Long-term Follow-up of Hand-degloving Injury Treated by Conventional Methods

Despite medical advances, degloving injury remains one of the most difficult traumatic injuries to treat. The conventional method for treating degloving injury of the hand is reconstruction with a groin flap. However, few reports have described the mid- or long-term functional and aesthetic outcomes after a hand reconstruction with a groin flap. This case report describes a 68-year-old woman with no specific medical history who presented with a severe degloving injury of the right hand, caused by a roller machine. The area of skin loss was covered with a pedicled groin flap that was separated after 3 weeks. Five years after the reconstruction, she had poor functional and aesthetic outcomes. The Japanese Society for Surgery of the Hand version of the Quick Disabilities of the Arm, Shoulder and Hand score was 57.5; the Hand20 score was 60; and the Michigan Hand Outcomes Questionnaire score was 37.5. The static two-point discrimination of the index and middle fingers was more than 15 mm, and Semmes-Weinstein monofilament examination showed that the sensation thresholds of these fingers were purple and blue. The range of motion was 10-degree angle of extension and 60-degree angle of flexion for the metacarpophalangeal joints of the index and middle fingers. Grip strength was 0.0 kg; pulp pinch strength of the index and middle fingers was 1.1 and 0.8 kg, respectively; and side pinch of the index and middle fingers was 0.1 and 0.7 kg, respectively.

Arterial Stiffness, Assessed Using the Cardio-Ankle Vascular Index, before and 2 Years after Total Knee Arthroplasty in Patients with Knee Osteoarthritis

Purpose: Cardiovascular disease (CVD) is a major risk factor for mortality in patients with osteoarthritis, and such comorbidities increase the risk of postoperative complications following total knee arthroplasty (TKA). Arteriosclerosis plays a major role in hemodynamic dysfunction and CVD; however, the postoperative changes in arteriosclerosis following TKA have not been evaluated. Therefore, we assessed the postoperative changes in arteriosclerosis using the cardio-ankle vascular index (CAVI) in patients undergoing TKA, and its relationships with preoperative patient characteristics. Methods: Arteriosclerosis was prospectively evaluated in 119 consecutive patients (140 knees) (15 males (17), 104 females (123); median age 73 years) with knee osteoarthritis who underwent TKA. CAVI was measured before and 2 years after TKA, and the relationships between CAVI and preoperative age, sex, BMI, physical activity status, comorbidities, clinical score, triglyceride concentration, cholesterol concentration, and smoking history were analyzed. Results: CAVI remained stable or improved in 54 joints (39%) and worsened in 86 joints (61%) 2 years post-operation. The median difference between pre- and postoperative CAVI was 0.2 (-0.3, 0.8), and the only preoperative factor associated with this change was preoperative CAVI (r = -0.469, p < 0.001). No other preoperative factor had a significant effect on postoperative arteriosclerosis. Conclusions: The results suggest that patients who undergo TKA subsequently show less severe arteriosclerosis, and the protective effect of TKA on arterial stiffness is greater in those with a higher preoperative CAVI. TKA may be an effective means of reducing the deterioration of arteriosclerosis associated with knee osteoarthritis, at least in the relatively short term.

Patient factors impacting localization of popliteal artery before total knee arthroplasty

PURPOSE

Intraoperative injury to the popliteal artery (PA) should be avoided during total knee arthroplasty (TKA). This study was performed to clarify the preoperative localization of the PA and the patient factors that impact its localization as a preventive measure.

METHODS

Ninety-seven patients (110 knees; 18 men, 79 women) with osteoarthritis who underwent primary TKA were retrospectively reviewed. Preoperative sagittal magnetic resonance imaging was used to measure the distance between the PA and the closest point at three levels: the femoral epicondyle (DPF), the tibial articular surface (DPAS), and the posterior tibial cortex (DPT). All variables are expressed in millimeters as median (interquartile range).

RESULTS

The median distance was 10.35 (7.90-12.34) mm for DPF, 6.32 (5.12-8.57) mm for DPAS, and 3.76 (2.28-5.26) mm for DPT. Body height and weight showed weak correlations with DPF (r = 0.324, p < 0.001 and r = 0.207, p = 0.03, respectively). DPF was smaller in women [9.82 (7.64-12.23) mm] than in men [11.27 (10.26-12.75) mm] (p = 0.004). A larger flexion angle and range of motion showed a weak negative correlation with DPT (r =  - 0.282, p = 0.003 and r =  - 0.236, p = 0.016, respectively). Multiple regression analysis revealed that DPF was related to body height (β = 0.341, p < 0.001) and that DPT was related to the flexion angle (β =  - 0.264, p = 0.005).

CONCLUSIONS

Special attention should be paid to women with a small physique on the femoral side and/or patients with a large flexion angle on the tibial side as a strategy to prevent PA-related complications.

Characteristics of Preoperative Arteriosclerosis Evaluated by Cardio-Ankle Vascular Index in Patients with Osteoarthritis before Total Knee Arthroplasty

PURPOSE

Cardiovascular disease (CVD) is a major risk factor for mortality in patients with osteoarthritis, and comorbidities increase postoperative complications after total knee arthroplasty (TKA). Arteriosclerosis plays a main role in hemodynamic dysfunction and CVD; however, arteriosclerosis has not been preoperatively evaluated before TKA using the cardio-ankle vascular index (CAVI). In this study, we evaluated the degree of preoperative arteriosclerosis using the CAVI in patients undergoing TKA, as well as its correlations with several preoperative patient factors.

METHODS

Arteriosclerosis was evaluated in 209 consecutive patients (251 knees) with osteoarthritis who underwent TKA at our institution between May 2011 and June 2022. The CAVI was measured in the supine position 1 day before TKA, and the correlations between the CAVI and several clinical factors were analyzed.

RESULTS

The CAVI was normal in 62 knees (25%), borderline in 71 knees (28%), and abnormal in 118 knees (47%). Univariate analysis revealed a moderate positive correlation between preoperative CAVI and age (r = 0.451, p < 0.001) and a weak negative correlation between preoperative CAVI and body weight (r = -0.306, p < 0.001) and body mass index (BMI) (r = -0.319, p < 0.001). Multivariate analysis showed that age (β = 0.349, p < 0.001) and BMI (β = -0.235, p < 0.001) were significantly correlated with preoperative CAVI.

CONCLUSION

Arteriosclerosis should be carefully managed intraoperatively and postoperatively in patients with osteoarthritis undergoing TKA, particularly in older patients and patients with a low BMI.

Unusually strong electronic correlation and field-induced ordered phase in YbCo2

We report the first study of electrical resistivity, magnetization, and specific heat on YbCo₂. The measurements on a single-phased sample of YbCo₂bring no evidence of magnetic ordering down to 0.3 K in a zero magnetic field. The manifestations of low Kondo temperature are observed. The specific heat value divided by temperature,C/T, keeps increasing logarithmically beyond 7 J/mol K²with decreasing temperature down to 0.3 K without no sign of magnetic ordering, suggesting a very large electronic specific heat. Analysis of the magnetic specific heat indicates that the large portion of the low-temperature specific heat is not explained simply by the low Kondo temperature but is due to the strong intersite magnetic correlation in both the 3dand 4felectrons. Temperature-dependent measurements under static magnetic fields up to 7 T are carried out, which show the evolution of field-induced transition above 2 T. The transition temperature increases with increasing field, pointing to a ferromagnetic character. The extrapolation of the transition temperature to zero field suggests that YbCo₂is in the very proximity of the quantum critical point. These results indicate that in the unique case of YbCo₂, the itinerant electron magnetism of Co 3d-electrons and the Kondo effect within the vicinity of quantum criticality of Yb 4f-local moments can both play a role.

Positive effect of total knee arthroplasty on progression of arteriosclerosis evaluated by cardio-ankle vascular index

INTRODUCTION

Physical function is expected to improve with an increase in physical activity owing to improvement in knee joint pain after total knee arthroplasty (TKA). This study was performed to evaluate the impact of TKA on arteriosclerosis by measuring the cardio-ankle vascular index (CAVI) before and after surgery.

MATERIALS AND METHODS

In total, 206 consecutive patients undergoing unilateral TKA were investigated. The CAVI, an index of the overall stiffness of the artery from the origin of the aorta to the ankle, was used to evaluate the degree of arteriosclerosis. The CAVI of the TKA side and non-TKA side was compared before and 1 year after TKA.

RESULTS

There were no differences in the CAVI before and after TKA on the TKA side and non-TKA side, although these values should have worsened at 1 year compared with preoperative values. The CAVI, which did not differ between the two sides preoperatively, differed significantly between the two sides postoperatively (p = 0.013). A generalized linear model showed no interaction between each time point and the measured sides in terms of the CAVI. The relationship between the preoperative CAVI and the difference between the preoperative and postoperative CAVI were examined, showing that R =  - 0.428 (p < 0.001) for the TKA side and R =  - 0.416 (p < 0.001) for the non-TKA side (significant negative correlation).

CONCLUSIONS

The lack of significant age-related deterioration over time on both sides suggests that TKA may slow the progression of arteriosclerosis, especially on the operated side. The effect of TKA was found to be greater with a higher CAVI (i.e., more advanced arteriosclerosis).

Cardiopulmonary arrest and in-hospital outcomes in young patients with acute myocardial infarction: insights from the Japanese nationwide registry

Background

Cardiopulmonary arrest (CPA) is the most serious presentation of acute myocardial infarction (AMI). However, the frequency and prognostic impact of CPA in young patients with AMI have been still unclear.

Objectives

This study aimed to characterize AMI in young patients who underwent primary percutaneous coronary intervention using large-scale nationwide all-comer registry data in Japan (J-PCI registry).

Methods

Data on risk factor profiles, clinical features, post-procedural complications, and in-hospital outcomes were reviewed within the J-PCI registry between 2014 and 2018.

