CD34-Positive Spindle Cell Tumor With CTNNB1 Mutation: An Unusual Spindle Cell Variant of Sinonasal Glomangiopericytoma

Sinonasal glomangiopericytoma is an uncommon mesenchymal tumor with a perivascular myoid phenotype, which is categorized as a borderline/low-grade malignant soft tissue tumor by the current World Health Organization Classification of Head and Neck tumors. Here, we present the case of a 53-year-old woman with an unusual spindle cell morphology of sinonasal glomangiopericytoma arising in the nasal cavity, mimicking solitary fibrous tumor. Microscopically, the tumor showed a cellular proliferation of spindle cells in fascicles including a focal long sweeping arrangement or whorls, or with a storiform growth pattern, associated with hemangiopericytoma-like gaping blood vessels embedded in a fibrous stroma. This arrangement of the spindle cells faintly indicated a solitary fibrous tumor rather than sinonasal glomangiopericytoma. Immunohistochemically, the tumor was positively reactive to not only beta-catenin (in the nuclei) but also CD34, although signal transducers and activators of transcription 6 was negative. Mutational analysis using Sanger sequencing detected a CTNNB1 mutation. We finally diagnosed the tumor as a sinonasal glomangiopericytoma, showing an unusual spindle cell variant. Such unusual spindle cell morphology with CD34-immunoreactivity potentially leads to an incorrect diagnosis of solitary fibrous tumor because such prominent fascicles including long sweeping structures, reminiscent of desmoid-type fibromatosis, have scarcely been described in the literature. Hence, careful morphological scrutiny using appropriate diagnostic adjuncts is necessary for correct diagnosis.

Nasal polyps show decreased mucociliary transport despite vigorous ciliary beating

OBJECTIVE

Mucociliary transport function in the airway mucosa is essential for maintaining a clean mucosal surface. This function is impaired in upper and lower airway diseases. Nasal polyps are a noticeable pathological feature that develop in some of the patients with chronic rhinosinusitis. Like ordinary nasal mucosae, nasal polyps have a ciliated pseudostratified epithelium with vigorous ciliary beating. We measured ex vivo Mucociliary Transport Velocity (MCTV) and Ciliary Beat Frequency (CBF) and explored the expressions of Planar Cell Polarity (PCP) proteins in nasal polyps in comparison with turbinate mucosae.

METHODS

Inferior turbinates and nasal polyps were surgically collected from patients with chronic rhinosinusitis. Ex vivo MCTV and CBF were measured using a high-speed digital imaging system. Expressions of PCP proteins were explored by fluorescence immunohistochemistry and quantitative RT-PCR.

RESULTS

The MCTV of nasal polyps was significantly lower than that of the turbinates (7.43 ± 2.01 vs. 14.56 ± 2.09 μm/s; p = 0.0361), whereas CBF did not differ between the two tissues. The MCTV vector was pointed to the posteroinferior direction in all turbinates with an average inclination angle of 41.0 degrees. Immunohistochemical expressions of Dishevelled-1, Dishevelled-3, Frizzled3, Frizzled6, Prickle2 and Vangl2 were lower in the nasal polyps than in the turbinates. Confocal laser scanning microscopy showed that Frizzled3 was localized along the cell junction on the apical surface. The expression levels of mRNAs for Dishevelled-1, Dishevelled-3 and Frizzled3 in the nasal polyps were also decreased in comparison with the turbinates.

CONCLUSION

These results indicate that muco ciliary transport in nasal polyps is impaired although vigorous ciliary beating is maintained, and that the impairment may be caused by a decrease in Dishevelled/Frizzled proteins and resultant PCP disarrangement.

LEVEL OF EVIDENCE

Level 3.

Trends and outcomes of early rehabilitation in intensive care unit for patients with cardiovascular disease – a cohort study with propensity score-matched analysis

Background

Early rehabilitation in the intensive care unit (ICU), including early mobility therapy, is known to improve the clinical outcomes in patients with critically ill. However, the effectiveness of acute-phase cardiovascular rehabilitation (CR) during ICU treatment have not been thoroughly evaluated in patients with cardiovascular disease (CVD).

Purpose

We aimed to investigate the trends and outcomes of acute-phase CR in the ICU for patients with CVD, including in-hospital and long-term clinical outcomes.

Methods

We reviewed 1948 consecutive patients with CVD admitted to tertiary academic ICU at a university hospital. Patients were arbitrarily assessed by an ICU team consisting of medical and surgical doctors, nurses and physiotherapists within 24 hours after admission to ICU to discover whether their rehabilitation could be initiated according to the specific clinical trial and statement. As clinical characteristics, disease aetiology, comorbid conditions, and ICU treatment were obtained from an electronic database. We evaluated the probability of return to walking independence and return to home as in-hospital clinical outcomes. All patients were followed for five years and investigated all-cause and cardiovascular events after hospital discharge as long-term clinical outcomes. The associations between the implementation of CR during ICU treatment (ICU-CR) and clinical outcomes were evaluated using propensity score-matched analysis with adjustment for clinical characteristics in all matched patients and various subgroups, including aged >65 years, surgical patients, emergency, and length of ICU stay ≥48 hours.

Results

Out of studied patients, 1092 patients received ICU-CR, the number of which positively correlated with year-trend (r=0.986, P<0.001). After propensity score matching with adjustment for clinical characteristics including calendar years, 758 patients were included for analysis (pairs of n=379 ICU-CR and non-ICU-CR). The ICU-CR was significantly associated with a higher probability of return to walking independence (incident rate ratio [IRR], 2.04; 95% confidence interval [CI], 1.77–2.36) and return to home (IRR, 1.22 95% CI, 1.05–1.41). These associations were consistently observed in various subgroups regarding CVD conditions (Figure 1). During the median follow-up periods of 2.6 years, all-cause clinical events and cardiovascular events occurred in 289 patients (38.1%) and 153 patients (20.2%), respectively. The ICU-CR showed significantly lower rates of five-year all-cause and cardiovascular events than non-ICU-CR (hazard ratio [95% CI] for all-cause events and cardiovascular events, 0.71 [0.56–0.89] and 0.69 [0.50–0.95], respectively, Figure 2).

Conclusions

The implementation of acute-phase CR in the ICU increased with year-trend, considered beneficial to improve in-hospital and long-term clinical outcomes in patients with CVD and various subgroups of relatively severe disease conditions.

Funding Acknowledgement

Type of funding sources: None.

Perme ICU Mobility Score as a comprehensive assessment tool of acute-phase rehabilitation is correlated with clinical outcomes in patients after cardiovascular surgery

Background

Early mobility therapy in the intensive care unit (ICU) is widely employed to improve the physical function and prognosis of patients with critically ill. On the other hand, patients who undergo cardiovascular surgery frequently suffer from disabilities after ICU care due to their cardiopulmonary conditions and treatments. However, few studies have reported the procedures and assessments of acute-phase rehabilitation in these patients. Recently, the Perme ICU Mobility Score (Perme Score) was developed as a reliable tool to assess comprehensive mobility status of patients in the ICU. We hypothesised that the Perme Score is a useful tool for assessing the mobility levels in the ICU and predicting clinical outcomes in patients undergoing acute-phase rehabilitation after cardiovascular surgery.

