Transoral neck surgery prevents attentional bias towards the neck compared to open neck surgery

OBJECTIVE

Measure attentional distraction of neck scars after open neck surgery compared to transoral endoscopic thyroidectomy via a vestibular approach (TOETVA) or transoral endoscopic parathyroidectomy via a vestibular approach (TOEPVA) using eye-tracking technology.

METHODS

Casual observers viewed facial images of patients who underwent open neck surgery, TOETVA/TOEPVA, or no surgery (controls). An eye-tracking monitor recorded eye fixations in real time. Multivariate Hotelling's analysis followed by post-hypothesis testing compared fixation durations for predefined regions of interest, including the eyes, nose, mouth, neck, and remaining face between open neck surgery patients, transoral neck surgery patients, and controls.

RESULTS

One hundred forty observers completed the experiment. The majority of their attention was directed towards the central triangle (eyes, nose, mouth). On multivariate analysis, distribution of attention was significantly different on the faces of those who underwent open neck surgery versus TOETVA/TOEPVA (T² = 43.66; F[32,131] = 14.5389, P < .0001). Observers attended significantly more to the neck (0.20 seconds, P < .0001; 95% CI, 0.13, 0.26 s) and less to the peripheral face (-0.24 seconds, P = .0031; 95% CI, -0.39, -0.08 s) of open neck surgery patients. In patients who followed up months after surgery, significant differences persisted (T² = 13.97; F[3451] = 4.6377, P = .0033). By contrast, fixation patterns for TOETVA/TOEPVA patients were not significantly different from controls (T² = 5.59, F[31,186] = 1.8602, P = .1345). Observer race and gender did not significantly affect attention to neck scars.

CONCLUSION

Scars following open neck surgery draw attention in casual observers. This attentional distraction is prevented in TOETVA/TOEPVA patients due to the absence of a scar, even months after surgery. Moreover, visual processing of TOETVA/TOEPVA patients' faces is similar to that of controls. These data support the effectiveness of transoral neck surgery in giving patients a cosmetic result that does not distract the attention of observers.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:1603-1608, 2020.

P3771Validation of risk scoring system predicting for progression of atrial fibrillation: the Fushimi AF Registry

Background

Atrial fibrillation (AF) increases the risks of thromboembolism and death. Progression from paroxysmal to sustained types (persistent or permanent) of AF is sometimes seen in clinical practice. We recently reported that progression of AF was associated with increased risk of clinical adverse events in Japanese AF patients. However, risk stratification schemes of predicting the progression of AF has not been fully established.

Methods

The Fushimi AF Registry, a community-based prospective survey, was designed to enroll all of the AF patients in Fushimi-ku, Kyoto, which is a typical urban district of Japan with a population of 283,000. Follow-up data were available for 4,454 patients. We investigated the risk factors of AF progression and validated the performance of various risk scoring systems predicting for progression of AF, such as APPLE, BASE-AF2, HATCH, and MB-LATER score, using data from 995 paroxysmal AF patients (mean age; 72.6±11.4 years, female; 42.2%, mean CHA2DS2-VASc score; 3.26±1.67) whose echocardiogram data were obtained at baseline.

Results

Of 995 AF patients, during the median follow-up of 1,477 days, progression from paroxysmal to sustained AF occurred in 160 patients (16.1%; 4.0 per 100 person-years). On a multivariate model, we indicated that history of AF ≥2 years (odds ratio [OR] 1.83; 95% confidence interval [CI] 1.28–2.61), left atrial diameter ≥40 mm (OR 1.45; 95% CI 1.02–2.08), daily drinker (OR 1.56; 95% CI 1.24–2.81), and cardiomyopathy (OR 2.58; 95% CI 1.17–5.69) were significantly associated with higher incidence of AF progression. Our model had better predictive potential for AF progression (area under curve [AUC] 0.612; 95% CI 0.566–0.658) than the APPLE (AUC 0.553; 95% CI 0.508–0.598; p=0.06), BASE-AF2 (AUC 0.571; 95% CI 0.526–0.617; p=0.04), CHADS2 (AUC 0.508; 95% CI 0.462–0.554; p<0.01), CHA2DS2-VASc (AUC 0.501; 95% CI 0.453–0.548; p<0.01), HATCH (AUC 0.502; 95% CI 0.456–0.548; p<0.01), and MB-LATER (AUC 0.528; 95% CI 0.483–0.572; p<0.01) score.

Conclusion

We identified 4 risk factors which may be useful to predict for progression of AF in Japanese patients. External validation of our model in other cohorts is needed.

Acknowledgement/Funding

Boehringer, Bayer, Pfizer, Bristol-Myers, Astellas, AstraZeneca, Daiichi Sankyo, Novartis, MSD, Sanofi and Takeda. Japan Agency for Medical Research

P6513Temporal trends in coronary intervention strategies and the impact on one-year clinical events: data from a Japanese multi-center real-world cohort study

Background

While it is clear that device technology of percutaneous coronary intervention (PCI) has advanced over the course of the last 40 years and the evidence for improvements in the efficacy of PCI is clear, it is less clear whether the prognosis following PCI continues to improve year by year.

