Stabilizing effect of total ankle arthroplasty by distal translation and lateralization of talus in varus ankle deformity

BACKGROUND

In end-stage arthritis indicated for total ankle arthroplasty (TAA), full-thickness cartilage damage, subchondral bone defect/shaving, and fluttering of the talar dome occur, shortening the distance between the tibial and talar insertions of ligaments and leading to laxity of ligaments surrounding the ankle joint. Under such conditions, medial ligaments (including the deltoid ligament) would not be expected to function properly. To stabilize the ankle joint during the stance phase, medial ligament function under tension is important. This study therefore examined whether TAA contributes to lengthening of the medial tibio-talar joint as evaluated radiographically, as a preferable method for achieving tensile effects on medial ligaments.

MATERIALS AND METHODS

Twenty-four feet with end-stage varus deformity of the ankle joint that underwent TAA were retrospectively investigated, excluding cases with any malleolar osteotomy or fracture. Distance between proximal and distal insertions of medial ligaments, lateralization of the talus, and talar tilt angle under valgus/varus stress condition were evaluated pre- and postoperatively.

RESULTS

Distance between proximal and distal insertions of medial ligaments was significantly elongated after TAA. At the same time, the talus showed significant lateralization. Furthermore, talar tilt under valgus/varus stress conditions was also significantly reduced after TAA.

CONCLUSION

TAA affects distal translation and lateralization of the talus in cases of varus ankle deformity. These effects might contribute to re-providing tensile force on lax medial ligaments, improving ligament function.

Basal differentiation and expression status of SOX2 and KLF4 in basal layers are prognostic factors for disease-specific survival in oral squamous cell carcinoma

BACKGROUND

Basal differentiation in oral squamous cell carcinoma is usually detected at invasive sites. However, its significance as a prognostic value has been poorly investigated.

METHODS

COL17 was selected as a basal differentiation marker because of its stable expression in the basal-like cells of oral squamous cell carcinoma. Sixty-five cases of oral squamous cell carcinoma were subclassified into COL17-high (30 cases) and -low (35 cases) types, and the prognostic value was analyzed by Cox regression analysis. In addition, the stem cell markers such as SOX2, KLF4, MYC as well as the stem cell-related markers BMI1, EZH2, and YAP and its paralog TAZ, were immunohistochemically analyzed. Their prognostic values were investigated along with their COL17 status by Cox regression analysis.

RESULTS

No significant difference was observed between the COL17-high and -low groups in the disease-specific survival and recurrence-free survival in oral squamous cell carcinoma. When the COL17-high and -low categories were combined with the SOX2, KLF4, EZH2, or YAP/TAZ status in the basal layers, together with gender and age as covariates, the hazard ratios reached 3.3, 3.7, 2.8, and 3.1, respectively. In addition, multivariate analysis, including COL17, SOX2, and KLF4, with gender and age as covariates, showed a significantly poor prognosis for disease-specific survival.

CONCLUSION

Based on the relatively high hazard ratios, it is indicated that basal differentiation and the expression status of SOX2 and KLF4 in the basal layers are prognostic factors for oral squamous cell carcinoma.

Acute stress transiently activates macrophages and chemokines in cervical lymph nodes

Acute restraint stress (RS) is routinely used to study the effects of psychological and/or physiological stress. We evaluated the impact of RS on cervical lymph nodes in rats at molecular and cellular levels. Male Sprague-Dawley rats were subjected to stress by immobilization for 30, 60, and 120 min (RS30, RS60, and RS120, respectively) and compared with rats of a no-stress control (C) group. The expression of genes encoding chemokines CXCL1/CXCL2 (Cxcl1 and Cxcl2) and their receptor CXCR2 (Cxcr2) was analyzed using reverse transcription-quantitative PCR (RT-qPCR) and microarray analyses. Immunohistochemistry and in situ hybridization were performed to determine the expression of these proteins and the macrophage biomarker CD68. Microarray analysis revealed that the expression of 514 and 496 genes was upregulated and downregulated, respectively, in the RS30 group. Compared with the C group, the RS30 group exhibited a 23.0-, 13.0-, and 1.6-fold increase in Cxcl1, Cxcl2, and Cxcr2 expression. Gene Ontology analysis revealed the involvement of these three upregulated genes in the cytokine network, inflammation, and leukocyte chemotaxis and migration. RT-qPCR analysis indicated that the mRNA levels of Cxcl1 and Cxcl2 were significantly increased in the RS30 group but were reverted to normal levels in the RS60 and RS120 groups. Cxcr2 mRNA level was significantly increased in the RS30 and RS120 groups compared with that in the C group. RS-induced CXCL1-immunopositive cells corresponded to B/plasma cells, whereas CXCL2-immunopositive cells corresponded to endothelial cells of the high endothelial venules. Stress-induced CXCR2-immunopositive cells corresponded to macrophages. Psychological and/or physiological stress induces an acute stress response and formation of an immunoreactive microenvironment in cervical lymph nodes, with the CXCL1/CXCL2-CXCR2 axis being pivotal in the acute stress response.

Multicenter retrospective study of nivolumab for recurrent/metastatic oral squamous cell carcinoma

OBJECTIVES

Immunotherapy with nivolumab for patients with recurrent/metastatic oral squamous cell carcinoma has not been evaluated. Here, we aimed to examine the efficacy, safety, and prognostic factors of nivolumab in these patients.

MATERIALS AND METHODS

This multicenter retrospective observational study involved patients who received nivolumab between April 2017 and June 2019. The patient characteristics were evaluated for association with progression-free and overall survival. Progression-free and overall survival rates were calculated; parameters that were significant in the univariate analysis were used as explanatory variables. Independent factors for progression-free and overall survival were identified using multivariate analysis.

RESULTS

Totally, 143 patients were included. The overall response and disease control rates were 27.3% and 46.2%, respectively. The median, 1- and 2-year progression-free survival rates were 2.7 months, 25.4%, and 19.2%, respectively; those for overall survival were 11.2 months, 47.3%, and 33.6%, respectively. The independent factors affecting progression-free survival were performance status and immune-related adverse event occurrence, whereas those affecting overall survival were performance status, target disease, and number of previous lines of systemic cancer therapy. Eight patients reported grade ≥3 immune-related adverse events.

CONCLUSION

Nivolumab was effective for recurrent/metastatic oral squamous cell carcinoma treatment and was well tolerated by patients.

Magnetic resonance imaging findings of sclerosing microcystic adenocarcinoma: A case report and review of the literature

Sclerosing microcystic adenocarcinoma (SMA) is a rare malignant tumor of the salivary glands that closely resembles cutaneous microcystic adnexal carcinoma (MAC). It was newly listed in the 5th edition of the WHO classification of head and neck tumors. This report describes the case of a 61-year-old woman who presented with masses on the floor of the mouth. The masses showed low signal intensity on T2-weighted images (T2WI) and with low apparent diffusion coefficient (ADC) values. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) revealed a plateau or persistence after rapid initial enhancement. Histopathologically, the tumors comprised small infiltrating strands of cells that formed small ducts and cysts embedded in thick fibrous stroma, consistent with SMA. Low signal intensity on T2WI with a low ADC value and a plateau or persistence after rapid initial enhancement on DCE-MRI reflect the fibrous and cellular components of the tumor and can be considered characteristic MRI findings of SMA.

Postoperative evaluation of bone bridge after alveolar bone graft with cortical bone lining technique

OBJECTIVE

For alveolar bone grafting (ABG), we have been performing surgery using a technique in which a cortical bone lining iliac endplate is applied to the anterior nasal aperture inferior margin. Herein, we used conventional and cortical bone lining techniques to examine the postoperative bone-bridge morphology after ABG.

STUDY DESIGN

Fifty-five unilateral patients who underwent ABG at our clinic from October 2012 to March 2019 were included. We used postoperative CT data to compare the labiolingual width of the grafted bone and anterior-posterior and vertical shapes of the nasal aperture inferior margin with respect to the ungrafted side.

RESULTS

The cortical bone lining technique was superior to the conventional method. The cortical bone lining technique showed good results regardless of alveolar cleft width or oral-nasal fistula. Also, tooth movement into the grafted area was involved in maintaining the residual graft bone; however, the cortical bone lining technique had better results.

CONCLUSIONS

The cortical bone lining technique allows for the physical closure of nasolateral mucosal fistulas when it is technically difficult, and it can apply sufficient pressure to the bone marrow cancellous bone filling over the cortical plate bone. Our results illustrate the effectiveness of the cortical bone lining technique.

Art engagement and psychological well-being among community-dwelling older adults in Japan: an observational cross-sectional study

OBJECTIVES

Art engagement, which includes individual art activities and museum and gallery visits, potentially contributes to improving psychological well-being. However, there is insufficient evidence of its effects on the older population, and few reports are from Asia, including Japan. This study examined the association between art engagement and psychological well-being among older adults in Japan.

STUDY DESIGN

An observational cross-sectional study design was used.

METHODS

Community-dwelling older adults aged ≥60 years were recruited from the visitors to public facilities (including community centres, sports centres and cultural centres) in Aichi, Japan, in 2022, and completed questionnaires. The psychological well-being assessment included five domains according to Seligman's PERMA framework: Positive emotion, Engagement, Relationship, Meaning and Accomplishment. Regarding art engagement, the frequencies of active art engagement (e.g. activities by individuals and participation in groups, such as music and painting) and receptive art engagement (e.g. visiting museums, galleries and the theatres) were assessed.

RESULTS

A total of 522 participants were included in the analysis (mean age = 74.1 years; 78.0% females). Results from the multivariable linear regression analysis, which adjusted for demographic and socio-economic factors, revealed that higher frequencies of active art engagement were significantly associated with higher scores in all five PERMA domain scores. Higher frequencies of receptive art engagement were significantly associated with higher levels of Positive emotion, Engagement and Meaning domain scores, but were only marginally associated with the Accomplishment domain and were not associated with the Relationships domain.

CONCLUSIONS

This study indicates that art engagement has the potential to enhance psychological well-being among older adults. National and local government strategies to increase accessibility to art and cultural activities for older adults are recommended.

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.

Characterization of lipidic plaque materials at calcified atheroma: its association with calcification thickness evaluated by optical coherence tomography and near-infrared spectroscopy imaging

Introduction

The degree of calcification and its thickness have been considered to affect stent expansion, leading to an increases risk of repeat revascularization in patients receiving PCI. Pathophysiologically, accumulation of lipidic materials within vessel wall could trigger the formation of plaque calcification. Elucidating characteristics of lipidic plaque components at calcified atheroma may enable to identify phenotypes with thick calcification which less likely responds to PCI.

Purpose

This study investigated the relationship of calcification thickness with lipidic plaque materials at calcified atheroma by using OCT and near-infrared spectroscopy (NIRS) imaging.

Methods

We analyzed 52 calcified lesions (culprit/non culprit lesions=44/8) in 47 CAD patients (stable CAD/ACS=36/11) from the REASSURE-NIRS registry (NCT04864171). OCT and NIRS imaging evaluated 4-mm segment exhibiting maximum superficial calcification arc. Calcification thickness on OCT imaging, its arc on IVUS imaging, and NIRS-derived lipid arc were analyzed at every 1-mm interval cross-sectional images. In addition, yellow-calcification ratio (YCR = lipid arc/calcification arc) was calculated (Figure 1).

