Prognostic value of estimating appendicular muscle mass in heart failure using creatinine/cystatin C

Objectives

As heart failure with concomitant sarcopenia has a poor prognosis, simple methods for evaluating the appendicular skeletal muscle mass index (ASMI) are required. Recently, a model incorporating anthropometric data and the sarcopenia index, that is, the ratio of serum creatinine to cystatin C (Cre/CysC), was developed to estimate the appendicular skeletal muscle mass. We hypothesized that this model would be superior to the previous model, which uses only anthropometric data to predict the prognosis. This study aimed to compare the prognostic value of low ASMI as defined by the biomarker and anthropometric models in patients with heart failure.

Methods

Among 847 patients, we estimated ASMI using an anthropometric model consisting of age, body weight, and height in 791 patients and a biomarker model that incorporates age, body weight, hemoglobin, and Cre/CysC in 562 patients. Patients were divided into low and non-low ASMI groups according to the ASMI estimated by each model, using the cut-off proposed by the Asian Working Group for Sarcopenia. The primary outcome was all-cause mortality.

Results

Overall, 53.4% and 39.1% of patients were diagnosed with low ASMI by anthropometric and biomarker models, respectively. The agreement of the diagnosis of low ASMI between the two models was poor, with a kappa coefficient of 0.56 (95% confidence interval: 0.49–0.63). Kaplan-Meier curves showed that a low ASMI was significantly associated with all-cause death in both models. However, this association was retained after adjustment for other covariates in the biomarker model (hazard ratio: 2.60, p=0.003), but not in the anthropometric model (hazard ratio: 0.70, p=0.257).

Conclusions and implications

Among patients hospitalized with heart failure, a low ASMI estimated using the biomarker model, but not the anthropometric model, was significantly associated with all-cause mortality.

Funding Acknowledgement

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

Increasing the class of foundational medication for heart failure is associated with improved prognosis in hospitalized patients with heart failure with reduced or mildly reduced ejection fraction

Aim

To clarify the association between changes in the number of foundational medications for heart failure (FMHF) during hospitalization for worsening heart failure and post-discharge prognosis.

Methods and results

We retrospectively analyzed a combined dataset of three large-scale registries of hospitalized patients with heart failure in Japan (NARA-HF, WET-HF, and REALITY-AHF) and included patients already diagnosed with heart failure with reduced or mildly reduced left ventricular ejection fraction (HFr/mrEF) before admission. Patients were stratified by changes in the number of prescribed FMHF classes, namely angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, beta blockers, and mineralocorticoid receptor blockers, from admission to discharge. The primary endpoint was defined as the combined endpoint of heart failure rehospitalization and all-cause death within 1-year of discharge. The cohort consisted of 1,113 patients, and 482 combined endpoints were observed. In total, 413 (37.1%) patients were on increased FMHF (increased group), 607 (54.5%) remained unchanged (unchanged group), and 93 (8.4%) had a decreased number of FMHF (decreased group) at discharge compared to the time of admission. In multivariable analysis, the increased group was associated with a significantly lower incidence of the primary endpoint compared with the unchanged group (hazard ratio 0.56, 95% confidence interval 0.45–0.60; P<0.001) and decreased group (hazard ratio 0.58, 95% confidence interval 0.40–0.84; P=0.004).

Conclusion

Increasing the number of FMHF cases during heart failure hospitalization is associated with a better prognosis in patients with HFr/mrEF.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): REALITY registry was funded by the Cardiovascular Research Fund of Japan.WET-HF registry was supported by a Grant-in-Aid for Young Scientists (Y.S. JSPS KAKENHI, 18K15860).

Derivation and validation of a machine learning-based risk prediction model for in-hospital mortality in patients with acute heart failure

Background

Although risk stratification is important in patients with acute heart failure (AHF) to predict patient prognosis, pre-existing risk models have not often been used due to its complexity. Recently, machine learning methods have been presented as an alternative approach to analyzing the predictive probability of large clinical datasets.

Purpose

The aim of this study is to develop a user-friendly risk score developed by one of machine learning methods and compare the performance of the new risk score to the existing conventional risk models.

Methods

A machine-learning-based risk model was developed using least absolute shrinkage and selection operator (LASSO) regression by identifying predictors of in-hospital mortality in the derivation cohort (REALITY-AHF) and externally validating and comparing its performance with two pre-existing risk models: the Get With The Guidelines risk score incorporating brain natriuretic peptide and hypochloremia (GWTG-BNP-Cl-RS) and the acute decompensated heart failure national registry (ADHERE) risk model.

Results

In-hospital deaths in the derivation and validation (NARA-HF) cohorts were 76 (5.1%) and 61 (4.9%), respectively. The risk score comprised four variables (systolic blood pressure, blood urea nitrogen, serum chloride, and C-reactive protein) and was developed according to the results of the LASSO regression weighting the coefficient for selected variables using a logistic regression model (4V-RS). Even though 4V-RS comprised fewer variables, In the validation cohort, it showed a higher area under the receiver operating characteristic curve (AUC) than the ADHERE risk model (AUC, 0.783 vs. 0.740; P=0.059) and a significant improvement in net reclassification (0.359; 95% CI, 0.10–0.67; p=0.006). 4V-RS performed similarly to GWTG-BNP-Cl-RS in terms of discrimination (AUC, 0.783 vs. 0.759; p=0.426) and net reclassification (0.176; 95% CI, −0.08–0.43; p=0.178).