Methods

The Kumamoto Intervention Conference Study Real-World Registry is a multi-center registry that enrolls consecutive patients undergoing PCI in 17 centers in Kyushu area, Japan. To elucidate the clinical impact of recent changes in treatment strategies, 8,841 consecutive participants (historical PCI: n=4,038, enrolled between January 2013 and December 2014, and current PCI: n=4,803, between January 2015 and March 2017) with 1-year follow-up data were analysed. Baseline demographic data, cardiovascular risk factors, and the medication being taken at discharge were documented. The primary endpoint was defined as a major adverse cardiac event (MACE), comprising cardiovascular death or non-fatal MI, including stent thrombosis (ST), occurring within 1 year of PCI.

Results

Regarding the relationships between presenting symptoms and PCI status, ACS, STEMI, NSTEMI, and UAP were similarly common, but the proportion of patients with multi-vessel disease was lower and the proportion with type B2/C lesions was higher in the current PCI group (p=0.004 and p<0.001, respectively). The prevalences of left main trunk lesions and Killip classes III or IV were comparable between the groups, but in-stent restenotic lesions were significantly more frequent in the historical PCI group (p<0.001). In addition to the change in the DAPT regimen, more optimal medical therapy was introduced during this time period, including the use of β-blockers, ACE-Is, and statins.

The incidences of MACE were comparable between historical PCI and current PCI (2.2% vs. 2.1%, p=0.693), even though complex lesions were more frequent during the more recent period. During this period, the use of radial approaches, drug eluting stents, and coronary imaging increased, but the use of intra-aortic balloon pumping (IABP) or thromboaspiration decreased. The incidences of major adverse cardiac or cerebrovascular events (MACCE), cardiac death, non-fatal MI, and stent thrombosis were similar between the historical and current periods (Figure). Multivariate analysis for overall patients, after adjustment, showed that multi-vessel disease, type B2/C lesions, ACS, and DES use were significant independent predictors of MACE.

Figure 1. Comparison of Clinical Events

Conclusion

An improvement in the prognosis associated with PCI has not occurred in recent years. However, the lesions being treated are becoming more complex, and the selection of evidence-based approaches, the use of coronary imaging, and the optimal medication treatments may have contributed to comparable outcomes being maintained.

Acknowledgement/Funding

Daiichi Sankyo Co., Ltd. Japan.

P5431The relationship between pulse rate and the risk of cardiac events in patients with atrial fibrillation: the Fushimi AF registry

Background

Relationship between pulse rate (PR) and cardiac events in patients with sustained (persistent and permanent) atrial fibrillation (AF) in routine clinical practice remains unclear.

Methods

The Fushimi AF Registry is a community-based prospective survey of the AF patients in Fushimi-ku, Kyoto. Follow-up data were available for 4,454 patients, and we obtained PR at baseline in 2,209 patients of 2,248 sustained AF patients. We divided these patients into four groups based on their PR; G1 (PR≥100 bpm, n=249), G2 (80 bpm≤PR<100 bpm, n=821), G3 (60 bpm≤PR<80 bpm, n=986), and G4 (PR<60 bpm, n=153), and examined the relationship between PR and cardiac events (composite of cardiovascular death and hospitalization for heart failure (HF)).

Results

Proportion of female and symptomatic AF were more in G1 group, and diastolic blood pressure was higher in G1 group, despite that systolic blood pressure was similar between the four groups. Prevalence of anemia was higher in G1 group, and that of chronic kidney disease was higher in G4 group. Prevalence of HF and left ventricular dysfunction tended to be higher in G1 group but not statistically significant. Beta-blockers and non-dihydropyridine calcium blockers were more often prescribed in G1 group. During the median follow-up of 1,449 days, cardiac events occurred in 399 patients (358 hospitalization for HF and 41 cardiovascular death). In Kaplan-Meier analysis, the incidence of cardiac events were comparable between the four groups (p=0.3). The incidence of all cause death (p=0.06) and stroke or systemic embolism (p=0.4) was also similar between the four groups. The incidence of cardiac events did not differ between the four groups when we divided the patients based on the presence of HF at baseline, and the incidence of cardiac events was also comparable between the four groups after adjusting potential confounders. However, when we examined the impact of PR according to 10 bpm increment, patients with very low PR (<50 bpm) (hazard ratio [95% confidence intervals], 2.22 [1.04–4.15]) and very high PR (≥110 bpm) (hazard ratio [95% confidence intervals], 1.67 [1.00–2.64]) had higher incidence of cardiac events than patients with PR of 70–79 bpm (Figure). Furthermore, we acquired the annual follow-up data of PR. Mean PR during the follow-up periods was not different between patients with cardiac events and those without (with vs without, 79.5±15.3 bpm vs 79.7±12.7 bpm; p=0.8), whereas maximum PR was less in patients with cardiac events (85.2±17.5 bpm vs 89.3±16.2 bpm; p<0.0001). Patients with maximum PR<60 bpm showed higher incidence of cardiac events, and the incidence of cardiac events was the lowest in patients with maximum PR of 80 to 99 bpm (maximum PR<60 bpm: 31.3%, 60–79 bpm: 24.5%, 80–99 bpm: 14.5%, 100 bpm: 16.1%; P<ehz746.03881).

Conclusion

PR did not appear to have strong impact on cardiac events in patients with sustained AF. However, low PR might be a risk for developing cardiac events.

