A Potent Kalihinol Analogue Disrupts Apicoplast Function and Vesicular Trafficking in P. falciparum Malaria

Here we report the discovery of MED6-189, a new analogue of the kalihinol family of isocyanoterpene (ICT) natural products. MED6-189 is effective against drug-sensitive and -resistant P. falciparum strains blocking both intraerythrocytic asexual replication and sexual differentiation. This compound was also effective against P. knowlesi and P. cynomolgi. In vivo efficacy studies using a humanized mouse model of malaria confirms strong efficacy of the compound in animals with no apparent hemolytic activity or apparent toxicity. Complementary chemical biology, molecular biology, genomics and cell biological analyses revealed that MED6-189 primarily targets the parasite apicoplast and acts by inhibiting lipid biogenesis and cellular trafficking. Genetic analyses in P. falciparum revealed that a mutation in PfSec13, which encodes a component of the parasite secretory machinery, reduced susceptibility to the drug. The high potency of MED6-189 in vitro and in vivo, its broad range of efficacy, excellent therapeutic profile, and unique mode of action make it an excellent addition to the antimalarial drug pipeline.

Association of body mass index and bloodstream infections in patients on extracorporeal membrane oxygenation: a single-centre, retrospective, cohort study

BACKGROUND

Obesity is associated with poor clinical outcomes in critically ill patients. However, under some clinical conditions, obesity has protective effects. Bloodstream infections (BSI) are among the most common nosocomial infections associated with extracorporeal membrane oxygenation (ECMO). BSI during ECMO is associated with higher mortality rates and poorer clinical outcomes.

AIM

To analyse whether body mass index (BMI) is associated with BSI during ECMO or with in-hospital mortality.

METHODS

All adult patients who had received ECMO support for >48 h were included in the analysis. The analysis of total duration of ECMO support, in-hospital mortality and BSI was stratified by BMI category. The Cox proportional hazards model was used to compare the risk of BSI among BMI categories.

FINDINGS

In total, 473 patients were enrolled in the study. The average age was 56.5 years and 65.3% were men. The total duration of ECMO was approximately 11.8 days, with a mortality rate of 47.1%. The incidence rates of BSI and candidaemia were 20.5% and 5.5%, respectively. The underweight group required ECMO for respiratory support, whereas the overweight and obese groups required ECMO for cardiogenic support (P<0.0001). No significant difference in BSI rate was found (P=0.784). However, after adjusting for clinical factors, patients in Group 4 (BMI 25.0-<30.0 kg/m2) exhibited lower mortality compared with patients in Group 2 (normal BMI) (P=0.004).

CONCLUSION

BMI was not associated with risk of BSI, but patients with higher BMI showed lower in-hospital mortality associated with ECMO support.

Potential overestimation of cognitive impairment because of hearing loss: impact of test modalities on cognitive test scores

OBJECTIVE

Hearing impairment in older adults may affect cognitive function and increase the risk of dementia. Most cognitive tests are delivered auditorily, and individuals with hearing loss may fail to hear verbal instructions. Greater listening difficulty and fatigue in acoustic conditions may impact test performance. This study aimed to examine the effect of decreased audibility on cognitive screening test performance in older adults.

METHOD

Older adults (n = 63) with different levels of hearing loss completed a standard auditory Mini-Mental State Examination test and a written version of the test.

RESULTS

Individuals with moderate to moderately severe hearing loss (41-70 dB) performed significantly better on the written (24.34 ± 4.90) than on the standard test (22.55 ± 6.25), whereas scores were not impacted for mild hearing loss (less than 40 dB).

CONCLUSION

Hearing evaluations should be included in cognitive assessment, and test performance should be carefully interpreted in individuals with hearing loss to avoid overestimating cognitive decline.

Impact of tuberculosis on the incidence of osteoporosis and osteoporotic fractures: a nationwide population-based cohort study

OBJECTIVES

Despite the high prevalence of tuberculosis (TB) and the disease burden of osteoporosis and osteoporotic fractures, there is still a lack of well-designed, large-scale studies demonstrating associations among them. We aimed to investigate the effect of TB on the incidence of osteoporosis and osteoporotic fractures.

STUDY DESIGN

This was a nationwide population-based cohort study.

METHODS

This study was conducted using the National Health Insurance Service Database of South Korea. We included patients with newly diagnosed TB aged >40 years from January 2006 to December 2017. An uninfected control for each TB patient was randomly extracted by frequency matching for sex, age, income level, residence, and registration date at a 2:1 ratio. The primary outcome was the incidence of osteoporosis and osteoporotic fractures between the two groups, adjusted for sex, age, income level, residence, comorbidities, body mass index, blood pressure, laboratory tests, alcohol drinking, and smoking. The risk factors associated with osteoporosis or osteoporotic fractures were also investigated.

RESULTS

A total of 164,389 patients with TB and 328,778 matched controls were included (71.9% males). The mean duration of follow-up was 7.00 ± 3.49 years. The incidence of osteoporosis in patients with TB was 6.1 cases per 1000 person-years, which was significantly higher than that in matched controls (adjusted hazard ratio [aHR] 1.349, 95% confidence interval [CI] 1.302-1.398, P < 0.001). The incidence of osteoporotic fractures was also higher in patients with TB than in controls (aHR 1.392, 95% CI 1.357-1.428, P < 0.001). Among fractures, the risk of hip fracture was the highest (aHR 1.703, 95% CI 1.612-1.798, P < 0.001).

CONCLUSIONS

TB independently contributes to the incidence of osteoporosis and osteoporotic fractures, particularly hip fractures.

Comparing the efficacy of different methods of faecal microbiota transplantation via oral capsule, oesophagogastroduodenoscopy, colonoscopy, or gastric tube

BACKGROUND

The increasing prevalence of multidrug-resistant organism (MDRO) carriage poses major challenges to medicine as healthcare costs increase. Recently, faecal microbiota transplantation (FMT) has been discussed as a novel and effective method for decolonizing MDRO.

AIM

To compare the efficacy of different FMT methods to optimize the success rate of decolonization in patients with MDRO carriage.

METHODS

This prospective cohort study enrolled patients with MDRO carriages from 2018 to 2021. Patients underwent FMT via one of the following methods: oral capsule, oesophagogastroduodenoscopy (EGD), colonoscopy, or gastric tube.

FINDINGS

A total of 57 patients underwent FMT for MDRO decolonization. The colonoscopy group required the shortest time for decolonization, whereas the EGD group required the longest (24.9 vs 190.4 days, P = 0.022). The decolonization rate in the oral capsule group was comparable to that in the EGD group (84.6% vs 85.7%, P = 0.730). An important clinical factor associated with decolonization failure was antibiotic use after FMT (odds ratio = 6.810, P = 0.008). All four groups showed reduced proportions of MDRO species in microbiome analysis after FMT.

CONCLUSION

Compared to other conventional methods, the oral capsule is an effective FMT method for patients who can tolerate an oral diet. The discontinuation of antibiotics after FMT is a key factor in the success of decolonization.

Solar background noise mitigation using the orbital angular momentum mode in vertical FSO downlink transmissions

Free-space optical communication (FSO) is used to provide network configuration flexibility. A network-flying platform-based vertical FSO connection can be employed to enhance mobile network coverage and capacity. Solar background noise can be a potential risk that disrupts the seamless connection in the vertical FSO downlink channel. In this paper, we propose signal transmission using an orbital angular momentum (OAM) beam. The OAM demodulation process can filter sunlight out of the optical receiver except for the signal corresponding to the azimuthal state. We experimentally verified that most of the solar background noise could be reduced. To verify the feasibility of the proposed scheme in a vertical FSO channel, we modeled a FSO vertical downlink with an OAM modulation/demodulation process.

Narrowband ultraviolet B phototherapy is associated with a reduction in topical corticosteroid and clinical improvement in atopic dermatitis: a historical inception cohort study

BACKGROUND

Despite decades of use, the magnitude of efficacy of narrowband ultraviolet B (NB-UVB) phototherapy for atopic dermatitis (AD) beyond industry-sponsored trials remains unclear.

AIM

To evaluate the clinical efficacy of NB-UVB in AD under real-world conditions.

METHODS

We conducted a historical inception cohort study using automated recording of dispensed drugs to provide an objective treatment outcome in a large population catchment of 420 000 people over 15 years. We analysed clinical treatment outcomes, recorded multicentre and prospectively over 15 years, of a large AD treatment cohort (n = 844), along with the drugs dispensed to this cohort.

RESULTS

The majority (70%) of patients with AD received significantly fewer topical corticosteroids (TCS) during the 12-month window after finishing NB-UVB compared with the 12-month window before starting the treatment (median reduction from 37.5 to 19.7 g/month). The number of patients dispensed with oral corticosteroids and antihistamines also dropped significantly (from 20% to 10% and from 69% to 31%, respectively), while all AD-unrelated drugs dispensed remained unchanged. Clinically, NB-UVB treatment achieved a 'clear' or 'almost clear' status in 48.7% of patients, while 20.4% achieved 'moderate clearance'. Treatment outcomes scores were validated by a strong correlation with reduction in AD-specific drug treatment.

CONCLUSION

Our data confirm the significant efficacy of NB-UVB for AD under conditions of routine care.

