Short-term outcomes of laparoscopic and robotic distal gastrectomy for gastric cancer: Real-world evidence from a large-scale inpatient database in Japan

BACKGROUND AND OBJECTIVES

Robotic distal gastrectomy (RDG) has been widely performed throughout Japan since it became insured in 2018. This study aimed to evaluate the short-term outcomes of RDG and laparoscopic distal gastrectomy (LDG) for gastric cancer using real-world data.

METHODS

A total of 4161 patients who underwent LDG (n = 3173) or RDG (n = 988) for gastric cancer between April 2018 and October 2022 were identified through the Japanese Diagnosis Procedure Combination Database, which covers 42 national university hospitals. The primary outcome was postoperative in-hospital mortality rate. The secondary outcomes were postoperative complication rates, time to diet resumption, and postoperative length of stay (LOS).

RESULTS

In-hospital mortality and postoperative complication rates in the RDG group were comparable with those in the LDG group (0.1% vs. 0.0%, p = 1.000, and 8.7% vs. 8.2%, p = 0.693, respectively). RDG was associated with a longer duration of anesthesia (325 vs. 262 min, p < 0.001), similar time to diet resumption (3 vs. 3 days, p < 0.001), and shorter postoperative LOS (10 vs. 11 days, p < 0.001) compared with LDG.

CONCLUSIONS

RDG was performed safely and provided shorter postoperative LOS, since it became covered by insurance in Japan.

Transmesenteric approach for laparoscopic endoscopic cooperative surgery for a duodenal adenoma located in the third portion of the duodenum

We report our experience in a patient with adenoma located in the horizontal part of the duodenum, which was effectively treated with the transmesenteric laparoscopic endoscopic cooperative surgery (LECS) approach. This approach, which entails incising the mesentery of the colon, simplified laparoscopic access to the horizontal part of the duodenum, which was minimally mobilized. Thus, the bulb and descending part of the duodenum were fixed to the retroperitoneum, facilitating stable handling of the endoscope and enabled safe and effective excision of an adenoma located in the horizontal part of the duodenum. This approach enabled safe and effective excision of an adenoma located in the horizontal part of the duodenum. The advantages of this method include a secure field of view, lower probability of damage to large vessels, and minimizing the defect to the intestine caused by the incision.

Cetuximab Enhances the Efficacy of MRTX1133, a Novel KRASG12D Inhibitor, in Colorectal Cancer Treatment

BACKGROUND/AIM

Kirsten Rat Sarcoma viral oncogene homolog (KRAS) has remained undruggable for decades. KRAS has predominantly been used to evaluate the applicability of anti-Epidermal Growth Factor Receptor (EGFR) antibody drugs. However, various KRAS inhibitors have recently emerged. Unfortunately, KRAS inhibitors have not been effective against colorectal cancer. Therefore, this study aimed to determine the effects of MRTX1133, a novel KRASG12D inhibitor, in combination with an anti-EGFR antibody, cetuximab, on signal transduction and cell proliferation.

MATERIALS AND METHODS

The KRASG12D-mutated LS513 and KRAS wild-type CACO-2 human colon cancer cell lines were utilized. The KRASG12D mutation was stably transduced into the CACO-2 cells using a retrovirus. We evaluated the effects of the drugs using the CCK-8 assay and assessed the activity of proteins related to the MAPK pathway using western blotting.

RESULTS

We demonstrated that the administration of MRTX1133, a novel KRASG12D inhibitor, to KRASG12D-mutated colorectal cancer cells led to feedback activation of the ERK pathway via EGFR activation, inducing drug resistance. Intriguingly, when MRTX1133 was used in combination with cetuximab, KRASG12D-mutant colorectal cancer growth was effectively inhibited, both in vitro and in vivo.

CONCLUSION

The combination of MRTX1133 and cetuximab serves as a potential and promising therapeutic approach for colorectal cancer with KRASG12D mutation. KRASG12D is a frequent genetic mutation not only in colorectal cancer, but also in pancreatic and lung cancer, and the results of this study open new avenues for potential treatment of many cancer patients.

Impact of Oophorectomy on Survival and Improving Nutritional Status in Ovarian Metastasis from Colorectal Adenocarcinoma

INTRODUCTION

Ovarian metastasis of colorectal cancer is known to have a poor prognosis. This study aimed to elucidate the characteristics of patients who underwent oophorectomy for ovarian metastasis from colorectal cancer.

METHODS

This retrospective study included 16 patients who underwent oophorectomy for colorectal cancer metastasis to the ovary from January 2004 to December 2017. Improvement in patient's symptoms and pre- and postoperative changes in various nutritional and inflammatory indicators were assessed. Survival analysis and identification of prognostic factors were conducted with a median follow-up of 40.7 (5-109) months.

RESULTS

Of 16 patients, 12 had (75%) synchronous and 4 (25%) had metachronous metastasis. Fourteen patients were symptomatic but symptoms resolved postoperatively. Thirteen patients (81.3%) had ascites and 5 (31.3%) had pleural effusion on preoperative computed tomography that disappeared after surgery in all cases. The median value of prognostic nutritional factor was significantly increased postoperatively (36.0 [preoperatively] vs. 47.5, p < 0.0001). The median (interquartile range) values for lymphocyte-C-reactive protein ratio were 715.2 (110-2,607) preoperatively and 6,095.2 (1,612.3-14,431.8) postoperatively (p = 0.0214). The median survival of the entire cohort was 60.4 months. The 3-year survival rates for R0 + R1 and R2 cases were 83% and 24% (p = 0.018), respectively. Univariate analysis showed that R2 resection and low postoperative lymphocyte-C-reactive protein ratio were associated with poor prognosis.

CONCLUSIONS

Oophorectomy for ovarian metastasis from colorectal cancers was safely performed. It improved the patients' symptoms and nutritional status and may result in improved prognosis.

Comparison of Short-term Outcomes Between Esophageal Bypass Surgery and Self-expanding Stent Insertion in Esophageal Cancer: A Propensity Score-matched Analysis Using a Large-scale Inpatient Database

BACKGROUND

Advanced esophageal cancer is occasionally accompanied by difficulty swallowing owing to esophageal stenosis or tracheoesophageal fistula formation. Esophageal bypass surgery and stent insertion are considered feasible palliative management options. The aim of this study was to evaluate the short-term outcomes of these palliative treatments.

MATERIALS AND METHODS

Patient data were obtained from a large-scale inpatient database of 42 National University Hospitals in Japan. Patients with advanced esophageal cancer who underwent esophageal bypass surgery or stent insertion between April 2016 and March 2021 were included in this study. One-to-one propensity score matching of patients who underwent bypass surgery or stent insertion was performed. The primary outcomes were time to diet resumption and length of hospital stay after surgery. The secondary outcome was the incidence of postoperative complications.

RESULTS

In 43 propensity score-matched pairs, the incidence of postoperative respiratory complications was significantly higher in the bypass group than in the stent group (32.6% vs. 9.3%, P = 0.008). Postoperative length of hospital stay was longer in the bypass group than in the stent group (24 vs. 10 d, P < 0.001). Logistic regression analysis revealed that stent insertion was associated with a decreased risk of respiratory complications (odds ratio 0.077, P < 0.007). Among patients who underwent the interventions (bypass surgery or stent insertion) and subsequently underwent anticancer therapy (chemotherapy/radiotherapy) during hospitalization, the interval between the intervention and anticancer therapy was longer in the bypass group than in the stent group (25 vs. 7 d, P = 0.003).

CONCLUSIONS

Esophageal stent insertion provides better short-term outcomes than bypass surgery in patients with advanced unresectable esophageal cancer.

MEK inhibitor and anti-EGFR antibody overcome sotorasib resistance signals and enhance its antitumor effect in colorectal cancer cells

The Kirsten rat sarcoma (KRAS) oncogene was "undruggable" until sotorasib, a KRAS^G12C selective inhibitor, was developed with promising efficacy. However, inhibition of mutant KRAS in colorectal cancer cells (CRC) is ineffective due to feedback activation of MEK/ERK downstream of KRAS. In this study, we screened for combination therapies of simultaneous inhibition to overcome sotorasib resistance using our previously developed Mix Culture Assay. We evaluated whether there was an additive effect of sotorasib administered alone and in combination with two or three drugs: trametinib, a MEK inhibitor, and cetuximab, an anti-epidermal growth factor receptor (EGFR) antibody. The MAPK pathway was reactivated in KRAS^G12C-mutated cell lines treated with sotorasib alone. Treatment with KRAS and MEK inhibitors suppressed the reactivation of the MAPK pathway, but upregulated EGFR expression. However, the addition of cetuximab to this combination suppressed EGFR reactivation. This three-drug combination therapy resulted in significant growth inhibition in vitro and in vivo. Our data suggest that reactive feedback may play a key role in the resistance signal in CRC. Simultaneously inhibiting KRAS, MEK, and EGFR is a potentially promising strategy for patients with KRAS^G12C-mutated CRC.

Goblet cell adenocarcinoma of the appendix: A case report of three cases

INTRODUCTION AND IMPORTANCE

Appendiceal goblet cell adenocarcinoma is in 0.3-0.9 % of appendectomy specimens. There is still controversy regarding whether surgery with dissection or additional resection is necessary for goblet cell adenocarcinoma and whether adjuvant chemotherapy is practical. We present three cases of goblet cell adenocarcinomas.

CASE PRESENTATION

Case 1: A 30-year-old woman was diagnosed with appendicitis and underwent appendicectomy. Histopathological evaluation revealed a malignant neoplasm with goblet-like cells and tumour infiltration into the subserosa. The patient underwent laparoscopic ileocecal resection, and the main lymph nodes at the root of the feeding vessels were removed. Case 2: A 50-year-old man was diagnosed with appendicitis and underwent appendicectomy. Histopathological evaluation revealed a malignant neoplasm with goblet-like cells; malignant cells were found at the surgical resection margins. The patient underwent laparoscopic ileocolic resection. Case 3: A 60-year-old man undergoing treatment for malignant melanoma. He was diagnosed with appendicitis associated with an appendiceal tumour, and emergency laparoscopic caecal resection was performed and diagnosed as goblet cell adenocarcinoma. We decided to prioritize treatment for malignant melanoma, and the patient is under follow-up for goblet cell adenocarcinoma and no metastasis was detected.

CLINICAL DISCUSSION

We performed additional resection in two case of goblet cell adenocarcinoma. Diagnosing appendiceal goblet cell adenocarcinoma is difficult, and the prognosis of patients with positive lymph nodes is poor. Surgical treatment should be considered for the advanced stages of this disease.

CONCLUSION

Goblet cell adenocarcinoma, diagnosed after appendectomy, additional resection including lymph node dissection may provide a long-term prognosis.