Results

53% of study subjects exhibited chronic kidney disease and 70% of them received a statin (averaged on-treatment LDL-C =89mg/dL). Throughout OCT and NIRS/IVUS imaging analysis of 260 cross-sectional images, the averaged calcification arc, its maximum thickness, lipid arc and YCR were 210° (167–285°), 0.78mm (0.62–0.95mm), 95° (31–169°) and 0.33 (0.09–0.59), respectively. As expected, thicker calcification more likely exhibited a greater calcification arc (r=0.30, p&lt;0.001). Furthermore, a greater thickness of calcification was associated with smaller lipidic plaque burden, reflected by yellow arc (r=−0.36, p&lt;0.001) and YCR (r=−0.36, p&lt;0.001) (Figure 2). After adjusting age, gender and ACS, calcification arc (p&lt;0.001) and YCR (p&lt;0.001) continued to predict thicker calcification.

Conclusion

Thickening of calcification was associated with severer calcification arc, which was accompanied by the shrinkage of lipidic plaques. Our findings suggest the evaluation of lipidic plaque component as a potential tool to identify calcified atheroma harbouring thick calcification, which may cause a greater risk of stent underexpansion.

Funding Acknowledgement

Type of funding sources: None.

The effect of achieving LDL-C &lt;1.8 mmol/L to prevent the first atherosclerotic cardiovascular events in the primary prevention settings of severe heterozygous familial hypercholesterolemia

Introduction

The International Atherosclerosis Society (IAS) has proposed “severe familial hypercholesterolemia” (FH) as a phenotype with the highest cardiovascular risk. LDL-C &lt;2.5 mmol/l is a recommended therapeutic goal for the primary prevention settings of severe FH. However, given that ESC guidelines recommends LDL-C &lt;1.8 mmol/l in FH patients, this stricter goal may be better to prevent the first atherosclerotic cardiovascular disease (ASCVD) in severe FH patients.

Purpose

To determine whether achieving LDL-C&lt;1.8 mg/dl is more beneficial to reduce the first ASCVD events.

Methods

A total of 148 severe FH subjects without any history of ASCVD were analyzed. Severe FH was defined as untreated LDL-C &gt;10.3 mmol/l, LDL-C &gt;8.0 mmol/l+ 1 high-risk feature, LDL-C &gt;4.9 mmol/l + 2 high-risk features according to IAS proposed statement. The occurrence of ASCVD (all-cause death, CAD, ischemic stroke and lower extremity artery disease (LEAD)) were compared in those with on-treatment LDL-C &lt; and ≥1.8 mmol/L.

Results

10.1% (=15/148) of study subjects achieved on-treatment LDL-C &lt;1.8 mmol/l. They were more likely to receive PCSK9 inhibitor (15.0 vs. 66.7%, p&lt;0.01), whereas there was no significant difference in FH-related physical characteristics (tendon xanthomas: 72.2 vs. 93.3%, p=0.12) and causative genotypes (LDLR: 68.4 vs. 66.7%, p=1.00, PCSK9: 8.3 vs. 6.7%, p=1.00, LDLR/PCSK9: 3.8 vs. 6.7%, p=0.48), untreated LDL-C (7.3±1.7 vs. 7.9±1.8 mmol/l, p=0.22) and lipoprotein(a) (23 [11–42] vs. 25 [15–70] mg/dl, p=0.41) levels between two groups. During the observational period (median=7.0 years), severe FH achieving on-treatment LDL-C &lt;1.8 mmol/l was associated with a lower likelihood of experiencing ASCVD events (Figure 1). Of note, any cardiovascular events did not occur in severe FH who achieved on-treatment LDL-C &lt;1.8 mmol/l. In those with on-treatment LDL ≥1.8 mmol/L, CAD (76.5%=26/34) was more dominant component of ASCVD, followed by ischemic stroke (17.6%=6/34) and LEAD (5.9%=2/34).

Conclusions

A significantly lower frequency of ASCVD was observed in severe FH who achieved LDL-C &lt;1.8 mmol/L in the primary prevention settings. Given that only 10.1% of severe FH patients achieved LDL-C &lt;1.8 mmol/l, more actions are required to motivate physicians for further intensified management of LDL-C in severe FH patients in the primary prevention settings.

Funding Acknowledgement

Type of funding sources: None.

Deterioration of cardiogenic shock after acute myocardial infarction defined by the society for cardiovascular angiography and intervention cardiogenic shock classification scheme

Background

Cardiogenic shock (CS) in patients with AMI presents worse cardiovascular outcomes, which suggests the need for better risk stratification and management. The Society for Cardiovascular Angiography and Intervention (SCAI) has recently proposed CS classification scheme, which stratifies CS into 5 groups according to hypotension and hypoperfusion. While stage A and B exhibits CS without hypotension and/or hypoperfusion, their clinical condition could rapidly deteriorate into stage C-E. However, clinical characteristics and in-hospital outcomes of CS exhibiting its deterioration remains uncertain.

Purpose

To characterize AMI patients who deteriorated their CS status from stage A and B into stage C-E.

Methods

This single-center observational study included 326 consecutive AMI patients receiving primary PCI who presented CS stage A and B on arrival (2019.09.01–2021.09.30). Deterioration of CS (D-CS) was defined as the progression from stage A and B on arrival to stage C-E after primary PCI. Clinical characteristics and outcomes were compared in those with and without D-CS.

Results

D-CS was identified in 16.0% of entire subjects (=52/326). Of these, 94.2 and 5.8% of them exhibited stage C and E, respectively (Figure). Patients with D-CS more likely presented STEMI (84.6 vs. 67.9%, p=0.01) with a lower systolic BP (sBP) level (130±31 vs. 148±26mmHg, p&lt;0.001) and a reduced LVEF (43±13 vs. 51±9%, p&lt;0.001), whereas there was no significant difference in lactate level (1.5±0.4 vs. 1.2±0.3 mmol/L, p=0.22). Pre-TIMI flow grade 0–1 (69.2 vs. 47.8%, p=0.006), left main trunk stenosis (9.6 vs. 1.5%, p=0.007) and chronic total occlusion (21.2 vs. 8.4%, p=0.01) were more frequently observed in those with D-CS. Despite achieving a shorter onset-to-reperfusion time (199 vs. 276 minutes, p=0.002), D-CS was associated with in-hospital all-cause mortality after adjusting clinical characteristics (HR=33.6, 95% CI: 2.2–502.0, p=0.01). Furthermore, mechanical circulatory support (MCS) (30.8 vs. 0%, p&lt;0.001) was more frequently required in patients with D-CS (IABP: 28.8 vs. 0%, p&lt;0.001, ECMO: 11.5 vs. 0%, p&lt;0.001, Impella: 3.8 vs. 0%, p=0.02). Further analysis identified sBP (HR=0.98, 95% CI: 0.97–1.00, p=0.008), LVEF (HR=0.94, 95% CI: 0.90–0.97, p&lt;0.001) and pre-TIMI flow grade 0–1 (HR=0.41, 95% CI: 0.19–0.86, p=0.01) as independent contributors to D-CS. ROC analysis demonstrated sBP &lt;135 mmHg (AUC=0.65) and LVEF &lt;50% (AUC=0.69) as best cut-off values to predict D-CS. Of note, a risk of D-CS increased in association with the number of these three factors (p&lt;0.001), and 44.0% of those with all of these factors presented D-CS (Figure).

Conclusion

16.0% of AMI without any hypotension/hypoperfusion on arrival exhibited deterioration of CS status on SCAI classification. The combination of sBP, LVEF and pre-TIMI flow grade could help to identify AMI subjects with a risk of D-CS, who may benefit from early adoption of intensified management including MCS prior to PCI.

Funding Acknowledgement

Type of funding sources: None.

Early vascular responses to abluminal biodegradable polymer-coated versus circumferential durable polymer-coated newer-generation drug-eluting stents in humans: a pathologic study

Background

Recent clinical trials are testing strategies for short (1–3 months) dual antiplatelet therapy (DAPT) following newer-generation drug-eluting stent (DES) placement. However, the safety of short DAPT regimens is not supported by biological evidence in humans.

Purpose

We sought to evaluate early pathologic responses to newer-generation DES by comparing abluminal biodegradable polymer-coated DES (BP-DES) with circumferential durable polymer-coated DES (DP-DES) in human autopsy cases.

Methods

The study included a total of 37 coronary lesions with thin strut newer-generation DES (DP-DES=23 [XIENCE=18, Resolute Integrity=5] and BP-DES=14 [SYNERGY=9, Ultimaster=5]) with duration of implantation &lt;90 days in 25 autopsy cases. The process of stent healing was precisely evaluated for every single strut in association with underlying tissue characteristics. The degree of strut coverage was defined as follows: grade 0 (bare struts), grade 1 (struts covered with thrombus, fibrin, or other tissues or cells without endothelium), grade 2 (struts covered with single-layered endothelium without underlying smooth muscle cell layers), and grade 3 (struts covered with endothelium and underlying smooth muscle cell layers) (Figure 1).

Results

Duration of implantation was similar in lesions with DP-DES and those with BP-DES (median=20 vs. 17 days). A total of 1986 struts (DP-DES=1261, BP-DES=725) were pathologically analyzed. Focal grade 2 coverage was observed as early as 5 days after the implantation in both stents. Multilevel mixed-effects ordered logistic regression model demonstrated that BP-DES exhibited greater strut coverage compared with DP-DES (odds ratio; 3.50, 95% CI; 1.31–9.41, P=0.013), which remained significant after adjustment for duration of implantation and underlying tissue characteristics (odds ratio; 2.64, 95% CI; 1.04–6.68, P=0.040). The time course of vessel healing assessed as predictive probability of strut coverage (grade 0–3) stratified by duration of implantation is shown in Figure 2. Predictive probability of grade 2 and 3 coverage was comparably limited at 30 days (DP-DES=17.7% vs. BP-DES=29.0%) and increased at 90 days (DP-DES=76.1% vs. BP-DES=85.9%). Both stents showed few inflammation and similar degree of fibrin deposition.

Conclusions

The current first pathologic study on early biological responses to newer-generation DES in humans demonstrated that single-layered endothelial coverage begins in days following the stent placement, and abluminal BP-DES potentially exhibit faster strut coverage with smooth muscle cell infiltration than circumferential DP-DES. Nevertheless, vessel healing remains suboptimal at 30 days in both DP- and BP-DES, which progresses with time to become substantial at 90 days. Our results suggest that very short duration of DAPT for 1 month should be applied with caution, taking into account the trade-off between bleeding and thrombotic risks.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant-in-Aid for Scientific Research (C) from the Japan Society for the Promotion of Science

Effects of prior osteoporosis treatment on the treatment response of romosozumab followed by denosumab in patients with postmenopausal osteoporosis

In patients with postmenopausal osteoporosis, prior osteoporosis treatment affected the bone mineral density increase of following treatment with 12 months of romosozumab, although it did not affect that of following treatment with 12 months of denosumab after romosozumab.

PURPOSE

To investigate the effects of prior osteoporosis treatment on the response to treatment with romosozumab (ROMO) followed by denosumab (DMAb) in patients with postmenopausal osteoporosis.

METHODS

In this prospective, observational, multicenter study, treatment-naïve patients (Naïve; n = 55) or patients previously treated with bisphosphonates (BP; n = 37), DMAb (DMAb; n = 45) or teriparatide (TPTD; n = 17) (mean age, 74.6 years; T-scores of the lumbar spine [LS] - 3.2 and total hip [TH] - 2.6) were switched to ROMO for 12 months, followed by DMAb for 12 months. Bone mineral density (BMD) and serum bone turnover markers were evaluated for 24 months.

