Longitudinal changes in life-space mobility and the factors influencing it among chronic community-dwelling post-stroke patients

PURPOSE

To identify longitudinal changes in life-space mobility and the factors influencing it among chronic, stable post-stroke patients.

MATERIALS AND METHODS

This prospective study included Japanese post-stroke patients who received day-care rehabilitation services and could undergo three life-space mobility assessments (at baseline, 12, and 24 months) for over 2 years, using the Life-Space Assessment (LSA) tool. Physical function, cognitive function, and activities of daily living were assessed by self-selected comfortable gait speed, Mini-Mental State Examination (MMSE), and Functional Independence Measure Motor subscale (FIM motor) scores, respectively, in addition to age, sex, time from onset, stroke type, and comorbidities. A multivariable linear mixed-effects model was used to examine the longitudinal changes in LSA scores and associated factors.

RESULTS

A total of 89 participants were enrolled. At baseline, the median age was 74 years, 33% were women, and median time from onset was 75 months. The LSA scores significantly declined over the two-year period. In the multivariate linear mixed-effects model adjusted for clinical characteristics, comfortable gait speed and age were significantly associated with changes in the LSA score, independent of FIM motor scores and MMSE scores.

CONCLUSIONS

Life-space mobility may persistently decline, and gait function may be a determinant influencing these changes in community-dwelling chronic post-stroke patients.Implications for RehabilitationLimited life-space mobility leads to less frequent participation in social activities and an increased risk of adverse health outcomes such as hospitalization.Changes in life-space mobility should be considered in the rehabilitation care plan for chronic post-stroke patients.Life-space mobility may decline persistently in stable post-stroke patients, even if they have periodically received day-care rehabilitation services.Since gait speed is a predominant factor affecting life-space mobility, regular assessment of gait function and appropriate strategies are needed to prevent deterioration of gait speed in chronic post-stroke patients.

Trends and outcomes of early rehabilitation in intensive care unit for patients with cardiovascular disease – a cohort study with propensity score-matched analysis

Background

Early rehabilitation in the intensive care unit (ICU), including early mobility therapy, is known to improve the clinical outcomes in patients with critically ill. However, the effectiveness of acute-phase cardiovascular rehabilitation (CR) during ICU treatment have not been thoroughly evaluated in patients with cardiovascular disease (CVD).

Purpose

We aimed to investigate the trends and outcomes of acute-phase CR in the ICU for patients with CVD, including in-hospital and long-term clinical outcomes.

Methods

We reviewed 1948 consecutive patients with CVD admitted to tertiary academic ICU at a university hospital. Patients were arbitrarily assessed by an ICU team consisting of medical and surgical doctors, nurses and physiotherapists within 24 hours after admission to ICU to discover whether their rehabilitation could be initiated according to the specific clinical trial and statement. As clinical characteristics, disease aetiology, comorbid conditions, and ICU treatment were obtained from an electronic database. We evaluated the probability of return to walking independence and return to home as in-hospital clinical outcomes. All patients were followed for five years and investigated all-cause and cardiovascular events after hospital discharge as long-term clinical outcomes. The associations between the implementation of CR during ICU treatment (ICU-CR) and clinical outcomes were evaluated using propensity score-matched analysis with adjustment for clinical characteristics in all matched patients and various subgroups, including aged >65 years, surgical patients, emergency, and length of ICU stay ≥48 hours.

Results

Out of studied patients, 1092 patients received ICU-CR, the number of which positively correlated with year-trend (r=0.986, P<0.001). After propensity score matching with adjustment for clinical characteristics including calendar years, 758 patients were included for analysis (pairs of n=379 ICU-CR and non-ICU-CR). The ICU-CR was significantly associated with a higher probability of return to walking independence (incident rate ratio [IRR], 2.04; 95% confidence interval [CI], 1.77–2.36) and return to home (IRR, 1.22 95% CI, 1.05–1.41). These associations were consistently observed in various subgroups regarding CVD conditions (Figure 1). During the median follow-up periods of 2.6 years, all-cause clinical events and cardiovascular events occurred in 289 patients (38.1%) and 153 patients (20.2%), respectively. The ICU-CR showed significantly lower rates of five-year all-cause and cardiovascular events than non-ICU-CR (hazard ratio [95% CI] for all-cause events and cardiovascular events, 0.71 [0.56–0.89] and 0.69 [0.50–0.95], respectively, Figure 2).

Conclusions

The implementation of acute-phase CR in the ICU increased with year-trend, considered beneficial to improve in-hospital and long-term clinical outcomes in patients with CVD and various subgroups of relatively severe disease conditions.

Funding Acknowledgement

Type of funding sources: None.

Perme ICU Mobility Score as a comprehensive assessment tool of acute-phase rehabilitation is correlated with clinical outcomes in patients after cardiovascular surgery

Background

Early mobility therapy in the intensive care unit (ICU) is widely employed to improve the physical function and prognosis of patients with critically ill. On the other hand, patients who undergo cardiovascular surgery frequently suffer from disabilities after ICU care due to their cardiopulmonary conditions and treatments. However, few studies have reported the procedures and assessments of acute-phase rehabilitation in these patients. Recently, the Perme ICU Mobility Score (Perme Score) was developed as a reliable tool to assess comprehensive mobility status of patients in the ICU. We hypothesised that the Perme Score is a useful tool for assessing the mobility levels in the ICU and predicting clinical outcomes in patients undergoing acute-phase rehabilitation after cardiovascular surgery.

Purpose

To investigate the associations between the Perme Score within the second days after cardiovascular surgery and the patients' clinical outcomes, including physical function and the incidence of clinical events.

Methods

We studied 224 consecutive patients (34.4% female; aged 65±13 years) who were admitted to the ICU of a tertiary academic hospital after cardiac and/or major vascular surgery. Clinical characteristics including patient profiles, comorbidities, surgical details and APACHE II and SOFA scores were evaluated on ICU admission. The Perme Score contains categories on mental status, potential mobility barriers, muscle strength and mobility level, with higher scores indicating greater activity levels in the ICU. We assessed the Perme Score within the second days after the surgery. As a physical function at hospital discharge, we measured the six-minute walk distance (6MWD). The primary endpoint was a composite outcome of the number of all-cause mortality and/or all-cause unplanned readmission. We analysed the associations of the Perme Score with the 6MWD and the incidence of clinical events using multiple regression analysis and multivariate Poisson regression analysis, respectively.

Results

After adjusting for clinical confounding factors, a higher Perme Score was an independent factor of a higher 6MWD (Table 1). During the median follow-up period of 1.3 years, 51 cases of all-cause mortality/readmission occurred in 37 (16.5%) patients, with an incidence rate of 18.6/100 person-years. In the multivariate Poisson regression analysis, even after adjusting for the severity score in the ICU, a higher Perme Score was significantly and independently associated with lower rates of all-cause clinical events (adjusted incident rate ratio: 0.96, 95% confidence interval: 0.93–0.99, P=0.008, Figure 1).

Conclusions

The Perme Score within the second days after cardiovascular surgery is correlated with physical function at hospital discharge and the incidence of clinical events after discharge. Thus, a comprehensive assessment of acute-phase rehabilitation after cardiovascular surgery may be useful in predicting clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.

Cancer as a risk factor for physical dysfunction and poor prognosis in patients with cardiovascular disease

Introduction

The emerging interdisciplinary field of cardio-oncology is of interest to clinicians because a history of cancer or cancer treatment is considered a severe risk factor for cardiovascular disease (CVD). Both cancer and CVD can reduce skeletal muscle mass; together, they can lead to a poorer prognosis. However, it is unclear whether a patient's cancer history can lower physical function and lead to a poor prognosis with the coexistence of cancer history and physical dysfunction in patients with CVD. This study aimed to identify the relationship between cancer history and physical function, as well as the prognostic value of their combination, in patients with CVD.

Methods

We reviewed 3,640 patients with CVD (mean age, 67.9±13.5 years) who underwent physical-function tests (gait speed and 6-min walking distance [6MWD]). We performed multivariate linear regression analysis to assess potential associations between cancer history and physical-function tests in patients with CVD. Additionally, we used the Kaplan–Meier curve and Cox regression analyses to assess survival and prognostic significance for patients divided into four groups according to the presence or absence of cancer history and high or low physical function.

