Feasibility and reliability of the pandemic-adapted online-onsite hybrid graduation OSCE in Japan

Objective structured clinical examination (OSCE) is widely used to assess medical students' clinical skills. Virtual OSCEs were used in place of in-person OSCEs during the COVID-19 pandemic; however, their reliability is yet to be robustly analyzed. By applying generalizability (G) theory, this study aimed to evaluate the reliability of a hybrid OSCE, which admixed in-person and online methods, and gain insights into improving OSCEs' reliability. During the 2020-2021 hybrid OSCEs, one examinee, one rater, and a vinyl mannequin for physical examination participated onsite, and a standardized simulated patient (SP) for medical interviewing and another rater joined online in one virtual breakout room on an audiovisual conferencing system. G-coefficients and 95% confidence intervals of the borderline score, namely border zone (BZ), under the standard 6-station, 2-rater, and 6-item setting were calculated. G-coefficients of in-person (2017-2019) and hybrid OSCEs (2020-2021) under the standard setting were estimated to be 0.624, 0.770, 0.782, 0.759, and 0.823, respectively. The BZ scores were estimated to be 2.43-3.57, 2.55-3.45, 2.59-3.41, 2.59-3.41, and 2.51-3.49, respectively, in the score range from 1 to 6. Although hybrid OSCEs showed reliability comparable to in-person OSCEs, they need further improvement as a very high-stakes examination. In addition to increasing clinical vignettes, having more proficient online/on-demand raters and/or online SPs for medical interviews could improve the reliability of OSCEs. Reliability can also be ensured through supplementary examination and by increasing the number of online raters for a small number of students within the BZs.

Natural history of severe aortic stenosis in elderly heart failure patients who declined transcatheter aortic valve implantation

Background

Transcatheter aortic valve implantation (TAVI) is an established minimally invasive treatment for elderly patients with severe aortic stenosis (AS). Although it is a relatively minimally invasive procedure, many elderly patients cannot undergo TAVI due to advanced age, advanced dementia, significantly impaired ADL, or because the patient or family does not wish to undergo TAVI. In general, severe AS patients died 5 years after an angina attack, 3 years after syncope symptoms, and 2 years after heart failure symptoms. However, few studies have investigated the prognosis of elderly patients with severe AS who declined TAVI.

Purpose

This study aimed to comprehend the natural history of elderly severe AS patients who declined aortic valve intervention and identify risk factors for death in the TAVI era.

Methods

We retrospectively reviewed 2,786 echocardiographic data from our hospital between 2017 and 2021. We identified 504 patients with AS in the echocardiography database. The severe AS was defined by the following echocardiography parameters: peak aortic flow velocity ≥4.0 m/s, aortic valve mean gradient ≥40 mmHg, aortic valve area (AVA)<1.0 cm2, or AVA index<0.6 cm2/m2. Patients with mild and moderate AS and patients who underwent surgical or transcatheter aortic valve intervention were excluded. Eventually, 82 patients fulfilled the study criteria and were analyzed in this study. Clinical events were investigated, and Cox proportional hazards analysis was performed to elucidate risk factors for mortality.

Results

The mean age was 89±6 years, and 63 (77%) were women. AHA/ACC classification was Stage A/B/C/D: 0%/52.4%/39.0%/8.5%. As event occurrence, we detected 34 (41.5%) all-cause deaths, 41 (50.0%) major adverse cardiovascular events, 32 (39.0%) development of heart failure, 13 (15.9%) chest pain attacks, and 3 (3.7%) syncope. The time from diagnosis of severe AS to all-cause death was 227±273 days, and the 1-, 2-, and 3-year survival rates were 61.5%, 46.2%, and 36.9%, respectively. Of the heart failure-onset population, 16 (50.0%) were found to have severe AS on initial heart failure admission. The incidence of heart failure at 1, 2, and 3 years after diagnosis of severe AS was 60.1%, 56.7%, and 45.4%, respectively. The time from heart failure to death was 107±147 days. Cox proportional hazards analysis adjusted with age, sex, comorbidities revealed that dementia (HR 4.5, P=0.014) and Katz index <5 (HR7.8, P=0.009) were independent risk factors for mortality.

Conclusions

Compared to the comprehension of the natural history of AS patients, the prognosis in severe AS patients who declined TAVI was extremely poor. Although the elderly patients did not have a high rate of angina attacks or syncope symptoms, probably due to their reduced ADL, the results suggest that dementia prevention and maintenance of exercise tolerance are essential since dementia and reduced ADL (Katz<5) are independent risk factors for mortality.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Clinical Research Promotion Foundation Reiwa 2 Michinari Hieda

Community pharmacists' measurement of health-related quality of life in outpatients taking high-risk drugs

Patients experiencing severe side effects when taking high-risk drugs may have a significantly reduced health-related quality of life (QOL); therefore, it is important to identify changes in the health-related QOL in these patients. This study aimed to determine the health-related QOL in community pharmacy outpatients taking high-risk drugs. This prospective observational study was conducted in 29 community pharmacies with 71 pharmacists in 12 regions and cities in Japan from October to December 2020 and 760 patients were enrolled. Using descriptive questionnaires of EuroQOL-5-dimensions-5-levels (EQ-5D-5L), community pharmacists obtained health-related QOL data from outpatients taking high-risk drugs. The mean health-related QOL of all outpatients was 0.869. The health-related QOL decreased with increasing age. The outpatient health-related QOL was 0.700, 0.763, 0.785, and 0.817 when taking antiepileptic, antidepressant, digitalis, and antiarrhythmic drugs, respectively, which was lower than the average health-related QOL of all outpatients. Mobility and pain/ discomfort accounted for a large proportion of the decline in the health-related QOL with increasing age. There were no significant differences in personal care with increasing age; however, the number of outpatients with mobility, normal activity, and pain challenges decreased with age. In contrast, outpatients aged <65 years with anxiety/depression showed a lower than overall average health-related QOL. To the best of our knowledge, this is the first study in Japan to report an investigation by community pharmacists regarding health-related QOL assessment in outpatients taking high-risk drugs.