Purpose

To investigate the associations between the Perme Score within the second days after cardiovascular surgery and the patients' clinical outcomes, including physical function and the incidence of clinical events.

Methods

We studied 224 consecutive patients (34.4% female; aged 65±13 years) who were admitted to the ICU of a tertiary academic hospital after cardiac and/or major vascular surgery. Clinical characteristics including patient profiles, comorbidities, surgical details and APACHE II and SOFA scores were evaluated on ICU admission. The Perme Score contains categories on mental status, potential mobility barriers, muscle strength and mobility level, with higher scores indicating greater activity levels in the ICU. We assessed the Perme Score within the second days after the surgery. As a physical function at hospital discharge, we measured the six-minute walk distance (6MWD). The primary endpoint was a composite outcome of the number of all-cause mortality and/or all-cause unplanned readmission. We analysed the associations of the Perme Score with the 6MWD and the incidence of clinical events using multiple regression analysis and multivariate Poisson regression analysis, respectively.

Results

After adjusting for clinical confounding factors, a higher Perme Score was an independent factor of a higher 6MWD (Table 1). During the median follow-up period of 1.3 years, 51 cases of all-cause mortality/readmission occurred in 37 (16.5%) patients, with an incidence rate of 18.6/100 person-years. In the multivariate Poisson regression analysis, even after adjusting for the severity score in the ICU, a higher Perme Score was significantly and independently associated with lower rates of all-cause clinical events (adjusted incident rate ratio: 0.96, 95% confidence interval: 0.93–0.99, P=0.008, Figure 1).

Conclusions

The Perme Score within the second days after cardiovascular surgery is correlated with physical function at hospital discharge and the incidence of clinical events after discharge. Thus, a comprehensive assessment of acute-phase rehabilitation after cardiovascular surgery may be useful in predicting clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.

O-130 Reproductive outcomes of normal ovarian reserve patients after progestin-primed ovarian stimulation with chlormadinone acetate vs GnRH antagonist: A retrospective study with inverse-probability-of-treatment weighting

Study question

To evaluate the effectiveness of chlormadinone acetate (CMA) for preventing premature LH surge in patients with normal ovarian reserve compared to cetrorelix.

Summary answer

In progestin-primed ovarian stimulation (PPOS) than GnRH antagonist (GnRH-ant), the incidence of premature LH surge was significantly lower, without significant difference in oocyte maturation rate.

What is known already

The GnRH-ant protocol is one of the conventional protocols which has some disadvantages including increased premature LH surge rate and cancelation rate. In recent years, the PPOS protocol has attracted attention as a new ovarian stimulation using progestin as an alternative to GnRH analog for suppressing a premature LH surge, however its efficacy is still controversial. In addition, many studies have investigated the reproductive outcomes of PPOS using medroxy-progesterone acetate or dydrogesterone; however, there are few reports of CMA, an oral progestin, which is inexpensive and widely used in Japan.

Study design, size, duration

This retrospective cohort study was performed in a reproduction center between March 2018 and October 2020 which included 977 Japanese patients with normal ovarian reserve undergoing PPOS with CMA (n = 299), or GnRH antagonist (GnRH-ant) with cetrorelix (n = 608) in their first IVF cycle at the reproduction center. In subgroup analysis, pregnancy outcomes after frozen embryo transfers (FET) between PPOS (n = 284) and GnRH-ant (n = 579) were also compared.

Participants/materials, setting, methods

The inclusion criteria were patients aged < 40 years and AMH ≧ 1.1 ng/mL, who underwent autologous oocyte retrieval in their first IVF cycle with freeze-all strategy. The primary outcome was the incidence of premature LH surge, the secondary outcomes was oocyte maturation rate. To reduce the impact of treatment bias and potential confounding factors, we conducted logistic regression models with inverse-probability-of-treatment weighting (IPTW).

Main results and the role of chance

After IPTW, baseline clinical data were well-balanced between the two groups, including age, AMH, BMI, the duration, type, and cause of infertility, antral follicle count, the history of recurrent spontaneous abortion, and previous IVF attempts. The premature LH surge rate was significantly lower with PPOS (3.1%) compared to GnRH-ant (20.1%) (odds ratio, 0.21; 95% confidence interval, 0.11–0.36). No significant differences were found in total gonadotropin dose (2400IU for PPOS vs 2400IU for GnRH-ant, p = 0.136), the number of oocyte retrieval (n = 15 vs n = 15, p = 0.484), oocyte maturation rate (78.8% vs 77.8%, p = 0.275), fertilization rate (73.0% vs 72.0%, p = 0.412), viable embryo rate per oocyte retrieval (40% vs 40%, p = 0.890), and good quality blastocyst rate (72.0% vs 69.6%, p = 0.092). However, the good quality day-3 embryo rate was significantly lower with PPOS (37.2% vs 49.1%, p < 0.05). There were no differences in the incidence of moderate-to-severe OHSS (0.3% vs 0.7%, p = 0.481). In FET cycles, the pregnancy outcomes, such as implantation rate (43.1 % vs 51.9 %, p = 0.013) and clinical pregnancy rate (46.5% vs 54.7%, p = 0.027) were significantly lower with PPOS, however, no significant differences were found in ongoing pregnancy rate (75.6% vs 80.5%, p = 0.325), and live birth rate (72.4% vs 79.5 %, p = 0.142).

Limitations, reasons for caution

This was a retrospective cohort study conducted in a single center. The participants in this study were limited to Japanese ethnicity. The results need to be validated across different centers and other ethnicities.

Wider implications of the findings

This is the first report assessing the reproductive outcomes on PPOS using CMA, widely used in Japan. The PPOS with CMA significantly suppressed the premature LH surge rate compared to GnRH-ant protocol, without decrease in oocyte maturation rate.

Trial registration number

N/A

Expression of T-Type Voltage-Gated Calcium Channel in the Cilia of Human Nasal Epithelial Cells

INTRODUCTION

The mucociliary transport function of the airway epithelium is largely dependent on ciliary beating. The control signal of ciliary beating is thought to be intracellular Ca2+. We herein investigated the expression of T-type voltage-gated calcium channel (VGCC), a generator of intracellular Ca2+ oscillation, in the human nasal mucosa.

METHODS

The inferior turbinate was collected from patients with chronic hypertrophic rhinitis. The expression of T-type VGCC α1 subunits was examined by immunohistochemistry, transmission immunoelectron microscopy, Western blot, and real-time reverse transcription-polymerase chain reaction (RT-PCR). Participation of T-type VGCC in the ciliary beat regulation was examined by pharmacological inhibition tests using specific blockers of T-type VGCC in ex vivo measurements of the ciliary beat frequency (CBF) and ATP release and in intracellular Ca2+ imaging of isolated ciliated cells.

RESULTS

Immunohistochemical staining showed the expressions of T-type VGCC α1 subunits, Cav3.1 and Cav3.3, on the surface of the epithelial cells. At the ultrastructural level, immunoreactivity for Cav3.1 was localized on the surface of the cilia, and that for Cav3.3 was localized in the cilia and at the base of the cilia. The existence of Cav3.1 and Cav3.3 was confirmed at the protein level by Western blot and at the transcriptional level by real-time RT-PCR. Specific blockers of T-type VGCC, mibefradil and NNC 55-0396, significantly inhibited CBF. These blockers also inhibited a CBF increase induced by 8-bromo-cAMP/8-bromo-cGMP and significantly lowered the intracellular Ca2+ level of isolated ciliated cells in a time-dependent manner. On the other hand, the ATP release from the nasal mucosa was not changed by mibefradil or NNC 55-0396.