Conclusions

The 4V-RS model comprising only four readily available data points at the time of admission performed similarly to the more complex pre-existing risk model in patients with AHF.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Cardiovascular Research Fund

Predicting new-onset heart failure hospitalization of patients with atrial fibrillation: development and external validations of a risk score

Background

Atrial fibrillation (AF) is a well-known risk factor for heart failure (HF), and HF development as a complication of AF is associated with a decline in the quality of life and poor prognosis. However, unlike thrombotic events, incidence of HF in patients with AF has not changed for decades, and a preventive strategy has yet to be developed.

Purpose

We sought to develop a risk model for new-onset HF admission in patients with AF and without a history of HF. Additionally, we attempted to externally validate the developed risk model.

Methods

We utilized two multicenter, prospective, observational registries of AF and analyzed the patients without a history of AF. One of which is defined as a derivation cohort, which included 2,857 patients, and the other is defined as a validation cohort, which included 2,516 patients. We developed a risk model by selecting variables with regularized regression and weighing coefficients by Cox regression analysis with the derivation cohort. The external validity was tested in the validation cohort.

Results

During the follow-up period, 148 patients (5.2%) in the derivation cohort and 104 patients (4.1%) in the validation cohort developed HF during the median follow-up period of 1,396 (interquartile range [IQR]: 1,078–1,820) days and 1,168 (IQR: 844–1,309) days, respectively. In the derivation cohort, four predictors (age, hemoglobin, serum creatinine, and log-transformed brain natriuretic peptide) were identified as potential risk factors for HF development. The developed risk model showed good discrimination and calibration in both the derivation (area under the curve [AUC], 0.77 [95% confidence interval (CI) 0.73–0.81]; Hosmer-Lemeshow test, P=0.257) and validation cohorts (AUC: 0.76 [95% CI 0.72–0.81]; Hosmer-Lemeshow test, P=0.475). Considering death not due to HF as a competing risk, the cumulative incidence curves for HF admission stratified by the risk score were generated, which showed higher HF hospitalization rate for the higher risk score categories.

Conclusion

The newly developed risk model with four readily available clinical characteristics and biomarkers performed well in the prediction of new-onset HF admission of patients with AF in both derivation and validation cohort.

Funding Acknowledgement

Type of funding sources: None.

Prognostic significance of 2019 Asian Working Group for Sarcopenia update on definition of sarcopenia

Background/Introduction

Sarcopenia plays a major role in the pathophysiology of frailty and is associated with worse outcome in the elderly population including patients with heart failure. A recent update of the most common definition of sarcopenia in Asia, Asian Working Group for Sarcopenia (AWGS2019), included significant changes in the diagnostic algorithm with newly dividing sarcopenia into severe and “non-severe” sarcopenia.

Purpose

The objective of this study was to evaluate the differences between AWGS2014 and AWGS2019 in patients with heart failure.

Methods

In the multicenter prospective FRAGILE-HF registry, which included elderly (≥65 years old) patients who were hospitalized with heart failure, we studied 865 patients (80±8 years old, 42% female). All-cause death in 1-year follow-up was tracked.

Results

Based on the original version of AWGS (AWGS2014), 183 patients (21%) were diagnosed with sarcopenia, which was associated with higher age, lower physical performance, less muscle mass, and greater heart failure risk (all p<0.001) as well as higher rate of all-cause death (HR 1.90, p=0.004 after adjustment by multivariable regression). Those patients with sarcopenia by AWGS2014 were reclassified mainly to severe sarcopenia (155, 84.7%) by AWGS2019, and 25 (13.7%) and 2 (1.1%) were classified into sarcopenia and non-sarcopenia. Meanwhile, 24 (3.5%) and 4 (0.6%) of patients without sarcopenia by AWGS2014 were reclassified into sarcopenia and severe sarcopenia, respectively. Although severe sarcopenia by AWGS2019 was associated with higher age, lower physical performance, less muscle mass, and greater heart failure risk (all p<0.001), patients with “non-severe” sarcopenia was rather younger (p<0.001) and had better physical performance (p=0.021) despite less muscle mass (p<0.001) than those without sarcopenia. Multivariate Cox analysis demonstrated severe sarcopenia by AWGS2019 was an independent prognostic factor (HR 1.77, p=0.014), but “non-severe” sarcopenia was not (HR 1.52, p=0.37). The prognosis of patients who were reclassified from non-sarcopenia to sarcopenia or severe sarcopenia were comparable to those remained non-sarcopenia. When added to other risk factors, the prognostic predictability of AWGS2019 was significantly lower than AWGS2014 (net reclassification improvement −0.26, p=0.025).

