Variability in sonographic anterior drawer test measurements of the ankle: Experienced versus beginner examiners

BACKGROUND

This study aimed to clarify the variability in the measurements of stress sonography of the ankle and determine the effects of examiner experience on the measurements.

METHODS

Twenty examiners (10 experienced and 10 beginners) were included in the study. Each examiner performed stress ultrasonography on a patient with a chronic anterior talofibular ligament injury and a patient with an intact ligament using the reverse anterior drawer method. Changes in ligament length before versus after stress were determined. The same 20 examiners performed ultrasonography on two other patients with an injured or intact ATFL using the anterior drawer method. The length change values and variance were compared between the groups using t-tests and F-tests.

RESULTS

Using the reverse anterior drawer method, the change in the anterior talofibular ligament length was 3.3 mm (range, 2.2-4.8 mm) in the experienced group and 2.7 mm (0.0-4.1 mm) in the beginner group for the ligament injured patient. The length changes for the patient with intact anterior talofibular ligament were 0.5 mm (0.1-0.9 mm) and 0.4 mm (-0.1-1.5 mm) in the experienced and beginner groups, respectively. There were no significant intergroup differences in measurement amount (P = 0.37) or variance (P = 0.72). Similarly, using the anterior drawer method, no significant differences between the groups were found in measurement amount or variance.

CONCLUSION

The quantitative evaluation of stress sonography of the ankle was variable regardless of examiner experience or stress method, particularly in patients with an anterior talofibular ligament injury. The amount of variability appeared to be unacceptably large for clinical application. Our study results highlight the need for technical standardization.

Multiplane HiLo microscopy with speckle illumination and non-local means denoising

Significance

HiLo microscopy synthesizes an optically sectioned image from two images, one obtained with uniform and another with patterned illumination, such as laser speckle. Speckle-based HiLo has the advantage of being robust to aberrations but is susceptible to residual speckle noise that is difficult to control. We present a computational method to reduce this residual noise without undermining resolution. In addition, we improve the versatility of HiLo microscopy by enabling simultaneous multiplane imaging (here nine planes).

Aim

Our goal is to perform fast, high-contrast, multiplane imaging with a conventional camera-based fluorescence microscope.

Approach

Multiplane HiLo imaging is achieved with the use of a single camera and z-splitter prism. Speckle noise reduction is based on the application of a non-local means (NLM) denoising method to perform ensemble averaging of speckle grains.

Results

We demonstrate the capabilities of multiplane HiLo with NLM denoising both with synthesized data and by imaging cardiac and brain activity in zebrafish larvae at 40 Hz frame rates.

Conclusions

Multiplane HiLo microscopy aided by NLM denoising provides a simple tool for fast optically sectioned volumetric imaging that can be of general utility for fluorescence imaging applications.

High-resolution multi-z confocal microscopy with a diffractive optical element

There has been recent interest in the development of fluorescence microscopes that provide high-speed volumetric imaging for life-science applications. For example, multi-z confocal microscopy enables simultaneous optically-sectioned imaging at multiple depths over relatively large fields of view. However, to date, multi-z microscopy has been hampered by limited spatial resolution owing to its initial design. Here we present a variant of multi-z microscopy that recovers the full spatial resolution of a conventional confocal microscope while retaining the simplicity and ease of use of our initial design. By introducing a diffractive optical element in the illumination path of our microscope, we engineer the excitation beam into multiple tightly focused spots that are conjugated to axially distributed confocal pinholes. We discuss the performance of this multi-z microscope in terms of resolution and detectability and demonstrate its versatility by performing in-vivo imaging of beating cardiomyocytes in engineered heart tissues and neuronal activity in c. elegans and zebrafish brains.

Sensitivity optimization of a rhodopsin-based fluorescent voltage indicator

The ability to optically image cellular transmembrane voltages at millisecond-timescale resolutions can offer unprecedented insight into the function of living brains in behaving animals. Here, we present a point mutation that increases the sensitivity of Ace2 opsin-based voltage indicators. We use the mutation to develop Voltron2, an improved chemigeneic voltage indicator that has a 65% higher sensitivity to single APs and 3-fold higher sensitivity to subthreshold potentials than Voltron. Voltron2 retained the sub-millisecond kinetics and photostability of its predecessor, although with lower baseline fluorescence. In multiple in vitro and in vivo comparisons with its predecessor across multiple species, we found Voltron2 to be more sensitive to APs and subthreshold fluctuations. Finally, we used Voltron2 to study and evaluate the possible mechanisms of interneuron synchronization in the mouse hippocampus. Overall, we have discovered a generalizable mutation that significantly increases the sensitivity of Ace2 rhodopsin-based sensors, improving their voltage reporting capability.