Prognostic significance of bone marrow 2-[18F]-fluoro-2-deoxy-d-glucose uptake in diffuse large B-cell lymphoma: relation to iliac crest biopsy results

AIM

To investigate the prognostic significance of bone marrow (BM) 2-[¹⁸F]-fluoro-2-deoxy-d-glucose (FDG) uptake in relation to posterior iliac crest BM biopsy (BMB) results in diffuse large B-cell lymphoma (DLBCL).

MATERIALS AND METHODS

Pretreatment integrated positron-emission tomography(PET)/computed tomography (CT) images of 512 DLBCL patients who underwent BMB and received rituximab combined with cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) chemotherapy were analysed retrospectively. BM uptake was assessed visually and by maximum standard uptake value (SUVmax). Associations with lymphoma-specific survival (LSS) were assessed using Kaplan-Meier and Cox regression analyses.

RESULTS

FDG(+) BM was observed in 64 cases (41 focal, 12 heterogeneous, 11 diffuse). This finding distinguished iliac crest involvement (positive in 59 and negative in 453) with 89.6% accuracy (459/512) and 93.6% specificity (424/453). In BMB(+) patients, BM-to-liver SUVmax ratio >1.8 concurred perfectly with FDG(+) BM. During 52 months of follow-up, there were 156 lymphoma-related deaths. In the entire population, multivariate analysis revealed high International Prognostic Index (IPI; p<0.001), old age (p=0.003), bulky disease (p=0.011), BMB(+) (p=0.028), and FDG(+) BM (p=0.019) as independent predictors of worse LSS. In the BMB(+) subgroup, high National Comprehensive Cancer Network-revised IPI (NCCN-IPI; p=0.029) and FDG(+) BM (p=0.008) were significant independent predictors. Among BMB(+) patients with low to low-intermediate NCCN-IPI, FDG(+) BM was associated with significantly worse 2-year LSS (33.3% versus 100%; p=0.017). The same was true among those with high-intermediate NCCN-IPI (34.7% versus 76.9%.; p=0.026).

CONCLUSION

Increased BM FDG in DLBCL is a predictor of worse LSS independent of BMB results and other prognostic variables including IPI/NCCN-IPI.

Association of body mass index with immune recovery, virological failure and cardiovascular disease risk among people living with HIV

OBJECTIVES

We conducted a longitudinal cohort analysis to evaluate the association of pre-treatment body mass index (BMI) with CD4 recovery, virological failure (VF) and cardiovascular risk disease (CVD) markers among people living with HIV (PLHIV).

METHODS

Participants who were enrolled between January 2003 and March 2019 in a regional Asia HIV cohort with weight and height measurements prior to antiretroviral therapy (ART) initiation were included. Factors associated with mean CD4 increase were analysed using repeated-measures linear regression. Time to first VF after 6 months on ART and time to first development of CVD risk markers were analysed using Cox regression models. Sensitivity analyses were done adjusting for Asian BMI thresholds.

RESULTS

Of 4993 PLHIV (66% male), 62% had pre-treatment BMI in the normal range (18.5-25.0 kg/m² ), while 26%, 10% and 2% were underweight (< 18.5 kg/m² ), overweight (25-30 kg/m2) and obese (> 30 kg/m² ), respectively. Both higher baseline and time-updated BMI were associated with larger CD4 gains compared with normal BMI. After adjusting for Asian BMI thresholds, higher baseline BMIs of 23-27.5 and > 27.5 kg/m² were associated with larger CD4 increases of 15.6 cells/µL [95% confidence interval (CI): 2.9-28.3] and 28.8 cells/µL (95% CI: 6.6-50.9), respectively, compared with normal BMI (18.5-23 kg/m² ). PLHIV with BMIs of 25-30 and > 30 kg/m² were 1.27 times (95% CI: 1.10-1.47) and 1.61 times (95% CI: 1.13-2.24) more likely to develop CVD risk factors. No relationship between pre-treatment BMI and VF was observed.

CONCLUSIONS

High pre-treatment BMI was associated with better immune reconstitution and CVD risk factor development in an Asian PLHIV cohort.

Virological failure and HIV drug resistance among adults living with HIV on second-line antiretroviral therapy in the Asia-Pacific

OBJECTIVES

To assess second-line antiretroviral therapy (ART) virological failure and HIV drug resistance-associated mutations (RAMs), in support of third-line regimen planning in Asia.

METHODS

Adults > 18 years of age on second-line ART for ≥ 6 months were eligible. Cross-sectional data on HIV viral load (VL) and genotypic resistance testing were collected or testing was conducted between July 2015 and May 2017 at 12 Asia-Pacific sites. Virological failure (VF) was defined as VL > 1000 copies/mL with a second VL > 1000 copies/mL within 3-6 months. FASTA files were submitted to Stanford University HIV Drug Resistance Database and RAMs were compared against the IAS-USA 2019 mutations list. VF risk factors were analysed using logistic regression.

RESULTS

Of 1378 patients, 74% were male and 70% acquired HIV through heterosexual exposure. At second-line switch, median [interquartile range (IQR)] age was 37 (32-42) years and median (IQR) CD4 count was 103 (43.5-229.5) cells/µL; 93% received regimens with boosted protease inhibitors (PIs). Median duration on second line was 3 years. Among 101 patients (7%) with VF, CD4 count > 200 cells/µL at switch [odds ratio (OR) = 0.36, 95% confidence interval (CI): 0.17-0.77 vs. CD4 ≤ 50) and HIV exposure through male-male sex (OR = 0.32, 95% CI: 0.17-0.64 vs. heterosexual) or injecting drug use (OR = 0.24, 95% CI: 0.12-0.49) were associated with reduced VF. Of 41 (41%) patients with resistance data, 80% had at least one RAM to nonnucleoside reverse transcriptase inhibitors (NNRTIs), 63% to NRTIs, and 35% to PIs. Of those with PI RAMs, 71% had two or more.

CONCLUSIONS

There were low proportions with VF and significant RAMs in our cohort, reflecting the durability of current second-line regimens.

Atherosclerotic cardiovascular disease screening and management protocols among adult HIV clinics in Asia

OBJECTIVES

Integration of HIV and non-communicable disease services improves the quality and efficiency of care in low- and middle-income countries (LMICs). We aimed to describe current practices for the screening and management of atherosclerotic cardiovascular disease (ASCVD) among adult HIV clinics in Asia.

METHODS

Sixteen LMIC sites included in the International Epidemiology Databases to Evaluate AIDS - Asia-Pacific network were surveyed.

RESULTS

Sites were mostly (81%) based in urban public referral hospitals. Half had protocols to assess tobacco and alcohol use. Protocols for assessing physical inactivity and obesity were in place at 31% and 38% of sites, respectively. Most sites provided educational material on ASCVD risk factors (between 56% and 75% depending on risk factors). A total of 94% reported performing routine screening for hypertension, 100% for hyperlipidaemia and 88% for diabetes. Routine ASCVD risk assessment was reported by 94% of sites. Protocols for the management of hypertension, hyperlipidaemia, diabetes, high ASCVD risk and chronic ischaemic stroke were in place at 50%, 69%, 56%, 19% and 38% of sites, respectively. Blood pressure monitoring was free for patients at 69% of sites; however, most required patients to pay some or all the costs for other ASCVD-related procedures. Medications available in the clinic or within the same facility included angiotensin-converting enzyme inhibitors (81%), statins (94%) and sulphonylureas (94%).

CONCLUSION

The consistent availability of clinical screening, diagnostic testing and procedures and the availability of ASCVD medications in the Asian LMIC clinics surveyed are strengths that should be leveraged to improve the implementation of cardiovascular care protocols.

Early mortality after late initiation of antiretroviral therapy in the TREAT Asia HIV Observational Database (TAHOD) of the International Epidemiologic Databases to Evaluate AIDS (IeDEA) Asia-Pacific

OBJECTIVES

Early mortality among those still initiating antiretroviral therapy (ART) with advanced stages of HIV infection in resource-limited settings remains high despite recommendations for universal HIV treatment. We investigated risk factors associated with early mortality in people living with HIV (PLHIV) starting ART at low CD4 levels in the Asia-Pacific.

METHODS

PLHIV enrolled in the Therapeutics, Research, Education and AIDS Training in Asia (TREAT Asia) HIV Observational Database (TAHOD) who initiated ART with a CD4 count < 100 cells/μL between 2003 and 2018 were included in the study. Early mortality was defined as death within 1 year of ART initiation. PLHIV in follow-up for > 1 year were censored at 12 months. Competing risk regression was used to analyse risk factors with loss to follow-up as a competing risk.

RESULTS

A total of 1813 PLHIV were included in the study, of whom 74% were male. With 73 (4%) deaths, the overall first-year mortality rate was 4.27 per 100 person-years (PY). Thirty-eight deaths (52%) were AIDS-related, 10 (14%) were immune reconstituted inflammatory syndrome (IRIS)-related, 13 (18%) were non-AIDS-related and 12 (16%) had an unknown cause. Risk factors included having a body mass index (BMI) < 18.5 [sub-hazard ratio (SHR) 2.91; 95% confidence interval (CI) 1.60-5.32] compared to BMI 18.5-24.9, and alanine aminotransferase (ALT) ≥ 5 times its upper limit of normal (ULN) (SHR 6.14; 95% CI 1.62-23.20) compared to ALT < 5 times its ULN. A higher CD4 count (51-100 cells/μL: SHR 0.28; 95% CI 0.14-0.55; and > 100 cells/μL: SHR 0.12; 95% CI 0.05-0.26) was associated with reduced hazard for mortality compared to CD4 count ≤ 25 cells/μL.