CONCLUSION

These results indicate that T-type VGCC α1 subunits, Cav3.1 and Cav3.3, exist at the cilia of the nasal epithelial cells and participate in the regulation of ciliary beating and that these channels act downstream of cAMP/cGMP.

Decreased CFTR/PPARγ and increased transglutaminase 2 in nasal polyps

OBJECTIVE

Transglutaminase (TGM)2 and peroxisome proliferator-activated receptor (PPAR)γ are thought to participate in the pathogenesis of nasal polyp formation in cystic fibrosis (CF). We herein investigated expressions of cystic fibrosis transmembrane conductance regulator (CFTR), TGM2, PPARγ and isopeptide bonds, a reaction product of TGM, in non-CF nasal polyps.

METHODS

Nasal polyps and inferior turbinates were collected from chronic rhinosinusitis patients without CF during transnasal endoscopic sinonasal surgery. Expressions of CFTR, TGM2, isopeptide bonds and PPARγ were examined by fluorescence immunohistochemistry and quantitative RT-PCR. Expression of CFTR was also analyzed by Western blot.

RESULTS

Immunohistochemical fluorescence of the nasal polyp was significantly lower for CFTR and PPARγ, and significantly higher for TGM2 and isopeptide bonds than that of the turbinate mucosa. Lower expression of CFTR in the nasal polyp than in the turbinate mucosa was also observed in Western blot. Expression of PPARG mRNA was significantly lower in the nasal polyp than in the turbinate mucosa, whereas expressions of CFTR mRNA or TGM2 mRNA did not differ between the two tissues. Immunohistochemical fluorescence for CFTR showed significant negative correlation with that for TGM2 and isopeptide bonds, and significant positive correlation with that for PPARγ. The fluorescence for TGM2 was positively correlated with that for isopeptide bonds and negatively correlated with that for PPARγ. The fluorescence for isopeptide bonds tended to be negatively correlated with that for PPARγ.

CONCLUSIONS

These results suggest a possible role of the CFTR-TGM2-PPARγ cascade in the pathogenesis of nasal polyp formation in non-CF patients as in CF patients.

The role of marshall bundle epicardial connections in atrial tachycardias after atrial fibrillation ablation

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial tachycardias (ATs) are often seen in the context of AF ablation.

Objectives

We evaluated the role of the Marshall bundle (MB) network in left atrial (LA) ATs using high-density high-spatial resolution 3D mapping.

Methods

199 post-AF ablation LA tachycardias were mapped in 140 consecutive patients (112 (80%) males, mean age: 61.8 years); 133 (66.8%) were macro-reentrant and 66 (33.2%) were scar-related re-entry. MB-dependent perimitral AT (PMAT) was diagnosed where the difference between the post pacing interval and the tachycardia cycle length (PPI-TCL) was <20ms in parts of the expected MB-dependent perimitral circuit (within the VOM, the ridge between the left pulmonary veins and LA appendage (LAA), the anterior LA and between 6- and 11-o’clock of the mitral annulus) and the PPI-TCL was >20ms in areas bypassed by the VOM (the distal coronary sinus (CS), the posterior LA and the mitral isthmus). MB-related re-entry was diagnosed by PPI-TCL <20ms at the left lateral ridge, posterior base of LAA, inferolateral LA or VOM ostium; and PPI-TCL >20ms in the septal annulus. Typically, in MB-dependent localized re-entry, the earliest activation was found along the MB-LA endocardial connection or MB-CS epicardial connection. 

Results

The MB network was found to participate in 60 (30.2%) re-entrant ATs, 31 PMATs and 29 localized re-entries. High-frequency multiphasic fragmented electrograms with long duration were often recorded endocardially or epicardially at the MB-LA or MB-CS connections. The amplitude and duration of these signals were 0.5 ± 0.79 mV and 65 ± 40 ms for MB-PMATs and 0.26 ± 0.28mV and 122 ± 67 ms for MB-localized re-entries. Unipolar EGMs at the site of endocardial-epicardial breakthrough had a rS pattern in all MB-related ATs. Of 60 MB-related ATs, 49 (81.6%) terminated with RF ablation, 44 (73.3%) at the MB-LA junction and 5 (8.3%) at the MB-CS junction, while 9 (15%) terminated after 2.5-5 cc of alcohol infusion inside the vein of Marshall (VOM). Of the 31 MB-related macroreentrant ATs, 17 (54.8%) terminated at the MB-LA junction, 5 (16.1%) at the MB-CS junction and 7 (22.6%) with alcohol infusion inside the VOM. Two macroreentries (6.5%) using the MB did not terminate with RF energy either endocardially at the MB-LA junction or epicardially at the MB-CS junction, and we were unable to identify or cannulate the VOM for ethanol infusion. Of the 29 localized re-entrant ATs using the MB, 27 (93.1%) terminated at the MB-LA junction, none terminated at the MB-CS junction and 2 (6.9%) terminated after alcohol infusion. After a mean follow up of 12 months, only 4 patients (6.7%) had AT recurrence.

Conclusions

MB re-entrant ATs accounted for up to 29% of the left ATs after AF ablation. Ablation of the MB-LA or CS-MB connections or alcohol infusion inside the VOM is required to treat these arrhythmias. Abstract Figure.

Low skeletal muscle density combined with muscle dysfunction predicts adverse events after adult cardiovascular surgery

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): This study was supported by the Grant for Japan Society for the Promotion of Science (JSPS) KAKENHI.

Introduction

Although muscle dysfunction is widely known as a poor prognostic factor in patients with cardiovascular disease, no study has examined whether the addition of low skeletal muscle density (SMD) assessed by computed tomography (CT) to muscle dysfunction is useful.

Purpose

The present study aimed to examine whether SMDs can strengthen the predictive ability of muscle dysfunction for adverse events in patients who underwent cardiovascular surgery.

Methods

We retrospectively reviewed 853 patients (median age: 69 years, 65.1% male) aged ≥40 years who had preoperative CT for risk management purposes and muscle dysfunctions measured during postoperative cardiac rehabilitation. Muscle dysfunctions were determined from weakness (low grip strength) and slowness (slow gait speed) based on the Asia Working Group for Sarcopenia. Low SMD based on transverse abdominal CT images was defined as a mean Hounsfield unit of the psoas muscle <45. To examine the complementary prognostic value for all-cause deaths, all-cause events, and cardiovascular-related events when low SMDs were added to four patterns of muscle dysfunction (weakness only, slowness only, weakness or slowness, and weakness and slowness), the continuous net reclassification improvement (cNRI) and integrated discrimination improvement (IDI) index were calculated.