Acknowledgement/Funding

Japan Agency for Medical Research and Development, AMED (15656344, 16768811), Boehringer Ingelheim, Bayer Healthcare, Pfizer, Bristol-Myers Squibb

P2563Effects of rivaroxaban on cardiac remodeling after experimental myocardial infarction in mice

Background

Rivaroxaban, a direct activated factor X (FXa) inhibitor, has been established for prevention and treatment of arterial and venous thrombosis. Although FXa plays an important role in thrombosis, FXa also involves in inflammation via the protease-activated receptor (PAR)-1 and PAR-2 pathway. We assessed the hypothesis that rivaroxaban might protect cardiac remodeling after myocardial infarction (MI) in mice.

Methods

MI was induced in wild-type mice by permanent ligation of the left anterior descending coronary artery. At 1 day after MI, mice were randomly assigned to the rivaroxaban and vehicle groups. In the rivaroxaban group, the mice were provided with regular chow diet including rivaroxaban (2400ppm) after the randomization. We evaluated the cardiac function by echocardiography, expression of mRNA and protein in the infarcted and non-infarcted area 7 days after MI. Furthermore, we measured infarct size, infiltration of inflammatory cells by pathological analysis 7 days after MI.

Results

The fractional shortening (%FS) and Interventricular Septal thickness in diastole (IVSTd) was significantly improved 7 days after MI in the rivaroxaban group compared with the vehicle group (%FS, p=0.01; IVSTd, p=0.013). As for pathological analysis, rivaroxaban decreased infarct size (p=0.026) and the number of infiltrated macrophages in the non-infarcted area (p=0.011) compared with vehicle. The mRNA expression in tumor necrosis factor (TNF)-α, transforming growth factor (TGF)-β in the infarcted area and atrial natriuretic peptide (ANP) in the non-infarcted area was significantly lower in the rivaroxaban group compared with the vehicle (TNF-α, p=0.015; TGF-β, p=0.019; ANP, p=0.012). PAR-1 and PAR-2 mRNA expression in the infarcted area significantly decreased 7 days after MI in the rivaroxaban group compared with the vehicle (PAR-1, p=0.005; PAR-2, p=0.037). Furthermore, western blot analysis demonstrated that the phosphorylation of Extracellular Signal-regulated Kinase (ERK) and c-Jun N-terminal Kinase (JNK) in the non-infarcted area significantly decreased 7 days after MI in the rivaroxaban group compared with the vehicle (ERK, p=0.015; JNK, p=0.002).

Conclusions

The present study showed that rivaroxaban protected against cardiac dysfunction, probably due to the suppression of PAR-mediated increase of pro-inflammatory cytokines post-MI. Rivaroxaban might be potentially effective for improving the cardiac remodeling after MI.

Acknowledgement/Funding

This study was supported in part by trust-research grant from Bayer Yakuhin, Ltd.

High-endothelial cell-derived S1P regulates dendritic cell localization and vascular integrity in the lymph node

While the sphingosine-1-phosphate (S1P)/sphingosine-1-phosphate receptor-1 (S1PR1) axis is critically important for lymphocyte egress from lymphoid organs, S1PR1-activation also occurs in vascular endothelial cells (ECs), including those of the high-endothelial venules (HEVs) that mediate lymphocyte immigration into lymph nodes (LNs). To understand the functional significance of the S1P/S1PR1-G_i axis in HEVs, we generated Lyve1;Spns2^Δ/Δ conditional knockout mice for the S1P-transporter Spinster-homologue-2 (SPNS2), as HEVs express LYVE1 during development. In these mice HEVs appeared apoptotic and were severely impaired in function, morphology and size; leading to markedly hypotrophic peripheral LNs. Dendritic cells (DCs) were unable to interact with HEVs, which was also observed in Cdh5^CRE-ERT2;S1pr1^Δ/Δ mice and wildtype mice treated with S1PR1-antagonists. Wildtype HEVs treated with S1PR1-antagonists in vitro and Lyve1-deficient HEVs show severely reduced release of the DC-chemoattractant CCL21 in vivo. Together, our results reveal that EC-derived S1P warrants HEV-integrity through autocrine control of S1PR1-G_i signaling, and facilitates concomitant HEV-DC interactions.

P3780Clinical characteristics and outcomes in Japanese atrial fibrillation patients with valvular heart disease: the Fushimi AF registry

Background

Previous studies have suggested that valvular atrial fibrillation (VAF), defined as atrial fibrillation (AF) patients with prosthetic valve or rheumatic mitral stenosis, increased the risks of thromboembolism. However, clinical characteristics and outcomes of VAF and non-valvular AF (NVAF) patients with other valvular heart disease (VHD) has not been fully described.

Method

The Fushimi AF Registry was designed to enroll all of the AF patients. In the entire cohort (4,454 patients), follow-up data including echocardiography data were available for 3,566 patients. We compared clinical characteristics and outcomes between 131 VAF patients (3.7%), 583 NVAF with VHD (NVAF-VHD: 16.3%) and 2,852 without VHD (Non-VHD: 80.0%).