TEMPO enables sequential genetic labeling and manipulation of vertebrate cell lineages

During development, regulatory factors appear in a precise order to determine cell fates over time. Consequently, to investigate complex tissue development, it is necessary to visualize and manipulate cell lineages with temporal control. Current strategies for tracing vertebrate cell lineages lack genetic access to sequentially produced cells. Here, we present TEMPO (Temporal Encoding and Manipulation in a Predefined Order), an imaging-readable genetic tool allowing differential labeling and manipulation of consecutive cell generations in vertebrates. TEMPO is based on CRISPR and powered by a cascade of gRNAs that drive orderly activation and inactivation of reporters and/or effectors. Using TEMPO to visualize zebrafish and mouse neurogenesis, we recapitulated birth-order-dependent neuronal fates. Temporally manipulating cell-cycle regulators in mouse cortex progenitors altered the proportion and distribution of neurons and glia, revealing the effects of temporal gene perturbation on serial cell fates. Thus, TEMPO enables sequential manipulation of molecular factors, crucial to study cell-type specification.

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

Background

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

Aims

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

Methods

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

Results

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

Conclusion

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

Funding Acknowledgement

Type of funding sources: None.

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

Background

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

Aims

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

Methods

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

Results

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

Conclusion

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

Funding Acknowledgement

Type of funding sources: None.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Disclosure of Interests

None declared

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

Funding Acknowledgements

Type of funding sources: None.

Introduction

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

Methods

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

Results

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

Conclusion

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

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

Funding Acknowledgements

Type of funding sources: None.

Background

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

Methods

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

Results

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

Conclusions

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

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

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

Synthesis of Crystalline CF3 -Rich Perfluoropolyethers from Hexafluoropropylene Oxide and (Trifluoromethyl)trimethylsilane

The synthesis of a CF₃ -rich perfluoropolyether (PFPE) was achieved via the fluoride-catalyzed reaction of hexafluoropropylene oxide (HFPO) with (trifluoromethyl)trimethylsilane (TMSCF₃ , so-called Ruppert-Prakash reagent). Nucleophilic addition of a CF₃ anion to HFPO affords an acyl fluoride via the ring-opening of HFPO, followed by fluoride elimination. Further addition of CF₃ anions to the acyl fluoride gives tertiary perfluoroalkoxide, which attacks HFPO to regenerate an acyl fluoride. Repetition of the sequence via substitution-polymerization afforded a new PFPE as a solid, whose structure was confirmed using ¹⁹ F NMR spectroscopy, GC-MS, and MALDI-TOF MS analysis. Thermal and X-ray diffraction analyses revealed a crystalline character. To the best of our knowledge, this is the first example of crystalline PFPE. Based on contact-angle measurements, the critical surface tension of this solid PFPE (13.4 mN m^-1 ) suggests a water- and oil-repellency of this CF₃ -rich PFPE that is higher than that of polytetrafluoroethylene (PTFE; 18.5 mN m^-1 ). This article is protected by copyright. All rights reserved.

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

Background

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

Aims

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

Methods

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

Results

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

Conclusion

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

Funding Acknowledgement

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

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

Study question

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

Summary answer

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

What is known already

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

Study design, size, duration

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

Participants/materials, setting, methods

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

Main results and the role of chance

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

Limitations, reasons for caution

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

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

Trial registration number

Not applicable

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

Study question

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

Summary answer

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

What is known already

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

Study design, size, duration

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

Participants/materials, setting, methods

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

Main results and the role of chance

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

Limitations, reasons for caution

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

Wider implications of the findings

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

Trial registration number

not applicable

In vivo glucose imaging in multiple model organisms with an engineered single-wavelength sensor