Importance of intraoperative indocyanine green imaging in the management of non-occlusive mesenteric ischemia: a case report

BACKGROUND

Non-obstructive intestinal ischemia (NOMI) is caused by intestinal vascular spasm and has a poor prognosis if not diagnosed and treated early. Indocyanine green (ICG) fluorescence imaging has been reported to be useful for the intraoperative assessment of the extent of intestinal resection required for NOMI. Few reports have described massive intestinal bleeding after conservative management of NOMI. We report a case of NOMI with massive postoperative bleeding from the site of an ICG contrast defect found before the initial surgery.

CASE PRESENTATION

A 47-year-old woman with hemodialysis-dependent chronic kidney disease presented complaining of severe abdominal pain. A computed tomography scan showed portal gas and dilation of the small intestine, leading to a diagnosis of NOMI and subsequent emergency surgery. At the time of initial surgery, the contrast effect of ICG was slightly reduced, showing a granular distribution in the ascending colon to cecum (fine grain pattern) and significantly reduced in parts of the terminal ileum except around blood vessels (perivascular pattern). However, there was no obvious gross necrosis of the serosal surface, and the intestinal tract was not resected. The acute postoperative course was uneventful; however, the patient went into shock on the 24th postoperative day due to massive, small intestinal bleeding, and emergency surgery was performed. The bleeding originated from the section of the ileum that had complete loss of ICG contrast effect before the initial surgery. A right hemicolectomy with the terminal ileum resection was performed, and an ileo-transverse anastomosis was performed. The second post-operative course was uneventful.

CONCLUSIONS

We report a case of delayed hemorrhage of the ileum shown to have poor blood flow on ICG imaging at the initial surgery. Intraoperative ICG fluorescence imaging is useful in assessing the degree of intestinal ischemia for NOMI. When patients with NOMI are followed up without surgery, complications such as bleeding should be noted.

RhoA G17E/Vav1 Signaling Induces Cancer Invasion via Matrix Metalloproteinase-9 in Gastric Cancer

BACKGROUND

RAS homolog family member A (RhoA), a member of the Rho family of small GTPases, and Vav1, a guanine nucleotide exchange factor for Rho family GTPases, have been reported to activate pathways related to the actin cytoskeleton and regulation of cell shape, attachment, and motility. The interaction between these molecules in lymphoma is involved in malignant signaling, but its function in epithelial malignancy is unknown. Here, we investigated the malignant signal of mutant RhoA in gastric cancer and demonstrated the potential of RhoA G17E/Vav1 as a therapeutic target for diffuse gastric cancer.

METHODS

The RhoA mutants R5W, G17E, and Y42C were retrovirally transduced into the gastric cancer cell line MKN74. The stably transduced cells were used for morphology, proliferation, and migration/invasion assays in vitro. MKN74 cells stably transduced with ectopic wild-type RhoA and mutant RhoA (G17E) were used in a peritoneal xenograft assay.

RESULTS

The RhoA mutations G17E and Y42C induced morphological changes in MKN74. G17E induced Vav1 expression at the mRNA and protein levels and promoted the migration and invasion of MKN74. An RNA interference assay of Vav1 revealed that RhoA G17E enhanced cancer cell invasion via Vav1. Furthermore, immunoprecipitation revealed that Vav1 and RhoA G17E specifically bind and function together through matrix metalloproteinase -9. In a peritoneal xenograft model of nude mice, RhoA G17E promoted peritoneal dissemination, whereas Vav1 knockdown suppressed it.

CONCLUSION

Overall, our findings indicate that RhoA G17E is associated with Vav1 and promoted cancer invasion via matrix metalloproteinase -9 in gastric cancer cells. Thus, RhoA G17E/Vav1 signaling in diffuse gastric cancer may be a useful therapeutic target.

Gastric glomus tumor resection using laparoscopic endoscopic cooperative surgery: A case report

Gastric glomus tumors are rare submucosal mesenchymal neoplasms that are difficult to diagnose preoperatively. We present a case of a 60-year-old woman who was diagnosed with a gastric glomus tumor using endoscopic ultrasonography-guided fine-needle aspiration biopsy. The tumor was successfully resected with laparoscopic endoscopic cooperative surgery (LECS). LECS could be an effective method for the resection of gastric glomus tumors.

Risk factors for umbilical incisional hernia after laparoscopic colorectal surgery

BACKGROUND

Laparoscopic colorectal surgery (LCRS) requires a small laparotomy at the umbilicus. The wound is small and inconspicuous, but if the patient develops an umbilical incisional hernia (UIH), the wound is visible and the patient suffers from symptoms of discomfort. However, the incidence of UIH after LCRS and its risk factors are not well understood. The purpose of this study was to investigate the risk factors for UIH after LCRS for colorectal cancer.

METHODS

This was a single-centre retrospective study of 135 patients with colorectal cancer, conducted at our hospital from April 2013 to March 2019. The diagnosis of UIH was based on computed tomography and physical examination findings. Preoperative patient data such as enlargement of the umbilical orifice (EUO), subcutaneous fat thickness (SFT) and intraperitoneal thickness (IPT) were collected and analysed using univariate and multivariate analyses for the presence of risk factors for UIH.

RESULTS

A total of 135 patients who underwent LCRS were analysed. The incidence of UIH was 20.7%. Univariate analysis revealed significantly high body mass index (BMI) ≥ 25 (P = 0.032), EUO (P < 0.001), SFT ≥18 mm (P = 0.011), and IPT ≥61 mm (P < 0.01) in the UIH group. Multivariate analysis revealed significant differences in EUO (P < 0.001), SFT ≥18 mm (P = 0.046) and IPT ≥61 mm (P = 0.022).

CONCLUSION

EUO was the most important risk factor for UIH, followed by IPT and SFT. These findings are predictive indicators of the development of UIH after LCRS and can be assessed objectively and easily with preoperative computed tomography.

Loss of social role awareness, a subdomain of social frailty, is an independent predictor of future adverse events in hospitalized older patients with heart failure

Background

Frailty is a complex syndrome characterized by a decline in functional reserve, and associated with aging and chronic diseases including heart failure (HF). The impact of physical frailty on prognosis and the effect of cardiac rehabilitation in HF patients have been well established. However, the data on the prognostic impact of social frailty (SF) in HF patients is limited.

Aims

We aimed to get new insight into mechanisms of the association of SF with clinical outcomes in older hospitalized HF patients.

Methods

A single-center, retrospective cohort study was conducted using data from 308 HF patients aged ≥65 years (mean age of 78±8 years; 49% females) who were admitted to our institute for the management of HF. SF was assessed using the validated Makizako's five questions. The following responses were considered positive for SF: (1) going out less frequently compared with last year; (2) not visiting friends; (3) not talking with someone every day; (4) not feeling helpful toward friends or family; and (5) living alone. SF was defined as two or more positive responses. The primary outcome was composite events defined by all-cause death and cardiovascular events. The missing data were imputed using multiple imputation by chained -equations algorithm.

Results

Of 308 older HF patients, 189 patients (61%) were SF. Patients with SF were significantly older, had lower body mass index, and a higher percentage of patients with physical frailty and cognitive frailty than those without SF. Seventy-five patients (24%) experienced composite events during a median follow-up period of 1.55-years (interquartile range, 0.88–2.20 years). Kaplan-Meier curves showed a significantly higher composite event rate in patients with SF than those without SF. In multivariate Cox regression analyses, SF was independently associated with a higher composite event rate after adjusting for pre-existing risk factors [adjusted hazard ratio (HR), 1.91; 95% confidence interval (CI), 1.09–3.35; p=0.03] (Figure 1A). In addition, further analyses showed that only the positive response on the question corresponding to the social role – not feeling helpful toward friends or family – among the questionnaire was an independent predictor for the incidence of the composite event (adjusted HR, 2.10; 95% CI, 1.29–3.41; p&lt;0.01, Figure 1B). Inclusion of the response to the question regarding the social role into the baseline prognostic model improved the accuracy of prediction of the composite event (continuous net reclassification improvement, 0.46; 95% CI, 0.21–0.71; p&lt;0.01; integrated discrimination improvement, 0.025; 95% CI 0.004–0.047; p=0.02; Figure 2).

Conclusion

Loss of social role awareness was associated with increased composite event risk and provided additive prognostic information in older HF patients, suggesting the importance of healthcare professionals' decision-making on the prevention and management of SF.

Funding Acknowledgement

Type of funding sources: None.

Coexistence of sarcopenia and osteoporosis in patients with heart failure: prevalence and association with functional status

Background

Sarcopenia, the loss of muscle mass and function, and osteoporosis, a condition of low bone mass and micro-architectural deterioration of bone, frequently coexist and are associated with low functional status in heart failure (HF) patients.

Aims

We aimed to investigate the impact of coexistence of sarcopenia and osteoporosis on functional status in HF patients.

Methods

This cross-sectional study was conducted using data from patients who admitted to our institute for the diagnosis and management of HF from 1 November 2015 to 30 April 2021. All patients received the dual-energy X-ray absorptiometry (DEXA) method before discharge. The diagnosis of sarcopenia was made according to the criteria of Asia Working Group for Sarcopenia 2019 recommendation as follows: reduced skeletal muscle mass [appendicular skeletal muscle mass index (ASMI) by DEXA, &lt;7.00 kg/m2 in males and &lt;5.40 kg/m2 in females] plus lower muscle strength (handgrip strength, &lt;28 kg in males and &lt;18 kg in females) and/or poor physical performance (gait speed, &lt;1.0 m/s; chair stand test time. ≥12 s; short physical performance battery ≤9 points). In addition, bone mineral densities (BMDs) at the lumbar spine, femoral neck, and total femur were measured by DEXA, and osteoporosis was diagnosed when BMDs at any of the three sites were less than 70% of Young Adult Mean (YAM). Functional status was assessed by the Barthel Index (BI) within three days before discharge, and patients with a BI score of &lt;85 points was defined as having functional dependence (FD). The missing data were imputed using multiple imputation by chained -equations algorithm.

Results

Four hundred-thirty eight patients [median age of 74 years (interquartile range, 65–82 years), 37% females] were included in the analyses. Of these, percentage of HF patients with sarcopenia, osteoporosis, and sarcopenia and osteoporosis was 45%, 34%, and 20%, respectively (Figure 1A). The analysis of covariance showed a lower %YAM at any sites in patients with sarcopenia than those without sarcopenia (Figure 1B). When patients were divided into subgroups according to the presence or absence of sarcopenia and osteoporosis, the prevalence of FD was 32%, 34%, and 48% in patients with osteoporosis alone, sarcopenia alone, and sarcopenia and osteoporosis, respectively. Multivariate logistic regression analysis indicated that an increase in adjusted odds ratio (OR) for predicting FD was observed across subgroups in the following order: patients with osteoporosis alone [OR, 1.64; 95% confidence interval (CI), 0.63–4.24; p=0.31], those with sarcopenia alone (OR, 2.44; 95% CI, 1.13–5.25; p=0.02) and those with both conditions (OR, 3.34; 95% CI, 1.52–7.38; p&lt;0.01) (Figure 2).