Results

In multivariate linear regression analysis, cancer history was independently associated with lower gait speed and 6MWD (gait speed, P=0.048 and 6MWD, P=0.040). A total of 581 deaths occurred over a median follow-up period of 3.08 years (interquartile range: 1.36–5.27). For all-cause mortality, patients with a history of cancer and reduced physical function were found to have a significantly higher mortality risk even after adjusting for several covariates (gait speed, HR: 1.66, P=0.003 and 6MWD, HR: 1.71, P=0.003).

Conclusion

Cancer history was correlated with physical dysfunction in patients with CVD. Moreover, the coexistence of cancer history and physical dysfunction resulted in poorer prognosis in patients with CVD.

Funding Acknowledgement

Type of funding sources: None.

Sex differences in frequency of instrumental activities of daily living after cardiac rehabilitation and its impact on long-term mortality in patients with heart failure

Introduction

While the major outcome of cardiac rehabilitation for heart failure (HF) is the improvement of exercise tolerance, prognosis, and quality of life, instrumental activities of daily living (IADL) has also been focused on as one of the its outcomes. IADL has been reported to be associated with all-cause mortality and quality of life in community-dwelling people and in patients with stable heart disease, but no report has examined the relationship between IADL after cardiac rehabilitation for HF and prognosis. In addition, it is assumed that sex differences may affect the frequency of performing each component of IADL, but there are no reports examining the association with prognosis by sex.

Purpose

The present study aimed to investigate the sex differences in frequency of IADL and its impact on outcomes.

Methods

We retrospectively studied 490 consecutive patients who were admitted due to acute decompensated HF and participated in outpatient cardiac rehabilitation after discharge. The study was performed in accordance with the tenets of the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of our institution. IADL frequency was assessed using the questionnaire-based Frenchay Activities Index (FAI). The primary endpoint was all-cause death and secondary endpoint was combined events (all-cause death and/or readmission due to HF). We performed the Kaplan–Meier and log-rank tests and multivariable Cox regression analysis to evaluate the prognostic predictive capability of the FAI.

Results

The study population had a median age of 69 (interquartile range [IQR]: 58–76) years, and 33.9% of patients were females. The median FAI score was 24 (IQR: 16–29) points. According to the Youden index based on the area under the curve calculated by the receiver operating characteristics curve, the cut-off values of FAI for all-cause death in all-over, females, and males were 23, 22, and 23 points, respectively. Over a median follow-up period of 4.8 years (IQR: 2.3–6.6 years), all-cause death and combined events were occurred in 95 (19.4%) and 213 (43.5%), respectively. After adjustment for several pre-existing prognostic factors, IADL assessed by the FAI was independently associated with all-cause mortality (hazard ratio [HR]: 0.961, 95% confidence interval [CI]:0.937–0.986) and combined events (HR: 0.968, 95% CI: 0.952–0.985), respectively. In addition, there was no interaction between sex in prognostic capability (P=0.664).

Conclusion

Lower IADL frequency assessed by FAI at the end of outpatient cardiac rehabilitation was shown to be associated with poorer prognosis in patients with HF, regardless of sex. The IADL level is generally higher in females than in males but seems to be a useful marker for risk stratification at the end of cardiac rehabilitation in both females and males.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant-in-Aid [JSPS KAKENHI Grant Number JP 19K19884]

Impact of small-airway disease on exercise intolerance and long-term outcomes in patients with heart failure and reduced or preserved ejection fraction

Introduction

Exercise intolerance in patients with heart failure (HF) is a strong indicator of a poor prognosis. As the respiratory impairment in HF patients, the small airway is reportedly more susceptible than central airways, which results in increased airway resistance and may cause poor outcomes. However, the impact of small-airway disease (SAD) on exercise intolerance and prognosis in patients with HF is still unclear.

Purpose

We investigated the associations between SAD and exercise intolerance in patients with HF, and the clinical significance of SAD for long-term clinical events with a reduced or preserved ejection fraction.

Methods

We reviewed 1015 patients with HF (mean age, 66.9±14.6 years; male, 64.5%) admitted for medical treatment. Patients with a prior history of chronic respiratory disease or an obstructive lung pattern – defined as the forced expiratory volume (%) in 1 s relative to <70% forced vital capacity using spirometry – were excluded. Characteristics including HF aetiology, comorbidities conditions, medications, blood parameters, and echocardiographic variables were obtained from clinical records. All patients underwent spirometry at hospital discharge, and SAD was defined as the maximum mid-expiratory flow (%) relative to a <60% predicted value. At hospital discharge, we measured 6-min walk distance (6MWD), and <300 m was considered as exercise intolerance. The primary endpoint was a composite clinical event of all-cause death and/or unplanned readmission for HF. Multivariate logistic regression analysis was used to assess the association between SAD and exercise intolerance. The multivariate Cox proportional hazard model was used to clarify whether SAD was an independent predictor for the incidence of clinical events. We also performed subgroup analyses in each multivariate analysis based on a left ventricular ejection fraction (LVEF) of 40%.

Result

SAD was observed in 479 (47.2%) patients. LVEF subgroups included 458 (45.1%) and 518 (51.0%) patients with LVEF <40% and ≥40%, respectively. After adjusting for clinical characteristics, SAD was independently associated with 6MWD <300 m (Figure 1). Moreover, this association was consistently observed in the LVEF <40% and ≥40% (Figure 1). During the median follow-up period of 1.5 years, all-cause death/readmission occurred in 431 patients (42.5%), and the incidence rate was 17.5/100 person-years. In the multivariate Cox proportional hazard model, SAD was independently associated with lower event-free survival rates in all patients and the LVEF <40% subgroup, but not LVEF ≥40% subgroup (Figure 2A, B, and C, respectively).

Conclusion

This study is the first to reveal that SAD is associated with exercise intolerance in patients with HF regardless of LVEF. Moreover, SAD may have a predictive significance for long-term outcomes in patients with HF and subgroups with reduced, but not preserved ejection fraction.

Funding Acknowledgement

Type of funding sources: None.

Relationship between the spread of coronavirus disease 2019, social frailty and depressive symptoms in patients with heart failure

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): the Japan Society for the Promotion of Science (JSPS) KAKENHI

Background

Owing to the spread of coronavirus disease 2019 (COVID-19), people have refrained from going out unnecessarily and have been maintaining social distance. These new lifestyle approaches have affected people physically, psychologically, and socially. Patients with heart failure (HF) are more likely to have social frailty, physical frailty, cognitive impairment, and depressive symptoms, and an overlap of these conditions leads to adverse events. Therefore, multi-domain assessment and understanding of the condition of patients with HF are important for disease management. The spread of COVID-19 is a predicted risk factor for these events, but its impact in patients with HF has not been investigated.

Purpose

We investigated whether the spread of COVID-19 is associated with the development of the multi-domain of frailty in patients with HF.

Methods

Patients who were independent in their daily activities before admission were included in the study. The presence of social frailty (Makizako’s five items), physical frailty (Fried phenotype model), cognitive impairment (Mini-Cog), and depressive symptoms (the Patient Health Questionnaire-2) in patients with HF were assessed at hospital discharge. Logistic regression analyses were used to examine the impact of the spread of COVID-19 on the development of the multi-domain of frailty in patients with HF.

Results

We included 482 patients in this study. Median patient age was 74 years, and 64.5% were male. In multivariate logistic regression analyses, the spread of COVID-19 was significantly associated with the development of social frailty (odds ratio [OR]: 1.15, 95% confidence interval [CI]: 1.02–1.30) and depressive symptoms (OR: 1.14, 95% CI: 1.02–1.27) but not with the development of physical frailty (OR: 1.24, 95% CI: 0.51–3.02) and cognitive impairment (OR: 1.72, 95% CI: 0.80–3.73).

Conclusion

The spread of COVID-19 was associated with the development of social frailty and depressive symptoms in patients with HF. Evaluation of social frailty and depressive symptoms during hospitalization would support disease management and understand their social and psychological conditions specific to the spread of COVID-19.

Prevalence of metabolic dysfunction-associated fatty liver disease and its association with physical function in patients with acute coronary syndrome

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): JSPS KAKENHI

Background

It is widely known that patients with acute coronary syndrome (ACS) are at increased risk of nonalcoholic fatty liver disease (NAFLD), which is linked to sarcopenia and physical dysfunction. However, the relationship between metabolic dysfunction-associated fatty liver disease (MAFLD) and physical dysfunction remains unclear.

Purpose

The purpose of this study was to investigate the prevalence of MAFLD in patients with ACS to assess the relationship between MAFLD and muscle strength, walking speed, and 6-minute walking distance (6 MWD).