Glucose is arguably the most important molecule in metabolism, and its dysregulation underlies diabetes. We describe a family of single-wavelength genetically encoded glucose sensors with a high signal-to-noise ratio, fast kinetics, and affinities varying over four orders of magnitude (1 μM to 10 mM). The sensors allow mechanistic characterization of glucose transporters expressed in cultured cells with high spatial and temporal resolution. Imaging of neuron/glia co-cultures revealed ∼3-fold faster glucose changes in astrocytes. In larval Drosophila central nervous system explants, intracellular neuronal glucose fluxes suggested a rostro-caudal transport pathway in the ventral nerve cord neuropil. In zebrafish, expected glucose-related physiological sequelae of insulin and epinephrine treatments were directly visualized. Additionally, spontaneous muscle twitches induced glucose uptake in muscle, and sensory and pharmacological perturbations produced large changes in the brain. These sensors will enable rapid, high-resolution imaging of glucose influx, efflux, and metabolism in behaving animals.

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

Background:

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

Objectives:

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

Methods:

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

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

Results:

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

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

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

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

Figure 1.

Conclusion:

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

Acknowledgements:

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

Disclosure of Interests:

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

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

Disclosure of Interests:

None declared

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

Background

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

Aims

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

Methods

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

Results

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

Conclusion

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

Funding Acknowledgement

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

A programmable sequence of reporters for lineage analysis

We present CLADES (cell lineage access driven by an edition sequence), a technology for cell lineage studies based on CRISPR-Cas9 techniques. CLADES relies on a system of genetic switches to activate and inactivate reporter genes in a predetermined order. Targeting CLADES to progenitor cells allows the progeny to inherit a sequential cascade of reporters, thereby coupling birth order to reporter expression. This system, which can also be temporally induced by heat shock, enables the temporal resolution of lineage development and can therefore be used to deconstruct an extended cell lineage by tracking the reporters expressed in the progeny. When targeted to the germ line, the same cascade progresses across animal generations, predominantly marking each generation with the corresponding combination of reporters. CLADES therefore offers an innovative strategy for making programmable cascades of genes that can be used for genetic manipulation or to record serial biological events.

Rational Design of Bioavailable Photosensitizers for Manipulation and Imaging of Biological Systems

Light-mediated chemical reactions are powerful methods for manipulating and interrogating biological systems. Photosensitizers, compounds that generate reactive oxygen species upon excitation with light, can be utilized for numerous biological experiments, but the repertoire of bioavailable photosensitizers is limited. Here, we describe the synthesis, characterization, and utility of two photosensitizers based upon the widely used rhodamine scaffold and demonstrate their efficacy for chromophore-assisted light inactivation, cell ablation in culture and in vivo, and photopolymerization of diaminobenzidine for electron microscopy. These chemical tools will facilitate a broad range of applications spanning from targeted destruction of proteins to high-resolution imaging.

Unlimited Genetic Switches for Cell-Type-Specific Manipulation

Gaining independent genetic access to discrete cell types is critical to interrogate their biological functions as well as to deliver precise gene therapy. Transcriptomics has allowed us to profile cell populations with extraordinary precision, revealing that cell types are typically defined by a unique combination of genetic markers. Given the lack of adequate tools to target cell types based on multiple markers, most cell types remain inaccessible to genetic manipulation. Here we present CaSSA, a platform to create unlimited genetic switches based on CRISPR/Cas9 (Ca) and the DNA repair mechanism known as single-strand annealing (SSA). CaSSA allows engineering of independent genetic switches, each responding to a specific gRNA. Expressing multiple gRNAs in specific patterns enables multiplex cell-type-specific manipulations and combinatorial genetic targeting. CaSSA is a new genetic tool that conceptually works as an unlimited number of recombinases and will facilitate genetic access to cell types in diverse organisms.

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

Background

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

Purpose

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

Methods

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

Results

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

Conclusion

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

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

Background

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

Purpose

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

Methods

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

Results

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

Kaplan-Meier curves of readmission rates

Conclusions

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Single-Cell Reconstruction of Emerging Population Activity in an Entire Developing Circuit

Animal survival requires a functioning nervous system to develop during embryogenesis. Newborn neurons must assemble into circuits producing activity patterns capable of instructing behaviors. Elucidating how this process is coordinated requires new methods that follow maturation and activity of all cells across a developing circuit. We present an imaging method for comprehensively tracking neuron lineages, movements, molecular identities, and activity in the entire developing zebrafish spinal cord, from neurogenesis until the emergence of patterned activity instructing the earliest spontaneous motor behavior. We found that motoneurons are active first and form local patterned ensembles with neighboring neurons. These ensembles merge, synchronize globally after reaching a threshold size, and finally recruit commissural interneurons to orchestrate the left-right alternating patterns important for locomotion in vertebrates. Individual neurons undergo functional maturation stereotypically based on their birth time and anatomical origin. Our study provides a general strategy for reconstructing how functioning circuits emerge during embryogenesis. VIDEO ABSTRACT.