Results

Among 213,297 patients with AMI, 23,985 (11.2%) were young (age, 20–49 years). Compared with the older group (age, 50–79 years; n=189,312), the young group included a higher number of men, smokers, patients with dyslipidemia, and patients with single-vessel disease, and a lower number of patients with hypertension and diabetes. Despite favorable clinical profiles, younger age was associated with a higher rate of presentation with CPA (Figure 1). Further, concomitant CPA was strongly associated with in-hospital mortality in the young group (Table 1).

Conclusions

Young patients with AMI presented a higher risk of CPA than older patients, which was strongly associated with in-hospital mortality.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): JSPS KAKENHI

Electrophysiological characteristics and catheter ablation of atypical fast-slow atrioventricular nodal reentrant tachycardia using an inferolateral left atrial slow pathway

Background

Understandings of subtypes of atypical atrioventricular nodal reentrant tachycardia (AVNRT) using variants of slow pathway (SP) are still growing. Inferolateral (inf-lat-) left atrial (LA) SP is a rare variant extending into an inf-lat-LA along the mitral annulus (MA).

Purpose

To characterize an unknown subtype of atypical fast-slow (F/S-) AVNRT using an inf-lat-LA-SP as a retrograde limb (inf-lat-LA-F/S-AVNRT).

Methods

This Japanese multicenter retrospective study enrolled 4 patients of inf-lat-LA-F/S-AVNRT that was characterized by the earliest site of atrial activation during tachycardia (EAA) between 3 and 6 o'clock along the MA. The diagnosis was made by an exclusion of AV reentrant tachycardia (AVRT) and atrial tachycardia (AT) according to the standard criteria and was confirmed by successful elimination of tachycardia and the inf-lat-LA-SP.

Results

Surface ECG during tachycardia revealed long RP appearance except one who had short RP due to a short conduction time across the inf-lat-LA-SP. During tachycardia, far-field LA activation preceding near-field activation of coronary sinus (CS) musculature was visible in the CS recording in 2. Retrograde conduction via the inf-lat-LA-SP with a decremental delay was consistently reproducible with ventricular stimulation in 2, 1 of whom had double atrial response, while it was always masked by the presence of a retrograde conduction via the fast pathway in 1 and a retrograde block at the lower common pathway in 1. An injection of a small dose of ATP transiently interrupted a retrograde conduction over the inf-lat-LA-SP, suggesting its ATP-sensitivity. Exclusion of AVRT was made by no resetting of tachycardia with left ventricular extrastimulus in 2 and VA dissociation during overdrive pacing of tachycardia in remaining 2. Exclusion of AT was made by V-A-V response after ventricular entrainment in 1 and termination without atrial capture by ventricular pacing in 2. Ablation of the right-sided SP was unsuccessful to eliminate the tachycardia, but ablation at or near the EAA by transseptal approach was successful to cure the tachycardia, associated with an elimination of a retrograde conduction over the inf-lat-LA-SP following a development of an accelerated junction rhythm in all. Low-frequency potentials preceding local atrial activation, consistent with a retrograde activation via the inf-lat-LA-SP were detected along the MA medial to the EAA in 1.

Conclusions

Differential diagnosis of tachycardia with the EAA in the inf-lat-LA and especially long RP appearance should include inf-lat-LA-F/S-AVNRT. Presumed arrhythmogenic substrate of the inf-lat-LA-SP seemed to be consistent with the remnant of embryogenic AV ring tissue in the electropharmacological and locational characteristics. Successful elimination of this AVNRT can be obtained by ablation of the inf-lat-LA-SP, but not of the right-sided SP.

Funding Acknowledgement

Type of funding sources: None.

Heterogeneous carotid plaque is associated with cardiovascular events after percutaneous coronary intervention

Background

The relationship between carotid artery ultrasound findings and clinical outcomes in percutaneous coronary intervention (PCI) patients has not been fully elucidated.

Purpose

To investigate the relationship between carotid artery ultrasound findings and cardiovascular risks in PCI patients.

Methods

This was a single-center retrospective study investigating 691 patients who underwent PCI and carotid ultrasound testing. Maximum carotid intima-media thickness (CIMT) was defined as the greatest CIMT at the maximally thick point among the common carotid artery, carotid bulb, and internal carotid artery. A carotid plaque was defined as vessel wall thickening with a CIMT ≥1.5 mm. The characteristics of carotid plaque (heterogeneity, calcification, or irregular/ulcerated surface) were evaluated visually. Patients were divided into those with and without heterogeneous carotid plaque (maximum CIMT ≥1.5 mm and heterogeneous texture). The endpoint was the incidence of a major adverse cardiovascular event (MACE) defined as a composite of cardiovascular death, myocardial infarction, and ischemic stroke.

Results

Among 691 patients, 312 were categorized as having a heterogeneous plaque. Patients with heterogeneous plaques were at a higher risk of MACE than those without (p=0.002). A heterogeneous plaque was independently associated with MACE after adjusting for covariates (hazard ratio [HR], 1.80; 95% confidence interval [CI], 1.06–3.04; p=0.03). Calcified or irregular/ulcerated plaques were correlated with a higher incidence of MACE but both were not independently associated with MACE (HR, 1.37; 95% CI, 0.70–2.67, p=0.36 and HR, 1.13; 95% CI, 0.66–1.93; p=0.66, respectively).

Conclusions

The presence of a heterogeneous carotid plaque in patients who underwent PCI predicted future cardiovascular events. These patients may require more aggressive medical therapy and careful follow-up.

Funding Acknowledgement

Type of funding sources: None.

Real-world data in the management of hypertension for patients with sleep disordered breathing after initiating continuous positive airway pressure treatment

Introduction

There are many reports that patients with cardiovascular diseases including hypertension have already suffered from sleep disordered breathing (SDB). Furthermore, Continuous Positive Airway Pressure (CPAP) is effective for hypertension for improvement of sympathetic nervous activity reason. Previously, we reported that SDB is just as, if not more, important as common classical risk factors (hypertension, dyslipidemia, diabetes mellitus) for patients with cardiovascular diseases (Figure 1).

Purpose

Our aim in this study is to estimate the real-world data in the management of hypertension for patients with SDB after initiating CPAP treatment.

Methods

All patients were conducted full night polysomnography. One-hundred ninety-five patients showed obstructive SDB {apnea hypopnea index (AHI) &gt;20/hour}, and CPAP treatment were initiated. According to Japanese society of hypertension guidelines for the managements of hypertension 2019 (JSH2019), we estimated the blood pressure and presence of blood pressure-lowering agents to assess effectiveness of CPAP treatment after six-month follow up.

Results

The study group consisted of 195 SDB patients (166 males, 29 females). The mean age was 59±7 years. Figure 2 showed the blood pressure and presence of blood pressure-lowering agents after initiating CPAP treatment. Group A which showed systolic blood pressure (SBP) &lt;130 mmHg without intake of blood pressure-lowering agents was 20.9%. Group B which showed SBP &lt;130 mmHg with intake of blood pressure-lowering agents was 9.6%. Group C showed SBP≥130 mmHg without intake of blood pressure-lowering agents was 30.5%. Group D showed SBP≥130 mmHg with intake of blood pressure-lowering agents was 39.0%.

Conclusion

We could estimate that there were high prevalence of hypertension for patients with SDB after initiating CPAP treatment. It is true that CPAP treatment have a beneficial effect on hypertension, but 70% patients (Group C and D) still remain inadequately treated. We need the strict blood pressure follow up for patient with SDB before and after initiating CPAP treatment.

Funding Acknowledgement

Type of funding sources: None.

Albuminuria predicts worsening renal function at 1 month after transcatheter aortic valve implantation

Background

Worsening renal function (WRF) at short term after transcatheter aortic valve replacement (TAVR) is reportedly associated with subsequent poor clinical outcomes. We previously reported preoperative albuminuria predicted mid-term WRF after TAVR. However, the impact of albuminuria on short-term WRF after TAVR is unknown.

Methods

Overall, 206 patients who underwent TAVR for severe aortic stenosis were investigated retrospectively. Patients were divided into two groups according to the preoperative urinary albumin-to-creatinine ratio (ACR): high (ACR ≥30 mg/g) and low (ACR &lt;30 mg/g). The incidence of 1-month WRF, defined as a decrease in estimated glomerular filtration rate (eGFR) ≥10% from baseline after TAVR, was investigated.

Results

More than half of the examined patients (n=106/206 [51.5%]) had a high ACR. Patients with a high ACR had significantly lower eGFR at baseline than those with a low ACR (49.3 [32.5–57.8] vs. 51.4 [37.7–65.8] mL/min/1.73 m2, p=0.03). Patients with a high ACR more frequently had acute kidney injury (8.5% vs. 1.0%, p=0.01) and 1-month WRF than those with a low ACR (29.2% vs. 12.0%, p=0.002). Multivariate analysis showed a high ACR was independently associated with 1-month WRF (odds ratio, 3.72; 95% confidence interval, 1.72–8.08; p&lt;0.001). Meanwhile, eGFR &lt;60 mL/min/1.73 m2 was not an independent predictor of 1-month WRF (odds ratio, 0.48; 95% confidence interval, 0.22–1.04, p=0.06).

Conclusions

Patients with preoperative albuminuria (ACR ≥30 mg/g) more frequently developed AKI and 1-month WRF after TAVR. Albuminuria was independently associated with 1-month WRF, suggesting albuminuria to be a universal predictor of deterioration of renal function at various time points.

Funding Acknowledgement

Type of funding sources: None.

Comparison of the Tibial Posterior Slope Angle Between the Tibial Mechanical Axis and Various Diaphyseal Tibial Axes After Total Knee Arthroplasty

Background

The posterior tibial slope angle (PTS) is crucial for sagittal alignment after total knee arthroplasty (TKA). This study aimed to determine which PTS based on the lateral view of standard knee radiographs (LSKRs; 36 × 43 cm) reflects the PTS based on a full-length lateral tibial radiograph (FLTR).

