Figure). In contrast, there was no significant difference in the risk of BARC type 3 or 5 bleeding between the two regimens (2.40% vs. 2.38%, HR: 1.01; 95% CI: 0.71–1.44; p-value=0.956; p-value for interaction= 0.935).

Central illustration

Conclusion

Together with other well-established clinical risk factors, the extent and complexity of stenting should be taken into account in tailoring antiplatelet regimens for secondary prevention. The 1-month DAPT followed by 23-month ticagrelor monotherapy reduced the ischemic events without increasing the risk of bleeding in patients who underwent complex PCI, when compared with the conventional DAPT.

Acknowledgement/Funding

The Global Leaders trial was supported by the resource from AstraZeneca, Biosensors, and The Medicines Company.

2213Impact of BMI on clinical outcomes in all-comers patients with coronary artery disease undergoing PCI: insights from the Global Leaders study

Background

It is uncertain if the obesity paradox still exists in contemporary PCI practice.

Purposes

We aimed to assess an association between baseline BMI and clinical outcomes at 2 years after PCI and to determine if the outcomes between two antiplatelet strategies depend on baseline BMI.

Methods

Global Leaders study compared 23-month ticagrelor monotherapy after 1 month of dual antiplatelet therapy (experimental strategy) with 12-month aspirin monotherapy after 12 months of conventional DAPT (reference strategy) in patients undergoing PCI with biolimus-A9 eluting stent.

Primary outcome of current study was 2-year all-cause mortality after PCI. Secondary outcomes were net adverse clinical event (NACE) and individual components of the composite endpoint.

Association between baseline BMI and outcomes were determined in the Cox model. Non-linearity was assessed using restrict cubic spline function. Patients were categorized according to WHO BMI categories; underweight (BMI <18.5), healthy weight (BMI 18.5–24.9), pre-obese state (BMI 25–29.9) and obesity (BMI ≥30). Interaction between BMI categories and antiplatelet strategies were assessed.

Results

BMI was available in 15,966 out of 15,968 patients with a median of 27.7 kg/m2 (IQR 25.0–30.7). Baseline BMI had a reverse J-shaped association with 2-year all-cause mortality. 3901 patients (24.4%) were in the group of healthy weight, 79 patients (0.5%) were under-weight, 7220 patients (45.2%) were pre-obese and 4766 patients (29.8%) were obese. Due to small number of underweight patients, outcomes after PCI were compared among three groups; healthy weight, overweight, and obesity.

Pre-obese and obese patients had lower risk of 2-year all-cause mortality than healthy-weight patients (HR pre-obesity vs. healthy-weight 0.71, 95% CI 0.58–0.88, HR obesity vs. healthy-weight 0.69, 95% CI 0.54–0.87). The risk of 2-year NACE was similar among three groups (healthy weight vs. pre-obesity; HR 1.04, 95% CI 0.94–1.16, healthy weight vs. obesity; HR 1.04, 95% CI 0.93–1.16). No significant difference in risk of any stroke, any MI, and BARC3 or 5 bleeding was found among three groups. Pre-obese patients had higher risk of revascularization than patients with healthy weight (HR 1.19, 95% CI 1.04–1.35). The risk of revascularization in obese patients was numerically higher than healthy-weight patients (HR 1.14, 95% CI 0.99–1.31).

For BARC 3 or 5 bleeding at 2 years, ticagrelor monotherapy was more favorable in obese patients (HR reference/experimental 1.63, 95% CI 1.06–2.52) while conventional DAPT strategy was more favorable in pre-obese patients (HR experimental/reference 0.76, 95% CI 0.55–1.05) (P interaction 0.02). No interaction between treatment strategy, BMI, and other outcomes was seen.

BMI and all-cause mortality and NACE

Conclusions

An obesity paradox, an association between elevated BMI and lower mortality, is still evident in this large PCI population. Effect of two antiplatelet strategies on bleeding may depend on baseline BMI.

P2811Impact of ticagrelor monotherapy on two-year clinical outcomes in patients with long stenting: insights from the Global Leaders trial

Background/Introduction

Data on the efficacy and safety of different antiplatelet regimens are limited in patients with increasing total stent length (TSL).

Purpose

To evaluate the impact of the experimental strategy (1-month dual antiplatelet therapy [DAPT] followed by 23-month ticagrelor monotherapy) vs. the reference regimen (12-month DAPT followed by 12-month aspirin monotherapy) in patients with increasing TSL.

Methods

The present post-hoc analysis of the Global Leaders trial evaluated the primary endpoint (the composite of the all-cause death and new Q-wave myocardial infarction [MI]) at two years in patients with increasing TSL. In addition, the patient-oriented composite endpoint (POCE) (the composite of all-cause death, any stroke, any MI, and any revascularization) and the net adverse clinical events (NACE) (the composite of POCE and Bleeding Academic Research Consortium [BARC] type 3 or 5 bleeding) were also assessed.