Result

Compared with Non-VHD, patients in VAF and NVAF-VHD were older (VAF vs. NVAF-VHD vs. Non-VHD: 74.3 vs. 76.9 vs. 72.9 years, respectively; p≤0.0001), more often female (56.5% vs. 51.1% vs. 36.9%, p≤0.0001), less in body weight (54.3 vs. 54.7 vs. 60.6 kg, p≤0.0001), more persistent/permanent type (64.1% vs. 65.4% vs. 45.8%, p≤0.0001), more likely to have heart failure (61.8% vs. 53.2% vs. 23.3%, p≤0.0001), had higher CHADS2 score (2.18 vs. 2.49 vs. 1.96, p≤0.0001) and CHA2DS2-VASc score (3.71 vs. 4.02 vs. 3.26, p≤0.0001), and received oral anticoagulant prescription more frequently (78.6% vs. 63.0% vs. 55.6%, p0.0001). NVAF-VHD was more likely to have previous stroke/systemic embolism (SE) than VHD or Non-VHD (14.5% vs. 23.5% vs. 19.6%, p=0.03). VAF or NVAF-VHD had larger left atrium than Non-VHD (50.5 vs. 47.2 vs. 42.4 mm, p<0.0001). Heart rate, diabetes mellitus and previous bleeding were comparable between the groups.

During the median follow-up of 1,471 days, the incidence rate of stroke/SE was not significantly different between three groups, however, NVAF-VHD showed modestly higher rate than Non-VHD (1.67 vs. 1.96 vs. 1.28 per 100 person-years, respectively, log rank p=0.054) (Figure). The incidence rates of all-cause death (4.62 vs. 5.74 vs. 3.21, p≤0.0001), cardiac death (1.07 vs. 1.01 vs. 0.44, p=0.0003), and those of hospitalization for heart failure (3.29 vs. 4.41 vs. 1.80, p≤0.0001) were higher in NVAF-VHD and VAF, than Non-VHD. After adjustment by relevant factors including the components of CHA2DS2-VASc score and oral anticoagulant use, NVAF-VHD, but not VAF, was an independent predictor for hospitalization for heart failure. Neither VAF nor NVAF-VHD was predictors for all-cause death, cardiac death or stroke/SE.

Figure 1. Incidence of stroke/SE

Conclusion

As compared with Non-VHD, the risk of stroke/SE in VAF and NVAF-VHD was not particularly high; although NVAF-VHD had modestly higher rate than Non-VHD. VAF and NVAF-VHD were associated with higher incidence rates of all-cause death, cardiac death and hospitalization for heart failure. NVAF-VHD was an independent predictor for hospitalization for heart failure in multivariate analysis.

Acknowledgement/Funding

Pfizer, Bristol-Myers Squibb, Boehringer Ingelheim, Bayer Healthcare and Daiichi Sankyo

P4334Effects of Asian dust on blood pressure and blood cell counts: a cross-sectional study of health check-up data

Introduction

Asian dust (AD) is one of the health care problems because AD increases risk for mortality, respiratory, and cardiovascular disease. Previous animal studies showed that particulate matter from AD induced oxidative stress and systemic inflammation, increased blood pressure and heart rate, and decreased cardiac contraction. However, few reports show association of AD with increased blood pressure in human healthy subjects.

Purpose

The aim of this study was to investigate effects of AD on blood pressure and blood cell counts in human.

Methods

Using generalized linear models, we estimated the association between short-term exposure to AD and systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR) and white blood cell (WBC) count in 296,168 participants aged 20 and older (men n=168,579, 56.9%) who underwent medical check-ups and had no anti-hypertensive agents between April 2005 and March 2015 in a health check-up center in Japan. AD days were the days on which AD events occurred, which were defined as decreased visibility (<10km) due to AD monitored by local meteorological observatory. Propensity score matching analysis was performed to reduce the effects of possible confounders such as age, sex, mean temperature, humidity. In multivariable generalized linear models, data of other air pollutant such as SO2, NO2, Ox or suspended particulate matter was used as covariate.

Results

During study period, 61 AD days were observed, and there were 4,670 participants undergoing medical check-ups on AD days. In the propensity score matched population (n=4,670, each), short-term exposure to AD was significantly associated with an increased risk of higher SBP, DBP, HR, or WBC count [β=1.303, 95% confidence interval (CI) 0.577 to 2.029 for SBP, β=0.630, 95% CI 0.122 to 1.138 for DBP, β=0.987, 95% CI 0.410 to 1.563 for HR, β=150.0, 95% CI 64.9 to 235.1 for WBC]. These significant associations were also observed in two-pollutant models. In subgroup analysis according to age, AD exposure had greater impact on SBP, DBP, and HR in younger people (20 to 40 years old), but WBC count in middle-high age (51 years and older).

GLM analysis according to age category

Conclusions

The present study showed that short-term exposure to AD was associated with higher SBP, DBP, HR and WBC count. Short-term exposure to AD may exacerbate sympathetic nervous system for the young and immune system for the elderly.

P5663Impact of proteinuria on cardiovascular outcomes in Japanese diabetic patients with atrial fibrillation: the Fushimi AF Registry

Background

Previous studies have suggested that proteinuria is independently associated with clinical outcomes in diabetic patients, irrespective of the presence of renal dysfunction. However, data regarding the impact of proteinuria on clinical outcomes in diabetic patients with atrial fibrillation (AF) are limited.

Methods

The Fushimi AF Registry is a community-based prospective survey of AF patients in our city in Japan. Follow-up data were available in 4,454 patients, and 634 diabetic patients with available data of proteinuria and estimated glomerular filtration rate (eGFR) were examined. We compared the clinical background and outcomes between patients with proteinuria (n=251) and those without (n=383). Then, we divided the patients into 4 subgroups according to the presence of proteinuria and renal dysfunction, and compared the clinical outcomes between groups; group 1 (without proteinuria, eGFR ≥60 ml/min/1.73 m2; n=203), group 2 (with proteinuria, eGFR ≥60; n=96), group 3 (without proteinuria, eGFR <60; n=180), group 4 (with proteinuria, eGFR <60; n=155).