Methods

A total of 290 patients (355 knees) who underwent primary TKA were retrospectively recruited. Cross-sectional views from the 3-dimensional digital model of the tibial prosthesis and bone complex in the sagittal plane were used as FLTRs and LSKRs. Considering the region 21.5 cm proximal to the site of FLTR as the spot for LSKR to determine the 5 tibial diaphyseal axes, the axis that simulates the PTS as determined by the tibial mechanical axis between the center of the tibial component and the ankle plafond in LSKR was determined and compared.

Results

PTS (α₅) defined by the line connecting the midpoints of tibial width between the region 10-cm distal to the knee joint and the distal end of the tibia based on LSKR revealed the least mean difference (0.13° ± 1.00°) and the strongest correlation (P < .001, r = 0.948) with PTS based on FLTR (α₀). The number of knees in α₅, indicating a difference of <2° from α₀, was 333 of 355 (93.8%). The equivalence test results indicated that α₀ and α₅ were statistically equivalent within a difference of 2° (P < .001).

Conclusions

PTS (α₅) can be used as a clinically reliable substitution of the true PTS on an FLTR for evaluating sagittal alignment after TKA.

Comparison of Operative Times in Primary Bilateral Total Knee Arthroplasty Performed by a Single Surgeon

Purpose: Prolonged operative time (OT) is associated with adverse complications after total knee arthroplasty (TKA). The purpose of this study was to determine whether preoperative factors, such as sex, age, body mass index, body weight (BW), body height, American Society of Anesthesiologists grade, tibiofemoral angle, hospital for special surgery scores, surgical side, surgical order, and calendar year of surgery, affect OT. Methods: One hundred and nineteen patients (238 knees) with osteoarthritis who underwent staged bilateral primary TKA performed by a single surgeon were evaluated. The medical records of 15 males and 104 females were retrospectively reviewed. All variables were expressed as median (interquartile range). Results: The OT for all TKAs was 57 min (51, 65). The OT on the left side (59 min (52−67)) was longer than that on the right side (55 min (50−62)) (p = 0.015). Multiple regression analysis revealed that longer OT was related to BW (β = 0.488, p < 0.001), calendar year of surgery (β = −0.218, p< 0.001), and operative side (β = −0.151, p = 0.007). The Jonckheere−Terpstra test showed a trend toward decreasing OT with calendar year on the left side (p = 0.037) (surgeon’s non-dominant side), but not on the right (p = 0.795). Body height, BW, and body mass index showed weak correlations (r = 0.212, p = 0.001; r = 0.352, p < 0.001; r = 0.290, p < 0.001, respectively) with OT. Conclusion: Patients with a large physique, and especially obesity, with an affected knee on the surgeon’s non-dominant side may require a longer OT; OT decreased over time.

Preoperative bone assessment by bone mineral density and bone turnover in patients undergoing total knee arthroplasty

Background

The preoperative overall bone quality in patients undergoing total knee arthroplasty (TKA) might influence the development of postoperative bone-derived complications. This study was performed to simultaneously evaluate the baseline bone mineral density (BMD) and bone turnover in these patients.

Methods

We prospectively measured the lumbar spine, total hip, and femoral neck BMD using dual-energy X-ray absorptiometry (DXA) in 214 patients (239 knees; women, 199 knees; men, 40 knees) 1 day preoperatively. Women were stratified into three age groups: <70 years (60s), <80 years (70s), and ≥80 years (80s). We assessed bone turnover using the urinary level of N-telopeptide (NTx) normalized to creatinine (NTx/Cre).

Results

The prevalence of osteoporosis as assessed by DXA (T-score of ≤ -2.5) was 22% in women and 5% in men. A decline in BMD with aging was found in the hip but not in the lumbar spine with significant differences among ages. Women showed a higher NTx/Cre level than men (p = 0.033). An NTx/Cre level suggesting a high fracture risk (>56.5 mmol BCE/mmol Cre) was present in 54% of women and 35% of men (p = 0.037). No significant differences were found in this prevalence among age groups in women. Seventeen percent of women and 0% of men had both osteoporosis and a high fracture risk simultaneously (p = 0.002). The proportion of women in this category was lower in the 60s than 70s age group (p = 0.019).

Conclusions

Preoperative bone health screening before TKA might be necessary for women aged ≥70 years to prevent complications caused by perioperative poor bone condition.

Development of Neonatal Airway Management Simulator for Evaluation of Tracheal Intubation

The long-term goal of this study is a training system that can simulate medical cases and advise physicians based on quantitative evaluation of neonatal resuscitation. In this paper, we designed and manufactured a neonatal airway management simulator for quantitative evaluation of tracheal intubation. This robotic simulator is equipped with 25 sensors of 6 types, which detect motions that lead to complications, inside the manikin replicated a neonate. A performance experiment of the developed sensor and an evaluation experiment with physicians were conducted. We observed that an erroneous operation in the laryngoscopy can be detected by the sensors in our simulator.

Incidental findings on computed tomography for preoperative assessment before transcatheter aortic valve implantation in japanese patients

Background

Extra-cardiovascular incidental findings (IFs) on preoperative computed tomography (CT) are frequently observed in transcatheter aortic valve implantation (TAVI) candidates. However, the backgrounds of TAVI candidates and comorbidities differ based on the race and/or country, and data on IFs in a specific population are not always applicable to another.

Objective

To assess the prevalence, type, and clinical impact of IFs in Japanese TAVI candidates.

Methods

This was a retrospective, single-center, observational study. CT reports of 257 TAVI candidates were reviewed, and IFs were classified as (a) insignificant: findings that did not require further investigation, treatment, or follow-up; (b) intermediate: findings that needed to be followed up or were considered for further investigation but did not affect the planning of TAVI; and (c) significant: findings that required further investigation immediately or affected the planning of TAVI.

Results

At least one IF was found in 254 patients (98.8%). Insignificant, intermediate, and significant IFs were found in 253 (98.4%), 153 (59.5%), and 34 (13.2%) patients, respectively. Newly indicated significant IFs were found in 19 patients (7.4%). In 2 patients (0.8%), TAVI was canceled because of significant IFs. In patients who consequently underwent TAVI, the presence of significant IFs was not associated with the duration from CT performance to TAVI [28 (19–40) days vs. 27 (19–43) days, p=0.74] and all-cause mortality during the median follow-up period of 413 (223–805) days (p=0.44).

Conclusion

Almost all Japanese TAVI candidates had at least one IF, and the prevalence of significant IFs was not negligible. Although the presence of significant IFs was not associated with mid-term mortality, appropriate management of IFs was considered important.

Funding Acknowledgement

Type of funding sources: None.

Regression of electrocardiographic left ventricular hypertrophy after transcatheter aortic valve replacement for aortic stenosis

Background

The changes in electrocardiographic left ventricular hypertrophy (ECG-LVH) after transcatheter aortic valve replacement (TAVR) are not fully elucidated.

Methods

This retrospective single-center study investigated 156 patients who underwent TAVR for severe aortic stenosis. Twelve-leads ECGs obtained before and at 2 days and 1, 6 and 12 months after TAVR were analyzed. Patients with an implanted pacemaker, with a bundle branch block before or after TAVR or whose electrocardiogram at any measuring point was not available were excluded. As an assessment of ECG-LVH, Sokolow-Lyon voltage, Cornell voltage, Cornell product and Peguero–Lo Presti voltage were evaluated.

Results

Finally, 64 patients were included. Sokolow-Lyon voltage, Cornell voltage, Cornell product and Peguero–Lo Presti voltage significantly decreased between 1 and 6 months after TAVR compared to baseline. The prevalence of ECG-LVH criteria for each parameter decreased as well. QRS duration significantly decreased at 6 months after TAVR and the number of patients with strain pattern decreased significantly at 1 month when compared to baseline. When the patients were divided into two groups, those with and without ECG-LVH at baseline, ECG-LVH parameter values decreased significantly, especially in patients with ECG-LVH at baseline.

Conclusion

Regression of ECG-LVH after TAVR was demonstrated as per various criteria of ECG-LVH. The voltages and prevalence of ECG-LVH decreased significantly between 1 and 6 months after TAVR.

Funding Acknowledgement

Type of funding sources: None.

695 Photo-otoscopy Audit: A Review of Change in Departmental Practice Due to COVID-19

Background

Photo-otoscopy is a new service set up during the COVID-19 pandemic, with the view to minimise unnecessary appointments, protect vulnerable patients, and optimise efficiency of ENT-outpatient appointments. The objectives are to assess rate of diagnostic photos and investigate how to improve this service.

Method

First cycle was performed between June and July and second cycle between October and December 2020. All patients attending Audiology who had a photo taken were included. Photos were analysed based on a number of variables to identify the proportion of diagnostic and non-diagnostic photos. First cycle highlighted a few changes to practice that were then instigated for second cycle.

Results

324 patients and 232 patients were included in first and second cycle respectively. 17 operators/audiologists were involved. There is slight improvement in percentage of diagnostic photos in second cycle compared to first (30.6% to 31.9% in right ear and 23.5% to 35.8% in left ear). Percentages of non-diagnostic photos with blurriness as sole reason have increased compared to first cycle. Percentages of non-diagnostic photos with all 3 variables present have reduced significantly. Mean percentage of acceptable photos per operator have also improved. 8 out of 10 ENT consultants/registrars found the service useful.

Conclusions

Rate of diagnostic photos remained low (<40%) despite implementation of changes to practice from first cycle. 38% of non-diagnostic photos were wax-related. There is significant variation in rate of diagnostic photos due to its operator-dependent nature. Given the expansion of telemedicine, there is definitely scope for future development for photo-otoscopy.