Methods

We reviewed patients with ACS who were assessed for hepatic steatosis using the fatty liver index, and the results were further assessed to determine the presence of MAFLD. Multiple regression analysis was used to examine the association between MAFLD and physical function.

Results

Among 479 enrolled hospitalized patients, MAFLD was identified in 234 (48.9%) patients. We conducted a multiple regression analysis in which MAFLD was independently associated with lower leg strength, gait speed, and 6 MWD (leg strength, P = 0.023; gait speed, P = 0.002 and 6 MWD, P = 0.017). Furthermore, having more metabolic impairment was still associated with lower physical function decline (leg strength, P for trend = 0.002; gait speed, P for trend = 0.019 and 6 MWD, P for trend = 0.003).

Conclusions

MAFLD is common in hospitalized patients with ACS, and most patients with MAFLD have many overlapping metabolic abnormalities. MAFLD is associated with impaired physical function, and the greater the number of overlapping metabolic abnormalities, the worse the motor function.

Skeletal muscle mass metrics as factors in the prognosis of heart failure patients

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): JSPS KAKENHI Grant

Background

Sarcopenia is a chronic condition that is characterized by the loss of skeletal muscle mass with declining muscle strength and/or performance that occurs gradually with aging. It has been reported that sarcopenia is highly prevalent in patients with heart failure (HF) and is a poor prognostic factor. Therefore, it is important to accurately assess skeletal muscle mass in patients with HF. However, there are no reports that have simultaneously examined different skeletal muscle mass metrics as factors in the prognosis of HF patients.

Purpose

The purpose of this study is to examine if the different skeletal muscle mass metrics are associated with the prognosis of HF patients.

Methods

We examined a total of 869 patients with HF, aged ≥20 years (73 [63, 80] years; 537 males), who were admitted to our hospital and participated in an inpatient cardiac rehabilitation program. We used skeletal muscle mass index (SMI) as measured by bioelectrical impedance analysis (BIA), mid-upper arm circumference (MUAC), arm muscle circumference (AMC), and calf circumference (CC) as metrics of skeletal muscle mass. The primary outcome was all-cause deaths, and secondary outcome was HF readmission. To investigate the association between each skeletal muscle mass metric and prognosis, patients were divided into three groups according to the tertiles of SMI, MUAC, AMC, and CC. In addition, cumulative event rates of survival curves, Gray test, and Fine & Gray test were performed to evaluate the prognostic predictive capability.

Results

Over a median follow-up period of 0.9 years (interquartile 0.4–1.9) years, a total of 80 deaths and 195 HF readmissions occurred in the patients. Cumulative event rates of survival curves and Gray test showed that there was a significant decrease in all-cause mortality and HF readmission in the high MUAC group and high AMC group compared to their respective low groups (P < 0.05). Fine & Gray test after multivariate adjustment showed significantly better prognosis in the high MUAC group and high AMC group compared to their respective low groups (All-cause mortality: high MUAC group, subdistribution hazard ratio [sHR] = 0.42, 95% confidence interval [CI] = 0.20-0.88, P < 0.05; high AMC group, sHR = 0.34, 95%CI = 0.16-0.72 P < 0.05, HF readmission: high MUAC group, sHR = 0.69, 95%CI = 0.47-1.00, P < 0.05; high AMC group, sHR = 0.63, 95%CI = 0.43-0.93, P < 0.05).

Conclusion

Patients with HF who maintained high MUAC and high AMC had a good prognosis. CC and SMI were not associated with the prognosis of HF patients. This suggests the importance of evaluating MUAC and AMC in HF patients.

Associations between kidney function and outcomes following cardiac rehabilitation in patients with heart failure

Background

Kidney dysfunction is considered one of the most prevalent comorbidities in patients with heart failure (HF). A combination of HF and kidney dysfunction is associated with peripheral muscle impairment, exercise intolerance, and poor prognosis. Conversely, cardiac rehabilitation (CR) for HF patients has been recognized to improve their clinical outcomes. However, the impact of kidney function on responses to CR in patients with HF is still unclear.

Purpose

This study aimed to investigate the associations between baseline kidney function and outcomes following CR including changes in physical function and prognosis in HF patients.

Methods

We reviewed a total of 3,727 patients who were admitted for HF treatment and underwent comprehensive CR during hospitalization. In addition to clinical characteristics, we assessed the kidney function using estimated glomerular filtration rate (eGFR) based on serum creatinine level at hospital discharge as baseline. The quadriceps strength (QS) and 6-minute walk distance (6MWD) were measured as muscle strength and functional capacity, respectively, at baseline. We also remeasured these parameter 5 months after hospital discharge in patients who participated in outpatient CR. The association between participation in outpatient CR and composite outcome of all-cause death and/or unplanned readmission were assessed using the multivariate Cox proportional hazard models in a subgroup of baseline eGFR. We also compared the changes in QS and 6MWD (ΔQS and Δ6MWD) between the eGFR stages.

Results

During the median follow-up period of 1.9 years, all-cause death/readmission occurred in 1604 (43.0%) patients, and their rate of incidence was 20.9/100 person-years. Out of studied patients, 1,585 (42.5%) patients participated in outpatient CR that was significantly associated with lower incidences of all-cause clinical events in patients with both eGFR ≥60 (adjusted hazard ratio [HR]: 0.73, 95% confidence interval [CI]: 0.60–0.89, P=0.002) and eGFR <60 (adjusted HR: 0.88, 95% CI: 0.78–0.99, P=0.045), but those with an eGFR <60 showed significant interaction between CR participation and adverse clinical events (interaction P<0.035, Figure 1). Among the outpatient CR participants, QS and 6MWD were significantly higher after 5-month CR than those at baseline (P<0.001, respectively), but the low baseline eGFR correlated with low ΔQS and Δ6MWD (trend P<0.001, respectively) even after adjustment for clinical confounding factors (Figure 2).

Conclusions

Although the outcomes following CR is affected by baseline kidney function, outpatient CR is significantly associated with the positive change in physical function and better prognosis in HF patients with low kidney function.

Funding Acknowledgement

Type of funding sources: None.

Associations of severity of liver damages with physical function and prognosis in patients with heart failure

Funding Acknowledgements

Type of funding sources: None.

Introduction

Heart failure (HF) and liver dysfunction often coexist because of complex cardiohepatic interactions, which adversely affects prognosis. However, the association between liver dysfunction and physical dysfunction, and between coexistence of both and prognosis in HF patients remains unclear.

Purpose

We evaluated the associations of severity of liver damage and physical function and prognosis in patients with HF.

Methods

The study population consisted of 895 patients with HF (mean age, 69.4 ± 14.2 years) who underwent liver function test using model for end-stage liver disease excluding international normalized ratio (MELD-XI) score and physical function test (grip strength, leg strength, gait speed, and 6-minute walking distance [6MWD]). The associations between MELD-XI score and physical function were assessed by multivariate linear regression model analysis. Moreover, we investigated the prognostic value of coexistence of liver dysfunction and physical dysfunction. The endpoint was all-cause mortality.

Results

After adjusting for covariates, MELD-XI score was independently associated with lower grip strength, leg strength, gait speed, and 6MWD (P < 0.001). In addition, hierarchical multivariate linear regression analysis revealed that adding MELD-XI scores or BNP explained additional variance in the physical function measures. The MELD-XI score added to the clinical model was significantly more predictive of physical function (grip strength, change in F: 27.105, P < 0.001; leg strength, change in F: 33.980, P < 0.001; gait speed, change in F: 22.826, P < 0.001; 6MWD, change in F: 59.193, P < 0.001) than BNP added to the clinical model. Eighty-six deaths occurred over a median follow-up period of 1.67 years (interquartile range: 0.62 – 3.04). Patients with high MELD-XI score and reduced physical function were found to have significantly higher mortality risk even after adjusting for several covariates (grip strength, hazard ratio [HR] = 3.80 [95% confidence interval (CI) = 2.04 – 7.08], P < 0.001; leg strength, HR = 4.65 [95% CI = 2.47 - 8.75], P < 0.001 and gait speed, HR = 2.49 [95% CI = 1.43 - 4.33], P = 0.001; 6MWD, HR = 5.48 [95% CI = 2.88 - 10.41], P < 0.001).

Conclusions

Liver dysfunction was correlated with reduced physical function. Moreover, the coexistence of lower physical function and liver dysfunction considerably affected prognosis in patients with HF.