CONCLUSIONS

Fifty-two per cent of early deaths were AIDS-related. Efforts to initiate ART at CD4 counts > 50 cell/μL are associated with improved short-term survival rates, even in those with late stages of HIV disease.

Early cidofovir administration might be associated with a lower probability of respiratory failure in treating human adenovirus pneumonia: a retrospective cohort study

Objective

To compare outcomes of early and delayed treatment with cidofovir for human adenovirus (HAdV) pneumonia.

Methods

A retrospective cohort study in Korean military hospitals was conducted between January 2012 and December 2018. Patients with potentially severe HAdV pneumonia with risk factors for respiratory failure were included and divided into early (within 7 days from symptom onset) and delayed (after 7 days from symptom onset) treatment groups. The primary outcome was respiratory failure development within 21 days after symptom onset.

Results

A total of 89 patients with potentially severe HAdV pneumonia were enrolled in the cohort; they included 62 early and 27 delayed treatment patients. All patients were males in their early 20s. Significantly fewer patients in the early treatment group progressed to respiratory failure (8/62, 12.9%), compared to the delayed group (18/27, 66.7%, p < 0.001). Early treatment was associated with a lower 21-day probability of respiratory failure by the Kaplan–Meier method (p < 0.001). On multivariate analysis, monocyte count, hypoxaemia, confusion, whole lung involvement, and early cidofovir treatment within 7 days from symptom onset were included, and monocyte count (HR 0.995, 95%CI 0.991–1.000, p 0.042), confusion (HR 4.964, 95%CI 1.189–20.721, p = 0.028), and early cidofovir treatment (HR 0.319, 95%CI 0.115–0.883, p = 0.028) were significantly associated with respiratory failure.

Conclusions

Early administration of cidofovir was associated with a lower hazard for respiratory failure development. It is suggested that cidofovir be administered within 7 days from symptom onset to prevent respiratory failure in patients with potentially severe HAdV pneumonia.

P3715Impact of sleep-disordered breathing on short-term functional outcomes in ischemic stroke patients: a cardiopulmonary coupling analysis using holter-monitoring

Background

Sleep-disordered breathing (SDB) assessed by conventional polysomnography is reported to have close association with worsened clinical outcomes in patients with ischemic stroke. The cardiopulmonary coupling (CPC) analysis using Holter-monitoring is an easily assessable method to evaluate SDB. However, its prognostic impact needs to be investigated.

Purpose

The present study investigated the prognostic impact of SDB defined by CPC analysis using Holter-monitoring at early stage of ischemic stroke on the functional disability at 3-month follow-up.

Methods

Total 692 patients with acute ischemic stroke who underwent Holter-monitoring were enrolled. The CPC analysis was conducted and SDB was defined as the presence of narrow-band (NB) coupling during sleep time. We investigated the association between SDB and functional disability at 3-month measured by modified Rankin scale (mRS).

Result

The NB coupling was present in 216 (31.2%) of 692 patients with mean age of 64.2±12.8 years. The NB group showed significantly higher proportion of severe functional disability (mRS ≥3; 45.3% vs. 12.3%, p<0.001) and persistent disability (ΔmRS≤0; 42.6% vs. 56.4%, p<0.001) after 3-month. In multivariate analysis, the presence of NB coupling was an independent predictor of higher risk of both severe and persistent functional disability (HR: 3.97; 95% CI: 2.37–6.64; p<0.001; and HR 1.92; 95% CI: 1.34–2.77; p<0.001, respectively). The results were consistent after propensity-score matched analysis with 175 patient pairs (C-statistics=0.759).

Parameters of functional disability Overall population (n=692) PSM population (n=350) no NB (n=476) NB (n=216) OR (95% CI) p-value no NB (n=175) NB (n=175) OR (95% CI) p-value Initial NIHSS ≥5 89 (18.6) 81 (37.5) <0.001 52 (29.7) 52 (29.7) >0.999 Discharge mRS ≥3 146 (30.6) 126 (58.3) <0.001 90 (51.4) 89 (50.8) 0.915 3-month mRS ≥3 59 (12.3) 98 (45.3) 5.86 (4.00–8.60) <0.001 38 (21.7) 72 (41.1) 2.52 (1.57–4.02) <0.001 3-month ΔmRS ≤0 (persisent disability) 203 (42.6) 122 (56.4) 1.74 (1.26–2.41) 0.001 77 (44.0) 100 (57.1) 1.69 (1.11–2.58) 0.014 Data are expressed as n (%). mRS = modified Rankin's scale; NB = narrow-band; NIHSS = National Institutes of Health Stroke Scale; OR = odds ratio; PSM = propensity-score matched.

Functional disabilities after 3-month

Conclusion

SDB assessed by CPC analysis at early phase of ischemic stroke was able to predict both greater and persistent functional disability at 3-month. The CPC analysis using Holter-monitoring is a useful modality for predicting functional disabilities in acute ischemic stroke.

P5744Sleep-disordered breathing assessed by holter-monitoring is associated to worsened one-year clinical outcomes in ischemic stroke patients: a cardiopulmonary coupling analysis

Background

Sleep-disorder breathing (SDB) using polysomnography is closely associated to poor functional and clinical outcomes in ischemic stroke patients. The cardiopulmonary coupling analysis using Holter-monitoring (CPC-Holter analysis) is an emerging feasible modality to investigate SDB.

Purpose

We investigated the association between SDB defined by CPC-Holter analysis and one-year clinical outcome in patients with acute ischemic stroke.

Methods

Total 666 patients with acute ischemic stroke who underwent Holter-monitoring were enrolled. The CPC-Holter analysis was conducted and SDB was defined as the presence of narrow-band (NB) coupling during sleep time. Primary outcome was recurrent ischemic stroke, and secondary outcome was major adverse cerebrovascular event (MACE), a composite of recurrent ischemic stroke, transient ischemic attack, and all-cause mortality within one year since discharge.

Result

The NB coupling was present in 205 (30.8%) of 666 patients with mean age of 64.1±12.8 years. The NB group showed significantly higher incidence of both recurrent ischemic stroke (8.3% vs. 1.4%, p<0.001) and MACE (14.9% vs. 3.0%, p<0.001) within one-year. In multivariate analysis, presence of NB coupling remained as an independent predictor of both recurrent ischemic stroke and MACE (HR: 4.81; 95% CI: 1.73–13.4; p=0.003; and HR 4.17; 95% CI: 1.74–10.0; p<0.001, respectively). The results were consistent after propensity-score matched analysis with 164 patient pairs (C-statistics=0.757).

One-year clinical outcomes Overall population (n=666) PSM population (n=328) no NB (=461) NB (n=205) Log-rank p-value OR (95% CI) no NB (n=164) NB (n=164) Log-rank p-value OR (95% CI) Recurrent ischemic stroke 6 (1.4) 14 (8.3) <0.001 5.73 (2.20–14.9) 3 (2.0) 11 (8.1) 0.026 3.85 (1.07–13.8) Transient ischemic attack 3 (0.7) 3 (1.7) 0.275 2 (1.3) 3 (2.1) 0.633 Hemorrhagic stroke 0 (0.0) 2 (1.2) 0.027 0 (0.0) 2 (1.5) 0.148 Total death 3 (0.7) 9 (4.8) 0.001 2 (1.3) 3 (1.9) 0.641 MACEs 12 (3.0) 25 (14.9) <0.001 4.63 (2.06–10.4) 7 (5.2) 17 (13.1) 0.030 2.95 (1.06–8.21) Data are expressed as n (%). CI = confidence interval; MACE = major adverse cardiovascular event; NB = narrow-band; OR = odds ratio.

One-year clinical outcomes

Conclusion

SDB assessed by CPC-Holter analysis at early phase of ischemic stroke is a powerful prognostic marker for predicting one-year adverse clinical outcomes. The CPC analysis using Holter-monitoring is a useful modality and could be easily applied to predict clinical outcomes in acute ischemic stroke patients.

P4791Performance of the HAS-BLED, ATRIA, and PRECISE-DAPT Bleeding Risk Scores in Atrial Fibrillation Patients Using Antiplatelet Agents or Oral Anticoagulants

Background

Various bleeding risk scores have been proposed to assess the risk of bleeding in atrial fibrillation (AF) patients undergoing anticoagulation. PRECISE DAPT score has been developed to assess the out-of hospital bleeding risk in patients receiving dual antiplatelet therapy (DAPT). Our objective was to compare the predictive performance between the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile International Normalized Ratio, Elderly, Drugs/Alcohol), ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation), and PRECISE-DAPT (Predicting Bleeding Complication in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet therapy) score in AF patients using antiplatelet agents or anticoagulants

Methods

We recruited 1,114 consecutive AF patients (51% male; median age, 71 years) receiving antiplatelet agents or oral anticoagulants from January 2014 through December 2018. Major bleeding was defined as according to the Bleeding Academic Research Consortium (BARC) criteria (type 3 or 5: hemodynamic instability, need for transfusion, drop in hemoglobin ≥3 g, and intracranial, intraocular or fatal bleeding). The performance of risk scores were assessed by C-statistic.