Preoperative characteristics and intraoperative factors do not correlate with accomplishments of active straight-leg raising, standing up, and walking after primary total knee arthroplasty

Background

The correlations between patient characteristics and early postoperative functional performances after total knee arthroplasty have not been adequately studied. The purpose of this study was to clarify the effects of preoperative characteristics (sex, age, body mass index, American Society of Anesthesiologists grade, hospital for special surgery score) and intraoperative factors (duration of surgery and tourniquet use) on the time required to accomplish active straight-leg-raising, standing up, and walking as the objective performances for the initiation of early postoperative rehabilitation.

Methods

This cross-sectional retrospective study included 307 patients (384 primary total knee arthroplasties). Postoperative times required until each activity was accomplished were measured. Various preoperative characteristics and intraoperative factors that might affect three objective performances were evaluated.

Results

The postoperative times required before each activity was accomplished were 1.5 ± 0.5 days for active straight-leg-raising, 1.2 ± 0.5 days for standing up, and 1.4 ± 0.7 days for walking. There were no significant correlations between any factor (age, body mass index, hospital for special surgery score, duration of surgery, and tourniquet use) and the three objective performances using Spearman’s correlation coefficient. There were no differences in sex or American Society of Anesthesiologists grade for three objective functional assessments by Wilcoxon rank sum test.

Conclusions

Differences in patient preoperative characteristics and intraoperative factors are unlikely to affect three objective functional performances in the early postoperative period. Therefore, there is no need to consider differences between patients when initiating early postoperative rehabilitation.

Alignment evaluation using different distal reference points after total knee arthroplasty

Background

To assess alignment for total knee arthroplasty, the center of the ankle has been used as the main reference point for the distal tibia; however, the true load-bearing mechanical axis should be determined as a line from the center of the femoral head to the lowest point of calcaneus. Thus, the purpose of this study was to compare the differences in alignment.

Methods

Patients with medial osteoarthritis who underwent primary total knee arthroplasty (Group A, center of ankle reference, or Group C, calcaneal contact reference) were recruited. We determined (1) the total number with calcaneal contact point lateral to the center of ankle and compared (2) percentage of displacement of the load-bearing axis at the level of the knee, (3) anatomical axis angle, (4) mechanical axis angle, and (5) tibial component angle.

Results

The study included 94 patients (128 knees), with the calcaneal contact reference point located lateral relative to the center of the ankle in 88.3% (113/128 knees). Using calcaneal contact point references, displacement of the load-bearing axis at the knee was greater (p < 0.0001, 38.7% vs 34.0%), and angles demonstrated significantly valgus alignment (p < 0.0001, 5.6° vs. 4.8° for anatomical axis angle, -3.0° vs. -4.2° for mechanical axis angle, and 89.9° vs. 88.6°for tibial component angle).

Conclusions

Varus alignment measured by the ankle reference method might correspond to the neutral alignment by the amount of valgus alignment indicated by the calcaneal reference. Surgeons should take this into account when preoperative planning, performing intraoperative procedures, and during postoperative evaluation.

Association between Sarcopenia, Its Defining Indices, and Driving Cessation in Older Adults

OBJECTIVES

Driving a car is essential for older adults to support their activities of daily living and maintain their quality of life. However, physical function - which often declines with age - is a key factor to determine whether older adults can continue driving safely. As such, we sought to examine the association between sarcopenia and driving cessation in older adults.

DESIGN

A prospective study.

SETTING

A community setting.

PARTICIPANTS

We conducted a study including 2,874 older adult participants from the community (mean age: 71.0 ± 4.7 years [range: 65-93 years], women: 36.3%).

MEASUREMENTS

We assessed whether they were still driving at baseline examination as well as their degree of sarcopenia. Sarcopenia was assessed according to the clinical definition provided by the EWGSOP2 by measuring muscle mass, muscle strength, and physical performance represented by gait speed. Driving cessation was determined based on driving status at the initial visit and at a follow-up examination approximately 15 months later.

RESULTS

At the baseline assessment, there were 62 participants (2.2%) with confirmed sarcopenia and 23 participants (0.8%) with severe sarcopenia. Participants were classified into either the ongoing driving (n = 2816) or driving cessation (n = 58) group. Low muscle strength and low muscle mass were associated with driving cessation (low muscle strength: odds ratio [OR] 2.09, 95% confidence interval [CI] 1.13-3.87; low muscle mass: OR 2.00, 95% CI 1.04-3.85). Slow gait was not associated with driving cessation (OR 1.35, 95% CI 0.68-2.69). Significantly, sarcopenia was associated with driving cessation (confirmed sarcopenia: OR 4.48, 95% CI 1.63-12.29; severe sarcopenia: OR 4.46, 95% CI 1.21-16.41).

CONCLUSIONS

Sarcopenia is associated with an increased likelihood of driving cessation in community-dwelling older adults. Evaluation of physical function related to sarcopenia would be useful for judgment of the ability to drive safely among older adults.

A Review of Parathyroid Surgery for Primary Hyperparathyroidism from the United Kingdom Registry of Endocrine and Thyroid Surgery (UKRETS)

BACKGROUND

The United Kingdom Registry of Endocrine and Thyroid Surgeons is a national database holding details on > 28,000 parathyroidectomies.

METHODS

An extract (2004-2017) of the database was analysed to investigate the reported efficacy, safety and use of intra-operative surgical adjuncts in targeted parathyroidectomy (tPTx) and bilateral neck exploration (BNE) for adult, first-time primary hyperparathyroidism (PHPT).

RESULTS

50.9% of 21,738 cases underwent tPTx. Excellent short-term (median follow-up 35 days) post-operative normocalcaemia rates were reported overall (tPTx 96.6%, BNE 94.5%, p < 0.05) and in image-positive cases (tPTx 96.7%, BNE 96%, p < 0.05). Intra-operative PTH improved overall normocalcaemia rates (tPTx 97.8% vs 96.3%, BNE 95% vs 94.4%: both p < 0.05). Intra-operative nerve monitoring reduced vocal cord (VC) dysfunction in image-positive tPTx, but not in BNE (97.8% vs 93.2%, p < 0.05). Complications were higher following BNE (7.4% vs 3.8%, p < 0.05), especially hypocalcaemia (5.3% vs 2%, p < 0.05). There was no difference in rates of subjective dysphonia following tPTx or BNE (2.4% vs 2.3%, p > 0.05), nor any difference in VC dysfunction when formally examined (4.9% vs 4.1%, p > 0.05).

CONCLUSIONS

In image-positive, first time, adult PHPT cases, tPTx is as safe and effective as BNE, with both achieving excellent short-term results with minimal complications.

Utility of computed tomography and 18 F-fluorodeoxyglucose with positron emission tomography/computed tomography for distinguishing appendiceal mucocele caused by mucinous adenocarcinoma from other pathologies

AIM

Differentiating appendiceal mucocele with mucinous adenocarcinoma from other pathologies before surgery is difficult. The objective of this study was to evaluate the utility of CT and ¹⁸ F-fluorodeoxyglucose (FDG) with positron emission tomography (PET)/CT for differentiating mucinous adenocarcinoma of appendiceal mucocele from other pathologies.

METHOD

The study included 25 patients who underwent surgery for clinically diagnosed appendiceal mucoceles detected on CT at the University of Tokyo Hospital. Among these patients, 19 underwent FDG-PET/CT preoperatively. We compared features of the CT imaging findings and maximum standard uptake values (SUV_max ) detected by FDG-PET/CT between mucocele with mucinous adenocarcinoma and other pathologies.

RESULTS

A total of 13 men (52%) and 12 women (48%) were included in this study, with a median age of 65 years (range 34-83). There were six patients (24%) with pathologically confirmed mucinous adenocarcinoma, 15 patients (60%) with appendiceal mucinous neoplasm and four patients (16%) with simple mucocele caused by chronic inflammation. On the CT findings, wall irregularity was the only significant feature for the two groups in this study (83.3% vs 0.0%, P < 0.01). There was a significant difference in the SUV_max levels on PET/CT between the two groups (100.0% vs 20.0%, P < 0.01).

CONCLUSION

Distinguishing between mucocele with mucinous adenocarcinoma and other pathologies using imaging modalities is challenging. Our results suggest that wall irregularity on CT and elevated SUV_max on PET/CT are useful factors that can be employed for such discrimination.

Efficacy of rapid decongestion strategy in patients hospitalized for acute heart failure

Background

Clinical congestion is the most dominant feature in patients with acute decompensated heart failure (HF). However, uncertainty exists due to the permutations and combinations of congestion status and decongestion strategies. We aimed to investigate the impact of congestion status and its improvement on 1-year mortality.

Methods

We prospectively included 453 consecutive patients hospitalized for acute decompensated HF between July 2015 and March 2017. Congestion was evaluated using the congestion score which consists of signs and symptoms including dyspnea, fatigue, orthopnea, jugular vein distension, rales, and edema. This score ranges from 0 to 3 for each value, and calculated by summing each score. We assessed this score at admission, day 3, and discharge.

Results

The median age was 81 (interquartile range 75–87) years, and 54.1% of the subjects were male. The 1-year mortality rate was 22.7%. The congestion scores at admission, day 3, and discharge were 10.7±3.9, 3.4±3.5, and 0.3±0.8, respectively. The rate of improvement during the first 3 days was 78% and 46.6% had residual congestion, defined as scores at day 3 ≥3. The score at day 3 and improvement rate during the first 3 days were related to 1-year all-cause mortality (P&lt;0.001). We examined combined predictive values by calculating multivariable-adjusted hazard ratios for associations of residual congestion and improvement rate during the first 3 days (cut-off value 64%); and prognostic variables identified by univariate Cox regression model (age, body mass index, systolic blood pressure, potassium level, albumin level, the prevalence of anemia and hypertension, left ventricular ejection fraction, ischemic etiology, previous HF hospitalization). Residual congestion and lesser improvement (% improvement &lt;64%) were associated with higher relative risk of 1-year all-cause mortality than residual congestion and higher improvement (% improvement ≥64%) [adjusted hazard ratio (aHR) 2.33, 95% CI 1.11–4.91, P=0.025], or resolved congestion (aHR 2.17, 95% CI 1.30–3.63, P=0.003). Similar analysis revealed significant relationship of the score at day 3 and the rate of improvement from admission to day 3 to cardiovascular mortality. Combined predictive values of residual congestion and lesser improvement with adjustment for prognostic variables identified by univariate Cox regression model (age, body mass index, systolic blood pressure, potassium level, albumin level, the prevalence of anemia, reduced eGFR, and hypertension, left ventricular ejection fraction, ischemic etiology, previous HF hospitalization) were higher than those with residual congestion and higher improvement (aHR 3.04, 95% CI 1.15–8.03, P=0.025), or resolved congestion (aHR 3.17, 95% CI 1.65–6.11, P&lt;0.001).