Abstract Figure. Kaplan–Meier survival curves

Low skeletal muscle density combined with muscle dysfunction predicts adverse events after adult cardiovascular surgery

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): This study was supported by the Grant for Japan Society for the Promotion of Science (JSPS) KAKENHI.

Introduction

Although muscle dysfunction is widely known as a poor prognostic factor in patients with cardiovascular disease, no study has examined whether the addition of low skeletal muscle density (SMD) assessed by computed tomography (CT) to muscle dysfunction is useful.

Purpose

The present study aimed to examine whether SMDs can strengthen the predictive ability of muscle dysfunction for adverse events in patients who underwent cardiovascular surgery.

Methods

We retrospectively reviewed 853 patients (median age: 69 years, 65.1% male) aged ≥40 years who had preoperative CT for risk management purposes and muscle dysfunctions measured during postoperative cardiac rehabilitation. Muscle dysfunctions were determined from weakness (low grip strength) and slowness (slow gait speed) based on the Asia Working Group for Sarcopenia. Low SMD based on transverse abdominal CT images was defined as a mean Hounsfield unit of the psoas muscle <45. To examine the complementary prognostic value for all-cause deaths, all-cause events, and cardiovascular-related events when low SMDs were added to four patterns of muscle dysfunction (weakness only, slowness only, weakness or slowness, and weakness and slowness), the continuous net reclassification improvement (cNRI) and integrated discrimination improvement (IDI) index were calculated.

Results

For all definitions of muscle dysfunction, the addition of SMDs was shown to significantly improve the cNRI (estimates: 0.377 to 0.468 for all-cause death, 0.220 to 0.248 for all-cause events, 0.308 to 0.322 for cardiovascular-related events) and IDI (estimates: 0.005 to 0.011 for all-cause death, 0.005 to 0.010 for all-cause events, 0.009 to 0.012 for cardiovascular-related events) in all analyses. Low SMDs combined with muscle dysfunctions were associated with the highest risk of all-cause death (Figure 1: A-D). Patients with neither low SMDs nor muscle dysfunction had the lowest risk of all-cause events and cardiovascular-related events (Figure1: E-L).

Conclusion

The predictive ability of muscle dysfunction for adverse events was consistently increased by addition of SMDs in patients who underwent cardiovascular surgery. Our results suggest that when CT is performed for any clinical investigation, the addition of the organic assessment of skeletal muscle can strengthen the diagnostic accuracy of muscle wasting.

Abstract Figure 1

Correlation between respiratory muscle weakness and frailty status as risk markers for prognosis in patients with cardiovascular disease

Background

Respiratory muscle weakness (RMW), frequently observed in patients with cardiovascular disease (CVD), is documented as a predictor for exercise intolerance and poor prognosis. On the other hand, frailty is commonly associated with disease condition, leading to increased risk of morbidity and mortality. Although the developmental mechanism of RMW and frailty is partly similar, the relationship between these statuses remains unclear.

Purpose

We aimed to investigate the correlation between RMW and frailty and its impact on prognosis in patients with CVD.

Methods

We studied 771 consecutive patients (68.5±13.1 years, 256 females) who were hospitalized for CVD treatment and underwent cardiac rehabilitation during hospitalization. Patients who received thoracic surgery within the last 3 months or could not perform respiratory function test were excluded from this study. As patient characteristics, we obtained body mass index, comorbidity conditions, smoking history, blood examinations, echocardiographical variables, and lung function from medical database. The frailty status on admission was assessed using frailty score consisting of 5 items including gait speed, nutrition/shrinking, physical activity, forgetfulness, and emotions/exhaustion, and patients who had 3 items were defined as frailty. We also measured maximal inspiratory pressure (PImax) as respiratory muscle strength at hospital discharge, and RMW was defined with PImax <70% of predicted value. Primary end-point was all-cause clinical events including all-cause death and/or unplanned readmission after hospital discharge. We examined the prevalence of RMW and frailty and the correlation between these statuses. The relationships of RMW with the clinical events for each presence or absence of frailty were also investigated using multivariate Cox proportional hazard models.

Results

RMW and frailty were defined in 163 (33.5%) and 126 (28.7%) patients, respectively, and 95 patients (12.4%) among them showed an overlap of both statuses (Figure 1). Frailty was detected as a significant indicator of RMW after adjusting for confounding factors (adjusted odds ratio: 1.57, 95% CI: 1.12–2.19, P=0.009). Over the median follow-up periods of 1.2 years, all-cause clinical events occurred in 154 patients (20.0%). RMW was significantly and independently associated with increased incidence of all-cause clinical events in patients with both non-frailty (adjusted hazard ratio [HR]: 1.64, 95% CI: 1.09–2.46, P=0.017) and frailty (adjusted HR: 1.97, 95% CI: 1.14–3.42, P=0.015) even after adjusting for clinical confounding factors (Figure 2).

Conclusions

This study is the first to demonstrate that RMW correlated to frailty in patients with CVD, and 12.4% of patients had overlap status. Moreover, RMW was significantly associated with an increased risk of all-cause clinical events in patients with CVD and frailty.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Japan Society for the Promotion of Science Grant-in-Aid

Working adeptly to diagnose and treat adult ADHD

Rely on DSM-5 criteria and an appropriate rating scale to assess how an individual's inattention, hyperactivity, and impulsivity interfere with functioning in different settings.

P6331Influence of dynapenia and obesity on prognoses of elderly heart failure patients

Background

In elderly people, a decline in activities of daily living is more closely associated with low muscle strength (dynapenia) than with low muscle mass. Moreover, the combination of low muscle strength and obesity (dynapenic obesity) is associated with a higher risk of mortality than dynapenia or obesity alone, but its influence on prognosis is still unknown in elderly heart failure (HF) patients. To clarify these relationships may contribute to the development of rehabilitation programs for elderly HF patients and the improvement their prognoses in the future.

Purpose

We aimed to investigate the influence of dynapenia and obesity on prognoses of elderly HF patients.

Methods

We evaluated 1006 elderly HF patients aged ≥65 years (76.5±6.9 years, 579 males) who were admitted to our hospital and participated in an inpatient cardiac rehabilitation program. We assessed patients' characteristics, including body mass index (BMI) and handgrip strength during hospitalization. Patients with low handgrip strength (<26 kg and <18 kg in males and females, respectively) and high BMI (≥25 kg/m2) were considered to have dynapenia and obesity, respectively. Moreover, patients fulfilling the above two criteria (dynapenia, obesity) were considered to have dynapenic obesity. Patients were divided into four groups: normal, dynapenia only, obesity only, and dynapenic obesity. We compared survival rates among the four groups using the Kaplan-Meier method and log-rank test. To identify predictors for all-cause mortality, we performed Cox regression analysis.

Results

During the 8-year follow-up period, 228 patients (21.2%) died. Eight-year cumulative incidences of mortality were 35.4%, 26.0%, 62.6%, and 33.1% in the normal, obesity only, dynapenia only, and dynapenic obesity groups, respectively. Significantly lower survival rates were observed in the dynapenia only group than in the other 3 groups (log-rank: 28.893, P<0.001). Cox regression analysis, after adjusting for age and sex, showed significantly poor prognosis in the dyanapenia only group than in the other 3 groups (normal group, hazard ratio [HR] = 0.684, 95% confidence interval [CI] = 0.488–0.959, P=0.028; obesity only group, HR = 0.330, 95% CI = 0.182–0.598, P<0.001; dynapenic obesity group, HR = 0.390, 95% CI = 0.206–0.739, P=0.004).

Conclusion

Elderly HF patients with dynapenia alone had poor prognoses. Obesity may have protective effects on the survival of dynapenia patients with HF.

P2514Pupillary area predicts all-cause mortality in patients with cardiovascular disease

Background

Autonomic dysfunction is among the most important pathophysiological factors involved in the high mortality rate associated with cardiovascular disease (CVD). Autonomic function is generally evaluated by heart rate variability, which is obtained by Holter electrocardiography. However, the measurement of heart rate variability requires continuous electrocardiographic monitoring for 24 h, which is time consuming and not always feasible. The pupillary area is controlled by the autonomic nervous system; however, limited data are available regarding the utility of the pupillary area for predicting prognosis in patients with CVD.

Purpose

We aimed to investigate whether pupillary area can be used as a novel prognostic marker in patients with CVD.