Conclusion

There was considerable overlap between sarcopenia and osteoporosis in HF patients, which appeared to be a risk factor for FD.

Funding Acknowledgement

Type of funding sources: None.

Intraoperative visualization of morphological patterns of the thoracic duct by subcutaneous inguinal injection of indocyanine green in esophagectomy for esophageal cancer

To prevent chylothorax after esophageal cancer surgery, it is important to recognize morphological patterns of the thoracic duct intraoperatively. The present study aimed to evaluate the safety and usefulness of near-infrared (NIR) fluorescence imaging with subcutaneous inguinal injection of indocyanine green (SII-ICG) to detect the thoracic duct during thoracoscopic esophagectomy for esophageal cancer. Patients (n = 16) who underwent thoracoscopic esophagectomy in the prone position with SII-ICG at Shinshu University Hospital between June 2020 and January 2022 were enrolled in the present study and retrospectively reviewed. Immediately prior to thoracoscopic esophagectomy, we injected 0.2-0.5 mg/kg ICG into the subcutaneous tissue in the bilateral inguinal region. The identification rate of the thoracic duct was 93.8% (n = 15), and the success rate of fluorescence using SII-ICG was 87.5% (n = 14). The visible thoracic ducts had four patterns: a typical pattern in 50% (n = 8), duplication pattern in 18.8% (n = 3), branching pattern in 12.5% (n = 2), and plexiform pattern in 12.5% (n = 2). In all cases, ICG fluorescence did not disappear and was visible during the thoracic surgery. No SII-ICG-related complications were observed. Intraoperative NIR fluorescence imaging of the thoracic duct using SII-ICG is a simple and safe method with very high detection sensitivity. This method can be a powerful tool for avoiding thoracic duct injuries during esophageal cancer surgery.

AB0363 COMPARING THE ULTRASONOGRAPHIC EVALUATION IN PATIENTS WITH JAPANESE RHEUMATOID ARTHRITIS BETWEEN JAK AND TNF INHIBITOR THERAPY

Background

JAK inhibitor (JAK) and TNF inhibitor (TNF) are the important therapeutic agent for the treatment of rheumatoid arthritis.However there is still few studies of improvement of ultrasonographic findings in RA treated comparison with JAK and TNF.

Objectives

To evaluate the clinical efficacy of JAK and TNF therapy patients with rheumatoid arthritis (RA) using ultrasonography (US).

Methods

Participants comprised 32 and 39 Japanese RA patients who had recently received JAK (BAR23, PEF9) and TNF. All patients with a diagnosis of RA according to the 2010 ACR/EULAR criteria. Patients underwent clinical and laboratory assessments every 4 weeks from baseline to 24 weeks, and US assessments at baseline, 4, 12 and 24 weeks. Gray scale (GS) and power doppler (PD) signals were scored using a semi-quantitative scale from 0 to 3 at 26 (0-78) synovial sites (22 joints) in the following joints: bilateral first to fifth metacarpopharangeal (MCP) joints (dorsal recess); first interphalangeal (IP) and second to fifth proximal interphalangeal (PIP) (dorsal recess) joints; and the wrists (dorsal radial, median and ulnar). We evaluated the improvement of GS and PD score from baseline to week 24.

Results

In the patients receiving JAK (n=32) and TNF (n=39), the mean age was 54.7 vs 55.1 years old (p=0.871), disease duration was 7.4 vs 6.1 years (p=0.290), the rate of MTX use was 75% vs 87% (p=0.187), the mean MTX dose was 9.9 vs 10.2 mg/w (p=0.813), the rate of ACPA positive was 94% vs 79% (p=0.086), DAS28-ESR was 4.79 vs 4.65 (p=0.435), CDAI was 22.4 vs 19.1 (p=0.239), GS score was 20.8 vs 18.3 (p=0.995) and PD score was 14.0 vs 11.0 (p=0.940). The degree of improvement respective changes in GS and PD score after 4, 12 and 24 weeks were as follows: GS: -5.1 vs -4.3 (p=0.817) and PD: -5.3 vs -2.7 (p=0.855) after 4 weeks, GS: -9.1 vs -6.6 (p=0.880) and PD: -7.9 vs -4.5 (p=0.476) after 12 weeks, GS: -10.4 vs -9.5 (p=0.463) and PD: -8.1 vs -6.7 (p=0.968) after 24 weeks between JAK and TNF (Figures 1 and 2). Next, The improvement rate of respective changes in GS and PD score after 4, 12 and 24 weeks were as follows: GS: -13.7% vs -18.3% (p=0.489) and PD: -20.4% vs -16.5% (p=0.777) after 4 weeks, GS: -29.7% vs -26.0% (p=0.922) and PD: -30.9% vs -30.8% (p=0.890) after 12 weeks, GS: -38.1% vs -36.4% (p=0.567) and PD: -33.4% vs -50.1% (p=0.977) after 24 weeks between JAK and TNF.

Conclusion

The present study provides evidence supporting the JAK and TNF therapy improved similarly the inflammatory synovitis of US findings.

Disclosure of Interests

None declared

Does serum 25-hydroxyvitamin D levels have impacts on sarcopenia in patients with chronic heart failure?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Sarcopenia is associated with poor functional status and clinical outcomes in heart failure (HF) patients. Although recent observational studies showed the relationship between lower serum vitamin D levels and the development of poor physical function in community-dwelling older adults, involvement of vitamin D status in the development of sarcopenia in HF patients remain unclear. This study aimed to investigate the impact of serum vitamin D concentrations on sarcopenia in patients with HF.

Methods

We retrospectively enrolled 269 consecutive patients [median age of 73 years (interquartile range 63-82 years); 35% female] admitted to our institute for diagnosis and management of HF, and received the dual-energy X-ray absorptiometry (DEXA) method during the period from 1 September 2018 to 30 September 2021. The 25-hydroxyvitamin D [25(OH)D] was detected by a chemiluminescence immunoassay (CLIA) technology. The diagnosis of sarcopenia was made according to the criteria of Asia Working Group for Sarcopenia incorporating reduced skeletal muscle mass (appendicular skeletal muscle index [ASMI], &lt;7.00 kg/m2 in males and &lt;5.40 kg/m2 in females), and lower muscle strength (handgrip strength, &lt;28 kg in males and &lt;18 kg in females) and/or poor physical performance (gait speed, &lt;1.0 m/s; chair stand test time, ≥12 s; short physical performance battery, ≤9 points).

Results

Of 269 patients, 116 (43%) patients had sarcopenia. An adjusted logistic regression model with a restricted cubic spline function showed that the odds ratio (OR) for sarcopenia increased as the serum 25(OH)D levels decreased. When the value that corresponded to an upper limit of 95% confidence interval (CI) for an OR of 1.0 was defined as the cut-off value of 25(OH)D levels for predicting sarcopenia, it was 18 ng/mL (Figure 1A). A multivariate logistic regression model was fit to calculate the propensity score (PS) for the 25(OH)D levels being &lt;18 ng/mL based on covariates such as age, sex, and N-terminal pro B-type natriuretic peptide. (C-statistics 0.761). The inverse probability of treatment weighting (IPTW) was computed using PS to minimize differences in potential confounding factors between patients with a low serum 25(OH)D levels (&lt;18 ng/mL) and those with a high serum 25(OH)D levels (≥18 ng/mL, Figure 1B). Results of the multivariate logistic regression analysis in the IPTW-weighted patients showed that a low serum 25(OH)D was independently associated with presence of sarcopenia (adjusted OR 2.03, 95% CI 1.31-3.16, p&lt;0.01). In addition, patients with a low serum 25(OH)D had a significantly lower muscle strength and poor physical performance, but not ASMI, than those with a high serum 25(OH)D (Figure 2).

Conclusion

Decreased serum 25(OH)D levels are associated with decline in muscle strength and physical performance in HF patients. Serum 25(OH)D levels of &lt;18 ng/mL may be a novel risk factor of sarcopenia in HF patients.

Novel equation for skeletal muscle mass estimation is useful for predicting mortality in patients with heart failure

Funding Acknowledgements

Type of funding sources: None.

Background

Skeletal muscle mass in heart failure (HF) patients is closely related to exercise tolerance and prognosis. Although the dual-energy X-ray absorptiometry (DEXA) method is a standard method for measuring skeletal muscle mass, it is not suitable in a daily clinical setting since it is a costly and hospital-based modality. We recently reported that an equation for appendicular skeletal muscle mass index (ASMI) estimation using anthropometric parameters predicted DEXA-measured ASMI in HF patients with reasonable accuracy. Here, we examined the prognostic impacts of ASMI predicted by the equation (predicted ASMI) in HF patients.

Methods

Data for 539 patients with HF ( 73 ± 14 years old, 43% female) who received the DEXA method and measurements of calf circumference (CC) and mid-arm circumference (MAC) between August 1, 2015, to August 31, 2020, were used for analyses. DEXA measured-appendicular skeletal muscle (ASM) was calculated as the sum of bone-free lean masses in the arms and legs, and ASMI was defined as ASM/height². Predicted ASMI was calculated as we previously reported: predicted ASMI (kg/m²) = [0.214 × weight (kg) + 0.217 × CC (cm) - 0.189 × MAC (cm) + 1.098 (male = 1, female = -1) + 0.576]/height² (m²). Low ASMI was defined as &lt;7.0 kg/m² in males and &lt;5.4 kg/m² in females, respectively. The primary endpoint was all-cause death. Multiple imputation using chained equations was used for the substitution of missing values.

Results

The median follow-up period was 1.75 years (interquartile range, 0.96 to 2.37 years), and 73 patients (15%) has died. Kaplan-Meier survival curves showed that patients with low DEXA measured-ASMI and patients with low predicted ASMI had significantly lower survival rates than those with high ASMI (Figure 1). In a multivariate Cox proportional hazard analyses adjusted for age, sex, logarithmic B-type natriuretic peptide, cystatin C based-estimated glomerular filtration rate, and gait speed, DEXA-measured ASMI [hazard ratio (HR), 0.982; 95% confidence interval (CI), 0.967 to 0.988; p&lt;0.001] and predicted ASMI (HR, 0.979; 95% CI, 0.962 to 0.996; p=0.018) were independent predictors of all-cause mortality, respectively. Inclusion of predicted ASMI into the adjustment model improved the accuracy of prediction of the mortality after discharge [continuous net reclassification improvement, 0.338, p&lt;0.01; integrated discrimination improvement, 0.020, p &lt; 0.05] (Figure 2).