Conclusions

This study suggested that rapid decongestion therapy after hospital admission could be prerequisite to improve 1-year mortality in acute decompensated HF.

Funding Acknowledgement

Type of funding source: None

Quality and clinical outcomes of primary percutaneous coronary intervention after ST-segment elevation myocardial infarction: a population density analysis of a Japanese nationwide registry

Background

Despite progress in acute myocardial infarction (MI) treatment, data on geographical disparities in its care remain limited.

Purpose

We aimed to assess the discrepancy by population density (PD) on the quality and clinical outcomes of patients with primary percutaneous coronary intervention (PCI) after ST-segment elevation MI (STEMI).

Methods

The J-PCI registry is a prospective procedural registry conducted by the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) to assure the quality of delivered care. Between January 2014 and December 2018, 209,521 patients underwent PCI for STEMI in 1,126 institutes. Population of administrative municipal-level districts was determined through the complete population census. The patients were divided into tertiles according to the PD of the PCI institution location (low: &lt;951.7/km2, n=69,797; middle: 951.7–4,729.7/km2, n=69,750; high: ≥4,729.7/km2, n=69,974).

Results

Patients treated in high PD administrative districts were younger (low: 69.1±12.9, middle: 68.7±12.9, high: 68.0±13.1) and likely to be male (low: 75.6%, middle: 76.0%, high: 76.6%). No significant correlation was observed between PD and door-to-balloon time (DTB: regression coefficients: 0.036 per 1000 people/km2, 95% CI: −0.232 to 0.304, P=0.79). Patients treated in low PD areas had higher crude in-hospital mortality rates than those treated in high PD areas (low: 2.89%, middle: 2.60%, high: 2.38%; P&lt;0.001). Moreover, PD and in-hospital mortality had a significantly inverse association, before and after adjusting for baseline characteristics (crude odds ratio [OR]: 0.983 per 1,000/km2, 95% confidence interval [CI]: 0.973–0.992, P&lt;0001; adjusted OR: 0.980 per 1,000/km2, 95% CI: 0.964–0.996, P=0.01, respectively). Higher PD districts had more operators per institute (low: 6, interquartile range [IQR] 3–10; middle: 7, IQR 3–13; high: 8, IQR 5–13, P&lt;0.001), suggesting an inverse association with in-hospital mortality (OR: 0.992, 95% CI: 0.986–0.999, P=0.03).

Conclusions

Marked geographical inequality was observed in immediate case fatality; patients treated in population-dense areas had a lower in-hospital mortality than those treated in less dense areas. Variation in the number of operators per institute, rather than traditional quality indicators (e.g. DTB) may explain the difference in in-hospital mortality.

Funding Acknowledgement

Type of funding source: None

Impact of stress myocardial blood flow as an important predictor for major adverse cardiac and cerebrovascular event in hemodialysis patients, even in patients without myocardial perfusion abnormality

Background

In the clinical setting, ischemic heart disease (IHD) is a major problem not only in general patients but also in regular hemodialysis (HD) patients. Positron emission tomography (PET) is becoming a reliable modality for detecting coronary artery disease. Of course, PET illustrates myocardial perfusion (MP), PET also measures myocardial blood flow (MBF) directly. We have reported stress MBF is an independent predictor in HD population. Although some prior studies show CFR is an independent predictor for their prognosis in patients without MP abnormality, there is limited data about the predictability of stress MBF in HD patients without MP abnormality.

Methods

A total 438 of HD patients who undergone 13NH3PET for suspected IHD were enrolled. All patients were undergone13NH3PET at Nagoya Radiological Diagnosis Foundation. After we excluded patients whose summed stress score (SSS) &lt;4, we identified 182 eligible patients. Patients were divided into two group according to the median value of CFR levels; low stress MBF group (≤2.56) and high stress MBF group (&gt;2.56). We followed up them up to 4.2 years (median 2.4 years) and collected their data. We evaluated their major adverse cardiac cerebrovascular event. We performed Kaplan-Meyer analysis and multivariable cox regression models. Furthermore, we evaluated the incremental value with C-index, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) when CFR added into a model with established risk factors.

Result

There were intergroup difference in baseline characteristics: age, gender, prior CVD and diabetes. Kaplan-Meyer analysis shows statistically intergroup difference [log rank p=0.013, hazard ratio (HR) 0.413, 95% confidential interval (CI) 0.220–0.775]. Multivariable cox regression model for MACCE shows CFR is an independent risk factor (p=0.004, HR 0.311, 95% CI 0.137–0.684). As regarding model discrimination, all of C-index (0.832 vs 0.796, p=0.15), NRI (0.513, p=0.008) and IDI (0.032, p=0.033) were greatest in a predicting model with established risk factors plus stress MBF.

Conclusion

The low stress MBF group has poor prognosis in MACCE comparing to the high stress MBF group. Stress MBF is an independent risk factor for MACCE. Adding stress MBF on conventional risk factors could more accurately predict MACCE in HD patients, even in patients without MP abnormality.

Funding Acknowledgement

Type of funding source: None

Diabetes and hemodialysis are important factor for decrease coronary flow reserve even in the patients with normal myocardial perfusion

Background

In clinical setting, patients with traditional coronary risk factors are at high risk for coronary artery disease (CAD). Such patients who complain chest discomfort are usually performed nuclear myocardial perfusion (MP) test. We sometimes find patients whose PET result shows normal MP and abnormal coronary flow reserve (CFR). However, there are limited data about the predictors for decreased CFR. In the view of describe above, we have investigated the parameters for decreased CFR in the patients without MP abnormality.

Methods and results

From 20th April 2013 to 21st December 2018, we performed 2,930 13N- ammonia PET for suspected CAD. After excluding the follows; 966 patients with repeated test, 54 patients with incomplete data, one patient missed, we investigated 1,909 eligible patients' data. We performed least square to identify the factors decreased CFR. Hemodialysis (HD), age, prior revascularization, diabetes (DM) and body mass index (BMI) were independent risk factor for decreased CFR in all population. On the other hand, HD, age, DM, hypertension and BMI were independent risk factor for decreasing CFR in patients without MP abnormality. According to the result of least square methods, we classified all patients into four groups; without DM/ without HD group, with DM/ without HD group, without DM/ with HD group and with DM/ with HD group. The value of CFR in each group were as follows: without DM/ without HD group (median, 1st quartile-3rd quartile; 2.88, 2.21–3.52), with DM/ without HD group (2.65, 2.00–3.38), without DM/ with HD group (2.29, 1.67–2.95) and with DM/ with HD group (1.97, 1.43–2.68). There were statistically significant intergroup differences. The value of CFR in the patients without MP abnormality were as follows: without DM/ without HD group (3.04, 2.47–3.65), with DM/ without HD group (2.98, 2.40–3.61), without DM/ with HD group (2.52, 2.10–3.08) and with DM/ with HD group (2.38, 1.86–2.97). Even in the patients without MP abnormality, there were also statistically significant intergroup differences.

Conclusion

According to our 13N-ammonia PET data analysis, DM and HD were important and independent factors for decreased CFR. Even in the patients without MP abnormality, DM and HD were important factor for decreased CFR.

Funding Acknowledgement

Type of funding source: None

Long term clinical outcome after self-expandable nitinol stent implantation for femoropopliteal occlusive disease in hemodialysis patients

Background

Endovascular therapy (EVT) using self-expandable bare nitinol stent (BNS) has been commonly accepted in patients with symptomatic femoropopliteal (FP) occlusive disease. However, poor clinical outcomes in hemodialysis (HD) patients are major problems. We investigated the impact of HD on clinical outcome after EVT in patients with FP disease.

Methods

A total of 427 consecutive HD patients undergoing successful EVT with BNS for FP disease were enrolled with 157 non-HD patients as a control group. They were followed-up for 5 years. We collected data on target lesion revascularization (TLR) rate, and limb salvage rate as well as survival rate. Propensity-score matching analysis was performed to investigate the true impact of HD on the outcome.

Results

Critical limb ischemia was observed in 44.0% of overall population (43.0% in HD group vs. 46.8% in non-HD group, p=0.42). Rates of diabetes (67.1% vs. 58.1%, p=0.045) and coronary artery disease (73.5% vs. 58.3%, p=0.0008) were higher, while age (70±10 years old vs. 76±10 years old, p&lt;0.0001) and TASC2 C/D lesion (27.9% vs. 44.6%, p=0.0002) were lower in HD group compared to non-HD group. Pre-procedural C-reactive protein level (0.4mg/l vs. 0.3mg/l, p=0.045) was higher and serum albumin level (3.6g/dl vs. 3.8g/dl, p=0.0045) was lower in HD group than those in non-HD group. The freedom rate from TLR at 5 years was significantly lower in HD group than in non-HD group [47.2% vs. 65.2%, hazard ratio (HR) 1.77, 95% confidence interval (CI) 1.23–2.64, p=0.0017]. The limb salvage rate was comparable between the groups (93.3% vs. 97.1%, HR 1.57, 95% CI 0.58–5.47, p=0.41), while the survival rate was significantly lower in HD group compared to non-HD group (60.6% vs. 86.0%, HR 2.53, 95% CI 1.56–4.36, p=0.0002). After propensity-score analysis, 250 patients (125 in each group) were matched without any difference of clinical characteristics in both groups. In the matched cohort, the freedom rate from TLR was still lower in HD group compared to non-HD group (46.7% vs. 66.6%, HR 2.25, 95% CI 1.35–3.87, p=0.0019). The adjusted limb salvage rate was consistently similar between the groups (95.4% vs. 97.3%, HR 1.10, 95% CI 0.20–5.94, p=0.91). Also, the adjusted survival rate was lower in HD group than in non-HD group (47.6% vs. 89.9%, HR 3.60, 95% CI 1.89–7.44, p&lt;0.0001).

