Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Identification and initial validation of maximal tumor area as a novel prognostic factor for overall and disease-free survival in patients with resectable colon cancer: a retrospective study

BACKGROUND

The tumor area may be a potential prognostic indicator. The present study aimed to determine and validate the prognostic value of tumor area in curable colon cancer.

METHODS

This retrospective study included a training and validation cohorts of patients who underwent radical surgery for colon cancer. Independent prognostic factors for overall survival (OS) and disease-free survival (DFS) were identified using Cox proportional hazards regression models. The prognostic discrimination was evaluated using the integrated area under the receiver operating characteristic curves (iAUCs) for prognostic factors and models. The prognostic discrimination between tumor area and other individual factors was compared, along with the prognostic discrimination between the tumor-node-metastasis (TNM) staging system and other prognostic models. Two-sample Wilcoxon tests were carried out to identify significant differences between the two iAUCs. A two-sided P <0.05 was considered statistically significant.

RESULTS

A total of 3051 colon cancer patients were included in the training cohort and 872 patients in the validation cohort. Tumor area, age, differentiation, T stage, and N stage were independent prognostic factors for both OS and DFS in the training cohort. Tumor area had a better OS and DFS prognostic discrimination characteristics than T stage, maximal tumor diameter, differentiation, tumor location, and number of retrieved lymph nodes. The novel prognostic model of T stage + N stage + tumor area (iAUC for OS, 0.714, P <0.001; iAUC for DFS, 0.694, P <0.001) showed a better prognostic discrimination than the TNM staging system (T stage + N stage; iAUC for OS, 0.664; iAUC for DFS, 0.658). Similar results were observed in an independent validation cohort.

CONCLUSIONS

Tumor area was identified as an independent prognostic factor for both OS and DFS in curable colon cancer patients, and in cases with an adequate number of retrieved lymph nodes. The novel prognostic model of combining T stage, N stage, and tumor area may be an alternative to the current TNM staging system.

The Link between Periodontal Disease and Asthma: How Do These Two Diseases Affect Each Other?

A growing body of evidence suggests that the effects of poor oral hygiene extend beyond the oral cavity and are associated with a variety of systemic diseases, including asthma. Asthma, which results in symptoms of cough, wheezing, and dyspnoea, and is characterized by airflow limitation with variability and (partial or complete) reversibility, is amongst the most prevalent respiratory diseases with approximately 262 million patients worldwide, and its prevalence and disease burden is on the increase. While asthma can occur at a young age, it can also develop later in life and affects a variety of age groups. Both of these diseases have a chronic course, and various researchers have suggested a link between the two. In this article, we aim to provide a literature review focusing on the association between the two diseases. The results demonstrate that medications (primarily, inhaler medicine), hypoxia induced by asthma, and the breathing behaviour of patients potentially trigger periodontal disease. In contrast, oral periodontopathogenic microorganisms and the inflammatory mediators produced by them may be involved in the onset and/or exacerbation of asthma. Common contributing factors, such as smoking, gastro-oesophageal reflux, and type-2 inflammation, should also be considered when evaluating the relationship between the two diseases.

Putative Bidirectionality of Chronic Obstructive Pulmonary Disease and Periodontal Disease: A Review of the Literature

The prevalence of chronic obstructive pulmonary disease (COPD) is increasing worldwide and is currently the third leading cause of death globally. The long-term inhalation of toxic substances, mainly cigarette smoke, deteriorates pulmonary function over time, resulting in the development of COPD in adulthood. Periodontal disease is an inflammatory condition that affects most adults and is caused by the bacteria within dental plaque. These bacteria dissolve the gums around the teeth and the bone that supports them, ultimately leading to tooth loss. Periodontal disease and COPD share common risk factors, such as aging and smoking. Other similarities include local chronic inflammation and links with the onset and progression of systemic diseases such as ischemic heart disease and diabetes mellitus. Understanding whether interventions for periodontal disease improve the disease trajectory of COPD (and vice versa) is important, given our rapidly aging society. This review focuses on the putative relationship between COPD and periodontal disease while exploring current evidence and future research directions.

Abstract 6005: Promoter methylation occurs at high frequencies regardless of mutation status of tumor-associated genes in oral malignancies

Background: Genetic and epigenetic alterations are both important in tumorigenesis. However, their association in oral carcinogenesis has not been fully investigated yet. In this study, we analyzed somatic mutations of tumor-related genes and promoter methylation of tumor-suppressor genes (TSGs) in oral malignancies/premalignancies, and analyzed their association.

Materials and Methods: 39 oral squamous cell carcinomas (OSCCs) and 2 oral epithelial dysplasias (OEDs) were obtained as fresh-frozen?. Somatic mutations of 46 tumor-related genes, 13 TSGs and 33 oncogenes, were analyzed by targeted next-generation sequencing (NGS). Promoter methylation of five TSG: (p16/INK4A, CMTM3, EGFLAM, NKX2-3, and RBP4) were determined by methylation-specific PCR (MSP).

Results: Somatic mutations of tumor-related genes were observed in 63.4% of 41 OSCCs/OEDs. Particularly, mutations of p53 and PIK3CA were observed 39.0% and 31.7%, respectively, of the 41 OSCCs/OEDs. Promoter methylation of p16/INK4A, CMTM3, NKX2-3, RBP4, and EGFLAM were observed in 34.1%, 48.8%, 41.5%, 68.3%, and 36.6%, respectively, of the 41 OSCCs/OEDs. No differences in the frequency of promoter methylation of the five genes were observed between tumors with and without somatic mutations of p53 and PIK3CA.

Conclusions: Promoter methylation was observed at high frequencies regardless of mutation status of p53 and PIK3CA in OSCCs/OEDs. Oral tumorigenesis appears to be difficult to be explained solely by genetic events indicating involvement of epigenetic events.

Citation Format: Masanobu Abe, Kazuto Hoshi, Toshikazu Ushijima. Promoter methylation occurs at high frequencies regardless of mutation status of tumor-associated genes in oral malignancies [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 6005.

Association between hospital surgical case volume and postoperative mortality in patients undergoing gastrectomy for gastric cancer: a systematic review and meta-analysis

BACKGROUND

Postoperative mortality is an important indicator for evaluating surgical safety. Postoperative mortality is influenced by hospital volume; however, this association is not fully understood. This study aimed to investigate the volume-outcome association between the hospital surgical case volume for gastrectomies per year (hospital volume) and the risk of postoperative mortality in patients undergoing a gastrectomy for gastric cancer.

METHODS

Studies assessing the association between hospital volume and the postoperative mortality in patients who underwent gastrectomy for gastric cancer were searched for eligibility. Odds ratios were pooled for the highest versus lowest categories of hospital volume using a random-effects model. The volume-outcome association between hospital volume and the risk of postoperative mortality was analyzed. The study protocol was registered with Prospective Register of Systematic Reviews (PROSPERO).

RESULTS

Thirty studies including 586 993 participants were included. The risk of postgastrectomy mortality in patients with gastric cancer was 35% lower in hospitals with higher surgical case volumes than in their lower-volume counterparts (odds ratio: 0.65; 95% CI: 0.56-0.76; P <0.001). This relationship was consistent and robust in most subgroup analyses. Volume-outcome analysis found that the postgastrectomy mortality rate remained stable or was reduced after the hospital volume reached a plateau of 100 gastrectomy cases per year.

CONCLUSIONS

The current findings suggest that a higher-volume hospital can reduce the risk of postgastrectomy mortality in patients with gastric cancer, and that greater than or equal to 100 gastrectomies for gastric cancer per year may be defined as a high hospital surgical case volume.

Formation and evolution of carbonaceous asteroid Ryugu: Direct evidence from returned samples

Samples of the carbonaceous asteroid Ryugu were brought to Earth by the Hayabusa2 spacecraft. We analyzed 17 Ryugu samples measuring 1 to 8 millimeters. Carbon dioxide-bearing water inclusions are present within a pyrrhotite crystal, indicating that Ryugu's parent asteroid formed in the outer Solar System. The samples contain low abundances of materials that formed at high temperatures, such as chondrules and calcium- and aluminum-rich inclusions. The samples are rich in phyllosilicates and carbonates, which formed through aqueous alteration reactions at low temperature, high pH, and water/rock ratios of <1 (by mass). Less altered fragments contain olivine, pyroxene, amorphous silicates, calcite, and phosphide. Numerical simulations, based on the mineralogical and physical properties of the samples, indicate that Ryugu's parent body formed ~2 million years after the beginning of Solar System formation.

A Comparative Study of Periodontal Health Status between International and Domestic University Students in Japan

BACKGROUND

In our previous study, international university students showed a significantly higher dental caries morbidity rate than domestic students. On the other hand, the periodontal health status of international university students has not been clarified yet. In this study, we compared the periodontal health status of international and domestic university students in Japan.

METHODS

We conducted a retrospective review of the clinical data of the university students that visited a dental clinic in the division for health service promotion at a university in Tokyo for screening between April 2017 and March 2019. Bleeding on probing (BOP), calculus deposition and probing pocket depth (PPD) were investigated.

RESULTS

The records of 231 university students (79 international and 152 domestic university students) were analyzed; 84.8% of international students were from Asian countries (n = 67). The international university students showed a higher percentage of BOP than domestic students (49.4% and 34.2%, respectively: p < 0.05) and they showed more extensive calculus deposition (calculus grading score [CGS]) than domestic university students (1.68 and 1.43, respectively: p < 0.01), despite no significant difference in PPD.

CONCLUSIONS

The current study shows that international university students have poorer periodontal health than domestic students in Japan, even though the result might include many uncertainties and possible biases. To prevent severe periodontitis in the future, regular checkups and thorough oral health care are essential for the university students, especially those from foreign countries.

Effects of Arterial Stiffness on Cerebral WM Integrity in Older Adults: A Neurite Orientation Dispersion and Density Imaging and Magnetization Transfer Saturation Imaging Study

BACKGROUND AND PURPOSE

Arterial stiffness is reported to be able to cause axonal demyelination or degeneration. The present study aimed to use advanced MR imaging techniques to examine the effect of arterial stiffness on the WM microstructure among older adults.

MATERIALS AND METHODS

Arterial stiffness was measured using the cardio-ankle vascular elasticity index (CAVI). The high-CAVI (mean CAVI ≥ 9 points) and the low-CAVI groups (mean CAVI < 9 points) were created. The neuronal fiber integrity of the WM was evaluated by neurite orientation dispersion and density imaging and magnetization transfer saturation imaging. Tract-Based Spatial Statistics and the tracts-of-interest analysis were performed. Specific WM regions (corpus callosum, internal capsule, anterior thalamic radiation, corona radiata, superior longitudinal fasciculus, forceps minor, and inferior fronto-occipital fasciculus) were selected in the tracts-of-interest analysis.

RESULTS

In Tract-Based Spatial Statistics, the high-CAVI group showed a significantly lower myelin volume fraction value in the broad WM and significantly higher radial diffusivity and isotropic volume fraction values in the corpus callosum, forceps minor, inferior fronto-occipital fasciculus, internal capsule, corona radiata, and anterior thalamic radiation than the low-CAVI group. In tracts-of-interest analysis using multivariate linear regression, significant associations were found between the mean CAVI and radial diffusivity in the anterior thalamic radiation and the corona radiata; isotropic volume fraction in the anterior thalamic radiation and the corona radiata; and myelin volume fraction in the superior longitudinal fasciculus (P < .05). Additionally, partial correlation coefficients were observed for the significant associations of executive function with radial diffusivity and myelin volume fraction (P < .05).