Results

For all definitions of muscle dysfunction, the addition of SMDs was shown to significantly improve the cNRI (estimates: 0.377 to 0.468 for all-cause death, 0.220 to 0.248 for all-cause events, 0.308 to 0.322 for cardiovascular-related events) and IDI (estimates: 0.005 to 0.011 for all-cause death, 0.005 to 0.010 for all-cause events, 0.009 to 0.012 for cardiovascular-related events) in all analyses. Low SMDs combined with muscle dysfunctions were associated with the highest risk of all-cause death (Figure 1: A-D). Patients with neither low SMDs nor muscle dysfunction had the lowest risk of all-cause events and cardiovascular-related events (Figure1: E-L).

Conclusion

The predictive ability of muscle dysfunction for adverse events was consistently increased by addition of SMDs in patients who underwent cardiovascular surgery. Our results suggest that when CT is performed for any clinical investigation, the addition of the organic assessment of skeletal muscle can strengthen the diagnostic accuracy of muscle wasting.

Abstract Figure 1

Calmodulin Regulates Ciliary Beats in the Human Nasal Mucosa Through Adenylate/Guanylate Cyclases and Protein Kinases A/G

BACKGROUND

The ciliary beat of the airway epithelium, including the sinonasal epithelium, has a significant role in frontline defense and is thought to be controlled by the level of intracellular Ca2+. Involvement of calmodulin and adenylate/guanylate cyclases in the regulation of ciliary beats has been reported, and here we investigated the interrelation between these components of the ciliary beat regulatory pathway.

METHODS

The inferior turbinates were collected from 29 patients with chronic hypertrophic rhinitis/rhinosinusitis during endoscopic sinonasal surgery. The turbinate mucosa was cut into thin strips, and mucociliary movement was observed under a phase-contrast light microscope equipped with a high-speed digital video camera.

RESULTS

The ciliary beat frequency (CBF) was significantly increased by stimulation with 100 μM CALP3 (calmodulin agonist), which was completely suppressed by adding 100 µM SQ22536 (adenylate cyclase inhibitor) and 10 µM ODQ (guanylate cyclase inhibitor) together and by adding 1 µM KT5720 (protein kinase A inhibitor) and 1 µM KT5823 (protein kinase G inhibitor) together. The CBF was significantly increased by stimulation with 10 µM forskolin (adenylate cyclase activator) and 10 µM BAY41-2272 (guanylate cyclase activator) and by stimulation with 100 µM 8-bromo-cAMP (cAMP analog) and 100 µM 8-bromo-cGMP (cGMP analog), which was not changed by adding 1 µM calmidazolium (calmodulin antagonist).

CONCLUSIONS

These results confirmed that the regulatory pathway of ciliary beats in the human nasal mucosa involves calmodulin, adenylate/guanylate cyclases, and protein kinases A/G and indicate that adenylate/guanylate cyclases and protein kinases A/G act downstream of calmodulin, but not vice versa, and that these cyclases relay calmodulin signaling.

Right coronary artery as a culprit artery for better prognosis in patients with acute myocardial infarction (AMI) with or without shock

Background

Although patients with acute myocardial infarction (AMI) complicated by cardiogenic shock, morbidity and mortality remain high even with early revascularization and modern intensive care.

Culprit artery and prognosis were associated in patients with acute myocardial infarction.

Purpose

Evaluation of short- and long-term prognosis of AMI with cardiogenic shock by right coronary artery (RCA) and left coronary artery (LCR)

Method

We investigated 3400 AMI patients (age 68.8±12.7 y.o.) were enrolled from Mie ACS registry. They were divided into 4 groups according to the culprit artery and presence or absence of cardiogenic shock: RCA without shock n=1114, RCA with shock n=74, LCA without shock n=2028, LCA with shock n=184. Primary endpoint was defined as all-cause mortality.

Results

During the median follow-up periods with 743 days, 12.6% of the patients experienced all-cause death. RCA and LAC with shock groups demonstrated significantly higher in-hospital mortality compared to groups without shock (p<0.001, Figure 1A). Interestingly, after discharge, LCA with shock group showed significant higher all-cause mortality compared with other 3 groups. Surprisingly, RCA with shock group showed similar favorable prognosis to that of without shock groups (Figure 1B). Multivariate analyses for after discharge mortality showed that LCA with shock group was strongest independent poor prognostic factor with hazard ratio of 2.3 (95% CI 1.4–3.7), but RCA with shock group was not.

Conclusion

Association of cardiogenic shock is the hazardous risk factor for cases with AMI, especially LCA infarction. Surprisingly, RCA AMI cases with shock showed favorable prognosis as well as AMI without shock.

Kaplan-Meier survival curves

Funding Acknowledgement

Type of funding source: None

Cardiac factors as well as non-cardiac factors were associated with frailty in patients with heart failure with preserved ejection fraction

Background

Frailty is associated with malnutrition and poor prognosis in patients with heart failure with preserved ejection fraction (HFpEF). However, the cardiac factors associated with frailty have not been fully examined in patients with HFpEF.

Purpose

The purpose of this study is to clarify the cardiac factors related to frailty in patients with HFpEF.

Methods

Of the 756 patients who registered prospective, multicenter, observational study of patients with HFpEF (PURSUIT-HFpEF) registry, 481 cases with clinical frailty score (CFS) and prognosis after discharge were examined. Frailty was defined as CFS ≥5. Outcomes were composite endpoint of all-cause death and heart failure readmission, and all-cause mortality. We compared outcomes between patients without and with frailty, and sought to identify factors which were associated with increase in clinical frailty score by the correlation analysis and linear regression analysis.

Results

Of 481 patients, 131 patients (27.2%) were frail. Male gender was less in patients with frailty than those without frailty (26.7% vs 73.3%, P<0.001). Frail patients had higher age (85.2±7.3 vs 78.7±9.4 years, P<0.001). During follow-up period of 396 [343, 697] days, composite endpoint (Kaplan-Meier event rate estimates, 77% vs. 60%; log-rank P<0.001), and all-cause mortality (Kaplan-Meier event rate estimates, 57% vs. 28%; log-rank P<0.001) was higher in patients with frailty than those without frailty. Multivariate Cox regression analysis revealed frailty was significantly and independently associated with mortality (HR=1.40, 95% CI=1.17–1.68, P<0.001). CFS was significantly correlated with age (r=0.401, P<0.001), sex (r=0.223, P<0.001), body mass index (r=−0.146, P=0.001), hemoglobin (r=−0.148, P=0.001), albumin (r=−0.222, P<0.001), left ventricular diastolic diameter (r=−0.184, P<0.001), interventricular septum thickness (r=−0.124, P=0.008), left ventricular mass (r=−0.217, P<0.001), tricuspid annular plane systolic excursion (r=−0.165, P=0.001), and tricuspid regurgitation pressure gradient (TRPG) (r=0.189, P<0.001). Multivariate linear regression analysis using these factors as covariates revealed age (standardized β: 0.337, P<0.001), sex (standardized β: 0.120, P=0.014), albumin (standardized β: −0.151, P=0.003) and TRPG (standardized β: 0.129, P=0.005) were significantly and independently associated with increase in clinical frailty score.

Conclusion

Our results suggest that not only nutritional factors but also a cardiac factor were associated with frailty, and frailty was associated with mortality in patients with HFpEF. Improvement of hemodynamics in HFpEF patients as well as improvement of nutrition might contribute to alleviation of frail in HFpEF patients.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnostics K.K.; Fuji Film Toyama Chemical Co. Ltd.