Conclusion

The freedom rate from TLR at 5 years after BNS implantation for FP disease were significantly lower in HD group than in non-HD group, though the limb salvage rate was similar between the groups. The survival rate was consistently lower in HD group compared to non-HD group. HD status had a great impact on TLR and mortality after EVT with BNS in patients with FP disease.

Funding Acknowledgement

Type of funding source: None

Effects of preceding endoscopic treatment on laparoscopic surgery for early rectal cancer

AIM

Endoscopic treatment for rectal cancer, such as endoscopic mucosal resection and endoscopic submucosal dissection, causes inflammation, oedema and fibrosis in the surrounding tissue. However, little is known about the effect of these endoscopic therapies on salvage laparoscopic rectal surgery. The objective of this retrospective cohort study was to analyse the effect of preceding endoscopic treatment on the outcomes of laparoscopic surgery for rectal cancer.

METHOD

We analysed 53 patients who underwent laparoscopic surgery for rectal cancer with clinical Tis or T1 at our department between May 2011 and June 2019. Data from 30 patients who underwent laparoscopic surgery after preceding endoscopic treatment (Group E + S) were compared with those of 23 patients who underwent laparoscopic surgery alone (Group S).

RESULTS

There was no significant difference between the groups with respect to preoperative details. The mean operative time tended to be longer in Group E + S, and the volume of intra-operative blood loss was greater in Group E + S than in Group S (median 63 ml vs 10 ml, P = 0.049). There were no significant differences between the groups in other surgical parameters or oncological outcomes.

CONCLUSION

Laparoscopic surgery after endoscopic treatment for rectal cancer may be difficult due to an increased risk of intra-operative bleeding. Long-term prognosis after surgery was not affected by preceding endoscopic treatment in rectal cancer.

A case of resected retroperitoneal metachronous solitary metastasis from caecal cancer

Colorectal cancer metastasis to the retroperitoneum, especially solitary metastasis allowing curative resection, is rare. We report a case of complete resection of retroperitoneal metachronous solitary metastasis from caecal cancer without distant metastasis. An 80-year-old woman with caecal cancer underwent laparoscopic ileocaecal resection with regional lymph node dissection. According to the eighth edition of the TNM classification, the pathological diagnosis was stage IIA (T3N0M0). Six months following the surgery, computed tomography revealed a solitary mass of 2cm diameter, dorsal to the right kidney. A second procedure for the removal of the tumour was performed. The lesion was pathologically diagnosed as a metachronous solitary retroperitoneal metastasis from caecal cancer. The patient is surviving and free from recurrence 17 months following the second procedure.

A Retrospective Comparison of Early Postoperative Pain after the First Vs Second TKA in Scheduled Staged Bilateral TKA

Background:

Acute postoperative pain control after Total Knee Arthroplasty (TKA) is important given that poorly controlled, persistent pain can delay rehabilitation. The purpose of this study was to compare pain intensity during the early postoperative period (following the first and second surgeries) in patients who underwent bilateral, scheduled, staged TKAs.

Materials and Methods:

We enrolled 32 patients (64 knees) in this study and evaluated the number of requests for analgesic agents during the first 3 days after TKA, time to walking, and the Wong–Baker FACES pain assessment score (WBS).

Results:

Comparing the postoperative period following the first and second TKA, there were no significant differences in WBS 24, 48, and 72 h postoperatively. The frequency of requests, and the total number of requests for analgesics did not differ when comparing the first and second TKA, at any time point. The total number of analgesic requests exhibited a moderately strong, positive correlation between the first and second TKA (p < 0.001, r = 0.623). Patients’ WBS scores and requests for analgesics showed a moderately strong, positive correlation, but only at 24 h following the second TKA (p = 0.002, r = 0.567). After both TKAs, patients required a median of 1 day to resume walking.

Conclusion:

Patients undergoing staged bilateral TKA experienced equivalent early postoperative pain when comparing their experience following their first and second TKAs. Therefore, regarding pain control following the second TKA, we recommend considering the analgesic administration schedule and requirements of the first TKA.

Vascular anatomy of the splenic flexure, focusing on the accessory middle colic artery and vein

AIM

Recently, the accessory middle colic artery (AMCA) has been recognized as the vessel that supplies blood to the splenic flexure. However, the positional relationship between the AMCA and inferior mesenteric vein (IMV) has not been evaluated. Herein, we aimed to evaluate the anatomy of the AMCA and the splenic flexure vein (SFV).

METHOD

Two hundred and five patients with colorectal cancer who underwent enhanced CT preoperatively were enrolled in the present study. The locations of the AMCA and IMV were evaluated, focusing on the positional relationship between the vessels and pancreas - below the pancreas or to the dorsal side of the pancreas.

RESULTS

The AMCA was observed in 74 (36.1%) patients whereas the SFV was found in 177 (86.3%) patients. The left colic artery (LCA) was the major artery accompanying the SFV in 87 (42.4%) of patients. The AMCA accompanied the SFV in 65 (32.7%) patients. In 15 (7.8%) patients, no artery accompanied the SFV. The origin of the AMCA was located on the dorsal side of the pancreas in 15 (20.3%) of these 74 patients. Similarly, the destination of the IMV was located on the dorsal side of the pancreas in 65 (31.7%) of patients.

CONCLUSION

The SFV was observed in most patients, and the LCA or AMCA was the common accompanying artery. In some patients these vessels were located on the dorsal side of the pancreas and not below it. Preoperative evaluation of this anatomy may be beneficial for lymph node dissection during left-sided hemicolectomy.

Kondo-Induced Giant Isotropic Negative Thermal Expansion

Negative thermal expansion is an unusual phenomenon appearing in only a handful of materials, but pursuit and mastery of the phenomenon holds great promise for applications across disciplines and industries. Here we report use of x-ray spectroscopy and diffraction to investigate the 4f-electronic properties in Y-doped SmS and employ the Kondo volume collapse model to interpret the results. Our measurements reveal an unparalleled decrease of the bulk Sm valence by over 20% at low temperatures in the mixed-valent golden phase, which we show is caused by a strong coupling between an emergent Kondo lattice state and a large isotropic volume change. The amplitude and temperature range of the negative thermal expansion appear strongly dependent on the Y concentration and the associated chemical disorder, providing control over the observed effect. This finding opens avenues for the design of Kondo lattice materials with tunable, giant, and isotropic negative thermal expansion.

Knee Osteoarthritis Grade does not Correlate with Quadriceps Muscle Strength or Bone Properties of the Calcaneus in Men Aged 80 Years or More who Can Walk independently

Purpose: Muscle weakness and bone deterioration in the elderly are related to falls and fractures, resulting in decreased mobility. Knee osteoarthritis also may contribute to falls and fractures and thereby affect mortality rates. The Kellgren–Lawrence (KL) classification is widely used in the radiographic evaluation of knee osteoarthritis. Aims: This study aimed to evaluate the quadriceps strength and bone properties of the calcaneus for each KL grade, and to clarify the impact of knee osteoarthritis grade on quadriceps strength and bone properties. Methods: This prospective cross-sectional study included data on 108 male patients (213 knees), aged ≥80 years, who could walk independently. A handheld dynamometer was used to measure quadriceps strength. Bone properties were evaluated using broadband ultrasound attenuation with a portable bone densitometer. Weight-bearing standing knee radiographs were evaluated using KL classification. Quadriceps strength and bone properties were evaluated for each KL grade and the correlations between the grade and quadriceps strength and bone properties were assessed simultaneously. Results: The numbers of participants in KL grades I–IV were 46, 102, 45, and 20, respectively. There were no differences among grades for either quadriceps strength or bone properties. Conclusions: Participants exhibited good quadriceps strength and bone properties regardless of their KL grade. Relatively high mechanical loading of muscle and bone incurred while walking independently, likely explaining this result. Clinically, this study demonstrated the absence of correlations between KL grade and quadriceps strength and bone properties, as was previously reported in studies showing the absence of a correlation between KL grade and pain.

Size of Medial Knee Osteophytes Correlates With Knee Alignment But Not With Coronal Laxity in Patients With Medial Knee Osteoarthritis

The severity of osteoarthritis (OA) has been related to osteophyte size. However, the effects on osteophyte size of repeated and increased loading associated with joint laxity and varus misalignment remain unclear. We investigated these relationships in patients with medial knee OA and compared the performances of computed tomography (CT) and radiography for assessing osteophyte parameters. We examined knee joint alignment on radiographs and knee laxity using arthrometry in 191 patients with medial knee OA who were undergoing total knee arthroplasty. We also measured femur and tibia osteophyte distance (largest perpendicular distance from the cortical line to outer margin of the osteophyte) using radiography and CT, osteophyte areas (largest area surrounded by the outer margin of an osteophyte) by CT and determined the locations of the osteophytes in the femur and tibia by CT. We then analyzed the correlations between the variables using Spearman's rank correlation tests. Osteophyte sizes in the femur and tibia as determined by radiography (distance) or CT (distance and area) were positively correlated with the degree of varus alignment but not with medial or lateral laxity. There was also a significant correlation between maximum osteophyte distances measured by radiography and CT. The greatest number and the largest osteophytes were located in the posterior third of the femur and middle third of the tibia, respectively. Osteophyte size was correlated with preoperative knee alignment but not with knee laxity in patients with medial knee OA. Osteophyte size can be evaluated using conventional radiography, without the need for CT. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:639-644, 2020.