Methods

We retrospectively reviewed 1342 consecutive Japanese patients hospitalized for CVD. The study was performed in accordance with the tenets of the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of our University Hospital. The pupillary area measurement was performed on both eyes at least 7 days after hospitalization for CVD using a portable videopupillography system (Iriscorder Dual C10641; Hamamatsu Photonics, Hamamatsu, Japan) consisting of a goggle-shaped measurement portion with a charge-coupled device camera and a control portion with a video monitor and microcomputer with software for data analysis. After securing the goggles on the patient's face and fully covering the patient's eyes, a 5-minute period was allowed for dark adaptation. All patients were tested once between 09:00 and 12:00 h. The primary outcome of this study was all-cause mortality, and the endpoint time was calculated as the number of days from the date of pupillary area measurement up to three years. We performed the Kaplan–Meier and log-rank tests and multivariable Cox regression analysis to evaluate the prognostic predictive capability of the pupillary area.

Results

The study population had a mean age of 65±13 years, and 69.4% of the patients were male. The median of the pupillary area was 18.5 mm2 (interquartile range: 13.3–23.4 mm2). Over a median follow-up period of 1.9 years (interquartile range: 1.0–3.0 years), a total of 114 deaths occurred in the patient population. The Kaplan–Meier and log-rank tests revealed that all-cause mortality was significantly higher in the small pupillary area group than in the large pupillary area group (P<0.0001, Figure). Furthermore, Cox regression analysis indicated that the pupillary area was an independent predictor of mortality (Hazard ratio: 0.96; 95% confidence interval: 0.93–0.98; P=0.006) even after adjusting for several preexisting prognostic factors.

Kaplan-Meire Curve

Conclusion

The pupillary area can be an independent predictor of prognosis in patients with CVD, and our observations suggest that the assessment of the pupillary area can be useful as a new noninvasive prognostic predictor in patients with CVD.

298Change in respiratory muscle strength predicts clinical events in patients with chronic heart failure

Background

Respiratory muscle weakness, frequently observed in patients with chronic heart failure (CHF), has been documented as a predictor for poor prognosis. Several studies have reported that respiratory muscle training increases respiratory muscle strength and consequently improves exercise tolerance and quality of life in these patients. However, the relationship between the change in respiratory muscle strength and prognosis is still unclear.

Purpose

We aimed to investigate whether the change in respiratory muscle strength following cardiac rehabilitation predicts the incidence of clinical events in CHF patients.

Methods

We studied 348 patients with CHF who were hospitalized because of decompensated heart failure and received 5-month cardiac rehabilitation during hospitalization and after hospital discharge. Clinical characteristics including aetiology of heart failure, comorbidity conditions, medications, blood examination and echocardiographic variables were obtained from clinical records. We also measured maximal inspiratory pressure (PImax) as respiratory muscle strength at hospital discharge and 5 months later. The change of PImax (ΔPImax) between the 5-month observation period was examined. We followed up the patients after the observation period and investigated the incidence of all-cause mortality or all-cause unplanned readmission. In statistical analysis, patients were divided into two groups based on the median value of ΔPImax. We compared the event-free survival rate between the two groups using the Kaplan-Meier method with a log-rank test. We also performed the Cox proportional hazard model to clarify whether the ΔPImax was an independent predictor for the incidence of clinical events.

Results

Over a median follow-up of 1.6 years, 121 patients (34.8%) died or readmitted, and their rate of incidence was 21.7/100 person-years. The higher ΔPImax was associated significantly with a higher rate of event-free survival (Log-rank: 8.085, P=0.004, Figure 1). In univariate Cox proportional hazard model, ΔPImax was a significant predictor for the all-cause mortality/readmission (unadjusted hazard ratio for PImax increase of 10 cmH2O: 0.842, 95% CI: 0.763 - 0.931, P=0.001). Even after adjustment for clinical confounding factors including baseline PImax, ΔPImax remained significant and independent predictor for the all-cause mortality/readmission (adjusted hazard ratio for PImax increase of 10 cmH2O: 0.862, 95% CI: 0.763 - 0.974, P=0.017, Figure 2).

Conclusion

This study is the first to demonstrate that the change in respiratory muscle strength following cardiac rehabilitation independently predicts the incidence of clinical events in patients with CHF. The increase in PImax of 10 cmH2O was associated significantly with a 14% decrease in the rate of all-cause mortality or readmission.

Acknowledgement/Funding

JSPS KAKENHI JP16K16442

P3106Atrial fibrillation is not associated with the responses to exercise training in heart failure patients with preserved ejection fraction

Background

Atrial fibrillation (AF) is known as a common arrhythmia in heart failure patients with preserved left ventricular ejection fraction (HFpEF). Several studies have reported that HFpEF patients with AF show lower exercise tolerance and poorer prognosis as compared with those with sinus rhythm (SR). On the other hand, exercise training is documented to improve peripheral muscle function and exercise tolerance in HFpEF patients. However, the relationship between AF status and outcomes due to exercise training is still unclear in these patients.

Purpose

We aimed to investigate the influence of AF on the responses to outcomes with exercise training in HFpEF patients.

Methods

We studied 426 patients with HFpEF who received 5-month cardiac rehabilitation including exercise training during hospitalization and after hospital discharge. As clinical characteristics, we obtained body mass index, disease aetiology, comorbidity conditions, blood examination and echocardiographic variables from medical records. We also measured isometric quadriceps strength (QS) and 6-minute walk distance (6MWD) as peripheral muscle strength and exercise tolerance, respectively. The QS and 6MWD were assessed at hospital discharge as the baseline and 5 months later. AF status was determined by the presence on electrocardiogram at baseline 6MWD or medical history of AF during hospitalization. In statistical analysis, we compared baseline clinical characteristics, QS and 6MWD between the rhythm status (SR group or AF group). We also examined the changes in QS and 6MWD from baseline to the 5-month observation period (ΔQS and Δ6MWD) and compared them between the 2 groups using analysis of covariance with adjustment for baseline clinical confounding factors.

Results

At baseline, 289 patients (68%) were in SR, and 111 patients (26%) had AF. The AF was associated significantly with older age (P<0.001) and lower levels of estimated glomerular filtration rate (P=0.013), QS (P<0.001) and 6MWD (P<0.001) at baseline. The QS increased significantly from 25.2±11.0 kg at baseline to 30.8±13.0 kg after 5-month cardiac rehabilitation in the SR group, and from 21.1±8.3 kg to 26.0±9.4 kg in the AF group (P<0.001, respectively). The 6MWD also increased significantly from 394.8±129.2 to 463.5±133.5 meters in the SR, and from 343.7±107.9 to 403.0±114.5 meters in the AF (P<0.001, respectively). There were no significant differences in ΔQS and Δ6MWD between the SR and AF groups even after adjustment for clinical confounding factors including baseline QS or 6MWD (Figure).

Conclusions

The AF status in HFpEF patients was associated with older age, lower peripheral muscle function and also lower exercise tolerance at baseline, but not associated with the responses to exercise training.

Acknowledgement/Funding

JSPS KAKENHI JP16K16442

Prognostic usefulness of arm circumference and nutritional screening tools in older patients with cardiovascular disease

BACKGROUND AND AIM

Arm circumference (AC) and nutritional screening tools have been shown to have prognostic capability in patients with cardiovascular disease (CVD). This study aimed to compare the prognostic predictive capabilities of AC and nutritional screening tools in older patients with CVD.

METHODS AND RESULTS

The study population consisted of 949 admitted patients ≥60 years old with CVD. Patients underwent AC measurement and nutritional screening before hospital discharge. We used the controlling nutritional status index (CONUT), the geriatric nutritional risk index (GNRI), and the prognostic nutritional index (PNI) as nutritional screening tools. The end point of the study was all-cause mortality. The mean age of the study population was 72.3 ± 7.2 years, and 68.2% of the patients were male. A total of 130 deaths occurred over a median follow-up period of 2.2 years (interquartile range, 1.1-3.8 years). After adjusting for other prognostic factors, AC (hazard ratio [HR]: 0.59; p < 0.001), CONUT (HR: 0.82; p = 0.016), GNRI (HR: 0.77; p = 0.040), and PNI (HR: 0.80; p = 0.014) were significant predictors of mortality. However, adding AC to the multivariate-adjusted model (0.739 vs. 0.714, respectively; p = 0.037), but not CONUT, GNRI, or PNI (0.724, 0.717, and 0.723 vs. 0.714; p = 0.072, p = 0.306, and p = 0.127, respectively), significantly increased the area under the curve on receiver operating characteristic curve.