Conclusions

About a half of “non-severe” sarcopenia in AWGS2019 were patients without sarcopenia in AWGS2014. The prognosis of such patients who were newly diagnosed as sarcopenia was good, resulting in low overall prognostic predictability of AWGS2019. A further consideration for diagnostic algorithms of sarcopenia may be warranted in patients with heart failure.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Japan Heart Foundation

Validation and comparison of BIOSTAT risk score and AHEAD score for patients with acute heart failure

Background/Introduction

Acute heart failure (AHF) is one of the major causes of mortality, and identifying the patients at high risk of mortality at the time of admission is crucial to improve clinical outcomes. Although some risk prediction models for patients with AHF have been proposed mainly from randomized clinical trials, the patients in such studies tend not to be similar to those in the real world. Recently, BIOSTAT risk score and AHEAD score derived from two large-scale registry dataset are proposed as useful risk stratification tools for patients with AHF. However, these scores have not been well externally validated and their prognostic prediction performance has not been directly compared.

Purpose

To validate and compare prognostication of BIOSTAT risk score and AHEAD score in AHF patients.

Methods

Patients who consecutively admitted to the cardiac intensive-care unit in our institution with a diagnosis of AHF from 2007 to 2011 were analyzed. Among them, patients with acute coronary syndrome, dialysis, malignancy were excluded. BIOSTAT risk score was calculated using 5 factors (age, blood urea nitrogen, BNP, hemoglobin, prescription of beta blockers), and AHEAD score was also calculated with 5 factors (atrial fibrillation, hemoglobin, age, creatinine, and diabetes mellitus). We also developed AHEAD + BNP model incorporating BNP into AHEAD score. Endpoint was 1-year all-cause death.

Results

Overall, 591 eligible patients were enrolled (mean age was 70±14 years old, 64.8% were male) and 96 patients (16.2%) died during the follow-up of 1-year. The median [interquartile range] of AHEAD score and BIOSTAT risk score were 2 [1–3] and 3 [2–4], respectively. The areas under the curves of receiver operating characteristic curve (AUC) were 0.66 for AHEAD, 0.68 for AHEAD + BNP, and 0.72 for BIOSTAT, respectively. The calibration plots for AHEAD, AHEAD + BNP, and BIOSTAT models showed good calibration (Hosmer-Lemeshow test: p=0.89, 0.74, and 0.74, respectively). The BIOSTAT model's AUC was significantly higher compared to AHEAD (p=0.018) and marginally statistically higher compared to AHEAD + BNP (p=0.054). However, BIOSTAT model showed statistically significant net reclassification improvement compared to both AHEAD (NRI: 0.43, p<0.001) and AHEAD + BNP (NRI: 0.43, p<0.001).

Conclusion

The BIOSTAT score comprised of five readily available clinical variables predict 1-year mortality of patients with AHF with good discrimination and calibration.

ROC curves

Funding Acknowledgement

Type of funding source: None

Negative impact of skeletal muscle impairment in older patients with heart failure with reduced versus preserved ejection fraction

Background/Introduction

Reduced functional capacity is an important phenotype of heart failure (HF), even though it may be considered multifactorial, especially in HF with preserved ejection fraction (HFpEF). Impairment in skeletal muscle may be one of extra-cardiac factors for reduced functional capacity and subsequent poor outcome.

Purpose

We sought to investigate the impact of the impairment in skeletal muscle, defined by the cut-offs proposed by the international consensus, on functional capacity and clinical outcome, in HF patients with preserved and reduced EF (HFrEF).

Methods

This is a multicenter prospective study including 1317 consecutive older (≥65 years) hospitalized patients with HF [HFpEF (ejection fraction ≥45%, n=675, 82±7 years, 46.4% male) and HFrEF (ejection fraction <45%, n=642, 78±8 years, 68.4% male)].

Results

HFrEF patients were more likely to have low skeletal muscle mass measured by bioelectrical impedance analysis (30.9% vs 22.1%, p=0.003) whereas less likely to have low muscle strength (handgrip strength; 62.9% vs 73.8%, p<0.001) than HFpEF, resulting in similar prevalence of sarcopenia between the two groups (21.6% vs 18.1%, p=0.19). In HFrEF, presence of sarcopenia was an independent predictor of reduced functional capacity assessed by a 6-minute walk distance (standardized beta=−0.093, p=0.039 in multivariate linear regression analysis) and 1-year mortality (adjusted hazard ratio (aHR) and 95% CI; 2.14 (1.22–3.70), p=0.009 in multivariate Cox-regression analysis). In patients with HFpEF, sarcopenia could predict mortality (aHR and 95% CI; 2.23 (1.23–3.91), p=0.009), though its association with reduced functional capacity was not significant after multivariate adjustment (standardized beta=−0.059, p=0.20). Kaplan-Meier survival curves in HFpEF and HFrEF are shown (Figure).