Interdisciplinary groups perform better than intradisciplinary groups in online group discussion activities

Online classes have been provided for health-care pre-licensure learners during the novel coronavirus disease 2019 pandemic. The purpose of this study was to evaluate the utility of online group work in interprofessional education. A total of 209 students were assigned to 50 groups (18 medical student groups, 13 nursing student groups, and 19 mixed medical/nursing student groups). Learners performed group work during the orientation for the course, which was hosted using an online video conferencing system. The learners first performed the activity individually (10 min) and then engaged in a group discussion to reach consensus on their answers (30 min). We calculated the scores before and after the group discussion and shared the results with the students. Scores were improved after the group discussion (mean ± SEM, 23.7 ± 0.9) compared with before (37.3 ± 1.3) (P < .0001). Lower scores after the group discussion, which indicated the effect of the group discussion on making better decisions, were observed most in the mixed medical/nursing student groups, followed by the nursing student and medical student groups. We noted only 3 groups in which the group discussion showed a negative effect on decision-making: all 3 of these groups were mixed (3 of 19 groups; 16%). These data demonstrated the power of group discussion for solving tasks when the participants' professional fields were mixed. However, the small size of the interdisciplinary groups might have resulted in less effective discussion, which might be due in part to psychological barriers arising from professional differences. Online group work is effective for facilitating discussion and building consensus about decisions in interprofessional education for medical and nursing students. Potential psychological barriers may exist in about 16% of mixed group students at the start, which should be kept in mind by instructors. Abbreviations: COVID-19: coronavirus disease 2019; IPE: Interprofessional Education; NASA: National Aeronautics and Space Administration; SD: standard deviation; WHO: World Health Organization.

Cost-effectiveness of primary prophylaxis of febrile neutropenia with pegfilgrastim in docetaxel, cisplatin and 5-fluorouracil therapy for esophageal cancer

Objective: The efficacy of docetaxel, cisplatin, and 5-fluorouracil (DCF) therapy in treating esophageal cancer has been reported. However, febrile neutropenia (FN) is a potentially serious adverse event of DCF therapy with an incidence of 10 to 40%. Pegfilgrastim, a granulocyte colony-stimulating factor (G-CSF), has been shown to have a primary prophylactic role in FN. However, it has been suggested that excessive use of expensive G-CSF should be avoided. Therefore, we performed a cost-utility analysis of primary prophylaxis with pegfilgrastim. Design: Cost-effectiveness analysis using decision tree modelling. Methods: We used a decision tree analysis model based on the report of primary prophylaxis with pegfilgrastim. Based on a previous study, the FN incidence rate was set at 40.0% (95% confidence interval (CI): 11.9-68.1) for the pegfilgrastim group and 43.5% (95%CI: 21.6-65.4) for the no pegfilgrastim group. The FN treatment cost was US$726.63, and the duration of FN was 3.65±1.20 days. The utility value of patients who received DCF therapy was 0.643, and the change in utility value at FN onset was -0.15. Expected cost, quality-adjusted life year (QALY), and incremental cost-effectiveness ratio (ICER) were calculated, and cost-utility analysis was performed. Results: The ICER of pegfilgrastim was 184,976.75 USD/QALY. As a result of sensitivity analysis, the utility of FN had the greatest impact on the cost-effectiveness analysis, followed by the drug cost of pegfilgrastim. Conclusion: Primary prophylaxis of FN with pegfilgrastim might not be cost-effectiveness. In determining whether to administer pegfilgrastim it is necessary to consider patient factors, not just the incidence of FN.

Positive disease-specific autoantibodies have limited clinical significance in diagnosing IgG4-related disease in daily clinical practice

OBJECTIVES

The 2019 ACR/EULAR classification criteria for IgG4-related disease (IgG4-RD) have exclusion criteria including positive disease-specific autoantibodies, and these have been documented to have a high specificity. This study aimed to further validate these criteria as well as identify characteristics of patients showing false-negative results.

METHODS

We retrospectively analysed 162 IgG4-RD patients and 130 mimickers. The sensitivity, specificity and fulfilment rates for each criterion were calculated, and intergroup comparisons were performed to characterize the false-negative cases.

RESULTS

Both the IgG4-RD patients and mimickers were aged ≥65 years with male predominance. The final diagnoses of mimickers were mainly malignancy, vasculitis, sarcoidosis and aneurysm. The classification criteria had a sensitivity of 72.8% and specificity of 100%. Of the 44 false-negative cases, one did not fulfil the entry criteria, 20 fulfilled one exclusion criterion and 27 did not achieve sufficient inclusion criteria scores. The false-negative cases had fewer affected organs, lower serum IgG4 levels, and were less likely to have received biopsies than the true-positive cases. Notably, positive disease-specific autoantibodies were the most common exclusion criterion fulfilled in 18 patients, only two of whom were diagnosed with a specific autoimmune disease complicated by IgG4-RD. In addition, compared with the true-positive cases, the 18 had comparable serum IgG4 levels, number of affected organs, and histopathology and immunostaining scores despite higher serum IgG and CRP levels.

CONCLUSIONS

The ACR/EULAR classification criteria for IgG4-RD have an excellent diagnostic specificity in daily clinical practice. Positive disease-specific autoantibodies may have limited clinical significance for the diagnosis of IgG4-RD.

POS0527 ACUTE KIDNEY INJURY (AKI) IN PATIENTS WITH RHEUMATOID ARTHRITIS (RA)

Background:

Methotrexate has been an anchor drug for patients with rheumatoid arthritis (RA). However, it is strictly prohibited to prescribe MTX to patients with severely decreased renal function because it can induce a fatal adverse event such as pancytopenia in these patients. On the other hand, since the average age of RA patients is gradually increasing, and many of them already have mildly to moderately impaired renal function, their renal function can easily decrease to below the critical level of the estimated glomerular filtration rate. Therefore, new development of acute kidney injury (AKI) during MTX administration might induce a fatal adverse event, making the identification of patients susceptible to AKI very important.

Objectives:

To clarify the frequency of AKI and the factors involved in it in RA patients.