CONCLUSIONS

Arterial stiffness could be associated with demyelination rather than axonal degeneration.

Global, Regional, and National Burdens with Temporal Trends of Early-, Intermediate-, and Later-Onset Gastric Cancer from 1990 to 2019 and Predictions up to 2035

Simple Summary

Early, intermediate, and late-onset gastric cancer (EOGC, IOGC, LOGC) incidence and death rates differed globally, regionally, and nationally in 2019. From 1990 to 2019, EOGC showed a slower decrease in incidence rate worldwide than IOGC and LOGC, whereas EOGC and LOGC showed slower decreases in mortality than IOGC. The worldwide incidence rate of EOGC was predicted to increase substantially from 2020 to 2035, while that for LOGC was predicted to increase slightly and that for IOGC was predicted to remain stable over the same period. This study revealed significant differences in the burdens and temporal trends of EOGC, IOGC, and LOGC, and highlighted the importance of tailored cancer-control measures in neglected subpopulations, especially in patients with EOGC.

Abstract

Background: Evidence for estimating and predicting the temporal trends of gastric cancer in different age groups is lacking. Methods: Data of early-, intermediate-, and later-onset gastric cancer (EOGC, IOGC, LOGC) was from the Global Burden of Diseases Study 2019. The incidences and deaths due to EOGC, IOGC, and LOGC were analyzed by period, sex, geographic location, and sociodemographic incidence. Temporal trends were evaluated by estimated annual percentage changes (EAPCs). The incidences and temporal trends were predicted until 2035. Results: There were substantial differences in the incidence and death rates of the three populations at global, regional and national levels in 2019. From 1990 to 2019, EOGC (EAPC, −0.84) showed a slower decrease in incidence rate worldwide than IOGC (EAPC, −1.77) and LOGC (EAPC, −1.10), whereas EOGC and LOGC showed slower decreases in mortality than IOGC. The worldwide incidence rate of EOGC (EAPC, 1.44) was predicted to increase substantially from 2020 to 2035, while that for LOGC (EAPC, 0.43) was predicted to increase slightly and that for IOGC (EAPC, −0.01) was predicted to remain stable over the same period. Conclusions: This study revealed differences in the burdens and temporal trends of EOGC, IOGC, and LOGC, and highlighted the importance of tailored cancer-control measures in neglected subpopulations, especially in patients with EOGC.

Reduction of noise induced by power supply lines using phase-locked loop

An experimental implementation for the reduction of power-line noise in delicate signal detection is presented. This implementation improves the signal-to-noise ratio without limiting the bandwidth of the measurement. A sinusoidal wave and its harmonics, both synchronized with the frequency of the power line, are used to cancel out the power supply noise induced in the measurement signal. The wave and the harmonics are generated via a phase-locked loop implementation. Their amplitude and phase are adjusted, and then they are added to the measurement signal using a series of operational amplifiers to compensate for the noise. Although we applied this method to the particular case of scanning tunneling microscopy measurements, considerably improving the image quality, our implementation can be applied to other measurement systems for which noise from the power lines can compromise the signal detection.

Involvement of growth differentiation factor 15 in paradoxical relationship between body mass index and mortality in patients with suspected or known coronary artery disease; The ANOX Study

Background

Obesity is a well-established risk factor for type 2 diabetes mellitus, hypertension and dyslipidemia, leading to coronary artery disease (CAD). Nevertheless, body mass index (BMI) is inversely associated with cardiovascular (CV) mortality in patients with cardiac disorders, termed “obesity paradox”. However, the underlying mechanism remains unclear.

Purpose

To clarify important factors involved in the pathogenesis of obesity paradox.

Methods

Using data from a multicenter, prospective cohort of 2,418 patients with suspected or known CAD enrolled in the ANOX study, we assessed the relationship between BMI at baseline and the incidence of CV death over 3 years, and investigated the involvement of several endocrine factors which were previously reported to have some roles in obesity and heart diseases, such as adiponectin, N-terminal pro-brain natriuretic peptide (NT-proBNP) and growth differentiation factor 15 (GDF-15), in the relationship between BMI and CV death.

Results

In Kaplan-Meier analyses, the lower quartiles of BMI and the higher quartiles of adiponectin levels were paradoxically associated with the higher cumulative incidence of CV death. To clarify the important factors involved in the paradoxical association between BMI or adiponectin and mortality, we first investigated independent determinants for BMI and adiponectin levels respectively, using multiple stepwise regression analyses among many clinical factors, and then narrow down the prognostic factors commonly associated with BMI and adiponectin, which were age, hemoglobin and NT-proBNP. Interestingly, circulating levels of GDF15 were significantly correlated with NT-proBNP levels, and the presence of anemia raised the gradient of the correlation line in a scatter plot (without anemia, r=0.139, p&lt;0.0001; with anemia, r=0.228, p&lt;0.0001). Moreover, the highest GDF15 quartile showed significantly lower BMI and higher adiponectin levels compared to the lower quartiles (p&lt;0.001 and p&lt;0.001, respectively, by Student t-test). In Cox proportional hazard models, hazard ratios (HRs) of BMI (per 1-unit increase) were 0.90 (95% confidence interval [CI], 0.85–0.96) for CV death. Additional adjustment for hemoglobin, NT-proBNP, adiponectin or GDF15 diminished the statistical significance (HR, 0.92 [95% CI, 0.87–0.99], 0.95 [0.89–1.01], 0.92 [0.87–0.99], or 0.93 [0.87–0.99], respectively).

Conclusions

The lower BMI and the higher adiponectin levels were paradoxically associated with the higher incidence of CV death in patients with CAD. This paradox may be mediated by cardiac endocrine factors induced by cardiac stresses, including GDF-15 in addition to natriuretic peptides.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

Association of beta blocker use with new-onset heart failure and mortality in atrial fibrillation without pre-existing heart failure: the Fushimi AF registry

Background

Heart failure (HF) is one of the major complications in atrial fibrillation (AF). We previously reported that not a few AF patients without pre-existing HF (defined as prior HF hospitalization, New York Heart Association functional class≥2, or left ventricular ejection fraction (LVEF)&lt;40%) subsequently developed new-onset HF. Beta blockers are the established therapy for HF, but it remains unclear whether beta blockers prevent new-onset HF and improve outcomes in AF patients without preexisting HF.

Methods

In the Fushimi AF registry, 778 of 3,262 patients without pre-existing HF were receiving beta blockers at baseline. We investigated the incidence of new-onset HF defined as cardiac death or HF hospitalization, and all-cause death in a propensity-matched cohort (N=1,198; mean age, 71 years; 39% female; mean LVEF, 66%). Additionally, annual follow-up prescription data before the onset of events were collected in 294 of patients with beta blockers and 395 of those without beta blockers. We also investigated the association of starting or stopping beta blockers with the incidence of new-onset HF and all-cause death.

Results

During the median follow-up of 5.8 years, new-onset HF and all-cause death occurred in 77 (12.9%) and 118 (19.7%) of patients with beta blockers, and 70 (11.7%) and 131 (21.9%) of those without beta blockers, respectively. Incidence of new-onset HF was comparable between patients with and without beta blockers (Figure 1), and incidence of all-cause death was also comparable between the two groups (Figure 2). In exploratory subgroup analyses, there was no interaction in the association of beta blockers with the incidence of events, except for pulse rate for new-onset HF and left atrial size for all-cause death. Hazard ratio of beta blockers for new-onset HF tended to be lower in patients with higher pulse rates (&gt;84 bpm) (Figure 1), and that for all-cause death was lower in those without left atrial enlargement (Figure 2). Of patients with follow-up prescription data, beta blockers were stopped in 55 (18.7%) and started in 97 (24.6%) patients, respectively. Patients with starting beta blockers had higher pulse rate (78.5±17.3 vs 74.9±13.9 bpm; p=0.03) and more symptomatic AF (58.8% vs 46.0%; p=0.03) compared to those without starting beta blockers, while there was no difference in baseline characteristics between those with and without stopping beta blockers. During the follow-up, the incidences of new-onset HF and all-cause death were also comparable between the patients with and without stopping beta blockers and those with and without starting beta blockers.

Conclusion

Beta blockers were not associated with the incidence of new-onset HF and all-cause death in AF patients without pre-existing HF. However, the exploratory subgroup analyses suggested the existence of subjects who may benefit from beta blockers.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Boehringer Ingelheim, Bayer Healthcare, Pfizer, Bristol-Myers Squibb, Astellas Pharma, AstraZeneca, Daiichi Sankyo, Novartis Pharma, MSD, Sanofi-Aventis, and Takeda Pharmaceutical.

Vascular endothelial factor C and D in patients with heart failure with preserved, mildly reduced, and reduced ejection fraction: the PREHOSP-CHF study

Background

The lymphatic system has been suggested to play an important role in cardiovascular diseases including heart failure (HF). Vascular endothelial growth factor C (VEGF-C) and D (VEGF-D) are key regulators of lymphangiogenesis, and we recently reported the association of low VEGF-C with the risk of all-cause death and high VEGF-D with the risk of HF hospitalization in patients with HF.

Purpose

To investigate the association of VEGF-C and VEGF-D with prognosis in patients with HF with preserved ejection fraction (EF) (HFpEF: EF≥50%), mildly reduced EF (HFmrEF: EF, 40–49%), and reduced EF (HFrEF: EF&lt;40%).

Methods

The PREHOSP-CHF study is a multicenter prospective cohort study to determine the predictive value of angiogenesis-related biomarkers in HF. A total of 1,024 patients (mean age 75.5±12.6 years; 58.7% male) admitted to acute decompensated HF were included in the analyses. Serum levels of VEGF-C and VEGF-D, as well as N-terminal pro B-type natriuretic peptide (NT-proBNP), high sensitivity cardiac troponin-I (hs-cTnI), high sensitivity C reactive protein, were measured at the time of discharge. Patients were followed-up over two years.

Results

The numbers of HFpEF, HFmrEF, and HFrEF were 429 (41.9%), 186 (18.2%), and 409 (39.9%), respectively. HFpEF patients were older, more likely to be female, and had more hypertension, atrial fibrillation, and anemia, but less coronary artery disease. NT-proBNP and hs-cTnI levels increased with decreasing EF. VEGF-C levels decreased with increasing EF (median [interquartile range]: HFpEF, 4508 [3318–5919] pg/ml; HFmrEF, 4719 [3663–6203] pg/ml; HFrEF, 5023 [3804–6382] pg/ml), whereas VEGF-D levels were comparable among the three EF groups (HFpEF, 404.6 [293.1–560.3] pg/ml; HFmrEF, 386.0 [298.5–556.3] pg/ml; HFrEF, 414.2 [296.1–557.3] pg/ml). In multivariate stepwise logistic regression analyses, anemia and high NT-proBNP were independently associated with low VEGF-C levels, and high NT-proBNP was independently associated with high VEGF-D levels, across all the EF groups. During the follow-up, incidences of all-cause death and HF hospitalizations were similar among the three EF groups (log-rank P=0.6 for all-cause death, and log-rank P=0.3 for HF hospitalization). On multivariate Cox proportional hazard analyses including established risk factors and cardiovascular biomarkers, VEGF-C levels tended to be inversely associated with the incidence of all-cause death in patients with HFpEF and HFrEF (Figure). On the contrary, VEGF-D levels were significantly and positively associated with the incidence of HF hospitalization in patients with HFpEF, and tended to be positively associated with it in patients with HFmrEF and HFrEF (Figure).