Conclusions

ASMI estimated by an equation using CC and MAC predicted the prognosis of HF patients at a similar level of accuracy to DEXA-measured ASMI, and it can be applied to the assessment of skeletal muscle mass in a daily clinical setting and in large population-based studies.

Comparison of Clinical Outcomes and Safety Between Open and Laparoscopic Surgery for Adhesive Small Bowel Obstruction: A Propensity-Matched Analysis of a National Inpatient Database

Background: The effectiveness of laparoscopic surgery for adhesive small bowel obstruction (ASBO) remains unclear. We aimed to compare the outcomes and safety of open and laparoscopic surgeries for ASBO. Methods: In this retrospective study, we analyzed an inpatient database of 42 national university hospitals in Japan. Patients who underwent surgery for the first episode of ASBO between April 2013 and March 2018 were identified. Using the propensity score method, patients who underwent laparoscopic surgery were matched one-to-one with those who underwent open surgery. We investigated postoperative clinical outcomes, including morbidity, mortality, length of hospital stay (LOS), and recurrence. Results: Overall, 306 and 96 patients underwent open and laparoscopic surgery, respectively (96 propensity score-matched pairs). The incidence rates of postoperative morbidity, mortality, and recurrence were comparable between the two groups. Cox regression analysis revealed a hazard ratio (HR) of 1.020 (P = .959) for readmission due to ASBO in the laparoscopic surgery group relative to the open surgery group. Postoperative hospital stay was longer for open surgery than for laparoscopic surgery (13.0 days versus 10.0 days, P < .001). Cox regression analysis revealed that laparoscopic surgery was associated with earlier postoperative discharge compared with open surgery (HR 1.641, P = .002). Conclusions: The postoperative LOS was shorter with laparoscopic surgery than with open surgery for ASBO, but there were no differences between the procedures in other clinical outcomes. Laparoscopic surgery is suitable to treat patients with ASBO.

Association of Daily Variance in Air Temperature With Postoperative Adhesive Small Bowel Obstruction

Introduction: The influence of air temperature on adhesive small bowel obstruction (ASBO) is unknown. This study aimed to investigate the relationship between air temperature and postoperative ASBO.

Methods: Overall, 312 patients with postoperative ASBO were included. They were categorized into two groups: the surgery group (n = 83) comprising patients who needed surgery, and the non-surgery group (n = 229) comprising patients who responded to conservative treatment. The associations between patients’ characteristics and weather variables on days of symptom onset with the need for surgical management were investigated. Weather variables included the daily mean barometric pressure, daily mean air temperature, day-to-day differences, daily variances, and diurnal variation in the air temperature. Day-to-day differences in weather variables were calculated as the daily mean variables on the day of symptom onset minus those on the previous day. The daily variances in weather variables were defined as the absolute value of day-to-day differences.

Results: Compared to the non-surgery group, the surgery group had older patients (75 vs. 70 years, p = 0.009), a higher proportion of female patients (44.6% vs. 32.3%, p = 0.046), increased incidence of closed-loop sign (50.6% vs. 0.9%, p < 0.001), a lower proportion of feces sign (18.1% vs. 31.3%, p = 0.024), and a prolonged hospital stay (11 vs. 22 days, p < 0.001). The number distribution of patients in the surgery group in day-to-day differences in air temperature was different from that of the non-surgery group; the former has several peaks whereas the latter has almost one peak. Daily variance in mean air temperature on the day of symptom onset was higher in the surgery group than in the non-surgery group (2.3 vs. 1.3℃, p < 0.001). Multiple logistic regression analysis revealed that increased daily variance in air temperature on the onset day was associated with the need for surgical management (odds ratio 1.254, p = 0.002) and closed-loop obstruction (odds ratio 1.235, p = 0.017). Regarding seasonal variations, the risk of the need for surgery and closed-loop obstruction in each ASBO patient was the highest in spring, followed by that in summer, autumn, and winter. Consistently, the daily variance in mean air temperature in spring was higher than that in summer, autumn, and winter (p < 0.0001, p < 0.0001, and p = 0.0047, respectively). The risk of the need for surgery and closed-loop obstruction in each ASBO patient was the highest in spring, followed by that in summer, autumn, and winter. Consistently, daily variance in mean air temperature was higher in spring than that in summer, autumn, and winter (p < 0.0001, p < 0.0001, and p = 0.0047, respectively).

Conclusion: Increased daily variance in mean air temperature on the day of onset is associated with the need for surgical management and closed-loop obstruction. Spring is characterized by the highest daily variance in mean air temperature among the four seasons, and is associated with high proportions of the need for surgery and closed-loop obstruction. These results can be clinically useful in terms of hospital resource reallocation and staffing, and can help clarify the pathogenesis of ASBO.

Laparoscopic left-sided mesocolic leaf flap repair for pelvic reconstruction after sacral tissue necrosis. A case report

Radical surgical procedures for malignant diseases of the pelvis result in a large pelvic defect that requires soft tissue reconstruction. The mesentery can be used for pelvic floor reconstruction when debridement with intestinal resection is required. A 75-year-old woman was diagnosed with sacral necrosis, infection and sepsis after carbon ion radiotherapy for sacral chordoma. She underwent sacral debridement three times, which resulted in a large pelvic defect of 14 × 13 cm. Surgery was performed to completely resect the necrotic tissue. We performed extended debridement of sacrum and adjacent tissue around the rectum and anus. Since it was impossible to preserve the anus, laparoscopic left hemicolectomy, abdominosacral resection, and left-sided mesocolic leaf repair for the pelvic defect, and reconstructed the pelvis and buttocks using a gluteal thigh flap were performed. Indocyanine green fluorescent (ICG) imaging was used to detect the margin of the pelvic floor and necrotic tissue and the blood flow of the left-sided mesocolic leaf flap. Left-sided mesocolic leaf reconstruction is useful for large pelvic defects. ICG imaging enabled the detection of the resection margins and the blood flow of the mesocolic leaf.

Current status of countermeasures for ageing of nuclear power plants in Japan

This paper summarizes ageing countermeasure program of the nuclear power plants performed by the Japanese Government and industries and related activities, and describes current research program and utilization of the research results for the aged nuclear power plants. Regulatory bodies (NISA of METI: Nuclear and Industrial Safety Agency of the Ministry of Economy, Trade and Industry') reviewed the ageing issues of nuclear power plants to enhance countermeasures for the aged plants. Nuclear Power Plant Life Engineering Center (PLEC) entrusted by NISA is carrying out the task relating to the aged plants.

Impact of seasonal and meteorological factors on the incidence of adhesive small bowel obstruction: A large‐scale study using a national inpatient database

Aim

Whether seasonal and meteorological factors affect the incidence of adhesive small bowel obstruction (ASBO) remains unclear. This study aimed to clarify the impacts of seasonal and meteorological factors on the occurrence of ASBO.

Methods

Clinical data of patients with ASBO were acquired from 42 national university hospitals in Japan, using a national inpatient database, between April 2012 and March 2020. Meteorological data were obtained from the Japan Meteorological Agency. The number of monthly admissions of patients with ASBO was compared between each of the 12 months. Daily weather variables were investigated to clarify their association with ASBO patient admissions on a total of 119 802 days (Formula for calculation: study period [2922 days] ×41 cities).

Results

Overall, 4985 patients with ASBO were admitted. The number of admissions in June was smaller than that in October, November, and December (39 vs 63.5, P = .002, 39 vs 65, P = .004, and 39 vs 59.5, P = .002, respectively). Logistic regression analysis revealed that January, October, November, and December were associated with increased risk of admission compared to June (odds ratio [OR], 1.264; P = .001; OR, 1.454; P < .001; OR, 1.408; P < .001; OR, 1.330; P < .001), respectively. Regarding the weather variables, higher barometric pressure and lower humidity were associated with increased risk of admission (OR, 1.011; P < .001 and OR, 0.995; P < .001), respectively.

Conclusion

The incidence of ASBO is susceptible to barometric pressure and humidity and varies monthly. These results can contribute to the prevention, early detection, and immediate and appropriate management of ASBO.

Barthel Index score predicts mortality in elderly heart failure: a goal of comprehensive cardiac rehabilitation

Background

Accurate prediction of mortality in heart failure (HF) patients is crucial for decision-making regarding HF therapies, but a strategy for the prediction of mortality in elderly HF patients has not been established. In addition, although favorable effects of comprehensive cardiac rehabilitation (CR) on clinical outcomes and functional status in HF patients have been demonstrated, a goal of comprehensive CR during hospitalization for reducing mortality remains unclear.

Aims

We examined whether assessment of basic activities of daily living (ADL) by the Barthel Index (BI), the most widely used tool for assessment of basic ADL, is useful for predicting all-cause mortality in elderly HF patients who received comprehensive CR.

Methods

This study was a single-center, retrospective and observational study. We retrospectively examined 413 HF patients aged ≥65 years (mean age, 78±7 years; 50% female) who were admitted to our institute for management of HF and received comprehensive CR during hospitalization. Functional status for performing basic ADL ability was assessed by the BI within 3 days before discharge. The clinical endpoint was all-cause death during the follow-up period.

Results

Of 413 HF patients, 116 patients (28%) died during a follow-up period of median 1.90-years (interquartile range, 1.20–3.23 years). Results of an adjusted dose-dependent association analysis showed that the hazard ratio (HR) of mortality increases in an almost linear fashion as the BI score decreases and that the BI score corresponding the hazard ratio of 1.0 is 85 (Figure A). To minimize the differences in potential confounding factors between patient with low BI (&lt;85) and patients with high BI (≥85), inverse probability treatment weighting (IPTW) was calculated using propensity score. Kaplan-Meier survival curves, in which selection bias was minimized by use of IPTW for confounders, showed that patients with low BI (&lt;85) had a higher mortality rate than did patients with high BI (≥85) (Figure B). In multivariate Cox regression analyses, low BI was independently associated with higher mortality after adjustment for predictors including brain natriuretic peptide and prior HF hospitalization (IPTW-adjusted HR, 1.75 [95% confidence interval, 1.03–2.98], p&lt;0.001). Inclusion of the BI into the adjustment model improved the accuracy of prediction of mortality (continuous net reclassification improvement, 0.292, p=0.008; integrated discrimination improvement, 0.017, p=0.022).

Conclusion

A BI score of &lt;85 at the time of discharge is associated with increased mortality independently of known prognostic markers, and achievement of functional status of a BI score ≥85 by comprehensive CR during hospitalization may contribute to a favorable outcome in elderly HF patients.