Methods:

Two hundred and fifty-two RA patients (211 females, 41 males, mean age 62.3 ± 12.5 years, disease duration 11.0 ± 9.5 years) diagnosed more than 3 years earlier and followed for more than 5 years, and also, others diagnosed ≥3 years earlier but followed for ≤5 years were enrolled. We measured BUN, Cr, RF and aCCP in patient serum, urinary proteins, urinary blood, and urinary casts and evaluated CDAI, SDAI, disease activity score (DAS) 28-CRP and DAS28-ESR. Steinbrocker functional classification and radiological grading were evaluated. History of diabetes mellitus, hypertension and hyperlipidemia was determined from the medical records. Medications for RA, including non-steroid anti-inflammatory drugs (NSAIDs), prednisolone, csDMARD (MTX, Tacrolimus, etc.), bDMARDs and tsDMARDs were evaluated. Estimated glomerular filtration rate (eGFR) was calculated by the new Japanese coefficient-modified Modification of Diet in Renal disease (MDRD) study equation. The criteria of AKI were that serum Cr increased by 0.3 mg /dl or increased by 1.5-fold between consecutive visits according to the KIDIGO criteria 1) and the report of Leither et al2).

Results:

Twenty (7.9%) patients developed AKI, 22 times. The causes of AKI were 10 infections, 6 dehydrations, 2 enteritis, 1 urticaria, 2 hypercalcemia due to VitD administration, and 1 ureteral stone. We divided our patients into group A (with AKI) and group B (without AKI). Group A was older (69.9±10.1 vs 61.7±12.6 years), had greater physician VAS (29.5±27.7 vs 15.7±18.3 mm), higher serum creatinine (0.79±0.19 vs 0.60±0.16 mg/dl), higher BUN (18.4±5.7 vs 15.1±4.4 mg/dl), lower eGFR(65.5±23.3 vs 86.4±22.4 ml/min), more frequent prednisolone administration (75.0% vs 41.9%), more frequent hyperlipidemia (50.0% vs 19.2%) and more frequent hypertension (60.0% vs 30.6%) than Group B by univariate analysis significantly (p<0.01). We then performed multifactorial analysis using logistic regression analysis. Greater physician VAS (OR 1.02, 1.00-1.04), lower eGFR (OR 1.04, 1.01-1.08) and prednisolone administration (OR 3.29, 1.02-10.63) were found as independent relevant factors for group A.

Conclusion:

Our study indicated that AKI developed in RA patients and suggested that renal function decline and prednisolone administration may be implicated. RA patients with impaired renal function and prednisolone administration need to be treated with special attention to the onset of AKI.

References:

[1]Kidney Disease: Improving Global Outcomes (KDIGO) Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2: 1-138, 2012

[2]Leither MD, Murphy DP, Bicknese L et al. The impact of outpatient acute kidney injury on mortality and chronic kidney disease: a retrospective cohort study. Nephrol Dial Transplant. 34:493-501, 2019

Disclosure of Interests:

None declared

Factors contributing to discrepant estimated glomerular filtration values measured by creatinine and cystatin C in patients with rheumatoid arthritis

This study aimed to clarify the factors underlying the discrepancy that has been noted between estimated glomerular filtration ratio (eGFR) measured using serum creatinine (Cr) and eGFR using serum cystatin C (CysC) in patients with rheumatoid arthritis (RA) and to identify those patients whose renal function should be evaluated using CysC. We retrospectively evaluated clinical features, disease activity, Steinbrocker radiological staging, and co-morbidities (diabetes mellitus, hypertension, dyslipidemia) in 238 RA patients. eGFR using serum creatinine (eGFR-Cr) and eGFR using serum cystatin C (eGFR-CysC) were calculated using the new Japanese coefficient-modified Modification of Diet in Renal Disease study equation. To clarify the cause(s) of differences of 20% or more between the two eGFRs, we divided our RA patients into Group A (eGFR-Cr/eGFR-CysC ≥ 1.2) and Group B (eGFR-Cr/eGFR-CysC < 1.2), and searched for factors independently related to Group A. Forty-five patients (18.9%) were assigned to Group A, and 193 (81.1%) to Group B. BMI (Odds Ratio [OR] 0.820, 95% confidence interval [CI] 0.675–0.996), Hb (OR 0.633, 95% CI 0.433–0.926), CK (OR 0.773 per 10 units, 95% CI 0.644–0.933), NSAID use (OR 0.099, 95% CI 0.020–0.494), diabetes mellitus (OR 6.024, 95% CI 1.508–24.390) and stage 4 Steinbrocker radiological stage (OR 10.309, 95% CI 2.994–35.714) were identified as independent relevant factors for Group A by a multifactorial analysis. Renal function in RA patients with low BMI, diabetes, anemia and low CK may be overestimated using eGFR-Cr alone, and such patients need to be evaluated using eGFR-CysC.

Wire-loop lesion is associated with serological immune abnormality, but not renal prognosis, in lupus nephritis

BACKGROUND

Wire-loop lesion (WL) is one of the active lesions of lupus nephritis (LN). However, few reports have focused on the clinicopathological relationships of WL to serological immune abnormality and renal prognosis.

METHODS

We enrolled 126 Japanese LN patients subjected to renal biopsy in 11 hospitals from 2000 to 2018. In patients with class III or IV of the International Society of Nephrology/Renal Pathology Society classification, we retrospectively compared clinicopathological findings between those with WL (WL+ group) and without WL (WL- group) to detect factors associated with WL. Chronic kidney disease (CKD) was defined as an estimated glomerular filtration rate of <60 mL/min/1.73m² for more than three months. We also compared these findings between those with CKD (CKD+ group) and without CKD (CKD- group) at the last visit to investigate factors associated with renal prognosis.