Conclusions

Low VEGF-C was associated with the risk of all-cause death in patients with HFpEF and HFrEF, while high VEGF-D was associated with the risk of HF hospitalization especially in HFpEF.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Grant-in-Aid for Clinical Research from the National Hospital Organization

Clinical characteristics and outcomes of atrial fibrillation patients with peripheral artery disease: the Fushimi AF Registry

Background

Atrial fibrillation (AF) represents the common arrhythmia and increases the risk of thromboembolism. Risk assessment for thromboembolism is important for the management of AF patients. Peripheral artery disease (PAD) is identified as a risk factor for thromboembolism in CHA2DS2-VASc score. However, there are little data on clinical characteristics and cardiovascular events of AF patients with PAD.

Purpose

In this study, we investigated the clinical characteristics and outcomes of AF patients with PAD.

Methods

The Fushimi AF Registry, a community-based prospective survey, was designed to enroll all of the AF patients who visited the participating medical institutions in Fushimi-ku, Kyoto, Japan. The inclusion criterion of the registry is the documentation of AF at 12-lead electrocardiogram or Holter monitoring at any time, and there are no exclusion criteria. We started to enroll patients from March 2011 and follow up data including prescription status were available in 4,464 patients from March 2011 to August 2021. Median follow-up period was 1,848 days.

Results

Of 4,464 patients, 183 patients had PAD (4.1%; PAD group). The mean age was higher in PAD group than no-PAD group (PAD group vs. no-PAD group: 76.7 vs. 73.5; p&lt;0.01). Patients with PAD had more co-morbidities such as stroke, systemic embolism, congestive heart failure, hypertension, diabetes mellitus, dyslipidemia coronary artery disease and chronic kidney disease than those without PAD. Thus, CHADS2 score, CHA2DS2-VASc score and HAS-BLED score were higher in PAD group than no-PAD group (2.81 vs. 2.00; p&lt;0.01, 5.17 vs. 3.30; p&lt;0.01, 2.42 vs. 1.71; p&lt;0.01, respectively). The proportion of patients with oral anticoagulant was similar between the two groups and the proportion of patients with antiplatelet drug was higher in PAD group than no-PAD group (59.0% vs. 55.6%; p=0.36, 62.9% vs. 24.7%; p&lt;0.01, respectively). The incidences of all-cause death, cardiac death and myocardial infarction were higher in PAD group than no-PAD group (11.4 vs. 4.6 per 100 person-years; log-rank p&lt;0.01, 1.7 vs. 0.8 per 100 person-years; log-rank p&lt;0.01, 1.2 vs. 0.2 per 100 person-years; log-rank p&lt;0.01). However, the incidence of stroke or systemic embolism was similar between the two groups (2.9 vs. 2.2 per 100 person-years, log-rank p=0.19). Finally, the incidence of composite of cardiac death, stroke, systemic embolism or myocardial infarction was higher in PAD group than no-PAD group (6.0 vs. 3.0 per 100 person-years; log-rank p&lt;0.01).

Conclusion

AF patients with PAD had significantly higher risk for death and cardiac events, whereas the incidence of thromboembolism was similar between AF patients with and without PAD.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Japan Agency for Medical Research and Development

Associations of soluble fms-like tyrosine kinase-1 with cardiovascular events and stroke in patients with atrial fibrillation and suspected or known coronary artery disease: the EXCEED-J study

Background

Atrial fibrillation (AF) increases the risk of stroke. Soluble fms-like tyrosine kinase-1 (sFlt-1), a vascular endothelial growth factor (VEGF) antagonist, has been suggested as a marker of endothelial dysfunction, which are associated with both AF and coronary artery disease (CAD). Recently, we demonstrated that sFlt-1 is independently associated with major adverse cardiovascular (CV) events (MACE) in patients with suspected or known CAD. However, the prognostic utility of sFlt-1 in patients with AF remains unknown.

Methods

Using data from a multicenter, prospective cohort of 3255 patients with suspected or known CAD, we investigated whether AF modifies the prognostic utility of sFlt-1. Heparin-free serum levels of sFlt-1, N-terminal pro-brain natriuretic peptide, high-sensitivity cardiac troponin-I, high-sensitivity C-reactive protein, cystatin C, neutrophil gelatinase-associated lipocalin, VEGF, and placental growth factor were measured in 324 patients with AF and 2931 patients without AF. The primary outcome was MACE defined as a composite of CV death, nonfatal myocardial infarction, and nonfatal stroke. The secondary outcomes were all-cause death, CV death, stroke, heart failure (HF) hospitalization, and coronary/peripheral artery revascularization. The biomarkers were natural log-transformed for use as continuous variables.

Results

After adjustment for potential clinical confounders including anticoagulant drug use, sFlt-1 was significantly associated with MACE (hazard ratio for 1 standard deviation increase [HR], 1.55; 95% confidence interval [CI], 1.14–2.08), CV death (HR, 1.68; 95% CI, 1.10–2.48), and stroke (HR, 1.89; 95% CI, 1.16–3.10), but not with all-cause death (HR, 1.32; 95% CI, 0.99–1.73), HF hospitalization (HR, 0.97; 95% CI, 0.73–1.25), or revascularization (HR, 0.99; 95% CI, 0.74–1.28) in patients with AF, whereas sFlt-1 was significantly associated with MACE (HR, 1.19; 95% CI, 1.02–1.37), all-cause death (HR, 1.19; 95% CI, 1.05–1.34), CV death (HR, 1.26; 95% CI, 1.03–1.48), and HF hospitalization (HR, 1.26; 95% CI, 1.11–1.42), but not with stroke (HR, 1.06; 95% CI, 0.81–1.33) or revascularization (HR, 1.01; 95% CI, 0.95–1.07) in patients without AF. Among other biomarkers, only VEGF was significantly associated with MACE (HR, 1.55; 95% CI, 1.02–2.44), and no biomarkers were significantly associated with CV death or stroke in patients with AF. sFlt-1 added incremental prognostic information for MACE (P=0.005 for net reclassification improvement [NRI], P=0.026 for integrated discrimination improvement [IDI]) and stroke (P=0.034 for NRI, P=0.018 for IDI), but not for CV death (P=0.021 for NRI, P=0.134 for IDI), to the model with potential clinical confounders in patients with AF.

Conclusions

sFlt-1 independently predicted MACE and stroke in patients with AF and suspected or known CAD. sFlt-1 may serve as a novel prognostic biomarker to stratify the risk of MACE and stroke in patients with AF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Health Labour Sciences Research Grant (2013-2014), AMED (2015-2017, Grant Number JP17ek0210008)

Association of cardiothoracic ratio with heart failure hospitalization in patients with atrial fibrillation: the Fushimi AF Registry

Background

Chest radiography is the most common diagnostic imaging test in clinical medicine, and the cardiothoracic ratio (CTR) is a readily available and non-invasive tool with which to assess the volume status and cardiomegaly. However, it remains unknown whether CTR on chest radiography is associated with the incidence of HF hospitalization in AF patients remains unclear.

Methods

The Fushimi AF Registry is a community-based prospective survey of AF patients in Fushimi-ku, Kyoto, Japan. The inclusion criterion of the registry is the documentation of AF at 12-lead electrocardiogram or Holter monitoring at any time, and there are no exclusion criteria. We started to enroll patients from March 2011, and follow-up data were available for 4,489 patients by the end of August 2021. In the present study, 3,727 patients with available data of CTR were examined. We divided the patients into two groups according to their CTR at baseline; Higher group (CTR ≥50.0%, n=2,696) and Lower group (CTR &lt;50.0%, n=1,031), and compared the clinical background and outcomes between the two groups.

Results

The proportion of female was grater in Higher group, and the patients in Higher group were older. The patients in Higher group had higher prevalence of HF, hypertension and chronic kidney disease. During the median follow-up of 3,033 days, in Kaplan-Meier analysis, the incidence rates of HF hospitalization were higher in Higher group (Higher group: 2.5% per person-year vs. Lower group: 1.1%; p&lt;0.01). Multivariate Cox proportional hazards regression analysis revealed that higher CTR (≥50.0%) was an independent determinant of the incidence of HF hospitalization. Furthermore, when we divided the patients into four groups based on the quartile of CTR; Q1 (CTR&lt;49.0%), Q2 (49.0≤CTR&lt;53.8%), Q3 (53.8≤CTR&lt;59.0%), Q4 (59.0%≤CTR), the incidence of HF hospitalization was more frequent in patients with higher CTR, regardless of the presence or absence of prior hospitalization for HF (Figure).

Conclusion

In Japanese AF patients, patients with higher CTR had significantly higher incidence of HF hospitalization, regardless of the prevalence of prior hospitalization for HF.

Funding Acknowledgement

Type of funding sources: None.

Serum amyloid A-low-density-lipoprotein complex and mortality in patients with suspected or known coronary artery disease: the ANOX study

Background

Serum amyloid A-low-density-lipoprotein (SAA-LDL) is a complex formed from the oxidative interaction between SAA and LDLs. A relatively small-scale study has shown that circulating SAA-LDL levels may serve as a prognostic marker in patients with stable coronary artery disease (CAD). However, the prognostic value of SAA-LDL should be confirmed in a larger-scale cohort study.

Methods

Using data from a multicenter, prospective cohort of 2416 patients with suspected or known CAD enrolled in the ANOX (Development of Novel Biomarkers Related to Angiogenesis or Oxidative Stress to Predict Cardiovascular Events) study, we assessed the prognostic value of serum levels of SAA-LDL. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke. Patients were followed up over 3 years.

Results

Stepwise regression analysis including baseline data on potential clinical confounders (i.e., age, sex, body mass index, hypertension, dyslipidemia, diabetes, current smoking, estimated glomerular filtration rate, the Gensini score, previous myocardial infarction, previous stroke, previous heart failure hospitalization, atrial fibrillation, malignancies, anemia, antihypertensive drug use, statin use, and aspirin use) and established cardiovascular biomarkers (i.e., N-terminal pro-brain natriuretic peptide, high-sensitivity cardiac troponin I [hs-cTnI], and high-sensitivity C-reactive protein [hs-CRP]) revealed that independent determinants of SAA-LDL levels were female sex, dyslipidemia, the Gensini score, absence of statin use, hs-cTnI, and hs-CRP. After adjusting for potential clinical confounders and established cardiovascular biomarkers, the highest quartile of SAA-LDL levels (vs. the lowest quartile) was significantly associated with the incidence of all-cause death (hazard ratio [HR], 1.51; 95% confidence interval [CI], 1.02–2.26), but not with that of cardiovascular death (HR, 1.11; 95% CI, 0.59–2.10) or MACE (HR, 1.57; 95% CI, 0.97–2.57). Stratified analyses revealed that this association was pronounced in patients with low hs-cTnI (&lt;75th percentile) (HR, 1.85; 95% CI, 1.06–3.30) and in patients with low hs-CRP levels (≤1.0 mg/L) (HR, 2.30; 95% CI, 1.17–4.79).

Conclusions

Elevated SAA-LDL levels were independently associated with the risk of all-cause death in patients with suspected or known CAD. The SAA-LDL level appears to serve as a prognostic biomarker for risk stratification in relatively low-risk patients with low hs-cTnI (&lt;75th percentile) or low hs-CRP (≤1.0 mg/L).