Results

The cohort of 15,450 patients treated with a biolimus-eluting biodegradable polymer stents were included in this analysis. In the longer TSL group (≥46mm), the experimental strategy significantly reduced the risk of the primary endpoint (3.78% vs. 5.68%, hazard ratio (HR): 0.67, 95% confidence interval (CI): 0.49–0.90, p=0.008, P interaction=0.042) as well as POCE (14.57% vs. 18.11%, HR: 0.79, 95% CI: 0.67–0.92, p=0.003, P interaction=0.010) and NACE (16.07% vs. 19.64%, HR: 0.80, 95% CI: 0.69–0.93, p=0.004, P interaction=0.012) at two years. The risk of BARC type 3 or 5 bleeding at two years was similar between the two antiplatelet regimens.

KM in patients with long stenting

Conclusion

Ticagrelor monotherapy significantly reduced the risk of the primary endpoint, POCE and NACE with a similar risk of BARC type 3 or 5 bleeding at two years in patients with the longer TSL.

Acknowledgement/Funding

The Global Leaders trial was supported by unrestricted grants from AstraZeneca, Biosensors, and The Medicines Company. ECRI (European Cardiovascular R

P2812Ischemic efficacy and bleeding safety of ticagrelor monotherapy in patients with multivessel percutaneous coronary intervention: insights from the Global Leaders trial

Background/Introduction

The optimal duration of DAPT after coronary stent implantation remains a matter of debate and a novel antiplatelet regimen without an increased risk of bleeding while maintaining an anti-ischemic efficacy is of paramount importance in patients at higher risk of ischemia.

Purpose

The aim of the present sub-study of the Global Leaders trial is to evaluate the efficacy and safety of the experimental antiplatelet strategy (1-month dual antiplatelet therapy [DAPT] followed by 23-month ticagrelor monotherapy) vs. the reference regimen (12-month DAPT followed by 12-month aspirin monotherapy) in patients with multivessel percutaneous coronary intervention (PCI).

Methods

The Global Leaders trial enrolled 15,991 patients treated by default with a biolimus A-9 eluting stent. The present sub-study of the trial sought to evaluate the impact of the long-term ticagrelor monotherapy on the primary endpoint (composite of all-cause death and new Q-wave myocardial infarction [MI] centrally adjudicated with the Minnesota code) at two years. In addition, the patient-oriented composite endpoint (POCE) (composite of all-cause death, any stroke, any MI, and any revascularization) and the net adverse clinical events (NACE) (composite of POCE and Bleeding Academic Research Consortium [BARC] type 3 or 5 bleeding) were also evaluated at two years.

Results

A total of 15,845 patients was included in this analysis, of whom 3,576 patients received multivessel PCI. At two years, the experimental strategy significantly reduced a risk of the primary endpoint (the composite of all-cause death and new Q-wave myocardial infarction [MI]) (3.05% vs. 4.85%, HR: 0.62, 95% CI: 0.44–0.88, p=0.006, Pinteraction=0.031) in patients with multivessel PCI. Similarly, the experimental treatment had a significant risk reduction in the patient-oriented composite endpoint (POCE), defined as the composite of all-cause death, any stroke, any MI, and any revascularization (13.37% vs. 16.74%, HR: 0.78, 95% CI: 0.66–0.93, p=0.005, Pinteraction=0.020) and the net adverse clinical events (NACE), defined as the composite of POCE and Bleeding Academic Research Consortium [BARC] defined bleeding type 3 or 5 (14.65% vs. 18.38%, HR: 0.78, 95% CI: 0.66–0.92, p=0.003, Pinteraction=0.014) at two years. There was no significant difference in BARC type 3 or 5 bleeding (2.44% vs. 2.65%, HR: 0.92, 95% CI: 0.61–1.39, p=0.685, Pinteraction=0.754) at two years between the two regimens.

KM in patients with multivessel PCI

Conclusion

The present study has demonstrated the experimental antiplatelet strategy, when compared with the reference regimen, could potentially have a favourable balance between ischemic efficacy and bleeding safety in patients who underwent multivessel PCI.