RESULTS

A BMD increase was observed at 12 and 24 months in the following patients: Naïve (18.2% and 22.0%), BP (10.2% and 12.1%), DMAb (6.6% and 9.7%), and TPTD (10.8% and 15.0%) (P < 0.001 between the groups at both 12 and 24 months) in LS and Naïve (5.5% and 8.3%), BP (2.9% and 4.1%), DMAb (0.6% and 2.2%), and TPTD (4.3% and 5.4%) (P < 0.01 between the groups at 12 months and P < 0.001 at 24 months) in TH, respectively. The BMD increase in LS from 12 to 24 months was negatively associated with the levels of bone resorption marker at 24 months. Incidences of major fragility fractures for the respective groups were as follows: Naïve (5.5%), BP (16.2%), DMAb (11.1%), and TPTD (5.9%).

CONCLUSIONS

Previous treatment affected the BMD increase of following treatment with ROMO, although it did not affect that of following treatment with DMAb after ROMO.

Interobserver Reliability on Intravoxel Incoherent Motion Imaging in Patients with Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Noninvasive perfusion-weighted imaging with short scanning time could be advantageous in order to determine presumed penumbral regions and subsequent treatment strategy for acute ischemic stroke (AIS). Our aim was to evaluate interobserver agreement and the clinical utility of intravoxel incoherent motion MR imaging in patients with acute ischemic stroke.

MATERIALS AND METHODS

We retrospectively studied 29 patients with AIS (17 men, 12 women; mean age, 75.2 [SD, 12.0 ] years; median, 77 years). Each patient underwent intravoxel incoherent motion MR imaging using a 1.5T MR imaging scanner. Diffusion-sensitizing gradients were applied sequentially in the x, y, and z directions with 6 different b-values (0, 50, 100, 150, 200, and 1000 seconds/mm²). From the intravoxel incoherent motion MR imaging data, diffusion coefficient, perfusion fraction, and pseudodiffusion coefficient maps were obtained using a 2-step fitting algorithm based on the Levenberg-Marquardt method. The presence of decreases in the intravoxel incoherent motion perfusion fraction and pseudodiffusion coefficient values compared with the contralateral normal-appearing brain was graded on a 2-point scale by 2 independent neuroradiologists. Interobserver agreement on the rating scale was evaluated using the κ statistic. Clinical characteristics of patients with a nondecreased intravoxel incoherent motion perfusion fraction and/or pseudodiffusion coefficient rated by the 2 observers were also assessed.

RESULTS

Interobserver agreement was shown for the intravoxel incoherent motion perfusion fraction (κ = 0.854) and pseudodiffusion coefficient (κ = 0.789) maps, which indicated almost perfect and substantial agreement, respectively. Patients with a nondecreased intravoxel incoherent motion perfusion fraction tended to show recanalization of the occluded intracranial arteries more frequently than patients with a decreased intravoxel incoherent motion perfusion fraction.

CONCLUSIONS

Intravoxel incoherent motion MR imaging could be performed in < 1 minute in addition to routine DWI. Intravoxel incoherent motion parameters noninvasively provide feasible, qualitative perfusion-related information for assessing patients with acute ischemic stroke.

Evaluation of patients with oral squamous cell carcinoma treated by radical irradiation with mold radiotherapy using a customized device: a retrospective clinical study

Background

It is very important to determine the indication of mold radiotherapy for the radical treatment of oral cancer. We investigated eight patients with oral squamous cell carcinoma who were treated by radical irradiation with mold radiotherapy using a customized device.

Methods

The subject is a case of curable superficial oral cancer of a few millimeters, or cancer of a size that can be cured by the placement of the radiation source. Of the eight patients, six were male and two were female, aged 64–93 years (mean, 78.9 years; median, 73.5 years). The primary sites were the buccal mucosa in three cases, gingiva in two cases, and floor of the mouth, soft palate, and lower lip in one case each. Five cases were in the T1 stage, and the remaining three cases were in T2. With respect to thickness, seven cases were of the superficial type and could not be detected by magnetic resonance imaging or computed tomography, and the remaining case showed a tumor thickness of 7.5 mm. All cases were diagnosed as squamous cell carcinoma by biopsy. Radical irradiation using mold radiotherapy was planned for all eight patients. Irradiation was delivered in 9–10 sessions, with a total dose of 45–50 Gy.

Results

Complete response was attained in six of the eight patients and partial response was observed in two patients, requiring additional treatment.

Conclusion

Since all patients with complete response had superficial cancers, we hypothesized that superficial cancers of the oral cavity with thicknesses of few millimeters could be indicated for mold irradiation. This method can be applied in complicated cases and older patients in whom surgery or chemotherapy may not be feasible. We believe that the results of our clinical studies will be of great help in choosing this method.

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.

Substantially elevated thromboembolic and bleeding risks in patients with AMI following acute/subacute stroke events

Introduction

AMI infrequently but concomitantly occurs after stroke events. Current guideline recommends primary PCI with DAPT in the setting of AMI. However, this approach is not necessarily applicable in AMI subjects following acute/subacute stroke events due to its bleeding risk. Clinical management and outcomes of these AMI subjects following remains uncertain.

Purpose

To characterize management and clinical outcomes in patients with AMI following acute/subacute stroke events (=post-stroke AMI).

Methods

The current study retrospectively analyzed 2041 AMI patients hospitalized at our institute from 2007 to 2018. Post-stroke AMI was defined as its occurrence within 14 days after ischemic/hemorrhagic stroke. The use of reperfusion and anti-thrombotic therapies, and the occurrence of major adverse cardiovascular events (=CV death, non-fatal MI and non-fatal stroke) and major bleeding events (BARC type 3 or 5) were compared in post-stroke and non-post-stroke AMI patients.

Results

Post-stroke AMI was identified in 1.1% of entire subjects (=23/2041). Of these, 65% of them (=15/23) had AMI within 3 days from the onset of stoke event. Over 60% of them was due to cardioembolic stroke, followed by hemorrhagic (9%), atherothrombotic ones (8%) and other causes (22%). Post-stroke AMI patients were more likely to exhibit Af (p=0.02) and a history of hemodialysis (p=0.009), and have a lower BMI (p=0.04) and hemoglobin level (p=0.02). They were less likely to receive emergent coronary angiography, and primary PCI was conducted in only 65% of post-stroke AMI patients (Table). Furthermore, they more frequently received thrombectomy (p=0.04) alone rather than stent implantation (p=0.002) (Table). With regard to anti-thrombotic therapy, the proportion of DAPT use was significantly lower in post-stroke AMI subjects (52 vs. 89%, p=0.0001), and 17% of them did not receive any anti-thrombotic agents. Of note, only 48% (p=0.04) and 43% (p=0.0001) of post-stroke AMI patients were treated with other established medical therapies including β-blocker and statin, respectively. During the observational period (median = 2.9 years), post-stroke AMI was associated with a greater likelihood experiencing major adverse cardiovascular events (log-rank p&lt;0.001, Figure), CV death (log-rank p&lt;0.0001) and stroke events (log-rank p&lt;0.0001). Furthermore, the frequency of their major bleeding events was substantially elevated (log-rank p&lt;0.001, Figure).

Conclusions

In our real-world data, the adoption of guideline-recommended reperfusion and anti-thrombotic therapies were considerably low in AMI subjects following acute/subacute stroke events. Given their elevated risk of cardiovascular and bleeding events, it is required to establish better therapeutic management for mitigating their thrombotic/bleeding risks.

Funding Acknowledgement

Type of funding sources: None. Table 1Figure 1

The relationship of the underlying lipidic plaque at the implanted newer-generation drug-eluting stents with future stent-related events: insights from the REASSURE-NIRS registry

Background

Lipid-rich plaque is an important substrate causing acute coronary events. Near-infrared spectroscopy (NIRS) imaging has been shown to visualize lipidic coronary plaque at non-culprit site associated with future coronary events. Given that histopathological studies reported that the unstable plaque underlying the implanted drug-eluting stent (DES) could cause neoatherosclerosis formation, we hypothesized that NIRS-based evaluation of lipidic plaque burden behind the implanted DES may clinically predict the occurrence of stent failure in patients with CAD receiving PCI.

Purpose

We aimed to investigate the relationship of stent-related events' risk with lipidic plaque materials behind the implanted DES imaged by NIRS/intravascular ultrasound (NIRS/IVUS) imaging.

Methods

The REASSURE-NIRS registry is an on-going multi-center registry to enroll CAD subjects receiving NIRS/IVUS-guided PCI. In this registry data, 406 lesions in 379 CAD subjects (ACS/non-ACS=150/229) receiving new-generation DES were analyzed. Minimum stent area (MSA) after PCI and maximum lipid-core-burden index in any 4mm-segment within the implanted stents (in-stent maxLCBI4mm) were measured. A 3-year lesion-oriented composite outcome [LOCO: culprit lesion-related MI + ischemia-driven target lesion revascularization (ID-TLR)] was compared in subjects stratified according to the tertile of in-stent maxLCBI4mm.

Results

The mean value of in-stent maxLCBI4mm was 221, and 17% of lesions exhibited in-stent maxLCBI4mm &gt;400. Patients with a greater in-stent maxLCBI4mm were more likely to exhibit a higher LDL-C level (p=0.026) with a longer stent length (p&lt;0.001) and a smaller MSA (p=0.033) (Picture 1). Over 95% of entire study subjects received a statin. During the observational period (median=726 days), the frequency of LOCO up to 3 years was 3.4% in entire study subjects (culprit lesion-related MI=1.0%, ID-TLR=2.8%). Kaplan-Meier curve analysis demonstrated that the occurrence of LOCO did not increase in association with in-stent maxLCBI4mm (log-rank p-value=0.25, Picture 2). In addition, in-stent maxLCBI4mm did not associate with each component of LOCO (culprit lesion-related MI: p=0.502, ID-TLR: p=0.872). Receiver Operating Characteristic analysis revealed that the predictive ability of in-stent maxLCBI4mm for the occurrence of LOCO was unsatisfactorily (c-statistics=0.486).

Conclusion

The amount of underlying lipidic materials at culprit lesions receiving new-generation DES implantation did not necessarily predict future stent-related events. Clinical significance of maxLCBI4mm behind the implanted DES may be different from that at naïve non-culprit plaques.

Funding Acknowledgement

Type of funding sources: None. Background and lesion characteristicsKaplan-Meier analysis for LOCO

Characterization of cholesterol efflux capacity in diabetic and non-diabetic patients with coronary artery disease: comparison between acute coronary syndrome and stable coronary artery disease

Introduction

Type 2 diabetic patients more likely exhibit a lower high-density lipoprotein (HDL) level. Given a greater glycation and oxidative stress in diabetic subjects, these atherogenic characteristics could cause dysfunctional HDL including a reduced cholesterol efflux capacity (CEC), which may account for an increased risk of diabetic macrovascular disease including acute coronary syndrome (ACS). However, it remains to be fully elucidated characteristics of HDL-mediated CEC in type 2 diabetic patients, in association with clinical presentation of coronary artery disease (CAD).

Purpose

To characterize CEC in CAD subjects with type 2 diabetes mellitus.

Methods

The current study prospectively analyzed 87 statin-naive patients with CAD. CEC was measured by using the collected apolipoprotein B-depleted serum. Liquid scintillation counting (Perkin-Elmer Analytical Sciences, MA, US) was used to quantify the efflux of radioactive cholesterol from J774 cells. Clinical characteristics and CEC were compared in diabetic and non-diabetic subjects.