RESULTS

Of 126 patients, 100 (79.4%) were classified as class III or IV. WL was found in 36 (36.0%) of them. Although the renal function did not differ, the WL+ group had a higher titre of serum anti-dsDNA antibodies and lower serum complement 3 levels than the WL- group. Linear regression analysis revealed a significant association only between anti-dsDNA antibodies and WL (β = 0.27, 95% confidence interval (CI) 0.001-0.100, p = 0.01). Of these patients, 69 were tracked for 59.6 ± 55.1 months. Kaplan-Meier analysis showed no difference in renal prognosis between these groups. Next, the CKD+ group included 15 (22.1%) patients. They were older and had higher frequencies of hypertension and hyperuricaemia, serum creatinine (Cr) level, glomerulosclerosis, interstitial inflammation, interstitial fibrosis and tubular atrophy than the CKD- group at the time of renal biopsy. The frequency of WL was not significantly different. Cox regression analysis revealed significant associations of CKD with hypertension, hyperuricaemia, serum Cr level at the time of renal biopsy clinically and with tubular atrophy histologically.

CONCLUSIONS

WL was associated with serum anti-dsDNA antibodies but not with renal prognosis, suggesting that WL reflects immune abnormality but is not an independent factor predictive of renal prognosis in LN.

Hypocomplementemia is related to elevated serum levels of IgG subclasses other than IgG4 in IgG4-related kidney disease

OBJECTIVES

This study investigated the clinical features of IgG4-RKD patients with hypocomplementemia compared with those without it, so as to clarify the factors related to hypocomplementemia.

METHODS

In this single-center retrospective study, we analyzed the clinical features of 25 patients with IgG4-RKD according to the presence/absence of hypocomplementemia. Additionally, we validated the results of a single-center study in a separate large multicenter cohort of 328 patients with IgG4-RD, and searched for factors related to hypocomplementemia.

RESULTS

Serum IgG levels (p < .001), non-IgG4 IgG levels, calculated as the total IgG minus IgG4 (p < .001), serum IgG1 levels (p = .017), and the number of involved organs (p = .018) were significantly higher in the hypocomplementemia group. At relapse of renal lesions in four patients, all had serum IgG4 re-elevation, with the three with hypocomplementemia presenting worsening of hypocomplementemia and re-elevation of non-IgG4 IgG levels. In a validation cohort of 328 patients with IgG4-RD, multivariate logistic regression analysis indicated elevation of non-IgG4 IgG levels to be an independent factor related to hypocomplementemia in the patients with IgG4-RKD.

CONCLUSION

The present study suggests that hypocomplementemia is associated with elevation of IgG subclasses other than IgG4 including IgG1 in IgG4-RKD.

P824The clinical impact of polyunsaturated fatty acid on clinical outcomes in acute coronary syndrome with dyslipidemia: HIJ-PROPER sub-analysis

Background

Polyunsaturated fatty acids, especially omega-3 and -6 series, are key essential nutrients that play an important role in humans to maintain cell membranes and function. A recent randomized trial reported that adding eicosapentaenoic acid (EPA) to statins was beneficial to cardiovascular disease patients who had a residual risk factor. Further, several studies have reported that the low baseline value for EPA to arachidonic acid (AA) ratio is related to worse clinical outcome and plaque vulnerability in coronary artery disease patients. However, effects of baseline EPA/AA ratio on clinical outcomes in ACS patients have not been thoroughly evaluated.

Objectives

This study aimed to examine the impact of baseline eicosapentaenoic acid to arachidonic acid (EPA/AA) ratio on clinical outcomes of acute coronary syndrome (ACS) patients and how lipid-lowering therapy affects serum EPA/AA levels in these patients.

Methods

This is a sub-analysis of HIJ-PROPER assessing the effect of aggressive low-density lipoprotein cholesterol (LDL-C)-lowering treatment with pitavastatin+ezetimibe in 1,734 ACS patients with dyslipidemia. Patients were divided into two groups based on EPA/AA level on admission (cut-off: 0.34 μg/mL; median of baseline EPA/AA level) and clinical outcomes were examined.

Results

Percent reduction of LDL-C from baseline to follow-up and mean LDL-C level during follow-up were similar regardless of baseline EPA/AA ratio. In the low EPA/AA group, the Kaplan–Meier estimate for the primary endpoint at 3 years was 27.2% in the pitavastatin+ezetimibe group, compared with 36.6% in the pitavastatin-monotherapy group [hazard ratio (HR), 0.69; 95% confidence interval (CI), 0.52–0.93; P=0.015). However, in the high EPA/AA group, there was no significant reduction in the primary endpoint by pitavastatin+ezetimibe therapy (HR, 0.92; 95% CI, 0.70–1.20; P=0.52).

Conclusions

Aggressive lipid-lowering therapy with ezetimibe had a positive effect on clinical outcomes in the low EPA/AA group of ACS patients with dyslipidemia, but not in the high EPA/AA group. This effect was independent of LDL-C reduction and suggests that EPA/AA measurement on admission in ACS patients contributes to a “personalized” lipid-lowering approach.

P3541Change in left ventricular ejection fraction and outcome in heart failure patients with mid-range ejection fraction: from the HIJ-HF prospective study

Introduction

Heart failure (HF) is categorized on the basis of the eft ventricular ejection fraction (LVEF). The European Society of Cardiology has proposed mid-range EF (HFmrEF) as a new category of HF that includes patients with an LVEF of 40–49%. However, the clinical characteristics, change in LVEF following treatment, and outcome of patients with HFmrEF remain clear.

Methods

We conducted a prospective observational study of Japanese hospitalized HF patients between 2015 and 2018 at a single-center (HIJ-HF III). HFmrEF was defined as 40–49% of LVEF on echocardiography at admission. We followed these patients and performed echocardiography to assess LVEF per year after hospital discharge. Clinical outcome was death from any cause.

Methods and results

We studied 138 patients with HFmrEF (median age 71 years, 69% male). They had 32% of ischemic heart disease, 9% of New York Heart Association functional class III or IV at discharge. During median follow-up of 20 [13–28] months, we assessed change in LVEF for 110 patients with HFmrEF. One year after hospital discharge, 49 patients (44%) improved LVEF (≥50%) and 21 patients (19%) reduced LVEF (<40%). HFmrEF patients who reduced LVEF (<40%) were significantly higher mortality rate than those who improved LVEF (≥50%) (14% vs. 2%, p<0.05) (Figure).