Funding Acknowledgement

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

A case of appendiceal ganglioneuroma in neurofibromatosis type 1

BACKGROUND

Neurofibromatosis type 1 is an autosomal dominant inherited disease associated with multiple skin neurofibromas or other neurogenic tumors, such as nodular plexiform neurinoma or cerebrospinal tumor. Gastrointestinal stromal tumors are often complicated in patients with neurofibromatosis type 1, although involvement of the appendix is rare, and there have been few reports of appendiceal ganglioneuroma.

CASE PRESENTATION

The patient was a 29-year-old man diagnosed with neurofibromatosis type 1 based on physical findings and his family history. During the follow-up of neurofibromatosis, computed tomography was performed to detect neurological tumors, such as neurofibromas in the brain, spinal cord, and gastrointestinal tract. Computed tomography showed a markedly thickened appendix wall, and an appendiceal tumor was suspected. Laparoscopic appendectomy was performed, and a 50 × 35 mm appendiceal submucosal tumor was resected with a negative resection margin. At histopathological examination, the tumor was diagnosed as ganglioneuroma; it showed short spindle-shaped cells and ganglion cells diffusely infiltrated into the proper muscle layer and fibrous tissue that grew around nerve cells. The patient was discharged on the 5th postoperative day without postoperative complications and was doing well at 13 months following the operation.

CONCLUSIONS

Gastrointestinal stromal tumor and neurofibroma are the most common gastrointestinal tumors associated with neurofibromatosis type 1, but ganglioneuroma of the appendix is rare. Appendiceal neurogenic tumors should be considered in patients with neurofibromatosis type 1, and surgical resection is necessary because of the risk of malignancy.

P–719 Self-declared infertility and child desire among women of reproductive age in the National Survey of Demography and Health, Brazil

Study question

This article aims to characterize from a socio-demographic point of view, women of reproductive age who wish to have children, declared themselves infertile, and their search for treatments and outcomes.

Summary answer

It is essential to develop specific population surveys on infertility in Brazil to identify its magnitude and main economic and social components.

What is known already

Commonly neglected in developing countries where public policy is incipient, infertility brings social, economic and psychological consequences to couples. It is considered as a serious public health problem whose impact varies among different populations and acquires relevance for specific communities. In Brazil, there are no clinical or demographic data that point us to the magnitude of the problem, its social characteristics and impact. Taking into account the postponement of motherhood for after 30 years, there will probably be an increase in the number of women and couples who may resort to infertility treatments to fulfil the desire for procreation.

Study design, size, duration

The National Survey of Demography and Health of Women and Children (PNDS) is a cross-sectional study and a household complex probabilistic sampling. The sampling units were selected according to a stratified model of simple random conglomerates in two stages: lottery draw and household draw. The last survey was conducted between June 2006 and May 2007 in 14,617 households. In the selected households, interviews were conducted with 15,575 women of reproductive age.

Participants/materials, setting, methods

The participants consisted of 15.575 women between 15 and 49 years, representative of the five Brazilian macro-regions. The information was obtained through questionnaires, applied in person, raising information on fertility, fecundity, contraception, use of health services and socioeconomic profile. The interviewer’s team was formed by approximately 100 people and 27 supervisors, all-female, divided into nine regional teams. The system used for data entry was the Census and Survey Processing System - CSPro.

Main results and the role of chance

The survey results indicate that of women who wish to have children, 9.2% declared themselves infertile; 50,8% of them sought health services for treatment; non-black women had higher percentages of demand compared to black women (62.4% versus 41.3%). Also, there were higher percentages of seeking help from women belonging to classes A (61.2%), B (83.3%) and C (60.9%) compared to those belonging to classes D (30.4%) and E (7.8%) On the other side, almost half of women did not seek help to get pregnant (49,1%); this percentage is higher among black women (58%). Moreover, women in classes D and E had the highest percentages of non-demand, 69.6% and 92.2%, respectively. The reasons cited for those who do not seek help, are “I think there is no solution” (54,7%); “I don’t think I can get help” (17.3%), “financial reasons” (26.8%) or “I don’t know where to get it” (1,2%). Among those who sought help, 48,5% are under treatment, 24,4% said there is no solution; 15,8% are waiting for service and 11,3% have no money for treatment. Significance limit was established for values ​​of p &lt; 0.05. The analysis was performed in the programs Stata v.9 and/or SPSS v.14.

Limitations, reasons for caution

The limitations of the study are recognized. Firstly, opinions are restricted to the moment of the interview and, thus, the desire for children may change over time. Secondly, the statement of infertility is based on self-declaration, not on clinical diagnosis.

Wider implications of the findings: This is the first study based on PNDS 2006 data on infertility and demand for treatments in Brazil. It can contribute to providing insights, raising new questions and discovering relevant categories and dimensions of analysis to be taken into account in future studies and surveys.

Trial registration number

Not applicable

P-719 Self-declared infertility and child desire among women of reproductive age in the National Survey of Demography and Health, Brazil

Study question

This article aims to characterize from a socio-demographic point of view, women of reproductive age who wish to have children, declared themselves infertile, and their search for treatments and outcomes.

Summary answer

It is essential to develop specific population surveys on infertility in Brazil to identify its magnitude and main economic and social components.

What is known already

Commonly neglected in developing countries where public policy is incipient, infertility brings social, economic and psychological consequences to couples. It is considered as a serious public health problem whose impact varies among different populations and acquires relevance for specific communities. In Brazil, there are no clinical or demographic data that point us to the magnitude of the problem, its social characteristics and impact. Taking into account the postponement of motherhood for after 30 years, there will probably be an increase in the number of women and couples who may resort to infertility treatments to fulfil the desire for procreation.

Study design, size, duration

The National Survey of Demography and Health of Women and Children (PNDS) is a cross-sectional study and a household complex probabilistic sampling. The sampling units were selected according to a stratified model of simple random conglomerates in two stages: lottery draw and household draw. The last survey was conducted between June 2006 and May 2007 in 14,617 households. In the selected households, interviews were conducted with 15,575 women of reproductive age.

Participants/materials, setting, methods

The participants consisted of 15.575 women between 15 and 49 years, representative of the five Brazilian macro-regions. The information was obtained through questionnaires, applied in person, raising information on fertility, fecundity, contraception, use of health services and socioeconomic profile. The interviewer’s team was formed by approximately 100 people and 27 supervisors, all-female, divided into nine regional teams. The system used for data entry was the Census and Survey Processing System - CSPro.

Main results and the role of chance

The survey results indicate that of women who wish to have children, 9.2% declared themselves infertile; 50,8% of them sought health services for treatment; non-black women had higher percentages of demand compared to black women (62.4% versus 41.3%). Also, there were higher percentages of seeking help from women belonging to classes A (61.2%), B (83.3%) and C (60.9%) compared to those belonging to classes D (30.4%) and E (7.8%) On the other side, almost half of women did not seek help to get pregnant (49,1%); this percentage is higher among black women (58%). Moreover, women in classes D and E had the highest percentages of non-demand, 69.6% and 92.2%, respectively. The reasons cited for those who do not seek help, are “I think there is no solution” (54,7%); “I don’t think I can get help” (17.3%), “financial reasons” (26.8%) or “I don’t know where to get it” (1,2%). Among those who sought help, 48,5% are under treatment, 24,4 % said there is no solution; 15,8% are waiting for service and 11,3% have no money for treatment. Significance limit was established for values of p &lt; 0.05. The analysis was performed in the programs Stata v.9 and/or SPSS v.14.

Limitations, reasons for caution

The limitations of the study are recognized. Firstly, opinions are restricted to the moment of the interview and, thus, the desire for children may change over time. Secondly, the statement of infertility is based on self-declaration, not on clinical diagnosis.

Wider implications of the findings

This is the first study based on PNDS 2006 data on infertility and demand for treatments in Brazil. It can contribute to providing insights, raising new questions and discovering relevant categories and dimensions of analysis to be taken into account in future studies and surveys.

Trial registration number

not applicable

Sex differences in non-strangulated postoperative adhesive small bowel obstruction: A retrospective cohort study

BACKGROUND

Adhesive small bowel obstruction (ASBO) is one of the major causes of postoperative morbidity. Non-surgical management is generally applied to non-strangulated ASBO. Several factors have been reported to affect the response to non-surgical management in patients with ASBO. However, the association between sex differences and non-strangulated ASBO remains unclear. This study aimed to elucidate the effect of sex differences in non-strangulated postoperative ASBO.

METHODS

We divided 139 patients with a first episode of non-strangulated postoperative ASBO into two groups: male group (n = 83) and female group (n = 56). Clinical features and prognosis were compared between the two groups.

RESULTS

Female patients had lower proportions of oesophageal/gastric malignancies (P = 0.044) and colorectal malignancies (P = 0.030) and a higher proportion of uterine/ovarian malignancies (P < 0.001) than male patients did. More female patients required surgical management than male patients (P = 0.003) did. Hospital length of stay (LOS) was longer (P = 0.046) in the female group than in the male group. Multiple logistic regression analysis showed that the female sex was associated with an increased risk of the need for surgical management (odds ratio 5.318, P = 0.006). Cox proportional hazards regression analysis revealed that the female sex was positively associated with increased LOS (hazard ratio 0.687, P = 0.045).

CONCLUSION

Female sex was associated with failure of non-surgical management and increased LOS in patients with non-strangulated postoperative ASBO.

Lymphocyte-to-Monocyte Ratio Is a Predictive Biomarker of Response to Treatment with Nivolumab for Gastric Cancer

INTRODUCTION

Patients with unresectable or recurrent gastric cancer who have an objective response (OR) to nivolumab monotherapy are expected to have a good long-term prognosis. However, the OR rate for nivolumab treatment is low at 11%, and there is a need for biomarkers to predict the treatment response. This study aimed to analyze the significance of systemic inflammation-related variables and clinicopathologic characteristics as predictive markers of response to nivolumab monotherapy in patients with advanced gastric cancer.

METHODS

In this retrospective cohort study, we enrolled 71 consecutive patients who received nivolumab monotherapy for unresectable or recurrent gastric cancer. Receiver operating characteristic curve analysis was performed to determine the cutoff values of systemic inflammation-related variables, predictors of treatment response, and other prognostic factors related to nivolumab therapy. We focused on systemic inflammation-related variables measured before nivolumab induction and 2 weeks after its first administration and performed multivariate analysis to assess whether they could be used as prognostic factors.

RESULTS

Multivariate analysis revealed that a lymphocyte-to-monocyte ratio (LMR) of ≤3.28 after 2 weeks of initial nivolumab treatment (2wLMR) is a statistically significant predictor of treatment response (p = 0.012). The progression-free survival (PFS) rate of patients with liver metastasis was significantly worse than that of the other patients (1-year PFS: 0.0 vs. 24.4%, respectively; p = 0.005). The overall survival (OS) of patients with a low 2wLMR was significantly longer than that in patients with a high 2wLMR (1-year OS: 37.4 vs. 18.9%, respectively; p = 0.022).

