Impact of COVID-19 on the mental health of primary schoolchildren during the later phase of the pandemic: A case report of an 18-month longitudinal survey in a Japanese primary school

Background

Drastic changes such as school closures and stay-at-home measures due to the global COVID-19 pandemic, may have long-term negative effects on children's mental health; however, longitudinal studies after 2021 are limited. This study aimed to observe the long-term effects of the COVID-19 pandemic on children's mental health by exploring changes in their mental health over a period of 18 months.

Study design

We conducted a longitudinal study at Chiba Prefecture in Japan, focusing on schoolchildren's mental health changes.

Methods

Data were obtained from the Strengths and Difficulties Questionnaire (SDQ) questionnaire conducted at single primary school three times from October 2021 to March 2023 which and included 183 participants. This study adopted a linear-mixed model to evaluate changes in children's SDQ scores, with sex and grade as the independent variables, and participants as a random effect.

Results

Regarding changes in SDQ scores, there were no significant changes in the total difficulty scores or in each subscale; Emotional Symptoms, Conduct Problems, Hyperactivity/Inattention, Peer Problems, and Prosocial Behavior. There was no statistically significant interaction between changes in SDQ scores and sex.

Conclusions

This report indicates that the impact of the COVID-19 pandemic on the mental health of Japanese primary schoolchildren was negligible in the later phase of the pandemic. However, the impact may differ from country to country owing to factors such as social restrictions during the COVID-19 pandemic.

MAFB in macrophages regulates cold-induced neuronal density in brown adipose tissue

Transcription factor MAFB regulates various homeostatic functions of macrophages. This study explores the role of MAFB in brown adipose tissue (BAT) thermogenesis using macrophage-specific Mafb-deficient (Mafbf/f::LysM-Cre) mice. We find that Mafb deficiency in macrophages reduces thermogenesis, energy expenditure, and sympathetic neuron (SN) density in BAT under cold conditions. This phenotype features a proinflammatory environment that is characterized by macrophage/granulocyte accumulation, increases in interleukin-6 (IL-6) production, and IL-6 trans-signaling, which lead to decreases in nerve growth factor (NGF) expression and reduction in SN density in BAT. We confirm MAFB regulation of IL-6 expression using luciferase readout driven by IL-6 promoter in RAW-264.7 macrophage cell lines. Immunohistochemistry shows clustered organization of NGF-producing cells in BAT, which are primarily TRPV1+ vascular smooth muscle cells, as additionally shown using single-cell RNA sequencing and RT-qPCR of the stromal vascular fraction. Treating Mafbf/f::LysM-Cre mice with anti-IL-6 receptor antibody rescues SN density, body temperature, and energy expenditure.

POTENTIAL LIFE PROGNOSTIC MARKER FOR MESENCHYMAL TUMOR RESEMBLING UTERINE LEIOMYOSARCOMA

Benign uterine leiomyoma (U.LMA) and malignant uterine leiomyosarcoma (U.LMS), both uterine mesenchymal tumors, are distinguished by the number of cells exhibiting mitotic activity. However, uterine mesenchymal tumors contain tumor cells with various cell morphologies; therefore, making a diagnosis, including differentiating between benign and malignant tumors, is difficult. For example, cotyledonoid dissecting leiomyoma (CDL) or uterine smooth muscle tumors of uncertain malignant potential (STUMPs) are a group of uterine mesenchymal tumors for which a differential diagnosis is challenging. To date, a standardized classification system for uterine mesenchymal tumors has not yet been established. Furthermore, definitive preoperative imaging techniques or hematological examinations for the potential inclusion of CDL or STUMP in the differential diagnosis have not been defined. Several clinical studies have reported that there is no correlation between biomarker expression and mitotic rate or tumor recurrence. The immunohistochemical biomarkers reported so far cannot effectively help determine the malignant potential of CDL or STUMPs in patients who wish to become pregnant in the future. The establishment of gene expression profiles or detection of pathogenic variants by using next-generation molecular techniques can facilitate disease prediction, diagnosis, treatment, and prognosis. We examined the oncological properties of STUMP in adults using molecular pathological techniques on tissue excised from patients with uterine mesenchymal tumor. In a clinical study conducted by our medical team, the results of gene expression profiling indicated factors that may be associated with malignancy of uterine mesenchymal tumors. We herein describe the problems in diagnosing uterine mesenchymal tumors along with the results of the latest clinical studies. It is expected that the establishment of a diagnostic method targeting the characteristics of mesenchymal tumor cells will lead to the treatment of malignant tumors with a low risk of recurrence and metastasis.

EFFECT OF RBD MUTATIONS IN SPIKE GLYCOPROTEIN OF SARS-COV-2 ON NEUTRALIZING IGG AFFINITY

Certain mutant strains of SARS-CoV-2 are known to spread widely among humans, including the receptor binding domain (RBD) mutant, Y453F, from farmed minks, and the RBD mutant, N501Y, a mutation common to three major SARS-CoV-2 subvariants (B.1.1.7, B.1.351, and B.1.1.248) and omicron type SARS-CoV-2 BQ.1.1 and XBB.1.16 subvariants. We investigated the characteristics of the RBD mutants, Y453F and N501Y, using three-dimensional structural analysis. We also investigated the effect of Y453F, N501Y or the mutants of RBD of omicron type SARS-CoV-2 BQ.1.1 and XBB.1.16 subvariants on neutralizing antibodies in serum derived from individuals including children (aged 5-11 years) inoculated with mRNA based COVID-19 vaccine (BNT162b2: Pfizer/BioNTech) or COVID-19-positive patients or children (aged 5-11 years) after vaccination with BNT162b2. Our results suggest that SARS-CoV-2 subspecies with the RBD mutations Y453F or N501Y partially escaped detection by 4 neutralizing monoclonal antibodies and 21 neutralizing antibodies in serums derived from COVID-19-positive patients. The significantly low antibody titer of children against Omicron type SARS-CoV-2 BQ.1.1 subvariant and XBB.1.16 subvariant in Japan. Infection with SARS-CoV-2 subspecies that causes serious symptoms in humans may spread globally. In particular, since the antibody titer against the omicron type is low in children (aged 5-11 years) who have been vaccinated with conventional vaccines, therefore it is important for children to receive vaccines specific for the omicron type.

Reduction in disialyl-T antigen levels in mice deficient for both St6galnac3 and St6galnac4 results in blood filling of lymph nodes

Sialic acid (SA) is present at the terminal ends of carbohydrate chains in glycoproteins and glycolipids and is involved in various biological phenomena. The biological function of the disialyl-T (SAα2-3Galβ1-3(SAα2-6)GalNAcα1-O-Ser/Thr) structure is largely unknown. To elucidate the role of disialyl-T structure and determine the key enzyme from the N-acetylgalactosaminide α2,6-sialyltransferase (St6galnac) family involved in its in vivo synthesis, we generated St6galnac3- and St6galnac4-deficient mice. Both single-knockout mice developed normally without any prominent phenotypic abnormalities. However, the St6galnac3::St6galnact4 double knockout (DKO) mice showed spontaneous hemorrhage of the lymph nodes (LN). To identify the cause of bleeding in the LN, we examined podoplanin, which modifies the disialyl-T structures. The protein expression of podoplanin in the LN of DKO mice was similar to that in wild-type mice. However, the reactivity of MALII lectin, which recognizes disialyl-T, in podoplanin immunoprecipitated from DKO LN was completely abolished. Moreover, the expression of vascular endothelial cadherin was reduced on the cell surface of high endothelial venule (HEV) in the LN, suggesting that hemorrhage was caused by the structural disruption of HEV. These results suggest that podoplanin possesses disialyl-T structure in mice LN and that both St6galnac3 and St6galnac4 are required for disialyl-T synthesis.