CONCLUSIONS

AC, but not nutritional screening tools, plays a complementary role to preexisting prognostic factors for predicting prognosis in older patients with CVD.

Human genome meeting 2016 : Houston, TX, USA. 28 February - 2 March 2016

O1 The metabolomics approach to autism: identification of biomarkers for early detection of autism spectrum disorder A. K. Srivastava, Y. Wang, R. Huang, C. Skinner, T. Thompson, L. Pollard, T. Wood, F. Luo, R. Stevenson O2 Phenome-wide association study for smoking- and drinking-associated genes in 26,394 American women with African, Asian, European, and Hispanic descents R. Polimanti, J. Gelernter O3 Effects of prenatal environment, genotype and DNA methylation on birth weight and subsequent postnatal outcomes: findings from GUSTO, an Asian birth cohort X. Lin, I. Y. Lim, Y. Wu, A. L. Teh, L. Chen, I. M. Aris, S. E. Soh, M. T. Tint, J. L. MacIsaac, F. Yap, K. Kwek, S. M. Saw, M. S. Kobor, M. J. Meaney, K. M. Godfrey, Y. S. Chong, J. D. Holbrook, Y. S. Lee, P. D. Gluckman, N. Karnani, GUSTO study group O4 High-throughput identification of specific qt interval modulating enhancers at the SCN5A locus A. Kapoor, D. Lee, A. Chakravarti O5 Identification of extracellular matrix components inducing cancer cell migration in the supernatant of cultivated mesenchymal stem cells C. Maercker, F. Graf, M. Boutros O6 Single cell allele specific expression (ASE) IN T21 and common trisomies: a novel approach to understand DOWN syndrome and other aneuploidies G. Stamoulis, F. Santoni, P. Makrythanasis, A. Letourneau, M. Guipponi, N. Panousis, M. Garieri, P. Ribaux, E. Falconnet, C. Borel, S. E. Antonarakis O7 Role of microRNA in LCL to IPSC reprogramming S. Kumar, J. Curran, J. Blangero O8 Multiple enhancer variants disrupt gene regulatory network in Hirschsprung disease S. Chatterjee, A. Kapoor, J. Akiyama, D. Auer, C. Berrios, L. Pennacchio, A. Chakravarti O9 Metabolomic profiling for the diagnosis of neurometabolic disorders T. R. Donti, G. Cappuccio, M. Miller, P. Atwal, A. Kennedy, A. Cardon, C. Bacino, L. Emrick, J. Hertecant, F. Baumer, B. Porter, M. Bainbridge, P. Bonnen, B. Graham, R. Sutton, Q. Sun, S. 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Fogelman O19 DDIT4 gene expression as a prognostic marker in several malignant tumors L. Bravo, W. Fajardo, H. Gomez, C. Castaneda, C. Rolfo, J. A. Pinto O20 Spatial organization of the genome and genomic alterations in human cancers K. C. Akdemir, L. Chin, A. Futreal, ICGC PCAWG Structural Alterations Group O21 Landscape of targeted therapies in solid tumors S. Patterson, C. Statz, S. Mockus O22 Genomic analysis reveals novel drivers and progression pathways in skin basal cell carcinoma S. N. Nikolaev, X. I. Bonilla, L. Parmentier, B. King, F. Bezrukov, G. Kaya, V. Zoete, V. Seplyarskiy, H. Sharpe, T. McKee, A. Letourneau, P. Ribaux, K. Popadin, N. Basset-Seguin, R. Ben Chaabene, F. Santoni, M. Andrianova, M. Guipponi, M. Garieri, C. Verdan, K. Grosdemange, O. Sumara, M. Eilers, I. Aifantis, O. Michielin, F. de Sauvage, S. Antonarakis O23 Identification of differential biomarkers of hepatocellular carcinoma and cholangiocarcinoma via transcriptome microarray meta-analysis S. Likhitrattanapisal O24 Clinical validity and actionability of multigene tests for hereditary cancers in a large multi-center study S. Lincoln, A. Kurian, A. Desmond, S. Yang, Y. Kobayashi, J. Ford, L. Ellisen O25 Correlation with tumor ploidy status is essential for correct determination of genome-wide copy number changes by SNP array T. L. Peters, K. R. Alvarez, E. F. Hollingsworth, D. H. Lopez-Terrada O26 Nanochannel based next-generation mapping for interrogation of clinically relevant structural variation A. Hastie, Z. Dzakula, A. W. Pang, E. T. Lam, T. Anantharaman, M. Saghbini, H. Cao, BioNano Genomics O27 Mutation spectrum in a pulmonary arterial hypertension (PAH) cohort and identification of associated truncating mutations in TBX4 C. Gonzaga-Jauregui, L. Ma, A. King, E. Berman Rosenzweig, U. Krishnan, J. G. Reid, J. D. Overton, F. Dewey, W. K. Chung O28 NORTH CAROLINA macular dystrophy (MCDR1): mutations found affecting PRDM13 K. Small, A. DeLuca, F. Cremers, R. A. Lewis, V. Puech, B. Bakall, R. Silva-Garcia, K. Rohrschneider, M. Leys, F. S. Shaya, E. Stone O29 PhenoDB and genematcher, solving unsolved whole exome sequencing data N. L. Sobreira, F. Schiettecatte, H. Ling, E. Pugh, D. Witmer, K. Hetrick, P. Zhang, K. Doheny, D. Valle, A. Hamosh O30 Baylor-Johns Hopkins Center for Mendelian genomics: a four year review S. N. Jhangiani, Z. Coban Akdemir, M. N. Bainbridge, W. Charng, W. Wiszniewski, T. Gambin, E. Karaca, Y. Bayram, M. K. Eldomery, J. Posey, H. Doddapaneni, J. Hu, V. R. Sutton, D. M. Muzny, E. A. Boerwinkle, D. Valle, J. R. Lupski, R. A. Gibbs O31 Using read overlap assembly to accurately identify structural genetic differences in an ashkenazi jewish trio S. Shekar, W. Salerno, A. English, A. Mangubat, J. Bruestle O32 Legal interoperability: a sine qua non for international data sharing A. Thorogood, B. M. Knoppers, Global Alliance for Genomics and Health - Regulatory and Ethics Working Group O33 High throughput screening platform of competent sineups: that can enhance translation activities of therapeutic target H. Takahashi, K. R. Nitta, A. Kozhuharova, A. M. Suzuki, H. Sharma, D. Cotella, C. Santoro, S. Zucchelli, S. Gustincich, P. Carninci O34 The undiagnosed diseases network international (UDNI): clinical and laboratory research to meet patient needs J. J. Mulvihill, G. Baynam, W. Gahl, S. C. Groft, K. Kosaki, P. Lasko, B. Melegh, D. Taruscio O36 Performance of computational algorithms in pathogenicity predictions for activating variants in oncogenes versus loss of function mutations in tumor suppressor genes R. Ghosh, S. Plon O37 Identification and electronic health record incorporation of clinically actionable pharmacogenomic variants using prospective targeted sequencing S. Scherer, X. Qin, R. Sanghvi, K. Walker, T. Chiang, D. Muzny, L. Wang, J. Black, E. Boerwinkle, R. Weinshilboum, R. Gibbs O38 Melanoma reprogramming state correlates with response to CTLA-4 blockade in metastatic melanoma T. Karpinets, T. Calderone, K. Wani, X. Yu, C. Creasy, C. Haymaker, M. Forget, V. Nanda, J. Roszik, J. Wargo, L. Haydu, X. Song, A. Lazar, J. Gershenwald, M. Davies, C. Bernatchez, J. Zhang, A. Futreal, S. Woodman O39 Data-driven refinement of complex disease classification from integration of heterogeneous functional genomics data in GeneWeaver E. J. Chesler, T. Reynolds, J. A. Bubier, C. Phillips, M. A. Langston, E. J. Baker O40 A general statistic framework for genome-based disease risk prediction M. Xiong, L. Ma, N. Lin, C. Amos O41 Integrative large-scale causal network analysis of imaging and genomic data and its application in schizophrenia studies N. Lin, P. Wang, Y. Zhu, J. Zhao, V. Calhoun, M. Xiong O42 Big data and NGS data analysis: the cloud to the rescue O. Dobretsberger, M. Egger, F. Leimgruber O43 Cpipe: a convergent clinical exome pipeline specialised for targeted sequencing S. Sadedin, A. Oshlack, Melbourne Genomics Health Alliance O44 A Bayesian classification of biomedical images using feature extraction from deep neural networks implemented on lung cancer data V. A. A. Antonio, N. Ono, Clark Kendrick C. Go O45 MAV-SEQ: an interactive platform for the Management, Analysis, and Visualization of sequence data Z. Ahmed, M. Bolisetty, S. Zeeshan, E. Anguiano, D. Ucar O47 Allele specific enhancer in EPAS1 intronic regions may contribute to high altitude adaptation of Tibetans C. Zeng, J. Shao O48 Nanochannel based next-generation mapping for structural variation detection and comparison in trios and populations H. Cao, A. Hastie, A. W. Pang, E. T. Lam, T. Liang, K. Pham, M. Saghbini, Z. Dzakula O49 Archaic introgression in indigenous populations of Malaysia revealed by whole genome sequencing Y. Chee-Wei, L. Dongsheng, W. Lai-Ping, D. Lian, R. O. Twee Hee, Y. Yunus, F. Aghakhanian, S. S. Mokhtar, C. V. Lok-Yung, J. Bhak, M. Phipps, X. Shuhua, T. Yik-Ying, V. Kumar, H. Boon-Peng O50 Breast and ovarian cancer prevention: is it time for population-based mutation screening of high risk genes? I. Campbell, M.