The Current Discussion Regarding End-of-Life Care for Patients with Out-of-Hospital Cardiac Arrest with Initial Non-Shockable Rhythm: A Narrative Review

Despite recent advances in resuscitation science, outcomes in patients with out-of-hospital cardiac arrest (OHCA) with initial non-shockable rhythm remains poor. Those with initial non-shockable rhythm have some epidemiological features, including the proportion of patients with a witnessed arrest, bystander cardiopulmonary resuscitation (CPR), age, and presumed etiology of cardiac arrest have been reported, which differ from those with initial shockable rhythm. The discussion regarding better end-of-life care for patients with OHCA is a major concern among citizens. As one of the efforts to avoid unwanted resuscitation, advance directive is recognized as a key intervention, safeguarding patient autonomy. However, several difficulties remain in enhancing the effective use of advance directives for patients with OHCA, including local regulation of their use, insufficient utilization of advance directives by emergency medical services at the scene, and a lack of established tools for discussing futility of resuscitation in advance care planning. In addition, prehospital termination of resuscitation is a common practice in many emergency medical service systems to assist clinicians in deciding whether to discontinue resuscitation. However, there are also several unresolved problems, including the feasibility of implementing the rules for several regions and potential missed survivors among candidates for prehospital termination of resuscitation. Further investigation to address these difficulties is warranted for better end-of-life care of patients with OHCA.

External validation of the rCAST for patients after in-hospital cardiac arrest: a multicenter retrospective observational study

No established predictive or risk classification tool exists for the neurological outcomes of post-cardiac arrest syndrome (PCAS) in patients with in-hospital cardiac arrest (IHCA). This study aimed to investigate whether the revised post-cardiac arrest syndrome for therapeutic hypothermia score (rCAST), which was developed to estimate the prognosis of PCAS patients with out-of-hospital cardiac arrest (OHCA), was applicable to patients with IHCA. A retrospective, multicenter observational study of 140 consecutive adult IHCA patients admitted to three intensive care units. The area under the receiver operating characteristic curves (AUCs) of the rCAST for poor neurological outcome and mortality at 30 days were 0.88 (0.82-0.93) and 0.83 (0.76-0.89), respectively. The sensitivity and specificity of the risk classification according to rCAST for poor neurological outcomes were 0.90 (0.83-0.96) and 0.67 (0.55-0.79) for the low, 0.63 (0.54-0.74) and 0.67 (0.55-0.79) for the moderate, and 0.27 (0.17-0.37) and 1.00 (1.00-1.00) for the high-severity grades. All 22 patients classified with a high-severity grade showed poor neurological outcomes. The rCAST showed excellent predictive accuracy for neurological prognosis in patients with PCAS after IHCA. The rCAST may be useful as a risk classification tool for PCAS after IHCA.

High versus low positive end-expiratory pressure setting in patients receiving veno-venous extracorporeal membrane oxygenation support for severe acute respiratory distress syndrome: study protocol for the multicentre, randomised ExPress SAVER Trial

INTRODUCTION

While limiting the tidal volume to 6 mL/kg during veno-venous extracorporeal membrane oxygenation (V-V ECMO) to ameliorate lung injury in patients with acute respiratory distress syndrome (ARDS) is widely accepted, the best setting for positive end-expiratory pressure (PEEP) is still controversial. This study is being conducted to investigate whether a higher PEEP setting (15 cmH2O) during V-V ECMO can decrease the duration of ECMO support needed in patients with severe ARDS, as compared with a lower PEEP setting.

METHODS AND ANALYSIS

The study is an investigator-initiated, multicentre, open-label, two-arm, randomised controlled trial conducted with the participation of 20 intensive care units (ICUs) at academic as well as non-academic hospitals in Japan. The subjects of the study are patients with severe ARDS who require V-V ECMO support. Eligible patients will be randomised equally to the high PEEP group or low PEEP group. Recruitment to the study will continue until a total of 210 patients with ARDS requiring V-V ECMO support have been randomised. In the high PEEP group, PEEP will be set at 15 cmH2O from the start of V-V ECMO until the trials for liberation from V-V ECMO (or until day 28 after the allocation), while in the low PEEP group, the PEEP will be set at 5 cmH2O. Other treatments will be the same in the two groups. The primary endpoint of the study is the number of ECMO-free days until day 28, defined as the length of time (in days) from successful libration from V-V ECMO to day 28. The secondary endpoints are mortality on day 28, in-hospital mortality on day 60, ventilator-free days during the first 60 days and length of ICU stay.