Generation of a MyoD knock-in reporter mouse line to study muscle stem cell dynamics and heterogeneity

Myoblast determination protein 1 (MyoD) dynamics define the activation status of muscle stem cells (MuSCs), aiding in muscle tissue regeneration after injury. However, the lack of experimental platforms to monitor MyoD dynamics in vitro and in vivo has hampered the investigation of fate determination and heterogeneity of MuSCs. Herein, we report a MyoD knock-in (MyoD-KI) reporter mouse expressing tdTomato at the endogenous MyoD locus. Expression of tdTomato in MyoD-KI mice recapitulated the endogenous MyoD expression dynamics in vitro and during the early phase of regeneration in vivo. Additionally, we showed that tdTomato fluorescence intensity defines MuSC activation status without immunostaining. Based on these features, we developed a high-throughput screening system to assess the effects of drugs on the behavior of MuSCs in vitro. Thus, MyoD-KI mice are an invaluable resource for studying the dynamics of MuSCs, including their fate decisions and heterogeneity, and for drug screening in stem cell therapy.

Large Maf transcription factor family is a major regulator of fast type IIb myofiber determination

Myofibers are broadly characterized as fatigue-resistant slow-twitch (type I) fibers and rapidly fatiguing fast-twitch (type IIa/IIx/IIb) fibers. However, the molecular regulation of myofiber type is not entirely understood; particularly, information on regulators of fast-twitch muscle is scarce. Here, we demonstrate that the large Maf transcription factor family dictates fast type IIb myofiber specification in mice. Remarkably, the ablation of three large Mafs leads to the drastic loss of type IIb myofibers, resulting in enhanced endurance capacity and the reduction of muscle force. Conversely, the overexpression of each large Maf in the type I soleus muscle induces type IIb myofibers. Mechanistically, a large Maf directly binds to the Maf recognition element on the promoter of myosin heavy chain 4, which encodes the type IIb myosin heavy chain, driving its expression. This work identifies the large Maf transcription factor family as a major regulator for fast type IIb muscle determination.

Lunar gravity prevents skeletal muscle atrophy but not myofiber type shift in mice

Skeletal muscle is sensitive to gravitational alterations. We recently developed a multiple artificial-gravity research system (MARS), which can generate gravity ranging from microgravity to Earth gravity (1 g) in space. Using the MARS, we studied the effects of three different gravitational levels (microgravity, lunar gravity [1/6 g], and 1 g) on the skeletal muscle mass and myofiber constitution in mice. All mice survived and returned to Earth, and skeletal muscle was collected two days after landing. We observed that microgravity-induced soleus muscle atrophy was prevented by lunar gravity. However, lunar gravity failed to prevent the slow-to-fast myofiber transition in the soleus muscle in space. These results suggest that lunar gravity is enough to maintain proteostasis, but a greater gravitational force is required to prevent the myofiber type transition. Our study proposes that different gravitational thresholds may be required for skeletal muscle adaptation.

Transcription factor c-Maf deletion improves streptozotocin-induced diabetic nephropathy by directly regulating Sglt2 and Glut2

The transcription factor c-Maf has been widely studied and has been reported to play a critical role in embryonic kidney development; however, the postnatal functions of c-Maf in adult kidneys remain unknown as c-Maf-null C57BL/6J mice exhibit embryonic lethality. In this study, we investigated the role of c-Maf in adult mouse kidneys by comparing the phenotypes of tamoxifen-inducible (TAM-inducible) c-Maf-knockout mice (c-Maffl/fl; CAG-Cre-ERTM mice named "c-MafΔTAM") with those of c-Maffl/fl control mice, 10 days after TAM injection [TAM(10d)]. In addition, we examined the effects of c-Maf deletion on diabetic conditions by injecting the mice with streptozotocin, 4 weeks before TAM injection. c-MafΔTAM mice displayed primary glycosuria caused by sodium-glucose cotransporter 2 (Sglt2) and glucose transporter 2 (Glut2) downregulation in the kidneys without diabetes, as well as morphological changes and life-threatening injuries in the kidneys on TAM(10d). Under diabetic conditions, c-Maf deletion promoted recovery from hyperglycemia and suppressed albuminuria and diabetic nephropathy by causing similar effects as did Sglt2 knockout and SGLT2 inhibitors. In addition to demonstrating the potentially unique gene regulation of c-Maf, these findings highlight the renoprotective effects of c-Maf deficiency under diabetic conditions and suggest that c-Maf could be a novel therapeutic target gene for treating diabetic nephropathy.

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.

Relation of lymphopenia to comorbidity burden and its prognostic value in patients with acute decompensated heart failure with preserved left ventricular ejection fraction: a multicentre study

Background

Systemic inflammation resulting from comorbidities is postulated to play a central role in the pathophysiology of heart failure (HF) with preserved ejection fraction (HFpEF). Lymphopenia is a common manifestation of systemic inflammation and a prognostic factor in patients with HF. However, the association of lymphopenia with the comorbidity burden is unknown, and its prognostic value in patients with HFpEF admitted due to acute decompensated heart failure (ADHF) also remains elusive.

Purpose

We sought to clarify the relation of lymphopenia with the comorbidity burden, as well as its prognostic value and complementarity with the Get with the Guidelines-Heart Failure (GWTG-HF) risk score in ADHF patients with HFpEF.

Methods

Patients' data were extracted from the Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT-HFpEF), which is a prospective multicentre registry for patients with ADHF with a LVEF ≥50%. We analysed data of patients admitted between June 2016 and December 2020 who survived to discharge. The total lymphocyte count (per μL) and GWTG-HF risk score were obtained on admission, as previously reported. Comorbidity burden was defined as the number of comorbidities from the following: atrial fibrillation, hypertension, diabetes mellitus, coronary artery disease, chronic kidney disease, chronic obstructive pulmonary disease, anaemia, and obesity. The study endpoint was all-cause death.

Results

Over a median follow-up of 417 days, 181 of the 1013 included patients died. The proportion of patients with a total lymphocyte count in the lowest tertile was increasing with the increase in comorbidity burden (Figure 1). In the multivariate Cox analysis, a total lymphocyte count in the intermediate (hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.00–2.41, p=0.0486) and lowest tertile (HR 2.23, 95% CI 1.47–3.38, p=0.0002) was independently associated with all-cause death. There was a significant difference in the all-cause death rate among the groups stratified by total lymphocyte count tertile (Figure 2). The total lymphocyte count had a higher C-statistic value (0.627) for the prediction of all-cause death than the GWTG-HF risk score, and the C-statistic value of the GWTG-HF risk score was improved when the total lymphocyte count was added (0.613 to 0.636, p=0.0260).

Conclusions

Lymphopenia was significantly associated with comorbidity burden. Furthermore, it was a useful marker of poor prognosis in hospitalised patients with acute HFpEF and was shown to be complementary to the contemporary HF prognostic score.

Funding Acknowledgement

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

Clinical trajectory and outcomes of patients with heart failure with preserved ejection fraction with normal or indeterminate diastolic function

Background

Heart failure (HF) with preserved ejection fraction (HFpEF) is a chronic and progressive disease, but limited therapeutic strategies are currently available. Although left ventricular diastolic dysfunction (DD) is a prominent mechanism of HFpEF, a certain number of patients with HFpEF have a normal diastolic function (ND) or indeterminate diastolic function (ID). With the progressive nature of HFpEF, diastolic function may change over time. However, the change of diastolic function, its predictor and prognosis in patients with clinically established HFpEF remains unknown.

Purpose

To investigate the clinical trajectory and outcomes of patients with HFpEF with ND or ID and to identify factors associated with progression from ND or ID at discharge to DD at 1-year follow-up.

Methods

Using data from a prospective multicenter observational study of patients with HFpEF, we extracted 289 patients with HFpEF with ND or ID at discharge who had echocardiographic data at 1-year follow-up for the re-evaluation of diastolic function. Diastolic function was assessed according to the 2016 American Society of Echocardiography recommendations. Patients were classified according to the absence or presence of progression from ND or ID to DD at 1 year. The primary endpoint was a composite of all-cause death and HF rehospitalization.

Results

Median age was 81 years, and 138 (47.8%) patients were female. At 1 year, 107 (37%) patients progressed to DD. During a median follow-up of 709 days, the composite endpoint occurred in 90 (31.1%) patients. Compared to patients without progression to DD, those with progression to DD had a significantly higher cumulative incidence rate of the composite endpoint (incidence rate: 11.7/100 person-year versus 23.3/100 person-year, P&lt;0.001). Progression to DD (adjusted HR: 2.014, 95% CI: 1.239–3.273, P=0.005) was independently associated with the composite endpoint. Age (adjusted OR: 1.046, 95% CI: 1.008–1.087, P=0.018), body mass index (BMI) (adjusted OR: 1.107, 95% CI: 1.029–1.192, P=0.006), and serum albumin (adjusted OR: 0.459, 95% CI: 0.216–0.974, P=0.042) were independently associated with progression from ND or ID to DD at 1 year.