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

The association of left ventricular ejection fraction with incident heart failure in patients with atrial fibrillation

Background

Atrial fibrillation (AF) increases the risk of incident heart failure (HF). Left ventricular ejection fraction (LVEF) is an important prognostic parameter in patients with HF. However, little is known regarding the association of LVEF with incident HF in patients with AF.

Purpose

The aim of this study is to investigate the relationship between LVEF at enrollment and incidence of HF hospitalization during follow-up period in patients with AF.

Methods

The Fushimi AF Registry is a community-based prospective survey of patients with AF in Fushimi-ku, Kyoto, Japan. The inclusion criterion of the registry is the documentation of AF at 12-lead electrocardiogram or Holter monitoring at any time, and there are no exclusion criteria. We started to enroll patients from March 2011, and follow-up data were available for 4,489 patients by the end of August 2021. In the present study, we investigated 3,544 patients with the data of LVEF at enrollment. We divided the patients into 4 groups stratified by LVEF (reduced LVEF [LVEF &lt;40%], mildly reduced LVEF [LVEF: 40–49%], slightly reduced LVEF [LVEF: 50–59%], and normal LVEF [LVEF ≥60%]), and compared the backgrounds and outcomes between these 4 groups.

Results

Of 3,544 patients, the mean age was 73.6±10.7 years, 1,420 (40%) were female, 1,781 (50%) were paroxysmal AF, and 1,085 (30%) had pre-existing HF. The mean CHADS2 and CHA2DS2-VASc scores were 2.1±1.3 and 3.4±1.7, respectively. The mean LVEF at enrollment was 63±12% (reduced LVEF: 197 [6%], mildly reduced LVEF: 250 [7%], slightly reduced LVEF: 532 [15%] and normal LVEF: 2,565 [72%], respectively). Patients with lower LVEF demonstrated lower prevalence of female and paroxysmal AF, and had a higher CHADS2 and CHA2DS2-VASc scores (all P&lt;0.01). A total of 605 patients were hospitalized for HF during the median follow-up period of 5.5 years, corresponding to an annual incidence of 3.4% per person-year. Kaplan-Meier curves demonstrated that LVEF at enrollment could stratify the incidence of HF hospitalization during follow-up in patients with AF (Picture 1). Multivariable Cox regression analysis revealed that lower LVEF strata were significantly associated with the increased risk of HF hospitalization even after adjustment by age, sex, type of AF and CHA2DS2-VASc score (Picture 1). An increased risk of HF hospitalization was observed even in patients with mildly reduced LVEF (adjusted hazard ratio: 2.56, 95% CI: 1.99–3.29) as well as in those with slightly reduced LVEF (adjusted hazard ratio: 1.79, 95% CI: 1.45–2.22) compared with those with normal LVEF. These results were also the case in AF patients without pre-existing HF (Picture 2).

Conclusion

LVEF at enrollment could stratify the incidence of HF hospitalization in patients with AF, suggesting the importance of measuring LVEF in all patients with AF. Even mildly (LVEF: 40–49%) or slightly (LVEF: 50–59%) reduced LVEF was independently associated with the risk of incident HF in patients with AF.

Funding Acknowledgement

Type of funding sources: None.

High flow nasal oxygen versus conventional oxygen therapy in gastrointestinal endoscopy with conscious sedation: Systematic review and meta-analysis with trial sequential analysis

OBJECTIVES

Although conventional oxygen therapy (COT) is widely used, hypoxemia frequently occurs in gastrointestinal endoscopy with conscious sedation and can lead to life-threatening consequences. High flow nasal oxygen (HFNO) has been applied to improve oxygenation in clinical entities. However, its efficacy to prevent hypoxemia in gastrointestinal endoscopy with conscious sedation has not been evaluated.

METHODS

We searched databases to identify randomized controlled trials that compared the efficacy of HFNO with COT in gastrointestinal endoscopy with conscious sedation. The primary outcome was hypoxemia. Meta-analyses with trial sequential analysis were performed using a random-effects model.

RESULTS

Eight trials with 3212 patients were included. Compared with COT, HFNO significantly reduced the risk of hypoxemia (eight trials; 3212 patients; risk ratio 0.30; 95% confidence interval [CI] 0.13-0.70). Trial sequential analysis showed that the cumulative Z curve did not cross the monitoring or futility boundaries, nor reach the required information size line, indicating that more trials are needed to reach a definitive conclusion. Subgroup analyses indicated the superiority of HFNO over COT with respect to hypoxemia in patients at low risk and high risk. HFNO further improved the lowest oxygen saturation (four trials; 459 patients; mean difference 2.30, 95% CI 0.84-3.77).

CONCLUSIONS

Compared with COT, HFNO can reduce the risk of hypoxemia and improve the lowest oxygen saturation in gastrointestinal endoscopy with conscious sedation. However, the results should be interpreted with caution due to substantial heterogeneity and limited evidence. Further studies are needed to verify the preliminary findings.

Surgical Strategies for Siewert Type II Esophagogastric Junction Carcinomas: A Randomized Controlled Trial

Aim

To determine the ideal surgical approach for Siewert type II EGJ carcinomas.

Methods

We conducted the randomized controlled trial (RCT) at Shanxi Cancer Hospital from January 2014 to August 2016. A total of 105 patients with T1-4N1-3M0 Siewert type II EGJ carcinomas were initially recruited. The final follow-up was up to June 30, 2019. Patients were randomized to undergo either a proximal gastrectomy plus jejunal interposition (PG+JI), proximal gastrectomy plus esophagogastrostomy (PG+EG), or total gastrectomy plus Roux-en-Y esophagojejunostomy (TG+RY). The primary endpoint was postoperative complications. Secondary endpoints were 5-year survival and recovery indexes.

Results

Among 105 patients, 100 patients (95.2%; mean age, 56.2 years) with tumors <3cm in size underwent surgery: PG+JI (n=33) vs. PG+EG (n=33) and TG+RY (n=34); 91 patients completed the study. Among the groups, the PG+JI group had the longest reconstruction time: 34.11 ± 6.10 min vs. 21.97 ± 3.30 min (PG+EG) vs. 30.56 ± 4.26 min (TG+RY); p<0.001. There was no postoperative mortality. In the per-protocol analysis, the PG+JI group showed a decreased tendency in complication rate: 6.9% vs. 23.3% (PG+EG) vs. 18.8% (TG+RY), but there was no significant difference. For recovery indexes, the TG+RY group had the lowest values of the amount of single meal, weight loss, hemoglobin, albumin, pepsin, and gastrin among the three groups. There was no significant difference among the three groups in 5-year survival.

Conclusions

Proximal gastrectomy is preferable for T1-4N1-3M0 Siewert type II EGJ carcinomas with tumors <3cm in size because of its better nutrition status under similar postoperative complication to total gastrectomy. Jejunal interposition can be recommended as a optional reconstruction approach after proximal gastrectomy.

Clinical Trial Registration

https://www.chictr.org.cn/, identifier ChiCTR-IIR-16007733.

AB0332 EVALUATION OF THE RABBIT RISK SCORE IN JAPANESE PATIENTS WITH RHEUMATOID ARTHRITIS NEWLY TREATED WITH BIOLOGIC DMARDS: DATA FROM THE IORRA COHORT

Background

Serious infection is one of the most critical adverse events in patients with rheumatoid arthritis (RA) using biologic disease-modifying antirheumatic drugs (bDMARDs). During the first year, infections occur more frequently. Therefore, estimating the risk of developing a serious infection is important for the safe use of bDMARDs. The Rheumatoid Arthritis Observation of Biologic Therapy (RABBIT) risk score predicted the incidence rate of serious infection during 1 year in patients with RA taking DMARDs. Moreover, it has been validated using data from various observational cohort studies and nationwide registries with favorable results, with a reported area under the receiver operating characteristic curve (AUROC) of 0.68–0.871–5. However, the RABBIT risk score has not been validated in RA patients starting a first bDMARD.

Objectives

To investigate the discriminatory ability of the RABBIT risk score for predicting the development of serious infection during 1 year after starting first bDMARDs in Japanese patients with RA using data from the Institute of Rheumatology, Rheumatoid Arthritis (IORRA) cohort.

Methods

The IORRA cohort is a large observational cohort at the Institute of Rheumatology, Tokyo Women’s Medical University. Japanese patients with RA visiting our institute were registered and clinical parameters were assessed biannually. This study enrolled patients with RA who were registered in the IORRA cohort and treated with a first bDMARD. Patients who were missing data needed to calculate the RABBIT risk score were excluded. The RABBIT risk score was calculated using the patient’s age, comorbidities, Japanese-Health Assessment Questionnaire score, history of previous infections, and types of DMARDs used. Serious infections were defined as those requiring hospitalization or treatment with intravenous antibiotics. The occurrence of serious infection during 1 year after starting the first bDMARDs was identified using data from the biannual IORRA cohort and confirmed using medical records. The discriminatory ability of the RABBIT risk score was analyzed by the AUROC.

Results

A total of 1,081 patients with RA and a median age of 55.3 years, in which females were the majority (88.2%), were included. Serious infection occurred in eight patients during 1 year before starting their first bDMARDs. The number of patients starting a TNF inhibitor, IL-6 inhibitor, and abatacept were 830 (76.8%), 170 (15.7%), and 81 (7.5%), respectively. A total of 23 patients (1.7%) had serious infections during 1 year after starting the first bDMARD; the most frequent infection was pneumonia (n=16, 69.6%). The median RABBIT score was 2.3 (IQR 1.6–5.4) in patients with serious infections during the follow-up period, and 1.6 (IQR 1.2–2.5) in patients without serious infections. The discriminatory ability of the RABBIT risk score was slightly poor, with an AUROC of 0.67 (95% CI, 0.52– 0.79).

Conclusion

The RABBIT risk score is highly practical; however, our present study suggested that some adjustments may be required to predict the risk of serious infection in Japanese patients with RA starting a first bDMARD.

Figure 1.

ROC curve of serious infection and RABBIT score with an AUROC of 0.67 (95% CI, 0.52– 0.79).

Disclosure of Interests

Tomoaki Higuchi: None declared, Eiichi Tanaka Speakers bureau: Abbvie, Asahi Kasei pharma co., Bristol Myers Squibb, Chugai Pharmaceutical, Daiichi Sankyo Co., Eisai Pharmaceutical, Janssen Pharmaceutical K.K., Nippon Kayaku, Pfizer, Takeda Pharmaceutical, Taisho Toyama Pharmaceutical Co., and UCB Pharma., Paid instructor for: Abbvie, Asahi Kasei pharma co., Bristol Myers Squibb, Chugai Pharmaceutical, Daiichi Sankyo Co., Eisai Pharmaceutical, Janssen Pharmaceutical K.K., Nippon Kayaku, Pfizer, Takeda Pharmaceutical, Taisho Toyama Pharmaceutical Co., and UCB Pharma., Eisuke Inoue Speakers bureau: Bristol-Meyers and Pfizer, Consultant of: Nippontect systems, Mai Abe: None declared, Kumiko Saka: None declared, Eri Sugano: None declared, Naohiro Sugitani: None declared, Yoko Shimizu: None declared, Moeko Ochiai: None declared, Rei Yamaguchi: None declared, Katsunori Ikari Speakers bureau: Asahi Kasei Pharma Corp., Astellas Pharma Inc., AbbVie Japan GK, Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., Janssen Pharmaceutical K.K., Kaken Pharmaceutical Co. Ltd., Mitsubishi Tanabe Pharma Corp. Pfizer Japan Inc., Takeda Pharmaceutical Co. Ltd., Teijin Pharma Ltd and UCB Japan Co. Ltd., Yamanaka Hisashi: None declared, Masayoshi Harigai Speakers bureau: AbbVie Japan, Ayumi, Boehringer Ingelheim Japan, Bristol-Myers Squibb, Chugai, Eisai, Eli Lilly Japan, GlaxoSmithKline, Kissei, Pfizer Japan Inc, Takeda, Teijin, Consultant of: AbbVie Japan, Boehringer Ingelheim Japan, Bristol-Myers Squibb, Kissei, Teijin, Grant/research support from: AbbVie Japan, Asahi Kasei, Astellas, Ayumi, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Kissei, Mitsubishi Tanabe, Nippon Kayaku, Sekiui Medical, Shionogi, Taisho, Takeda, Teijin.