Results

Bleeding events occurred in 135 patients (12.1%) during 30 days, and 72 patients (6.5%) from 30 days till 1-year follow-up. Based on the C-statistic, PRECISE-DAPT score (AUC: 0.72, 95% CI: 0.69–0.75) had a good performance, significantly better than HAS-BLED (AUC: 0.64, 95% CI: 0.61–0.67) (p=0.008) or ATRIA scores (AUC: 0.57, 95% CI: 0.54–0.60) (p<0.001) for 30-days bleeding prediction. Also, PRECISE-DAPT score had a good C-statistic (AUC: 0.72, 95% CI: 0.69–0.75) for 1-year bleeding events compared with HAS-BLED (AUC: 0.64, 95% CI: 0.60–0.67) (p=0.02) or ATRIA (AUC: 0.61, 95% CI: 0.58–0.65) (p=0.01).

ROC curve for bleeding

Conclusions

The PRECISE-DAPT score has been used for assessing bleeding events during DAPT. Also, the PRECISE-DAPT score predicted bleedings better than HAS-BLED or ATRIA scores in AF patients. So, the PRECISE-DAPT score may be considered as bleeding risk score during DAPT or oral anticoagulation in clinical practice.

P1248Characteristics and clinical significance of right ventricular involvement in patients with hypertrophic cardiomyopathy

Background

A few studies have demonstrated bi-ventricular hypertrophy in hypertrophic cardiomyopathy (HCM). However, clinical significance of HCM with right ventricular (RV) involvement has not been fully established. Therefore, we aimed to investigate the structural characteristics and clinical significance of RV hypertrophy in patients with HCM.

Methods

In a single center, large HCM registry, 256 patients with HCM who underwent both cardiac magnetic resonance (CMR) and transthoracic echocardiography within 6 months were retrospectively analyzed. RV involvement was defined as increased RV wall thickness >7 mm on CMR in any segments of RV free wall and apex. Patients who had evidence of significant RV pressure overload (RV systolic pressure >50mmHg) or had undergone septal myectomy were excluded. Cardiovascular outcomes were defined as the composite of cardiovascular death and hospitalization for cardiovascular disease.

Results

Among 256 patients, 41 (16%) showed RV involvement. During follow-up period (median 1099 days), 32 cardiovascular outcomes (3 cardiovascular death and 29 cardiovascular hospitalization) were occurred. Patients with RV involvement showed a significantly higher left ventricular (LV) thickness (23.8±5.8 vs. 21.2±5.0 mm, p=0.004), more advanced diastolic dysfunction, and larger left atrial volume index (LAVI, 48.5±20.3 vs. 40.2±14.9 mm/m2, p=0.016) compared to those without RV involvement. In multivariate cox regression analysis, presence of RV involvement (HR: 4.21, 95% CI: 1.99–8.90, p<0.001) and LV ejection fraction <50% (HR: 4.29, 95% CI: 1.37–13.43, p=0.012) were independently associated with cardiovascular outcomes. The Kapan-Meier curve showed that there was a significant decrease in probability of cardiovascular outcomes-free survival in patients with RV involvement (p=0.007) after using 1:1 propensity score matching (n=82) to adjust for age, sex, LV ejection fraction, LV maximal wall thickness, LAVI, and RV systolic pressure than patients without RV involvement (Figure 1).

Figure 1

Conclusion

RV involvement in patients with HCM were not rare (16%). Patients with RV involvement showed more advanced LV structure and dysfunction, suggesting an indicator of severe HCM. RV involvement in HCM has clinical significance related to cardiovascular outcomes.

Treatment of latent tuberculous infection among health care workers at a tertiary hospital in Korea

OBJECTIVE

To evaluate the acceptance of, adherence to, and outcomes of latent tuberculous infection (LTBI) treatment among health care workers (HCWs).

DESIGN

This was a retrospective study in a tertiary hospital in Korea. From May to August 2017, 2190 HCWs simultaneously underwent a tuberculin skin test (TST) and interferon-gamma release assay (IGRA). LTBI was diagnosed if the TST induration was 10 mm or IGRA results were positive.

RESULTS

Of 2190 HCWs tested, 1006 (45.9%) were diagnosed with LTBI. Of these, 655 (65.1%) HCWs visited out-patient clinics, 234 (35.7%) of whom were advised treatment by physicians. Among these, 120 (51.3%) accepted the physicians' recommendations. In general, HCWs who were older, male and smoked were less likely to visit out-patient clinics. Sixty (50%) HCWs received 3 months of isoniazid plus rifampicin (3HR) and 57 (47.5%) HCWs received 4 months of rifampicin (4R). The proportion of HCWs with 2 side effects (3HR 20% vs. 4R 7.0%, P = 0.041) and drug stoppage rate (3HR 20% vs. 4R 5.3%, P = 0.017) were higher in the 3HR group than in the 4R group. Of the 120 HCWs, 78 (65%) completed LTBI treatment.

CONCLUSION

Overall, the acceptance and completion rate for LTBI treatment was not adequate. For effective LTBI management in HCWs, further programmatic strategies are needed.

Quantitative analysis of topical treatments in atopic dermatitis: unexpectedly low use of emollients and strong correlation of topical corticosteroid use both with depression and concurrent asthma

BACKGROUND

Despite decades of use, the actual amounts of topical corticosteroids (TCS) and emollients used in moderate-to-severe atopic dermatitis (AD) under real-world conditions are unknown. Thus, it remains unclear whether inadequate use is widespread.

OBJECTIVES

To quantify the use of TCS and emollients in moderate-to-severe AD.

METHODS

Double-blinded drug prescribing was recorded prospectively at the point of drug dispensing within a catchment area of approximately 450 000 people over a 31-year period in a population-based cohort marked by failure of disease control in primary care (n = 844). For each patient, prescribing was recorded over a 12-month period in order to minimize fluctuations.

RESULTS

This approach resulted in a near-complete dataset, which was essentially free of reporting bias and recording bias. Atopic comorbidities matched expected frequencies. Median use of TCS was statistically significantly higher in juvenile patients (age < 16 years) compared with adult patients (49·2 vs. 38·1 g per month), in male vs. female patients (46·8 vs. 29·7 g per month) and in patients receiving concurrent asthma treatment (40·4 vs. 26·7 g per month). TCS use was strongly associated with antidepressant treatment. Emollient use was unexpectedly low with a median of 9·6 g per day (range 1·4-30·1). Results were replicated in an independent validation cohort.

CONCLUSIONS

Deficient use of emollients may be a factor contributing to AD severity. Our analysis showed that the use of TCS does not exceed current guidelines. Accurate quantification of topical treatments provides a widely accessible strategy to measure the real-world impact of novel AD treatments. What's already known about this topic? Both emollient and topical corticosteroid (TCS) use have been a mainstay of atopic dermatitis (AD) treatment for over 60 years. The actual quantities used by patients under real-world conditions are unknown. What does this study add? The real-world use of emollients is fourfold lower than the amount recommended in current guidelines. Underuse of emollients may be a significant factor in disease exacerbation. The use of TCS is significantly higher in male patients and is higher in patients with AD who also have asthma. The use of TCS is strongly associated with concurrent antidepressant treatment.

Diabetes, mortality and glucose monitoring rates in the TREAT Asia HIV Observational Database Low Intensity Transfer (TAHOD-LITE) study

OBJECTIVES

Diabetes is a growing cause of morbidity and mortality in people living with HIV (PLHIV) receiving antiretroviral therapy (ART). We investigated the association between fasting plasma glucose (FPG) levels and mortality, and factors associated with FPG monitoring rates in Asia.

METHODS

Patients from the Therapeutics Research, Education, and AIDS Training in Asia (TREAT Asia) HIV Observational Database Low Intensity Transfer (TAHOD-LITE) cohort were included in the present study if they had initiated ART. Competing risk and Poisson regression were used to analyse the association between FPG and mortality, and assess risk factors for FPG monitoring rates, respectively. FPG was categorized as diabetes (FPG ≥ 7.0 mmol/L), prediabetes (FPG 5.6-6.9 mmol/L) and normal FPG (FPG < 5.6 mmol/L).

RESULTS

In total, 33 232 patients were included in the analysis. Throughout follow-up, 59% had no FPG test available. The incidence rate for diabetes was 13.7 per 1000 person-years in the 4649 patients with normal FPG at ART initiation. Prediabetes [sub-hazard ratio (sHR) 1.32; 95% confidence interval (CI) 1.07-1.64] and diabetes (sHR 1.90; 95% CI 1.52-2.38) were associated with mortality compared to those with normal FPG. FPG monitoring increased from 0.34 to 0.78 tests per person-year from 2012 to 2016 (P < 0.001). Male sex [incidence rate ratio (IRR) 1.08; 95% CI 1.03-1.12], age > 50 years (IRR 1.14; 95% CI 1.09-1.19) compared to ≤ 40 years, and CD4 count ≥ 500 cells/μL (IRR 1.04; 95% CI 1.00-1.09) compared to < 200 cells/μL were associated with increased FPG monitoring.