ETHICS AND DISSEMINATION

Ethics approval for the trial at all the participating hospitals was obtained on 27 September 2022, by central ethics approval (IRB at Hiroshima University Hospital, C2022-0006). The results of this study will be presented at domestic and international medical congresses, and also published in scientific journals.

TRIAL REGISTRATION NUMBER

The Japan Registry of Clinical Trials jRCT1062220062. Registered on 28 September 2022.

PROTOCOL VERSION

28 March 2023, version 4.0.

Predictive Accuracy of the Breathing Frequency-Ratio of Oxygen Saturation Index for Re-Intubation in Mechanically Ventilated Subjects With COVID-19

BACKGROUND

Several studies have suggested that high-flow nasal cannula (HFNC) is useful for respiratory support after extubation in subjects with COVID-19 pneumonia, whereas 18.2% subsequently needed to undergo re-intubation. This study aimed to evaluate whether the breathing frequency (f)-ratio of oxygen saturation (ROX) index, which has been shown to be useful for predicting future intubation, is also useful for re-intubation in subjects with COVID-19.

METHODS

We retrospectively analyzed mechanically ventilated subjects with COVID-19 who underwent HFNC therapy after extubation at 4 participating hospitals between January 2020-May 2022. We evaluated the predictive accuracy of ROX at 0, 1, and 2 h for re-intubation until ICU discharge and compared the area under the receiver operating characteristic (ROC) curve of the ROX index with those of f and S_pO2 /F_IO2 .

RESULTS

Among the 248 subjects with COVID-19 pneumonia, 44 who underwent HFNC therapy after extubation were included. A total of 32 subjects without re-intubation were classified into the HFNC success group, and 12 with re-intubation were classified into the failure group. The overall trend that the area under the ROC curve of the ROX index was greater than that of the f and S_aO2 /F_IO2 was observed, although there was no statistical significance at any time point. The ROX index at 0 h, at the cutoff point of < 7.44, showed a sensitivity and specificity of 0.42 and 0.97, respectively. A trend of positive correlation between the time until re-intubation and ROX index at each time point was observed.

CONCLUSIONS

The ROX index in the early phase of HFNC therapy after extubation was useful for predicting re-intubation with high accuracy in mechanically ventilated subjects with COVID-19. We may need close observation for subjects with < 7.44 ROX index just after extubation because of their high risk for re-intubation.

Lung Abscess and Pyothorax in Critically Ill COVID-19 Patients: A Single-Center Retrospective Study

The mortality rate of patients with COVID-19 pneumonia requiring mechanical ventilation remains high. This study determined the percentage and characteristics of patients who developed lung abscesses or pyothorax and their mortality rates among adult patients with COVID-19 admitted to the ICU who required mechanical ventilation. Of the 64 patients with COVID-19 assessed, 30 (47%) developed ventilator-associated pneumonia (VAP), of whom 6 (20%) developed pyothorax or lung abscess. There were no statistically significant differences in patient characteristics, treatment after ICU admission, or outcomes between those with and without these complications, except for age. VAP complicated by Lung abscess or pyothorax was caused by a single organism, with Staphylococcus aureus (n = 4) and Klebsiella species (n = 2) being the primary causative agents. Occur infrequently in patients with COVID-19 requiring mechanical ventilation. Large-scale studies are required to elucidate their effects on clinical outcomes.

ACE values in the diagnosis of sarcoidosis

Background

In clinical practice, we often encounter the patients with sarcoidosis showing relatively high in the normal range of serum angiotensin-converting enzyme (ACE) value.

Purpose

We aimed to examine the serum ACE value of the patients with sarcoidosis and determine the new cut-off value for detecting the patients with sarcoidosis.

Methods and results

We retrospectively examined all 3781 subjects (51.1% men, 60.1±17.0 y.o.) in whom ACE was measured for any reasons including suspected sarcoidosis between 2009 and 2020 in our hospital. Of 293 patients with sarcoidosis, 101, 212, 84, and 88 were diagnosed as sarcoidosis in heart, lung, skin, and eyes, respectively. After excluding 477 patients taking ACE inhibitor and/or immunosuppression agent or those with any diseases affecting serum ACE levels, we analyzed 3304 subjects including 215 with sarcoidosis. Serum ACEs were 19.6 IU/L [IQR, 15.1–31.5] in the subjects with sarcoidosis and 10.7 [8.4–16.5] in those without (P&lt;0.01). In ROC curve analysis of ACE for diagnosis of sarcoidosis, the cut-off point was 14.7 IU/L and the AUC was 0.865. When we used the current cut-off of 21.4 or new cut-off value of 14.7, sensitivity, specificity, PPV, NPV, and accuracy were shown in Table. Finally, they were divided into four groups based on the presence of cardiac and/or extra cardiac sarcoidosis, ACE values in Group A, B, C, and D were 17.9, 20.9, 18.6, and 10.7, respectively (Figure 1).