-A. Young, P. James, Lifepool O53 Comprehensive coverage from low DNA input using novel NGS library preparation methods for WGS and WGBS C. Schumacher, S. Sandhu, T. Harkins, V. Makarov O54 Methods for large scale construction of robust PCR-free libraries for sequencing on Illumina HiSeqX platform H. DoddapaneniR. Glenn, Z. Momin, B. Dilrukshi, H. Chao, Q. Meng, B. Gudenkauf, R. Kshitij, J. Jayaseelan, C. Nessner, S. Lee, K. Blankenberg, L. Lewis, J. Hu, Y. Han, H. Dinh, S. Jireh, K. Walker, E. Boerwinkle, D. Muzny, R. Gibbs O55 Rapid capture methods for clinical sequencing J. Hu, K. Walker, C. Buhay, X. Liu, Q. Wang, R. Sanghvi, H. Doddapaneni, Y. Ding, N. Veeraraghavan, Y. Yang, E. Boerwinkle, A. L. Beaudet, C. M. Eng, D. M. Muzny, R. A. Gibbs O56 A diploid personal human genome model for better genomes from diverse sequence data K. C. C. Worley, Y. Liu, D. S. T. Hughes, S. C. Murali, R. A. Harris, A. C. English, X. Qin, O. A. Hampton, P. Larsen, C. Beck, Y. Han, M. Wang, H. Doddapaneni, C. L. Kovar, W. J. Salerno, A. Yoder, S. Richards, J. Rogers, J. R. Lupski, D. M. Muzny, R. A. Gibbs O57 Development of PacBio long range capture for detection of pathogenic structural variants Q. Meng, M. Bainbridge, M. Wang, H. Doddapaneni, Y. Han, D. Muzny, R. Gibbs O58 Rhesus macaques exhibit more non-synonymous variation but greater impact of purifying selection than humans R. A. Harris, M. Raveenedran, C. Xue, M. Dahdouli, L. Cox, G. Fan, B. Ferguson, J. Hovarth, Z. Johnson, S. Kanthaswamy, M. Kubisch, M. Platt, D. Smith, E. Vallender, R. Wiseman, X. Liu, J. Below, D. Muzny, R. Gibbs, F. Yu, J. Rogers O59 Assessing RNA structure disruption induced by single-nucleotide variation J. Lin, Y. Zhang, Z. Ouyang P1 A meta-analysis of genome-wide association studies of mitochondrial dna copy number A. Moore, Z. Wang, J. Hofmann, M. Purdue, R. Stolzenberg-Solomon, S. Weinstein, D. Albanes, C.-S. Liu, W.-L. Cheng, T.-T. Lin, Q. Lan, N. Rothman, S. Berndt P2 Missense polymorphic genetic combinations underlying down syndrome susceptibility E. S. Chen P4 The evaluation of alteration of ELAM-1 expression in the endometriosis patients H. Bahrami, A. Khoshzaban, S. Heidari Keshal P5 Obesity and the incidence of apolipoprotein E polymorphisms in an assorted population from Saudi Arabia population K. K. R. Alharbi P6 Genome-associated personalized antithrombotical therapy for patients with high risk of thrombosis and bleeding M. Zhalbinova, A. Akilzhanova, S. Rakhimova, M. Bekbosynova, S. Myrzakhmetova P7 Frequency of Xmn1 polymorphism among sickle cell carrier cases in UAE population M. 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Abduljaleel P13 Digital expression profiling of Purkinje neurons and dendrites in different subcellular compartments A. Kratz, P. Beguin, S. Poulain, M. Kaneko, C. Takahiko, A. Matsunaga, S. Kato, A. M. Suzuki, N. Bertin, T. Lassmann, R. Vigot, P. Carninci, C. Plessy, T. Launey P14 The evolution of imperfection and imperfection of evolution: the functional and functionless fractions of the human genome D. Graur P16 Species-independent identification of known and novel recurrent genomic entities in multiple cancer patients J. Friis-Nielsen, J. M. Izarzugaza, S. Brunak P18 Discovery of active gene modules which are densely conserved across multiple cancer types reveal their prognostic power and mutually exclusive mutation patterns B. S. Soibam P19 Whole exome sequencing of dysplastic leukoplakia tissue indicates sequential accumulation of somatic mutations from oral precancer to cancer D. Das, N. Biswas, S. Das, S. Sarkar, A. Maitra, C. Panda, P. Majumder P21 Epigenetic mechanisms of carcinogensis by hereditary breast cancer genes J. J. Gruber, N. Jaeger, M. Snyder P22 RNA direct: a novel RNA enrichment strategy applied to transcripts associated with solid tumors K. Patel, S. Bowman, T. Davis, D. Kraushaar, A. Emerman, S. Russello, N. Henig, C. Hendrickson P23 RNA sequencing identifies gene mutations for neuroblastoma K. Zhang P24 Participation of SFRP1 in the modulation of TMPRSS2-ERG fusion gene in prostate cancer cell lines M. Rodriguez-Dorantes, C. D. Cruz-Hernandez, C. D. P. Garcia-Tobilla, S. Solorzano-Rosales P25 Targeted Methylation Sequencing of Prostate Cancer N. Jäger, J. Chen, R. Haile, M. Hitchins, J. D. Brooks, M. Snyder P26 Mutant TPMT alleles in children with acute lymphoblastic leukemia from México City and Yucatán, Mexico S. Jiménez-Morales, M. Ramírez, J. Nuñez, V. Bekker, Y. Leal, E. Jiménez, A. Medina, A. Hidalgo, J. Mejía P28 Genetic modifiers of Alström syndrome J. Naggert, G. B. Collin, K. DeMauro, R. Hanusek, P. M. Nishina P31 Association of genomic variants with the occurrence of angiotensin-converting-enzyme inhibitor (ACEI)-induced coughing among Filipinos E. M. Cutiongco De La Paz, R. Sy, J. Nevado, P. Reganit, L. Santos, J. D. Magno, F. E. Punzalan , D. Ona , E. Llanes, R. L. Santos-Cortes , R. Tiongco, J. Aherrera, L. Abrahan, P. Pagauitan-Alan; Philippine Cardiogenomics Study Group P32 The use of “humanized” mouse models to validate disease association of a de novo GARS variant and to test a novel gene therapy strategy for Charcot-Marie-Tooth disease type 2D K. H. Morelli, J. S. Domire, N. Pyne, S. Harper, R. Burgess P34 Molecular regulation of chondrogenic human induced pluripotent stem cells M. A. Gari, A. Dallol, H. Alsehli, A. Gari, M. Gari, A. Abuzenadah P35 Molecular profiling of hematologic malignancies: implementation of a variant assessment algorithm for next generation sequencing data analysis and clinical reporting M. Thomas, M. Sukhai, S. Garg, M. Misyura, T. Zhang, A. Schuh, T. Stockley, S. Kamel-Reid P36 Accessing genomic evidence for clinical variants at NCBI S. Sherry, C. Xiao, D. Slotta, K. Rodarmer, M. Feolo, M. Kimelman, G. Godynskiy, C. O’Sullivan, E. Yaschenko P37 NGS-SWIFT: a cloud-based variant analysis framework using control-accessed sequencing data from DBGAP/SRA C. Xiao, E. Yaschenko, S. Sherry P38 Computational assessment of drug induced hepatotoxicity through gene expression profiling C. Rangel-Escareño, H. Rueda-Zarate P40 Flowr: robust and efficient pipelines using a simple language-agnostic approach;ultraseq; fast modular pipeline for somatic variation calling using flowr S. Seth, S. Amin, X. Song, X. Mao, H. Sun, R. G. Verhaak, A. Futreal, J. Zhang P41 Applying “Big data” technologies to the rapid analysis of heterogenous large cohort data S. J. Whiite, T. Chiang, A. English, J. Farek, Z. Kahn, W. Salerno, N. Veeraraghavan, E. Boerwinkle, R. Gibbs P42 FANTOM5 web resource for the large-scale genome-wide transcription start site activity profiles of wide-range of mammalian cells T. Kasukawa, M. Lizio, J. Harshbarger, S. Hisashi, J. Severin, A. Imad, S. Sahin, T. C. Freeman, K. Baillie, A. Sandelin, P. Carninci, A. R. R. Forrest, H. Kawaji, The FANTOM Consortium P43 Rapid and scalable typing of structural variants for disease cohorts W. Salerno, A. English, S. N. Shekar, A. Mangubat, J. Bruestle, E. Boerwinkle, R. A. Gibbs P44 Polymorphism of glutathione S-transferases and sulphotransferases genes in an Arab population A. H. Salem, M. Ali, A. Ibrahim, M. Ibrahim P46 Genetic divergence of CYP3A5*3 pharmacogenomic marker for native and admixed Mexican populations J. C. Fernandez-Lopez, V. Bonifaz-Peña, C. Rangel-Escareño, A. Hidalgo-Miranda, A. V. Contreras P47 Whole exome sequence meta-analysis of 13 white blood cell, red blood cell, and platelet traits L. Polfus, CHARGE and NHLBI Exome Sequence Project Working Groups P48 Association of adipoq gene with type 2 diabetes and related phenotypes in african american men and women: The jackson heart study S. Davis, R. Xu, S. Gebeab, P Riestra, A Gaye, R. Khan, J. Wilson, A. Bidulescu P49 Common variants in casr gene are associated with serum calcium levels in koreans S. H. Jung, N. Vinayagamoorthy, S. H. Yim, Y. J. Chung P50 Inference of multiple-wave population admixture by modeling decay of linkage disequilibrium with multiple exponential functions Y. Zhou, S. Xu P51 A Bayesian framework for generalized linear mixed models in genome-wide association studies X. Wang, V. Philip, G. Carter P52 Targeted sequencing approach for the identification of the genetic causes of hereditary hearing impairment A. A. Abuzenadah, M. Gari, R. Turki, A. Dallol P53 Identification of enhancer sequences by ATAC-seq open chromatin profiling A. Uyar, A. Kaygun, S. Zaman, E. Marquez, J. George, D. Ucar P54 Direct enrichment for the rapid preparation of targeted NGS libraries C. L. Hendrickson, A. Emerman, D. Kraushaar, S. Bowman, N. Henig, T. Davis, S. Russello, K. Patel P56 Performance of the Agilent D5000 and High Sensitivity D5000 ScreenTape assays for the Agilent 4200 Tapestation System R. Nitsche, L. Prieto-Lafuente P57 ClinVar: a multi-source archive for variant interpretation M. Landrum, J. Lee, W. Rubinstein, D. Maglott P59 Association of functional variants and protein physical interactions of human MUTY homolog linked with familial adenomatous polyposis and colorectal cancer syndrome Z. Abduljaleel, W. Khan, F. A. Al-Allaf, M. Athar , M. M. Taher, N. Shahzad P60 Modification of the microbiom constitution in the gut using chicken IgY antibodies resulted in a reduction of acute graft-versus-host disease after experimental bone marrow transplantation A. Bouazzaoui, E. Huber, A. Dan, F. A. Al-Allaf, W. Herr, G. Sprotte, J. Köstler, A. Hiergeist, A. Gessner, R. Andreesen, E. Holler P61 Compound heterozygous mutation in the LDLR gene in Saudi patients suffering severe hypercholesterolemia F. Al-Allaf, A. Alashwal, Z. Abduljaleel, M. Taher, A. Bouazzaoui, H. Abalkhail, A. Al-Allaf, R. Bamardadh, M. Athar