CONCLUSIONS

Thus, the 2wLMR could be a useful biomarker to predict response to nivolumab treatment and the prognosis of unresectable and recurrent gastric cancer.

Laparoscopic abdominosacral resection for rectal and anal canal carcinoma with pagetoid spread

INTRODUCTION

Perianal Paget's disease is associated with adenocarcinoma and can spread to the perianal skin. It often requires extensive resection of the perianal skin and rectum. Many studies have shown the efficacy of laparoscopic abdominoperineal resection for lower rectal cancer. However, extensive resection of the dorsal side of the perineal skin is difficult in the lithotomy position. We report a laparoscopic abdominosacral approach using the jackknife position for perianal Paget's disease.

MATERIALS AND SURGICAL TECHNIQUE

Surgery was started using the lithotomy position, and total mesorectal excision with central lymphadenectomy was performed laparoscopically. Pelvic floor muscles were divided 2 cm away from the rectum. The sigmoid colon was then divided with a linear stapler, and a terminal colostomy was made. The sacral approach was then followed with the patient placed in a jackknife position. A skin incision was made 1-2 cm from the negative margin confirmed by preoperative mapping biopsy and resected en-bloc. We used this approach in two patients with a mean operative time of 483 minutes, including 53.5 minutes for the position change. All tumor margins, including the skin, were cancer-free, and primary wound closure was possible in both of the cases. Both patients were doing well without any recurrence 10 and 13 months postoperatively.

CONCLUSION

Laparoscopic abdominosacral resection is safe and effective and facilitates extensive perineal skin resection, especially on the dorsal side, with a less invasive laparoscopic procedure.

AB0145 SMARTPHONE- AND SMARTWATCH-ACQUIRED DAILY STEPS, ACTIVITY, AND BAROMETRIC PRESSURES ASSOCIATED WITH SUBJECTIVE MEASURES OF RHEUMATOID ARTHRITIS: A PROSPECTIVE STUDY FOR RA DIGITAL PHENOTYPING

Background:

Symptoms in patients with rheumatoid arthritis (RA) are potentially influenced by exercise load and meteorological change, and often vary from day to day, especially in unstable condition of RA. Patients with RA not infrequently experience worsening of joint symptoms when the load on the joint, such as walking and doing housework, exceeds a moderate range. However, the worsening of joint symptoms is often not observed in the midst of the loading of the joint, but often becomes apparent after a few hours or days.

Objectives:

To elucidate the relationship between smartphone- and smartwatch-acquired daily objective data (barometric pressures, steps, and activity) and daily subjective patient reported outcomes of RA.

Methods:

A smartphone (iPhone 8) and a wristband-type smartwatch (Fitbit Versa 2) were lent to each patient for free. A mobile app was developed and installed into the smartphones to collect patients’ daily subjective RA symptoms including Pt-P-VAS (patient-pain-visual analogue scale), Pt-G-VAS (pt-general-VAS), PtTJCount(68)(patient self-determined tender joint count among 68 joints), PtTJCount(28), PtSJCount(66)(patient self-determined swollen joint count among 66 joints), PtSJCount(28). Also, the smartwatch data and physicians’ assessment were collected from the same subject. Physicians’ and patients’ assessment of TJC, SJC, and G-VAS was independently performed without seeing each other’s assessment.

We conducted a simple linear regression analysis with outcome variables of Pt-P-VAS, Pt-G-VAS, PtTJCount(68), PtTJCount(28), PtSJCount(66), and PtSJCount(28). The independent variables included smartphone-acquired daily steps and barometric pressure of the reported day and the previous day, and smartwatch-acquired minutes of “lightly active (1-3 METs equivalent)”, “fairly active(3-6 METs equivalent)”, and “very active(>6 METs equivalent)” of the reported day and previous day. We defined low barometric pressure as below 1000 hPa. The level of activity was measured by the smartwatch. Patients were blinded to daily barometric pressure data and their daily active time when the patients answered daily symptom questions on the smartphones.

Results:

A total of five patients were enrolled. At baseline, mean (± standard deviation (SD)) age was 50.8±14.8 years; all patients were females; mean disease duration was 6.6±4.9 years; mean SDAI was 18.6±25.5; mean DAS28-CRP was 3.23±1.85; mean morning stiffness was 134±116 min; mean HAQ-DI was 0.7±0.9. Mean observation period was 77.8 days. Because of the missing data, the sample size (N) for the regression analysis varies with the outcomes: Pt-P-VAS and Pt-G-VAS are 250 while PtTJCount and PtSJCount are 260.

The table 1 showed that the patients’ assessment of TJC, SCJ, and G-VAS was correlated well with the physicians’ assessment.

Table 1.Evaluation itemCorrelation between physicians and patients (ρ)Tender Joint Count (68)0.909Tender Joint Count(28)0.913Swollen Joint Count(66)0.896Swollen Joint Count(28)0.890General VAS0.688

The figure 1 showed the change associated with one SD increment in each independent variable with 90% confidence intervals. Low barometric pressure was associated with bad health conditions (high Pt-G-VAS, Pt-P-VAS, and SJCount). Moreover, longer very active time in the previous day (“veryactive_1” in the Figure 1) was associated with bad health condition (high SJCount). Many steps were associated with good health conditions (low Pt-G-VAS, Pt-P-VAS, and SJCount).

Figure 1.

Conclusion:

High barometric pressure was associated with good health conditions, and longer very active time in the previous day was associated with bad health condition. Barometric pressure data and physical activity data acquired by mobile digital devices may predict the change in RA symptoms. Further investigation in larger patient numbers is warranted.

Acknowledgements:

The authors would like to thank Harumi Kondo for her assistance.

Disclosure of Interests:

Keisuke Izumi Speakers bureau: Abbvie, Asahi Kasei Pharma, Bristol Myers Squibb, Chugai Pharmaceutical, Eli-Lily, Mochida Pharmaceutical, Ono Pharmaceutical, Grant/research support from: Abbvie, Asahi Kasei Pharma, Daisuke Moriwaki Employee of: CyberAgent, Inc., Takamichi Toda Employee of: AI Shift, Inc., Misako Higashida-Konishi: None declared, Manami Koyama: None declared, Hisaji Oshima: None declared, yutaka okano Speakers bureau: Asahi Kasei Pharma, Yuko Kaneko Speakers bureau: AbbVie, Astellas, Ayumi, Bristol–Myers Squibb, Chugai, Eisai, Eli Lilly, Hisamitsu, Jansen, Kissei, Kirin, Novartis, Pfizer, Sanofi, Takeda, Taisho, Tanabe-Mitsubishi, and UCB, Shigeru Ko: None declared, Tsutomu Takeuchi Speakers bureau: Abbott Japan Co, Ltd, Bristol–Myers KK, Chugai Pharmaceutical Co, Ltd, Eisai Co, Ltd, Janssen Pharmaceutical KK, Mitsubishi Tanabe Pharma Co, Pfizer Japan Inc, Takeda Pharmaceutical Co, Ltd, Astellas Pharma and Daiichi Sankyo Co, Ltd., Consultant of: Astra Zeneca KK, Eli Lilly Japan KK, Novartis Pharma KK, Mitsubishi Tanabe Pharma Co, Asahi Kasei Medical KK, Abbvie GK and Daiichi Sankyo Co, Ltd., Grant/research support from: Abbott Japan Co, Ltd, Astellas Pharma, Bristol-Myers KK, Chugai Pharmaceutical Co, Ltd, Daiichi Sankyo Co, Ltd, Eisai Co, Ltd, Janssen Pharmaceutical KK, Mitsubishi Tanabe Pharma Co, Pfizer Japan Inc, Sanofi–Aventis KK, Santen Pharmaceutical Co, Ltd, Takeda Pharmaceutical Co, Ltd, Teijin Pharma Ltd, Abbvie GK, Asahikasei Pharma Corp and Taisho Toyama Pharmaceutical Co, Ltd.

POS0635 COMPARING THE ULTRASONOGRAPHIC EVALUATION IN PATIENTS WITH JAPANESE RHEUMATOID ARTHRITIS BETWEEN BARICITINIB AND TNF ANTAGONIST THERAPY

Background:

Baricitinib (BAR) and TNF antagonist are the important therapeutic agent for the treatment of rheumatoid arthritis.However there is still few studies of improvement of ultrasonographic findings in RA treated comparison with BAR and TNF.

Objectives:

To evaluate the clinical efficacy of BAR and TNF therapy patients with rheumatoid arthritis (RA) using ultrasonography (US).

Methods:

Participants comprised 16 and 45 Japanese RA patients who had recently received BAR and TNF. All patients with a diagnosis of RA according to the 2010 ACR/EULAR criteria. Patients underwent clinical and laboratory assessments every 4 weeks from baseline to 24 weeks, and US assessments at baseline, 4, 12 and 24 weeks. Gray scale (GS) and power doppler (PD) signals were scored using a semi-quantitative scale from 0 to 3 at 26 (0-78) synovial sites (22 joints) in the following joints: bilateral first to fifth metacarpopharangeal (MCP) joints (dorsal recess); first interphalangeal (IP) and second to fifth proximal interphalangeal (PIP) (dorsal recess) joints; and the wrists (dorsal radial, median and ulnar). We evaluated the improvement of GS and PD score from baseline to week 24.

Results:

In the patients receiving BAR (n=16) and TNF (n=45), the mean age was 55.9 vs 54.6 years old (p=0.682), disease duration was 10.2 vs 6.1 years (p=0.094), the rate of MTX use was 75% vs 89% (p=346), the mean MTX dose was 9.3 vs 10.2 mg/w (p=0.443), the rate of ACPA positive was 94% vs 82% (p=0.476), DAS28-ESR was 4.25 vs 4.61 (p=0.289), CDAI was 15.8 vs 18.5 (p=0.210), GS score was 21.6 vs 16.3 (p=0.436) and PD score was 15.0 vs 9.5 (p=0.260). The degree of improvement respective changes in GS and PD score after 4, 12 and 24 weeks were as follows: GS: -7.2 vs -3.7 (p=0.268) and PD: -7.6 vs -2.3 (p=0.158) after 4 weeks, GS: -10.9 vs -5.0 (p=0.161) and PD: -9.2 vs -3.8 (p=0.049) after 12 weeks, GS: -12.9 vs -6.1 (p=0.485) and PD: -11.3 vs -5.7 (p=0.062) after 24 weeks between BAR and TNF (Fig.1, 2). Next, The improvement rate of respective changes in GS and PD score after 4, 12 and 24 weeks were as follows: GS: -23.8% vs -11.6% (p=0.580) and PD: -30.3% vs -16.5% (p=0.343) after 4 weeks, GS: -39.6% vs -15.6% (p=0.129) and PD: -47.1% vs -30.8% (p=0.210) after 12 weeks, GS: -52.2% vs -22.2% (p=0.248) and PD: -77.1% vs -50.1% (p=0.048) after 24 weeks between BAR and TNF.