Conclusions

This study demonstrated that 44% of HFmrEF patients improved LVEF following treatment but 19% patients reduced LVEF. Reduced LVEF was associated with poor prognosis.

P830Differences in the usefulness of aggressive lipid-lowering therapy among single-vessel and multi-vessel coronary artery disease patients: HIJ-PROPER sub-study

Background

Acute coronary syndrome (ACS) patients with multi-vessel disease (MVD) are at high risk of recurrent cardiovascular events. Previous study, examining stable atherosclerotic cardiac disease, reported that aggressive lipid-lowering therapy was more beneficial in MVD patients than in single-vessel disease (SVD) patients. However, no report has investigated the effects of aggressive lipid-lowering treatment according to the number of diseased coronary arteries in ACS patients.

Purpose

The purpose of the present study was to elucidate the efficacy of aggressive lipid-lowering therapy in ACS patients with MVD and SVD in modern early invasive strategy era.

Methods

The study population was derived from the HIJ-PROPER study, in which, ACS patients with dyslipidemia were randomized to pitavastatin + ezetimibe therapy (targeting LDL-C less than 70mg/dl) or pitavastatin-monotherapy (targeting LDL-C less than 90mg/dl). In the present study, the treatment efficacy was compared between patients with MVD and SVD. The primary end point was a composite of major advanced cardiovascular events (MACEs), including all-cause death, non-fatal myocardial infarction, non-fatal stroke, and ischemia driven revascularization.

Results

We identified 1702 eligible patients (mean age, 65.6 years; male, 75.6%); 869 patients (51.1%) had MVD and 833 (48.9%) patients had SVD. The rate of acute revascularization was 96.2%. The incidence of MACEs was significantly higher in MVD group compared to SVD group (43.7% vs 25.9%, hazard ratio 1.95, 95% confidence interval 1.65–2.31, p<0.001). In MVD group, there was no significant difference in MACEs between pitavastatin + ezetimibe therapy and pitavastatin-monotherapy group. (43.5% vs. 43.9%, 1.0, 0.82–1.23; p=0.95). However, in SVD group, pitavastatin + ezetimibe therapy showed significantly fewer MACEs than pitavastatin-monotherapy (34.6% vs. 47.4%, 0.72, 0.55–0.94, p=0.02). (Figure)

Conclusion

This study showed that ACS patients with SVD enjoyed significantly greater benefits from pitavastatin + ezetimibe therapy compared with pitavastatin monotherapy, whereas the patients with MVD did not. High rate of revascularization in acute phase of ACS might affect the efficacy of aggressive lipid-lowering therapy and our results in the present study suggest different treatment approach would be necessary in ACS patients with MVD in modern early invasive strategy era.

Association between dysphagia risk and unplanned hospitalization in older patients receiving home medical care

AIM

Home medical care for older adults with chronic conditions is becoming an increasing important issue in Japan. We need to support long-term medical care at home and avoid unplanned hospitalizations, which can adversely affect activities of daily living and quality of life. In this study, we investigated whether swallowing function is a risk for unplanned hospitalization in older patients with functional decline who are receiving home medical care.

METHODS

In the current study, we examined data obtained in the Observational study of Nagoya Elderly with HOme MEdical study (ONEHOME) that investigated the medical health of older adults receiving home medical care services in Nagoya City, Japan. The data analyzed were patients' age, sex, number of medications, Dysphagia Severity Scale, Charlson Comorbidity Index, Barthel Index, Mini Nutritional Assessment - Short Form, Frailty Index and dementia independent scale. The Dysphagia Severity Scale was categorized into the presence or absence of dysphagia risk. The association between dysphagia risk and days until first hospitalization was investigated by Cox regression analysis.

RESULTS

In total, 86 out of 178 patients had a hospitalization during the study period of 4 years. Cox regression analysis with adjustment for age, sex, Charlson Comorbidity Index, Barthel Index and Mini Nutritional Assessment - Short Form scores showed that a lower Dysphagia Severity Scale score was significantly associated with unexpected hospitalization.

CONCLUSIONS

Dysphagia risk predicts the first unexpected hospitalization in older individuals receiving home medical care. Patients' swallowing function is an important factor for estimating prognosis. Geriatr Gerontol Int 2019; 19: 977-981.

Change in quality of life and potentially associated factors in patients receiving home-based primary care: a prospective cohort study

Background

The trajectories for health-related quality of life of patients receiving home-based primary care are not well identified. Our objective was to investigate changes in the quality of life (QOL) and factors that affected the QOL of patients receiving home-based primary care.

Methods

Our prospective cohort study, the Observational study of Nagoya Elderly with HOme MEdical (ONE HOME) study, recruited 184 patients undergoing home-based primary care with a 5-year follow-up period. Patients’ demographic data, socioeconomic status, physical diseases, medication use, feeding intake status, nutritional status, and functional status were measured annually. The 4-item quality of life index (QOL-HC [home care]) including self-perceived and family-reported QOL ratings that had been developed and previously validated in home care settings was used. Linear regression models were used for cross-sectional and longitudinal analyses.

Results

The participants’ mean age was 78.8 ± 10.8 years, and 55.9% of the sample was male. Most patients were frail, disabled, and/or malnourished. Self-perceived and family-reported QOL scores dropped sequentially on annual follow-ups. In the multivariate longitudinal analysis, patients who were divorced (β = 1.74) had high baseline QOL scores (β = 0.75) and reported higher QOL ratings. In addition, high functional dependency was associated with a low self-perceived QOL rating, with a β-value of − 1.24 in the pre-bedridden group and − 1.39 in the bedridden group. Given the family-reported QOL rating, the baseline QOL scores (β = 0.50) and Mini-Nutritional Assessment–Short-Form scores (β = 0.37) were found to have positive associations with the QOL rating.

Conclusions

For the disabled receiving home-based primary care, independent functional status and divorce were positively associated with better self-perceived QOL, whereas nutritional status was correlated with better family-reported QOL.

