Correlation Analysis Between Echinocytosis Stages and Blood Viscosity During Oxygenator Perfusion: An In Vitro Study

The study aimed to investigate the effect of red blood cell (RBC) morphology on oxygenator perfusion, focusing on stages of echinocytosis and their correlation with blood viscosity. A test circuit with an oxygenator and human RBC mixtures was used to induce changes in RBC shape by increasing sodium salicylate concentrations (0, 10, 20, 30, 60, and 120 mmol/L), while hematocrit, blood temperature, and anticoagulation were maintained. Blood viscosity was measured using a continuous blood viscosity monitoring system based on pressure-flow characteristics. Under a scanning electron microscope, the percentages of discocytes, echinocytes I-III, spheroechinocytes, and spherocytes were determined from approximately 400 cells per RBC sample. Early echinocytes, mainly discocytes and echinocytes I and II in the range of 0-30 mmol/L were predominant, resulting in a gradual increase in blood viscosity from 1.78 ± 0.12 to 1.94 ± 0.12 mPa s. At 60 mmol/L spherocytes emerged, and at 120 mmol/L, spheroidal RBCs constituted 50% of the population, and blood viscosity sharply rose to 2.50 ± 0.15 mPa s, indicating a 40% overall increase. In conclusion, the presence of spherocytes significantly increases blood viscosity, which may affect oxygenator perfusion.

Intraoperative hypertensive crisis in a dog with functional paraganglioma of the gall bladder

A 15-year-old spayed female mongrel presented with anorexia and an abdominal mass. The mass originated from the gall bladder and was surgically resected along with divisionectomy of the central hepatic division. Paroxysmal hypertension and tachycardia were noted during manipulation of the mass. Following resection, arterial blood pressure decreased significantly. Histopathological analysis confirmed a diagnosis of neuroendocrine neoplasm. Immunohistochemical staining for synaptophysin and chromogranin A yielded diffuse and strong positive results, while gastrin was positive in only 10% of the cells. The preoperative elevated concentrations of catecholamine in the urinalysis showed a marked decrease after surgery. Based on these findings, the tumour was diagnosed as a functional paraganglioma of the gall bladder. The patient has undergone regular thoracic radiographs and ultrasound examinations and, until 431 days after surgery, has shown no signs of metastases or recurrences. Based on our literature search, we report the first case of functional paraganglioma of the gall bladder in a dog.

Clinical relationship between histopathological necrotic/partial necrotic findings and disease condition of gallbladder mucoceles in dogs

Gallbladder mucocele (GM) is a common extrahepatic biliary disease recognized in dogs and is defined as the expansion and extension of the gallbladder by an accumulation of semi-solid bile or bile acid. Histopathological diagnosis of necrotizing cholecystitis and transmural coagulative necrosis of the gallbladder wall shows poor prognosis. Conversely, histopathological diagnosis with partial necrotic findings is often achieved. We hypothesized that histopathological partial necrosis of the gallbladder wall is the primary lesion of necrotic cholecystitis or transmural ischemic necrosis. Therefore, we investigated the relationship between histopathological necrosis/ partial necrosis findings and their clinical conditions. We retrospectively analyzed 55 dogs diagnosed with GM that had undergone cholecystectomy at the Yamaguchi University Animal Medical Center. The group with histopathological necrosis/partial necrosis of the gallbladder wall showed elevated levels of preoperative white blood cells, alanine transaminase, alkaline phosphatase, γ-glutamyltransferase, total bilirubin, and C-reactive protein compared to the non-necrotic group. Partial necrosis of the gallbladder wall may affect the progression of the disease and hematological abnormalities. Additionally, all death cases until 2 weeks were included in the histopathological necrosis/partial necrosis group. In this study, we found that poor prognosis factors were associated with partial necrosis of the gallbladder wall. Furthermore, these cases of partial necrosis showed elevated levels of blood test parameters. These results suggest that necrosis of the gallbladder wall is associated with poor prognosis and poor pathophysiological conditions.

Association between blood pressure classification using the 2017 American College of Cardiology/American Heart Association blood pressure guideline and hypertensive retinopathy

Purpose

We aimed to explore the association of blood pressure (BP) classification using the 2017 American College of Cardiology/ American Heart Association Guideline and the prevalence of hypertensive retinopathy using a nationwide epidemiological database.

Methods

This study is a retrospective observational cross-sectional analysis using the health claims database of the JMDC between 2005 and 2020. We analyzed 280,599 participants who did not take anti-hypertensive medications. Each participant was categorized as having normal BP (systolic BP [SBP] <120 mm Hg and diastolic BP [DBP] <80 mm Hg; n=159,524); elevated BP (SBP 120–129 mm Hg and DBP <80 mm Hg; n=35,603); stage 1 hypertension (SBP 130–139 mm Hg or DBP 80–89 mm Hg; n=54,795); or stage 2 hypertension (SBP ≥140 mm Hg or DBP ≥90 mm Hg; n=30,677). Retinal photography at health check-up was classified as normal, grade 1, grade 2, grade 3, or grade 4 according to the Keith-Wagener-Barker system.

Results

Median (interquartile range) age was 46 (40–53) years, and 50.4% were men. Hypertensive retinopathy which was defined as ≥ Keith-Wagener-Barker system grade 1, was observed in 16,836 participants (6.0%). Multivariable logistic regression analysis showed that, compared with normal BP, elevated BP (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.23–1.38), stage 1 hypertension (OR 1.71, 95% CI 1.64–1.79), and stage 2 hypertension (OR 4.10, 95% CI 3.93–4.28) were associated with higher prevalence of hypertensive retinopathy. Even among 92,121 participants without obesity, high waist circumference, diabetes mellitus, dyslipidemia, cigarette smoking, and alcohol drinking, multivariable logistic regression analysis showed that, compared with normal BP, elevated BP (odds ratio 1.34, 95% CI 1.19–1.51), stage 1 hypertension (OR 1.79, 95% CI 1.61–1.98), and stage 2 hypertension (OR 4.42, 95% CI 4.00–4.92) were associated with higher prevalence of hypertensive retinopathy. The association between BP category and hypertensive retinopathy was observed in all subgroups stratified by age or sex.