Conclusion:

The present study provides evidence supporting both the BAR and TNF therapy showed improvement effect over time, but in a comparison between BAR and TNF, the PD score of BAR showed a siginificant improvement effect compared to TNF at 12 and 24 weeks. It was suggeted that BAR may improve inflammatory synovitis earlier compared to TNF.

Disclosure of Interests:

None declared

Drug sensitivity profile of minor KRAS mutations in colorectal cancer using mix culture assay: The effect of AMG-510, a novel KRAS G12C selective inhibitor, on colon cancer cells is markedly enhanced by the combined inhibition of MEK and BCL-XL

Colorectal cancer with a Kirsten rat sarcoma 2 viral oncogene homolog (KRAS) gene mutation is considered to be resistant to anti-EGFR agents. G12D is the most common KRAS mutation in colorectal cancer, followed by G12V and G13D. According to clinical and basic research data, patients with colorectal cancer exhibiting G12D and G12V KRAS mutations are resistant to anti-EGFR agents; however, this is not true of G13D and other minor mutations, which are still not well understood. The current study focused on minor KRAS mutations (G12A, G12C, G12S, Q61H and A146T) and evaluated whether these were resistant to anti-EGFR antibodies using a mix culture assay. The results demonstrated that all KRAS mutations, including minor mutations, were resistant to two anti-EGFR agents: Cetuximab and panitumumab. The combined effect of MEK and BCL-XL inhibition on colorectal cancer cells with KRAS minor mutations were subsequently evaluated. The combined effect of MEK and BCL-XL inhibitors was confirmed in all KRAS minor mutations. The sensitivity of AMG510, a novel KRAS G12C selective inhibitor, was also assessed. The mix culture assay revealed that AMG510 selectively exerted an antitumor effect on colon cancer cells with a G12C KRAS mutation. The combination of MEK and BCL-XL inhibition markedly enhanced the effect of AMG510 in colon cancer cells. The current study suggested that AMG510 may have potential clinical use in combination with MEK and BCL-XL inhibitors in the treatment of patients with colorectal cancer exhibiting the G12C KRAS mutation.

Clinical determinants and prognostic impact of osteoporosis in patients with chronic heart failure

Background

Despite accumulating evidence of a close association between orthopedic fractures and chronic heart failure (CHF), the clinical risk factors of osteoporosis, defined as reduction in bone mineral densities (BMDs), in CHF patients have not been systematically analyzed. In addition, the impact of osteoporosis on prognosis of CHF remains unclear.

Aims

We aimed to clarify the prevalence, clinical risk factors, and prognostic impact of osteoporosis in CHF patients.

Methods

We retrospectively examined 303 CHF patients (75 years, [interquartile range (IQR), 66–82 years]; 41% female). BMDs at the lumber spine, femoral neck, and total femur were measured by dual-energy X-ray absorptiometry (DEXA), and osteoporosis was diagnosed when BMD at any of the three sites was less than 70% of Young Adult Mean.

Results

The prevalence of osteoporosis in the CHF patients was 40%. Patients with osteoporosis were older (79 [IQR, 74–86] vs. 72 [IQR, 62–80] years), included a large percentage of females, had slower gait speed and had lower body mass index (BMI). Loop diuretics and warfarin were used more frequently and direct oral anticoagulants (DOACs) were used less frequently in patients with osteoporosis than in patients without osteoporosis. Multivariate logistic regression analysis indicated that sex (odds ratio [OR] 5.07, 95% Confidence Interval [CI] 2.68–9.61, p&lt;0.01), BMI (OR, 0.83; 95% CI, 0.75–0.91; p&lt;0.01), gait speed (OR, 0.80; 95% CI, 0.70–0.92; p&lt;0.01), loop diuretics use (OR, 2.52; 95% CI, 1.20–5.27; p=0.01) and no DOACs use (OR, 0.43; 95% CI, 0.19–0.96; p=0.04) were independently associated with osteoporosis. During the mean follow-up period of 290±254 days, 92 patients (30.4%) had adverse events. When patients with osteoporosis were divided into subgroups according to the number of sites with BMD of an osteoporosis level, Kaplan-Meier survival curves showed that the rate of adverse events (death and cardiovascular events) was higher in patients with osteoporotic BMD at two or more sites than in patients without osteoporosis (51% vs. 23%, p=0.03) (Figure). In multivariate Cox regression analyses, osteoporotic BMD at two or more sites was an independent predictor of adverse events after adjustment for age, sex, and NT-proBNP level (Hazard ratio, 1.74; 95% CI, 1.01–2.99; p=0.04).

Conclusion

The risk of osteoporosis may be increased in users of loop diuretics and may be decreased in users of DOACs in CHF patients. Extent of osteoporosis is a novel predictor of adverse events in CHF patients.

Funding Acknowledgement

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

Low‑dose trametinib and Bcl‑xL antagonist have a specific antitumor effect in KRAS‑mutated colorectal cancer cells

KRAS‑mutant colorectal cancer (CRC) is a highly malignant cancer with a poor prognosis, however specific therapies targeting KRAS mutations do not yet exist. Anti‑epidermal growth factor receptor (EGFR) agents, including cetuximab and panitumumab, are effective for the treatment of certain patients with CRC. However, these anti‑EGFR treatments have no effect on KRAS‑mutant CRC. Therefore, new therapeutic strategies targeting KRAS‑mutant CRC are urgently needed. To clarify the direct effect of KRAS gene mutations, the present study transduced mutant forms of the KRAS gene (G12D, G12V and G13D) into CACO‑2 cells. A drug‑screening system (Mix Culture assay) was then applied, revealing that the cells were most sensitive to the MEK inhibitor trametinib among tested drugs, Cetuximab, Panitumumab, Regorafenib, Vemurafenib, BEZ‑235 and Palbociclib. Trametinib suppressed phosphorylated ERK (p‑ERK) expression and inhibited the proliferation of KRAS‑mutant CACO‑2 cells. However, low‑dose treatment with trametinib also increased the expression of the anti‑apoptotic protein Bcl‑xL in a dose‑dependent manner, leading to drug resistance. To overcome the resistance of KRAS‑mutant CRC to apoptosis, the combination of trametinib and the Bcl‑xL antagonist ABT263 was assessed by in vitro and in vivo experiments. Compared with the effects of low‑dose trametinib monotherapy, combination treatment with ABT263 had a synergistic effect on apoptosis in mutant KRAS transductants in vitro. Furthermore, in vivo combination therapy using low‑dose trametinib and ABT263 against a KRAS‑mutant (G12V) xenograft synergistically suppressed growth, with an increase in apoptosis compared with the effects of trametinib monotherapy. These data suggest that a low dose of trametinib (10 nM), rather than the usual dose of 100 nM, in combination with ABT263 can overcome the resistance to apoptosis induced by Bcl‑xL expression, which occurs concurrently with p‑ERK suppression in KRAS‑mutant cells. This strategy may represent a promising new approach for treating KRAS‑mutant CRC.

Impact of barometric pressure on adhesive small bowel obstruction: a retrospective study

Background

Adhesive small bowel obstruction (ASBO) is one of the most common causes of postoperative morbidity. According to Boyle’s law, decreased barometric pressure expands the volume of intestinal gas. We aimed to elucidate the relationship between barometric pressure and ASBO.

Methods

We divided 215 admissions of 120 patients with ASBO into three groups: the fasting group, which responded to fasting (n = 51); the decompression group, which was successfully treated with gastrointestinal decompression (n = 104); and the surgery group which required emergency or elective surgery to treat ASBO (n = 60). We compared and examined clinical backgrounds, findings on admission, and barometric pressure during the peri-onset period (29 days: from 14 days before to 14 days after the onset of ASBO).

Results

There were significant differences among the three groups regarding gender, history of ASBO, hospital length of stay, and barometric pressure on the onset day of ASBO. Barometric pressure on the onset day was significantly higher in the fasting group than in the decompression group (p = 0.005). During pre-onset day 5 to post-onset day 2, fluctuations in the barometric pressure in the fasting and decompression groups showed reciprocal changes with a symmetrical axis overlapping the median barometric pressure in Matsumoto City; the fluctuations tapered over time after onset. In the fasting group, the barometric pressure on the onset day was significantly higher than that on pre-onset days 14, 11, 7, 4, 3, and 2; post-onset days 3 and 10; and the median pressure in Matsumoto City. Conversely, in the decompression group, the barometric pressure on the onset day was lower than that on pre-onset days 14, 5–2; post-onset days 1, 2, 7, 8, 11, 13, and 14; and the median pressure in Matsumoto City. In the surgery group, the barometric pressure on the onset day was equivalent to those on the other days.

Conclusions

ASBO with response to conservative treatment is vulnerable to barometric pressure. Additionally, ASBO that is successfully treated with fasting and decompression is associated with a different barometric pressure on the onset day and reciprocal fluctuations in the barometric pressure during the peri-onset period.

Types and site distributions of intestinal injuries in seat belt syndrome

OBJECTIVE

Intestinal injuries in seat belt syndrome are relatively uncommon but can be potentially lethal due to accompanying peritonitis and hemorrhaging. It can be difficult to identify the exact injury sites of the intestine as multiple areas are often damaged and massive intraperitoneal hemorrhaging may make it challenging to determine causal bleeding points of mesenteric injuries. This study aimed to clarify the incidence and distribution of intestinal injuries in seat belt syndrome.

METHODS

We retrospectively reviewed the clinical records of 25 patients who underwent laparotomy for suspected intestinal injuries due to seat belt syndrome during a frontal impact. The incidence and distribution of the sites of intestinal injuries, as well as associated injuries, were investigated. Intestinal injuries were divided into bowel and mesenteric injuries. Additionally, bowel injuries were classified into two types: perforation and non-perforation (seromuscular tears/intramural hematomas). Regarding the injured sites, the small intestine was divided into the following three parts: (1) the ligament of Treitz (100-cm distal from the ligament [proximal jejunum]), (2) the ileocecal valve (100-cm proximal from the valve [distal ileum]), and (3) the intermediate area between those two regions (jejunoileal junction).