Conclusion

More than one-third of patients with HFpEF with ND or ID progressed to DD at 1 year and had poor clinical outcomes. Age, BMI, and serum albumin were independently associated with this progression.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by grants from Japan Society for the Promotion of Science KAKENHI (No. JP 17K09496) and Japan Agency for Medical Research and Development (No. JP16lk1010013).

Association between prognosis and the use of angiotensin-converting enzyme inhibitors and/or angiotensin II receptor blocker in frail patients with heart failure with preserved ejection fraction

Background

The effectiveness of angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin II receptor blockers (ARB) has not been demonstrated in patients with heart failure with preserved ejection fraction (HFpEF). We recently reported significant interaction between the use of ACE-I and/or ARB (ACE-I/ARB) and frailty on prognosis in patients with HFpEF.

Purpose

In the present study, we examined the association between ACE-I/ARB and prognosis in patients with HFpEF stratified by the presence or absence of frailty.

Methods

We examined the association between the use of ACE-I/ARB and prognosis according to the presence (Clinical Frailty Scale (CFS) ≥5) or absence (CFS ≤4) of frailty in patients with HFpEF in a post-hoc analysis of registry data. Primary endpoint was the composite of all-cause mortality and heart failure admission. Secondary endpoints were all-cause mortality and heart failure admission.

Results

Of 1059 patients, median age was 83 years and 45% were male. Kaplan-Meier analysis showed that the risk of composite endpoint (log-rank P=0.001) and all-cause death (log-rank P=0.005) in patients with ACE-I/ARB was lower in those with CFS ≥5, but similar between patients with and without ACE-I/ARB in patients with CFS ≤4 (composite endpoint: log-rank P=0.830; all-cause death: log-rank P=0.192). In a multivariable Cox proportional hazards model, use of ACE-I/ARB was significantly associated with lower risk of the composite endpoint (hazard ratio = 0.52, 95% CI: 0.33–0.83, P=0.005) and heart failure admission (hazard ratio = 0.45, 95% CI: 0.25–0.83, P=0.010) in patients with CFS ≥5, but not in patients with CFS ≤4 (composite endpoint: hazard ratio = 1.41, 95% CI: 0.99–2.02, P=0.059; heart failure admission: hazard ratio = 1.43, 95% CI: 0.94–2.18, P=0.091). The association between ACE-I or ARB and prognosis did not significantly differ by CFS (CFS ≤4: log-rank P=0.562; CFS ≥5: log-rank P=0.100, for with ACE-I vs. ARB, respectively). Adjusted HRs for CFS 1–4 were higher than 1.0, but were less than 1.0 at CFS 5.

Conclusions

In patients with HFpEF, use of ACE-I/ARB was associated with better prognosis in patients with frailty as assessed with the CFS, but not in those without frailty.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Roche

Deep vein thrombosis after leadless pacemaker implantation

Background

A leadless pacemaker has been used widely. The necessity of using large sheath (23 Fr) is one of the disadvantages of implanting leadless pacemaker. There are some reports about deep vein thrombosis (DVT)after leadless pacemaker, but the accurate number of DVT after leadless pacemaker implantation is unknown.

Method

This retrospective study analyzed patients who were implanted leadless pacemaker from January 2018 to August 2022. We included the patients who were conducted ultrasound for DVT both before and after leadless implantation. The primary endpoint was incidence of DVT by ultrasound one day after leadless pacemaker implantation in the leg where sheath was inserted.

Results

89 patients were included in this study. The mean age of this study was 86.2±7.4 years old and 88 patients (99%) were implanted leadless pacemaker from their right femoral vein. 49 patients (55%) took anticoagulant before leadless pacemaker implantation. About the primary endpoint, 12 patients (13.5%: 8 patients without anticoagulant and 4 patients with anticoagulant) had newly asymptomatic DVT. After the univariate analysis, patients with low body weight (OR: 0.90, CI: 0.83–0.98, p=0.011), short height (OR: 0.87, CI: 0.79–0.96, p=0.005) and small diameter of the femoral vein (OR: 0.65, CI: 0.46–0.92, p=0.015) tended to have DVT. The use of anticoagulant did not affect the incidence of DVT (OR: 0.365, CI: 0.10–1.3, p=0.114).

Conclusion

Asymptomatic DVT by ultrasound is found in 13.5% of patients after leadless pacemaker. The small body patients might have easier to have DVT after leadless pacemaker. We should consider performing ultrasound to check for DVT in high-risk patients after leadless pacemaker implantation.

Funding Acknowledgement

Type of funding sources: None.

The clinical relevance of quality of life in patients with acute decompensated heart failure with preserved ejection fraction: insights from the PURSUIT-HFpEF Registry

Background

Improvement of quality of life (QOL) is one of the most important therapeutic goals for patients with heart failure with preserved ejection fraction (HFpEF). It is, therefore, clinically relevant to comprehensively identify aggravating factors among cardiac factors, non-cardiac comorbidities, and social factors. The aim of this study was to elucidate determinant factors of impaired QOL and clarify the association between QOL and prognosis in patients with HFpEF.

Methods and results

Patient data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT HFpEF) study. EuroQol 5 dimensions 5-level (EQ-5D-5L) data were obtained at discharge to evaluate patients' health-related QOL. A total of 864 patients were enrolled in this study. Multivariable logistic regression analysis revealed that only non-cardiac factors such as age, female sex, frailty, malnutrition and inflammation were significantly associated with low EQ-5D-5L score, whereas cardiac factors showed no significant association after multivariable adjustment. A total of 206 patients died over a mean follow-up period of 2.0±1.2 years. Kaplan–Meier survival curve analysis demonstrated a significant increase in risk of mortality stratified by tertiles of EQ-5D-5L score (p&lt;0.0001). Cox multivariable analysis revealed that patients with low EQ-5D-5L score had a significantly greater risk of mortality than those with high EQ-5D-5L score (adjusted hazard ratio: 2.20 (1.40–3.45), p=0.001).

Conclusion

Among patients with HFpEF, non-cardiac factors such as age, female sex, frailty, malnutrition and inflammation are significantly associated with impaired QOL. The QOL score itself also offers useful prognostic information in patients with HFpEF.

Funding Acknowledgement

Type of funding sources: None.

Insight into the relationship between heart rate and mortality in patients in sinus rhythm with heart failure with preserved ejection fraction

Background

There are several reports showing that elevated heart rate (HR) is associated with poor outcomes in patients in sinus rhythm (SR) with heart failure with preserved ejection fraction (HFpEF), although the association is weak or none in HFpEF patients with atrial fibrillation (Af). However, in previous studies, cardiac and non-cardiac factors which may be associated with elevated HR, have not been fully adjusted for.

Purpose

The purpose of this study is to explore covariates of elevated HR and to investigate the relationship between heart rate and mortality in HFpEF patients in SR.

Methods and results

Of the 1161 patients, who registered prospective multicenter, observational study of patients with HFpEF (PURSUIT-HFpEF), 726 patients in SR were examined. We performed laboratory testing and echocardiography in the compensated stage (in stable condition after treatment of acute decompensated HF). Geriatric nutritional risk index (GNRI) was calculated as nutrition index. Resting heart rate (HR) was analyzed as categorical (tertiles, T1–3). We followed the patients for median of 598 days (interquartile range 329–1028 days) to observe the outcome all-cause mortality.

The Kaplan analysis revealed that there was a significant difference between heart rate and mortality (log-rank, p=0.001). Characteristics were compared between patients in T1 (HR ≤63) and T3 (HR ≥75). There were no differences in cardiac factors between patients in T1 and T3. C-reactive protein (CRP) was significantly higher in patients in T3 than those in T1 (p=0.0004,). GNRI was significantly lower in patients in T3 than those in T1 (p=0.001). After adjustment for covariates including N-terminal pro-B type natriuretic peptide and estimated glomerular filtration rate, CRP and GNRI significantly correlated with HR (continuous variable) by multiple regression analysis (beta-coefficient = 1.52, p=0.003 and beta-coefficient = −0.14, p=0.04, respectively). Taking T1 as the reference, multivariable Cox regression analysis revealed that T3 was independently associated with mortality (hazard ratio: 2.10, 95% confidence interval: 1.33–3.32, p=0.001).