Frequency-specific efficacy of intratympanic steroid on idiopathic sudden sensorineural hearing loss

Background: Hearing recovery would be different in each sound frequency in patients with idiopathic sudden sensorineural hearing loss (ISSNHL).Aims/objectives: To analyze frequency-specific efficacy of intratympanic steroid on ISSNHL.Materials and methods: Of a total of 381 patients with ISSNHL (hearing threshold ≥40 dB; ≤30 days until treatment), 174 patients (174 ears) received systemic steroid plus hyperbaric oxygen therapy (HBO group), and 207 patients (208 ears) received systemic plus intratympanic steroid (IT group). Hearing thresholds at 125-8000 Hz were measured at every octave before and after treatment.Results: % of patients with hearing gains ≥10 dB in the IT group was significantly higher for 500 Hz and the average of 5 mid-frequencies, tended to be higher for 1000 Hz, but was significantly lower for 8000 Hz, compared to the HBO group. Multiple regression analysis showed that hearing recovery was negatively correlated with patients' age for 125/2000/4000/8000 Hz and with days from onset to treatment for all frequencies, and also revealed better hearing recovery at 500/1000 Hz in the IT group than in the HBO group.Conclusions: Intratympanic steroid is more effective than hyperbaric oxygen to yield better hearing outcomes at mid-frequencies and would be advantageous to restore sound/speech perception.Significance: Superiority of intratympanic steroid over hyperbaric oxygen for treating ISSNHL was verified.

Potential patient screening for late-onset Pompe disease in suspected sleep apnea: a rationale and study design for a Prospective Multicenter Observational Cohort Study in Japan (PSSAP-J Study)

BACKGROUND

Pompe disease is an autosomal recessive disorder caused by deficiency of the acid α-glucosidase (GAA) enzyme. GAA deficiency induces progressive glycogen accumulation which leads to weakness of the respiratory muscle including the diaphragm. Pompe disease is one of the few myopathies, for which an established therapy is available. Thus, earlier detection of potential late-onset Pompe disease (LOPD) and earlier intervention would have a significant clinical impact.

PURPOSE

Our hypothesis is that sleep problems including sleep disordered breathing (SDB) and clinical symptoms may indicate an early stage of LOPD since decreased respiratory muscle activity generally first presents during sleep. Thus, the aims of this prospective, multicenter observational cohort study in Japan (PSSAP-J) are to demonstrate a higher prevalence of LOPD in a sleep lab-based population (primary outcome), and to identify predictive factors for LOPD from findings in diagnostic polysomnography (PSG) and clinical symptoms (secondary outcomes).

METHODS

The study design is a prospective multicenter observational cohort study. Consecutive patients who present to sleep labs due to suspected SDB for an overnight PSG will be enrolled. All patients will be measured for creatine kinase, GAA activity, and if necessary, genetic analysis of GAA. Furthermore, chest X-ray, pulmonary function test, and arterial blood gas analysis will be collected. Then, prevalence and specific findings of LOPD will be assessed.

RESULT

Congenital myopathy shows a shift from slow-deep to rapid-shallow breathing during transition from wakefulness to sleep accompanying a symptom of waking with gasping (actual further results are pending).

DISCUSSION

The distribution in respiratory physiology between during wakefulness and sleep specific to LOPD may provide insights into early-stage detection.

CLINICAL TRIAL REGISTRATION NUMBER

UMIN000039191, UMIN Clinical Trials Registry ( http://www.umin.ac.jp/ctr ).

A Transmission-Line-Based Cochlear Standing Wave Model To Elucidate Mechanism of Human Auditory System

How do people hear sounds? As a counterpart of Prof. G. V. Békésy's traveling wave theory, we have proposed resonance theory of outer hair cells and cochlear standing wave theory, respectively. Based on these proposals, this paper develops a transmission-line-based cochlear standing wave model. Since the macroscopic cochlear model is designed as it looks like, various auditory physiology can be explained. Transient analyses with pure-tone excitation and Gaussian pulse excitation are carried out, and Prof. D. Kemp's otoacoustic emission (OAE) is demonstrated successfully.Clinical relevance-Our new model has a great potential to explain auditory physiology including structural inner disorders, hearing loss, and even tinnitus.

Expression of Cl- channels/transporters in nasal polyps

PURPOSE

Nasal polyp formation is a common sequela of prolonged chronic rhinosinusitis, but the mechanism underlying this disease state is still controversial. We compared the expressions of Cl^- channels/transporters in nasal polyps with those in inferior turbinates to explore whether a deficiency in Cl^- transport may participate in the pathophysiology of nasal polyp formation as in patients with cystic fibrosis.

METHODS

Nasal polyps and inferior turbinates were collected from 12 chronic rhinosinusitis patients with hypertrophic rhinitis and/or nasal polyps. Expressions of cystic fibrosis transmembrane conductance regulator (CFTR), pendrin, Na⁺-K⁺-2Cl^- cotransporter 1 (NKCC1), SLC26A3, TMEM16A and anion exchanger 2 (AE2) were examined by fluorescence immunohistochemistry using Alexa Fluor 488.

RESULTS

CFTR was weakly expressed on the epithelial surface of the turbinate mucosa whereas the nasal polyps showed almost no fluorescence. Pendrin was mainly expressed on the epithelial surface in both tissues. The fluorescence was moderate in the nasal polyps and strong in the turbinate mucosa. For NKCC1, moderate fluorescence was observed throughout the entire epithelial layer of the nasal polyps, but the turbinate mucosa exhibited almost no fluorescence. On the other hand, no fluorescence for SLC26A3, TMEM16A or AE2 was seen in either tissue.

CONCLUSION

These results suggest that CFTR, pendrin and NKCC1 may participate in the pathogenesis of nasal mucosal edema and play roles in the mechanism of nasal polyp formation.

P1788The outcome of TAVI in patients with small annulus and the comparison between intra-annular and supra-annular devices in small anulus: From the analysis of the Japanese nationwide registry

Background

Transcatheter aortic valve implantation (TAVI) has been widely accepted strategy of the treatment for aortic stenosis in patients at intermediate to high or prohibitive surgical risk. The Asian people are of smaller body size compared to Western people. As the result, Asian people have smaller aortic annulus size, which accommodate only smaller transcatheter heart valves (THVs), however, the details and consequences of small aortic annulus size in TAVI is uncertain.

Purpose

The purposes of this study were to clarify the short-term outcomes of TAVI in patients with small annulus and the differences of intra-annular and supra-annular THVs in small annulus using Japanese national TAVI registry.

Methods

Multi-detector computed tomography (MDCT) was performed before TAVI and the annulus area was registered. We compared the 30-day clinical outcomes between patients with and without small annulus (annulus area 3.14cm2). Further investigation to compare intra-annular and supra-annular THVs in patients with small annulus was conducted.

Results

The total of 5,870 patients (103 sites in Japan) who underwent TAVI between August 2013 to December 2017 were enrolled in this study. Out of 5,870 patients, 647 had small annulus.