Prevalence and risk factors of constipation and pollakisuria among older home-care patients

AIM

The prevalence of constipation and prevalence of pollakisuria among older patients receiving home medical care have not been reported, and risk factors for these symptoms are not clear in this setting. The present study sought to determine the prevalence and risk factors of constipation and pollakisuria among older patients receiving home medical care in Japan.

METHODS

This study utilized data from patients in the Observational Study of Nagoya Elderly with Home Medical Care (n = 153). We carried out univariate and multivariate logistic regression analyses with the presence of constipation or pollakisuria as the dependent variable to evaluate the relationships between constipation or pollakisuria and several covariates.

RESULTS

The prevalence of constipation and pollakisuria were 56.9% and 15.7%, respectively. Multivariate logistic analysis showed that constipation was associated with Charlson Comorbidity Index score, polypharmacy and pollakisuria, and pollakisuria was associated with constipation and insomnia. Cardiovascular disease was inversely associated with constipation.

CONCLUSIONS

The prevalence of constipation among home-care patients was as high as that reported for nursing home residents and higher than that among community-dwelling individuals. Clinicians should be aware of increased constipation risk among home-care patients, particularly for those with a high Carlson Comorbidity Index score, polypharmacy and/or pollakisuria. Geriatr Gerontol Int 2019; 19: 277-281.

[Agreement in the responses to self-reported and proxy-reported versions of QOL-HC: a new quality-of-life scale for patients receiving home-based medical care]

AIM

We developed quality-of-life (QOL) scales for patients receiving home medical care. The objective of this study was to examine the agreement between the scores of the scales answered by patients and those answered by their proxy, as cognitive decline may interfere with one's ability to understand complex topics, such as the QOL.

METHODS

Participants were pairs of patients receiving home medical care and their proxy. The patients were asked to complete self-reported QOL scales (QOL-HC), and their proxies were asked to complete proxy-reported versions of the QOL scales (QOL-HC for caregivers). We then statistically examined the extent of agreement between the self- and proxy-reported QOL-HC scores using contingency tables and Spearman's rank correlation coefficient. The SPSS software program, version 24, was used for all statistical analyses.

RESULTS

The concordance rate between patients and caregivers for questions 1 ( "Do you have peace of mind?" ), 2 ( "Do you feel satisfied with your life when you reflect on it?" ), 3 ( "Do you have someone that you spend time talking with?" ), and 4 ( "Are you satisfied with the home care service system?" ) were 52.3%, 52.3%, 79.5%, and 81.8%, respectively. The total scores for the patients and caregivers were significantly correlated (Spearman's ρ=0.364*).

CONCLUSIONS

We created the first QOL scale for patients receiving home-based medical care and for caregivers. The findings of this study suggest that the QOL-HC can be used in clinical practice for the assessment of patients receiving professional home care.

Short-term risk of hepatocellular carcinoma after hepatitis C virus eradication following direct-acting anti-viral treatment

BACKGROUND

With the development of direct-acting anti-virals (DAAs), almost all patients with chronic hepatitis C virus (HCV) infection can achieve sustained viral response (SVR).

AIM

To evaluate the short-term risk of HCC among patients with SVR by DAAs, including those with cirrhosis or previous HCC.

METHODS

This large-scale, multicentre cohort study included 1,675 consecutive patients who achieved SVR by treatment with interferon-free sofosbuvir-based regimens, divided into groups with (n = 152) or without previous HCC (n = 1,523). The Kaplan-Meier method and Cox proportional hazard analysis were used to calculate the cumulative HCC incidence and related factors of HCC.

RESULTS

During the follow-up period (median: 17 months), 46 (2.7%) patients developed HCC. The 1-year cumulative rates of de novo HCC were 0.4% and 4.9% for the noncirrhosis and cirrhosis groups respectively (log-rank test: P < 0.001). For cirrhotic patients, serum α-fetoprotein level at the end of treatment (EOT-AFP) was the strongest predictor of de novo HCC. The 1-year cumulative de novo HCC rates were 1.4% and 13.1% in the EOT-AFP < 9.0 ng/mL and ≥ 9.0 ng/mL groups (cut-off value) respectively (log-rank test: P < 0.001). The 1-year cumulative rates of HCC recurrence were 6.5% and 23.1% for the noncirrhosis and cirrhosis groups respectively (log-rank test: P = 0.023). For cirrhotic patients, previous HCC characteristics were significantly associated with HCC recurrence. In contrast, sex, age and metabolic features did not influence de novo HCC or recurrence.

CONCLUSIONS

For cirrhotic patients after elimination of HCV, serum EOT-AFP level and previous HCC characteristics would be useful markers for predicting de novo HCC or recurrence.

Impact of double positive for anti-centromere and anti-SS-a/Ro antibodies on clinicopathological characteristics of primary Sjögren's syndrome: a retrospective cohort study

OBJECTIVES

The purpose of our study was to define the clinical characteristics of anti-centromere antibody and anti-SS-A/Ro antibody (ACA/SS-A) double positive Sjögren's syndrome (SS) and to clarify the clinical impact of these antibodies.

METHODS

We examined 108 patients (6 males, mean age 57.9 years) with SS who underwent labial salivary gland biopsy. The patients were divided into four groups by ACA and anti-SS-A/Ro antibody positivity. Symptoms, laboratory and pathological data, and scleroderma-related data were compared among the groups.

RESULTS

The cohort consisted of 16 ACA/SS-A double positive, 20 ACA single positive, 67 SS-A single positive, and 5 ACA/SS-A double negative SS. ACA/SS-A double positive SS were significantly older than SS-A single positive SS (mean age 71.1 vs. 53.1 years). They had higher EULAR Sjögren's syndrome disease activity index (ESSDAI) at diagnosis (mean 3.81 vs. 0.50) and higher serum IgG (mean 2009 vs. 1389 mg/dL) than ACA single positive SS. No patients developed skin sclerosis during a mean follow-up period of 45.6 months (range: 1-178).

CONCLUSION

These results demonstrate that ACA/SS-A double positive SS is distinct from ACA single positive and SSA single positive SS. The combination of ACA and anti-SS-A/Ro antibody in SS should deserve greater attention in clinical practice.