Results

The averaged HbA1c in diabetic patients was 6.7±1.2, and 66.7% of them achieved HbA1c &lt;7.0%. Diabetic subjects more likely exhibited a history of hypertension and dyslipidemia, and multi-vessel disease (Table). Moreover, a lower CEC level was observed in diabetic patients, accompanied by a lower HDL-C and apolipoprotein A-I levels with a higher level of triglyceride (Table). HDL-C (r=0.62, p-value&lt;0.01) and Apolipoprotein A-I (r=0.70, p-value &lt;0.01) were associated with CEC, whereas there was no significant difference in CEC between subjects with HbA1c &lt;7.0% vs. ≥7.0% (0.74±0.07 vs. 0.78±0.08, p=0.22). On multivariate analysis, type 2 diabetes mellitus was an independent contributor to CEC &lt;0.79 (median) (HR=2.75, 95% CI: 1.11–6.82, p=0.03). Interestingly in particular, CEC was substantially lower in diabetic patients with ACS compared to those with stable CAD (Figure). By contrast, clinical presentation of CAD did not affect CEC in non-diabetic subjects (Figure).

Conclusions

A lower CEC level was observed in subjects with type 2 diabetes mellitus. In particular, this HDL functionality was profoundly diminished in those presenting ACS. Our findings suggest functionality of HDL as a potential therapeutic target in diabetic patients experiencing ACS.

Funding Acknowledgement

Type of funding sources: None. Table 1Figure 1

Comparison of coronary atherosclerotic features in response to achieving LDL-C &lt;55 mg/dl between non-diabetic and diabetic patients: insights from the REASSURE-NIRS registry

Introduction

Current ESC guideline recommends achieving LDL-C &lt;1.4 mmol/l in very high-risk subjects. Despite fabvourable anti-atherosclerotic effects of lowering LDL-C, its efficacy is diminished in type 2 diabetic patients. Whether response of coronary atheroma to on-treatment LDL-C &lt;1.4 mmol/l differs in diabetic and non-diabetic subjects has not been elucidated yet.

Methods

The REASSURE-NIRS registry is an on-going multi-center registry to enroll CAD subjects receiving PCI under the guidance of near-infrared spectroscopy/intravascular ultrasound (NIRS/IVUS: DualProTM, Nipro, Tokyo, Japan) imaging. Culprit lesions in 557 CAD patients who already received a statin were evaluated by NIRS/IVUS. Maximum 4-mm-lipid-core burden-index (maxLCBI4mm) and plaque calcification grade at culprit sites were measured. Calcification grade at each 1-mm cross-sectional image was defined as follows: calcium arc 0° = 0, 0–90° = 1, 90–180° = 2, 180–270° = 3, 270–360° = 4. MaxLCBI4mm and the averaged calcification grade were compared in diabetic and non-diabetic subjects stratified according to on-treatment LDL-C level, respectively.

Result

The proportion of diabetic (n=293, HbA1c; 6.9±0.9%) and non-diabetic patients (n=264) with on-treatment LDL-C &lt;1.4 mmol/l was 8.54 and 16.67%, respectivey (p=0.01). In non-diabetic patients, achieving LDL-C &lt;1.4mmol/L was associated with a lower maxLCBI4mm, whereas, in diabetic patients, maxLCBI4mm was numerically smaller under achieving LDL-C &lt;1.4 mmol/l, but this comparison did not meet statistical significance (Figure 1). Furthermore, a greater degree of calcification grade in non-diabetic patients was observed in association with on-treatment LDL-C level (Figure 2). However, plaque calcification at diabetic coronary atheroma was not necessarily induced under achieving stricter LDL-C goal. Subgroup analysis demonstrated that diabetic patients with body mass index ≥25 (odds ratio = 0.15; 95% CI: 0.18–1.19, p=0.04), estimated glomerular filtration rate &lt;60 (mL/min/1.73m2) (odds ratio = 0.31; 95% CI: 0.10–0.90, p=0.03) and non-insulin use (odds ratio = 0.36; 95% CI: 0.14–0.87, p=0.02) benefit from achieving LDL-C &lt;1.4 mmol/l.

Conclusion

Achieving LDL-C &lt;1.4 mmol/l was associated with more stabilized atheroma in non-diabetic patients with CAD, whereas these favourable effects were not observed in diabetic subjects. Our findings suggest the potential need to modify additional atherogenic risks for stabilizing diabetic coronary atheroma under achieving LDL-C &lt;1.4 mmol/l.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Characterization of residual lipid-rich plaques despite achieving LDL-C &lt;1.8mmol/l with a statin in patients with coronary artery disease: insights from the REASSURE-NIRS registry

Introduction

Recent studies have demonstrated favourable modification of lipidic plaque materials under achieving LDL-C &lt;1.8mmol/l with a statin, which potentially accounts for its clinical benefit. However, coronary events still occur even under optimal LDL-C management. This may suggest the presence of residual lipid-rich coronary plaque despite on-treatment LDL-C &lt;1.8mmol/l. Given that near-infrared spectroscopy (NIRS) enables quantitative evaluation of lipidic plaque in vivo, we employed this imaging modality to investigate characteristics and drivers of residual lipid-rich plaques in statin-treated patients with coronary artery disease (CAD) who achieved LDL-C &lt;1.8mmol/l.

Purpose

To clarify the frequency, clinical demographics and factors associated with residual lipid-rich plaques under LDL-C &lt;1.8mmol/l.

Methods

The REASSURE-NIRS registry is an on-going multi-center registry to enroll CAD subjects receiving NIRS/intravascular ultrasound-guided PCI. The current analysis included 133 statin-treated stable CAD patients with on-treatment LDL-C &lt;1.8mmol/l from August 2015 to December 2020. The maximum 4-mm lipid core burden index (maxLCBI4mm) at culprit lesions was measured by NIRS imaging prior to PCI. Clinical characteristics were compared in patients with and without maxLCBI4mm ≥400 at culprit lesions.

Results

In the current study, 45% (=58/128) of study subjects exhibited maxLCBI4mm ≥400 at culprit lesions under on-treatment LDL-C &lt;1.8 mmol/l. They were more likely to be female, whereas there were no differences in age and the frequency of risk factors. Most of study subjects received moderate to high-intensity statin (p=0.79), and over one-fourth of them were treated with ezetimibe (p=0.56). Under these lipid-lowering therapies, LDL-C level was significantly higher in patients with maxLCBI4mm ≥400 (Table). Additionally, a lower frequency of LDL-C &lt;1.4mmol/l was observed in those exhibiting maxLCBI4mm ≥400 (31.0 vs. 45.7%), but this comparison failed to meet statistical significance (p=0.09). Despite LDL-C control with a statin, deterioration of coronary flow after PCI with stent implantation more frequently occurred in patients with maxLCBI4mm ≥400 (Table). Multivariate analysis demonstrated that an independent factor associated with maxLCBI4mm ≥400 was LDL-C level (OR=1.05; 95% CI=1.00–1.10, p=0.03), but not other lipid and clinical parameters.

Conclusion

Almost half of CAD subjects who achieved LDL-C level &lt;1.8mmol/l still exhibited the accumulation of lipidic plaque materials within vessel wall. Given that LDL-C level was associated with this residual lipid-rich plaque features, our findings support current ESC-guideline recommended LDL-C goal (&lt;1.4mmol/l) to optimize the secondary prevention in stable CAD patients.

Funding Acknowledgement

Type of funding sources: None.

Role of non-face-to-face social contacts in moderating the association between living alone and mental health among community-dwelling older adults: a cross-sectional study

OBJECTIVE

We examined the association between living alone and mental health and the moderating effects of face-to-face and non-face-to-face social contacts, among community-dwelling older adults.

STUDY DESIGN

Cross-sectional study.

METHODS

This cross-sectional study recruited Japanese adults older than 60 years, who attended health check-ups held in a suburban town hall in July and August of 2018 and 2019. As mental health outcomes, depression was assessed using the Geriatric Depression Scale 15-items, loneliness was assessed using the University of California, Los Angeles Loneliness Scale 3-items, and happiness was self-rated on a 10-point scale. Face-to-face social contacts were evaluated by participants' frequency of meetings with relatives or friends, whereas non-face-to-face contacts were measured by the frequency of interactions via letter, telephone or e-mail. Multivariable linear regression analysis was conducted to examine the association between living alone with each mental health outcome and the effect modifications of having face-to-face and non-face-to-face social contacts.

RESULTS

Data from 300 older adults were analysed. The participants' mean age was 73.0 years, 51.3% were female, and 16.0% lived alone. Living alone was significantly associated with poorer mental health. Regarding loneliness and low happiness, having face-to-face and non-face-to-face contacts more than once a week alleviated the adverse association of living alone (loneliness: face-to-face contacts, P = 0.020; non-face-to-face contacts, P = 0.028; happiness: face-to-face contacts, P = 0.020; non-face-to-face contacts, P = 0.001).

CONCLUSIONS

Our findings suggest that non-face-to-face, as well as face-to-face social contacts have a moderating effect on the adverse association of living alone with loneliness and happiness.

General rules for clinical and pathological studies on oral cancer (2nd edition): a synopsis

For doctors and other medical staff treating oral cancer, it is necessary to standardize the basic concepts and rules for oral cancer to achieve progress in its treatment, research, and diagnosis. Oral cancer is an integral part of head and neck cancer and is treated in accordance with the general rules for head and neck cancer. However, detailed rules based on the specific characteristics of oral cancer are essential. The objective of this article was to contribute to the development of the diagnosis, treatment, and research of oral cancer, based on the correct and useful medical information of clinical, surgical, pathological, and imaging findings accumulated from individual patients at various institutions. Our general rules were revised as the UICC was revised for the 8th edition and were published as the Japanese second edition in 2019. In this paper, the English edition of the "Rules" section is primarily presented.

Association between Decreased Social Participation and Depressive Symptom Onset among Community-Dwelling Older Adults: A Longitudinal Study during the COVID-19 Pandemic

OBJECTIVES

The coronavirus disease (COVID-19) pandemic has imposed restrictions on people's social behavior. However, there is limited evidence regarding the relationship between changes in social participation and depressive symptom onset among older adults during the pandemic. We examined the association between changes in social participation and the onset of depressive symptoms among community-dwelling older adults during the COVID-19 pandemic.

DESIGN

This was a longitudinal study.

SETTING

Communities in Minokamo City, a semi-urban area in Japan.

PARTICIPANTS

We recruited community-dwelling older adults aged ≥ 65 years using random sampling. Participants completed a questionnaire survey at baseline (March 2020) and follow-up (October 2020).

MEASUREMENTS

Depressive symptoms were assessed using the Two-Question Screen. Based on their social participation status in March and October 2020, participants were classified into four groups: "continued participation," "decreased participation," "increased participation," and "consistent non-participation."

RESULTS

A total of 597 older adults without depressive symptoms at baseline were analyzed (mean age = 79.8 years; 50.4% females). Depressive symptoms occurred in 20.1% of the participants during the observation period. Multivariable Poisson regression analysis showed that decreased social participation was significantly associated with the onset of the depressive symptoms, compared to continued participation, after adjusting for all covariates (incidence rate ratio = 1.59, 95% confidence interval = 1.01-2.50, p = 0.045).

CONCLUSION

Older adults with decreased social participation during the COVID-19 pandemic demonstrated a high risk of developing depressive symptoms. We recommend that resuming community activities and promoting the participation of older adults, with sufficient consideration for infection prevention, are needed to maintain mental health among older adults.