Conclusion

Our investigation showed that the prevalence of hypertensive retinopathy increased with the blood pressure category, suggesting that atherosclerotic change could start even in elevated BP and stage 1 hypertension.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by grants from the Ministry of Health, Labour and Welfare, Japan (19AA2007 and H30-Policy-Designated-004) and the Ministry of Education, Culture, Sports, Science and Technology, Japan (17H04141).

Association between surgical treatment and in-hospital mortality in patients with infective endocarditis stratified by NYHA classification: a nationwide retrospective study in Japan

Background

Heart failure (HF) is one of the major complications of infective endocarditis (IE). The ESC guideline described that surgical treatment should be performed for the patients with IE complicated with HF. However, decision making of surgical indication in real-world clinical setting is not easy for patients with IE concomitant with HF due to complicated conditions, and the clinical benefit of surgical intervention for IE and HF is unclear.

Purpose

We sought to uncover the association between surgical treatment and in-hospital mortality among the patients admitted for community-acquired IE respectively according to the severity of HF symptoms (NYHA class I to IV).

Methods

We studied 3,403 patients diagnosed as IE (mean age 65.9 years, 61.6% males) with records of baseline NYHA classification (I to IV) who survived for more than 2 days, using the Diagnosis Procedure Combination database, a nationwide inpatient database in Japan. Patients were classified into four groups: 919 patients (27.0%) in NYHA I, 1,007 patients (29.6%) in NYHA II, 767 patients (22.5%) in NYHA III, and 710 patients (20.9%) in NYHA IV. A multivariable logistic regression model adjusted for age, gender, Barthel Index, Charlson Comorbidity Index, and usage of inotropic therapy at admission was performed to evaluate the association between the surgical treatment and in-hospital mortality.

Results

Patients with higher NYHA classification were significantly older and were more likely to be female than those with lower NYHA classification. At admission, patients with higher NYHA classification had lower baseline activities and higher comorbidities, and also had more complications including stroke, shock and disseminated intravascular coagulation than those with lower NYHA classification. In-hospital mortality was seen in 406 patients (11.9%) in the entire cohort. The mortality rate significantly increased with the NYHA class (NYHA I, 3.6%; NYHA II, 8.4%; NYHA III, 11.9%; NYHA IV, 27.9%: p<0.001). According to the multivariable logistic regression analysis, surgical treatment was independently associated with lower in-hospital mortality (Odds ratio 0.395, 95% Confidence Interval 0.297–0.526; p<0.001). A fragmentated analysis in each NYHA classification showed that the survival benefit of surgical intervention was pronounced in patients with higher NYHA class (Figure). The limitation of our study was including the potential unmeasured confounders, which lead to overestimate the relationship between the surgical treatment and in-hospital mortality even after excluding the critically ill patients who died within 2 days and adjusting for the measured confounders.

Conclusion

Surgical treatment was associated with lower in-hospital mortality among the patients with IE complicated with HF, particularly among those with more advanced HF status. Our study implies that surgical treatment might be beneficial for the patients with advanced HF.

Funding Acknowledgement

Type of funding source: None

Geographic variation in the outcome of patients hospitalized for heart failure: analysis of a nationwide inpatient database

Background

The prevalence of heart failure (HF) is increasing in developed countries. Considering the significant socioeconomic burden of HF, nationwide actions against HF are indispensable. To that end, relevant information on regional variations among HF patients are required.

Purpose

We aimed to explore the geographic variations in the characteristics and outcomes of hospitalized HF patients using a nationwide inpatient database.

Methods and results

Using the Diagnosis Procedure Combination database which is a nationwide inpatient database in Japan, we carried out a comprehensive analysis of 447,818 hospitalized patients with HF (median age 81 years, 238,192 men) who were admitted between January 2010 and March 2018 in Japan. We divided the study population into seven geographical regions based on the location of the admitted hospital. Background characteristics were almost similar among all seven regions. The implementation rates of intubation, hemodialysis, inotropic agent, and advanced circulatory supports including intra-aortic balloon pumping and extracorporeal membrane oxygenation varied among the seven regions. There was a significant difference in the length of hospital stay and the in-hospital mortality among the seven regions. The multivariable logistic regression analysis including baseline clinical charasteristics and medication administered within two days after hospital admission fitted with a generalized estimation equation for in-hospital mortality showed that there was still a significant difference in the in-hospital mortality among the seven regions (Table).

Conclusion

The analysis of a nationwide inpatient database showed that geographical variations existed regarding the outcomes of patients hospitalized for HF. This suggests the necessity of further efforts to establish a standardized medical care system in this era of HF pandemic.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Grants from the Ministry of Health, Labour and Welfare, Japan (19AA2007 and H30-Policy-Designated-004) and the Ministry of Education, Culture, Sports, Science and Technology, Japan (17H04141)

Systematic Evaluation of KCNQ1 variant using ACMG/AMP Guidelines and Risk Stratification in Long QT Syndrome Type 1

Background

Mutation/variant-site specific risk stratification in long-QT syndrome type 1 (LQT1) has been well investigated, but it is still challenging to adopt current enormous genomic information to clinical aspects caused by each mutation/variant. We assessed a novel variant-specific risk stratification in LQT1 patients.