Fibrin Gel Induces the Migration of Smooth Muscle Cells from Rabbit Aortic Explants

A major step in the pathogenesis of atherosclerosis is the vectorial migration of smooth muscle cells (SMCs) from the arterial media into the intima. Although subcultured SMCs usually show synthetic phenotype, the behaviour of contractile SMCs may be crucial for the subsequent migration of the cells. In the present study, we utilized an in vitro assay system to evaluate the effects of fibrin gels on the migration of SMCs from explants taken from rabbit aorta. After cultured for 5-7 days in a serum-free condition, SMCs appeared from explants covered with fibrin gel. The cells were positive on immunostaining for SMC specific α-actin. No migration of SMCs from the control explants without fibrin gel was observed. Then the percentage of explants showing cell migration and the number of migrating cells increased with time. The migration of SMCs into fibrin gels was not dependent on the concentration of fibrinogen used for the preparation of fibrin gel in the range of 1.5-3 mg/ml. Variations of thrombin concentration in the range of 0.25-1.25 U/ml had no significant effect. However, there was less migration of SMCs with higher concentrations of thrombin. Thrombin inhibitors, hirudin and PPACK had no significant effect on the migration of SMCs. An RGD-containing peptide, GRGDS inhibited the migration of SMCs although a control peptide GRGES at the same concentration had no significant effect. A monoclonal antibody to αvβ3, LM609, completely inhibited the migration of SMCs from the explants, suggesting that αvβ3 integrin is involved in the migration of SMCs into fibrin gels. SMCs which migrated from the explants showed the positive staining with the monoclonal antibodies against SMC myosin heavy chain isoforms, SMemb, SM1 and SM2, suggesting that they are in an intermediate state changing from contractile to synthetic state. In conclusion, the present study showed that fibrin gel induces the migration of SMCs from explants into itself and the process may not need other growth factors or cytokines.

New clues to the nature of immunoglobulin G4-related disease: a retrospective Japanese multicenter study of baseline clinical features of 334 cases

Background

The aim was to further characterize immunoglobulin G4-related disease (IgG4-RD) by a large-scale multicenter study of its clinical and laboratory features conducted by multidisciplinary physicians of IgG4-RD in Japan.

Methods

Various specialists retrospectively evaluated IgG4-RD patients diagnosed between 1996 and 2015 in five hospitals by analyzing their baseline clinical features, laboratory, imaging, and pathological test findings, and treatment.

Results

Of the 334 patients listed, 205 were male and median age at diagnosis was 65 years. The mean number of organs involved was 3.2 at diagnosis. The most frequently affected organs were the salivary glands, followed by the lacrimal glands, lymph nodes, pancreas, retroperitoneum/periaorta, kidneys, and lungs. The mean serum level of IgG4 was 755 mg/dl, and more than 95% of patients had elevated serum IgG4 levels. The median serum level of C-reactive protein (CRP) was 0.1 mg/dl and the level was less than 1 mg/dl in 90% of patients. A total of 34.7% of patients had low serum levels of C3. Serum levels of C3 and non-IgG4 IgG, calculated as the total IgG minus IgG4, showed an inverse correlation in patients with kidney lesions, while serum IgG4 levels were not correlated with serum C3 levels. Corticosteroid was administered in 78.0% of patients, and was effective in all.

Conclusions

The serum CRP level is generally low and the serum IgG4 level is elevated in most Japanese IgG4-RD patients, in contrast to western patients. These original findings suggest that these two parameters in IgG4-RD differ in some interesting ways from those hitherto reported in western populations. Additional studies, especially international comparative ones, are needed to elucidate the extent and significance of these differences between populations. Attention will also have to be paid to whether the existence of such differences requires consideration when devising international classification criteria.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-017-1467-x) contains supplementary material, which is available to authorized users.

Changes in serum interleukin-6 levels as possible predictor of efficacy of tocilizumab treatment in rheumatoid arthritis

OBJECTIVES

We aimed to evaluate the association between the change in serum IL-6 during the clinical course of tocilizumab (TCZ) therapy and rheumatoid arthritis (RA) disease activity or occurrence of adverse events.

METHODS

General laboratory data including serum IL-6 levels and physical findings were obtained every 4 weeks, and, in addition, at the time when any adverse events occurred.

RESULTS

The proportion achieving Clinical Disease Activity Index (CDAI) remission at 52 weeks was significantly lower in 20 patients with serum IL-6 ≥ 30 pg/ml at 12 weeks than 24 patients with serum IL-6 < 30 pg/ml. In 17 patients with serum IL-6 ≥ 30 pg/ml at 24 weeks, the proportion achieving CDAI remission was also significantly lower than 27 patients with serum IL-6 < 30 pg/ml then. In these 17 patients, Disease Activity Score (DAS) 28-ESR and CDAI at 52 weeks were significantly higher than those with serum IL-6 < 30 pg/ml. Age- and sex-adjusted logistic regression analysis showed logIL-6 at 12 weeks to be a predictive factor for DAS28-ESR remission at 52 weeks.

CONCLUSION

Serum IL-6 levels from 12 to 24 weeks after TCZ initiation better reflect the efficacy of TCZ at 52 weeks.

Factors related to renal cortical atrophy development after glucocorticoid therapy in IgG4-related kidney disease: a retrospective multicenter study

Background

In immunoglobulin G4-related kidney disease (IgG4-RKD), focal or diffuse renal cortical atrophy is often observed in the clinical course after glucocorticoid therapy. This study aimed to clarify the factors related to renal atrophy after glucocorticoid therapy in IgG4-RKD.

Methods

We retrospectively evaluated clinical features including laboratory data and computed tomography (CT) findings before and after glucocorticoid therapy in 23 patients diagnosed with IgG4-RKD, all of whom were followed up for more than 24 months.