Results

Age was comparable between patients with or without proteinuria. Patients with proteinuria had higher prevalences of previous heart failure (HF), stroke/systemic embolism, hypertension and renal dysfunction. The prevalences of previous myocardial infarction, and major bleeding were similar between two groups. During the median follow-up of 1,505 days, the incidence rates of HF hospitalization (4.1/100 person-years vs. 2.5/100 person-years; p<0.01) and cardiovascular death (1.8/100 person-years vs. 0.4/100 person-years; p<0.01) were higher in patients with proteinuria. When we divided patients into 4 subgroups, the incidences of HF hospitalization (group 1: 1.8/100 person-years vs. group 2: 3.4/100 person-years vs. group 3: 3.8/100 person-years vs. group 4: 4.9/100 person-years; p<0.01) and cardiovascular death (group 1: 0.3/100 person-years vs. group 2: 1.8/100 person-years vs. group 3: 0.5/100 person-years vs. group 4: 2.2/100 person-years; p<0.01) tended to be higher in not only group 3 and group 4 but also group 2 than group 1 (Figure). Multivariate Cox proportional hazards regression analysis including female gender, age (≥75 years), hypertension, pre-existing HF, renal dysfunction (eGFR <60),low left ventricular ejection fraction (<40%) and proteinuria revealed that proteinuria was an independent determinant of both of HF hospitalization (adjusted hazard ratio [HR]: 1.57, 95% confidence interval [CI]: 1.05–2.34) and cardiovascular death (HR: 3.76, 95% CI: 1.59–8.88).

Figure 1

Conclusion

In Japanese diabetic patients with AF, proteinuria was associated with higher incidences of HF hospitalization and cardiovascular death, irrespective of the presence of renal dysfunction.

P3758Clinical characteristics and outcomes of atrial fibrillation patients with thrombocytopenia: the Fushimi AF Registry

Background

Thrombocytopenia is sometimes found in routine blood tests and is reported as a risk factor of major bleeding events and incidence of all-cause death after percutaneous coronary intervention. However, the influence of thrombocytopenia on clinical outcomes in patients with atrial fibrillation (AF) remains unknown.

Purpose

We aimed to investigate relationship between baseline platelet count and clinical outcomes such as all-cause death, hospitalization for heart failure, and the major bleeding event in AF patients.

Methods

The Fushimi AF Registry was designed to enroll all of the AF patients in Fushimi-ku, Kyoto. Fushimi-ku is densely populated with a total population of 283,000 and is assumed to represent a typical urban community in Japan. Follow-up data with baseline platelet counts were available in 4,179 patients from March 2011 to November 2018. We divided the entire cohort into 3 groups according to baseline platelet level: No thrombocytopenia (≥150,000/μL, n=3,323), Mild thrombocytopenia (100,000–149,999/μL, n=707), and Moderate/severe thrombocytopenia (≤99,999/μL, n=149).

Results

In the entire cohort, the mean age was 73 years, 40% were women, and the mean body weight and body mass index was 59 kg and 23.1 kg/m2, and the median platelet count were 192,000/μL (interquartile range 156,000 to 232,000/μL), respectively.

Compared to No thrombocytopenia, patients with thrombocytopenia were older (No vs. Mild vs. Moderate/severe; 73.3 years vs. 76.5 years vs. 75.8 years, p<0.0001), more likely to have heart failure (27.0% vs. 32.8% vs. 41.6%, p<0.0001), more likely to have chronic renal disease (35.7% vs. 42.6% vs. 57.7%, p<0.0001), and had higher CHADS2 score (2.05 vs. 2.17 vs. 2.34, p=0.0039) and CHA2DS2-VASc score (3.40 vs. 3.52 vs. 3.71, p=0.0416). Patients with thrombocytopenia had lower hemoglobin (13.0 vs. 12.8 vs. 11.6, p<0.0001) than No thrombocytopenia. However, prevalence of previous major bleeding events was comparable between three groups (4.66% vs. 4.67% vs. 5.37%, p=0.92)

On Kaplan-Meier analysis, the incidence of all-cause death was higher in Mild group (hazard ratio [HR] 1.51; 95% confidence interval [CI] 1.28–1.77) and Moderate/severe group (HR 2.97; 95% CI 2.28–3.80) than No group (Figure 1). The incidence of hospitalization for heart failure was higher in Mild group (HR 1.62; 95% CI 1.31–1.99) and Moderate/severe group (HR 2.64; 95% CI 1.76–3.81) than No group (Figure 2). The incidence of major bleeding event was higher in Mild group (HR 1.46; 95% CI 1.11–1.91) and Moderate/severe group (HR 2.45; 95% CI 1.41–3.91) than No group (Figure 3).

Conclusion

Thrombocytopenia in AF patients was associated with higher incidence of all-cause death, hospitalization for heart failure, and major bleeding event in the Fushimi AF Registry.