Conclusion(s)

In older patients with HF, sarcopenia was similarly contributed to mortality in HFpEF and HFrEF whereas its influence on functional capacity was pronounced in HFrEF.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Japan Heart Foundation Research Grant

Social frailty provides additive prognostic impact on one-year outcome in aged patients with congestive heart failure

Background

Frailty is associated with multisystem declines in physiologic reserve and increased vulnerability to stressors, resulting in increased risks of adverse clinical outcomes in patients with heart failure (HF). Although frailty is conceptualized as an accumulation of deficits in multiple areas, most of the studies have focused mainly on physical frailty, and the social domains is one of the least investigated area.

Objectives

We prospectively evaluated the incidence and prognostic implication of social frailty (SF) in older patients with HF.

Methods

The FRAGILE-HF is a multicenter, prospective cohort study including patients hospitalized for HF and aged ≥65 years old. We defined SF by Makizako's 5 items, which are 5 questions proposed and validated to be associated with future disability. The primary endpoint of this study was a composite of death from any cause and rehospitalization due to HF. The impact of SF on all-cause mortality alone was also evaluated.

Results

Among 1,240 hospitalized HF patients, 5 simple questions revealed that 825 (66.5%) were in SF. During 1-year observation period after the discharge, the combined endpoint was observed in 399 (32.2%) patients, and 145 (11.7%) patients died. Kaplan-Meier analysis showed that SF patients had significantly higher rates of both the combined endpoint and all-cause mortality than those without SF (Log-rank test: p<0.05 for both, Figures). Moreover, SF remained independently associated with higher event rate of the combined endpoint (hazard ratio: 1.30; 95% confidence interval: 1.02 to 1.66; p=0.038) and all-cause mortality (hazard ratio: 1.53; 95% confidence interval: 1.01 to 2.30; p=0.044), even after adjusting for other covariates. Significant incremental prognostic value was shown when information on social frailty was added to known risk factors for combined endpoint (NRI: 0.189, 95% confidence interval: 0.063–0.316, p=0.003) and all-cause mortality (NRI: 0.234, 95% confidence interval: 0.073–0.395, p=0.004).

Conclusions

Among older hospitalized patients with heart failure, two-thirds of the population was with SF. Evaluating SF provides additive prognostic information in elderly patients with heart failure.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Novartis Pharma Research Grants, Japan Heart Foundation Research Grant

P3534Optimal dosing of initial bolus of intravenous furosemide in acute heart failure: insights from REALITY-AHF

Background

Although intravenous diuretics are a cornerstone in the treatment of patients with acute heart failure (AHF), optimal dosing of initial bolus of IV diuretics has not been well elucidated.

Methods

The initial IV bolus dose of furosemide and its association with outcomes were analyzed in 1290 AHF patients (median age, 81 years, 55% were male) derived from REALITY-AHF (Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure). The patients were divided into 3 groups; lower dose (lower than recommended dose, n=371), standard dose (same as recommended dose, n=807), and higher dose (higher than recommended dose, n=112) groups according to the recommended initial IV bolus furosemide dose derived from the maintenance loop diuretics dose (for those without taking oral loop diuretics or taking ≤40mg/day oral furosemide-equivalent loop diuretics, 20mg IV bolus furosemide; those on >40mg/day oral furosemide-equivalent loop diuretics, IV bolus furosemide at the same dose as oral loop diuretic dose). Outcomes were length of hospital stay, diuretic response (urine output achieved within 48 hours of admission per 40 mg furosemide-equivalent diuretics dose), and 60-day all-cause mortality.

Results

Median amount of first IV bolus furosemide dose were 10, 20, and 40 mg for lower, standard, and higher dose groups, respectively. After adjustment for other covariates, length of hospital stay was significantly longer by 2.6 days (p=0.018) in the lower dose group compared to the standard dose group, and there was no difference between the standard and high dose groups (p=0.221). Diuretic response within 48 hours of admission was significantly better in the lower dose group (beta coefficient: 244 mL, p=0.025) and significantly worse in the higher dose group (beta coefficient: - 1098 mL, p<0.001) compared to the standard dose group after adjustment for covariates. During 60 days of admission, 91 deaths were observed, and 60-day mortality was significantly higher in the higher dose group (HR: 2.80, 95% CI: 1.49–5.26, p=0.001), but not in the lower dose group (HR: 1.18, 95% CI: 0.67–2.08, p=0.571) compared to the standard dose group after adjustment for other prognostic factors.

Conclusion

Treatment with the recommended initial bolus of IV furosemide is associated with a shorter hospital stay compared to lower dose regimen and better diuretic response and better 60-day survival compared to higher dose regimen in patients with AHF.

Acknowledgement/Funding

This study was funded by The Cardiovascular Research Fund, Tokyo, Japan.

428In-hospital coronary angiography is associated with increased evidence based medications and better survival in patients hospitalized with acute heart failure - results from REALITY-AHF

Background

Coronary artery disease is a major cause of heart failure (HF). Urgent coronary angiography (CAG) is recommended for patients with acute HF (AHF) complicated with acute coronary syndrome (ACS); however, clinical usefulness of in-hospital CAG in AHF patients without ACS remains unknown.

Purpose

To investigate the association between in-hospital CAG and all-cause mortality at 1-year after hospital discharge and effects of medications at discharge on this association.