Lp (a) &gt;50 mg/dl predicts atherosclerotic cardiovascular events in patients with heterozygous familial hypercholesterolemia who achieved LDL-C &lt;2.6 mmol/l

Introduction

Lipoprotein (a) [Lp (a)] is a plasma lipoprotein which exhibits atherogenic properties. Lp(a) ≥50 mg/dl has been recently shown to associate with a risk of atherosclerotic cardiovascular diseases (ASCVD) in patients with heterozygous familial hypercholesterolemia (HeFH). While current guideline recommends lowering LDL-C as a first-line therapeutic approach in HeFH subjects, it remains to be fully determined whether an elevated level of Lp(a) confers additional ASCVD risks in HeFH patients who achieved a lower LDL-C level.

Purpose

To investigate cardiovascular outcomes in HeFH subjects with a lower LDL-C but an elevated Lp(a) levels.

Methods

182 HeFH patients with on-treatment LDL-C &lt;2.6 mmol/l under lipid-lowering therapies were analyzed. Clinical characteristics and MACE (= a composite of all-cause death, ACS, stroke, PAD and coronary revascularization) were compared in HeFH subjects with Lp(a) ≥ vs. &lt;50 mg/dl.

Results

The averaged LDL-C and Lp (a) levels were 1.9 mmol/l and 26.8 mg/dl, respectively. 19.2% of study subjects exhibited Lp(a)≥50 mg/dl. HeFH patients with Lp(a) ≥50 mg/dl were more likely to be older and have a history of hypertension, but these comparisons did not meet statistical significance. There was no significant difference in on-treatment LDL-C, HDL-C and Triglyceride level (Table). However, during the observational period (median=4.7 years), there was a 2.7-fold (95% CI, 1.41–5.02; p=0.004) greater likelihood of experiencing MACE in subjects with Lp(a) ≥50 mg/dl (picture). Even after adjusting clinical demographics, Lp(a) ≥50 mg/dl remained an independent predictor for the occurrence of MACE (hazard ratio=2.53, 95% CI: 1.29–4.82, p&lt;0.001).

Conclusions

Despite achieving on-treatment LDL-C &lt;2.6 mmol/l, an elevated risk of MACE was observed in HeFH patients with Lp(a) ≥50 mg/dl. Our findings suggest an increased level of Lp(a) as a risk stratification marker and a potential therapeutic target in patients with HeFH.

Clinical outcome

Funding Acknowledgement

Type of funding source: None

Effect of eicosapentaenoic acid/docosahexaenoic acid on coronary high-intensity plaques detected with non-contrast T1-weighted imaging: subgroup analysis of the AQUAMARINE EPA/DHA study

Background

In the recent the Reduction of Cardiovascular Events with EPA-Intervention Trial (REDUCE-IT), statin therapy plus high-dose eicosapentaenoic acid (EPA) significantly reduced the risk of cardiovascular death in patients with coronary artery disease (CAD) with elevated triglyceride (TG) levels. An epidemiologic study has shown that increasing the intake of long-chain n-3 polyunsaturated fatty acids, especially EPA and docosahexaenoic acid (DHA), are associated with a lower risk of fatal CAD. However, the anti-atherosclerotic effect of high-dose EPA/DHA has not be clarified.

We reported that coronary high-intensity plaques (HIPs) detected with non-contrast T1-weighted imaging (T1WI) on cardiac magnetic resonance (CMR), which can be uniquely quantitative assessed using the plaque-to-myocardium signal intensity ratio (PMR) of ≥1.4, are significantly associated with future coronary events. Moreover, we demonstrated that intensive statin therapy reduces the PMR of coronary HIPs by 19% but is unlikely to completely resolve HIP (PMR&lt;1.0).

In the AQUAMARINE EPA/DHA study, our goal was to assess the anti-atherogenic effect of EPA/DHA in an exploratory manner by examining the change in PMR of coronary HIPs after 12 months of EPA/DHA therapy in patients with CAD on statin therapy.

Methods

This study was designed as a single-center, triple-arm, parallel-group, randomized controlled, open-label, superiority trial examining the effect of 12 months of additional EPA/DHA therapy on coronary HIPs in patients with CAD who receiving statin therapy. Eligible subjects are randomly assigned to the 2 g/day EPA/DHA group (n=26), the 4 g/day group (n=23), or the no EPA/DHA (statin-only) group (n=24) between May 2014 and December 2017. The PMR was defined as the signal intensity of the coronary plaque divided by that of nearby left ventricular myocardium. The primary endpoint is the change in PMR after EPA/DHA treatment.

Results

These 3 groups were well matched at baseline, with no statistically significant differences in age, male sex, conventional coronary risk factors, TG level, medications, and PMR. Figure 1 shows subgroup analysis of patients with high triglyceride levels (&gt;150mg/dl). In the patient-based analysis (A), 12 months of EPA/DHA therapy significantly reduced the PMR of primary lesions. In the segment-based analysis (B), additional reduction of PMR was observed in the high-dose EPA/DHA group compared with the no EPA/DHA treatment group.

Discussion

The present study of patients with high triglyceride levels demonstrated that EPA/DHA had a dose-dependent anti-atherosclerotic effect. This finding may provide additional information of EPA/DHA for lowering the residual risk in patients with CAD on statin therapy.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Takeda Pharmaceutical Co., Ltd.

Characterization of thromboembolic and bleeding risks in cancer patients with acute myocardial infarction under the use of guideline-recommended dual-antiplatelet therapy

Background

Atherosclerotic cardiovascular disease including acute myocardial infarction (AMI) has become one of major co-existing diseases in cancer patients due to their improved survival rate. Current guideline recommends dual-antiplatelet therapy (DAPT) in patients with AMI. Given that the presence of cancer elevates not only coagulability but bleeding risks, these substrate may further worsen cardiovascular outcomes and bleeding risks in cancer subjects with AMI receiving DAPT.

Methods

We retrospectively analyzed 712 AMI patients treated by primary PCI with drug-eluting stent and DAPT between 2007 and 2017. The diagnosis of cancer was determined through medical record review. Clinical characteristics, thromboembolic (=all-cause death+non-fatal MI+stroke) and bleeding events were compared in AMI subjects with vs. without cancer.

Results

Cancer was identified in 11.1% (=79/712) of study subjects. Of these, around 40% of them had gastrointestinal cancer (=35/79), followed by lung cancer (=5/79) and breast cancer (=8/79). Cancer patients were more likely to be older (77±7 v. 69±13 years, p&lt;0.001) with a history of Af (25 v. 10%, p&lt;0.001), CKD (eGFR&lt;60: 60 v. 42%, p=0.002), anemia (hemoglobin: 12.8±1.8 v. 13.9±1.8 g/dl, p&lt;0.001). Under anti-thrombotic (DAPT=86%, triple-antiplatelet therapy=14%) and optimal medical therapies (ACE-I=90%, beta-blocker=76%, statin=96%), more frequent occurrence of thromboembolic events was observed in patients with cancer (34.2 v. 12.6%, p=0.004, Picture). Furthermore, the presence of cancer was associated with more than four times greater risk of bleeding events compared to non-cancer subjects (18.9 v. 4.3%, p&lt;0.001, Picture). In particular, the frequency of both major (10.1 vs. 3.3%, p=0.003) and minor (8.9 vs. 0.9%, p&lt;0.001) bleeding events was significantly higher in patients with cancer. In multivariate analysis, cancer independently predicted bleeding events (Table).

Conclusions

Under the use of guideline recommended DAPT, the concomitance of cancer in AMI subjects was a predictor for thromboembolic as well as bleeding events. In particular, the relationship between cancer and bleeding was significant. These observations underscore the appropriate selection and duration of anti-thrombotic agents in AMI subjects with cancer.

Cardiac/Bleeding Events in AMI Subjects

Funding Acknowledgement

Type of funding source: None

Prevalence, clinical characteristics and prognosis of intracranial artery atherosclerosis in heterozygous familial hypercholesterolemia: insights from magnetic resonance angiography imaging analysis

Introduction

Heterozygous familial hypercholesterolemia (HeFH) exhibits substantially atherogenic substrate which involves coronary and peripheral arteries. Whether atherosclerosis in HeFH propagates to intracranial arteries causing stroke remains to be determined.

Purpose

To characterize intracranial artery stenosis (IAS) in subjects with HeFH.

Methods

148 HeFH subjects who underwent MRI/MRA imaging to evaluate intracranial arteries were analyzed. IAS was defined as the presence of stenosis with its % diameter stenosis ≥25%. Clinical demographics and cardiovascular events (all-cause death, ACS, stroke and PAD) were compared in those with and without IAS.

Results

IAS was observed in 24.3% (=36/148) of study subjects. It was more frequently located at middle cerebral artery (30.6%=11/36), followed by internal carotid artery (25.0%=9/36). 47.2% of IAS exhibited % diameter stenosis ≥75%. Furthermore, 58.3% of HeFH patients with IAS exhibited concomitance of CAD, PAD or carotid stenosis. They were more likely to be older (Table). While there was no significant difference in LDL-C level, an elevated triglyceride level was observed in those with IAS (Table). Of note, during the observational period (median=14.1 years), IAS was associated with a greater likelihood of experiencing not only stroke but other cardiovascular events (all-cause death + ACS + PAD) (picture). Multivariate analysis demonstrated triglyceride level ≥1.7mmol/l as an independent predictor of IAS in HeFH patients (HR=5.53, 95% CI: 1.85–16.5, p=0.002).

Conclusions

Around one-fourth of HeFH patients harboured IAS, which was associated with concomitance of atherosclerosis in other vascular beds and the occurrence of stroke and other cardiovascular events. Given the relationship of IAS with hypertriglyceridemia, this lipid feature may be an important contributor to atherosclerotic formation which involves intracranial artery in HeFH patients.

Clinical outcome

Funding Acknowledgement

Type of funding source: None

Characterization of plaque features exhibiting physiological mismatch between fractional flow reserve and resting index: near-infrared spectroscopy imaging analysis

Background

In addition to fractional flow reserve (FFR), resting indexes (RI) have been shown as another physiological measure to evaluate myocardial ischemia. Despite the clinical usefulness of RI without the use of intravenous vasodilatory agent, discrepancy between FFR and RI infrequently occurs. Whether this physiological mismatch is derived by specific plaque feature remains unknown.

Purpose

To characterize coronary plaques associated with coronary physiological mismatch.

Methods

We analyzed 59 coronary arteries (LAD/RCA/LCX=49/4/6) with FFR≤0.80 in 57 stable CAD subjects receiving PCI. Following measurement of FFR and RI, culprit lesion was evaluated by near-infrared spectroscopy and intravascular ultrasound (NIRS/IVUS). The analyzed vessels were stratified according to FFR and RI values: FFR≤0.75+RI&gt;0.89 (n=6: physiological mismatch), FFR&gt;0.75+RI&gt;0.89 (n=6), FFR≤0.75+RI≤0.89 (n=33) and FFR&gt;0.75+RI≤0.89 (n=14).

Results

The median values of percent diameter stenosis, FFR and RI were 51%, 0.75 and 0.87, respectively. Physiological mismatch was observed in 10.1% (=6/59) of analyzed vessels. On IVUS imaging, maximum percent plaque area was greater than 70% in all groups (p=0.29). Furthermore, there were no significant differences in angiographic and IVUS-derived minimum lumen area across 4 groups (Table). However, culprit lesions exhibiting physiological mismatch contained a substantially larger amount of lipid plaque, reflected by a higher maximum 4-mm lipid-core burned index (maxLCBI4mm: p=0.04) on NIRS imaging (Table). Multivariate analysis demonstrated maxLCBI4mm as the only plaque feature associated with physiological mismatch (odds ratio=1.010, 95% CI: 1.001–1.019, p=0.02).