Methods

We classified a pathogenicity of 142 KCNQ1 variants among 927 LQT1 patients (536 probands and 391 family members) based on the American College of Medical Genetics and Genomics (ACMG) and Association for Molecular Pathology (AMP) guidelines and evaluated whether the ACMG/AMP-based classification was associated with arrhythmic risk in LQT1 patients.

Results

Among 142 KCNQ1 variants, 60 (42.3%), 58 (40.8%), and 24 (16.9%) variants were classified into pathogenic (P), likely pathogenic (LP), and variant of unknown significance (VUS), respectively. The ACMG/AMP guideline-based classification was significantly associated with syncopal events (particularly those during exercise) and LQT risk score (Schwartz score) in overall population. On the other hand, arrhythmic risk was completely different between probands and families even in the same variants. The baseline QTc interval and variant location could stratify the risk in family members but not in probands, however, the ACMG/AMP-based KCNQ1 variant classification stratified the risk in LQT1 probands as well as family members. Multivariate analysis showed that proband (HR=2.52; 95% CI: 1.93–3.30; p<0.0001), longer QTc interval (≥500ms) (HR=1.41; 95% CI: 1.11–1.79; p<0.0001), variants at membrane spanning (MS) (vs. those at N/C terminus) (HR=1.40; 95% CI: 1.07–1.85; p=0.02), C-loop (vs. N/C terminus) (HR=1.58; 95% CI: 1.11–2.24; p=0.01), and P variants [(vs. LP) (HR=1.71; 95% CI: 1.33–2.23; p<0.0001), (vs. VUS) (HR=1.96; 95% CI: 1.19–3.46; p=0.007)] were significantly associated with syncopal events. A clinical score (0–4) based on the proband, QTc (≥500ms), variant location (MS or C-loop) and P variant by the ACMG/AMP guidelines allowed identification of patients more likely to have arrhythmic events (Figure A and B).

Conclusion

Comprehensive evaluation of clinical findings and pathogenicity of KCNQ1 variants based on the ACMG/AMP-based evaluation may stratify arrhythmic risk of congenital long-QT syndrome type 1.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Health Science Research Grant from the Ministry of Health,Labor and Welfare of Japan for Clinical Research on Measures for Intractable Diseases (H24-033, H26-040, H27-032) and a research grant from the Japan Agency for Medical Research and Development (AMED) (15km0305015h0101, 16ek0210073h0001)

Cardiovascular health metrics of 122,788 couples: analysis of a nationwide epidemiological database

Introduction

The American Heart Association suggests that cardiovascular health (CVH) metrics based on established risk factors and behaviors to reduce the morbidity and mortality of cardiovascular disease. Couples share environmental and lifestyle habits, and therefore, there can be an intra-couple correlation of CVH metrics. However, the clinical data on the association of the CVH metrics among couples are limited.

Purpose

We aimed to explore the intra-couple relationship of the AHA-defined cardiovascular health metrics using a nationwide epidemiological database.

Methods

This study is a retrospective observational cross-sectional analysis using the health claims database of the Japan Medical Data Center between January 2005 and December 2016. We modified the American Heart Association CVH metrics and defined ideal CVH component as following: 1) nonsmoking, 2) body mass index <25 kg/m2, 3) physical activity at goal, 4) untreated blood pressure <120/80 mm Hg, 5) untreated fasting glucose <100 mg/dL, and 6) untreated total cholesterol <200 mg/dL.

Results

We analyzed 122,788 heterosexual couples enrolled in the Japan Medical Data Center database. The average age of participants was 50.2±9.5 years in men and 48.6±8.9 years in women. Good correlation was observed between couples in terms of the modified ideal CVH metrics (Figure 1A). The prevalence of meeting ≥5 ideal components in the female partners increased from 31% in the male partners meeting no ideal components to 55% in those meeting 6 ideal components. The concordance ratio is particularly higher in the component of smoking status, blood pressure, and fasting glucose level. A man who meets ≥5 ideal components probably had a woman partner who meets ≥5 ideal components (Odds ratio 1.6, 95% CI: 1.6–1.7, p<0.001). The P value for the McNemar test was significant for all components, indicating that women apparently met ideal metrics for metrics in discordant Couples (Figure 1B).

Conclusion

Our investigation showed that there was a good intra-couple correlation of the ideal modified CVH metrics, suggesting the potential of couple-based assessment and management for improving CVH status.

Funding Acknowledgement

Type of funding source: None

Association between insulin resistance and left ventricular diastolic dysfunction in non-diabetic general population

Background

Insulin resistance due to visceral fat accumulation plays a central role in the development of diabetic mellitus and subsequent cardiovascular disease. Abdominal obesity and diabetic mellitus are associated with the progression of left ventricular diastolic dysfunction which is the major structural abnormality in patients with heart failure. However, whether insulin resistance influences left ventricular diastolic dysfunction in non-diabetic subjects is unclear.

Purpose

In this study, we aimed to clarify the association between insulin resistance and left ventricular diastolic dysfunction in non-diabetic general population.

Methods

We examined 2,572 non-diabetic subjects with preserved left ventricular systolic function (ejection fraction ≥50%) and without a past history of diabetic mellitus, heart failure, coronary artery disease, atrial fibrillation, stroke, moderate to severe valvular disease, who underwent medical check-ups at the University of Tokyo Hospital from January 2009 to December 2018. Diabetes mellitus was defined as fasting glucose level ≥126 mg/dL or a subject's use of oral antidiabetic medications or insulin. We calculated the Homeostasis Model Assessment-Insulin Resistance (HOMA-IR) score [HOMA-IR = fasting glucose (mg/dL) × insulin (μU/mL) / 405], and defined insulin resistance as HOMA-IR ≥2.5. Left ventricular diastolic function was assessed by echocardiography, using tissue doppler analysis (E/E' ratio in septal and lateral). Visceral adiposity was assessed as visceral fat volume measured by computed tomography scanner.