Predictive factors for longer operative times in patients with medial knee osteoarthritis undergoing total knee arthroplasty

Background

Prolonged operative time has frequently been implicated as a risk factor for various complications after total knee arthroplasty (TKA). We aimed to determine whether preoperative factors such as sex, age, body mass index (BMI), prosthetic design, tibiofemoral angle (TFA), range of motion, coronal laxity, Hospital for Special Surgery score and periarticular bone mineral density (BMD) affect operative time.

Methods

We evaluated 164 patients (187 knees) with medial osteoarthritis who underwent primary TKA performed by a single surgeon. The medical records of 27 males and 137 females (median age of 77 and 72 years, respectively) were retrospectively reviewed. TFA was measured on non-weightbearing, standard radiographs. We used dual-energy X-ray absorptiometry to measure BMD, and an arthrometer to evaluate total coronal laxity in each patient.

Results

According to univariate analyses, there was a weak positive correlation between BMI and operative time (r = 0.265, p < 0.001), between TFA and operative time (r = 0.235, p = 0.001) and between BMD of the femur and tibia and operative time (r = 0.280, p < 0.001, r = 0.286, p < 0.001, respectively). No significant correlations were found between the other factors and operative time. Based on multivariate analyses, only BMD of the tibia and TFA were significantly correlated with operative time (β = 0.418, p < 0.001 and β = 0.182, p = 0.007, respectively).

Conclusions

TFA and BMD of the tibia were the variables more strongly correlated with operative time. Surgeons should recognize preoperatively that patients who have increased TFA, higher periarticular BMD, and higher BMI may have longer operative times.

Level of evidence

Level IV retrospective study.

Cognitive Frailty as a Risk Factor for Incident Disability During Late Life: A 24-Month Follow-Up Longitudinal Study

OBJECTIVES

Association between cognitive frailty as identified by a new operational definition and incident disability in the community setting remains unclear. This will be the catalyst for preventive interventions designed to treat adverse health problems among elderlies.

DESIGN

A 24-month follow-up longitudinal study on a community-based cohort.

SETTING

Community-setting.

PARTICIPANTS

Participants included a total of 9,936 older adults aged 65 years or older.

MEASUREMENTS

Frailty was characterized as slow walking speed or/and muscle weakness represented by grip strength. Cognitive function was assessed according to several tests. Cognitive impairment was defined below the age-education reference threshold. Participants were categorized into the four groups: robust, cognitive impairment alone, frailty alone, and cognitive frailty (both frail and cognitive impairment). Incident disability data was extracted from the Japanese Long-Term Care system.

RESULTS

The prevalence of cognitive frailty was 11.2%. The cumulative incidence rates of incident disability in each group were also estimated (robust, 9.6/1,000 person-years (95% CI 7.9 to 11.7); cognitive impairment, 21.3/1,000 person years (95% CI 16.3 to 27.7); frailty, 45.4/1,000 person years (95% CI 39.5 to 52.3); and cognitive frailty, 79.9/1,000 person years (95% CI 68.6 to 93.1)). Adjusted Cox proportional hazard model revealed that the cognitive frailty group had the highest hazard ratio (HR 3.86, 95%CI 2.95 - 5.05, P < 0.001).

CONCLUSIONS

A proper operational definition was developed to determine cognitive frailty among elderlies. Cognitive frailty is more associated with incident disability in community-setting than cognitive impairment or physical frailty alone.

A PHANTOM STUDY TO DETERMINE THE OPTIMAL PLACEMENT OF EYE DOSEMETERS ON INTERVENTIONAL CARDIOLOGY STAFF

The International Commission on Radiological Protection has substantially reduced the recommended maximum annual eye lens dose for workers. Use of a dedicated eye dosemeter is one method for accurate dose monitoring. The main aim of this study was to yield recommendations for optimal placement of eye dosemeters to estimate the eye dose to interventional cardiology physicians and nurses. A phantom measurement was conducted to simulate typical interventional cardiology procedures. Considering eight X-ray tube angulations, the left side of the head position provide good estimates for physician, and the forehead position provide good estimates for nurse.

Combination gemcitabine plus S-1 versus gemcitabine plus cisplatin for advanced/recurrent biliary tract cancer: the FUGA-BT (JCOG1113) randomized phase III clinical trial

BACKGROUND

Gemcitabine plus cisplatin (GC) is the standard treatment of advanced biliary tract cancer (BTC); however, it causes nausea, vomiting, and anorexia, and requires hydration. Gemcitabine plus S-1 (GS) reportedly has equal to, or better, efficacy and an acceptable toxicity profile. We aimed to confirm the non-inferiority of GS to GC for patients with advanced/recurrent BTC in terms of overall survival (OS).

PATIENTS AND METHODS

We undertook a phase III randomized trial in 33 institutions in Japan. Eligibility criteria included chemotherapy-naïve patients with recurrent or unresectable BTC, an Eastern Cooperative Oncology Group Performance Status of 0 - 1, and adequate organ function. The calculated sample size was 350 with a one-sided α of 5%, a power of 80%, and non-inferiority margin hazard ratio (HR) of 1.155. The primary end point was OS, while the secondary end points included progression-free survival (PFS), response rate (RR), adverse events (AEs), and clinically significant AEs defined as grade ≥2 fatigue, anorexia, nausea, vomiting, oral mucositis, or diarrhea.

RESULTS

Between May 2013 and March 2016, 354 patients were enrolled. GS was found to be non-inferior to GC [median OS: 13.4 months with GC and 15.1 months with GS, HR, 0.945; 90% confidence interval (CI), 0.78-1.15; P = 0.046 for non-inferiority]. The median PFS was 5.8 months with GC and 6.8 months with GS (HR 0.86; 95% CI 0.70-1.07). The RR was 32.4% with GC and 29.8% with GS. Both treatments were generally well-tolerated. Clinically significant AEs were observed in 35.1% of patients in the GC arm and 29.9% in the GS arm.

CONCLUSIONS

GS, which does not require hydration, should be considered a new, convenient standard of care option for patients with advanced/recurrent BTC.

CLINICAL TRIAL NUMBER

This trial has been registered with the UMIN Clinical Trials Registry (http://www.umin.ac.jp/ctr/index.htm), number UMIN000010667.

P2619Combined evaluation of nutrition screening indexes on long-term mortality in patients hospitalized for acute heart failure

Background

Along with an aging society, the global burden of heart failure (HF) is evident in Japan. Recent reports showed that malnutrition is one of the frequent comorbidity in patients with HF, and this grievous issue is related to worsening prognosis in such subjects. There are many screening tools of nutrition risks, however, feasible indexes or strategies for evaluating nutrition risk in patients with HF remain to be identified definitively.

Purpose

The purpose of the present study was to examine the effectiveness of various nutrition indexes on 3-year mortality in hospitalized acute HF patients.

Methods

The study population comprised a total of 817 individuals who were hospitalized for acute HF between November 2009 and December 2015, and was followed up for 3 years. All the previously established objective nutritional indexes [The controlling nutritional status (CONUT) score, geriatric nutritional risk index (GNRI), and subjective global assessment (SGA)] were evaluated at the time of hospital admission. Malnutrition status of each index was defined as CONUT score ≥5, GNRI <91, or SGA (B and C), respectively. We evaluated combined predictive values of these indexes for 3-year mortality by Cox regression model, and calculated the net reclassification improvement (NRI) and the integrated discrimination improvement (IDI).

Results

The median age was 79 (interquartile range 70–85) years, and 55.7% of the subjects were male. The frequency of malnutrition was 18.1% in CONUT score, 31.9% in GNRI, and 25.9% in SGA. The rate of 3-year mortality was 32.2%. All indexes were related to the occurrence of 3-year mortality by univariate analyses (P<0.001). We examined combined predictive values by calculating multivariable-adjusted hazard ratios (aHR) and 95% confidence intervals (CI) for associations of malnutrition by these 3 indexes and prognostic variables identified by multivariable Cox regression model (age, body mass index, systolic blood pressure, reduced eGFR, albumin, and prior HF hospitalization). Malnutrition of all 3 indexes (5.6% of the subjects) was associated with higher relative risk of 3-year mortality than well-nutrition (aHR 1.90; 95% CI 1.07–3.35, P=0.028), or malnutrition of any 1 index (aHR 1.95; 95% CI 1.18–3.21, P=0.009). Next, we individually included each value into a reference model (age, body mass index, reduced eGFR, albumin, prior HF hospitalization, and ischemic etiology by multivariable logistic regression analysis with P<0.05). SGA was superior according to comprehensive discrimination, calibration, and reclassification analysis (NRI 0.212, P=0.003; IDI 0.005, P=0.029). Similar analysis with other indexes (CONUT score or GNRI) revealed no improvement.

Conclusion

Our present results suggest that simultaneous addition of CONUT, GNRI, and SGA seems useful for predicting long-term mortality in acute HF. In addition, nutritional screening with SGA independently improves mortality risk stratification.

P790Verification of selective arterial blood sampling for the assessment of in-hospital mortality in acute decompensated heart failure

Background

Acidosis or lactate accumulation is frequently observed in patients with acute decompensated heart failure (ADHF). Although each value can be easily obtained and evaluated by arterial blood sampling, sampling to all patients is difficult in daily clinical practice. Therefore, the prognostic impact of acidosis or lactate accumulation on this condition remains to be identified definitively.

Purpose

The purpose of the study was to verify the effectiveness of selective arterial blood sampling at emergency department in patients with ADHF by evaluating an association with in-hospital mortality.