The burden and trend of gastric cancer and possible risk factors in five Asian countries from 1990 to 2019

The burdens and trends of gastric cancer are poorly understood, especially in high-prevalence countries. Based on the Global Burden of Disease Study 2019, we analyzed the incidence, death, and possible risk factors of gastric cancer in five Asian countries, in relation to year, age, sex, and sociodemographic index. The annual percentage change was calculated to estimate the trends in age-standardized incidence rate (ASIR) and age-standardized death rate (ASDR). The highest ASIR per 100,000 person-years in 2019 was in Mongolia [44 (95% uncertainty interval (UI), 34 to 55)], while the lowest was in the Democratic People’s Republic of Korea (DPRK) [23 (95% UI, 19 to 29)]. The highest ASDR per 100,000 person-years was in Mongolia [46 (95% UI, 37 to 57)], while the lowest was in Japan [14 (95% UI, 12 to 15)]. Despite the increase in the absolute number of cases and deaths from 1990 to 2019, the ASIRs and ASDRs in all five countries decreased with time and improved sociodemographic index but increased with age. Smoking and a high-sodium diet were two possible risk factors for gastric cancer. In 2019, the proportion of age-standardized disability-adjusted life-years attributable to smoking was highest in Japan [23% (95% UI, 19 to 28%)], and the proportions attributable to a high-sodium diet were highest in China [8.8% (95% UI, 0.21 to 33%)], DPRK, and the Republic of Korea. There are substantial variations in the incidence and death of gastric cancer in the five studied Asian countries. This study may be crucial in helping policymakers to make better decisions and allocate appropriate resources.

Systemic Disorders Closely Associated with Malocclusion in Late Adolescence: A Review and Perspective

Oral diseases such as dental caries and periodontal disease are reported to be associated with various systemic diseases such as heart disease, respiratory disease, diabetes, rheumatism, and metabolic syndrome, thus increasing the importance of prevention and early treatment [...].

Pebbles and sand on asteroid (162173) Ryugu: In situ observation and particles returned to Earth

The Hayabusa2 spacecraft investigated the C-type (carbonaceous) asteroid (162173) Ryugu. The mission performed two landing operations to collect samples of surface and subsurface material, the latter exposed by an artificial impact. We present images of the second touchdown site, finding that ejecta from the impact crater was present at the sample location. Surface pebbles at both landing sites show morphological variations ranging from rugged to smooth, similar to Ryugu's boulders, and shapes from quasi-spherical to flattened. The samples were returned to Earth on 6 December 2020. We describe the morphology of >5 grams of returned pebbles and sand. Their diverse color, shape, and structure are consistent with the observed materials of Ryugu; we conclude that they are a representative sample of the asteroid.

Screening and validation of a novel T stage-lymph node ratio classification for operable colon cancer

Background

Lymph node ratio (LNR) has advantages in predicting prognosis compared with American Joint Committee on Cancer (AJCC) pathological N stage. However, the prognostic value of a novel T stage-lymph node ratio (TLNR) classification for colon cancer combining LNR and pathological primary tumor stage (T stage) is currently unknown.

Methods

We included 62,294 patients with stage I-III colon cancer from the Surveillance, Epidemiology, and End Results Program as a training cohort. External validation was performed in 3,327 additional patients. A novel LNR stage was established and combined with T stage in a novel TLNR classification. Patients with similar survival were grouped according to T and LNR stages, with T1LNR1 as a reference.

Results

We developed a novel TLNR classification as follows: stages I (T1LNR1-2, T1LNR4), IIA (T1LNR3, T2LNR1-2, T3LNR1), IIB (T1LNR5, T2LNR3-4, T3LNR2, T4aLNR1), IIC (T2LNR5, T3LNR3-4, T4aLNR2, T4bLNR1), IIIA (T3LNR5, T4aLNR3-4, T4bLNR2), IIIB (T4aLNR5, T4bLNR3-4), and IIIC (T4bLNR5). In the training cohort, the novel TLNR classification had better prognostic discrimination (area under receiver operating characteristic curve, 0.621 vs. 0.608, two-sided P<0.001), superior model-fitting ability for predicting overall survival (Akaike information criteria, 561,129 vs. 562,052), and better net benefits compared with the AJCC 8^th tumor/node/metastasis classification. Similar results were found in the validation cohort for predicting both overall and disease-free survival.

Conclusions

This novel TLNR classification may provide better prognostic discrimination, model-fitting ability, and net benefits than the AJCC 8^th TNM classification, for potentially better stratification of patients with operable stage I-III colon cancer; however, further studies are required to validate the novel TLNR classification.

Distinct association of VEGF-C and VEGF-D with prognosis in patients with chronic heart failure: the PREHOSP-CHF study

Background

The lymphatic system has been suggested to play an important role in cardiovascular (CV) diseases including heart failure (HF). Vascular endothelial growth factor C (VEGF-C) and VEGF-D are key regulators of lymphoangiogenesis.

Purpose

To investigate the association of VEGF-C and VEGF-D with prognosis in patients with chronic HF (CHF).

Methods

The PREHOSP-CHF study is a multicenter prospective cohort study to determine the predictive value of angiogenesis-related biomarkers in CHF. A total of 1,024 patients (mean age, 75.5±12.6 years; male, 58.7%) admitted to acute decompensated HF were included in the analyses. The primary outcome was MACE defined as a composite of CV death or HF hospitalization. The secondary outcomes were all-cause death, CV death, and HF hospitalizations. Serum levels of VEGF-C and VEGF-D, as well as N-terminal pro B-type natriuretic peptide (NT-proBNP), high sensitivity cardiac troponin-I (hs-cTnI), high sensitive C reactive protein (hs-CRP), VEGF, and soluble VEGF receptor-2 (sVEGFR-2) were measured at the time of discharge. Patients were followed-up over two years.

Results

Median [interquartile range] of VEGF-C and VEGF-D levels were 4821 [3633–6131] pg/ml and 404 [296–559] pg/ml, respectively. In multivariate stepwise regression analysis, independent determinants of VEGF-C levels were younger age, female gender, absence of prior HF hospitalization, chronic kidney disease, and anemia, lower ejection fraction, lower NT-proBNP levels, higher VEGF levels, and higher sVEGFR-2 levels, while those of VEGF-D levels were lower body mass index, presence of diabetes and atrial fibrillation, and higher NT-proBNP levels. During the follow-up, a total of 209 (20.4%) all-cause deaths, 112 (10.9%) CV deaths, and 309 (30.2%) HF hospitalizations occurred. After adjusting for established risk factors and CV biomarkers, VEGF-C levels were significantly and inversely associated with the incidence of MACE and non-CV death (Fig.1, model 4). On the other hand, VEGF-D levels were significantly and positively associated with the incidence of HF hospitalization (Fig. 1, model 4). When we divided the patients into 4 groups based on the median of VEGF-C and VEGF-D levels, patients with low VEGF-C and high VEGF-D showed significantly higher incidence of MACE, all-cause death, CV death, and HF hospitalization compared to those with high VEGF-C and low VEGF-D (Fig. 2).

Conclusions

Among patients with CHF, VEGF-C and VEGF-D had different characteristic and association with the incidence of adverse events. VEGF-C levels were inversely associated with the incidence of MACE and non-CV death, and VEGF-D levels were positively associated with the incidence of HF hospitalization. These results suggests different effects of VEGF-C and VEGF-D in CHF. Combination of VEGF-C and VEGF-D enables us to make good risk stratification in patients with CHF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant-in-Aid for Clinical Research from the National Hospital Organization Figure 1Figure 2

Association of low total cholesterol level with clinical outcomes in patients with atrial fibrillation: the Fushimi AF registry

Background

Hyperlipidemia is a well-established risk factor for cardiovascular disease. However, low cholesterol is also reported to be associated with poor outcome in patients with chronic disease, which is called “cholesterol paradox”, and the association of cholesterol level with the incidence of clinical outcomes in patients with atrial fibrillation (AF) remains unclear.

Methods

In the Fushimi AF Registry, a community-based prospective survey of the AF patients in Fushimi-ku, Kyoto, Japan, follow-up data and baseline total cholesterol levels were available in 3,054 patients. We excluded 767 patients who were taking statins, and 2,267 patients were included in the analyses. We defined low cholesterol as total cholesterol &lt;150 mg/dl, and examined the incidence of all-cause death, stroke/systemic embolism (SE), heart failure (HF) hospitalization, and major bleeding.

Results

Patients with low cholesterol (N=464 (20.4%)) were older, more often male, and had higher prevalence of low body weight (&lt;50 kg), permanent/persistent AF, prior stroke/SE, HF, chronic kidney disease, and anemia (hemoglobin &lt;11 g/dl). CHA2DS2-VASc score was higher in patients with low cholesterol (low cholesterol vs others; 3.6±1.6 vs 3.2±1.7: P&lt;0.001). Prescription of oral anti-coagulants was comparable between the groups (50.0% vs 54.5%: P=0.09). During the median follow-up of 1,805 days, the incidence of all-cause death, stroke/SE, HF hospitalization, and major bleeding was significantly higher in patients with low cholesterol (all-cause death, 10.9 vs 3.8 /100 person-years; stroke/SE, 3.4 vs 1.9 /100 person-years; HF hospitalization, 4.7 vs 2.5 /100 person-years; major bleeding, 2.7 vs 1.4 /100 person-years) (Figure 1). After adjustment for the components of CHA2DS2-VASc score, low body weight, permanent/persistent AF, chronic kidney disease, anemia, and prescription of oral anti-coagulants, low cholesterol was significantly associated with the incidence of all-cause death and stroke/SE, but not with that of HF hospitalization or major bleeding (Figure 2, model 3). Total cholesterol levels were still significantly and inversely associated with the incidence of all-cause death (hazard ratio, 0.94; 95% confidence interval, 0.92–0.96 for 10 mg/dl increase) and stroke/SE (hazard ratio, 0.96; 95% confidence interval, 0.92–0.999 for 10 mg/dl increase), when analyzed as continuous variables. Subgroup analysis revealed that the risk of low cholesterol for all-cause death was more pronounced in female (interaction P, 0.049), patient without prior stroke/SE (interaction P, 0.01), those without HF (interaction P, 0.01), and those without vascular disease (interaction P, 0.001). The risk for stroke/SE was more pronounced in patients without vascular disease (interaction P, 0.01).