Results

Mean age was 53.3±9.8 years, and 1,746 subjects (67.9%) were male. Overall, HOMA-IR was 1.1 on average, and HOMA-IR ≥2.5 was observed in 5.0% of study population. BMI and the prevalence of obesity were higher in subjects with HOMA-IR ≥2.5 than in those without. There was no significant difference in left ventricular ejection fraction between HOMA-IR ≥2.5 and ≤2.5. E/E' ratio in septal and lateral were higher in subjects with HOMA-IR ≥2.5 than in those without. Multivariable logistic regression analysis demonstrated that obesity and waist circumference, visceral fat volume were independently associated with HOMA-IR ≥2.5, however, age, hypertension, hypercholesterolemia were not. Further, multiple regression analysis including insulin resistance, age, male gender, obesity, hypertension, hypercholesterolemia, cigarette smoking and visceral fat volume, showed that insulin resistance was an independent determinant of increasing E/E' in both septal and lateral, whereas visceral fat volume was not (Figure 1).

Conclusion

The results of the present study suggest that insulin resistance due to visceral fat accumulation might be associated with the development of left ventricular diastolic dysfunction in non-diabetic general population without overt cardiovascular disease.

Figure 1

Funding Acknowledgement

Type of funding source: None

Venous thromboembolisms and rheology in ovarian cancer patients after postoperative adjuvant paclitaxel and carboplatin therapy

In ovarian cancer patients, chemotherapy can be an independent risk factor for the development of thromboembolic complications, such as venous thromboembolism (VTE). The factors and their values that lead to the development of VTE are remaining unknown in patients undergoing chemotherapy with paclitaxel and carboplatin. This study investigated serial rheological parameters (D-dimer, red blood cell count, hematocrit, and plasma viscosity) for VTE that developed following chemotherapy for ovarian cancer. Forty-eight ovarian cancer patients undergoing chemotherapy were enrolled in this study. A significant difference in the mean values of plasma viscosity and hematocrit was observed between the VTE group (n = 5) and the non-VTE group (n = 43) (P < 0.10). Univariate and multiple regression analyses by stepwise selection identified plasma viscosity as the independent variable associated with VTE development. The VTE incidence was the same as in previous reports. The results support the contention that plasma viscosity could be an index for development of VTE in ovarian cancer after chemotherapy.

P198 Validation of the updated blood pressure classification based on the ACC/AHA guidelines in the perspective of subclinical atherosclerosis in general population

Background

American College of Cardiology (ACC) and American Heart Association (AHA) revised their guideline for hypertension in 2017, and the threshold of normal blood pressure (BP) was lowered, in the perspective of the prevention of optimal prevention of cardiovascular diseases. On the other hand European Society of Cardiology and European Society of Hypertension updated their guideline in 2018. However, the cut off value of blood pressure for hypertension was not changed (sBP ≥ 140 mmHg or dBP ≥ 90 mmHg). Therefore, the validity of the updated guideline of ACC/AHA still remains controversial, and there is so far no evidence regarding the BP category according to the ACC/AHA guidelines in general population.

Purpose

We aimed to clarify the association between the updated BP classification and carotid intima-media thickness (IMT), as a marker of subclinical atherosclerosis, in general population using a community-based cohort.

Methods

We analyzed 1,241 subjects undergoing medical check-ups at the University of Tokyo Hospital. Study subjects were categorized into 3 groups based on their BP levels: normal pressure (sBP &lt; 130 mmHg and dBP &lt; 80 mmHg); stage 1 hypertension (130 mmHg ≤ sBP &lt; 140 mmHg or 80 mmHg ≤ dBP&lt; 90 mmHg); and stage 2 hypertension (sBP ≥ 140 mmHg or dBP ≥ 90 mmHg, including subjects prescribed with antihypertensive agents). We defined carotid plaque as IMT ≥ 1.1 mm.

Results

Out of 1,241 subjects, 556 patients (44.8%) were categorized in the normal BP group, whereas 236 subjects (19.0%) and 449 subjects (36.2%) were categorized in the stage 1 and stage 2 hypertension groups, respectively. Among subjects categorized in the stage 2 hypertension group, 348 subjects (77.5%) patients were taking antihypertensive medications. Percentage of male gender, and age increased with BP category. Classical CVD risk factors such as diabetes mellitus and hypercholesterolemia were common in subjects in the hypertension groups. IMT increased as the BP category progressed from normal BP to stage 2 hypertension. The prevalence of carotid plaque also increased with an increase in BP. Univariate regression analysis showed the linear association between the BP category and prevalence of carotid plaque. Multivariable logistic regression analysis demonstrated that BP category as well as age ≥60 years, male gender, body mass index ≥25 kg/m2, and diabetes mellitus were independently associated with carotid plaque formation. BP category was associated with the prevalence of carotid plaque formation in any subgroup divided by age (&lt; 60 years old, and ≥60 years old) or gender.

Conclusions

Thickening of IMT developed in stage 1 hypertension, and further increased in stage 2 hypertension even in general population, indicating the importance of the therapeutic intervention according to the updated ACC/AHA guideline for hypertension.

Abstract P198 Figure.

P5293Effect of metabolically health obesity on carotid intima-media thickness in general population: a community-based cohort study

Introduction

Obesity is a common and independent risk factor for all-cause mortality. More specifically, obesity is a major component of atherosclerosis in association with metabolic disorders including metabolic syndrome (MetS), resulting in various cardiovascular diseases (CVD). Alternatively, obese subjects without MetS are prevalent, also referred to as metabolically healthy obesity (MHO). However, most preceding studies regarding MHO have been limited by small cohorts. Therefore, the effect of MHO on atherosclerosis in the general population remains unclear.