Methods

From the REALITY-AHF study, 1344 patients hospitalized with AHF were enrolled in this study and followed up for 1-year after hospital discharge.

Results

In-hospital CAG was undergone in 511 patients (38%). CAG group had a significantly lower 1-year mortality compared with non-CAG group (unadjusted hazard ratio [HR]; 0.30, 95%-confidence interval [CI] 0.21–0.43, P<0.001, after adjustment for MAGGIC score; HR 0.45, 95%-CI 0.29–0.70, P<0.001, in propensity-score matched 296 pairs; HR 0.60, 95%-CI 0.37–0.98, P=0.04). At discharge, aspirin, statins and beta blockers were prescribed more in CAG group compared with non-CAG group (aspirin 46% versus 30%, P<0.001, statins 51% versus 35%, P<0.001, and beta blockers 76% versus 65%, P=0.007). The prescription of aspirin or statins at discharge was associated with a better 1-year survival in patients with multivessel disease (P<0.001), but not in patients without significant stenosis or single vessel disease (P=0.95) (Figure).

CAG results, medications and mortality

Conclusions

In patients hospitalized with AHF, in-hospital CAG was associated with increased evidence based medications at discharge and a better long-term survival. Aspirin and statins at discharge might improve outcomes in AHF patients with multivessel disease.

Acknowledgement/Funding

This study was funded by The Cardiovascular Research Fund, Tokyo, Japan.

P4516Incremental prognostic values of cognitive impairment diagnosed by mini-mental state examination and mini-cog in older hospitalized patients with heart failure

Introduction

Cognitive impairment (CI) is associated with worse prognosis in patients with heart failure, especially in the elderly; however, its incremental prognostic ability in pre-existing prognostic models has not been well elucidated. Moreover, although some tools have been proposed for evaluating cognitive function, their difference in prognostic prediction has not been explicitly compared.

Methods

A total of 352 heart failure patients aged ≥75 years admitted to three hospitals were evaluated for their cognitive function using the Mini-Mental State Examination (MMSE) and Mini-cog during index hospitalization. We diagnosed CI if MMSE and Mini-cog were ≤23 and ≤2, respectively. The primary endpoint was all-cause death.

Results

The median age of the entire cohort was 85 (IQR: 80–88) years, and 47.7% of the subjects were male. Based on the MMSE and Mini-cog, the CI was diagnosed in 167 (47.4%) and 159 (45.2%) patients, respectively. The two diagnostic tools showed poor to moderate agreement (Cohen's kappa coefficient: 0.37, 95% CI: 0.27–0.47). During the follow-up period of median 346 (IQR: 195–489) days, 53 patients (15.1%) died. Although the Kaplan-Meier analysis showed that CI diagnosed using Mini-cog (CI-MC) was associated with significantly higher mortality (P=0.001), this association was not significant for CI diagnosed using MMSE (CI-MMSE) (P=0.059). On multivariate Cox regression analysis, CI-MMSE and CI-MC were individually associated with worse prognosis in older heart failure patients even after adjustment for Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) risk model and log B-type natriuretic peptide levels (CI-MMSE, HR: 2.05 [95% CI: 1.16–3.61]; and CI-MC, HR: 2.57 [95% CI: 1.46–4.53]). The receiver operating characteristic curve analysis for Mini-cog showed significantly higher area under the curve (AUC) than that for MMSE (0.61 vs. 0.52, p=0.045). To test the incremental prognostic capability, models were constructed by individually adding each score to the MAGGIC risk model, and the net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were evaluated. CI-MMSE did not show incremental prognostic predictability (NRI: 0.28, p=0.069; IDI: 0.01, p=0.090), whereas CI-MC (NRI: 0.45, p=0.001; IDI: 0.03, p=0.001) did. Adding CI-MC instead of CI-MMSE to the MAGGIC risk model showed significant reclassification improvement (NRI: 0.45, p=0.002, IDI: 0.02, p=0.041).

Conclusion

In older patients with heart failure, CI defined by Mini-Cog is superior in providing additive prognostic value than that defined by CI based on MMSE.

Acknowledgement/Funding

This study is partially funded by Japan Heart Foundation Research Grant and Novartis Research Grants.

Association between transforming growth factor-β1 -509 C>T variants and hepatocellular carcinoma susceptibility: a meta-analysis