Acknowledgement/Funding

Pfizer, Bristol-Myers Squibb, Boehringer Ingelheim, Bayer Healthcare,and Daiichi-Sankyo

P884Short-term exposure to asian dust is associated with myocardial infarction with nonobstructive coronary arteries

Background

Asian dust (AD) is considered as one of air pollution that increases risk of acute myocardial infarction (AMI). However, it has not been elucidated whether AD might increase the risk of myocardial infarction with nonobstructive coronary arteries (MINOCA).

Methods

A time-stratified case-crossover design and conditional logistic regression models was used to investigate the association between short-term exposure to AD and admission of AMI during the spring months in a nationwide administrative Diagnostic Procedure Combination (DPC) database, the Japanese Of All cardiac and vascular Diseases (JROAD)-DPC, between April 2012 through March 2016. MINOCA was defined as AMI having angiography without revascularization and coronary atherosclerosis, whereas myocardial infarction with obstructive coronary artery disease (MI-CAD) was AMI with revascularization and/or coronary atherosclerosis. Data for AD events, air pollutants (PM2.5, Ox, NO2, SO2), and meteorological variables were obtained from the nearest monitoring station of the hospital.

Results

During the study period, 3,233 MINOCA and 27,202 MI-CAD patients were identified from 30,435 AMI patients. Although the occurrence of AD events 2 days before the admission was not associated with the admission of AMI and MI-CAD, the AD events was significantly associated with the admission of MINOCA with adjustment for meteorological variables and each air pollutant. In subgroup analysis of MINOCA, patients without low ADL was associated with higher risk of the admission due to AD exposure than those with low ADL, with significant interaction.

Conclusions

AD events might be more likely to trigger onset of MINOCA than MI-CAD.

Acknowledgement/Funding

None

The Multivector Gracilis Free Functional Muscle Flap for Facial Reanimation

Importance

A multivector functional muscle flap that closely simulates the biomechanical effects of facial muscle groups is essential for complete smile restoration after facial paralysis.

Objective

To determine the feasibility of a multivector gracilis muscle flap design for reanimation after facial paralysis and to analyze the effect on the smile display zone.

Design, Setting, and Participants

Prospective analysis of patients who underwent a double paddle multivector gracilis flap for complete facial paralysis between June 2015 and December 2016 was carried out in a tertiary hospital.

Interventions

The gracilis muscle was harvested as a double paddle flap and inserted along 2 vectors for facial reanimation.

Main Outcomes and Measures

The primary outcome measures were: (1) dental display (the number of maxillary teeth displayed on paralyzed vs normal sides), (2) exposed maxillary gingival scaffold width, (3) interlabial gap at midline and canine, (4) facial asymmetry index (FAI), and (5) dynamic periorbital wrinkling.

Results

There were 10 women and 2 men between ages 20 and 64 years (mean [SD], 46 [15] years). Five flaps were reinnervated with facial and masseteric nerves, 5 with masseteric nerve only, and 2 with crossfacial nerve only. There was functional muscle recovery in all cases. On average there was additional 3.1 maxillary teeth exposed posttreatment when smiling (5.5 vs 8.6; CI, 7.9 to 16.6; P < .001). The mean exposed maxillary gingival scaffold width improved from 31.5 mm to 43.7 mm (95% CI, 1.9 to 4.3; P < .001). There was no significant difference in interlabial exposure at midline (7.1 mm vs 7.7 mm; CI, -1.5 to 2.7; P = .56) but a 56.4% improvement at the level of the canines (3.9 vs 6.1; CI, 0.1 to 4.3; P = .04). The mean FAI when smiling was reduced from 9.1 mm to 4.5 mm (CI, -8.0 to -1.2; P = .01). Dynamic wrinkling of the periorbital area with smiling was noted in 4 patients.

Conclusions and Relevance

The gracilis flap can be reliably designed as a functional double paddle muscle flap for a multivector facial reanimation. The multivector gracilis flap design is effective in improving all components of the smile display zone and has the potential for producing periorbital-wrinkling characteristic of a Duchenne smile.

Level of Evidence

4.

Societal Identification of Facial Paralysis and Paralysis Location

Importance

When able to identify facial paralysis, members of society regard individuals with facial paralysis differently. They perceive a decrease in attractiveness, more negative affect, and lower quality of life. However, the ability of lay people in society to accurately identify the presence of facial paralysis has not yet been defined.

Objective

To determine societal members' ability to (1) identify paralysis in varying degrees of paralysis severity and (2) localize the defect on the face.

Design, Setting, and Participants

A prospective observational study conducted in an academic tertiary referral center using a group of 380 casual observers was carried out.

Main Outcomes and Measures

Surveys were designed containing smiling and repose images of normal faces and faces with unilateral facial paralysis of 3 severity levels (low, medium, and high) as categorized by House-Brackmann (HB) grade. The photographs were then shown to casual observers in a web-based survey. After reviewing both normal faces and faces with varying degrees of paralysis, they then indicated (1) whether paralysis was present and (2) if so, where the paralysis was on the face.