Bright and photostable chemigenetic indicators for extended in vivo voltage imaging

Genetically encoded voltage indicators (GEVIs) enable monitoring of neuronal activity at high spatial and temporal resolution. However, the utility of existing GEVIs has been limited by the brightness and photostability of fluorescent proteins and rhodopsins. We engineered a GEVI, called Voltron, that uses bright and photostable synthetic dyes instead of protein-based fluorophores, thereby extending the number of neurons imaged simultaneously in vivo by a factor of 10 and enabling imaging for significantly longer durations relative to existing GEVIs. We used Voltron for in vivo voltage imaging in mice, zebrafish, and fruit flies. In the mouse cortex, Voltron allowed single-trial recording of spikes and subthreshold voltage signals from dozens of neurons simultaneously over a 15-minute period of continuous imaging. In larval zebrafish, Voltron enabled the precise correlation of spike timing with behavior.

Cyanide-Free One-Pot Synthesis of Methacrylic Esters from Acetone

Methacrylic esters, represented by methyl methacrylate (MMA), are widely used as commodity chemicals. Here, the one-pot synthesis of methacrylic esters from acetone, a haloform and alcohols in the presence of an organic base is described. Using DBU as the organic base for the reaction of acetone, chloroform and methanol in acetonitrile afforded MMA in 66 % yield. When the solvent was replaced by benzonitrile, the product MMA was successfully purified by distillation. Applicability of this process to various alcohols was also investigated to show ethyl, phenyl, CF₃ CH₂ , and n-C₆ F₁₃ CH₂ CH₂ esters were obtained in moderate yields. The use of bromoform instead of chloroform resulted in the improvement of the yield, for example, methyl and n-C₆ F₁₃ CH₂ CH₂ esters up to 81 and 70 %, respectively. The reaction with deuterated starting materials acetone-d₆ and MeOH-d₄ , with DBU in acetonitrile afforded deuterated MMA (MMA-d₈ ) in 70 % yield.

Dynamic super-resolution structured illumination imaging in the living brain

Cells in the brain act as components of extended networks. Therefore, to understand neurobiological processes in a physiological context, it is essential to study them in vivo. Super-resolution microscopy has spatial resolution beyond the diffraction limit, thus promising to provide structural and functional insights that are not accessible with conventional microscopy. However, to apply it to in vivo brain imaging, we must address the challenges of 3D imaging in an optically heterogeneous tissue that is constantly in motion. We optimized image acquisition and reconstruction to combat sample motion and applied adaptive optics to correcting sample-induced optical aberrations in super-resolution structured illumination microscopy (SIM) in vivo. We imaged the brains of live zebrafish larvae and mice and observed the dynamics of dendrites and dendritic spines at nanoscale resolution.

Chronology-based architecture of descending circuits that underlie the development of locomotor repertoire after birth

The emergence of new and increasingly sophisticated behaviors after birth is accompanied by dramatic increase of newly established synaptic connections in the nervous system. Little is known, however, of how nascent connections are organized to support such new behaviors alongside existing ones. To understand this, in the larval zebrafish we examined the development of spinal pathways from hindbrain V2a neurons and the role of these pathways in the development of locomotion. We found that new projections are continually layered laterally to existing neuropil, and give rise to distinct pathways that function in parallel to existing pathways. Across these chronologically layered pathways, the connectivity patterns and biophysical properties vary systematically to support a behavioral repertoire with a wide range of kinematics and dynamics. Such layering of new parallel circuits equipped with systematically changing properties may be central to the postnatal diversification and increasing sophistication of an animal’s behavioral repertoire.

Newborn babies have limited abilities. Indeed, most of our actions shortly after birth are the result of reflexes that serve our most basic need: to stay alive. As we get older, however, our behaviour gradually becomes more sophisticated. During this time, the billions of cells in our brain form new connections to build intricate ‘circuits’ of neurons that allow for more complicated thoughts and actions.