The transcriptional activity of transforming growth factor-β (TGF-β) is increased in subjects with hepatocellular carcinoma (HCC). Recent studies have indicated that the -509C genotype in hepatitis B virus (HBV)-infected subjects and the -509T genotype in hepatitis C virus (HCV)-infected subjects can increase the transcriptional activity of the TGF-β1 gene. We conducted a meta-analysis to clarify whether these two hepatitis viruses affect the association between TGF-β1 C-509T variants and HCC susceptibility. Using data derived from 8 case-control studies available in the PubMed database (5 with Asian and 3 with Caucasian populations), including 1,427 cases and 3,735 controls [1,610 patients with chronic liver disease and 2,125 healthy controls], we calculated pooled odds ratios with corresponding 95% confidence intervals. We used dominant (TT + CT vs. CC), recessive (TT vs. CC + CT), and co-dominant (TT vs. CC and CT vs. CC) genetic models. An overall analysis showed no association between the TGF-β1 C-509T variants and HCC susceptibility for all models. In contrast, a subgroup analysis, based on the infecting hepatitis viruses, provided the following results. Among the cases and controls with chronic liver disease, the TGF-β1 C-509T variants were significantly associated with decreased HCC susceptibility for two models with HBV-infected subjects, whereas the variants were significantly associated with increased HCC susceptibility for one model with HCV-infected subjects. Among the cases and healthy controls, there was a significant association between the TGF-β1 C-509T variants and increased HCC susceptibility for two models involving HCV-infected subjects. Among the cases and the entire control group, the same results were obtained for all genetic models with HCV-infected subjects. Although further data accumulation is required, our results suggest that these two hepatitis viruses affect the association between TGF-β1 C-509T variants and HCC susceptibility in opposite manners.

Smooth pursuit eye movements and express saccades in schizophrenic patients

Abnormalities of saccades such as disinhibition have been hypothesized as one cause of smooth pursuit eye movement (SPEM) dysfunctions in schizophrenia. Thus, we studied saccadic eye movements in schizophrenics with SPEM dysfunction. Subjects were divided into three groups: 10 normal control subjects, 10 schizophrenic subjects without SPEM dysfunction and 10 schizophrenic subjects with SPEM dysfunction characterized by a cogwheel appearance. Visually guided saccades in gap and overlap paradigms (Saslow, 1967) were examined and saccadic reaction times (SRTs) were measured in all subjects. Only schizophrenics with SPEM dysfunctions tended to manifest excessive reflexive saccades, named express saccades (Fischer, 1987), in the gap paradigm. Moreover, most of them were also found to have express saccades in the overlap paradigm, whereas normal subjects and schizophrenic subjects without SPEM dysfunction did not show such phenomena under the same conditions. In particular, most express saccades in the overlap paradigm in schizophrenics with SPEM dysfunction, were found in movements to the right.

Smooth pursuit eye movements and voluntary control of saccades in the antisaccade task in schizophrenic patients

It has been hypothesized that a saccade control dysfunction is one cause of a smooth pursuit eye movement (SPEM) dysfunction in schizophrenia. We studied the voluntary control of saccades in schizophrenic patients with the SPEM dysfunction using an antisaccade task. The mean error rate in the antisaccade task was significantly higher in the two schizophrenic groups with and without a SPEM dysfunction than in the normal control group. Furthermore, the schizophrenic group with the SPEM dysfunction showed significantly more errors than the schizophrenic group without the SPEM dysfunction. These findings seem to suggest a close relationship between the SPEM dysfunction and the appearance of errors which indicates an inability to inhibit reflexive saccades voluntarily in the antisaccade task. However, 4 of 10 subjects with the SPEM dysfunction showed an error rate less than the mean error rate of the schizophrenic group without the SPEM dysfunction. So, a voluntary control disorder of saccades as the main cause of the SPEM dysfunction appeared to be unlikely. An interesting finding of this study was that many schizophrenic subjects with the SPEM dysfunction showed errors with the latencies similar to those in express saccades, particularly in the rightward direction. This finding may suggest a close relationship between the SPEM dysfunction in schizophrenic patients and some pathological conditions of express saccades such as disinhibition of express saccades.

Smooth pursuit eye movement dysfunction as a biological marker for prediction of disease courses of schizophrenia: a preliminary report

We investigated the relationship between a smooth pursuit eye movement (SPEM) dysfunction and long-term disease courses of schizophrenia. Many schizophrenic patients without the SPEM dysfunction tended to show an acute onset of illness, undulating courses and relatively good outcomes. On the other hand, patients with cogwheel-like SPEM dysfunction tended to show a chronic onset, simple courses, relatively severe outcomes and negative symptoms.

The influence of interfering input from the peroneal nerve on tibial-nerve somatosensory evoked potential

Using a conditioning-test paradigm, we studied the recovery function of tibial nerve somatosensory evoked potentials (SEPs) conditioned by preceding peroneal nerve stimulation. The inter-stimulus intervals (ISIs) ranged from 0 to 400 msec, where 0 msec indicated simultaneous arrival of tibial and peroneal nerve volleys at the L1 spine. The recovery curve was W-shaped, showing two peaks of SEP suppression, maximum at 6 msec ISI (1st phase) and 50-75 ISI msec (2nd phase). In the 1st phase suppression, we found distinct differences in wave forms between 0-2 msec ISI and 4-6 msec ISI. At 0-2 msec ISI, P40-N50-P60 amplitude decreased and latencies shortened, while P31 and N35 were unchanged. At 4-6 msec ISI, all peaks, possibly excluding P31, were markedly depressed. We attribute the former change to an "occlusive effect" and the latter to an "inhibitory effect," each mediated via a central synaptic network between the two nerves. The attenuation of the 2nd but not the 1st phase suppression by peroneal nerve block distal to the stimulating electrodes provided evidence that the 2nd phase suppression resulted primarily from interfering afferent signals generated by peroneal nerve peripheral receptors, activated by foot movement.