Thirty-day mortality, new pacemaker implantation and stroke rate were comparable between patients with and without small annulus. Echocardiography within 30 days after TAVI revealed that patients with small annulus had significantly smaller indexed effective orifice area (iEOA, 1.10.cm2/m2 [0.92–1.35] vs. 1.16 cm2/m2 [0.96–1.39], p<0.001), higher mean pressure gradient (10.0 mmHg [6.9–14.2] vs. 8.5 mmHg [6.0–11.5], p<0.001) and lower frequency of paravalvular leakage moderate (17.3% vs. 24.4%, p<0.001). Patient-prosthesis mismatch (PPM) were more frequent in patients with small annulus (p=0.002). Logistic regression analysis revealed that small annulus (OR: 1.82; 95% CI: 1.45–2.30, p<0.001), female gender (OR: 0.54; 95% CI: 0.42–0.70, p<0.001), weight (OR: 1.03; 95% CI: 1.02–1.04, p<0.001), height (OR: 1.04; 95% CI: 1.02–1.05, p<0.001), hyperlipidemia (OR: 1.25; 95% CI: 1.07–1.47, p=0.006), femoral access (OR: 0.80; 95% CI: 0.66–0.97, p=0.026) were significantly associated with the PPM after TAVI.

The use of SAPIEN 3 20mm THV in patients with small annulus was associated with the smaller iEOA (0.94 cm2/m2 [0.78–1.06] vs. 1.07 cm2/m2 [0.84–1.24], p=0.001) and higher mean pressure gradient (14.0 mmHg [10.0–18.5] vs. 11.0 [7.0–14.0], p<0.001) compared to the usage of Evolut R 23 mm THV. The rate of paravalvular leakage more than moderate was similar in both THVs (14.4% vs. 16.5%, p=0.69).

Conclusions

Small annulus did not affect clinical 30-day outcomes, however, small annulus was associated with smaller iEOA and higher mean pressure gradient. Supra-annular device might contribute the better hemodynamical improvement in patients with small annulus without increase of paravalvular leakage.

Acknowledgement/Funding

None

P5734The outcome of intra-aortic balloon pumping support for acute myocardial infarction with extracorporeal membrane oxygenation therapy

Background

It has been reported that intra-aortic balloon pumping (IABP) support for acute myocardial infarction (AMI) with cardiogenic shock did not reduce short and long-term mortality. However, the significance of IABP support for AMI patients with extracorporeal membrane oxygenation (ECMO) therapy remains unclear. The aim of this study was to investigate the effect of IABP support for the short and long-term outcome in AMI patients who received ECMO.

Methods

Using the database of the Osaka Acute Coronary Insufficiency Study (OACIS), 12,093 consecutive AMI patients were enrolled in this analysis. Among these, we analyzed 520 patients with ECMO. We classified the patients into two groups, patients who received IABP support [IABP group (n=460)] and patients who did not [no IABP group (n=60)]. Primary outcome was all-cause death.

Results

Study patients had following baseline clinical characteristics, age: 66.8±12.0 year old, male: 78.3%, diabetes mellitus: 41.0%, Killip class≥II: 66.2%, multi-vessel disease: 72.3%, peak creatine phosphokinase >3000IU/L: 68.1%. During a mean follow-up period of 349±625 days, Kaplan-Meier analysis revealed that the all-cause death was significantly lower in IABP group than no IABP group for 30-day (45.5% vs 72.7%, log-rank p<0.001) and long-term (66.2% vs 78.4%, Log rank p=0.005) follow-up period. Cox multivariate analysis revealed that IABP support was significantly associated with a reduced risk of mortality (Hazard ratio 0.445, 95% confidence interval 0.289 to 0.687, p<0.001).

Conclusions

IABP support for AMI patients with ECMO was significantly associated with reduced risks of the short and long-term mortality, suggesting that IABP support might contribute to improvement of the survival in AMI patients with ECMO.

Calmodulin and protein kinases A/G mediate ciliary beat response in the human nasal epithelium

BACKGROUND

Mucociliary clearance of the airway epithelium is an essential function for mucosal defense. We recently proposed a hypothetical mechanism of ciliary beat regulation, in which the pannexin-1 (Panx1)-P2X7 unit serves as an oscillator generating a periodic increase in intracellular Ca²⁺ ([Ca²⁺ ]_i ). In the present study, we examined the localization of Panx1 and P2X7 at the ultrastructural level, and investigated the regulatory pathway subsequent to [Ca²⁺ ]_i increase.

METHODS

The inferior turbinate mucosa was collected from patients with chronic hypertrophic rhinitis during endoscopic sinonasal surgery. The mucosa was examined by transmission immunoelectron microscopy for Panx1 and P2X7. Alternatively, the mucosa was cut into thin strips, and ciliary beat frequency (CBF) was measured under a phase-contrast light microscope with a high-speed digital video camera.

RESULTS

In immunoelectron microscopy, immunoreactivities for Panx1 and P2X7 were localized along the plasma membrane of the entire length of the cilia. CBF was significantly increased by stimulation with 100 µM acetylcholine (Ach). The Ach-induced CBF increase was significantly inhibited by calmidazolium (calmodulin antagonist), SQ22536 (adenylate cyclase inhibitor), ODQ (guanylate cyclase inhibitor), KT5720 (protein kinase A inhibitor), and KT5823 (protein kinase G inhibitor). Fluorodinitrobenzene (creatine kinase inhibitor) completely inhibited the ciliary beat in a time- and dose-dependent manner.

CONCLUSION

These results indicate that Panx1 and P2X7 coexist at the cilia of the human nasal epithelial cells and that the ciliary beat is regulated by calmodulin, adenylate/guanylate cyclases and protein kinases A/G, and crucially depends on creatine kinase.

P1717The clinical impact of intra-aortic balloon pumping for acute coronary syndrome from Mie ACS registry

Background

Intra-Aortic Balloon Pumping (IABP) was widespread used in cases of Acute Coronary Syndrome (ACS) at daily clinical situation in Japan, even though the efficacy of IABP in AMI patients with cardiogenic shock was not proved. The aim of this study was to investigate the efficacy of IABP use in ACS patients in Japan.

Methods

We investigated 2-year all-cause-mortality of 2,660 enrolled ACS patients including 358 patients with IABP and 2,302 patients without IABP from Mie ACS registry.

Results

We compared a 1:1 propensity score-matched cohort of 426 ACS patients with or without IABP (n=213, respectively). 2-year mortality was significantly higher in patients with IABP than without IABP (p=0.02, Figure A). In addition, IABP usage was independent predictor of mortality with hazard ratio of 1.6 by multivariate analysis. However, 2-year mortality was not statistically different between 2 groups only when analyzed patients with shock (p=0.60, Figure B).

Figure 1

Conclusion

IABP was not commonly recommended in ACS patients. However, IABP was might as well used in some situation especially in shock.

128Change in geriatric nutritional risk index predicts one-year mortality in patients with heart failure with preserved ejection fraction

Background

Malnutrition is associated with adverse prognosis in heart failure patients. However, in patients with heart failure with preserved ejection fraction (HFpEF), the effects of change in nutritional status during hospitalization on prognosis is unknown. Geriatric nutritional risk index (GNRI) is a widely used objective index for evaluating nutritional status. Low GNRI (<92) has moderate or severe nutritional risk and high GNRI (≥92) has no or low nutritional risk.