It is clear that the brain circuits that support new behaviours must develop in a way that does not interfere with the existing circuits that are vital for survival. However, the challenge has been to find a way to peer into a brain as it develops to see how these new circuits form.

In recent years, zebrafish have revolutionised research into neuronal circuits in animals. Developing over the course of a few days, these small transparent fish provide a window into the brain during the earliest stages of development. Indeed, the circuits of neurons that descend from the brain and connect to the spinal cord have already been mapped in these animals. Now, Pujala and Koyama have begun to follow the careful development of these ‘descending’ neurons, and relate it to the appearance of new behaviours in young zebrafish.

Time-lapse imaging with a fluorescent protein that is active only in specific descending neurons revealed that new circuits are laid down over existing ones, like the growth rings in a tree. Next, at different timepoints in zebrafish development, Pujala and Koyama traced these neurons backwards from the spine to the brain to identify which connections formed first. This showed that the spinal connections develop one after the other, in the same order that the neurons mature.

Next, Pujala and Koyama asked how the activity of neurons that mature early or late in development relates to specific behaviours in young zebrafish. Early-born circuits connect to neurons that produce powerful, reflex-driven, whole-body movements such as an escape response. The later circuits connect to different neurons through slower, less direct pathways; the late-born neurons also generate the refined movements that are acquired later in a zebrafish’s development and help the fish to explore its environment.

These findings show that descending circuits in zebrafish run parallel to each other, but with distinct connections and properties that allow them to control different kinds of movements. While this study was conducted using an animal model, a better understanding of how such circuits develop and the movements they control may one day aid the treatment of patients with neurodegenerative diseases or injuries where connections have been lost.

Observing the cell in its native state: Imaging subcellular dynamics in multicellular organisms

True physiological imaging of subcellular dynamics requires studying cells within their parent organisms, where all the environmental cues that drive gene expression, and hence the phenotypes that we actually observe, are present. A complete understanding also requires volumetric imaging of the cell and its surroundings at high spatiotemporal resolution, without inducing undue stress on either. We combined lattice light-sheet microscopy with adaptive optics to achieve, across large multicellular volumes, noninvasive aberration-free imaging of subcellular processes, including endocytosis, organelle remodeling during mitosis, and the migration of axons, immune cells, and metastatic cancer cells in vivo. The technology reveals the phenotypic diversity within cells across different organisms and developmental stages and may offer insights into how cells harness their intrinsic variability to adapt to different physiological environments.

50 Hz volumetric functional imaging with continuously adjustable depth of focus

Understanding how neural circuits control behavior requires monitoring a large population of neurons with high spatial resolution and volume rate. Here we report an axicon-based Bessel beam module with continuously adjustable depth of focus (CADoF), that turns frame rate into volume rate by extending the excitation focus in the axial direction while maintaining high lateral resolutions. Cost-effective and compact, this CADoF Bessel module can be easily integrated into existing two-photon fluorescence microscopes. Simply translating one of the relay lenses along its optical axis enabled continuous adjustment of the axial length of the Bessel focus. We used this module to simultaneously monitor activity of spinal projection neurons extending over 60 µm depth in larval zebrafish at 50 Hz volume rate with adjustable axial extent of the imaged volume.

50 Hz volumetric functional imaging with continuously adjustable depth of focus

Understanding how neural circuits control behavior requires monitoring a large population of neurons with high spatial resolution and volume rate. Here we report an axicon-based Bessel beam module with continuously adjustable depth of focus (CADoF), that turns frame rate into volume rate by extending the excitation focus in the axial direction while maintaining high lateral resolutions. Cost-effective and compact, this CADoF Bessel module can be easily integrated into existing two-photon fluorescence microscopes. Simply translating one of the relay lenses along its optical axis enabled continuous adjustment of the axial length of the Bessel focus. We used this module to simultaneously monitor activity of spinal projection neurons extending over 60 µm depth in larval zebrafish at 50 Hz volume rate with adjustable axial extent of the imaged volume.

A genetically encoded Ca2+ indicator based on circularly permutated sea anemone red fluorescent protein eqFP578

BACKGROUND

Genetically encoded calcium ion (Ca2+) indicators (GECIs) are indispensable tools for measuring Ca2+ dynamics and neuronal activities in vitro and in vivo. Red fluorescent protein (RFP)-based GECIs have inherent advantages relative to green fluorescent protein-based GECIs due to the longer wavelength light used for excitation. Longer wavelength light is associated with decreased phototoxicity and deeper penetration through tissue. Red GECI can also enable multicolor visualization with blue- or cyan-excitable fluorophores.