Conclusion

Low total cholesterol level was significantly associated with the incidence of all-cause and stroke/SE in AF patients not taking statins, suggesting the existence of cholesterol paradox in AF.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Boehringer Ingelheim, Bayer Healthcare, Pfizer, Bristol-Myers Squibb, Astellas Pharma, AstraZeneca, Daiichi-Sankyo, Novartis Pharma, MSD, Sanofi-Avent

The relationship between diastolic blood pressure and the risk of cardiovascular events in patients with atrial fibrillation whose systolic blood pressure was treated to less than 130 mmHg

Background

Hypertension is one of the major risk factors of cardiovascular events in patients with atrial fibrillation (AF). Low diastolic blood pressure (DBP) has been reported to be associated with the incidence of cardiovascular events, but current guidelines recommend an intensive blood pressure target of less than 130/80 mmHg for AF patients taking oral anticoagulants without mentioning the lower limits of DBP.

Methods

The Fushimi AF Registry is a community-based prospective survey of AF patients in a city of Japan. Follow-up data were available in 4,472 patients, and hypertensive patients who received prescription of any antihypertensive agents and whose systolic blood pressure was treated to less than 130 mmHg were available were examined (n=1,319). We divided the patients into four groups according to their DBP at baseline; G1 (DBP&lt;60 mmHg, n=349), G2 (60≤DBP&lt;70, n=434), G3 (70≤DBP&lt;80, n=386) and G4 (80≤DBP, n=150), and compared the clinical background and outcomes among groups.

Results

The proportion of female was grater in G1 group, and the patients in G1 group were older. During the median follow-up of 2,458 days, in Kaplan-Meier analysis, the incidence rates of cardiovascular events (composite of cardiac death, ischemic stroke, systemic embolism, non-fatal myocardial infarction and heart failure hospitalization during follow up) were the highest in G1 group and the lowest in G3 group (G1: 7.2% per person-year vs. G2: 4.9% vs. G3: 2.2% vs. G4: 4.4%; p&lt;0.01). Multivariate Cox proportional hazards regression analysis revealed that DBP was an independent determinant of cardiovascular events (G1 vs. G3; hazard ratio (HR): 1.96, 95% confidence intervals (CI): 1.39–2.76, G2 vs. G3; HR: 1.79, 95% CI: 1.28–2.50, G4 vs. G3; HR: 1.56, 95% CI: 0.99–2.45) (Figure 1). When we examined the association of DBP according to 10 mmHg increment, patients with excessively low DBP (&lt;50 mmHg) had significantly higher incidence of cardiovascular events than patients with DBP of 70–79 mmHg (HR: 2.80, 95% CI: 1.81–4.33), and DBP exhibited J curve association with higher incidence of cardiovascular events (Figure 2).

Conclusion

In Japanese AF patients whose systolic blood pressure was treated to less than 130 mmHg, patients with excessively low DBP had significantly higher incidence of cardiovascular events, and DBP exhibited J curve association with higher incidence of cardiovascular events.

Funding Acknowledgement

Type of funding sources: None.

Previous pacemaker therapy was not associated with the risk of clinical events in patients with atrial fibrillation: the Fushimi AF Registry

Background

Patients with atrial fibrillation (AF) occasionally require pacemaker implantation. Meanwhile, patients with implanted pacemaker are occasionally found to have subclinical AF and develop clinical AF. However, little is known about the clinical outcomes of AF patients with implanted pacemaker.

Purpose

We aimed to investigate the clinical outcomes in AF patients undergoing previous pacemaker therapy.

Methods

The Fushimi AF Registry is a community-based prospective survey of the AF patients in a city of Japan. Follow-up data including prescription status were available for 4,447 patients. After exclusion of patients with implantable cardioverter defibrillator and cardiac resynchronization therapy, we investigated 293 AF patients with pacemaker implantation at baseline. We performed propensity score-matching analysis to assess the impact of pacemaker therapy in AF patients.

Results

Of a total cohort, patients with pacemaker were more often female (51.2% vs. 39.7%; p&lt;0.01) and older (78.0 vs. 73.3 years of age; p&lt;0.01). Patients with pacemaker were more likely to have pre-existing heart failure (33.1% vs. 26.6%; p&lt;0.01), valvular heart disease (22.9% vs. 16.8%; p&lt;0.01), chronic kidney disease (48.8% vs. 34.7%; p&lt;0.01), and history of performing direct current cardioversion (7.2% vs. 3.1%; p&lt;0.01), compared with patients without pacemaker. Mean CHA2DS2-VASc score was higher in patients with pacemaker (3.80 vs. 3.34; p&lt;0.01). Patients with pacemaker were more often prescribed oral anticoagulants (62.1% vs. 55.2%; p=0.02), verapamil (13.3% vs. 9.4%; p=0.03), and loop diuretics (30.7% vs. 21.8%; p&lt;0.01). Using propensity score-matching, 291 patients with pacemaker and 291 without pacemaker were matched and baseline characteristics were comparable. The median follow-up period was 1,819 days. All-cause death occurred in 91 patients with pacemaker (6.0 /100 person-years) and 79 patients without pacemaker (5.9 /100 person-years), with a hazard ratio (HR) for patients with pacemaker of 1.01 (95% confidence interval [CI], 0.75 to 1.37; p=0.93). Furthermore, HR of cardiac death for patients with pacemaker was 1.00 (95% CI, 0.23 to 4.32; p=0.99), that of stroke or systemic embolism was 0.69 (95% CI, 0.44 to 1.07; p=0.10) and that of hospitalization for heart failure was 0.94 (95% CI, 0.65 to 1.37; p=0.76).

Conclusion

We identified that patients undergoing previous pacemaker therapy were not associated with the incidence of various adverse clinical events in Japanese AF patients.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Boehringer Ingelheim, Bayer Healthcare, Pfizer, Bristol-Myers Squibb, Astellas Pharma, AstraZeneca, Daiichi Sankyo, Novartis Pharma, MSD, Sanofi-Aventis, Takeda Pharmaceutical, and the Practical Research Project for Life-Style related Diseases including Cardiovascular Diseases and Diabetes Mellitus from Japan Agency for Medical Research and Development.

Association of the degree of thrombocytopenia with cause of death in patients with atrial fibrillation: the Fushimi AF Registry

Background

Thrombocytopenia is sometimes found in routine blood tests and is associated with an increased risk of mortality in general population. We have previously reported that atrial fibrillation (AF) patients with thrombocytopenia have a higher mortality than those without thrombocytopenia. However, association of the degree of thrombocytopenia with cause of death in AF patients is unknown.

Purpose

We aimed to investigate the association of baseline platelet count with cause of death including cardiac death, intracranial death, malignancy, infection, extracranial bleeding death, renal failure death, respiratory failure death and undetermined death.

Methods

The Fushimi AF Registry was designed to enroll all of the AF patients in Fushimi-ku, Kyoto. Fushimi-ku is densely populated with a total population of 283,000 and is assumed to represent a typical urban community in Japan. We started to enroll patients from March 2011, and follow-up data with baseline platelet counts less than 150,000/μL were available in 853 patients by the end of September 2020. We divided them into 3 groups according to baseline platelet level: Mild thrombocytopenia (100,000–149,999/μL, n=703), Moderate thrombocytopenia (50,000–99,999/μL, n=120), and Severe thrombocytopenia (&lt;50,000/μL, n=30).

Results

In the entire cohort, the mean age was 76 years, 34% were women, the mean body weight and body mass index was 59.3 kg and 22.9 kg/m2, and the median platelet count were 121,000/μL (interquartile range 109,000 to 141,000/μL). Compared to Mild thrombocytopenia, patients with Moderate or Severe thrombocytopenia were more likely to have chronic kidney disease (42.2% vs 54.2% vs 73.3%, p=0.0003), have higher HAS-BLED score (1.90 vs 2.14 vs 2.00, p=0.047) and lower hemoglobin (12.8g/dL vs 11.7g/dL vs 11.2g/dL, p&lt;0.0001) and were less often prescribed anti platelet drugs. Age, sex, body weight, systolic blood pressure, previous stroke, previous major bleeding, hypertension, diabetes mellitus, CHADS2 score and CHA2DS2-VASc score were comparable between three groups. During the median follow-up period, the incidence rate (per 100 person-years) of all-cause death was 6.82 vs 15.27 vs 9.64. (p&lt;0.001) On univariate analysis, the incidence of all-cause death was higher in Moderate group than Mild group. (HR: 2.15; 95% CI 1.61–2.87, p&lt;0.0001), but there was no significant difference between Mild and Severe groups. (HR: 1.44; 95% CI 0.78–2.64, p=0.243). The incidence of cardiac death was comparable between three groups. (Mild vs Moderate: HR 0.65; 95% CI 0.15–2.75, p=0.56, Mild vs Severe: HR 1.11; 95% CI 0.15–8.23, p=0.92) Regarding other causes of death such as intracranial bleeding, extracranial bleeding, malignancy, infection, renal failure, respiratory failure and undetermined cause, there was no significant difference.

Conclusion

Mortality was higher according to the degree of thrombocytopenia in AF patients, but the cause of death was not different among three groups.

Funding Acknowledgement

Type of funding sources: None.

Predictors and risk model for heart failure hospitalization in atrial fibrillation patients without pre-existing heart failure: the Fushimi AF Registry

Background

Atrial fibrillation (AF) increases the risk of hospitalization for heart failure (HF), as well as that of thromboembolism. The strategy for prediction of thromboembolism has been well-established; however, little focus has been placed on the risk stratification for and prevention of HF hospitalization in AF patients.

Purpose

The aim of this study is to investigate the predictors and risk model of HF hospitalization in non-valvular AF patients without pre-existing HF.

Methods

The Fushimi AF Registry is a community-based prospective survey of AF patients in Fushimi-ku, Kyoto, Japan. The inclusion criterion of the registry is the documentation of AF at 12-lead electrocardiogram or Holter monitoring at any time, and there are no exclusion criteria. We started to enroll patients from March 2011, and follow-up data were available for 4,472 patients by the end of October 2020. From the registry, we excluded patients without a pre-existing HF (defined as having one of the following; prior hospitalization for HF, New York Heart Association class ≥2, or left ventricular ejection fraction [LVEF] &lt;40%), and those with valvular AF (mitral stenosis or prosthetic heart valve). Among 3,188 non-valvular AF patients without pre-existing HF, we explored the risk factors for the HF hospitalization during follow-up period. The risk model for predicting HF hospitalization was determined by the cumulative numbers of risk factors which were significant on multivariate analysis.

Results

The mean age was 72.4±10.8 years, 1197 were female and 1787 were paroxysmal AF. The mean CHADS2 and CHA2DS2-VASc scores were 1.7±1.2 and 2.9±1.6, respectively. During the median follow-up period of 5.1 years, HF hospitalization occurred in 285 (8.9%), corresponding to an annual incidence of 1.8 events per 100 person-years. In multivariable Cox regression analysis, advanced age (≥75 years), valvular heart disease, coronary artery disease, reduced LVEF (&lt;60%), chronic obstructive pulmonary disease (COPD) and anemia were independently associated with the higher incidence of HF hospitalization (all P&lt;0.001) (Picture 1). A risk model based on these 6 variables could stratify the incidence of HF hospitalization during follow-up period (log-rank; P&lt;0.001) (Picture 2). Patients with ≥3 risk factors had an 11-fold higher incidence of HF hospitalization compared with those not having any of these risk factors (hazard ratio: 11.3, 95% confidence interval: 7.0–18.4; P&lt;0.001).

Conclusions

Advanced age, coronary artery disease, valvular heart disease, reduced LVEF, COPD and anemia were independently associated with the risk of HF hospitalization in AF patients without pre-existing HF. There was good prediction for endpoint of HF hospitalization using these 6 variables, providing the opportunities for the implementation of strategies to reduce the incidence of HF among AF patients.

Funding Acknowledgement

Type of funding sources: None.