Conclusion

Although elevated HR was associated with enhanced inflammation and malnutrition, it itself was an independent predictor of death in HFpEF patients in SR.

Funding Acknowledgement

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

Prognostic impact of the serial change of a systemic inflammation-nutrition index in patients with heart failure with preserved ejection fraction: insights from pursuit-hfpef registry

Background

Malnutrition and inflammation are associated with poor outcomes with heart failure (HF). It has been reported that advanced lung cancer inflammation index (ALI), calculated by body mass index × serum albumin level / neutrophil to lymphocyte ratio (NLR) can be useful for the risk stratification and predicting the post-discharge prognosis of the patients with acute decompensated heart failure (ADHF). However, there is no information available on the prognostic value of the serial ALI change in ADHF patients with preserved ejection fraction (HFpEF).

Methods and results

Patients' data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT HFpEF) study, which is a prospective multicenter observational registry for ADHF-HFpEF in Osaka. Laboratory data and body weight measurements were performed at the discharge and 1 year after the discharge. We analyzed 527 patients after exclusion of patients on dialysis, in-hospital death, missing follow-up data, or missing data to calculate ALI. The study patients were categorized by the serial change from baseline to 1 year after the discharge (ΔALI) as follows: low tertile: ΔALI &lt;−6.99 (n=176), middle tertile: −6.99 ≤ ALI &lt;8.44 (n=176), and high tertile: 8.44 ≤ ΔALI (n=175). The endpoints of the present study were all-cause death (ACD) and cardiovascular death (CVD). During a mean follow-up period of 1.5±1.0 years, 94 patients had ACD and 40 patients had CVD. The Kaplan-Meier analysis revealed that the patients with middle and low ΔALI at 1 year after heart failure hospitalization had a significantly greater risk of reaching the ACD and CVD than those with high ΔALI (ACD: 22% vs 22% vs 10%, p=0.0011, CVD: 10% vs 9% vs 3%, p=0.014). On multivariate Cox analysis, ΔALI was significantly associated with ACD independently of age, gender, serum NT-proBNP level, and baseline ALI after adjustment for NYHA functional class, serum creatinine level, serum hemoglobin level, serum CRP level, serum sodium level and LVEF.

Conclusion

This study showed that patients with the increased ALI after the discharge had improved outcome in comparison to those without the increased ALI. The serial change of ALI, a systemic inflammation-nutrition index, might be useful for stratifying ADHF patients with HFpEF at risk for the total mortality and cardiovascular mortality.

Funding Acknowledgement

Type of funding sources: None.

Influence of using history of immune checkpoint inhibitor therapy for neutropenia caused by combination therapy of ramucirumab and docetaxel

Recently, pretreatment with immune checkpoint inhibitors (ICIs) has been shown to enhance the therapeutic effects of the combination therapy of ramucirumab (RAM) and docetaxel (DTX); however, its influence on the drug's side effects remains unclear. This study investigated the influence of pretreatment with ICIs on the incidence of neutropenia caused by RAM + DTX therapy in patients with non-small cell lung cancer (NSCLC). Patients with NSCLC who received RAM + DTX therapy at Gifu Prefectural General Medical Center between April 2016 and December 2020 were enrolled. Retrospective data regarding age, sex, performance status and detailed treatment history, among others, at treatment initiation were collected from the patients' electronic medical records. Additionally, data on the course number of RAM + DTX therapy, supportive therapy and blood biochemical parameters, including leukocyte and neutrocyte counts, during the treatment period were collected. We identified 41 patients receiving RAM + DTX therapy. Among the more than grade 3 adverse events caused by this therapy, neutropenia was the most common (78.1%). Despite the fact that all previous risk factors influencing this incidence rate had corresponded, the only factor influencing the incidence rate of neutropenia more than grade 3 was ICI treatment history. A difference in the incidence of neutropenia more than grade 3 in the Kaplan-Meier curve was observed between patients with and without ICI pretreatment history (p = 0.037). The pretreatment history of ICI therapy affects the incidence of neutropenia caused by RAM + DTX therapy in patients with NSCLC.

Measurements of Strong-Interaction Effects in Kaonic-Helium Isotopes at Sub-eV Precision with X-Ray Microcalorimeters

We have measured the 3d→2p transition x rays of kaonic ^{3}He and ^{4}He atoms using superconducting transition-edge-sensor microcalorimeters with an energy resolution better than 6 eV (FWHM). We determined the energies to be 6224.5±0.4(stat)±0.2(syst)  eV and 6463.7±0.3(stat)±0.1(syst)  eV, and widths to be 2.5±1.0(stat)±0.4(syst)  eV and 1.0±0.6(stat)±0.3(stat)  eV, for kaonic ^{3}He and ^{4}He, respectively. These values are nearly 10 times more precise than in previous measurements. Our results exclude the large strong-interaction shifts and widths that are suggested by a coupled-channel approach and agree with calculations based on optical-potential models.

Characteristics and prognosis in heart failure with preserved ejection fraction patients without left ventricular hypertrophy

Background

Clinical heterogeneity exists in heart failure with preserved ejection fraction (HFpEF). Left ventricular (LV) structure in HFPEF is characterized by normal LV cavity size and LV hypertrophy (LVH). However some of HFPEF patients do not have LV hypertrophy, and these patients may have distinct characteristics,

Purpose

The purpose of this study is to clarify the clinical characteristics and the prognosis for HFPEF patients without LVH.

Methods

We studied 1097 patients, who were hospitalized for acute decompensated heart failure with LVEF ≥50%, and enrolled in the PURSUIT-HFpEF registry. Laboratory testing and echocardiography were examined in the compensated stage (in stable condition after treatment of acute decompensated HF). We divided these patients into 2 groups based on LV mass index (LVMI) in the compensated stage according to the American Society of Echocardiography/European Association of Cardiovascular Imaging recommendations; patients with LVH (48%) and those without LVH (52%).

Results

Patients without LVH had significantly lower levels of C-reactive protein and N-terminal pro brain natriuretic peptide (NT-proBNP) and higher levels of estimated glomerular filtration rate in the compensated stage than those with it (p&lt;0.05 for all). Cox hazard regression analysis showed that absence of LVH was favorably associated with the primary composite endpoint of all-cause death, HF rehospitalization, and cerebrovascular events (hazard ratio 0.776, 95% confidence interval 0.620-to 0.970, p&lt;0.05).

On the other hand, the frequency of atrial fibrillation (Af) in the decompensated stage was higher in patients without LVH than those with it (52.1% vs 39.3%, p&lt;0.001). Multivariate logistic analysis showed that absence of LVH was independently associated with presence of Af in the decompensated stage (odds ratio=1.520, 95% confidence interval 1.130 to 2.050, P&lt;0.01)

Conclusions

HFPEF patients without LVH have less organ damage and favorable prognosis. Af may play a role in the decompensation of HF in HFPEF patients without LVH.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Roche Diagnostics K.K. (Grant number: not applicable)Fuji Film Toyama Chemical Co., Ltd. (Grant number: not applicable)

Prediction of functional capacity by the HFA-PEFF score in patients with acute decompensated heart failure with preserved ejection fraction: a post-hoc analysis from the PURSUIT-HFpEF registry

Background

Diagnosing heart failure with preserved ejection fraction (HFpEF) is still challenging, and the H2FPEF- and the HFA-PEFF score were proposed as simple and reliable diagnostic tools. We recently reported that the HFA-PEFF score was significantly associated with the composite endpoint of all-cause death and heart failure readmission in patients with acute decompensated HFpEF (Sotomi. Eur J Heart Fail, in press).

Purpose

To investigate the relation whether the HFA-PEFF or H2FPEF score can evaluate functional capacity in patients with HFpEF

Methods

We calculated H2FPEF score and the second step of HFA-PEFF score among the registered patients in the PURSUIT-HFpEF (Prospective, Multicenter, Observational Study of Patients with Heart Failure with Preserved Ejection Fraction) study, which is a multicenter registration of patients hospitalized for acute decompensated HFpEF. We performed 6 minute walk (6MW) test and measured NT-proBNP before discharge. We followed the study patients for median of 360 days (IQR 237–630 days) to observe the major adverse cardiovascular events (MACE; composite of death, heart failure hospitalization and stroke).