RESULTS

Here we report the development, structure, and validation of a new RFP-based GECI, K-GECO1, based on a circularly permutated RFP derived from the sea anemone Entacmaea quadricolor. We have characterized the performance of K-GECO1 in cultured HeLa cells, dissociated neurons, stem-cell-derived cardiomyocytes, organotypic brain slices, zebrafish spinal cord in vivo, and mouse brain in vivo.

CONCLUSION

K-GECO1 is the archetype of a new lineage of GECIs based on the RFP eqFP578 scaffold. It offers high sensitivity and fast kinetics, similar or better than those of current state-of-the-art indicators, with diminished lysosomal accumulation and minimal blue-light photoactivation. Further refinements of the K-GECO1 lineage could lead to further improved variants with overall performance that exceeds that of the most highly optimized red GECIs.

Glycaemic control and hypoglycaemia with insulin glargine 300 U/mL compared with glargine 100 U/mL in Japanese adults with type 2 diabetes using basal insulin plus oral anti-hyperglycaemic drugs (EDITION JP 2 randomised 12-month trial including 6-month extension)

AIMS

To compare insulin glargine 300 U/mL (Gla-300) with glargine 100 U/mL (Gla-100) in Japanese adults with uncontrolled type 2 diabetes on basal insulin and oral anti-hyperglycaemic drugs over 12 months.

METHODS

EDITION JP 2 was a randomised, open-label, phase 3 study. Following a 6-month treatment period, participants continued receiving previously assigned once daily Gla-300 or Gla-100, plus oral anti-hyperglycaemic drugs, in a 6-month extension period. Glycaemic control, hypoglycaemia and adverse events were assessed.

RESULTS

The 12-month completion rate was 88% for Gla-300 and 96% for Gla-100, with comparable reasons for discontinuation. Mean HbA_1c decrease from baseline to month 12 was 0.3% in both groups. Annualised rates of confirmed (≤3.9mmol/L [≤70mg/dL]) or severe hypoglycaemia were lower with Gla-300 than Gla-100 (nocturnal [00:00-05:59h]: rate ratio 0.41; 95% confidence interval: 0.18 to 0.92; anytime [24h]: rate ratio 0.64; 95% confidence interval: 0.44 to 0.94). Cumulative number of hypoglycaemic events was lower with Gla-300 than Gla-100. Adverse event profiles were comparable between treatments.

CONCLUSION

Over 12 months, Gla-300-treated participants achieved sustained glycaemic control and experienced less hypoglycaemia, particularly at night, versus Gla-100, supporting 6-month results.

Image Quality Required for the Diagnosis of Skull Fractures Using Head CT: A Comparison of Conventional and Improved Reconstruction Kernels

BACKGROUND AND PURPOSE

Although skull fractures are generally assessed on bone images obtained by using head CT, the combined multikernel technique that enables evaluation of both brain and bone through a change in the window settings of an image set has been reported. The purpose of this retrospective study was to determine the image quality required for the accurate assessment of skull fractures by using head CT.

MATERIALS AND METHODS

A random sample of 50 patients (25 nonfracture and 25 simple nondisplaced skull fractures) was selected, and sets of conventional brain and bone images and improved combined multikernel images were reconstructed (4614 images). Three radiologists indicated their confidence levels regarding the presence of skull fractures by marking on a continuous scale for each image set. The mean area under the receiver operating characteristic curve was calculated for each kernel, and the statistical significance of differences was tested by using the Dorfman-Berbaum-Metz method.

RESULTS

Although a difference in the diagnostic performance of the 3 radiologists was suggested, the mean area under the curve value showed no significant differences among the 3 reconstruction kernels (P = .95 [bone versus combined]), P = .91 [bone versus brain]), and P = .88 [brain versus combined]). However, the quality of brain images was distinctly poorer than the quality of the other 2 images.

CONCLUSIONS

There was no significant difference in the diagnostic performance of brain, bone, and combined multikernel images for skull fractures. Skull fracture diagnosis is made possible by brain image assessments. Combined multikernel images offer the advantage of high-quality brain and bone images.