Results

Seventeen patients were men, and six were women (average age 62.0 years). Average follow-up period was 54.9 months. The average estimated glomerular filtration rate (eGFR) at diagnosis was 81.7 mL/min/1.73 m². All patients had had multiple low-density lesions on contrast-enhanced CT before glucocorticoid therapy, and showed disappearance or reduction of these lesions after it. Pre-treatment eGFR and serum IgE level in 11 patients in whom renal cortical atrophy developed 24 months after the start of glucocorticoid therapy were significantly different from those in 12 patients in whom no obvious atrophy was found at that time (68.9 ± 30.1 vs 93.5 ± 14.1 mL/min/1.73 m², P = 0.036, and 587 ± 254 vs 284 ± 263 IU/mL, P = 0.008, respectively). Pre-treatment eGFR and serum IgE level were also significant risk factors for renal atrophy development 24 months after the start of therapy with an odds ratio of 0.520 (per 10 mL/min/1.73 m², 95% confidence interval (CI) 0.273–0.993, P = 0.048) and 1.090 (per 10 IU/mL, 95% CI: 1.013–1.174, P = 0.022), respectively, in age-adjusted, sex-adjusted, serum IgG4 level-adjusted logistic regression analysis. Receiver operating characteristic curve analysis showed that eGFR of less than 71.0 mL/min/1.73 m² and serum IgE of more than 436.5 IU/mL were the most appropriate cutoffs and yielded sensitivity of 63.6% and specificity of 100%, and sensitivity of 90.9% and specificity of 75.0%, respectively, in predicting renal atrophy development.

Conclusions

This study suggests that pre-treatment renal insufficiency and serum IgE elevation predict renal atrophy development after glucocorticoid therapy in IgG4-RKD.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-016-1175-y) contains supplementary material, which is available to authorized users.

Risk Factors for the Discontinuation of Home Medical Care among Low-functioning Older Patients

OBJECTIVES

Older patients receiving home medical care often have declining functional status and multiple disease conditions. It is important to identify the risk factors for care transition events in this population in order to avoid preventable transitions. In the present study, therefore, we investigated the factors associated with discontinuation of home medical care as a potentially preventable care transition event in older patients.

METHODS

Baseline data for participants in the Observational study of Nagoya Elderly with HOme MEdical (ONEHOME) study and data on the mortality, institutionalization, or hospitalisation of the study participants during a 2-year follow-up period were used. Discontinuation of home care was defined as admission to a hospital for any reason, institutionalization, or death. Univariate and multivariate Cox hazard models were used to assess the association of each of the factors with the discontinuation of home care during the observational period. The covariates included in the multivariate analysis were those significantly associated with the discontinuation of home care at the level of P<0.05 in the univariate analysis.

RESULTS

The univariate Cox hazard model revealed that a low hemoglobin level (< 11g/dL), low serum albumin level (< 3g/dL), higher Charlson Comorbidity Index score, and low Mini Nutritional Assessment Short Form score (< 7) were significantly associated with the discontinuation of home care. A multivariate Cox hazard model including these four factors demonstrated that all four were independently associated with home-care discontinuation.

CONCLUSIONS

The present results demonstrated that anemia, hypoalbuminemia, malnourishment, and the presence of serious comorbidities were associated with the discontinuation of home medical care among low-functioning older patients.

Development and validation of a new quality of life scale for patients receiving home-based medical care: The Observational Study of Nagoya Elderly with Home Medical Care

AIM

To develop and validate a scale that assesses quality of life in patients receiving home-based medical care.

METHODS

A new quality of life scale was developed and evaluated in four phases: (i) item generation; (ii) first field study with a 14-item questionnaire; (iii) preliminary validation study, to reduce the number of items to four; and (iv) second field study comprising 40 patients, to evaluate the validity of the final version. Participants were requested to answer both the final version of the scale and the Short Form-8, to enable identification of any relationship between the two.

RESULTS

Items were generated after discussions with doctors and care managers, and 14 items were selected for the draft version. In the preliminary validation study, 10 items were deleted, based on the results of statistical analysis of the data from the first field study. A psychometric analysis showed that the final four-item questionnaire had internal consistency (Cronbach's α = 0.7), and a significant association with the Short Form-8.

CONCLUSIONS

We created the first quality of life scale for patients receiving home-based medical care. The scale's internal consistency was confirmed, as well as its external validity. This scale can be used independently of factors such as a patient's age, sex, level of independence in the presence of dementia or disability, swallowing function, hearing ability and communication ability, and can be used with ease in routine clinical practice. Geriatr Gerontol Int 2017; 17: 440-448.

Effectiveness of triple therapy with simeprevir for chronic hepatitis C genotype 1b patients with prior telaprevir failure

Favourable efficacy and safety profiles for simeprevir in combination with pegylated interferon alpha (PEG-IFNα) and ribavirin (triple therapy) have been shown in clinical trials. This study was carried out to evaluate the effectiveness of simeprevir-based triple therapy for patients with prior telaprevir treatment failure. This multicentre, observational cohort consisted of 345 consecutive Japanese patients infected with HCV genotype 1b, including 20 who had experienced telaprevir-based triple therapy. Amino acid substitutions in the NS3/4A region were identified by direct sequencing at the time of relapse or breakthrough in treatment with telaprevir and at the initiation of treatment with simeprevir. Patients were stratified according to prior response to PEG-IFNα and ribavirin. Of the 20 patients with telaprevir treatment failure, 10 (50.0%) achieved sustained virological response at week 12 after the end of treatment (SVR12). For patients treatment naïve [3/4 (75.0%)] or with prior relapse [1/1 (100%)] or partial response [5/6 (83.3%)] to PEG-IFNα and ribavirin, almost all achieved SVR12, mainly because of the improvement of treatment adherence, especially to direct-acting antiviral agent and ribavirin. However, of the nine patients with prior null response to PEG-IFNα and ribavirin, only one (11.1%) achieved SVR12, despite all having received an adequate treatment dosage, and five (55.6%) achieved rapid virological response. The treatment outcome of simeprevir-based triple therapy for HCV genotype 1b patients with prior telaprevir failure depended on the prior response to PEG-IFNα and ribavirin. For patients with prior null response to PEG-IFNα and ribavirin, retreatment with simeprevir-based triple therapy is not a useful option.