Purpose

The purpose of this study was to clarify the effect of change in GNRI during hospitalization on one-year mortality and the association between the value of GNRI and one-year mortality in patients with HFpEF.

Methods

We prospectively registered patients with HFpEF in PURSUIT-HFpEF registry when they were hospitalized for heart failure in 29 hospitals. Preserved ejection fraction was defined as more than 50% of left ventricular ejection fraction. Of the 486 patients who registered PURSUIT-HFpEF, 228 cases with one-year follow-up data were examined. GNRI was calculated as follows: 14.89 × serum albumin (g/dl) + 41.7 × body mass index/22.

Results

Mean age was 81±10 years and 100 patients (44%) were male. During a median [interquartile range] follow-up period of 374 [342, 400] days, 28 patients (12%) died. Mortality was significantly higher in patients with low GNRI at admission (n=65) than those with high GNRI at admission (n=163) (26% vs. 9%, log-rank P=0.011) and higher in patients with low GNRI at discharge (n=109) than those with high GNRI at discharge (n=119) (22% vs. 6%, log-rank P=0.002). Multivariate analysis with Cox proportional hazard model with patient characteristics at admission revealed that low GNRI at admission was independently associated with mortality (hazard ratio: 0.96, 95% CI: 0.93–0.99, P=0.035) and that with patient characteristics at discharge revealed that low GNRI at discharge was independently associated with mortality (hazard ratio: 0.94, 95% CI: 0.91–0.97, P<0.001). We also compared mortality by dividing patients into 4 group according to whether GNRI was high or low at the time of admission and discharge. Patients with low GNRI at admission and at discharge (n=59) exhibited the highest mortality, on the other hand, patients with high GNRI at admission and low GNRI at discharge (n=50) exhibited higher mortality than those with high GNRI both at admission and at discharge (n=113) (Low and low: 28% vs. High and low: 14% vs. High and high: 6% vs. Low and high: 0%, log-rank P=0.010).

All cause mortality

Conclusion

GNRI at admission or at discharge was independently associated with one-year mortality in patients with HFpEF. Moreover, worsening GNRI during hospitalization is associated with the worse prognosis. It is important to prevent lowering GNRI during treatment of acute decompensated HFpEF.

Acknowledgement/Funding

Roche Diagnostics, FUJIFILM Toyama Chemical

P2659Difference of prognostic impact of Killip classification in ACS patients with or without hemodialysis

Background

Cardiovascular deaths are more frequently in hemodialysis (HD) patients compared to general population. However, difference of prognosis of acute coronary syndrome (ACS) patients with or without HD were not well evaluated.

Purpose

The purpose of this study was to evaluate the clinical and prognostic characteristics of ACS patients with HD compared to that of ACS patients without HD.

Methods

We investigated 3427 ACS patients including 63 HD and 3364 non-HD patients between 2013 and 2017 using date from Mie ACS registry, a retrospective and multicenter registry. The primary outcome was defined as all-cause mortality.

Results

HD patients showed significantly higher prevalence of diabetes mellitus, past treatment of coronary artery disease, history of myocardial infarction and Killip ≥2 compared to non-HD patients (p<0.05, respectively). During the follow-up periods (median 719 days), 425 (12.4%) patients experienced all-cause death. HD patients demonstrated the higher all-cause mortality rate compared to that of non-HD patients during the follow-up (11.9% versus 38.1%, p<0.001, chi square). Kaplan Meier survival curves demonstrated that HD and non-HD patients with Killip 1 showed similar 30-day mortality, and Killip ≥2 patients also showed similar prognosis (Left side of figure). On the other hand, all cause mortality at 2 years were higher in Killip 1 HD patients compared to Killip 1 non-HD patients and similar between Killip 1 HD patients and Killip ≥2 non-HD patients in the 30 days landmark analysis (Right side of figure). In addition, cox regression analyses for all cause mortality demonstrated that HD was a strongest independent prognostic factor not of 30-day mortality but of after 30-day mortality with hazard ratio of 4.09 (95% confidential interval: 2.32–7.21, p<0.001).

Figure 1

Conclusion

Careful management are required in chronic phase for ACS patients with HD even in Killip 1 classification.

Efficacy of Intratympanic Steroid on Idiopathic Sudden Sensorineural Hearing Loss: An Analysis of Cases With Negative Prognostic Factors

Purpose We retrospectively studied the efficacy of intratympanic steroid administration in comparison with hyperbaric oxygen (HBO) therapy for idiopathic sudden sensorineural hearing loss (ISSNHL) with negative prognostic factors. Method We enrolled 301 patients (302 ears) with ISSNHL (average hearing level at 250-4000 Hz ≥ 40 dB; time from onset to treatment ≤ 30 days). From August 2002 to March 2009, 174 patients (174 ears) received systemic steroid plus HBO therapy (HBO group), and from June 2015 to January 2018, 127 patients (128 ears) received systemic plus intratympanic steroid (IT group). Hearing outcomes were evaluated by 6 indices: cure rate, marked-recovery rate (percent of patients with hearing gain ≥ 30 dB), recovery rate (percent of patients with hearing gain ≥ 10 dB), hearing gain, hearing level after treatment, and percent hearing improvement compared to the unaffected contralateral ear. Results The recovery rate was significantly higher in the IT group than in the HBO group (80.5% vs. 68.4%, p = .019). The IT group showed a higher recovery rate than the HBO group in patients aged ≥ 60 years ( p = .010), patients with early (≤ 7 days from onset) treatment ( p = .005), patients with initial hearing levels ≥ 90 dB ( p = .037), and patients with vertigo/dizziness ( p = .040). The IT group also showed higher hearing gain and percent hearing improvement than the HBO group in patients with vertigo/dizziness ( p = .046 and p = .026, respectively). Conclusions Systemic plus intratympanic steroid is more effective for ISSNHL than systemic steroid plus HBO, particularly in patients with negative prognostic factors, such as old age, profound hearing loss, and/or presence of vertigo/dizziness.

Usefulness of Silent MR Angiography for Intracranial Aneurysms Treated with a Flow-Diverter Device

BACKGROUND AND PURPOSE

The flow-diverter device has been established as a treatment procedure for large unruptured intracranial aneurysms. The purpose of this study was to compare the usefulness of Silent MR angiography and time-of-flight MRA to assess the parent artery and the embolization state of the aneurysm after a flow-diverter placement.

MATERIALS AND METHODS

Seventy-eight large, unruptured internal carotid aneurysms in 78 patients were the subjects of this study. After 6 months of treatment, they underwent follow-up digital subtraction angiography, Silent MRA, and TOF-MRA, performed simultaneously. All images were independently reviewed by 2 neurosurgeons and 1 radiologist and rated on a 4-point scale from 1 (not visible) to 4 (excellent) to evaluate the parent artery. The aneurysmal embolization status was assessed with 2 ratings: complete or incomplete occlusion.

RESULTS

The mean scores of Silent MRA and TOF-MRA regarding the parent artery were 3.18 ± 0.72 and 2.31 ± 0.86, respectively, showing a significantly better score with Silent MRA (P < .01). In the assessment of the embolization of aneurysms on Silent MRA and TOF-MRA compared with DSA, the percentages of agreement were 91.0% and 80.8%, respectively.