Results

We enrolled 757 patients (age 81±9 years, male gender 45%) hospitalized for acute decompensated HFpEF for the present study. The H2FPEF score was obtained in 588 (77.7%) patients and all patients had ≥2 points. The HFA-PEFF score was obtained in 615 (81.2%) patients, though global longitudinal strain was not available. We divided these patients into 3 groups based on the HFA-PEFF score (score 2 to 4, 5, and 6) or on the H2FPEF score (score 0 to 3, 4 to 5 and 6 to 8). There were a significant difference in NT-pro BNP between 3 groups based on HFA-PEFF score (p=0.01, Table 1), and patients with score 6 had significantly higher NT-proBNP than those with score 2 to 4 (p=0.02). A significant difference was observed in 6MW distance among these groups (p=0.04, Table), and those with score 6 had significantly shorter distance than those with score 2 to 4 (p=0.04). Cox proportional hazard model selected HFA-PEFF score as a significant predictor for MACE, and Kaplan-Meier survival analysis demonstrated that classification of HFA-PEFF score significantly stratified the patients' risk for MACE. On the other hand, there was no significant difference in 6MW distance among 3 groups based on H2FPEF score (p=0.53), and H2FPEF score was not an independent predictor for MCE by the Cox model analysis. Moreover, the lowest H2PEF score group had higher NT-proBNP than other 2 groups (p=0.02)

Conclusions

The HFA-PEFF score predicted functional capacity as well as prognosis in patients hospitalized for HFpEF, while the H2PEF score did not.

Funding Acknowledgement

Type of funding sources: None. Table 1

The impact of substrate and trigger ablation for reduction of functional mitral regurgitation in patients with persistent atrial fibrillation

Background

Functional mitral regurgitation (FMR) is not uncommon in atrial fibrillation (AF) patients. Left atrial (LA) substrate remodeling and corresponding mitral valve annulus dilation has been reported as the most possible cause of FMR. Percutaneous catheter ablation (CA) is an effective treatment for AF. Although significant FMR could be improved by sinus restoration, patients with mitral regurgitation were more likely to experience recurrent AF post ablation, especially those with significant mitral regurgitation. There is no information available on the efficacy of CA for persistent AF in patients with FMR.

Purpose

The purpose of this study is to investigate the predictors of FMR improvement by CA and to determine the efficacy of substrate and trigger CA for persistent AF in patients with FMR.

Methods

We prospectively studied 512 consecutive patients admitted for persistent AF ablation from the EARNEST-PVI (Prospective Multicenter Randomized Study of Effect of Extensive Ablation on Recurrence in Patients with Persistent Atrial Fibrillation Treated with Pulmonary Vein Isolation) trial.

On admission, enrolled patients were randomly assigned in a 1:1 ratio to pulmonary vein isolation (PVI) or PVI-plus additional ablation (linear ablation or/and CFAE ablation). Of the 512 patients, we studied 94 patients with preoperative echocardiography showing moderate or greater baseline FMR. FMR grades were classified into 5 grades (0/1/2/3/4). The FMR improvement group (FMRI(+)) was defined as a case in which the FMR was improved by two or more grades compared the preoperative echocardiography and the one year follow-up examination.

Results

Of the 94 patients, 42 were in the PVI group and 52 were in the PVI-plus additional ablation group. There were 30 cases in the FMRI(+) group and 64 cases in the FMRI(−) group. There were no significant baseline differences in age, sinus rhythm maintenance, plasma B-type natriuretic peptide (BNP) level, left ventricular diastolic dimension, or left atrium dimension between the FMRI(+) and FMRI(−) groups. AF duration was significantly shorter in the FMRI(+) group than FMRI(−) groups (5.8±9.4 months vs 12.4±15.4 months, p&lt;0.0001). In addition, significantly more additional ablation cases were observed in the FMRI(+) group than in the FMRI(−) group (73.3% vs 46.8%, p=0.016). In multivariate analyses, only additional ablation was an independent predictor of FMRI (odds ratio 0.226 95% CI 0.081–0.626; p=0.004).

Conclusions

Catheter ablation is a valid option for the treatment of AF in patients with functional MR and additional substrate and trigger ablation were the only independent predictor of FMR improvement.

Funding Acknowledgement

Type of funding sources: None.

Influence of renal dysfunction on clinical outcomes in elderly patients with atrial fibrillation: a subanalysis of the phase 3, randomized, placebo-controlled ELDERCARE-AF trial

Background

Renal dysfunction is common in elderly patients with atrial fibrillation (AF) and is thought to be associated with increased risk of thromboembolic and bleeding events. Once-daily low-dose (15 mg) edoxaban was superior to placebo in preventing stroke or systemic embolic events (S/SEE) without significantly increasing major bleeding events in very elderly (≥80 years) non-valvular AF (NVAF) patients in whom standard oral anticoagulant therapy at approved doses was inappropriate (ELDERCARE-AF trial). Little is known about how renal dysfunction affects the effects of low-dose edoxaban in these patients.

Purpose

We used prespecified subgroup analysis to investigate the relation between renal function (assessed by creatinine clearance, CrCl) and the efficacy and safety of edoxaban in elderly NVAF patients.

Methods

ELDERCARE-AF patients were divided into 3 subgroups according to baseline CrCl: normal renal function/mild dysfunction (CrCl &gt;50 mL/min), moderate renal dysfunction (CrCl ≥30 to ≤50 [“30–50”] mL/min) and severe renal dysfunction (CrCl ≥15 to &lt;30 [“15–30”] mL/min). Primary efficacy and safety endpoints were annualized incidence of S/SEE and ISTH-defined major bleeding, respectively.

Results

Of 984 patients randomized to edoxaban 15 mg or placebo (each group N=492), 681 completed the trial. The 303 discontinuations were due to withdrawal of consent (n=158), death (n=135), or other causes (n=10). Discontinuation rate was the same in the edoxaban and placebo groups. S/SEE incidence in patients with CrCl &gt;50, 30–50 and 15–30 mL/min was 2.0%, 1.3% and 3.5%, respectively, in edoxaban, and 4.4%, 4.6% and 9.7%, respectively, in placebo. In those with CrCl 30–50 and 15–30 mL/min, it was significantly lower in edoxaban than in placebo (adjusted hazard ratio [HR], 0.30 [95% CI, 0.10–0.91], p=0.03; and 0.33 [95% CI, 0.16–0.71], p&lt;0.01, respectively). Incidence of major bleeding in patients with CrCl &gt;50, 30–50 and 15–30 mL/min was 1.0%, 1.8% and 6.2%, respectively, in edoxaban, and 0.9%, 1.5% and 2.4%, respectively, in placebo. Incidence of major bleeding in those with CrCl 15–30 mL/min was higher in edoxaban but not significantly (adjusted HR, 2.53 [95% CI, 0.96–6.72], p=0.062). Incidence of gastrointestinal bleeding in patients with CrCl 15–30 mL/min was 4.3% in edoxaban and 1.6% in placebo (adjusted HR, 2.61 [95% CI, 0.79–8.68], p=0.12). Incidence of all-cause death in patients with CrCl &gt;50, 30–50 and 15–30 mL/min was 5.8%, 6.8% and 15.2%, respectively, in edoxaban, and 7.0%, 6.3% and 15.5%, respectively, in placebo (no significant intergroup differences).

Conclusions

Incidence of S/SEE, major bleeding and all-cause death increased with declining renal function in elderly NVAF patients. Edoxaban 15 mg remained superior to placebo in preventing S/SEE, even in those with moderate to severe renal dysfunction. Incidence of major bleeding in patients with severe renal dysfunction was higher (non-significantly) with edoxaban than with placebo.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi-Sankyo Co., Ltd.