Impact of atrial fibrillation on soluble fms-like tyrosine kinase-1 and cardiovascular events in patients with suspected or known coronary artery disease: the EXCEED-J study

Background

Soluble fms-like tyrosine kinase-1 (sFlt-1), a vascular endothelial growth factor (VEGF) antagonist, has been suggested as a marker of endothelial dysfunction. Circulating sFlt-1 levels are associated with adverse outcomes in patients with preeclampsia, chronic kidney disease, and heart failure. Atrial fibrillation (AF) and coronary artery disease (CAD) are both associated with endothelial dysfunction. However, whether sFlt-1 can predict cardiovascular (CV) events and whether AF modifies the relationship between sFlt-1 and CV events in patients with suspected or known CAD are unknown.

Methods

We performed a nationwide, multicenter, prospective cohort study to determine the prognostic value of sFlt-1 and other biomarkers in patients with suspected or known CAD undergoing elective angiography. Heparin-free fasting serum was collected from the peripheral vein to determine levels of sFlt-1, VEGF, placental growth factor, cystatin C, neutrophil gelatinase-associated lipocalin, N-terminal pro-brain natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin-I (hs-cTnI), and high-sensitivity C-reactive protein (hs-CRP). The primary outcome was 3-point major adverse CV events (3P-MACE) defined as a composite of CV death, nonfatal myocardial infarction, and nonfatal stroke. The secondary outcomes were all-cause death, CV death, and 5P-MACE defined as a composite of 3P-MACE, heart failure hospitalization, and coronary/peripheral artery revascularization.

Results

3311 patients were consecutively enrolled between Nov 2013 and May 2017. After excluding 56 ineligible patients, 3255 patients (324 AF and 2931 non-AF) were followed up over 3 years (follow-up rate, 99%). During the follow-up, 156 patients developed 3P-MACE, 215 died from any cause, 82 died from cardiovascular disease, and 1361 developed 5P-MACE. The sFlt-1 level was significantly higher in AF compared to non-AF patients (p&lt;0.001). Stepwise regression analysis revealed that the sFlt-1 level was independently associated with AF. After adjusting for potential clinical confounders, serum levels of sFlt-1, NT-proBNP, hs-cTnI and cystatin C, but not other biomarkers, were significantly associated with 3P-MACE in the entire cohort. These associations were still significant in non-AF patients, whereas only the sFlt-1 level was significantly associated with 3P-MACE in AF patients. Serum levels of sFlt-1, but not other biomarkers, were also significantly associated with CV death in AF patients. Among the biomarkers, only the hs-CRP level was significantly associated with all-cause death, and no biomarker was significantly associated with 5P-MACE in AF patients. Furthermore, sFlt-1 provided an incremental prognostic information for 3P-MACE to the model with potential clinical confounders in AF, but not in non-AF patients.

Conclusions

Serum levels of sFlt-1 were significantly associated with 3P-MACE in patients with suspected or known CAD. This association was pronounced in AF patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The EXCEED-J study is supported by Health Labour Sciences Research Grant (2013-2014), AMED (2015-2017, Grant Number JP17ek0210008) and Grant-in-Aid for Clinical Research from the National Hospital Organization (2018-2020).

Practices and perspectives of primary care physicians in Japan and the United States about diagnosing dementia: a qualitative study

Background

While dementia is a common problem in Japan and the US, primary care physicians' practices and perspectives about diagnosing dementia in these different healthcare systems are unknown.

Methods

Qualitative research was conducted in an ethnographic tradition using semi-structured interviews and thematic analysis in primary care settings across Japan and in the Midwest State of Michigan, US. Participants were a total of 48 primary care physicians, 24 each from Japan and the US participated. Both groups contained a mixture of geographic areas (rural/urban), gender, age, and years of experience as primary care physicians.

Results

Participants in Japan and the US voiced similar practices for making the diagnosis of dementia and held similar views about the desired benefits of diagnosing dementia. Differences were found in attitudes about the appropriate timing of formally diagnosing dementia. Japanese physicians tended to make a formal diagnosis when problems that would benefit from long-term care services emerged for family members. US physicians were more proactive in diagnosing dementia in the early stages by screening for dementia in health check-ups and promoting advance directives when the patients were still capable of decision-making. Views about appropriate timing of diagnostic testing for dementia in the two systems reflect what medical or nursing care services physicians can use to support dementia patients and caregivers.

Conclusions

Benefits of making the diagnosis included the need to activate the long-term care services in Japan and for early intervention and authoring advance directives in the US. Testing to establish an early diagnosis of dementia by primary care physicians only partly relates to testing and treatment options available. Benefits of making the diagnosis included the need to activate the long-term care services in Japan and for early intervention and authoring advance directives in the US.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02457-7.

Prognostic value of modified Lauren classification in gastric cancer

BACKGROUND

It remains controversial as to which pathological classification is most valuable in predicting the overall survival (OS) of patients with gastric cancer (GC).

AIM

To assess the prognostic performances of three pathological classifications in GC and develop a novel prognostic nomogram for individually predicting OS.

METHODS

Patients were identified from the Surveillance, Epidemiology, and End Results program. Univariate and multivariate analyses were performed to identify the independent prognostic factors. Model discrimination and model fitting were evaluated by receiver operating characteristic curves and Akaike information criteria. Decision curve analysis was performed to assess clinical usefulness. The independent prognostic factors identified by multivariate analysis were further applied to develop a novel prognostic nomogram.

RESULTS

A total of 2718 eligible GC patients were identified. The modified Lauren classification was identified as one of the independent prognostic factors for OS. It showed superior model discriminative ability and model-fitting performance over the other pathological classifications, and similar results were obtained in various patient settings. In addition, it showed superior net benefits over the Lauren classification and tumor differentiation grade in predicting 3- and 5-year OS. A novel prognostic nomogram incorporating the modified Lauren classification showed superior model discriminative ability, model-fitting performance, and net benefits over the American Joint Committee on Cancer 8^th edition tumor-node-metastasis classification.

CONCLUSION

The modified Lauren classification shows superior net benefits over the Lauren classification and tumor differentiation grade in predicting OS. A novel prognostic nomogram incorporating the modified Lauren classification shows good model discriminative ability, model-fitting performance, and net benefits.

P–248 Statistical estimation for incidence of blastocyst trophectoderm vesicles (TVs) and efficacy of assisted hatching (AH)

Study question

The aim of this study is to analyse the association between blastocyst diameter and TVs development, and to examine the efficacy of AH.

Summary answer

Blastocysts with a diameter of more than 170 μm leads to high incidence of TVs and AH applied from the incidence should be effective.

What is known already

TVs are protrusion of trophectoderm cells often observed in expanding blastocyst stages. TVs can be observed in expanding blastocysts regardless of Intracytoplasmic sperm injection (ICSI) and Conventional-IVF (C-IVF), when the internal pressure of blastocysts increase. The rate of TVs incidence in blastocysts inseminated by ICSI is higher than that by C-IVF, due to penetration of the needle into the zona pellucida. Moreover, it has been reported that TVs may inhibit blastocyst hatching. However, the developmental timing of TVs is still unclear, and there is no study that has analysed the association between blastocyst diameter and the incidence of TVs.

Study design, size, duration

1) Diameters and TVs incidence of blastocysts by ICSI and C-IVF were measured, and the cut-off value and the area under the curve (AUC) of the receiver operating characteristic (ROC) curve were calculated to estimate the timing of TV incidence. 2) We analysed the clinical pregnancy rates of blastocysts with TVs treated by AH compared to those of blastocysts by C-IVF not subjected to AH.

Participants/materials, setting, methods

This study included 821 transferred frozen blastocysts ranging from March 2018 to November 2019. The embryos were cultured in a dry incubator after insemination by ICSI or C-IVF. Blastocyst freezing conditions were set at day5 to day7 with a diameter of more than 150 μm in inner diameter of zona pellucida, and this was measured before freezing. The ROC curve was performed using EZR statistical analysis software.

Main results and the role of chance

1) The incidence of TVs in blastocysts by ICSI and C-IVF was 27.5% (117/424) and 14.6% (58/397) respectively. The rate of the incidence of TVs in blastocysts inseminated by ICSI and C-IVF; 8.6% (12/140) and 0.95% (1/105) in 150–159 μm, 12.7% (14/110) and 8.2% (6/73) in 160–169 μm, 40.6% (28/69) and 10.5% (6/57) in 170–179 μm, 55.6% (30/54) and 25.5% (13/51) in 180–189 μm, 66.7% (20/30) and 35.7% (10/28) in 190–199 μm, and 68.4% (13/19) and 26.8% (22/82) in the diameter of more than 200 μm. The cut-off value of the ROC curve was respectively 170 μm (sensitivity 78.6% and specificity 73.0%) and 176 μm (sensitivity 84.5% and specificity 59.6%) in the diameter; the AUC was 0.8 [95%CI:0.752–0.848] and 0.74 [95%CI:0.687–0.793] respectively. 2) The clinical pregnancy rate of TVs blastocyst vs C-IVF blastocyst was 52.7% (88/167) vs 57.8% (37/64) respectively. There is no significant difference between the two clinical pregnancy rates (P = 0.556).

Limitations, reasons for caution

The findings of this study have to be seen in light of some limitations. Since this study aimed to analyse the incidence of TVs based on blastocyst size, we did not take into account the grade according to the Gardner classification and the number of trophectoderm cells.

Wider implications of the findings: Blastocysts inseminated by ICSI and C-IVF were highly likely to have TVs above 170 μm and 176 μm respectively. The clinical pregnancy rates of the blastocyst with TV treated by AH was similar to those of the C-IVF blastocyst.

Trial registration number

Not applicable

Interaction between sodium dodecylsulfate (SDS) and pluronic L61 in aqueous medium: assessment of the nature and morphology of the formed mixed aggregates by NMR, EPR, SANS and FF-TEM measurements

The interaction of copolymer L61 i.e., (EO)2(PO)32(EO)2 (where EO and PO are ethylene and propylene oxides, respectively) with surfactant SDS (sodium dodecylsulfate) in relation to their self-aggregation, dynamics and microstructures has been physicochemically studied in detail employing the Nuclear Magnetic Resonance (NMR), Electron Paramagnetic Resonance (EPR), Small-Angle Neutron Scattering (SANS), and Freeze-Fracture Transmission Electron Microscopy (FF-TEM) methods. The NMR self-diffusion study indicated a synergistic interaction between SDS and L61 forming L61-SDS mixed complex aggregates, and deuterium (2H) NMR pointed out the nonspherical nature of these aggregates with increasing [L61]. EPR spectral analysis of the motional parameters of 5-doxyl steraric acid (5-DSA) as a spin probe provided information on the microviscosity of the local environment of the L61-SDS complex aggregates. SANS probed the geometrical aspects of the SDS-L61 assemblies as a function of both [L61] and [SDS]. Progressive evolution of the mixed-aggregate geometries from globular to prolate ellipsoids with axial ratios ranging from 2 to 10 with increasing [L61] was found. Such morphological changes were further corroborated with the results of 2H NMR and FF-TEM measurements. The strategy of the measurements, and data analysis for a concerted conclusion have been presented.