A circuit motif in the zebrafish hindbrain for a two alternative behavioral choice to turn left or right

Animals collect sensory information from the world and make adaptive choices about how to respond to it. Here, we reveal a network motif in the brain for one of the most fundamental behavioral choices made by bilaterally symmetric animals: whether to respond to a sensory stimulus by moving to the left or to the right. We define network connectivity in the hindbrain important for the lateralized escape behavior of zebrafish and then test the role of neurons by using laser ablations and behavioral studies. Key inhibitory neurons in the circuit lie in a column of morphologically similar cells that is one of a series of such columns that form a developmental and functional ground plan for building hindbrain networks. Repetition within the columns of the network motif we defined may therefore lie at the foundation of other lateralized behavioral choices.

DOI:http://dx.doi.org/10.7554/eLife.16808.001

Humans and other vertebrate animals constantly make choices about whether to respond to the left or to the right. Do they look left or right; turn left or right; reach left or right? In humans, the distinction between left and right is so fundamental that it has entered our collective thinking. Many societies define their political positions, for example, in terms of leaning to the left or to the right.

However, we know little about the wiring of the brain that accomplishes the task of making physical left-right choices. Koyama et al. therefore set out to identify the neural circuit responsible for the decision to turn either left or right. Zebrafish larvae were chosen as subjects because they execute rapid left or right turns to escape predators. Given that one wrong turn can result in the death of the zebrafish, a correct choice matters more than in most of the other decisions that animals make.

Experiments revealed that a process of competition between neurons on the left and right sides of the brain underlies this decision-making. Neurons on the right collect evidence that an attack is coming from the right, and drive turns to the left, away from the threat. These neurons also attempt to silence competing neurons on the left that act to produce turns to the right. By weighing up the evidence from left and right sides, the circuit as a whole comes to a decision about the best direction in which to turn.

The region of the brain that controls the left versus right escape response in zebrafish is present in all vertebrates. Moreover, it appears to have a similar structure across species, consisting of repeating columns of neurons. This raises the possibility that other left-right choices in fish and other animals occur in a similar way – a principle that can be tested in future work.

DOI:http://dx.doi.org/10.7554/eLife.16808.002

New insulin glargine 300 U/ml versus glargine 100 U/ml in Japanese people with type 2 diabetes using basal insulin and oral antihyperglycaemic drugs: glucose control and hypoglycaemia in a randomized controlled trial (EDITION JP 2)

AIMS

To compare the efficacy and safety of insulin glargine 300 U/ml (Gla-300) with glargine 100 U/ml (Gla-100) in Japanese people with type 2 diabetes using basal insulin plus oral antihyperglycaemic drug(s) [OAD(s)].

METHODS

The EDITION JP 2 study (NCT01689142) was a 6-month, multicentre, open-label, phase III study. Participants (n = 241, male 61%, mean diabetes duration 14 years, mean weight 67 kg, mean body mass index 25 kg/m(2), mean glycated haemoglobin (HbA1c) 8.02 %, mean basal insulin dose 0.24 U/kg/day) were randomized to Gla-300 or Gla-100, while continuing OAD(s). Basal insulin was titrated to target fasting self-monitored plasma glucose 4.4-5.6 mmol/l. The primary efficacy endpoint was HbA1c change over 6 months. Safety endpoints included hypoglycaemia and weight change.

RESULTS

Gla-300 was non-inferior to Gla-100 for HbA1c reduction [least squares (LS) mean difference 0.10 (95% confidence interval [CI] -0.08, 0.27) %]. The mean HbA1c at month 6 was 7.56 and 7.52 % with Gla-300 and Gla-100, respectively. Nocturnal confirmed (≤3.9 mmol/l) or severe hypoglycaemia risk was 38% lower with Gla-300 versus Gla-100 [relative risk 0.62 (95% CI 0.44, 0.88)]; annualized rates were 55% lower at night [rate ratio 0.45 (95% CI 0.21, 0.96)] and 36% lower at any time [24 h; rate ratio 0.64 (95% CI 0.43, 0.96)]. Severe hypoglycaemia was infrequent. A significant between-treatment difference in weight change favoured Gla-300 [LS mean difference -1.0 (95% CI -1.5, -0.5) kg; p = 0.0003]. Adverse event rates were comparable between groups.

CONCLUSIONS

Japanese people with type 2 diabetes using basal insulin plus OAD(s) experienced less hypoglycaemia with Gla-300 than with Gla-100, while glycaemic control did not differ.