Purpose

In this study, we sought to clarify the effect of MHO on carotid intima-media thickness (IMT) as a marker of early stage atherosclerosis using a community-based cohort in general population.

Methods

We examined subjects who underwent medical check-up at our University Hospital. We defined obesity as body mass index ≥25.0 kg/m2. Abdominal obesity, defined as waist circumstance at umbilical level ≥85 cm in men and ≥90 cm in women, was obligatory for the diagnosis of MetS. In addition to abdominal obesity, any two of the following three abnormalities should be observed for the diagnosis of MetS, [1] Dyslipidemia: triglyceride ≥150 mg/dL, HDL-C <40 mg/dL, or use of lipid lowering medication, [2] Hypertension: systolic blood pressure ≥130 mmHg, diastolic blood pressure ≥85 mmHg, or use of antihypertensive medication, and [3] Hyperglycemia: fasting plasma glucose ≥110 mg/dL or use of hypoglycemic medication. MHO was defined as obese subjects without MetS, whereas we defined metabolically unhealthy obesity (MUO) as obese subjects with MetS. We defined carotid plaque as IMT ≥1.1 mm.

Results

Among 1,241 subjects, 857 subjects (69%) were categorized in the normal body weight group, whereas 275 subjects (22%) were categorized as MHO, and 109 subjects (9%) were categorized as MUO. Compared to non-obese subjects, prevalence of classical cardiovascular risk factors including hypertension, diabetes mellitus, and dyslipidemia increased in subjects with MHO, and further increased in those with MUO. IMT was higher in obese subjects compared to those without obesity. Similarly, the prevalence of carotid plaque formation was also higher in obese subjects. Multivariable logistic regression analysis demonstrated that age ≥60 years, male sex, hypertension, diabetes mellitus, MHO subjects (Odds ratio [OR]; 1.6, p=0.005), and MUO subjects (OR 1.7, p=0.04) were independently associated with carotid plaque formation. There was no statistical difference in the risk of carotid plaque formation between subjects with MHO and MUO.

IMT and Carotid Plaque

Conclusions

IMT and the prevalence of carotid plaque are higher in both subjects with MHO and MUO compared to non-obese subjects in the general population. We need to take obesity regardless of the presence of MetS into consideration as high-risk subjects for subsequent CVD.

P4389Effect of cigarette smoking on carotid artery atherosclerosis: a community-based cohort study

Background

Cigarette smoking is closely associated with the development of cardiovascular diseases (CVD), and the European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines recommend smoking bans.On the other hand, the relationship between cigarette smoking and subclinical atherosclerosis has not been fully studied. Carotid intima-media thickness (cIMT) is commonly used as a subclinical atherosclerosis marker, and a carotid plaque feature is also known to be an important predictor of cardiovascular diseases.

Purpose

We sought to clarify the association between cigarette smoking and subclinical atherosclerosis by evaluating carotid plaque including cIMT and carotid plaque features in general population.

Methods and results

Among 1,209 participants with no prior coronary artery disease who received a medical check-up with cardiovascular examination at our institution, 450 participants (37.2%) were smokers (including both past and current smokers). We defined carotid plaque as cIMT ≥1.1 mm and high-risk plaque as carotid plaque with hypoechoic dominant and/or plaque ulceration. The value of cIMT and the rate of carotid plaque were not different between smokers and never smokers (Figure A & B). However, the rate of carotid high-risk plaque was significantly higher in participants with smokers than those with never smokers (29.7%, vs 23.5%, p=0.011) (Figure C). Even after adjustment with covariates including age, gender and traditional cardiovascular risk factors, cigarette smoking was independently associated with high-risk plaque formation (odds ratio 1.384, 95% CI 1.020–1.877; p=0.037). According to the subgroup analysis classified by age, cigarette smoking was associated with not only the development of high-risk plaque but also the increased value of cIMT in the subgroup over 60 years old, whereas only the rate of high-risk plaque was higher in smokers than never smokers in the subgroup under 60 years old.

Carotid plaque and smoking

Conclusion

The development of high-risk carotid artery plaque may precede thickening of cIMT in cigarette smokers, suggesting that the novel insight for the pathological mechanism underlying cardiovascular events and cigarette smoking.

Lung transplantation via cardiopulmonary bypass: excellent survival outcomes from extended criteria donors

OBJECTIVES

The role of intraoperative cardiopulmonary bypass (CPB) in lung transplant (LTx) surgery is controversial. CPB enables slow pulmonary reperfusion and initial ventilation with low oxygen concentrations, both theoretically protective of transplanted lungs. In this study, we explored clinical outcomes following extended criteria donor LTx surgery implementing a thoroughly protective allograft reperfusion strategy using CPB.

METHODS

Thirty-nine consecutive adult patients who underwent bilateral LTx with elective CPB and protective allograft reperfusion were reviewed. Bilaterally implanted lungs were reperfused simultaneously, via slow CPB flow reduction and initial ventilation with 21% oxygen and nitric oxide, followed by a brief modified ultrafiltration. During weaning from CPB, mean pulmonary arterial pressure was strictly maintained at 10-15 mmHg by controlling CPB and pulmonary flow. The clinical outcomes in 23 patients who received lungs from extended criteria donors (ECD group) were elucidated and compared to 16 patients undergoing LTx from standard criteria donors (SCD group).

RESULTS

No life-threatening deterioration was observed to graft functionality during the first 72 h after LTx in the ECD group; however, only one patient required post-transplant extracorporeal membrane oxygenation. In three of 23 ECD LTx patients (12%), surgical revision for bleeding was required. Survival outcomes for the ECD group were favorable, with 100% survival at 6-months, 87.0% at 1-year, and 80.7% at 5-years. Outcomes in the ECD group were comparable to those in the SCD group.