CONCLUSIONS

Diabetes and prediabetes were associated with mortality. FPG monitoring increased over time; however, less than half of our cohort had been tested. Greater resources should be allocated to FPG monitoring for early diabetic treatment and intervention and to optimize survival.

Long-term loss to follow-up in the TREAT Asia HIV Observational Database (TAHOD)

OBJECTIVES

With earlier antiretroviral therapy (ART) initiation, time spent in HIV care is expected to increase. We aimed to investigate loss to follow-up (LTFU) in Asian patients who remained in care 5 years after ART initiation.

METHODS

Long-term LTFU was defined as LTFU occurring after 5 years on ART. LTFU was defined as (1) patients not seen in the previous 12 months; and (2) patients not seen in the previous 6 months. Factors associated with LTFU were analysed using competing risk regression.

RESULTS

Under the 12-month definition, the LTFU rate was 2.0 per 100 person-years (PY) [95% confidence interval (CI) 1.8-2.2 among 4889 patients included in the study. LTFU was associated with age > 50 years [sub-hazard ratio (SHR) 1.64; 95% CI 1.17-2.31] compared with 31-40 years, viral load ≥ 1000 copies/mL (SHR 1.86; 95% CI 1.16-2.97) compared with viral load < 1000 copies/mL, and hepatitis C coinfection (SHR 1.48; 95% CI 1.06-2.05). LTFU was less likely to occur in females, in individuals with higher CD4 counts, in those with self-reported adherence ≥ 95%, and in those living in high-income countries. The 6-month LTFU definition produced an incidence rate of 3.2 per 100 PY (95% CI 2.9-3.4 and had similar associations but with greater risks of LTFU for ART initiation in later years (2006-2009: SHR 2.38; 95% CI 1.93-2.94; and 2010-2011: SHR 4.26; 95% CI 3.17-5.73) compared with 2003-2005.

CONCLUSIONS

The long-term LTFU rate in our cohort was low, with older age being associated with LTFU. The increased risk of LTFU with later years of ART initiation in the 6-month analysis, but not the 12-month analysis, implies that there was a possible move towards longer HIV clinic scheduling in Asia.

Acquisition of Carbapenemase-Producing Enterobacteriaceae in Solid Organ Transplantation Recipients

BACKGROUND

Carbapenemase-producing Enterobacteriaceae (CPE) can lead to life-threatening outcomes with rapid spread of the carbapenemase gene in solid organ transplantation (SOT) recipients because of limitations of available antibiotics. We examined the characteristics and importance of CPE acquisition in SOT recipients with large numbers of CPE isolates.

METHODS

Between November 2015 and October 2016, 584 CPE isolates were found in 37 recipients and verified by carbapenemase gene multiplex polymerase chain reaction (PCR). One hundred recipients with at least 2 negative results in carbapenemase PCR for stool surveillance and no CPE isolates in clinical samples were retrospectively included.

RESULTS

Most CPE isolates were Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae (546, 93.5%). The most frequent transplantation organ was lung (43.3%), and the most common sample with CPE isolates other than stool was respiratory tract (22.6%). The median time between SOT and first CPE acquisition was 7 days. All-cause mortality was significantly higher in recipients with CPE than in those without CPE (24.3% vs 10.0%; P = .03). In multivariate regression analysis, stool colonization of vancomycin-resistant Enterococci and/or Clostridium difficile during 30 days before SOT (odds ratio [OR], 3.28; 95% CI, 1.24-8.68; P = .02), lung transplantation (OR, 4.50; 95% CI, 1.19-17.03; P = .03), and intensive care unit stay ≥2 weeks (OR, 6.21; 95% CI, 1.72-22.45; P = .005) were associated with acquisition of CPE.

CONCLUSIONS

Early posttransplantation CPE acquisition may affect the clinical outcome of SOT recipients. Careful screening for CPE during the early posttransplantation period would be meaningful in recipients with risk factors.

Nosocomial person-to-person transmission of severe fever with thrombocytopenia syndrome

OBJECTIVES

This study is an epidemiologic investigation of nosocomial severe fever with thrombocytopenia syndrome virus (SFTSV) transmission among healthcare workers (HCWs) after contact with an index patient. The aim of this study was to determine whether exposure to blood or bloody respiratory secretion is associated with human-to-human transmission of SFTSV.

METHODS

Eleven days after the index patient died, two HCWs who had close exposure to the patient presented with typical symptoms of SFTS. An epidemiological investigation was conducted on all 25 HCWs who had been in close contact with the index patient. Clinical and laboratory data were collected, and transmission rate before and after the index patient had haemorrhagic manifestations was analysed.

RESULTS

Among 25 HCWs who had direct contact with the index patient, five HCWs were confirmed to have SFTS. All five HCWs had contact to blood or bloody respiratory secretions of the index patient without adequate use of personal protective equipment (PPE). No HCW with contact before haemorrhagic manifestations of the index patient contracted SFTS. Overall, the transmission rate was higher for HCWs who had contact after the index patient had haemorrhagic manifestations (33.3%, five of 15 HCWs, vs. 0%, zero of ten HCWs, p 0.041).

CONCLUSIONS

In HCWs who are inadequately protected, person-to-person transmission of SFTSV may be associated with contact with blood or bloody respiratory secretions. Therefore, universal precaution and full PPE is highly recommended for protection against SFTSV when there are signs of bleeding.

Cardiovascular disease-related mortality and factors associated with cardiovascular events in the TREAT Asia HIV Observational Database (TAHOD)

OBJECTIVES

With aging of the HIV-positive population, cardiovascular disease (CVD) increasingly contributes to morbidity and mortality. We investigated CVD-related and other causes of death (CODs) and factors associated with CVD in a multi-country Asian HIV-positive cohort.

METHODS

Patient data from 2003-2017 were obtained from the Therapeutics, Research, Education and AIDS Training in Asia (TREAT Asia) HIV Observational Database (TAHOD). We included patients on antiretroviral therapy (ART) with > 1 day of follow-up. Cumulative incidences were plotted for CVD-related, AIDS-related, non-AIDS-related, and unknown CODs, and any CVD (i.e. fatal and nonfatal). Competing risk regression was used to assess risk factors of any CVD.

RESULTS

Of 8069 patients with a median follow-up of 7.3 years [interquartile range (IQR) 4.4-10.7 years], 378 patients died [incidence rate (IR) 6.2 per 1000 person-years (PY)], and this total included 22 CVD-related deaths (IR 0.36 per 1000 PY). Factors significantly associated with any CVD event (IR 2.2 per 1000 PY) were older age [sub-hazard ratio (sHR) 2.21; 95% confidence interval (CI) 1.36-3.58 for age 41-50 years; sHR 5.52; 95% CI 3.43-8.91 for ≥ 51 years, compared with < 40 years], high blood pressure (sHR 1.62; 95% CI 1.04-2.52), high total cholesterol (sHR 1.89; 95% CI 1.27-2.82), high triglycerides (sHR 1.55; 95% CI 1.02-2.37) and high body mass index (BMI) (sHR 1.66; 95% CI 1.12-2.46). CVD crude IRs were lower in the later ART initiation period and in lower middle- and upper middle-income countries.

CONCLUSIONS

The development of fatal and nonfatal CVD events in our cohort was associated with older age, and treatable risk factors such as high blood pressure, triglycerides, total cholesterol and BMI. Lower CVD event rates in middle-income countries may indicate under-diagnosis of CVD in Asian-Pacific resource-limited settings.

Early development of de novo hepatocellular carcinoma after direct-acting agent therapy: Comparison with pegylated interferon-based therapy in chronic hepatitis C patients

Patients with chronic hepatitis C who achieve a sustained viral response after pegylated interferon therapy have a reduced risk of hepatocellular carcinoma, but the risk after treatment with direct-acting antivirals is unclear. We compared the rates of early development of hepatocellular carcinoma after direct-acting antivirals and after pegylated interferon therapy. We retrospectively analysed 785 patients with chronic hepatitis C who had no history of hepatocellular carcinoma (211 treated with pegylated interferon, 574 with direct-acting antivirals) and were followed up for at least 24 weeks after antiviral treatment. De novo hepatocellular carcinoma developed in 6 of 574 patients receiving direct-acting antivirals and in 1 of 211 patients receiving pegylated interferon. The cumulative incidence of early hepatocellular carcinoma development did not differ between the treatment groups either for the whole cohort (1.05% vs 0.47%, P = .298) or for those patients with Child-Pugh Class A cirrhosis (3.73% vs 2.94%, P = .827). Multivariate analysis indicated that alpha-fetoprotein level >9.5 ng/mL at the time of end-of-treatment response was the only independent risk factor for early development of hepatocellular carcinoma in all patients (P < .0001, hazard ratio 176.174, 95% confidence interval 10.768-2882.473) and in patients treated with direct-acting agents (P < .0001, hazard ratio 128.402, 95% confidence interval 8.417-1958.680). In conclusion, the rate of early development of hepatocellular carcinoma did not differ between patients treated with pegylated interferon and those treated with direct-acting antivirals and was associated with the serum alpha-fetoprotein level at the time of end-of-treatment response.

Impact of Pretransplant Infections on Clinical Course in Liver Transplant Recipients

BACKGROUND

Uncontrolled infections are known to be an absolute contraindication for liver transplantation; however, the posttransplant prognosis of recipients treated for pretransplant infection is unclear. The aim of this study was to analyze pretransplant infections among liver transplant recipients and to determine their impact on posttransplant clinical outcomes.