Three cases of suspected sugammadex-induced hypersensitivity reactions

Neuromuscular blocking agents have been implicated in 60-70% of anaphylactic events associated with anaesthesia. We report two cases of probable hypersensitivity reaction to sugammadex and an additional suspected but less supported case of possible immune-mediated reaction or other adverse reaction. The patients were given a bolus of sugammadex 100 mg immediately before extubation. In all three patients, a possible allergic reaction was suspected within 4 min of sugammadex administration, but with different degrees of severity. Skin testing was positive in two of these patients. Hypersensitivity to sugammadex unaccompanied by cardiovascular or respiratory symptoms might be missed during the course of anaesthesia. Careful monitoring for possible allergic responses is required in patients who have received sugammadex.

Response of an aerosol mass spectrometer to organonitrates and organosulfates and implications for atmospheric chemistry

Organonitrates (ON) are important products of gas-phase oxidation of volatile organic compounds in the troposphere; some models predict, and laboratory studies show, the formation of large, multifunctional ON with vapor pressures low enough to partition to the particle phase. Organosulfates (OS) have also been recently detected in secondary organic aerosol. Despite their potential importance, ON and OS remain a nearly unexplored aspect of atmospheric chemistry because few studies have quantified particulate ON or OS in ambient air. We report the response of a high-resolution time-of-flight aerosol mass spectrometer (AMS) to aerosol ON and OS standards and mixtures. We quantify the potentially substantial underestimation of organic aerosol O/C, commonly used as a metric for aging, and N/C. Most of the ON-nitrogen appears as NO(x)+ ions in the AMS, which are typically dominated by inorganic nitrate. Minor organonitrogen ions are observed although their identity and intensity vary between standards. We evaluate the potential for using NO(x)+ fragment ratios, organonitrogen ions, HNO(3)+ ions, the ammonium balance of the nominally inorganic ions, and comparison to ion-chromatography instruments to constrain the concentrations of ON for ambient datasets, and apply these techniques to a field study in Riverside, CA. OS manifests as separate organic and sulfate components in the AMS with minimal organosulfur fragments and little difference in fragmentation from inorganic sulfate. The low thermal stability of ON and OS likely causes similar detection difficulties for other aerosol mass spectrometers using vaporization and/or ionization techniques with similar or larger energy, which has likely led to an underappreciation of these species.

Prophylaxis versus episodic treatment to prevent joint disease in boys with severe hemophilia

BACKGROUND

Effective ways to prevent arthropathy in severe hemophilia are unknown.

METHODS

We randomly assigned young boys with severe hemophilia A to regular infusions of recombinant factor VIII (prophylaxis) or to an enhanced episodic infusion schedule of at least three doses totaling a minimum of 80 IU of factor VIII per kilogram of body weight at the time of a joint hemorrhage. The primary outcome was the incidence of bone or cartilage damage as detected in index joints (ankles, knees, and elbows) by radiography or magnetic resonance imaging (MRI).

RESULTS

Sixty-five boys younger than 30 months of age were randomly assigned to prophylaxis (32 boys) or enhanced episodic therapy (33 boys). When the boys reached 6 years of age, 93% of those in the prophylaxis group and 55% of those in the episodic-therapy group were considered to have normal index-joint structure on MRI (P=0.006). The relative risk of MRI-detected joint damage with episodic therapy as compared with prophylaxis was 6.1 (95% confidence interval, 1.5 to 24.4). The mean annual numbers of joint and total hemorrhages were higher at study exit in the episodic-therapy group than in the prophylaxis group (P<0.001 for both comparisons). High titers of inhibitors of factor VIII developed in two boys who received prophylaxis; three boys in the episodic-therapy group had a life-threatening hemorrhage. Hospitalizations and infections associated with central-catheter placement did not differ significantly between the two groups.

CONCLUSIONS

Prophylaxis with recombinant factor VIII can prevent joint damage and decrease the frequency of joint and other hemorrhages in young boys with severe hemophilia A. (ClinicalTrials.gov number, NCT00207597 [ClinicalTrials.gov].).