CONCLUSIONS

Despite a certain extent of risk associated with full-dose heparinization, use of CPB does not undermine survival outcomes after ECD LTx surgery if protective allograft reperfusion is securely performed.

Lactobacillus gasseri PA-3 utilizes the purines GMP and guanosine and decreases their absorption in rats

Excessive intake of purine-rich foods elevates serum uric acid levels, making it a risk factor for hyperuricemia. We hypothesized that lactic acid bacteria ingested with food might utilize purines and contribute to their decreased absorption in the intestines, thereby preventing hyperuricemia. We previously reported that Lactobacillus gasseri PA-3 (PA-3) incorporates adenosine/inosine and related purines and that oral ingestion of PA-3 reduced the absorption of these purines in rats. However, it is unclear whether PA-3 also decreases the absorption of other purines, such as guanosine 5'-monophosphate (GMP) and guanosine. This study investigated whether PA-3 incorporates GMP and guanosine and reduces their absorption in rats. PA-3 incorporated both purines, with ¹⁴C-GMP uptake being greater than that of ¹⁴C-guanosine. Radioactivity in rat blood was significantly lower 30, 45, and 60 minutes after administration of ¹⁴C-GMP plus PA-3 than after administration of ¹⁴C-GMP alone and was significantly lower 15 minutes after administration of ¹⁴C-guanosine plus PA-3 than after administration of ¹⁴C-guanosine alone. PA-3 incorporates GMP and guanosine in vitro. Oral administration of PA-3 with GMP and guanosine reduces the intestinal absorption of these purines in vivo. These findings, together with those of previous studies, indicate that PA-3 reduces the absorption of major purines contained in foods. PA-3 may also attenuate the excessive absorption of dietary purines in humans, protecting these individuals against hyperuricemia.

Effect of serotonin transporter genotype on self-reported efficacy and activity changes of brain prefrontal area in response to placebo

Patients benefit from drug therapy not only through pharmacological mechanisms, but also through non-pharmacological action (placebo effect), which may be mediated in part by the prefrontal area of the brain. We consider that the difference between responders and non-responders to placebo might be related to polymorphisms in the serotonin transporter-linked polymorphic region (5-HTTLPR). To study this idea, we performed a randomized double-blind clinical trial using caffeine and lactose (placebo). Activity in the prefrontal area of the brain was measured in terms of blood flow by means of near-infrared spectroscopy (NIRS) as an objective indicator. Self-reported feelings of drowsiness on established scales were used as subjective indicators. Twenty-one subjects in block A took caffeine on the first day and placebo on the third day, and 21 in block B took placebo on the first day and placebo on the third day. After placebo administration, improvement of sleepiness was significantly enhanced, a similar extent to that after caffeine medication. Among the 42 subjects, 22 showed S/S type polymorphism in the serotonin transporter (52.4 %), 17 showed S/L type (40.5 %) and 3 showed L/L type (7.10 %). Statistical analysis of the results indicate that subjects with L/L genotype showed a significantly greater placebo response in terms of both self-reported feeling of drowsiness and blood flow in the prefrontal area of the brain associated with working memory (46 area). Our results indicate that the L/L genotype of 5-HTTLPR, which is rare in Japanese (3.2 %) but common in Americans (32.2 %), may be associated with a greater placebo effect.

Angiopoietin-like protein 2 promotes chondrogenic differentiation during bone growth as a cartilage matrix factor

OBJECTIVE

Chondrocyte differentiation is crucial for long bone growth. Many cartilage extracellular matrix (ECM) proteins reportedly contribute to chondrocyte differentiation, indicating that mechanisms underlying chondrocyte differentiation are likely more complex than previously appreciated. Angiopoietin-like protein 2 (ANGPTL2) is a secreted factor normally abundantly produced in mesenchymal lineage cells such as adipocytes and fibroblasts, but its loss contributes to the pathogenesis of lifestyle- or aging-related diseases. However, the function of ANGPTL2 in chondrocytes, which are also differentiated from mesenchymal stem cells, remains unclear. Here, we investigate whether ANGPTL2 is expressed in or functions in chondrocytes.

METHODS

First, we evaluated Angptl2 expression during chondrocyte differentiation using chondrogenic ATDC5 cells and wild-type epiphyseal cartilage of newborn mice. We next assessed ANGPTL2 function in chondrogenic differentiation and associated signaling using Angptl2 knockdown ATDC5 cells and Angptl2 knockout mice.

RESULTS

ANGPTL2 is expressed in chondrocytes, particularly those located in resting and proliferative zones, and accumulates in ECM surrounding chondrocytes. Interestingly, long bone growth was retarded in Angptl2 knockout mice from neonatal to adult stages via attenuation of chondrocyte differentiation. Both in vivo and in vitro experiments show that changes in ANGPTL2 expression can also alter p38 mitogen-activated protein kinase (MAPK) activity mediated by integrin α5β1.

CONCLUSION

ANGPTL2 contributes to chondrocyte differentiation and subsequent endochondral ossification through α5β1 integrin and p38 MAPK signaling during bone growth. Our findings provide insight into molecular mechanisms governing communication between chondrocytes and surrounding ECM components in bone growth activities.

Nanogel-based nasal ghrelin vaccine prevents obesity

Obesity is associated with multiple comorbidities such as cardiovascular diseases and has a huge economic impact on the health-care system. However, the treatment of obesity remains insufficient in terms of efficacy, tolerability, and safety. Here we created a nasal vaccine against obesity for the first time. To avoid the injectable administration-caused pain and skin-related adverse event, we focused on the intranasal route of antigen delivery. We developed a vaccine antigen (ghrelin-PspA (pneumococcal surface protein A)), which is a recombinant fusion protein incorporating ghrelin, a hormone that stimulates food intake and decreases energy expenditure, and PspA, a candidate of pneumococcal vaccine as a carrier protein. Ghrelin-PspA antigen was mixed with cyclic di-GMP adjuvant to enhance the immunogenicity and incorporated within a nanometer-sized hydrogel for the effective antigen delivery. Intranasal immunization with ghrelin-PspA vaccine elicited serum immunoglobulin G antibodies against ghrelin and attenuated body weight gain in diet-induced obesity mice. This obesity-attenuating effect was caused by a decrease in fat accumulation and an increase in energy expenditure that was partially due to an increase in the expression of mitochondrial uncoupling protein 1 in brown adipose tissue. The development of this nasal vaccine provides a new strategy for the prevention and treatment of obesity.