METHODS

This study retrospectively analyzed 357 subjects who had undergone living-donor liver transplantation between January 2008 and May 2014.

RESULTS

Among 357 recipients, 71 patients (19.8%) had 74 episodes of infectious complications before liver transplantation. These complications consisted of pneumonia (n = 13), spontaneous bacterial peritonitis (n = 12), catheter-related infection (n = 10), urinary tract infection (n = 12), biliary tract infection (n = 6), and skin and soft-tissue infection (n = 3). Twenty-six patients experienced 29 episodes of bacteremia, and the most common pathogens were coagulase-negative staphylococci (n = 8), followed by Klebsiella pneumoniae (n = 7), Staphylococcus aureus (n = 4), and Streptococcus species (n = 3). Twenty-one bacteremic episodes (70%) occurred within 1 month before transplantation (n = 4). Recipients with pretransplant infections had significantly more frequent posttransplant infections (71.8% [51 of 71] vs 47.2% [35 of 286]; P = .0001), posttransplant bacteremia (33.8% [24 of 71] vs 20.3% [58 of 286]; P = .015), and longer posttransplant intensive care unit stays (11.2 ± 10.7 days vs 7.3 ± 4.2 days; P = .0004) than those without pretransplant infections. However, episodes of rejection (P = .36), length of hospitalization (P = .10), 28-day mortality (P = .31), and 1-year mortality (P = .61) after transplantation were not significantly different between the 2 groups.

CONCLUSIONS

Pretransplant infection had an impact on posttransplant morbidity, although not on rejection and mortality. Alertness for posttransplant infection and proper management (including effective antimicrobial coverage) would improve patient morbidity.

Benefits of active middle ear implants over hearing aids in patients with sloping high tone hearing loss: comparison with hearing aids

In this retrospective chart review we compared the subjective and objective benefits of active middle ear implants (AMEIs) with conventional hearing aids (HAs) in patients with sloping high tone hearing loss. Thirty-four patients with sensorineural hearing loss were treated with AMEIs. Of these, six had sloping high tone hearing loss and had worn an HA for more than 6 months. Objective assessments, a pure-tone audiogram, as well as a word recognition test, and the Korean version of the Hearing in Noise Test (K-HINT), and a subjective assessment, the Abbreviated Profile of Hearing Aid Benefit (APHAB) questionnaire, were performed. Tests were conducted under three circumstances: 1) the unaided state before surgery; 2) the HA-aided state before surgery; and 3) the AMEI-aided state 3 months after surgery. The average high-frequency hearing gain (≥ 2 kHz) was significantly better with AMEIs than with HAs. Although the result had no statistical significance, AMEIs showed a superior word recognition score (WRS) compared to HAs. However, the most comfortable hearing level at which the WRS was tested was significantly decreased with an AMEI compared to an HA. In the K-HINT, patients with an AMEI showed greater recognition than those fitted with an HA under both quiet and noisy conditions. The APAHB scores revealed that patients were more satisfied with an AMEI rather than an HA on all subscales. The use of vibroplasty in patients with sloping high tone loss resulted in positive hearing outcomes when compared to conventional HAs. Based on the data from this study, AMEIs provided better objective and subjective results and could, therefore, be a better alternative for the treatment of sloping hearing loss.

Abstract P6-08-09: Incidence and risk factors for congestive heart failure in early breast cancer received anthracycline and/or trastuzumab; big-data analysis of Korean health insurance review and assessment service database

Background: Anthracycline (AC) and/or trastuzumab (T) are the most commonly used for neo-/adjuvant therapy for early breast cancer. However, use of those regimens are limited owing to congestive heart failure (CHF). Although reported incidence from pivotal trials is very low and acceptable, no big data-based population study has not been conducted in Koreans yet. The aim of this study was to analyze the incidence, time to occurrence, and risk factors for CHF in patients with early breast cancer, who were treated with AC and/or T therapy, in Korea.

Methods: We used the Health Insurance Review and Assessment Service database and included women with no prior history of CHF who were aged &gt;19 years and diagnosed as having early breast cancer between 2007 and 2016. Only patients who had received breast cancer surgery and AC and/or T therapy were included. Patients with metastatic cancer codes were excluded.

Result: In total, 86,086 patients were included for this analysis. The incidence and median time to occurrence of CHF according to chemotherapy type were, 3.27% and 683.5 days in the AC only group, 6.39% and 374 days in the AC followed by T group, and 4.43% and 286 days in the T with or without non-AC group, respectively.

The multivariate Cox regression analysis revealed that the adjusted hazard ratio (HR) for CHF was increased with older age; in those aged ≥65 years versus &lt;50 years (HR, 2.79; 95% confidence interval [CI], 2.50–3.12). The HR in the AC followed by T group was significantly higher than that in the AC only group (HR, 2.21; 95% CI, 2.05-2.37). The T with or without non-AC group also showed a significantly higher HR than the AC only group (HR, 1.67; 95% CI, 1.37-2.04). CCI scores of ≥2 were significant predictors of CHF; score 2 versus 0 (HR, 1.30; 95% CI, 1.18-1.45), and score ≥3 versus 0 (HR, 1.87; 95% CI, 1.69-2.06). In addition, preexisting medical conditions were significant predictors for CHF: hypertension (HR, 1.58; 95% CI, 1.45-1.72), diabetes (HR, 1.17; 95% CI, 1.07-1.28), and ischemic heart disease (HR, 1.60; 95% CI, 1.45-1.76).

Conclusion: This is the first big data-based population study in Korea on the development of CHF after treatment with AC and/or T. The overall incidence of CHF was 3% to 6%, with a median time to occurrence of 1 to 2 years. Adjusted HR increased with older age, AC followed by T therapy, CCI scores ≥2, and preexisting conditions.

Table 1. Incidence and median time to occurrence of congestive heart failure according to chemotherapy typeChemotherapy typeTotalCHF event (%)Median time to occurenceAC only66,6992,182 (3.27%)683.5AC followed by T17,0621,090 (6.39%)374T ± non-AC2,325103 (4.43%)286

Table 2. Cox proportional hazards model for congestive heart failure, adjusted for age, chemotherapy type, and Charlson comorbidity index scoreVariableP-valueHR95% CIAge (ref &lt;50 years)   50-64 years&lt;0.00011.541.43-1.66≥65 years&lt;0.00012.792.50-3.12Chemotherapy type (ref AC only)   AC folloewed by T&lt;0.00012.212.05-2.37T ± non-AC&lt;0.00011.671.37-2.04Charlson comorbidity index score (ref 0)   10.12061.080.98-1.192&lt;0.00011.301.18-1.45≥3&lt;0.00011.871.69-2.06

Citation Format: Choi JY, Cho EY, Lee JW, Kim JW, Choi YJ, You JY, Bae SY, Jung SP, Cho KR, Park KH. Incidence and risk factors for congestive heart failure in early breast cancer received anthracycline and/or trastuzumab; big-data analysis of Korean health insurance review and assessment service database [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-08-09.

Pure laparoscopic living donor hepatectomy: Focus on 55 donors undergoing right hepatectomy

Although laparoscopic donor hepatectomy is increasingly common, few centers with substantial experience have reported the results of pure laparoscopic donor right hepatectomy (PLDRH). Here, we report the experiences of 60 consecutive liver donors undergoing pure laparoscopic donor hepatectomy (PLDH), with most undergoing right hepatectomy. None of the 60 donors who underwent PLDH had intraoperative complications and none required transfusions, reoperation, or conversion to open hepatectomy. Forty-five donors who underwent PLDRH between November 2015 and December 2016 were compared with 42 who underwent conventional donor right hepatectomy (CDRH) between May 2013 and February 2014. The total operation time was longer (330.7 vs 280.0 minutes; P < .001) and the percentage with multiple bile duct openings was higher (53.3% vs 26.2%; P = .010) in the PLDRH group. However, the length of postoperative hospital stay (8.4 vs 8.2 days; P = .495) and rate of complications (11.9% vs 8.9%; P = .733) and re-hospitalizations (4.8% vs 4.4%; P = 1.000) were similar in both groups. PLDH, including PLDRH, is feasible when performed by a highly experienced surgeon and transplant team. Further evaluation, including long-term results, may support these preliminary findings of comparative outcomes for donors undergoing PLDRH and CDRH.

Reliability and validity of the Korean-language version of the Communication Function Classification System in children with cerebral palsy

PURPOSE

The Communication Function Classification System (CFCS) and Viking Speech Scale (VSS) are useful systems for describing the broad communication function and speech intelligibility, respectively, of children with cerebral palsy (CP). The aims of this study were to determine the reliability and validity of the Korean version of the CFCS and also to investigate the association between the CFCS and the VSS and other functional classifications for children with CP.

MATERIALS AND METHODS

Participants were 50 children with CP (33 males, 17 females; mean age 7.2 years, range 4-16 years) recruited from a rehabilitation hospital. We analysed the interrater and intrarater reliabilities of the Korean version of the CFCS and VSS between parents, a physiatrist, and a speech-language pathologist (SLP). The social function domain of the Paediatric Evaluation of Disability Inventory was assessed to examine the concurrent validity of the CFCS and VSS.