Conclusion

Plaque feature associated with coronary physiological mismatch was the extent of lipidic materials but not the quantity of coronary atheroma. Since the accumulation of lipidic plaque component is caused by endothelial dysfunction, this vascular substrate could impair baseline vasomotion, thereby causing a lower FFR despite preserved RI value. Evaluation of lipidic burden may be a potential option to avoid unnecessary deferral of revascularization in subjects with normal RI value.

maxLCBI4mm in each group

Funding Acknowledgement

Type of funding source: None

AB0840 INFLUENCE OF PSORIATIC ARTHRITIS (PsA) ON BONE LOSS AND ANALYSIS BETWEEN AXIAL AND PERIPHERAL PsA IN JAPANESE PATIENTS

Background:

Osteoporosis is one of the major comorbidities in patients with psoriasis and psoriatic arthritis (PsA). It has been reported that PsA induces fragility bone structure1and high risk of osteoporosis2. However, there is no report about relationship between psoriatic arthritis and osteoporosis in Japanese patients and its mechanism has not been elucidated.

Objectives:

The objective of this study is to investigate influence of PsA on bone mineral density (BMD) and its mechanism including analysis between axial and peripheral PsA in Japanese patients.

Methods:

This study was retrospective study. We examined 58 cases of PsA and 29 cases of RA that underwent DXA tests at our facility from January 2017 to July 2019 (Table 1). The axial PsA was classified as axial SpA using the ASAS classification criteria. First, we investigated influence of PsA containing both axial (n=30,19 males, 11 females, mean age: 50.6 years) and peripheral (n=28, 19 males, 9 females, mean age: 58.0 years) subtypes on BMD measured by dual-energy X-ray absorptiometry. Second, we measured serum bone metabolism markers (P1NP: type I procollagen-N-propeptide, TRACP-5b: tartrate-resistant acid phosphatase 5b) and bone remodeling effector molecules (Dkk1: Dickkopf1, sclerostin, 25(OH)D: 25-hydroxyvitamin D) to elucidate differences in BMD between axial and peripheral PsA. Furthermore, rheumatoid arthritis (RA) (n=29, 2 males, 27 females, mean age: 66.2 years), as a reference disease, was also evaluated for comparison with axial and peripheral PsA.

Osteoporosis and Osteopenia were defined as T-score ≤ -2.5 or %YAM ≤70%., -1.0< T-score >-2.5 or 80>%YAM >70% respectively.

Results:

58 patients with PsA indicated low T-score, Z-score and %YAM in both lumbar spine and proximal femur (Table 1). Axial PsA and peripheral PsA showed osteoporosis in 16.7% and 35.7%, and osteopenia in 20.0% and 32.1%, respectively, despite the fact that there were many middle-aged men. Comparison between axial and peripheral PsA, axial PsA showed higher BMDthan peripheral PsA. In bone remodeling makers, P1NP in both PsA were almost same, but TRACP-5b, bone resorption marker, in axial PsA was lower than that in peripheral PsA(Table 2). In bone remodeling influencer molecules, Dkk1, and sclerostin in axial PsA was slightly higher than those in peripheral PsA, whereas 25(OH)D is almost same as the both PsA. On the other hand, RA also indicated low T-score and %YAM in both lumbar spine. P1NP in RA showed slightly lower, but TRACP-5b and Homocysteine in RA higher than those in axial and peripheral PsA. Dkk1 and sclerostin in RA were slightly lower than those in both PsA.

Conclusion:

Peripheral PsA indicated more severe bone loss than axial PsA in our study. There were some differences in bone remodeling markers and bone remodeling effector molecules between axial and peripheral PsA, but the relationships between BMD and these parameters were not confirmed. Further studies are needed to elucidate bone loss mechanism in these PsA.

References:

[1]Zhu TY, et al. Osteoporosis Int. 2015; 26:261–272.

[2]Kathuria R, et al. J Am Acad Dermatol. 2017;76:1045-53.

Disclosure of Interests:

Shigeyoshi Tsuji Grant/research support from: Eli Lilly, Speakers bureau: AbbVie, Asahi Kasei, Chugai, Daiichi Sankyo, Eli Lilly, Eisai, Mitsubishi Tanabe, Celgene, and Novartis Pharma K.K., Tetsuya Tomita Consultant of: Eli Lilly and Company, Mari Higashiyama: None declared, Takaaki Noguchi: None declared, Toshikazu Mouri: None declared, Jun Hashimoto Speakers bureau: AbbVie, Asahi Kasei, Chugai, Daiichi Sankyo, Eli Lilly, Eisai, Mitsubishi Tanabe, Celgene, and Novartis Pharma K.K.

Concrete with high-purity volcanic glass fine powder manufactured from pyroclastic deposit

Volcanic deposits, which are pozzolanically reactive, have long been known to improve the durability of concrete. Nevertheless, it has also been pointed out that the use of a natural pozzolan as a supplementary cementitious material (SCM) can pose problems of low workability and slow strength development. Also, in addition, its composition and physical properties have large variety and variability. We have been conducting studies on the total utilization of volcanic deposits for applications suitable for respective properties by classifying them by floating speed difference and particle diameter. It is reported that sorting out particles less than 2.4 g/cm3 by dry gravity classification and removal of smaller clay fraction by dust collector is technically effective to recover high purity volcanic glass from pyroclastic flow deposits called “Ito-Shirasu”, which is a local name for pyroclastic flow deposits in Japan. In this study, concrete containing high-purity volcanic glass powders with different finenesses are investigated regarding fresh properties, strength development, chloride ion penetration and CO2 reduction. As a result, it was found that volcanic glass powders made an excellent contribution to the improvement of flowability comparable to fly ash, the enhancement of strength comparable to silica fume, and the restraint of chloride ion penetration. Volcanic glass powders can also contrbute to the reduction of CO2 emission because the content of Portland cement can be significantly reduced to obtain the same strength compared to concrete with 100% Portland cement. This study provides a possibility to produce high performance SCMs in volcanic regions worldwide from volcanic ejecta by sorting out a high purity volcanic glass by the same method.

P177 Left atrial strain in patients with cardiac amyloidosis. Relationship to left atrial amyloid deposition focusing on prognosis

Background

 In cardiac amyloidosis (CA), the left atrium (LA) is frequently infiltrated by the amyloid fibrils. It is currently known that LA strain is a marker of LA function and prognosis in many cardiac diseases, however its significance in CA remains unknown. 

Purpose

 Our aim was to investigate correlation between LA strain measured by Cardiovascular Magnetic Resonance (CMR) and amyloid deposit in LA, and also evaluate the LA strain on the prognostic significance. 

Methods and results

 Of 74 consecutive patients with biopsy-proven CA, we analyzed 42 patients (age 72 ± 10 years; 76 % males) with contrast-enhanced CMR, and examined LA late gadolinium enhancement (LGE) and CMR derived LA strain using feature tracking method. Of the 42 patients, 29 patients (69 %) was transthyretin cardiac amyloidosis (ATTR-CA) in the majority. We divided these 42 patients into two groups according to the CMR measured peak atrial longitudinal strain (PALS) (&gt; = or &lt; median); high-strain (&gt; = 6.67 %, n = 21) and low-strain (＜ 6.67 %, n = 21) and compared the patient’s characteristics, blood test data, echocardiography and CMR parameters. There were no significant differences between two groups in these parameters but in the extent of LA-LGE (54 % vs 80 %, p = 0.008). The PALS correlated with the extent of LA-LGE (ρ= 0.50, p = 0.001). In multivariate analysis including LVEF, E/e’ and BNP, LA-LGE was an independent determinant of PALS. During three-year follow up, the LA strain significantly related to heart failure hospitalization in the ATTR-CA patients (p = 0.036)(Figure). 

Conclusions

 In CA patients, CMR measured LA longitudinal strain correlates with the LA-LGE. It also provides useful information for poor prognosis of patients with ATTR-CA.

Abstract P177 Figure. Heart failure hospitalization in ATTR-CA

P5635Predictive ability of lipdic burden for FFR-derived physiological measures: insights from near-infrared spectroscopy imaging analysis

Background

Fractional flow reserve (FFR) has enabled to physiologically assess the myocardial ischemia of coronary artery with intermediate stenosis. Mechanistically, not only the severity of coronary stenosis but also the extent of maximal vasodilatation within the entire coronary artery potentially affects this physiological measure. Since the accumulation of lipidic materials within vessel wall increases vascular stiffness via inducing endothelial dysfunction, the presence of lipidic atheroma burden may affect physiological measures.

Purpose

To investigate the association of FFR with lipidic coronary atheroma by near-infrared spectroscopy/intravascular ultrasound (NIRS/IVUS) imaging, which quantitatively visualize lipidic burden in vivo.

Methods

We analyzed 61 coronary arteries (LAD/RCA/LCX=52/5/4) with FFR≤0.80 in 59 stable coronary artery disease subjects receiving PCI. Following FFR measurement, NIRS/IVUS imaging was conducted to evaluate the extent of atheroma burden (maximum percent plaque area=max%PA) and lipidic materials (lipid core burden index within the entire vessel=LCBIvessel). The analyzed vessels were stratified according to FFR: definite FFR group (FFR≤0.74, n=34) and gray-zone FFR group (0.75≤FFR≤0.80, n=27).

Results

NIRS/IVUS imaging analysis (analyzed longitudinal length=77±7mm) was more likely to exhibit a significantly higher LCBIvessel and a larger max%PA in the definite FFR group (Table). Of note, FFR was significantly correlated to LCBIvessel (ρ=-0.299, p=0.02), but not max%PA (ρ=-0.255, p=0.07). Multivariate analysis demonstrated that an independent determinant of FFR≤0.74 was LCBIvessel [odds ratio (OR)=1.016, 95% confidential interval (CI)=1.002–1.031, p=0.02], but not max%PA [OR=1.084, 95% CI=0.994–1.182, p=0.07]. Area under the receiver-operating characteristic curve analysis elucidated that the addition of LCBIvessel to angiography- and IVUS-derived measures resulted in a significant improvement for detecting FFR≤0.74 (picture).

Definite FFR Group (FFR≤0.74, n=34) Gray-zone FFR Group (0.75≤FFR≤0.80, n=27) p value Fractional flow reserve (FFR) 0.68±0.05 0.78±0.02 <0.01 Percent diameter stenosis (%) 56.2±13.1 51.9±7.8 0.16 Maximum percent plaque area (max%PA, %) 84.3±6.9 79.9±7.2 0.01 Lipid core burden index within the entire vessel (LCBIvessel) 102.0±60.2 65.6±51.6 0.01

ROC analysis for detecting FFR≦0.74

Conclusion

The propagation of lipidic burden associates with the physiological measures. The present findings indicate the possibility that vessel characteristics or instability may have influence for causing ischemia on the coronary artery.

P938Extensive formation of atherosclerotic cardiovascular disease in subjects with severe familial hypercholesterolemia defined by the international atherosclerosis society criteria

Introduction

The International Atherosclerosis Society (IAS) has proposed “severe familial hypercholesterolemia (FH)” as a FH phenotype with the highest cardiovascular risk. Coronary artery disease (CAD) represents a major atherosclerotic change in FH patients. Given their higher LDL-C level and atherogenic clinical features, more extensive formation of atherosclerosis cardiovascular disease including not only CAD but stroke/peripheral artery disease (PAD) may more frequently occur in severe FH.

Methods

481 clinically-diagnosed heterozygous FH subjects were analyzed. Severe FH was defined as untreated LDL-C>10.3 mmol/l, LDL-C>8.0 mmol/l+ 1 high-risk feature, LDL-C>4.9 mmol/l + 2 high-risk features or presence of clinical ASCVD according to IAS proposed statement. Cardiac (cardiac death and ACS) and non-cardiac (stroke and peripheral artery disease) events were compared in severe and non-severe FH subjects.