A Novel Blood Viscosity Estimation Method Based on Pressure-Flow Characteristics of an Oxygenator During Cardiopulmonary Bypass

During cardiopulmonary bypass (CPB), blood viscosity conspicuously increases and decreases due to changes in hematocrit and blood temperature. Nevertheless, blood viscosity is typically not evaluated, because there is no technology that can provide simple, continuous, noncontact monitoring. We modeled the pressure-flow characteristics of an oxygenator in a previous study, and in that study we quantified the influence of viscosity on oxygenator function. The pressure-flow monitoring information in the oxygenator is derived from our model and enables the estimation of viscosity. The viscosity estimation method was proposed and investigated in an in vitro experiment. Three samples of whole bovine blood with different hematocrit levels (21.8, 31.0, and 39.8%) were prepared and perfused into the oxygenator. As the temperature changed from 37°C to 27°C, the mean inlet pressure (P_in ) and outlet pressure (P_out ) of the oxygenator and the flow (Q) and viscosity of the blood were measured. The estimated viscosity was calculated from the pressure gradient (ΔP = P_in  - P_out ) and Q and was compared to the measured blood viscosity. A strong correlation was found between the two methods for all samples. Bland-Altman analysis revealed a mean bias of -0.0263 mPa.s, a standard deviation of 0.071 mPa.s, limits of agreement of -0.114-0.166 mPa.s, and a percent error of 5%. Therefore, this method is considered compatible with the torsional oscillation viscometer that has plus or minus 5% measurement accuracy. Our study offers the possibility of continuously estimating blood viscosity during CPB.

Effect of the Pulsatile Extracorporeal Membrane Oxygenation on Hemodynamic Energy and Systemic Microcirculation in a Piglet Model of Acute Cardiac Failure

The objective of this study was to compare the effects of pulsatile and nonpulsatile extracorporeal membrane oxygenation (ECMO) on hemodynamic energy and systemic microcirculation in an acute cardiac failure model in piglets. Fourteen piglets with a mean body weight of 6.08 ± 0.86 kg were divided into pulsatile (N = 7) and nonpulsatile (N = 7) ECMO groups. The experimental ECMO circuit consisted of a centrifugal pump, a membrane oxygenator, and a pneumatic pulsatile flow generator system developed in-house. Nonpulsatile ECMO was initiated at a flow rate of 140 mL/kg/min for the first 30 min with normal heart beating, with rectal temperature maintained at 36°C. Ventricular fibrillation was then induced with a 3.5-V alternating current to generate a cardiac dysfunction model. Using this model, we collected the data on pulsatile and nonpulsatile groups. The piglets were weaned off ECMO at the end of the experiment (180 min after ECMO was initiated). The animals did not receive blood transfusions, inotropic drugs, or vasoactive drugs. Blood samples were collected to measure hemoglobin, methemoglobin, blood gases, electrolytes, and lactic acid levels. Hemodynamic energy was calculated using the Shepard's energy equivalent pressure. Near-infrared spectroscopy was used to monitor brain and kidney perfusion. The pulsatile ECMO group had a higher atrial pressure (systolic and mean), and significantly higher regional saturation at the brain level, than the nonpulsatile group (for both, P < 0.05). Additionally, the pulsatile ECMO group had higher methemoglobin levels within the normal range than the nonpulsatile group. Our study demonstrated that pulsatile ECMO produces significantly higher hemodynamic energy and improves systemic microcirculation, compared with nonpulsatile ECMO in acute cardiac failure.

A prospective randomized trial comparing the clinical effectiveness and biocompatibility of heparin-coated circuits and PMEA-coated circuits in pediatric cardiopulmonary bypass

OBJECT

We compared the clinical effectiveness and biocompatibility of poly-2-methoxyethyl acrylate (PMEA)-coated and heparin-coated cardiopulmonary bypass (CPB) circuits in a prospective pediatric trial.

METHODS

Infants randomly received heparin-coated (n=7) or PMEA-coated (n=7) circuits in elective pediatric cardiac surgery with CPB for ventricular septum defects. Clinical and hematologic variables, respiratory indices and hemodynamic changes were analyzed perioperatively.

RESULTS

Demographic and clinical variables were similar in both groups. Leukocyte counts were significantly lower 5 minutes after CPB in the PMEA group than the heparin group. Hemodynamic data showed that PMEA caused hypotension within 5 minutes of CPB. The respiratory index was significantly higher immediately after CPB and 1 hour after transfer to the intensive care unit (ICU) in the PMEA group, as were levels of C-reactive protein 24 hours after transfer to the ICU.

CONCLUSION

Our study shows that PMEA-coated circuits, unlike heparin-coated circuits, cause transient leukopenia during pediatric CPB and, perhaps, systemic inflammatory respiratory syndrome after pediatric CPB.