RESULTS

The intrarater reliabilities of the CFCS and VSS were excellent in a physiatrist (ƙ = 0.92, ƙ = 0.94, respectively) and an SLP (ƙ = 0.98, ƙ = 0.98) and very good in parents (ƙ = 0.87, ƙ = 0.89). The interrater reliability of the CFCS and VSS was very good between the physiatrist and SLP (ƙ = 0.87, ƙ = 0.89) and good between parents and the SLP (ƙ = 0.63, ƙ = 0.78) and between parents and the physiatrist (ƙ = 0.61, ƙ = 0.76). The CFCS and VSS were strongly related with the social function domain of Paediatric Evaluation of Disability Inventory. In addition, we found very strong associations between the VSS and CFCS.

CONCLUSIONS

The Korean version of the CFCS is a valid and reliable tool to classify communication ability and is strongly associated with the VSS, a reliable tool to classify speech intelligibility.

Towards the identification of Idiopathic Parkinson's Disease from the speech. New articulatory kinetic biomarkers

Although a large amount of acoustic indicators have already been proposed in the literature to evaluate the hypokinetic dysarthria of people with Parkinson’s Disease, the goal of this work is to identify and interpret new reliable and complementary articulatory biomarkers that could be applied to predict/evaluate Parkinson’s Disease from a diadochokinetic test, contributing to the possibility of a further multidimensional analysis of the speech of parkinsonian patients. The new biomarkers proposed are based on the kinetic behaviour of the envelope trace, which is directly linked with the articulatory dysfunctions introduced by the disease since the early stages. The interest of these new articulatory indicators stands on their easiness of identification and interpretation, and their potential to be translated into computer based automatic methods to screen the disease from the speech. Throughout this paper, the accuracy provided by these acoustic kinetic biomarkers is compared with the one obtained with a baseline system based on speaker identification techniques. Results show accuracies around 85% that are in line with those obtained with the complex state of the art speaker recognition techniques, but with an easier physical interpretation, which open the possibility to be transferred to a clinical setting.

Comparison of Kaposi Sarcoma Risk in Human Immunodeficiency Virus-Positive Adults Across 5 Continents: A Multiregional Multicohort Study

BACKGROUND

We compared Kaposi sarcoma (KS) risk in adults who started antiretroviral therapy (ART) across the Asia-Pacific, South Africa, Europe, Latin, and North America.

METHODS

We included cohort data of human immunodeficiency virus (HIV)-positive adults who started ART after 1995 within the framework of 2 large collaborations of observational HIV cohorts. We present incidence rates and adjusted hazard ratios (aHRs).

RESULTS

We included 208140 patients from 57 countries. Over a period of 1066572 person-years, 2046 KS cases were diagnosed. KS incidence rates per 100000 person-years were 52 in the Asia-Pacific and ranged between 180 and 280 in the other regions. KS risk was 5 times higher in South African women (aHR, 4.56; 95% confidence intervals [CI], 2.73-7.62) than in their European counterparts, and 2 times higher in South African men (2.21; 1.34-3.63). In Europe, Latin, and North America KS risk was 6 times higher in men who have sex with men (aHR, 5.95; 95% CI, 5.09-6.96) than in women. Comparing patients with current CD4 cell counts ≥700 cells/µL with those whose counts were <50 cells/µL, the KS risk was halved in South Africa (aHR, 0.53; 95% CI, .17-1.63) but reduced by ≥95% in other regions.

CONCLUSIONS

Despite important ART-related declines in KS incidence, men and women in South Africa and men who have sex with men remain at increased KS risk, likely due to high human herpesvirus 8 coinfection rates. Early ART initiation and maintenance of high CD4 cell counts are essential to further reducing KS incidence worldwide, but additional measures might be needed, especially in Southern Africa.

Incidence, prevalence, and mortality of Adamantiades-Behçet's disease in Korea: a nationwide, population-based study (2006-2015)

BACKGROUND

The epidemiology of Adamantiades-Behçet's disease varies among ethnic populations worldwide. Trends in the incidence of Adamantiades-Behçet's disease have not been investigated based on the Korean National Health Insurance database.

OBJECTIVES

This study investigated the incidence and mortality of Adamantiades-Behçet's disease by age using nationwide population data in Korea.

METHODS

A nationwide population-based cohort study was performed using the Korean National Health Insurance Claims Database from 2006 to 2015. The incidence of Adamantiades-Behçet's disease was calculated by age, sex, calendar year and habitat. And comorbid metabolic diseases were also analysed in patients with Adamantiades-Behçet's disease.

RESULTS

The annual incidence of Adamantiades-Behçet's disease per 100 000 person-years was 3.976 (2.587 for males and 5.373 for females) from 2006 to 2015. The incidence of Adamantiades-Behçet's disease peaked among people in their 40s (6.561 per 100 000 person-years). Incidence was significantly higher in subjects with comorbid metabolic conditions, such as diabetes mellitus, hypertension and dyslipidemia. The mortality rate per 1000 person-years increased with age in patients with Adamantiades-Behçet's disease.

CONCLUSIONS

This study showed the incidence, prevalence and mortality of Adamantiades-Behçet's disease. Metabolic conditions increased the risk of Adamantiades-Behçet's disease among Koreans.

Smoking and projected cardiovascular risk in an HIV-positive Asian regional cohort

OBJECTIVES

The aim of the study was to assess the prevalence and characteristics associated with current smoking in an Asian HIV-positive cohort, to calculate the predictive risks of cardiovascular disease (CVD), coronary heart disease (CHD) and myocardial infarction (MI), and to identify the impact that simulated interventions may have.

METHODS

Logistic regression analysis was used to distinguish associated current smoking characteristics. Five-year predictive risks of CVD, CHD and MI and the impact of simulated interventions were calculated utilizing the Data Collection on Adverse Effects of Anti-HIV Drugs Study (D:A:D) algorithm.

RESULTS

Smoking status data were collected from 4274 participants and 1496 of these had sufficient data for simulated intervention calculations. Current smoking prevalence in these two groups was similar (23.2% vs. 19.9%, respectively). Characteristics associated with current smoking included age > 50 years compared with 30-39 years [odds ratio (OR) 0.65; 95% confidence interval (CI) 0.51-0.83], HIV exposure through injecting drug use compared with heterosexual exposure (OR 3.03; 95% CI 2.25-4.07), and receiving antiretroviral therapy (ART) at study sites in Singapore, South Korea, Malaysia, Japan and Vietnam in comparison to Thailand (all OR > 2). Women were less likely to smoke than men (OR 0.11; 95% CI 0.08-0.14). In simulated interventions, smoking cessation demonstrated the greatest impact in reducing CVD and CHD risk and closely approximated the impact of switching from abacavir to an alternate antiretroviral in the reduction of 5-year MI risk.

CONCLUSIONS

Multiple interventions could reduce CVD, CHD and MI risk in Asian HIV-positive patients, with smoking cessation potentially being the most influential.

Atopic dermatitis is inversely associated with hepatitis B antigen positivity: a population-based cohort study

BACKGROUND

No clear association between hepatitis B virus (HBV) infection and atopic dermatitis (AD) has been established. Some studies have reported that subjects with HBV had an increased risk of atopy; other studies reported an inverse association between HBV seropositivity and allergic diseases.

OBJECTIVE

We evaluated the association between AD and hepatitis B antigen (HBsAg) positivity using Korean National Health and Nutrition Examination Survey data.

METHODS

In total, 14 776 participants aged >19 years were included in the analysis. Multiple logistic regression analyses were used to evaluate the odds ratio of HBsAg positivity in association with AD and asthma.

RESULTS

The prevalence of HBsAg positivity was lower in individuals with AD than in those without AD (mean [SE], 0.7% [0.4] vs. 3.7% [0.2]; P < 0.001). However, HBsAg positivity was not significantly associated with asthma (3.7% [0.2] vs. 2.8% [0.8]; P < 0.001). HBsAg positivity decreased the risk of AD significantly (OR = 0.223; 95% CI = 0.069-0.72).

CONCLUSIONS

This study demonstrates an inverse association between AD and HBsAg positivity using a nationwide, population-based, cross-sectional health examination and survey.

Testosterone effects on pain and brain activation patterns

BACKGROUND

This study investigated whether pain and pain-related unpleasantness ratings were altered by blood testosterone levels. We also investigated whether activation of brain regions that represent pain intensity [primary somatosensory cortex (S1)] and pain-related unpleasantness [perigenual ACC (pACC) and orbitofrontal cortex (OFC)] were affected by blood testosterone levels.

METHODS

Twenty-six healthy men were recruited. Blood testosterone levels were measured before fMRI scanning. The participants were classified into two groups (high vs. low testosterone) according to their blood testosterone level (each group n = 13). The middle finger was immersed in a 50°C water bath (50°C, 30 s, five times) to induce identical noxious stimulation in all participants.

RESULTS

The low testosterone group showed statistically significantly higher pain (P = 0.047), unpleasantness (P = 0.047), anxiety (P = 0.015), and fear ratings (P = 0.01) than the high testosterone group. Fear rating increased as pain rating rose and as testosterone level decreased (P < 0.001). When participants received noxious stimulation, the pACC and OFC were more highly activated in the low testosterone group compared to the high testosterone group. Activation of S1, a region related to pain intensity, did not differ between both groups.