Results

Severe FH was identified in 50.1% of study subjects. They exhibit increased levels of LDL-C and Lipoprotein (a) with a higher frequency of LDLR mutation. Furthermore, a proportion of %LDL-C reduction>50% was greater in severe FH under more lipid-lowering therapy (Table). However, during the observational period (median=6.3 years), severe FH was associated with a 5.9-fold (95% CI, 2.05–25.2; p=0.004) and 5.8-fold (95% CI, 2.02–24.7; p=0.004) greater likelihood of experiencing cardiac-death/ACS and stroke/PAD, respectively (picture). Multivariate analysis demonstrated severe FH as an independent predictor of both cardiac-death/ACS (hazard ratio=3.39, 95% CI=1.12–14.7, p=0.02) and stroke/PAD (hazard ratio=3.38, 95% CI=1.16–14.3, p=0.02) events.

Clinical characteristics of severe FH Non-severe FH Severe FH P-value Baseline LDL-C (mmol/l) 5.3±1.5 6.6±2.0 <0.0001 Lp(a) (mg/dl) 15 [8–28] 21 [10–49] <0.0001 LDLR mutation (%) 49.6% 58.9% 0.00398 On-treatment LDL-C (mmol) 133 [106–165] 135 [103–169] 0.9856 %LDL-C reduction>50% 21.3% 49.8% <0.0001 High-intensity statin (%) 13.3% 42.3% <0.0001 PCSK9 inhibitor (%) 6.3% 21.2% <0.0001

Clinical outcome

Conclusions

Severe FH subjects exhibit substantial atherosclerotic risks for coronary, carotid and peripheral arteries despite lipid lowering therapy. Our finding underscore the screening of systemic arteries and the adoption of further stringent lipid management in severe FH patients.

P1561An elevated risk of heart failure and stroke events in octogenarian Japanese patients with acute myocardial infarction who received percutaneous coronary intervention

Background

The proportion of the octogenarian population is expanding especially in Eastern society. Due to the clustering of risk factors, acute myocardial infarction (AMI) represents a major cardiovascular complication in octogenarian subjects. This suggests the need to further optimize their therapeutic management to prevent future cardiac events after AMI. However, analysis of clinical characteristics and cardiovascular outcomes in octogenarian subjects with AMI who received the current established medical therapies is limited.

Purpose

To investigate clinical features and prognosis in octogenarian AMI subjects treated with percutaneous coronary intervention (PCI).

Methods

We analyzed 1547 AMI subjects underwent PCI between 2007 and 2017. Baseline characteristics and the occurrence of composite major adverse cardiovascular events (cardiac death, non-fatal MI, revascularization, heart failure and stroke) were compared in octogenarian and non-octogenarian subjects.

Results

22.0% (340/1547) of study subjects was octogenarian. They were more likely to have chronic kidney disease (CKD) and a lower level of LDL-C on admission (Table). Moreover, a higher prevalence of severer Killip class and LVEF <30% were observed in octogenarians (Table). However, they were not optimally treated with the established medical therapies at discharge (Table). During the observational period (median=3.1 years), the composite of cardiovascular events more frequently occurred in octogenarian subjects. Of note, they exhibited a 2.15-fold and 3.01-fold increased risk for heart failure and stroke events, respectively (Figure).

Table 1 Non-Octogenarian (n=1207) Octogenarian (n=340) P-value CKD* (%) 33.8 63.2 <0.0001 LVEF <30% (%) 5.7 10.3 0.02 Killip class 1.33±0.03 1.55±0.05 <0.0001 LDL-C (mmol/L) 3.20±0.03 2.80±0.05 <0.0001 Statin (%) 86.3 78.2 0.0006 Beta-blocker (%) 74.0 65.8 0.005 ACE-I/ARB (%) 87.3 76.6 <0.0001 DAPT (%) 86.0 88.6 0.42 *CKD is defined as estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2.

Figure 1

Conclusions

Octogenarian subjects with AMI were high-risk group associated with heart failure and stroke events. Their distinct clinical backgrounds may affect the adoption of optimal medical therapies, potentially resulting in worse cardiovascular outcomes. Further intensified management should be applied to octogenarian subjects with AMI.

P5502Comparison of clinical characteristics and prognosis between non-octogenarians and octogenarians with cardiac troponin positive acute myocardial infarction

Background

Cardiac troponin (cTn) is the preferred biomarker for the diagnosis of acute myocardial infarction (AMI). Octogenarians who presented cTn positive AMI are not usually recruited in clinical trials. Therefore, their clinical characteristics and prognosis are rarely investigated.

Objective

To study the characteristics and prognosis in octogenarians who presented cTn positive AMI.

Methods and results

The Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET) is a prospective and multicenter registry. A total of 3,283 consecutive AMI patients who were diagnosed by cTn-based criteria were included. The patients were divided into non-octogenarians (n=2,593) and octogenarians (n=690). Compared with non- octogenarians, octogenarians showed significantly lower incidence of diabetes mellitus (37.6% and 31.9%, p=0.006) and dyslipidemia (53.6% and 45.6%, p<0.001), and significantly higher incidence of hypertension (64.1% and 75.3%, p<0.001) and chronic kidney disease (38.7% and 68.7%, p<0.001). Octogenarians showed significantly longer onset to door time (p<0.001) and longer door to device time (p<0.001). Though, compared with non-octogenarians, octogenarians showed lower peak CK (2,506 and 1,926, p<0.001), LVEF was significantly lower in octogenarians (54.6% and 52.6%, p=0.005). The presentation of AMI was different between the two group. The incidence of ST-segment elevation MI (STEMI) was 70.7% in non-octogenarians and 62.0% in octogenarians. Non-STEMI with CK elevation and without CK elevation were 16.2% and 13.1% in non- octogenarians, and 20.9% and 17.1% in octogenarians. In-hospital mortality was higher in octogenarians (4.7% and 13.2%, P<0.001). Especially, octogenarians with STEMI and non-STEMI with CK elevation showed the highest in-hospital mortality. And octogenarians without CK elevation showed similar in hospital mortality with non-octogenarians with STEMI (Figure).

Conclusions

J-MINUET showed the poor prognosis of octogenarians who were diagnosed as AMI based on cTn.

Acknowledgement/Funding

None

6131Association between hospital care quality and readmission among Japanese patients with heart failure. From JROAD-DPC study

Background

Measuring the process of care has become a widely used practice to improve a quality of care. Recently, some studies have demonstrated poor to no correlation between 30-day readmission rates and quality of care for heart failure (HF) among hospitalized HF patients. However the investigation about relationships of care quality for HF and 1 year outcome is limited.

Purpose

To investigate the relationship between quality of care in each hospitals and readmission among HF patients in Japan.

Methods

From Japanese Registry of All cardiac and vascular diseases (JROAD-DPC) database in 2014, 84,325 HF patients hospitalized to 741 certificated hospitals by Japanese Circulation Society were analyzed. A primary endpoint was readmission for HF in one year. Five performance measures were defined as prescription rate of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB), prescription rate of beta blocker and prescription rate of spironolactone, measurement rate of echocardiography and measurement rate of B-type natriuretic peptide (BNP) during hospitalization. For each of the five measures, a composite score was created by giving points ranging from 1 to 4 from the lower quartile of rates, with the score ranging from 5 to 20 points. Hazard ratios (HR) indicating the effects of the performance measures were estimated using Cox proportional hazard models. Covariates included age, gender, Charson score, and NYHA class.

Results

In Japanese HF patients (age; 78.1 years old, man 52%), the HF readmission rate in one year was 14,520 (17.2%). The readmission rate decreased with higher quartiles of prescription rate in each medications and performance rates. The highest quartile of each measurements was significantly lower risk for readmission compared to the lowest quartile (ACE/ARB, adjusted HR 0.87 [95% CI, 0.83–0.91], p<0.001; beta-blocker, 0.83 [0.79–0.88], p<0.001; spironolactone, 0.88 [0.83–0.92], p<0.001; echocardiography, 0.90 [0.86–0.94], p<0.001; BNP, 0.92 [0.87–0.96], p<0.001). Kaplan-Meier curves showed that readmission rates were better among higher composite score, compared to lower composite score (Log-rank test=p<0.001). (Figure) Higher composite scores were associated with statistically significant risk reduction of 23% for HF readmission (HR 0.77, 95% CI [0.73–0.81], p<0.001).

Figure 1

Conclusion

The hospital performance measures were associated with a significant risk reduction of readmission in Japanese patients with HF.

P3392Potential of imaging-guided PCI for event suppression in Japanese acute myocardial infarction patients: J-MINUET substudy

Background

Intravascular ultrasound (IVUS) and Optical Coherence Tomography (OCT) has been widely used in clinical settings. Although favorable results of imaging-guided percutaneous coronary intervention (PCI) compared with angio-guided PCI were observed in several studies, impacts of institutional-based usage frequency, about imaging-guided PCI, have not been well elucidated.

Methods

To elucidate the impact of imaging-guided PCI and the effects of frequency of its usage, we analyzed data of the Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET). This was a prospective and multicenter registry consisting of 3,283 AMI patients, who were hospitalized within 48 hours of onset from July 2012 to March 2014. Clinical follow-up data was obtained for 3 years. In this sub-study, a total of 2,788 patients who underwent urgent PCI having detailed procedural information were enrolled. We analyzed the differences of utilization rates of imaging-guided PCI among the participating institutions and the impacts for the clinical events. The participating institutions were divided into 3 groups by the frequency of IVUS usage: low frequency institutions: under 50%; moderate frequency institutions: 50% to 90%; and, high frequency institutions: over 90%.

Results

In this cohort registry, patients were enrolled from 28 institutions. The utilization rate of coronary imaging varied widely depending on each institution from 15.4% to 100% (mean 85.7%±24.3, median 97.4%). When the institutions were divided into 3 groups by the frequency of intravascular imaging usage, four low frequency institutions enrolled 295 patients, five moderate frequency institutions enrolled 624 patients, and 19 high frequency institutions enrolled 1,491 patients. Although the incidence of MACE (death, MI, stroke, cardiac failure, or revascularization for unstable angina) decreased stepwise (33.2%, 23.7%, and 19.7%) (gray bar in the Figure), the event rates of the imaging-guided PCI cases among the 3 groups were comparable (21.6%, 21.9%, and 19.6%) (white bar in the Figure). On the other hand, a gradual event reduction between the 3 groups was observed in the angio-guided PCI cases (black bar in the Figure). In comparison of MACE rate between imaging-guided and angio-guided PCI, there were statistically significant differences in the low frequency and moderate frequency institutions (p=0.001 and p=0.012, respectively). In contrast, comparable event rates were observed in the high frequency institutions (p=0.441).

MACE rate by imaging usage frequency

Conclusions

In Japanese ACS patients treated with imaging-guided PCI, better suppression of clinical events during 3-year was found in the institutions with the more frequent use of intravascular imaging, mainly due to stepwise event suppression in the cases of angio-guided PCI. On the other hand, the clinical benefit of coronary imaging was obtained independently of the frequency of use and its experience.

P1701Sex-related difference in receiving bystander cardiopulmonary resuscitation and clinical outcome among out-of-hospital cardiac arrest patients

Background

Early studies from US and Europe have reported that female out-of-hospital cardiac arrest (OHCA) patients were less likely to receive bystander cardiopulmonary resuscitation (CPR). However, little is known about sex-related difference in receiving CPR and clinical outcome among adult OHCA patients in Japan.