Recovery functions of common peroneal, posterior tibial and sural nerve somatosensory evoked potentials

We studied recovery functions of the somatosensory evoked potentials (SEPs) of common peroneal (CPN), posterior tibial (PTN) and sural nerves (SN) using a paired conditioning-test paradigm. The interstimulus interval (ISI) of paired stimuli ranged from 2 to 400 msec. In all SEPs with ISIs of 12-20 msec, the amplitude recovery was close to or beyond 100% of the control response, though their latencies and wave forms were not the same as the control. Further increases of the ISI resulted in significant depression of SEP (late phase suppression), most markedly in CPN, and less prominently in SN-SEP. With a longer than 50 msec ISI there was progressive recovery of SEP, but full recovery differed depending on the nerve stimulated; 400 msec ISI was required for CPN-, 250 msec for PTN- and 100 msec for SN-SEP. The peroneal nerve block by local anesthetic injected just distal to the stimulus electrodes abolished the late phase SEP suppression observed before the nerve block. These findings suggest that the late phase SEP suppression is attributable to the "secondary" afferents as a result of activation of peripheral receptors (muscle, joint and/or cutaneous) by the efferent volley initiated from the stimulus point. The greater and longer duration of peripheral receptor activation in CPN than in PTN or SN stimulation could explain the more pronounced and the longer duration of late phase suppression in CPN-SEP.

The silent period produced by electrical stimulation of mixed peripheral nerves

The electromyographic silent period (SP) produced by electrical stimulation of the median and ulnar nerve, before and after lidocaine block of the ulnar nerve at the elbow, was recorded in the voluntarily contracting abductor pollicis brevis (APB) muscle of 4 normal subjects. Prior to block, stimulation of the corresponding segment in either nerve (e.g., wrist and elbow) elicited SPs with similar end points. With more proximal stimulation, the SPs consistently ended earlier. Following the block, ulnar nerve stimulation below the elbow failed to elicit a SP in any subject, despite a mechanical twitch caused by the antagonistic contraction of adductor pollicis muscle. Ulnar nerve stimulation above the block elicited a SP in all subjects similar to the preblock SP. In all 4 subjects, submaximal median nerve stimulation at the wrist produced an H-reflex, followed by a SP in the absence of the direct M-response. This SP, due to selective activation of sensory fibers, lacked a collision component, but, was otherwise similar to the SP elicited by supramaximal wrist stimulation. These findings indicate that the ascending volley following electrical stimulation of a mixed peripheral nerve produces the SP without apparent contribution from the descending motor volley.

Saccadic eye movements in tracking, fixation, and rest in schizophrenic and normal subjects

Horizontal eye movements were recorded electrooculographically during two different eye fixation tasks, during an eyes-closed waking state, and during eye tracking on a sinusoidally moving target in 16 chronic schizophrenics and in 12 normal subjects. The relationship between saccadic eye movements during tracking and in the other experimental situations was investigated. The intensities of eye fixation were successively decreased from Experiment I (eye fixation on a stationary target) through Experiment II (eye fixation on an imagined spot in the dark) to Experiment III (eyes closed in the dark, no cue for eye fixation), in that order. The frequency of saccades increased as the intensities of fixation decreased from Experiment I to Experiment III in both schizophrenic and normal groups. It was demonstrated that the frequency of saccades was higher in schizophrenics than in normal subjects in all of the experimental conditions. Some correlations were found between the increased frequency of saccades seen during eye tracking and the similar increases seen in eyes-fixated or eyes-closed states in schizophrenic subjects. It is suggested that the increased saccades seen during eye tracking and in other experimental conditions in schizophrenics are related to a deficit of nonvoluntary attention, due to a failure of an inhibitory mechanism.

Incidence of adult T-cell leukemia-lymphoma and its familial clustering

The yearly incidence of ATLL in the Uwajima district is 6.6 patients per 100,000 inhabitants aged over 40. The yearly morbidity rate from ATLL of persons in this district who are positive for HTLV-antibody and older than 40 is 1 patient per 1,631. Familial occurrence was observed in 9/38 families available for pedigree analyses. Even in the endemic area, the existence of positive HTLV antibody is remarkably high in ATLL families, suggesting that HTLV has been transmitted from generation to generation mainly within these particular families.

Relative advance of eye movement to the target in the rightward tracking in schizophrenics

Time relationship between the horizontal smooth pursuit eye movement (SPEM) and tracking target in the leftward or rightward tracking was investigated in 28 normal and 25 chronic schizophrenic subjects. Normal subjects were more liable to show a relative advance of SPEM in relation to the target in the leftward pursuit than in the rightward pursuit. These findings suggest that the spatial task such as SPEM depends more on the right hemispheric function in normal subjects. On the other hand, many of schizophrenic subjects showed a relative advance of SPEM to the target in the rightward pursuit. These findings suggest the dominance of the left hemispheric function in eye tracking tasks in schizophrenic subjects. The finding in the present study would support the hypothesis of the left hemispheric overactivation in the schizophrenic patients.