Nuclear factor E2-related factor 2 (NRF2) deficiency accelerates fast fibre type transition in soleus muscle during space flight

Microgravity induces skeletal muscle atrophy, particularly in the soleus muscle, which is predominantly composed of slow-twitch myofibre (type I) and is sensitive to disuse. Muscle atrophy is commonly known to be associated with increased production of reactive oxygen species. However, the role of NRF2, a master regulator of antioxidative response, in skeletal muscle plasticity during microgravity-induced atrophy, is not known. To investigate the role of NRF2 in skeletal muscle within a microgravity environment, wild-type and Nrf2-knockout (KO) mice were housed in the International Space Station for 31 days. Gene expression and histological analyses demonstrated that, under microgravity conditions, the transition of type I (oxidative) muscle fibres to type IIa (glycolytic) was accelerated in Nrf2-KO mice without affecting skeletal muscle mass. Therefore, our results suggest that NRF2 affects myofibre type transition during space flight.

Autophagy and glycolysis independently attenuate silibinin-induced apoptosis in human hepatocarcinoma HepG2 and Hep3B cells

PURPOSE

The mechanism of cytotoxicity of silibinin on two human hepatocellular carcinoma (HCC) cell lines, HepG2 (p53 wild-type) and Hep3B cells (p53 null), is examined in relation with the induction of autophagy and phosphorylation of AMP-activated protein kinase (p-AMPK).

MATERIALS AND METHODS

Levels of apoptosis in relation to the levels of autophagy and those of glycolysis-related proteins, glucose transporter 1/4 (Glut1/4) and hexokinase-II (HK2), in HepG2 and Hep3B cells were examined.

RESULTS

Silibinin-induced apoptosis was incomplete for HCC cell death in that up-regulated autophagy and/or reduced level of glycolysis, which are induced by silibinin treatment, antagonized silibinin-induced apoptosis. Inhibition of autophagy with 3-methyl adenine (3MA) or blocking of AMP-activated protein kinase (AMPK) activation with Compound C (CC) enhanced silibinin-induced apoptosis. The results confirm that AMPK involved in autophagy as well as in glycolysis remaining with silibinin is responsible for attenuation of silibinin-induced apoptosis. Blocking of AMPK or autophagy contributes to the enhancement of silibinin's cytotoxicity to HepG2 and Hep3B cells.

CONCLUSION

This study shows that incomplete apoptosis of HCC by silibinin treatment becomes complete by repression of autophagy and/or glycolysis.

Transcriptome analysis of gravitational effects on mouse skeletal muscles under microgravity and artificial 1 g onboard environment

Spaceflight causes a decrease in skeletal muscle mass and strength. We set two murine experimental groups in orbit for 35 days aboard the International Space Station, under artificial earth-gravity (artificial 1 g; AG) and microgravity (μg; MG), to investigate whether artificial 1 g exposure prevents muscle atrophy at the molecular level. Our main findings indicated that AG onboard environment prevented changes under microgravity in soleus muscle not only in muscle mass and fiber type composition but also in the alteration of gene expression profiles. In particular, transcriptome analysis suggested that AG condition could prevent the alterations of some atrophy-related genes. We further screened novel candidate genes to reveal the muscle atrophy mechanism from these gene expression profiles. We suggest the potential role of Cacng1 in the atrophy of myotubes using in vitro and in vivo gene transductions. This critical project may accelerate the elucidation of muscle atrophy mechanisms.

Lymph node dissection for gastric cancer: Establishment of D2 and the current position of splenectomy in Europe and Japan

Two European phase III trials comparing D1 and D2 demonstrated that D2 did not improve the overall survival and was associated with a high mortality related to splenectomy. However, a long-term follow-up study showed that the gastric cancer-related death rate was significantly higher in D1 than D2. Based on these findings, the standard surgery in Europe became D2 without pancreatico-splenectomy to prevent mortality. In contrast, the JCOG9501 phase III comparing D2 and D2 plus para-aortic nodal dissection did not showed a survival efficacy of extended lymphadenectomy, but the mortality rate was quite low in both surgeries. Subsequently, the JCOG0110 phase III study comparing D2 and spleen-preserving D2 for upper gastric cancer not invading the greater curvature clearly showed the non-inferiority of spleen preservation. Thus, spleen-preserving D2 was made the standard surgery for these tumors in Japan. However, splenectomy is often selected for complete dissection of the splenic-hilar nodes, a frequent metastatic site for upper gastric tumors invading the greater curvature. Recently, an approach involving splenic hilar nodal dissection without splenectomy has been developed.

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.

ESTIMATED CRITICALITY LOWER-LIMIT MULTIPLICATION FACTOR OF LOW-ENRICHED URANIUM DIOXIDE-CONCRETE SYSTEM USING THE BOOTSTRAP METHOD

The present paper aims to evaluate the estimated criticality lower-limit multiplication factor of fuel debris in a form of uranium dioxide-concrete mixture for a study of criticality control on the fuel debris generated through the molten core concrete interaction in a severe accident of a light water reactor. The estimated criticality lower-limit multiplication factor is evaluated using the bootstrap method where the assumption of the normal distribution is not necessary. In addition, it is calculated taking into account correlation coefficients that represent the degrees of neutronic similarity between the target system and benchmark critical experiment systems, experimental uncertainties of benchmark data, and statistical uncertainties of calculated effective multiplication factor by a continuous energy Monte Carlo code. This paper shows that the estimated criticality lower-limit multiplication factor using the bootstrap method can be comparable with a baseline upper-subcritical-limit which is evaluated by Whisper-1.1 without margins of subcriticality for uncertainties from nuclear covariance data and undetected errors in software.

Quantum Criticality inside the Anomalous Metallic State of a Disordered Superconducting Thin Film

The field-induced superconductor-insulator transition (SIT) in two-dimensional (2D) systems is a famous example of a quantum phase transition. However, an emergence of an anomalous metallic state induced by field has been a long-standing problem in 2D superconductors. While theories predicted that the emergence is attributed to strong phase fluctuations of the superconducting order parameter due to quantum fluctuations, usual resistance measurements have not probed them directly. Here, using Nernst effect measurements, we uncover superconducting fluctuations in the vicinity of the field-induced metallic state in an amorphous Mo_{x}Ge_{1-x} thin film. The field range where the vortex Nernst signals are detectable remains nonzero toward zero temperature, and it locates inside the metallic state defined by the magnetoresistance, indicating that the metallic state results from quantum vortex liquid (QVL) with phase fluctuations due to quantum fluctuations. Slow decay of transport entropy of vortices in the QVL with decreasing temperature suggests that the metallic state originates from broadening of a quantum critical point in SIT.

Long-term outcomes and recurrence-free interval after the treatment of keloids with a standardized protocol

BACKGROUND

Recurrence rates of keloids have generally been reported at one time point. However, the longer the duration after treatment, the greater the likelihood that such lesions will recur. In this study, we analysed the time to recurrence during long-term follow-up.

MATERIAL AND METHODS

We retrospectively reviewed recurrence-free interval in 52 patients with keloid (age 8-79 years) who had been treated between June 2006 and January 2011 using a standardised protocol developed by our group.

RESULTS

Mean duration of follow-up was 37.5 (range, 7-120) months in patients with keloid. Kaplan-Meier survival curves revealed a statistically significant difference in recurrence-free interval between ear keloids and keloids excluding ear keloids. Recurrence rate for keloids was high in the first 2 years after treatment.

CONCLUSIONS

Kaplan-Meier analysis was useful for understanding the tendency of recurrence of keloids after treatment using a standardised protocol.

Validation of the HFA-PEFF- and H2FPEF score in Japanese patients with heart failure with preserved ejection fraction

Background

Diagnosing heart failure with preserved ejection fraction (HFpEF) still remains challenging, and simple and reliable diagnostic tools have been required. Recently, novel and evidence-based diagnostic algorithms for HFpEF were proposed, such as H2FPEF score (Circulation. 2018) and HFA-PEFF score (Eur Heart J 2019), and their accuracy was validated in the outside patient group. However, there are regional and ethnic variations in patient characteristics of HFpEF, particularly between Western and Asian countries, and it is not elucidated whether these diagnostic scores are useful in Asian population.

Purpose

To investigate the validity of the HFA-PEFF- and H2FPEF score in Japanese patients with HFpEF.