Results

A total of 380 participants (267 [70.3%] women and 113 [29.7%] men with a mean [SD] age of 29 [12] years) successfully completed the survey, viewing 2860 facial photographs in aggregate. The accuracy rate of identifying paralysis increased from low-grade through high-grade paralysis. Facial paralysis was identified in 249 (34.6%) of 719 facial photographs with low-grade paralysis, 448 (63.2%) of 709 with medium-grade paralysis, and 696 (96.7%) of 720 with high-grade paralysis (χ2 = 912.6, P < .001); 6.2% (44/731) of normal faces were incorrectly identified as having paralysis (χ2 = 912.6, P < .001). Participants correctly localized paralysis in 157 (63.0%) of 249 low-grade photographs, 307 (68.5%) of 448 medium-grade photographs, and 554 (79.6%) of 696 high-grade photographs (χ2 = 32.5, P < .001). In general, participants tended to identify facial paralysis more accurately in smiling vs repose faces (48.6% vs 20.6%, 92.4% vs 33.7%, and 96.7% vs 96.6% in low-, medium-, and high-grade paralysis, respectively) (χ2 = 62.2, P < .001; χ2 = 262.6, P < .001; χ2 = 0.0, P = .96, respectively).

Conclusions and Relevance

The ability of individuals to identify the presence of facial paralysis increased as paralysis severity increased. Further, smiling increased accurate identification. However, even when individuals can identify paralysis, they are not necessarily able to accurately localize the paralysis on a face. This may speak to a phenomenon in which perception of a facial defect comes from a holistic interpretation of a face, rather than a clinically accurate specification of the defect location. These findings are important in the future counseling of patients.

Level of Evidence

NA.

Health-related QOL of elderly patients with pulmonary M. avium complex disease in a university hospital

BACKGROUND

Little is known about the clinical characteristics and health-related quality of life (HQOL) of elderly patients with pulmonary Mycobacterium avium complex (pMAC) disease.

OBJECTIVES

To evaluate HQOL using the 36-Item Short-Form Health Survey and St George's Respiratory Questionnaire (SGRQ) and to investigate the predictors of HQOL changes among elderly patients with pMAC disease.

METHODS

This prospective cohort registry was conducted at Keio University Hospital, Tokyo, Japan, between May 2012 and July 2015 and included 84 patients with pMAC disease aged 75 years who had completed the HQOL questionnaire and 48 patients with pMAC disease who had been followed up and completed the HQOL questionnaire in cross-sectional and longitudinal analyses, respectively.

RESULTS

In cross-sectional analyses, elderly patients with pMAC disease had significantly lower role-physical, general health, vitality, social functioning, role-emotional and role/social component scores than the general Japanese elderly population. Analysis of covariance revealed that patients with cavitary lesions had significantly worse physical functioning and SGRQ scores (P < 0.05). Longitudinal analysis showed that under-treatment, short duration of disease and positive sputum smear at baseline were predictors of worse HQOL at 12 months.

CONCLUSIONS

Elderly patients with pMAC disease have reduced HQOL. Further large studies on HQOL are required to refine the use of this parameter in the treatment of these patients.

The deformable most-likely-point paradigm

In this paper, we present three deformable registration algorithms designed within a paradigm that uses 3D statistical shape models to accomplish two tasks simultaneously: 1) register point features from previously unseen data to a statistically derived shape (e.g., mean shape), and 2) deform the statistically derived shape to estimate the shape represented by the point features. This paradigm, called the deformable most-likely-point paradigm, is motivated by the idea that generative shape models built from available data can be used to estimate previously unseen data. We developed three deformable registration algorithms within this paradigm using statistical shape models built from reliably segmented objects with correspondences. Results from several experiments show that our algorithms produce accurate registrations and reconstructions in a variety of applications with errors up to CT resolution on medical datasets. Our code is available at https://github.com/AyushiSinha/cisstICP.

Endonasal endoscopic resection of olfactory neuroblastoma: an 11-year experience

OBJECTIVE

Olfactory neuroblastoma (ONB) is a rare malignant neoplasm of the sinonasal cavity. Surgery has been and remains a mainstay of treatment for patients with this tumor. Open craniofacial resections have been the treatment of choice for many decades. More recently, experience has been growing with endoscopic approaches in the management of patients with ONB. The object of this study is to report the authors’ experience over the past 11 years with ONB patients treated with purely endonasal endoscopic techniques.

METHODS

The authors performed a retrospective chart review of 20 consecutive patients with ONB who underwent a completely endonasal endoscopic approach for an oncological tumor resection at their institution between January 2006 and January 2017. Patient demographics, tumor stage, pathological grade, frozen section analysis, permanent margin assessment, perioperative complications, postoperative therapy, length of follow-up, and outcomes at last follow-up were collected and analyzed.

RESULTS

Eighteen patients presented with newly diagnosed disease, with a modified Kadish stage of A in 2 cases, B in 3, C in 11, and D in 2. Two patients presented with recurrent tumors. An average of 25.3 specimens per patient were examined by frozen section analysis. Although analysis of intraoperative frozen section margins was negative in all but 1 case, microscopic foci of tumor were found in 7 cases (35%) on permanent histopathological analysis. Perioperative complications occurred in 7 patients (35%) including 1 patient who developed a cerebrospinal fluid leak; there were no episodes of meningitis. All but 1 patient received postoperative radiotherapy, and 5 patients received postoperative chemotherapy. With a mean follow-up of over 5 years, 19 patients were alive and 1 patient died from an unrelated cause. There were 2 cases of tumor recurrence. The 5-year overall, disease-specific, and recurrence-free survival rates were 92.9%, 100%, and 92.9%, respectively.

CONCLUSIONS

The current results provide additional evidence for the continued use of endoscopic procedures in the management of this malignancy.