Acknowledgement/Funding

The Global Leaders trial was supported by unrestricted grants from AstraZeneca, Biosensors, and The Medicines Company. ECRI (European Cardiovascular R

Growth activation of influenza virus by trypsin and effect of T-705 (favipiravir) on trypsin-optimized growth condition

Influenza virus is activated by proteolytic cleavage of hemagglutinin by trypsin. After determining the optimal trypsin concentration, intracellular and extracellular influenza A/PR/8/34 (H1N1) and A/Victoria/361/2011 (H3N2) virus productions were compared in cultures treated with T-705 (favipiravir) and GS 4071 (an active form of oseltamivir). Although both drugs efficiently inhibited extracellular viral RNA release in a dose-dependent manner, T-705 inhibited it to the level of the inoculum without trypsin treatment, while GS 4071 inhibited it to a final level 10 times higher than that without trypsin. T-705 inhibited intracellular viral RNA production to the level of input virus in both trypsin-treated and untreated cells. In contrast, GS 4071 dose-dependently inhibited intracellular viral RNA production in cells treated with trypsin but allowed viral RNA synthesis. The level of maximum inhibition by GS 4071was 10 times higher than that of cells without trypsin and 1,000 times greater than the inoculum titer in cells without trypsin. T-705 inhibited both intracellular and extracellular virus production 1,000 and 10 times more strongly, respectively, than GS 4071. T-705 has powerful anti-influenza activity in the absence of trypsin and even in the trypsin-optimized growth condition, suggesting the therapeutic advantage in treatment of influenza complicated with bacterial pneumonia. Keywords: influenza; T-705; Tamiflu; trypsin; bacterial trypsin-like protease.

Efficacy of a new blood pressure monitor (inflationary non-invasive blood pressure, iNIBP™): a randomised controlled study

The inflationary non-invasive blood pressure monitor (iNIBP™) uses a new measurement method, whereby the cuff is slowly inflated whilst simultaneously sensing oscillations, to determine the diastolic blood pressure first and then the systolic pressure. It may measure blood pressure more quickly than the conventional non-invasive blood pressure monitor. We studied 66 patients undergoing general anaesthesia, comparing the time taken to measure the blood pressure between the two monitors at times when there were marked changes (increases or decreases by 30 mmHg or greater) in the systolic blood pressure. The median (IQR) [range]) time was significantly longer for the non-invasive blood pressure monitor (38.8 (31.5-44.7) [18.0-130.0] s) than for the iNIBP (14.6 (13.7-16.4) [11.5-35.5] s), p = 0.001, 95%CI for difference 22-25 s). We also studied 30 volunteers to evaluate the accuracy of the iNIBP, comparing it with the mercury sphygmomanometer. There was good agreement between the two monitors, with a mean difference of 0 (95% limit of agreement -12 to 11) mmHg for the systolic blood pressure. We also compared the degree of pain during cuff inflation between the automated non-invasive blood pressure and iNIBP monitors. Pain was significantly more for the non-invasive blood pressure monitor (22 of 30 volunteers had less pain with the iNIBP). We have shown that the iNIBP measured the blood pressure quicker than the conventional non-invasive blood pressure monitor and the speed of measurement was not significantly affected by marked changes in the blood pressure.

Urothelial Carcinoma of the Bladder, Lipid Cell Variant: Case Report and Literature Review

The lipid cell variant of urethral carcinoma (UC) is rare and poorly understood clinicopathologically. A nodular tumor detected in the bladder of an 87-year-old man with asymptomatic gross hematuria was transurethrally resected, and high-grade UC, lipid cell variant, was diagnosed pathologically. The tumor cells resembled lipoblasts and contained numerous cytoplasmic vacuoles. Immunohistochemically, the tumor cells stained positive for the epithelial markers CK7, CK20, EMA, CAM5.2, and 34betaE12 and negative for vimentin and S100. Focal positivity for adipophilin was detected in cytoplasm but not in the vacuoles. These findings suggest that the patient had lipid-producing UC.

Third Dentition Is the Main Cause of Premolar Supernumerary Tooth Formation

While the prevalence of supernumerary teeth (ST) is high in permanent dentition, the etiology of ST in humans remains unclear. However, multiple murine models of ST have elaborated on dated mechanisms traditionally ascribed to ST etiology: one involves the rescue of rudimental teeth, and the second considers the contribution of odontogenic epithelial stem cells. It remains unclear whether these mechanisms of ST formation in mice are applicable to humans. The third dentition is usually regressed apoptotic-that is, the teeth do not completely form in humans. Recently, it was suggested that ST result from the rescue of regression of the third dentition in humans. The present investigation evaluates the proportion of collected general ST cases that evinced a third dentition based on the clinical definition of ST derived from the third dentition. We also investigated the contribution of SOX2-positive odontogenic epithelial stem cells to ST formation in humans. We collected 215 general ST cases from 15,008 patients. We confirmed that the general characteristics of the collected ST cases were similar to the results from previous reports. Of the 215 cases, we narrowed our analysis to the 78 patients who had received a computed tomography scan. The frequency of ST considered to have been derived from the third dentition was 26 out of 78 cases. Evidence of a third dentition was especially apparent in the premolar region, was more common in men, and was more likely among patients with ≥3 ST. SOX2-positive odontogenic epithelial stem cells within the surrounding epithelial cells of developing ST were observed in non-third dentition cases and not in third dentition cases. In conclusion, the third dentition is the main cause of ST in humans. The odontogenic epithelial stem cells may contribute to ST formation in cases not caused by a third dentition.