Methods

This study was a nation-wide, population-based observational study of OHCA in Japan from 2011 to 2015. We included all adult cardiogenic OHCA patients. We excluded patients witnessed by emergency medical services (EMS) from the present analysis. To account for the age-related difference, we stratified by age category: 18–39, 40–64, 65–79, and ≥80. To examine the association between patient sex and neurological outcome at 30-day, we fitted multivariable logistic regression model with adjustment for age, bystander CPR status, first document rhythm, dispatcher instruction and EMS response time.

Results

There were 339,317 adult cardiogenic, not EMS-witnessed OHCA patients (median age, 80; female, 43.5%) in Japan from 2011 to 2015. Overall, 171,122 (50.4%) received CPR by citizen, 34,283 (10.1%) had initial shockable rhythm, and 11,421 (3.4%) had favorable neurological status at 30-day. Female patients were more likely to receive bystander CPR (vs. male; 53.8% vs. 47.8%), and were less likely to have initial shockable rhythm (5.2% vs. 13.9%) and favorable neurological status at 30-day (1.8% vs. 4.6%) (all; p<0.001). With stratification by age category, elderly female patients (aged ≥65) were more likely to received bystander CPR (P<0.001), whereas male patients were more likely to received bystander CPR among patients aged <40. Multivariable logistic regression analysis showed that female patients had a lower rate of favorable neurological status at 30-day, compared to male patients in all age categories (all; P<0.05).

Sex difference in bystander CPR Overall Male (n=191,672) Female (n=147,645) p-value All (n=339,317) 50.4% 47.8% 53.8% <0.001 Aged 18–39 (n=6,216) 56.0% 56.9% 53.5% 0.02 Aged 40–64 (n=50,320) 48.5% 48.5% 48.3% 0.69 Aged 65–80 (n=105,141) 46.5% 45.5% 48.3% <0.001 Aged ≥80 (n=177,640) 53.2% 49.0% 56.7% <0.001

OR for neurological outcome at 30-day

Conclusion

Unlike the situation in Europe and US, female OHCA patients, especially elderly female, were more likely to receive bystander CPR in Japan. However, female patients had worse clinical outcome after OHCA. Further investigations including in-hospital treatment are needed to clarify the sex-difference in clinical outcome after OHCA.

Acknowledgement/Funding

None

P1954Prognostic value of the CHADS2 score for adverse cardiovascular events in acute myocardial infarction patients without atrial fibrillation: J-MINUET Substudy

Background

The CHADS2score has mainly been used to predict the likelihood of cerebrovascular accidents in patients with atrial fibrillation. However, increasing attention is being paid to this scoring system for risk stratification of patients with coronary artery disease. We investigated the value of the CHADS2 score in predicting cardiovascular events in Japanese acute myocardial infarction (AMI) patients without atrial fibrillation.

Methods

To elucidate the prognostic value of CHADS2score in AMI patients, we analysed data of the Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET). This was a prospective and multicenter registry consisting of 3,283 AMI patients, who were hospitalized within 48-hours of onset from July 2012 to March 2014. We calculated the CHADS2 scores for 3,044 patients without clinical evidence of atrial fibrillation. The presence of heart failure was substituted by Killip classification>2 on admission. Clinical follow-up data was obtained for 3 years. In addition to the in-hospital mortality,we evaluated cardiovascular events, defined as all cause deathor non-fatal MI during 3-year follow up periods.

Results

In this study, enrolled patients were classified into low- (point 0–1), intermediate- (point 2–3), and high-score (point 4–6) groups by calculating CHADS2 score. Overall patients with low, intermediate and high score were divided into 1,395, 1,393 and 256 patients, respectively. In-hospital mortality among low, intermediate, and high score groups were 2.8%, 7.4% and 14.8%, respectively (P<0.001). The incidence of cardiovascular eventsamong low, intermediate, and high score groups were 7.8%, 16.3%, 29.3%, respectively (P<0.001). Kaplan-Meier analysis showed a significant difference between the groups (Figure). The event rates were significantly higher in both high score and intermediate score group than in low score group (P<0.001). Multivariate Cox hazard analysis identified CHADS2 score (per 1 point) as an independent predictor of cardiovascular events in addition to chronic kidney disease and lower body mass index. (hazard ratio, 1.344; 95% CI, 1.239–1.459; P<0.001). Among the factors constituting CHADS2 score, heart failure and age were identified as independent predictors for in-hospital mortality. With respect to the cardiovascular event during 3 years, heart failure, age, and previous stroke were revealed as significant independent predictors.

Conclusion

This large cohort study indicated that the CHADS2 score is useful for the prediction of in-hospital mortality and the cardiovascular events during 3-year follow up in Japanese AMI patients without atrial fibrillation.

P3406Validation of atherothrombotic risk score for secondary prevention in patients with acute myocardial infarction: the J-MINUET study

Background

Thrombolysis in Myocardial Infarction (TIMI) Risk Score for Secondary Prevention and CREDO-Kyoto Thrombotic Risk Score are contemporary secondary prevention risk scoring systems. However, these scoring systems have not been validated in other populations.

Purpose

The aim of this study was to validate of the TIMI Risk Score for Secondary Prevention and CREDO-Kyoto Thrombotic Risk Score in patients in the early phase of acute myocardial infarction (AMI).

Methods

The Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET) is a prospective multicenter registry conducted in 28 Japanese medical institutions. We enrolled 3,283 consecutive patients with AMI who were admitted to participating institutions within 48 hours of symptom onset between July 2012 and May 2014. Among them, 3,070 patients were included in this study after excluding 213 patients who died in the hospital. Clinical follow-up data were obtained up to 3 years. The primary endpoint was a composite of all-cause death, non-fatal MI and non-fatal stroke. The patients were stratified by the TIMI Risk Score for Secondary Prevention and CREDO-Kyoto Thrombotic Risk Score.

Results

At the 3-year follow-up, the primary endpoint had occurred in 337 patients (11.0%). All-cause death, non-fatal MI and non-fatal stroke had occurred in 177 (5.8%), 80 (2.6%) and 80 (2.6%) patients, respectively. TIMI Risk Score for Secondary Prevention and CREDO-Kyoto Thrombotic Risk Score showed a graded association with the composite of all-cause death, non-fatal MI and non-fatal stroke at 3 years in the J-MINUET population (Figure).

Validation of atherothrombotic risk

Conclusions

TIMI Risk Score for Secondary Prevention and CREDO-Kyoto Thrombotic Risk Score were shown to be applicable to the patients in the early phase of AMI.

P884Short-term exposure to asian dust is associated with myocardial infarction with nonobstructive coronary arteries

Background

Asian dust (AD) is considered as one of air pollution that increases risk of acute myocardial infarction (AMI). However, it has not been elucidated whether AD might increase the risk of myocardial infarction with nonobstructive coronary arteries (MINOCA).

Methods

A time-stratified case-crossover design and conditional logistic regression models was used to investigate the association between short-term exposure to AD and admission of AMI during the spring months in a nationwide administrative Diagnostic Procedure Combination (DPC) database, the Japanese Of All cardiac and vascular Diseases (JROAD)-DPC, between April 2012 through March 2016. MINOCA was defined as AMI having angiography without revascularization and coronary atherosclerosis, whereas myocardial infarction with obstructive coronary artery disease (MI-CAD) was AMI with revascularization and/or coronary atherosclerosis. Data for AD events, air pollutants (PM2.5, Ox, NO2, SO2), and meteorological variables were obtained from the nearest monitoring station of the hospital.

Results

During the study period, 3,233 MINOCA and 27,202 MI-CAD patients were identified from 30,435 AMI patients. Although the occurrence of AD events 2 days before the admission was not associated with the admission of AMI and MI-CAD, the AD events was significantly associated with the admission of MINOCA with adjustment for meteorological variables and each air pollutant. In subgroup analysis of MINOCA, patients without low ADL was associated with higher risk of the admission due to AD exposure than those with low ADL, with significant interaction.

Conclusions

AD events might be more likely to trigger onset of MINOCA than MI-CAD.

Acknowledgement/Funding

None

Peripheral administration of κ-opioid receptor antagonist stimulates gonadotropin-releasing hormone pulse generator activity in ovariectomized, estrogen-treated female goats

Pulsatile gonadotropin-releasing hormone (GnRH) secretion is indispensable for reproduction in mammals. Kisspeptin neurons in the hypothalamic arcuate nucleus (ARC), referred to as KNDy neurons because of the coexpression of neurokinin B and dynorphin A, are considered as components of the GnRH pulse generator that produces rhythmic GnRH secretion. The present study aimed to investigate if peripheral administration of PF-4455242, a κ-opioid receptor (KOR, a dynorphin A receptor) antagonist, facilitates pulsatile luteinizing hormone (LH) secretion and GnRH pulse generator activity in estrogen-treated ovariectomized Shiba goats to determine the possibility of using KOR antagonists to artificially control ovarian activities. PF-4455242 was intravenously infused for 4 h (1 or 10 μmol/kg body weight/4 h) or as a single subcutaneous injection (1 or 10 μmol/kg body weight). In a separate experiment, the same KOR antagonist (10 μmol/kg body weight/4 h) was intravenously infused during the recording of multiple unit activity (MUA) in the ARC that reflects the activity of the GnRH pulse generator to test the effects of KOR antagonist administration on GnRH pulse generator activity. Intravenous infusion and single subcutaneous injection of the KOR antagonist significantly increased the frequency of LH pulses compared with controls. Intravenous infusion of KOR antagonist also significantly increased the frequency of episodic bursts in the MUA. The present study demonstrates that peripherally administered KOR antagonist stimulates pulsatile LH secretion by acting on the GnRH pulse generator, and peripheral administration of PF-4455242 can be used to facilitate pulsatile LH secretion, which in turn facilitates ovarian activities in farm animals.

A modified preauricular and transmandibular approach for surgical management of osteosarcoma of the mandibular condyle within the masticator space and infratemporal fossa: a case report

Background

Osteosarcomas of the head and neck region are rare entities that comprise < 10% of all osteosarcomas. Multimodality treatment of patients with osteosarcoma is well-established for osteosarcoma in long bones, and the benefits of chemotherapy in long bones are clearly known. However, there is no consensus regarding the effects of chemotherapy in cases of head and neck osteosarcoma. The prognostic factor for head and neck osteosarcoma is complete tumor resection with negative margin, which is a radical surgery. However, a clear margin may be difficult to achieve in the head and neck region.

Case presentation

We present a case of a 69-year-old Japanese woman who developed osteosarcoma of the condyle within the masticator space and infratemporal fossa, which was treated with radical surgery using a modified preauricular and transmandibular approach. Although we recommended adjuvant treatment after surgery, the patient refused this treatment. There was no evidence of local recurrence or distant metastasis through 30 months of follow-up.

Conclusions

Our modified preauricular and transmandibular approach allowed access to the masticator space and infratemporal fossa, thereby increasing complete resection of the tumor and resulting in minimal functional and cosmetic deficits.

Refractory Hypotension during Combined General and Epidural Anaesthesia in a Patient on Tricyclic Antidepressants

We report a case of refractory hypotension that occurred after epidural injection of local anaesthetic, in a patient who was receiving tricyclic antidepressant therapy and was under general anaesthesia. The patient failed to respond to repeated injections of appropriate doses of sympathomimetics, but did respond to high-dose catecholamine infusions. We suggest that epidural anaesthesia should be used with care when combined with general anaesthesia for patients on long-standing tricyclic antidepressant therapy. If refractory hypotension should occur in such patients, the use of direct-acting vasoconstrictors such as noradrenaline should be considered.