Model insomnia by methylphenidate and caffeine and use in the evaluation of temazepam

Experimental sleep disturbances (model insomnia) were produced by the administration of methylphenidate (MPD) 10 mg and caffeine (CAF) 150 mg. The effect of temazepam (TEM), 15 mg or 30 mg, on the model was investigated. All-night polysomnography was performed on 8 normal young male subjects under each of the following 9 conditions: baseline, MPD 10 mg, CAF 150 mg, TEM 15 mg, TEM 30 mg, MPD + TEM 15 mg, MPD + TEM 30 mg, CAF + TEM 15 mg, CAF + TEM 30 mg. A reduction in total sleep time and total amount of stage REM (S-REM) sleep and an increase in the sleep latency and wake time (S-W) were observed in both the MPD and CAF nights. The sleep latency was significantly longer in the CAF night than in the MPD night. Administration of TEM 15 mg or TEM 30 mg alone caused very few modifications in the sleep parameters. These drugs in combination with MPD or CAF resulted in almost complete recovery of the sleep disturbance induced by MPD or CAF. The results indicate that CAF and MPD produced similar models of insomnia except for a greater sleep latency for CAF than for MPD. Both models were useful in the evaluation of hypnotic drugs such as temazepam.

Flickering light spot as a tracking target for the study of smooth pursuit eye movements in schizophrenics--a new method

Smooth pursuit eye movements (SPEM) were studied in 26 schizophrenics and 20 normal controls. A light spot on a screen of cathode ray oscilloscope was used as a tracking target. In order to induce SPEM disorder easily, the subjects were required to track a light spot which flickered in various frequencies. This new method devised by the authors has clearly demonstrated that the SPEM in schizophrenic was more profoundly disturbed by the flickering of the tracking target than that in the normal control subjects. It was supposed that poor tracking of a flickering light spot in schizophrenics may be due to the inadequate concentration of attention to visual stimuli, and/or inability to predict the movements of a tracking target.

Smooth pursuit eye movements in epileptics under antiepileptic medication

1) Smooth pursuit eye movements (SPEM) were recorded in 18 normal, 20 schizophrenic and 50 epileptic subjects. Most of the schizophrenic and epileptic subjects were under medication, antipsychotic drugs in the former and antiepileptic drugs in the latter. 2) In schizophrenics and epileptics, rate of the saccadic component in SPEM was higher than that of normal controls. The rate of large amplitude saccades was higher in epileptics than in schizophrenics. 3) Though small amplitude saccades were usually superimposed on SPEM in schizophrenic patients, both large and small amplitude saccades superimposed irregularly on the smooth tracking curve were observed in epileptics, and overshoots or undershoots were also seen frequently. 4) SPEM disorder in epileptics was observed in more than half of patients receiving antiepileptic medication, especially in patients with a long period of treatment. SPEM disorder in epileptics tended to occur frequently in patients who received phenytoin in doses higher than a certain level; i.e. approximately 150 mg per day for a long period of time. 5) It is conceivable that the SPEM disorder represents a latent or subclinical cerebellar dysfunction due to phenytoin medication. It is suggested that the SPEM measurement is a useful tool to find out subclinical side effects of antiepileptic drug in the treatment of epilepsy.

The changing style of symptomatology of hysteria

The symptomatology of 412 hysteric women was investigated and analyzed at the Neuropsychiatric Clinic, Tohoku University Hospital, from 1952 till 1973, according to the study stages, 1952-1957 and 1958-1973, and the patients' residence, both rural and urban. Withdrawal with taciturnity was seen in 27% of them and stubbornness with egocentricity in 14% as the frequent personality traits. Physical distress was significantly a frequent problem in the recent rural patients. Among symptoms insomnia and tinnitus have decreased. Mutism and deviated attitude were seen more frequently in the rural patients. Astasia-abasia and syncope have increased. Generally speaking, hysteric symptomatology seemed to have become of tranquil style recently and the rural patients showed more frequently nonverbal expression in terms of mutism and deviated attitude than the urban patients.

Pregnancy and delivery in penicillamine treated patients with Wilson's disease

Pregnancy and delivery of two patients with Wilson's disease are reported. Case 1 was a 20-year-old housewife who had been taking D-penicillamine fore more than 10 years and had remained asymptomatic except an episode of dissociative reaction. She apparently survived longer than any of her three sisters who died of the same disease. She discontinued the use of D-penicillamine by herself when she was at the 22nd week of pregnancy. Case 2 was a 32-year-old housewife who developed an episode of mental disorder of short circuit reaction type with mild neurological symptoms and Kayser-Fleischer rings after the prolonged interval of medication since the first pregnancy and delivery. Three months after the complete recovery of neuropsychiatric symptoms she was at the 12th week of pregnancy and withheld penicillamine from herself. During the pregnancy they had not revealed any exacerbation in terms of clinical and laboratory findings. Each of them was delivered of a healthy baby. Although the pregnancy and delivery of both patients were successful, the authors recommended that they should not prolong the interval of medication to protect themselves against the onset or relapse of the illness.