RESULTS

In total, there were 64 major injuries among 25 patients requiring surgical intervention: 34 bowel injuries (20 perforations and 14 non-perforations) and 30 mesenteric injuries. Significantly more bowel perforations occurred in the small intestine (1 [interquartile range (IQR), 0-1]) than in the large intestine (0 [IQR, 0-0]) (p = 0.003). Similarly, significantly more mesenteric injuries occurred in the small intestine (1 [IQR, 0-1.25]) than in the large intestine (0 [IQR, 0-0]) (p < 0.001). Specific sites of the mesenteric injuries in the small intestine included the jejunoileal junction (0 [IQR, 0-1]) and distal ileum (0 [IQR, 0-1]); the jejunoileal junction was significantly more vulnerable than the proximal jejunum (0 [IQR, 0-0]) (p = 0.015).

CONCLUSIONS

In patients with seat belt syndrome, the small intestine was more vulnerable to perforation and mesenteric injury than the large intestine. Additionally, for mesenteric injuries, the jejunoileal junction was more likely to be damaged than the proximal jejunum.

Treatment of Rectal Cancer-Induced Disseminated Carcinomatosis of the Bone Marrow with FOLFOX plus Cetuximab and Panitumumab

Disseminated carcinomatosis of the bone marrow (DCBM) in colorectal cancer is an extremely rare complication with a poor prognosis. Here, we report a case of DCBM due to rectal cancer successfully treated with a combination of FOLFOX and an anti-epidermal growth factor receptor (EGFR) agent. The patient was a 38-year-old man diagnosed with rectal cancer with multiple bone and para-aortic lymph node metastases complicated by disseminated intravascular coagulation (DIC). He first recovered from DIC following cotreatment with FOLOX plus cetuximab; subsequently, the second attack was successfully treated with FOLFOX plus panitumumab. His initial condition was extremely poor, but he survived with two FOLFOX plus anti-EGFR regimens and died 333 days after introduction of chemotherapy.

P4537Impact of body composition analysis on prediction of short-term readmission events in heart failure: muscle wasting vs. obesity

Background

Obesity, defined as higher body mass index (BMI), is associated with better prognosis in patients with chronic heart failure (CHF), though the presence of obesity is a risk factor of development of CHF (Obesity paradox). On the other hand, muscle wasting, i.e. reduction in skeletal muscle mass, is frequently observed in CHF, leading to lower exercise capacity and poor cardiovascular outcome.

Purpose

The aim of this study was to examine whether analysis of body composition improves prediction of short-term readmission rates in patients with CHF.

Methods

We retrospectively analyzed data for 167 consecutive HF patients who were admitted to our institute for management of HF and received a Dual-energy X-ray absorptiometry (DEXA) scan. Muscle wasting was defined as DEXA-measured appendicular skeletal muscle mass index <7.0 kg/m2 in male and <5.4 kg/m2 in female according to the Asian Working Group for Sarcopenia criteria. Obesity was defined according to the criteria by the use of DEXA-measured percent body fat mass: >25% in male, >30% in female. The primary endpoint was readmission due to cardiac events including worsening heart failure, arrhythmia, and cardiopulmonary arrest during a 180-days follow-up period after discharge.

Results

The mean age of the patients was 74±13 years and 46% of them were male. The mean BMI was 21.8±3.8 kg/m2. Forty-seven percent of the patients were classified as NYHA functional class III. The most frequent etiology of HF was cardiomyopathy (30%), followed by ischemic heart disease (27%) and valvular heart disease (27%). The prevalence of muscle wasting and that of obesity were 69% and 59%, respectively. Patients with muscle wasting had lower BMI level, higher prevalence of NYHA functional class III and diabetes mellitus compared with those without muscle wasting. On the other hand, patients with obesity had higher prevalence of hypertension and dyslipidemia, higher level of BMI, fasting plasma insulin and triglyceride, and lower level of HDL-cholesterol compared with those without obesity. During the follow-up period, 34 patients (19%) were re-hospitalized due to cardiac events. Kaplan-Meier survival curves showed that patients with obesity had a significantly lower readmission rate during a 180-days follow-up period than did the patients without obesity (14.3% vs. 29.0%, Log-Rank test, p<0.01). There was no difference in readmission rates between patients with and without muscle wasting (20.0% vs. 21.2%, p=0.88). In multivariate Cox regression analyses adjusted for age, sex, diabetes, and renal function, obesity was independently associated with lower readmission rates (hazard ratio 0.45, 95% confidence interval 0.22–0.93). However, the association between obesity and readmission rate was lost after the adjustment for NT-proBNP levels.

Conclusion

Body composition analysis by DEXA enables to find CHF patients with increased fat mass who have lower risk of short-term readmission.

P1538Low energy intake predicts readmission of elderly heart failure patients independently of nutritional status

Background

Malnutrition is frequently present and closely associated with poor clinical outcomes in elderly heart failure (HF) patients. Our previous study showed that low energy intake (EI) is associated with worse functional status in elderly HF inpatients after cardiac rehabilitation, but significance of EI in prediction of hospital readmission has not been elucidated fully.

Purpose

We examined whether low EI is a predictor of readmission for cardiac events in elderly HF patients.

Methods

We retrospectively retrieved data for 298 HF patients aged ≥65 years (median age of 77 years, interquartile range [IQR]: 71 - 82, female: 53%) who admitted to our institute for diagnosis and treatment of HF. Medical records were reviewed with regard to demography, medical history, comorbidities, medications, laboratory data, echocardiograms, functional status, nutritional status and total energy intake. Nutritional status was assessed using the Mini Nutritional Assessment Short Form (MNA-SF) and total EI per day were calculated at discharge by a registered dietitian and a trained physical therapist. The primary endpoint was readmission due to cardiovascular events including worsening HF, arrhythmia, angina pectoris and myocardial infarction during a 1-year follow-up period.

Results

The median period of follow-up was 235 days (IQR: 78–365 days). The 1-year readmission rate for cardiovascular events was 54.4%. The cutoff values of MNA-SF score and EI, calculated by ROC curve analysis to predict the primary endpoint, were 7 points (area under the curve [AUC]: 0.59, sensitivity: 0.65, specificity: 0.50) and 31.8 kcal/kg/day (AUC: 0.59, sensitivity: 0.83, specificity: 0.35), respectively. Patients with low MNF-SF score (≤7) or low EI (≤31.8 kcal/kg/day) had significantly higher readmission rate during a 1-year follow-up period than did the patients with high MNF-SF score or EI (MNA-SF: 60.7% vs. 45.6%, p<0.01, EI: 60.4% vs. 36.8%, p<0.01), respectively. When patients were classified into four groups using cutoff values of MNA-SF score and EI, 1-year readmission rate was significantly higher in patients with low EI than in those with high EI regardless of MNF-SF scores. In multivariate Cox proportional hazard analyses adjusted for known prognostic factors in addition to age and gender, hazard ratios (HR) were significantly higher in patients with high MNA-SF score and low EI (adjusted HR: 2.81, 95% confidential interval [CI]: 1.15 - 9.32, p=0.02) and low MNA-SF score (≤7) and low EI (adjusted HR: 4.16, 95% CI: 1.72 - 13.72, p<0.01) than those with high MNA-SF score and high EI.

Kaplan-Meier curves of readmission rates

Conclusions

Low energy intake is a nutritional status-independent predictor of 1-year readmission rate in elderly HF patients.

P6453Activation of necroptotic pathway by downregulated caspase-8 expression is associated with progression of left ventricular remodeling in nonischemic dilated cardiomyopathy

Background

Necroptosis, a form of programmed necrosis, has been suggested to be involved in the pathogenesis of various pathological conditions including heart failure. Protein expression of caspase-8, an endogenous inhibitor of necroptosis, is reported to be downregulated in human failing hearts, but its clinical significance remains unclear.

Methods

Endomyocardial biopsy specimens were obtained from patients with nonischemic dilated cardiomyopathy (n=57, 56.2±14.5 years old, 70% male). The area stained with antibodies against caspase-8 and phospho-MLKL-Ser358 was calculated using an image analyzer, and fibrotic and cardiomyocyte areas were determined by Masson's Trichrome staining. Using a level of median caspase-8 expression (6.04% of the area of the myocardium with caspase-8 signal), patients were classified into a high caspase-8 expression group (H-cas8) and a low caspase-8 expression group (L-cas8).

Results

Caspase-8 signals were detected in cytoplasm and intercalated disks of cardiomyocytes. Patients in the L-cas8 group was younger (51.3±13.1 vs. 61.2±14.3 years old) and had larger left ventricular end-diastolic volume (LVEDV: 174±49 vs. 131±41 ml), larger left ventricular end-systolic volume (LVESV: 123±51 vs. 87±39 ml), and higher ratio of mitral peak velocity of early filling to late diastolic filling (E/A: 1.94±1.48 vs. 1.12±0.66) compared with the H-cas8 group. Caspase-8 expression level was positively correlated with age (r=0.34, p=0.01) and negatively correlated with LVEDV (r=−0.47, p<0.01), LVESV (r=−0.40, p<0.01), and E/A (r=−0.39, p<0.01) in simple linear regression analysis. The extent of myocardial fibrosis was not correlated with caspase-8 expression level. Multiple regression analysis indicated that LVEDV, LVESV, and E/A were independent explanatory factors of caspase-8 expression level after adjusting age and sex. Phospho-MLKL signals, an index of activation of necroptotic pathway, were frequently observed in cytoplasm, intercalated disks, and nuclei in the L-cas8 group but not in the H-cas8 group.

Conclusion

Lower caspase-8 expression in cardiomyocytes was associated with increased phosphorylation of MLKL and larger left ventricular volume, suggesting that downregulated caspase-8 may contribute to progression of myocardial remodeling via activation of MLKL in human dilated cardiomyopathy.

High incidence of other primary malignancies in patients with synchronous multiple gastric cancers "a multi-center retrospective cohort study"

This study evaluated the relationship between synchronous multiple gastric cancer and other primary malignancies. During 2002–2013, 1094 consecutive surgically treated gastric cancer patients were enrolled. Preoperatively, we performed total colonoscopy and whole-body computed tomography. When malignancies in other organs were suspected, detailed organ-specific examinations were performed. Synchronous multiple gastric cancer occurred in 102 patients (9.3%)which was frequently observed in patients with preoperative other primary malignancies (p < 0.001). Preoperative other primary malignancy was an independent risk factor for synchronous multiple gastric cancer (p = 0.001; hazard ratio: 2.145, 95% confidence interval: 1.354–3.399) and an independent prognostic factor of overall survival in patients undergoing gastrectomy with curative intent (p = 0.021; hazard ratio: 1.481, 95% confidence interval: 1.060–2.070). Thus, patients with preoperative other primary malignancies have a high risk of synchronous multiple gastric cancer. Careful preoperative examination is recommended to improve survival.