The effects of posture on the ventilatory responses during exercise

This study was undertaken to evaluate the postural effect on ventilatory responses during both supine and sitting exercise. Seven healthy men performed two exercise tests utilizing the ramp protocol (20 watts/min) with a cycle ergometer in each position. The results were as follows: The oxygen uptake and the oxygen pulse measured at 180 watts and at anaerobic threshold in the sitting were significantly higher compared with those in the supine position. The average of carbon-dioxide output, minute ventilation and tidal volume at lower exercise intensities showed higher values in the sitting compared with those in the supine position, whereas there were no significant differences for respiratory rate. There was significant difference in the slope of the minute ventilation to carbon-dioxide output plot between sitting and supine position. In conclusion, the higher minute ventilation in the sitting position was mainly performed by higher tidal volume which may counteract the effects of an increase in physiological dead space. The lower slope of the minute ventilation to carbon-dioxide output plot which shows more effective ventilation in the supine position may be due to decreased physiological dead space and higher diffusion capacity.

Cardiopulmonary responses at various angles of cycle backrest inclination

The purpose of this study was to evaluate cardiopulmonary responses during submaximal cycle exercise at various angles of backrest inclination. Ten healthy Japanese men of mean age 25.9 yrs, height 170.6 cm, and body mass 66.1 kg, performed cycle exercises at a constant workload which reached the anaerobic threshold, at 20 degrees, 40 degrees, and 60 degrees of backrest inclination from the vertical plane, but the angle between the seat and back rest was kept at 110 degrees. The results were as follows: 1) Both cardiac output and stroke volume showed a higher value at the resting control state and during exercise as the backrest angle increased. 2) Oxygen consumption, carbon dioxide output, heart rate, gas exchange ratio, and oxygen pulse were not affected by the angle of backrest inclination. 3) Tidal volume at 20 degrees of backrest inclination was higher than at 60 degrees. 4) No significant differences were found in minute ventilation between each backrest angle. These findings suggest that changes in the backrest angle significantly alter cardiopulmonary parameters at rest and during exercise; in particular, an angle difference of 40 degrees may be enough to alter tidal volume, cardiac output and stroke volume, but not the minute ventilation.

Correction: Highly selective aluminium-catalysed intramolecular Prins reaction for l-menthol synthesis

Correction for ‘Highly selective aluminium-catalysed intramolecular Prins reaction for l-menthol synthesis’ by H. Itoh et al., RSC Adv., 2014, 4, 61619–61623.

Prognostic implications of CEBPA mutations in pediatric acute myeloid leukemia: a report from the Japanese Pediatric Leukemia/Lymphoma Study Group

CCAAT/enhancer-binding protein alpha (CEBPA) mutations are a favorable prognostic factor in adult acute myeloid leukemia (AML) patients; however, few studies have examined their significance in pediatric AML patients. Here we examined the CEBPA mutation status and clinical outcomes of pediatric AML patients treated in the AML-05 study. We found that 47 (14.9%) of the 315 evaluable patients harbored mutations in CEBPA; 26 cases (8.3%) harbored a single mutation (CEBPA-single) and 21 (6.7%) harbored double or triple mutations (CEBPA-double). After excluding core-binding factor-AML cases, patients harboring CEBPA mutations showed better overall survival (OS; P=0.048), but not event-free survival (EFS; P=0.051), than wild-type patients. Multivariate analysis identified CEBPA-single and CEBPA-double as independent favorable prognostic factors for EFS in the total cohort (hazard ratio (HR): 0.47 and 0.33; P=0.02 and 0.01, respectively). CEBPA-double was also an independent favorable prognostic factor for OS (HR: 0.30; P=0.04). CEBPA-double remained an independent favorable factor for EFS (HR: 0.28; P=0.04) in the normal karyotype cohort. These results suggest that CEBPA mutations, particularly CEBPA-double, are an independent favorable prognostic factor in pediatric AML patients, which will have important implications for risk-stratified therapy.

Molecular Orbital Calculations on the Interaction of PF3 and CO with Ni and Cu Atoms

The interaction of Ni and Cu atoms with PF3 and CO ligands was investigated by means of ab initio MO calculations. Coupling occurs mainly through the HOMO (8a1 for PF3 and 5 a for CO) levels with the metal 4s and 3dz2 orbitals, if the 3dn-1 4s1 electronic configuration of the metal atom is considered. The estimated M-PF3 bond lengths are 2.0 Å for Ni and 2.5 Å for Cu. Calculations with Ni(3d10) revealed for PF3 a more pronounced electron transfer to the ligand than for CO. The results are consistent with experimental UPS data for mononuclear complexes as well as corresponding adsorption systems. In particular, split-off d-states observed in UPS data for adsorbed PF3 are attributed to the pronounced lowering of the 3d-orbital energy of the metal atom upon interaction with this electropositive ligand.

Mosaic KCNJ2 mutation in Andersen-Tawil syndrome: targeted deep sequencing is useful for the detection of mosaicism

Andersen-Tawil syndrome (ATS) is an inherited disease characterized by ventricular arrhythmias, periodic paralysis, and dysmorphic features. It results from a heterozygous mutation of KCNJ2, but little is known about mosaicism in ATS. We performed genetic analysis of KCNJ2 in 32 ATS probands and their family members and identified KCNJ2 mutations in 25 probands, 20 families who underwent extensive genetic testing. These tests revealed that seven probands carried de novo mutations while 13 carried inherited mutations from their parents. We then specifically assessed a single proband and the respective family. The proband was a 9 year old girl who fulfilled the ATS triad and carried an insertion mutation (p.75_76insThr). We determined that the proband's mother carried a somatic mosaicism and that the proband's younger brother also carried the ATS phenotype with the same insertion mutation. The mother, who exhibited mosaicism, was asymptomatic, although she exhibited Q(T)U prolongation. Mutant allele frequency was 11% as per TA cloning and 17.3% as per targeted deep sequencing. Our observations suggest that targeted deep sequencing is useful for the detection of mosaicism and that the detection of mosaic mutations in parents of apparently sporadic ATS patients can help in the process of genetic counseling.