Conclusion(s)

In the current cut-off value of serum ACE, sensitivity for detecting sarcoidosis was comparatively low, though positive predictive value was low when the new-cut-off value was used in our study. Further examinations may be needed for the patients suspected sarcoidosis with relatively high ACE in the normal range.

Funding Acknowledgement

Type of funding sources: None.

Indoor gas phase photoactivity of yttrium modified titanate films for fast acetaldehyde oxidation

Photoactive materials hold structural and catalytic features that make them particularly suitable for environmental applications and in the present work, protonated H₃Ti₃O₇-Y nanofiber-like materials were prepared via the microwave assisted hydrothermal technique. The as-prepared nanofibers exhibited high surface area with titanate structure. The nanofibers, before and after yttrium incorporation, were well-distributed and the fibrous morphology could be observed clearly; as the yttrium loading increased, ribbons and the anatase phase were formed. Practical films of these nanofibers confirmed their likely UV-photoactive properties with 200 ppm of acetaldehyde degradation within 25 min in the presence of 50% of humidity. Activity retention was achieved, keeping stability for 2 consecutive cycles at room temperature. Nowadays, the increase in home office work sets human health at risk, for the exposure to toxic volatile organic compounds and microorganisms such as viruses and bacteria is more frequent indoors. In this context, the synthesized photoactive yttrium-titanate films stand as upcoming practical UV-driven materials for cleaning pollution that concentrated urban activity and indoor environments.

Prevalence of rapid response systems in small hospitals: A questionnaire survey

The rapid response system (RRS) was introduced for early stage intervention in patients with deteriorating clinical conditions. Responses to unexpected in-hospital patient emergencies varied among hospitals. This study was conducted to understand the prevalence of RRS in smaller hospitals and to identify the need for improvements in the responses to in-hospital emergencies.A questionnaire survey of 971 acute-care hospitals in western Japan was conducted from May to June 2019 on types of in-hospital emergency response for patients in cardiac arrest (e.g., medical emergency teams [METs]), before obvious deterioration (e.g., rapid response teams [RRTs]), and areas for improvement.We received 149 responses, including those from 56 smaller hospitals (≤200 beds), which provided fewer responses than other hospitals. Response systems for cardiac arrest were used for at least a limited number of hours in 129 hospitals (87%). The absence of RRS was significantly more frequent in smaller hospitals than in larger hospitals (13/56, 23% vs 1/60, 2%; P < .01). METs and RRTs operated in 17 (11%) and 15 (10%) hospitals, respectively, and the operation rate for RRTs was significantly lower in smaller hospitals than in larger hospitals (1/56, 2% vs 12/60, 20%; P < .01). Respondents identified the need for education and more medical staff and supervisors; data collection or involvement of the medical safety management sector was ranked low.The prevalence of RRS or predetermined responses before obvious patient deterioration was ≤10% in small hospitals. Specific education and appointment of supervisors could support RRS in small hospitals.

Occurrence and incidence rate of peripheral intravascular catheter-related phlebitis and complications in critically ill patients: a prospective cohort study (AMOR-VENUS study)

Background

The lack of precise information on the epidemiology of peripheral intravascular catheter (PIVC)-related phlebitis and complications in critically ill patients results in the absence of appropriate preventive measures. Therefore, we aimed to describe the epidemiology of the use of PIVCs and the incidence/occurrence of phlebitis and complications in the intensive care unit (ICU).

Methods

This prospective multicenter cohort study was conducted in 23 ICUs in Japan. All consecutive patients aged ≥ 18 years admitted to the ICU were enrolled. PIVCs inserted prior to ICU admission and those newly inserted after ICU admission were included in the analysis. Characteristics of the ICU, patients, and PIVCs were recorded. The primary and secondary outcomes were the occurrence and incidence rate of PIVC-related phlebitis and complications (catheter-related blood stream infection [CRBSI] and catheter failure) during the ICU stay.