CONCLUSION

Compared to the high testosterone group, the low testosterone group had significant activation in the pACC and OFC, regions that represent pain-related unpleasantness, but not in S1 that represents pain intensity, leading to higher pain ratings. These findings emphasize the importance of considering the effects of testosterone levels when treating patients.

Validation of the Korean National Healthcare-associated Infections Surveillance System (KONIS): an intensive care unit module report

BACKGROUND

National surveillance data should be validated to identify methodological problems within the surveillance programme and data quality issues.

AIM

To test the validity of healthcare-associated infection (HAI) rate data from the Korean National Healthcare-associated Infections Surveillance System (KONIS).

METHODS

Records from intensive care units of 12 (14.8%) of 81 participating hospitals for January-March 2014 were examined. The validation team reviewed 406 medical records of 110 patients with 114 reported HAIs - including 34 urinary tract infections (UTIs), 57 bloodstream infections (BSIs) and 23 cases of pneumonia (PNEU) - and 296 patients with no reported HAIs during one-day visits conducted in August and September 2014. The reviewers' diagnosis of HAI was regarded as the reference standard; in ambiguous cases, the KONIS Steering Committee confirmed the diagnosis of HAI.

FINDINGS

Sensitivity values for UTIs, BSIs and PNEU were 85.3%, 74.0% and 66.7%, and specificity values were 98.7%, 99.1% and 98.7%, respectively. Positive predictive values were 85.3%, 94.7% and 78.3%, and negative predictive values were 98.7%, 94.6% and 97.7%, respectively. Sensitivity for PNEU was lower than that for UTIs and BSIs. The hospitals participating in KONIS infrequently reported conditions that were not HAIs. Sensitivity for BSIs was lower in this study than in KONIS validation studies conducted in 2008 and 2010.

CONCLUSIONS

KONIS data are generally reliable; however, sensitivity for BSIs exhibited a decrease. This study shows the need for ongoing validation and continuous training of surveillance personnel to maintain the accuracy of surveillance data.

Normal-appearing white matter demyelination in neuromyelitis optica spectrum disorder

BACKGROUND AND PURPOSE

Increasing evidence suggests the presence of demyelination in the normal-appearing white matter (NAWM) of patients with neuromyelitis optica spectrum disorder (NMOSD). The objective was to determine the presence of subclinical demyelination in the NAWM of patients with NMOSD using myelin water imaging (MWI).

METHODS

Whole brain and regions-of-interest (ROIs) analyses, including the centrum semiovale, corona radiata, genu and splenium of the corpus callosum, and optic radiation, were conducted in the NAWM of 28 NMOSD patients and 18 healthy controls (HCs) using two MWI modalities: conventional MWI and direct visualization of short transverse relaxation time component (ViSTa) MWI.

RESULTS

Conventional myelin water fractions (MWFs) of the global NAWM and three ROIs (centrum semiovale, corona radiata, and genu of the corpus callosum) were slightly lower in NMOSD patients than in HCs, although not statistically significant. On the other hand, ViSTa MWF values of the global NAWM and all ROIs except the genu of the corpus callosum were significantly lower in NMOSD patients relative to HCs. In particular, the MWF in the optic radiation was significantly reduced in NMOSD patients relative to HCs in both MWI methods, even in patients who had no brain involvement. Additionally, patients with optic neuritis showed lower MWF than patients without optic neuritis and a negative correlation was identified between the MWF of the optic radiation and visual functional system score.

CONCLUSIONS

This study identified the presence of widespread demyelination in the NAWM of NMOSD patients and highlighted the optic radiation as a site of marked demyelination.

Abstract P2-04-24: Changes of tumor-infiltrating lymphocytes and programmed death-ligand1 positivity after neoadjuvant chemotherapy in patients with locally advanced breast cancer

Background

Recently, the balance in immune system between immune surveillance and tolerance is known to be associated with the prognosis of breast cancer patients. The aim of this study was to investigate changes of tumor-infiltrating lymphocytes (TILs) and programmed death-ligand1 (PD-L1) status after neoadjuvant chemotherapy (NAC) and their impact on recurrence in patients with locally advanced breast cancer.

Methods

Paired samples (before and after NAC) of triple negative or HER2+ breast cancer tissue were obtained from clinical stage II or III patients (n=39) undergoing NAC and subsequent breast resection. The assessment of immunohistochemical (IHC) staining for PD-L1 were performed. Immunostaining of forkhead box P3 (Foxp3) and CD4/CD8 were performed for subtyping of TILs in triple negative breast cancer (TNBC) only. Clinicopathologic data including baseline characteristics, tumor response and recurrence were reviewed.

Results

Proportion of PD-L1 (+) tumor cells in pre-chemotherapy tissue was 20% (5/25) in HER2+ and 28.6% (4/14) in TNBC. It could not predict pathologic complete response. Most post-chemotherapy tissue (21/24) showed same PD-L1 positivity with pre-chemotherapy tissue. The rest showed the decreased PD-L1 positivity after NAC.

In cases of TNBC, the increased number of CD8+ T cells was significantly associated with PD-L1 positivity in pre-chemotherapy tissue. (p=0.001) Foxp3+ T cell proportions decreased significantly (p=0.046) and CD8+/Foxp3+ T-cell ratio increased significantly (p=0.023) after NAC. The patients with increased number of CD8+ T cells after NAC had a tendency to live longer without recurrence compared to patients with decreased CD8+ T cells (62.3 vs 38.1 months, p=0.158).

Conclusion

Our data provides the clinical evidence that PD-L1 positivity are associated with CD8+ T cell proportion and increased CD8+ T cells after NAC might be good prognostic marker. The role of immunologic balance as a prognostic marker for recurrence must be evaluated in future study.

Citation Format: Choi YJ, Lee JH, Moon SY, Choi JY, Jung SP, Bae JW, Park KH. Changes of tumor-infiltrating lymphocytes and programmed death-ligand1 positivity after neoadjuvant chemotherapy in patients with locally advanced breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-04-24.

Ten-Year Experience With Bowel Transplantation at Seoul St. Mary's Hospital

A retrospective review of intestinal transplantation (ITx) at Seoul St. Mary's Hospital was made by collecting clinical data over the past 10 years. Fifteen consecutive cases from 2004 were analyzed. Five children and 10 adults (6 months to 69 years of age) were included. Primary diseases in adults included 4 mesenteric vessel thromboses, 2 strangulations, and 1 each of visceral myopathy, malignant gastrointestinal stromal tumor (GIST), mesenteric lymphangiectasis, and injury. Pediatric cases involved 2 Hirschsprung disease, 2 visceral myopathy, and 1 necrotizing enterocolitis. Three of 7 stomas were closed using a serial transverse enteroplasty procedure before transplantation. The ITx were performed using 3 living-donor Itx, 12 deceased-donor ITx, 14 isolated Itx, and 1 modified multivisceral transplantation. Daclizumab, basiliximab, alemtusumab, or basiliximab with rabbit antithymocyte globulin (rATG) was used for the induction; tacrolimus monotherapy was used as the basic maintenance immunosuppressant; and m-TOR inhibitor was used for renal dysfunction patients. Seven cases of acute cellular rejection were treated with rATG. Three cases of antibody-mediated rejection were treated with rituximab alone or with rituximab and bortezomib combination. There were 4 cases of early mortality within 6 months after Itx. Causes of death were declamping shock, cardiac tamponade with acute cellular rejection, dysmotility, and sepsis. Surgical complications consisted of 1 feeding jejunostomy displacement, and a minor leakage at a colo-colostomy site. One-year survival of the patient and graft was 73.33% (Kaplan-Meier survival curve). Although the total number of ITx is small, its social impact has been remarkable in changing the related laws and reimbursement policy in Korea.

Short-Term Outcomes of ABO-Incompatible Living Donor Kidney Transplantation With Uniform Protocol: Significance of Baseline Anti-ABO Titer

Antibody-mediated rejection (AMR) is one of the major causes of poor outcomes in ABO-incompatible kidney transplantation (ABOi KT). Studies investigating AMR risk factors found that anti-ABO titer is a major issue. However, the significance of antibody titer has been debated. This retrospective study analyzed AMR risk factors in 59 patients who underwent ABOi KT between August 2010 and January 2015. We also analyzed AMR risk factors in recipients with high anti-ABO baseline titers (≥1:64 on dithiothreitol at 37°C phase or ≥1:256 on antihuman globulin phase). The 2-year patient survival rate was 95.8%, and the 2-year graft survival rate was 94.9%. Nine patients (15.3%) experienced clinical (6 of 59 [10.2%]) or subclinical (3 of 59 [5.1%]) AMR. One patient experienced graft loss from hyperacute rejection. AMR risk factor analysis revealed that baseline antibody titer was associated with incidence of AMR. In patients with high baseline titers, low doses of rituximab (200-mg single-dose), an antibody against CD20, was predictive for AMR. Six patients who received pretransplant intravenous immunoglobulin did not experience AMR even when they had high baseline antibody titers. Our results indicate that a high baseline antibody titer affected the incidence of AMR. ABOi KT candidates with high baseline titers need to undergo an intensified preconditioning protocol, including high-dose rituximab (375 mg/m(2)) and intravenous immunoglobulin.