CONCLUSIONS

Silent MRA is superior for visualizing blood flow images inside flow-diverter devices compared with TOF-MRA. Furthermore, Silent MRA enables the assessment of aneurysmal embolization status. Silent MRA is useful for assessing the status of large and giant unruptured internal carotid aneurysms after flow-diverter placement.

Decreased ciliary beat responsiveness to acetylcholine in the nasal polyp epithelium

OBJECTIVE

We investigated the difference in ciliary beat responsiveness to acetylcholine in ex vivo and the difference in the expressions of associated molecules (M1/M3 muscarinic receptors, pannexin-1 and P2X7 purinergic receptor) between the nasal polyp and turbinate mucosa.

STUDY DESIGN

Laboratorial study.

PARTICIPANTS

Nasal polyp and inferior turbinate were collected from patients with hypertrophic rhinitis and/or nasal polyp during endoscopic sinonasal surgery.

MAIN OUTCOME MEASURES

The mucosa was cut into thin strips, and ciliary movement was observed under a phase-contrast light microscope equipped with a high-speed digital video camera. The samples were also examined by scanning electron microscopy, fluorescence immunohistochemistry, and quantitative reverse transcription-polymerase chain reaction.

RESULTS

Cilia were well preserved in both tissues at the ultrastructural level. The baseline ciliary beat frequency (CBF) was not different between the two tissues. The CBF of the turbinate was significantly increased by stimulation with acetylcholine (P < 0.001), but that of the polyp was not. The ratio of the acetylcholine-stimulated CBF to the baseline CBF was significantly lower in the polyp than in the turbinate (P < 0.001). Immunohistochemical study revealed that immunoreactivities for M3, pannexin-1 and P2X7 were weaker in the polyp than in the turbinate. The mRNA expressions of M1, M3 and P2X7 were significantly lower and that of pannexin-1 tended to be lower in the polyp than in the turbinate.

CONCLUSIONS

These results indicate that ciliary beat responsiveness to acetylcholine is decreased in the nasal polyp. This may be explained by the decreased expressions of M3, P2X7 and probably pannexin-1 in this tissue.

The impact of external fixation on mortality in patients with an unstable pelvic ring fracture: a propensity-matched cohort study

AIM

There is not adequate evidence to establish whether external fixation (EF) of pelvic fractures leads to a reduced mortality. We used the Japan Trauma Data Bank database to identify isolated unstable pelvic ring fractures to exclude the possibility of blood loss from other injuries, and analyzed the effectiveness of EF on mortality in this group of patients.

PATIENTS AND METHODS

This was a registry-based comparison of 1163 patients who had been treated for an isolated unstable pelvic ring fracture with (386 patients) or without (777 patients) EF. An isolated pelvic ring fracture was defined by an Abbreviated Injury Score (AIS) for other injuries of < 3. An unstable pelvic ring fracture was defined as having an AIS ≥ 4. The primary outcome of this study was mortality. A subgroup analysis was carried out for patients who required blood transfusion within 24 hours of arrival in the Emergency Department and those who had massive blood loss (AIS code: 852610.5). Propensity-score matching was used to identify a cohort like the EF and non-EF groups.

RESULTS

With the use of propensity-score matching using the completed data, 346 patients were matched. When the propensity-score matching was adjusted, EF was associated with a significantly lower risk of death (p = 0.047). In the subgroup analysis of patients who needed blood transfusion within 24 hours and those who had massive blood loss, EF was associated with a significantly lower risk of death in patients who needed blood transfusion within 24 hours (p = 0.014) and in those with massive blood loss (p = 0.016).

CONCLUSION

The use of EF to treat unstable pelvic ring fractures was associated with a significantly lower risk of death, especially in patients with severe fractures. Cite this article: Bone Joint J 2018;100-B:233-41.

Incidence of elevated procalcitonin and presepsin levels after severe trauma: a pilot cohort study

Procalcitonin (PCT) and presepsin (PSEP) are useful biomarkers for diagnosing sepsis; however, elevated PCT and PSEP levels may be observed in conditions other than sepsis. We hypothesised that PCT and PSEP levels could increase after severe traumatic injuries. Trauma patients with an Injury Severity Score of ≥16 from October 2013 to September 2015 were enrolled in our study. We examined PCT and PSEP levels and their positive rates on days 0 and 1. PCT and PSEP levels on days 0 and 1 were compared. Risk factors for increasing sepsis biomarker levels were identified by multivariate logistic regression analyses. In this study, 75 patients were included. PCT levels on days 0 and 1 were 0.1±0.4 and 1.8±6.3 ng/ml, respectively (P=0.02). PSEP levels on days 0 and 1 were 221±261 and 222±207 pg/ml, respectively (P=0.98). As per multivariate logistic regression analyses, packed red blood cell (PRBC) transfusion was the only independent risk factor for higher PCT levels on day 1 (P=0.04). Using PCT to diagnose sepsis in trauma patients on day 1 requires caution. PRBC transfusion was found to be a risk factor for increasing PCT levels. On the other hand, PSEP levels were not affected by trauma during the early phases.

Non-REM sleep-disordered breathing affects performance on the psychomotor vigilance task

PURPOSE

Although many studies have investigated the clinical importance of sleep apnea on rapid eye movement (REM) and non-REM (NREM) sleep, the relationship between behavioral performance and apneic events during different sleep phases remains unclear. In the present study, we sought to investigate the effect of sleep phase fragmentation due to sleep-disordered breathing (SDB) during REM and NREM on the vigilance and sustainability of attention based on psychomotor vigilance task (PVT) performance.

METHODS

From a pool of subjects who underwent consecutive diagnostic polysomnography (PSG) for obstructive sleep apnea, 163 adult subjects with both REM and NREM sleep ≥ 30 min were enrolled for our study and performed a standardized 10-min PVT. The main outcome variables of the PVT were mean reaction time (RT), PVT Lapse count, and the slope of the reciprocal RT. Subjective sleepiness was measured using the Epworth Sleepiness Scale (ESS).

RESULTS

After multivariate linear regression analysis with adjustment for age, sex, body mass index, and the apnea-hypopnea index (AHI) of the counterpart sleep phase, we found that AHI during NREM (AHI_NREM) compared to AHI during REM (AHI_REM) was significantly associated with PVT lapses.

CONCLUSIONS

Our results suggest that SDB during NREM has a significant impact on vigilance lapses compared to that of REM.

High expression of ABCG2 induced by EZH2 disruption has pivotal roles in MDS pathogenesis

Both proto-oncogenic and tumor-suppressive functions have been reported for enhancer of zeste homolog 2 (EZH2). To investigate the effects of its inactivation, a mutant EZH2 lacking its catalytic domain was prepared (EZH2-dSET). In a mouse bone marrow transplant model, EZH2-dSET expression in bone marrow cells induced a myelodysplastic syndrome (MDS)-like disease in transplanted mice. Analysis of these mice identified Abcg2 as a direct target of EZH2. Intriguingly, Abcg2 expression alone induced the same disease in the transplanted mice, where stemness genes were enriched. Interestingly, ABCG2 expression is specifically high in MDS patients. The present results indicate that ABCG2 de-repression induced by EZH2 mutations have crucial roles in MDS pathogenesis.