In Vivo Multicolor Imaging with Fluorescent Probes Revealed the Dynamics and Function of Osteoclast Proton Pumps

In vivo two-photon fluorescence imaging is a powerful modality to monitor cell dynamics in biomedical studies. To detect protein functions in living animals in real-time, fluorescent probes must show a quick response to the target function in specific tissues. Here, we developed a rhodamine-based small-molecule fluorescent probe called Red-pHocas (red pH-activatable fluorescent probe for osteoclast activity sensing) to reversibly detect the acidic environments for the spatiotemporal analysis of the function of osteoclast proton pumps. The introduction of electron-withdrawing N-alkyl substituents in the rhodamine spirolactam fluorophore remarkably increased the kinetics of the fluorescence response to acidic pHs, which allowed the rapid and reversible monitoring of acidic compartments and the analysis of the dynamics of osteoclast proton pumps during osteoclastic bone resorption. In vivo multicolor two-photon imaging using Red-pHocas in fluorescent reporter mice revealed that bone acidification occurred synchronously with the accumulation of proton pumps onto the bone surfaces. To our knowledge, this is the first study to demonstrate the direct involvement of osteoclast proton pumps in bone acidification under intravital conditions by means of an imaging probe.

Endoscopic navigation in the clinic: registration in the absence of preoperative imaging

PURPOSE

Clinical examinations that involve endoscopic exploration of the nasal cavity and sinuses often do not have a reference preoperative image, like a computed tomography (CT) scan, to provide structural context to the clinician. The aim of this work is to provide structural context during clinical exploration without requiring additional CT acquisition.

METHODS

We present a method for registration during clinical endoscopy in the absence of CT scans by making use of shape statistics from past CT scans. Using a deformable registration algorithm that uses these shape statistics along with dense point clouds from video, we simultaneously achieve two goals: (1) register the statistically mean shape of the target anatomy with the video point cloud, and (2) estimate patient shape by deforming the mean shape to fit the video point cloud. Finally, we use statistical tests to assign confidence to the computed registration.

RESULTS

We are able to achieve submillimeter errors in registrations and patient shape reconstructions using simulated data. We establish and evaluate the confidence criteria for our registrations using simulated data. Finally, we evaluate our registration method on in vivo clinical data and assign confidence to these registrations using the criteria established in simulation. All registrations that are not rejected by our criteria produce submillimeter residual errors.

CONCLUSION

Our deformable registration method can produce submillimeter registrations and reconstructions as well as statistical scores that can be used to assign confidence to the registrations.

Stretched Earlobe Piercings Negatively Impact Casual Observer Perceptions

Patients with stretched earlobes seek reconstruction to mitigate social stigma. To date, there have been no studies measuring the impact of stretched earlobe piercings on casual observer perceptions. One-hundred seventy-three casual observers were enrolled via public-access web sites. Participants were randomly shown frontal and profile views of six subjects with stretched earlobe piercings and four controls. Participants evaluated photos for first impressions using a survey containing choices regarding personal attributes. Latent class analysis was performed to categorize observer ratings. Analysis of variance (ANOVA), bootstrap analysis, and permutations testing were used to evaluate the relationship between perceived attractiveness, success, and approachability scoring and stretched earlobe status. Latent class analysis categorized responses into three classes: positive, negative, and neutral. Patients with stretched earlobe piercings were significantly less likely to be classified as positive by observers without body modifications (i.e., tattoos and piercings) in comparison to control photos (30.9 and 40.1%, p = 0.007) and more likely to be classified as negative (38.5 and 28.1%, p = 0.002). These changes were abolished when photos were evaluated by observers with body modifications (p > 0.05). ANOVA revealed that stretched earlobe piercings and observer body modification status have a significant effect on rated approachability (F [1,1726] = 4.08, p = 0.04) and successfulness (F[1,1726] = 9.67, p = 0.002; F [1,1726] = 70.33, p < 0.0005). No significance was found for rated attractiveness (p > 0.05). Patients with stretched earlobe piercings were more likely to be classified as having negative affect display and being less approachable and successful compared with controls when evaluated by observers without body modifications. This effect was abolished when photos were evaluated by observers with body modifications. These findings validate patient motivations for seeking stretched earlobe repair.

Imaging the Bone-Immune Cell Interaction in Bone Destruction

Bone is a highly dynamic organ that is continuously being remodeled by the reciprocal interactions between bone and immune cells. We have originally established an advanced imaging system for visualizing the in vivo behavior of osteoclasts and their precursors in the bone marrow cavity using two-photon microscopy. Using this system, we found that the blood-enriched lipid mediator, sphingosine-1-phosphate, controlled the migratory behavior of osteoclast precursors. We also developed pH-sensing chemical fluorescent probes to detect localized acidification by bone-resorbing osteoclasts on the bone surface in vivo, and identified two distinct functional states of differentiated osteoclasts, "bone-resorptive" and "non-resorptive." Here, we summarize our studies on the dynamics and functions of bone and immune cells within the bone marrow. We further discuss how our intravital imaging techniques can be applied to evaluate the mechanisms of action of biological agents in inflammatory bone destruction. Our intravital imaging techniques would be beneficial for studying the cellular dynamics in arthritic inflammation and bone destruction in vivo and would also be useful for evaluating novel therapies in animal models of bone-destroying diseases.