Methods

A total of 917 consecutive patients with ADHF from April 2012 to March 2017 were enrolled. We compared baseline characteristics and in-hospital mortality between patients with or without arterial blood sampling. Patients performed blood sampling were assigned to four groups according to the presence or absence of acidosis (PH <7.35) and lactate accumulation (>2.0 mmol/L), and predictive value of acidosis and/or lactate accumulation for in-hospital mortality was calculated by multivariable logistic regression analysis.

Results

Of all patients, 689 patients (75.1%) underwent blood sampling. Systolic blood pressure and heart rate at hospital arrival, use of emergency medical service, previous heart failure hospitalization, New York Heart Association classification grade IV, presence of jugular vein distention, and the prevalence of hypertension and dementia, were significantly different between the two groups (P<0.05). There was no difference in the occurrence of in-hospital mortality between patients with or without blood sampling (9.3% in patients with blood sampling versus 9.2% in those without blood sampling, respectively; P=0.972). In 689 patients who underwent blood sampling, we examined combined predictive value of acidosis and/or lactate accumulation for in-hospital mortality by multivariable logistic regression analysis with adjustments for covariates with P<0.05 (age, systolic blood pressure at hospital arrival, left ventricular ejection fraction, and cold profile), and showed that acidosis with lactate accumulation [adjusted odds ratio (OR) 3.30, 95% confidence interval (CI) 1.22–8.93, P=0.019], acidosis without lactate accumulation (adjusted OR 4.06, 95% CI 1.12–14.7, P=0.033), lactate accumulation without acidosis (adjusted OR 2.69, 95% CI 1.14–6.33, P=0.024) were significantly (P<0.05) associated with in-hospital mortality. Our results indicated that patients presenting acidosis without lactate accumulation revealed the highest in-hospital mortality among the four groups.

Conclusion

Arterial blood sampling at emergency department could be beneficial for stratifying high risk patients with ADHF. Furthermore, routine blood sampling could be allowed in patients with ADHF if we can secure safety.

P6240The impact of stress myocardial blood flow as a very strong predictor for all-cause mortality, cardiovascular mortality and adverse cardiac and cerebrovascular event in hemodialysis population

Background

In the clinical setting, ischemic heart disease (IHD) is a major problem not only in general patients but also in regular hemodialysis (HD) patients. 13ammonia positron emission tomography (13NH3PET) is an established and excellent diagnostic device for IHD. Although coronary flow reserve is the most important index in IHD diagnosis, there are limited data about stress myocardial blood flow (MBF). We investigated the prognosis predictability of stress MBF in all-cause mortality, cardiovascular (CV) mortality and adverse cardiac and cerebrovascular event (MACCE).

Methods and results

A total 438 of HD patients who undergone 13NH3PET for suspected IHD were enrolled. 29 cases were excluded due to revascularization therapy in 60 days. In total we collected 409 eligible cases. All patients were undergone13NH3PET at Nagoya Radiological Diagnosis Foundation. Patients were divided into two group according to the median value of stress MBF levels; low stress MBF group (<2.12) and high stress MBF group (≥2.12). We followed up them up to 4.2 years (median 2.4 years) and collected their data. We evaluated their all-cause mortality, CV mortality and MACCE. Kaplan-Meyer analysis shows that intergroup difference in all-cause mortality (log rank p=0.001, hazard ratio [HR] 0.411, 95% confident interval [CI] 0.261–0.632), CV mortality (log rank p=0.002, HR 0.324, 95% CI 0.157–0.625) and MACCE (log rank p<0.001, HR 0.465, 95% CI 0.324–0.657). Multiple cox analysis that include established risk factors shows CFR is an independent risk factor for all-cause mortality (HR 0.261, 95% CI 0.154–0.442), CV mortality (HR 0.172, 95% CI 0.079–0.374) and MACCE (HR 0.329, 95% CI 0.213–0.503). As a result of the incremental value with C-index, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) when CFR added into a model with established risk factors, each indicator shows adding stress MBF on established risk factors improve the predictability in all-cause mortality, CV mortality and MACCE (all-cause mortality; NRI 0.642, p<0.001, IDI 0.091, p<0.001, CV mortality NRI 0.809, p<0.001, IDI 0.116, p<0.001, MACCE; NRI 0.646, p<0.001, IDI 0.072, p<0.001).

Conclusion

Considering prognosis of HD population, stress MBF is an important and independent predictor for all-cause mortality, CV mortality and MACCE. As a result of our investigation, stress MBF is one of most strong predictors in HD population.

P3529Prognostic impact of cohabitation status in hospitalized patients with acute heart failure

Background

The prevalence of heart failure (HF) in the elderly is steadily increasing, therefore, the prudent care and treatment according to individual's characteristics, comorbidities, or prognosis, should be prerequisite. Although cohabitations status in each elderly patient is different, an association of this condition with long-term prognosis remains to be identified definitively in Japan.

Purpose

The purpose of the present study was to examine the prognostic impact of cohabitation status on 3-year mortality among hospitalized acute HF patients.

Methods

The study population comprised a total of 817 individuals who were hospitalized for acute HF between November 2009 and December 2015, and was followed up for 3 years. We classified patients into three groups (cohabitation with spouse, cohabitation with another generation, and living alone). We evaluated relative predictive values between these three groups for 3-year mortality by Cox regression model.

Results

The median age was 79 (interquartile range 70–85) years, and 55.7% of the subjects were male. Median length of hospital stay was 16 (interquartile range 11–23) days. The distribution of three groups was cohabitation with spouse (50.9%), cohabitation with another generation (28.5%), and living alone (20.6%). The overall rate of 3-year mortality was 32.2% (n=263), 31.5% (n=131) in cohabitation with spouse, 38.2% (n=89) in cohabitation with another generation, and 25.6% (n=43) in living alone. Cohabitation with another generation was significantly related to the occurrence of 3-year mortality by univariate analysis (P<0.001). Age (84 years vs. 77 years), the frequency of female (69.1% vs. 33.4%), left ventricular ejection fraction (52.7% vs. 47.5%) were significantly greater, whereas body mass index (21.2 vs. 22.6), smoking status (27.0% vs. 53.4%), ischemic etiology (27.5% vs. 35.6%), and the prevalence of type 2 diabetes mellitus (32.2% vs. 41.4%) and atrial fibrillation (20.6% vs. 29.8%) were significantly (P<0.05) smaller in cohabitation with another generation than others. The ratio of home return and optimal medical therapy were similar between the 2 groups. Cohabitation with another generation was associated with higher relative risk of 3-year mortality than living alone [Hazard Ratio (HR) 1.65; 95% Confidence Interval (CI) 1.15–2.38, P=0.007], or cohabitation with spouse (HR 1.46; 95% CI 1.12–1.92, P=0.006). Multivariable Cox regression model, with adjustment for age, albumin, brain natriuretic peptide, and prior HF hospitalization, revealed that cohabitation with another generation was no longer significant.

Conclusion

Our present results suggest that cohabitation status affected on long-term prognosis in patients with HF, especially cohabitation with another generation posed as worst predictor. We should pay more attention to social factors including cohabitation status in the clinical practice.

P1959Impact of hemodialysis in patients undergoing bypass surgery for peripheral arterial disease - 10-year follow-up study

Background

Although lower extremities bypass surgery has been commonly performed as the standard option to treat peripheral artery disease (PAD) even in patients on hemodialysis (HD) as well as general population, poorer prognosis still remains major problems in this specific population. In this 10-year follow-up study, we investigated the impact of HD after surgical revascularization in patients with PAD.

Methods

A total of 660 patients undergoing successfully bypass surgery were enrolled. Patients with acute limb ischemia were excluded. We compared 392 HD patients with 428 limbs and 268 non-HD (NHD) patients with 296 limbs during 10 years follow-up period. Primary endpoint was defined as major adverse cardiovascular events (MACE) including all-cause death, non-fatal myocardial infarction and stroke. Second endpoint was major adverse limb events (MALE) including any revascularization and major amputation. To minimize the differences of clinical characteristics between the two groups, propensity score adjusting with all baseline variables was performed.

Results

Prevalence of diabetes (53.3% vs. 35.2%), critical limb ischemia (77.5% vs. 52.1%) and infra-popliteal artery (48.2% vs. 19.6%) were higher in HD group compared to NHD group (p<0.0001 in all), inversely, age was younger in HD group than in NHD group (67±9 years vs. 71±9 years, p<0.0001). The 30-day mortality rate was comparable (3.1% in HD group vs. 1.5% in NHD group, p=0.19). The 10-year event-free survival rate for MACE was significantly lower in HD group compared to NHD group (45.3% vs. 67.4%, p<0.0001) and for MALE (60.0% vs. 80.0%, p=0.0007), respectively. After propensity score adjustment, the freedom rate from MACE was still lower in HD group compared to NHD group [45.6% vs. 67.6%, hazard ratio (HR) 1.89, 95% confidence interval (CI) 1.33–2.72, p=0.0003], however, the rate from MALE was statistically comparable between the two group (65.7% vs. 76.9%, 1.27, 95% CI 0.87–1.90, p=0.21). Furthermore, although the 10-year limb salvage rate was crudely lower in HD group compared to NHD group (80.6% vs. 91.6%, HR 1.57, 95% CI 1.05–2.40, p=0.0027), it was comparable after propensity score adjustment (89.4% vs. 90.1%, HR 1.09, 95% CI 0.59–1.88, p=0.79). Also, the mortality rate was consistently lower in HD patients (adjusted HR 2.37, 95% CI 1.62–3.50, p<0.0001).

Conclusion

The long-term freedom rate from MACE and mortality was markedly lower in HD patients compared to non-HD patients. However, the rate from MALE, especially limb salvage rate was similar between HD and NHD after adjustment for clinical characteristics. These results suggest that detection at the early stage of PAD may potentially improve the poor outcomes in this high risk population.