Management of bone metastasis and cancer treatment-induced bone loss during the COVID-19 pandemic: An international perspective and recommendations

Optimum management of patients with cancer during the COVID-19 pandemic has proved extremely challenging. Patients, clinicians and hospital authorities have had to balance the risks to patients of attending hospital, many of whom are especially vulnerable, with the risks of delaying or modifying cancer treatment. Those whose care has been significantly impacted include patients suffering from the effects of cancer on bone, where delivering the usual standard of care for bone support has often not been possible and clinicians have been forced to seek alternative options for adequate management. At a virtual meeting of the Cancer and Bone Society in July 2020, an expert group shared experiences and solutions to this challenge, following which a questionnaire was sent internationally to the symposium's participants, to explore the issues faced and solutions offered. 70 respondents, from 9 countries (majority USA, 39%, followed by UK, 19%) included 50 clinicians, spread across a diverse range of specialties (but with a high proportion, 64%, of medical oncologists) and 20 who classified themselves as non-clinical (solely lab-based). Spread of clinician specialty across tumour types was breast (65%), prostate (27%), followed by renal, myeloma and melanoma. Analysis showed that management of metastatic bone disease in all solid tumour types and myeloma, adjuvant bisphosphonate breast cancer therapy and cancer treatment induced bone loss, was substantially impacted. Respondents reported delays to routine CT scans (58%), standard bone scans (48%) and MRI scans (46%), though emergency scans were less affected. Delays in palliative radiotherapy for bone pain were reported by 31% of respondents with treatments often involving only a single dose without fractionation. Delays to, or cancellation of, prophylactic surgery for bone pain were reported by 35% of respondents. Access to treatments with intravenous bisphosphonates and subcutaneous denosumab was a major problem, mitigated by provision of drug administration at home or in a local clinic, reduced frequency of administration or switching to oral bisphosphonates taken at home. The questionnaire also revealed damaging delays or complete stopping of both clinical and laboratory research. In addition to an analysis of the questionnaire, this paper presents a rationale and recommendations for adaptation of the normal guidelines for protection of bone health during the pandemic.

Novel operative technique of advancement urethral meatoplasty utilizing buccal mucosa for Vulvar Paget's disease with urethral invasion: two case reports

BACKGROUND

Vulvar Paget's disease (VPD) is a rare malignant disorder originating in the external genitalia. It occasionally invades into urethral or vaginal mucosa of female, making surgical treatment more complicating. In case of urethral invasion of Paget's cells, systematic mapping biopsy of urethral mucosa is the standard of care to determine the range of surgical resection. Resection of urethral mucosa and simple skin grafting often result in urethral stricture after surgery, which severely deteriorates patient's quality of life.

CASE PRESENTATION

We applied a new technique of advancement urethral meatoplasty using buccal mucosa, in two Japanese cases of VPD with urethral invasion. After broad resection of vulvar skin together with the urethral mucosa, buccal mucosa was implanted between advanced urethral mucosa and skin graft. In both cases, we could prevent urethral stricture one year and two years after surgery, respectively.

CONCLUSION

This technique prevented urethral stricture after surgery and could be a useful technique as part of urethroplasty for VPD.

TET repression and increased DNMT activity synergistically induce aberrant DNA methylation

Chronic inflammation is deeply involved in various human disorders, such as cancer, neurodegenerative disorders, and metabolic disorders. Induction of epigenetic alterations, especially aberrant DNA methylation, is one of the major mechanisms, but how it is induced is still unclear. Here, we found that expression of TET genes, methylation erasers, was downregulated in inflamed mouse and human tissues, and that this was caused by upregulation of TET-targeting miRNAs such as MIR20A, MIR26B, and MIR29C, likely due to activation of NF-κB signaling downstream of IL-1β and TNF-α. However, TET knockdown induced only mild aberrant methylation. Nitric oxide (NO), produced by NOS2, enhanced enzymatic activity of DNA methyltransferases (DNMTs), methylation writers, and NO exposure induced minimal aberrant methylation. In contrast, a combination of TET knockdown and NO exposure synergistically induced aberrant methylation, involving genomic regions not methylated by either alone. The results showed that a vicious combination of TET repression, due to NF-κB activation, and DNMT activation, due to NO production, is responsible for aberrant methylation induction in human tissues.

Prognostic Values of Preoperative Inflammatory and Nutritional Markers for Colorectal Cancer

Background

Increasing evidence indicates that inflammation and nutritional status are associated with survival outcomes in patients with colorectal cancer (CRC). This study aimed to investigate the prognostic values of preoperative inflammatory and nutritional factors and develop a prognostic model individually predicting overall survival (OS) and disease-free survival (DFS) in patients with CRC.

Methods

We retrospectively collected data on patients with CRC who underwent radical surgery. Independent prognostic inflammatory and nutritional markers were identified and novel prognostic models were developed incorporating the identified factors. The discriminative ability and model-fitting performance were evaluated by receiver operating characteristic curves and Akaike information criteria. Clinical usefulness was assessed by decision curve analysis.

Results

A total of 400 eligible patients were identified. Multivariate analysis identified pN stage, tumor differentiation grade, neutrophil count, and body mass index as independent prognostic factors for OS, and pN stage, tumor differentiation grade, neutrophil count, neutrophil-lymphocyte ratio, and serum albumin as prognostic factors for DFS. The combined inflammatory and nutritional prognostic model showed better discriminative ability, model-fitting performance, and net benefits than the inflammatory and nutritional models alone, and the American Joint Committee on Cancer (AJCC) 8th TNM classification for predicting OS and DFS.

Conclusion

Preoperative nutritional and inflammatory factors have significant prognostic value in patients with CRC. A novel prognostic model incorporating preoperative inflammatory and nutritional markers provides better prognostic performance than the AJCC 8th TNM classification. A novel nomogram incorporating preoperative inflammatory and nutritional markers can individually predict OS and DFS in patients with CRC.

Derivation and validation of a novel score to detect heart failure with preserved ejection fraction in patients with atrial fibrillation: the Fushimi AF registry

Background

Heart failure with preserved ejection fraction (HFpEF) is an important comorbidity of atrial fibrillation (AF). However, it is sometimes difficult to detect HFpEF among AF patients with preserved EF, since AF and HF share similar symptoms.

Purpose

The aim of this study was to identify factors associated with having HFpEF in AF patients with preserved EF, and derive a new score for HFpEF in AF patients.

Methods

The Fushimi AF Registry is a community-based prospective survey of the AF patients in Fushimi-ku, Kyoto, Japan. Follow-up data were available for 4,466 patients, and 3,083 patients had preserved EF (≥50%). Of the 3,083 patients, 444 had prior HF hospitalization at baseline and we defined these patients as HFpEF. We examined the factors associated with having HFpEF, and derived a new score for detecting HFpEF in AF patients. Thereafter, we validated this score in patients without prior HF hospitalization.

Result

The mean age of the patients with EF ≥50% was 73.6 years, and 41.3% were female. Compared with the patients without prior HF hospitalization, HFpEF patients were older, more often female, less in body weight, had more heart disease (valvular heart disease, cardiomyopathy, old myocardial infarction, and coronary artery disease), chronic kidney diseases (CKD), anemia (Hb &lt;11 g/dL), sustained AF (persistent or permanent), left atrial enlargement (&gt;45 mm), and dilation of cardio-thoracic ratio (CTR) (&gt;54%) at baseline. In multivariate analysis, heart diseases, CKD, sustained AF, dilatation of CTR, left atrial enlargement, and anemia were significantly associated with HFpEF (Table 1). We derived a new score to diagnose HFpEF in AF patients (2 points for heart diseases, 1 point for CKD, sustained AF, dilatation of CTR, left atrial enlargement, and anemia; range 0 to 7 points). In a receiver-operating characteristic curve, optimal cut-off point for detecting HFpEF was 3 (Figure 1). We validated this score in patients without prior hospitalization for HF (n=2,639). Of these, 298 patients had HF symptoms of NYHA 2–4 (Symptomatic-HF), and 2,341 patients had neither prior HF hospitalization nor HF symptoms (No-HF). Notably, 207 patients (69.5%) in symptomatic-HF group and 748 patients (32.0%) in No-HF group were classified into HFpEF based on this new score. Furthermore, patients diagnosed as HFpEF by this score had higher incidence of new hospitalization for HF during the follow-up in both symptomatic-HF group and No-HF group. (Figure 2).

Conclusion

We derived a new score to diagnose HFpEF in AF patients based on the presence of prior HF hospitalization (2 points for heart diseases, 1 point for CKD, sustained AF, dilatation of CTR, left atrial enlargement, and anemia). In patients without prior HF hospitalization, sizable number of patients had high HFpEF score (≥3), and those patients showed higher incidence of new HF hospitalization.

Funding Acknowledgement

Type of funding source: None

Clinical outcomes of Japanese atrial fibrillation patients with combined valvular heart disease: the Fushimi AF Registry

Background

We previously reported that valvular heart disease (VHD) was not at the significant risk of stroke/systemic embolism (SE), but was associated with an increased risk of hospitalization for heart failure (HF) in Japanese atrial fibrillation patients. However, the impact of combined VHD on clinical outcomes has been little known.

Purpose

The aim of this study is to investigate the prevalence of combined VHD and its clinical characteristics and impact on outcomes such as stroke/SE, all-cause death, cardiac death and hospitalization for HF.

Method

The Fushimi AF Registry is a community-based prospective survey of AF patients in one of the wards of our city which is a typical urban district of Japan. We started to enroll patients from March 2011, and follow-up data were available for 4,466 patients by the end of November 2019. In the entire cohort, echocardiography data were available for 3,574 patients. 68 AF patients with prosthetic heart valves were excluded and we compared clinical characteristics and outcomes between 488 single VHD (103 Aortic valve disease (AVD), 315 mitral valve disease (MVD), 70 tricuspid valve disease (TVD)) and 158 combined VHD (46 AVD and MVD, 11 AVD and TVD, 66 MVD and TVD, 35 AVD and MVD and TVD).

Result

Compared with single VHD, patients with combined VHD were older (combined vs. single VHD: 78.5 vs. 76.0 years, respectively; p&lt;0.01), more likely to have persistent/permanent type AF (73.4% vs. 63.9%, p=0.02) and prescription of warfarin (63.1% vs. 53.8%, p=0.04). Combined VHD was less likely to have diabetes mellitus (13.9% vs. 23.6%, p=0.01) and dyslipidemia (26.6% vs. 40.4%, p&lt;0.01). Sex, body weight, hypertension, pre-existing HF were comparable between the two groups.

During the median follow-up of 1,474 days, the incidence rate of stroke/SE was not significantly different between the two groups (1.58 vs. 1.89 per 100 person-years, respectively, log rank p=0.10). The incidence rate of all-cause death (7.35 vs. 5.33, p=0.65), cardiac death (1.20 vs. 0.99, p=0.91) and hospitalization for HF (5.55 vs. 4.43, p=0.53) were also not significantly different. We previously reported AVD had significant impacts on cardiac adverse outcomes in AF patients, and we further analyzed event rates between combined VHD including AVD (AVD and MVD/TVD) and without AVD (MVD and TVD). Combined VHD with AVD group had higher incidence rate of all-cause death (10.7 vs. 5.79, p=0.03) than that without AVD group. However, the incidence rate of stroke/SE (1.98 vs. 1.56, p=0.59), cardiac death (0.98 vs. 1.14, p=0.68), hospitalization for HF (8.03 vs. 5.38, p=0.17) were not significantly different between the two groups.

Conclusion

As compared with single VHD, the risk of stroke/SE, all-cause death, cardiac death and hospitalization for HF in combined VHD was not significantly different. Among patients with combined VHD, those having AVD had higher incidence rate of all-cause death than those without AVD.

Figure 1

Funding Acknowledgement

Type of funding source: None