Methods

We calculated H2FPEF score and the second step of HFA-PEFF score among the registered patients in the PURSUIT-HFpEF (Prospective, Multicenter, Observational Study of Patients with Heart Failure with Preserved Ejection Fraction) study, which is a multicenter registration of patients hospitalized for HFpEF. The obtained scores were compared with the scores of the HFpEF cohort in the previous validation studies. We followed the study patients for median of 360 days (IQR 237–630 days) to observe the major adverse cardiovascular events (MACE; composite of death, heart failure hospitalization and stroke).

Results

We enrolled 757 patients hospitalized for HFpEF between June 2016 and August 2019 for the present study. H2FPEF score was obtained in 588 (77.7%) patients among them. Compared with the HFpEF cohorts in the previously reported sub-analysis of TOPCAT trial, the PURSUIT-HFpEF cohort had lower mean value of HFpEF score (4.0±1.8 points vs. 6.0±2.0 points in Americans or 5.3±1.9 points in Russians). It had significantly higher proportion (40.3%, p&lt;0.001) of patients in the low likelihood of HFpEF category (0–3 points) than the TOPCAT cohorts (8.0% in Americans and 19.6% in Russians).

HFA-PEFF score was obtained in 615 (81.2%) patients, though global longitudinal strain was not available. The mean value of HFA-PEFF score was 5.0±0.8, and all patients had ≥2 points. The proportion of patients in the high likelihood of HFpEF category (5–6 points) was 88.3%, which was significantly higher (p&lt;0.001) than those of the HFpEF cohort from Europe and USA in the previous validation study (Eur J Heart Fail 2019). There was no correlation between H2FPEF score and HFA-PEFF score (R=0.06, p=0.14). Cox proportional hazard model selected HFA-PEFF score as a significant predictor for MACE during follow-up period, whereas H2PEF score was not selected. Kaplan-Meier survival analysis demonstrated that patients with 6 points of HFA-PEFF score had higher incidence rate of MACE than those with ≤5 points (p=0.002).

Conclusion

The HFA-PEFF score could be more useful for the diagnosis and risk stratification for HFpEF than the H2PEF score in the Japanese cohort.

Funding Acknowledgement

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

Impact of simple nutrition index on the long-term mortality of acute decompensated heart failure patients with preserved left ventricular ejection fraction: insight from PURSUIT-HFpEF registry

Background

The novel nutrition index; triglyceride (TG) × total cholesterol (TG) × body weight (BW) index (TCBI) has been reported to be an easy and useful predictor for patients with coronary artery disease. However, there is no information available on the prognostic value of TCBI in patients with heart failure with preserved LVEF (HFpEF) who admitted with acute decompensated heart failure (ADHF).

Methods and results

Data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT HFpEF) study. PURSUIT-HFpEF study is a prospective multicenter observational study in which collaborating hospitals recorded clinical, echocardiographic, and outcome data of ADHF pts with HFpEF. We enrolled consecutive 757 HFpEF patients who admitted with ADHF from June 2016 to June 2019. TCBI was calculated by the formula; TG × TC × BW / 1000 at the discharge. After we excluded patients with in-hospital death or without sufficient data, we analyzed 419 patients. The primary endpoint was all-cause mortality. During a median follow up period of 1.1 (0.9–1.9) years, 59 patients died. ROC analysis revealed that TCBI at discharge was a fair discriminator for predicting all-cause mortality (AUC 0.676, sensitivity 53%, specificity 78%). Multivariate Cox proportional analysis showed that TCBI (p=0.002) was an independent predictor for all cause death after adjustment with major confounders such as age, gender, NT-proBNP, hemoglobin and serum creatinine level. We divided patients into 4 groups according to quartiles of TCBI. Kaplan-Meier analysis showed a significantly higher risk of all-cause death in relation to the decrease in TCBI.

Conclusion

TCBI, a simple and novel nutrition index, is a useful and strong long-term prognostic indicator in ADHF patients with HFpEF.

Funding Acknowledgement

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

Clinical characteristics and prognostic impact of pulmonary hypertension in heart failure with preserved ejection fraction: the PURSUIT HFpEF study

Background

Heart failure (HF) with preserved ejection fraction (HFpEF) can develop pulmonary hypertension (PH), which can result from pre-capillary PH as well as post-capillary PH. However, the prevalence and clinical significance of pre-capillary component of PH in HFpEF remain unknown.

Purpose

We aimed to investigate prevalence, clinical features, and prognostic impact of pre-capillary and/or post capillary PH associated with HFpEF.

Methods

From the PURSUIT-HFpEF (Prospective Multicenter Observational Study of Patients with Heart Failure with Preserved Ejection Fraction) registry, 204 patients (men: 46%, age: 79±9 years) who were hospitalized with HF and underwent right heart catheterization were divided into 4 groups according to the PH guidelines: non-PH, isolated post-capillary PH (Ipc-PH), pre-capillary PH, and combined pre- and post-capillary PH (Cpc-PH). Patients who had been diagnosed with idiopathic pulmonary arterial hypertension were excluded from the analysis.

Results

The prevalence of PH was 31% (Ipc-PH: 22%, pre-capillary PH: 3%, Cpc-PH: 6%). The prevalence of subcategories of PH was significantly different depending on mean right atrial pressure (RAP) (figure). Echocardiography at discharge showed no significant differences in RV diameter or TAPSE, but smaller LV diameter and higher E/e' in pre-capillary PH and Cpc-PH, which resulted in a higher operant diastolic elastance (Ed). Composite endpoint of all-cause mortality and HF hospitalization at 1 year occurred 13% in non-PH, 25% in Ipc-PH, 49% in pre-capillary PH, and 63% in Cpc-PH, respectively (p=0.001 by log-rank test).

Conclusions

Distinct prevalence of PH was observed in the groups with different RAP levels. Pre-capillary component of PH was associated with impaired LV diastolic function and worse outcomes in HFpEF.

Figure 1

Funding Acknowledgement

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

Prognostic value of nutritional status in patients with heart failure with preserved ejection fraction, with and without atrial fibrillation: insights From PURSUIT-HFpEF Registry

Background

Malnutrition is one of the most important comorbidities among heart failure (HF) patients, and serum cholinesterase (CHE) has been reported to be a prognostic factor in HF patients. On the other hand, atrial fibrillation (AF) is frequently observed in patients with HF with preserved ejection fraction (HFpEF). However, there is little information available on the prognostic value of nutritional status in HFpEF patients, with and without AF. We sought to clarify the prognostic value of CHE in HFpEF with and without AF and compare it with that of other nutrition indices such as gastric nutritional risk index (GNRI), controlling nutritional status (CONUT), and the prognostic nutritional index (PNI).

Methods and results

Patients data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT HFpEF) study, which is a prospective multicenter observational registry for acute decompensated heart failure patients with left ventricular ejection fraction ≥50% in Osaka. We analyzed 380 patients (median age: 80 [75–87] years, male: 46%) after exclusion of patients with in-hospital death, missing follow-up data, or missing data to calculate nutritional indices. On admission, 155 patients had AF. Laboratory data were obtained at discharge. During a mean follow up period of 1.1±0.6 years, 131 patients had a composite endpoint (CE) of all-cause death and hospitalization for worsening heart failure or cerebrovascular disorder. In multivariate Cox analysis, in patients with AF, CHE was significantly associated with CE independently of age, gender and body mass index after the adjustment with serum albumin, total cholesterol levels and total lymphocyte count, while it was not significantly associated with CE in patients without AF. C-index of CHE (0.708) was higher than that of GNRI (0.555, p=0.0028), CONUT (0.651, p=0.208) and PNI (0.635, p=0.208) in AF patients, while there were no significant differences in those nutritional indices in patients without AF. Kaplan-Meier curve analysis revealed that AF patients with lower CHE (&lt;208 U/L = median value) had higher risk of CE than those with higher CHE (44% vs 18%, adjusted HR 3.26 95% CI [1.66–6.67], p=0.0005), while there was no significant difference in the occurrence rate of CE between patients with and without higher CHE in non-AF group (42% vs 31%, adjusted HR 1.28 95% CI [0.78–2.13], p=0.33).

Conclusions

Prognostic value of CHE would be stronger than other nutritional indices in HFpEF patients with AF, while it would be weak in HFpEF patients without AF.

Funding Acknowledgement

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

The impact of frailty and aging on prognosis in patients with heart failure with preserved ejection fraction – insights from PURSUIT-HFpEF registry

Introduction

Frailty and aging are two common conditions both associated with increased vulnerability to stressful events with high risk of adverse outcomes.

Purpose

To evaluate the association between frailty and aging and their impacts on clinical outcome in patients with heart failure with preserved ejection fraction (HFpEF).

Methods

Analysis was performed from a prospective multicenter observational registry for HFpEF (PURSUIT-HFpEF Registry) conducted in the Osaka region of Japan. A total of 757 patients hospitalized for acute heart failure (diagnosed by using Framingham criteria) met the inclusion criteria: a left ventricular ejection fraction ≥50% and brain natriuretic peptide ≥100pg/ml. We included 483 patients (age, 80±9 years; men, 45%; atrial fibrillation, 35%) whose follow-up data after survival discharge were available. Patients' frailty and aging were evaluated using the clinical frailty scale (CFS) and age quartiles (Q1: &lt;76 years (n=122), Q2: 76–82 years (n=111), Q3: 82–87 years (n=127), Q4: &gt;87 years (n=123)), respectively. The primary clinical endpoint was defined as the composite of death, re-hospitalization for heart failure, and cerebrovascular accident.

Results

The median (interquartile range) CFS rating was 3 (2–5), and there was a little correlation between CFS rating and age (r2=0.16, p&lt;0.001). The prevalence of frailty, defined as a CFS rating &gt;4 (n=132), was positively correlated with age quartiles (Q1: 9.0%, Q2: 21.4%, Q3: 29.9%, Q4: 48.0%, p&lt;0.001). During the median follow-up period 396 days (interquartile range, 344–698) after discharge, the clinical endpoint was observed in 172 patients. The incidence was higher in patients with frailty than those without it (49.6% vs. 30.4%, log-rank p&lt;0.001). It was also correlated with age quartiles (Q1: 23.0%, Q2: 34.2%, Q3: 36.2%, Q4: 48.8%, log-rank p=0.001). Multivariate Cox regression analysis revealed that frailty (hazard ratio, 1.52; 95% confidence interval, 1.09–2.10; p=0.013) and age (hazard ratio per quartile increase, 1.24; 95% confidence interval, 1.07–1.43; p=0.004) were both associated with the clinical endpoint. Subgroup analysis in 352 patients without frailty also revealed the significant impact of age on the endpoint (1.26; 1.06–1.51; p=0.008). However, in 131 patients with frailty, there was no significant impact of age on the endpoint (1.16; 0.90–1.51; p=0.25).

Conclusions

Frailty was common and was associated with aging in HFpEF patients. Although they were both associated with unfavorable events, aging was no longer a significant predictor of adverse outcomes under the frailty conditions.

Funding Acknowledgement

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

The comparison of clinical significance between atrial and ventricular structural remodeling in patients with heart failure with preserved ejection fraction – insights from PURSUIT-HFpEF registry

Introduction

Structural remodeling is an important aspect of pathophysiology of heart failure (HF). The compensatory mechanism against diastolic dysfunction would be more obvious on the left atrium rather than left ventricle in HF with preserved ejection fraction (HFpEF).

Purpose

To investigate the impact of left atrial (LA) and left ventricular (LV) remodeling on clinical outcomes in HFpEF patients.

Methods

Analysis was performed from a prospective multicenter observational registry for HFpEF (PURSUIT-HFpEF Registry) conducted in the Osaka region of Japan. A total of 757 patients hospitalized for acute HF (diagnosed by using Framingham criteria) met the inclusion criteria: a LV ejection fraction ≥50% and brain natriuretic peptide ≥100pg/ml. We included 381 patients (age, 82±9 years; men, 45%; atrial fibrillation (AF), 34%) whose follow-up data after survival discharge were available and whose LA volume index (LAVI) and left ventricular end-diastolic volume index (LVEDVI) at discharge were measured by the biplane Simpson's method using echocardiography. The primary endpoint was defined as the composite of death, re-hospitalization for HF, and cerebrovascular accident.

Results

The LAVI and LVEDVI at discharge was 54±25 ml/m2 and 55±21 ml/m2, respectively (r2=0.014, p=0.021). When patients were classified into the LAVI tertiles groups (T1: &lt;40ml/m2 (n=124), T2: 41–59ml/m2 (n=127), T3: &gt;60ml/m2 (n=130)), there was a positive correlation between the prevalence of diastolic dysfunction and the LAVI tertiles (T1, 21.0%; T2, 48.8%; T3, 51.5%; p&lt;0.001). On the other hand, significant association was not observed between the prevalence of diastolic dysfunction and the LVEDVI tertile groups (p=0.42). During the median follow-up period of 396 days (IQR, 345–698), the composite endpoint was observed in 131 patients and there was a positive correlation between the endpoint and the LAVI tertiles (T1, 24.2%; T2, 38.6%; T3, 40.3%; p=0.011). On the other hand, no correlation was found between the endpoint and the LVEDVI tertiles (p=0.13). After adjustment for age, gender, and presence of diastolic dysfunction, Cox regression analysis revealed that not LVEDVI but LAVI at discharge was a significant predictor of the composite endpoint in the entire cohort (hazard ratio per 10 ml/m2 increase; 1.09; 95% confidence interval, 1.02–1.16; p=0.009) and in the sinus rhythm subgroup (1.10; 1.01–1.20; p=0.034). However, not LAVI but LVEDVI was a significant predictor for the adverse outcomes in the AF subgroup (1.23; 1.04–1.46; p=0.016).

Conclusions

Increased LAVI at discharge, which was associated with diastolic dysfunction, related to unfavorable prognosis in patients with HFpEF. However, LAVI was no more a predictor for the adverse outcomes but LVEDVI was in the AF subgroup. The clinical significance of atrial and ventricular remodeling may differ between sinus rhythm and AF rhythm in HFpEF population.

Funding Acknowledgement

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

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&lt;0.001). Frail patients had higher age (85.2±7.3 vs 78.7±9.4 years, P&lt;0.001). During follow-up period of 396 [343, 697] days, composite endpoint (Kaplan-Meier event rate estimates, 77% vs. 60%; log-rank P&lt;0.001), and all-cause mortality (Kaplan-Meier event rate estimates, 57% vs. 28%; log-rank P&lt;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&lt;0.001). CFS was significantly correlated with age (r=0.401, P&lt;0.001), sex (r=0.223, P&lt;0.001), body mass index (r=−0.146, P=0.001), hemoglobin (r=−0.148, P=0.001), albumin (r=−0.222, P&lt;0.001), left ventricular diastolic diameter (r=−0.184, P&lt;0.001), interventricular septum thickness (r=−0.124, P=0.008), left ventricular mass (r=−0.217, P&lt;0.001), tricuspid annular plane systolic excursion (r=−0.165, P=0.001), and tricuspid regurgitation pressure gradient (TRPG) (r=0.189, P&lt;0.001). Multivariate linear regression analysis using these factors as covariates revealed age (standardized β: 0.337, P&lt;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.

Highly conserved extracellular residues mediate interactions between pore-forming and regulatory subunits of the yeast Ca2+ channel related to the animal VGCC/NALCN family

Yeasts and fungi generate Ca²⁺ signals in response to environmental stresses through Ca²⁺ channels essentially composed of Cch1 and Mid1. Cch1 is homologous to the pore-forming α₁ subunit of animal voltage-gated Ca²⁺ channels (VGCCs) and sodium leak channels nonselective (NALCNs), whereas Mid1 is a membrane-associated protein similar to the regulatory α₂/δ subunit of VGCCs and the regulatory subunit of NALCNs. Although the physiological roles of Cch1/Mid1 channels are known, their molecular regulation remains elusive, including subunit interactions regulating channel functionality. Herein, we identify amino acid residues involved in interactions between the pore-forming Cch1 subunit and the essential regulatory Mid1 subunit of Saccharomyces cerevisiae. In vitro mutagenesis followed by functional assays and co-immunoprecipitation experiments reveal that three residues present in a specific extracellular loop in the repeat III region of Cch1 are required for interaction with Mid1, and that one essential Mid1 residue is required for interaction with Cch1. Importantly, these residues are necessary for Ca²⁺ channel activity and are highly conserved in fungal and animal counterparts. We discuss that this unique subunit interaction-based regulatory mechanism for Cch1 differs from that of VGCCs/NALCNs.