Results

We included 2741 patients and 7118 PIVCs, of which 48.2% were inserted in the ICU. PIVC-related phlebitis occurred in 7.5% (95% confidence interval [CI] 6.9–8.2%) of catheters (3.3 cases / 100 catheter-days) and 12.9% (95% CI 11.7–14.2%) of patients (6.3 cases / 100 catheter-days). Most PIVCs were removed immediately after diagnosis of phlebitis (71.9%). Grade 1 was the most common phlebitis (72.6%), while grade 4 was the least common (1.5%). The incidence rate of CRBSI was 0.8% (95% CI 0.4–1.2%). In cases of catheter failure, the proportion and incidence rate per 100 intravenous catheter-days of catheter failure were 21% (95% CI 20.0-21.9%) and 9.1 (95% CI 8.7–10.0), respectively.

Conclusion

PIVC-related phlebitis and complications were common in critically ill patients. The results suggest the importance of preventing PIVC-related complications, even in critically ill patients.

Trial registration

UMIN-CTR, the Japanese clinical trial registry (registration number: UMIN000028019, July 1, 2017).

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-020-00518-4.

Prospective validation of 0-hour/1-hour algorithm using high-sensitivity cardiac troponin I in Japanese patients presenting to emergency department

Background

The diagnostic performance of 0-hour/1-hour algorithm using high-sensitivity cardiac troponin I (hsTnI) for non-ST-segment elevation myocardial infarction (NSTEMI) has not been evaluated in an Asian population.

Purpose

We aimed to prospectively validate the 0-hour/1-hour algorithm using hsTnI in a Japanese population.

Method

We enrolled 754 Japanese patients (mean age of 70 years, 395 men) presenting to our emergency department with symptoms suggestive of NSTEMI. The hsTnI concentration was measured using the Siemens ADVIA Centaur hsTnI assay at presentation and after 1 hour. Patients were divided into three groups according to the algorithm: hsTnI below 3 ng/L (only applicable if chest pain onset &gt;3 hours) or below 6 ng/L and delta 1 hour below 3 ng/L were the “rule-out” group; hsTnI at least 120 ng/L or delta 1 hour at least 12 ng/L were in the “rule-in” group; the remaining patients were classified as the “observe” group. Based on the Fourth Universal Definition of Myocardial Infarction, the final diagnosis was adjudicated by 2 independent cardiologists using all available information, including coronary angiography, coronary computed tomography, and follow-up data. Safety of rule-out was quantified by the negative predictive value (NPV) for NSTEMI, accuracy of rule-in by the positive predictive value (PPV), and overall efficacy by the proportion of patients triaged towards rule-out or rule-in within 1 hour.

Results

Prevalence of NSTEMI was 6.5%. The safety of rule-out (NPV 100%), accuracy of rule-in (PPV 26%), and overall efficacy (54%) were shown in Figure.

Conclusion

The 0-hour/1-hour algorithm using hsTnI is very safe and effective in triaging Japanese patients with suspected NSTEMI.

Funding Acknowledgement

Type of funding source: None

Residual Analysis of Aflatoxins in Spice by HPLC Coupled with Solid-Phase Dispersive Extraction and Solid-Phase Fluorescence Derivatization Method

BACKGROUND

Aflatoxins (AFs) are carcinogenic mycotoxins. A simple, quick, and accurate method for the micro-analysis of AFs in foodstuffs, especially spices, is needed.

OBJECTIVE

A sophisticated pretreatment method that combines solid-phase dispersive extraction (SPDE) and solid-phase fluorescence derivatization using immunoaffinity (IA) gel as the solid phase was developed to analyze AFs in spices simply, quickly, and sensitively by liquid chromatography with fluorescence detection.

METHOD

White and black pepper samples were extracted with a mixed solution of methanol/water (4:1) and then diluted with 7% aqueous solution of Triton-X. The solution was subjected to cleanup by SPDE using IA gel. Trifluoroacetic acid was added to the IA gel for on-site solid-phase fluorescence derivatization.

RESULTS

Chromatograms containing well-separated peaks and few interference peaks from contaminants were obtained. The method detection limit of AFs in white and black pepper was 0.15-0.29 ng/g. Repeatability and intermediate precision were <10% and <15%, respectively, and accuracy was 61.7-87.8%. In addition, inter-laboratory precision was <29% and mean recovery was 61.5-76.7%. A favorable z-score of |Z| ≦ 1 was obtained in seven laboratories, although one laboratory gave 2 < |Z| < 3.

CONCLUSIONS

The validity, reliability, practicality, and robustness of the developed method were verified.

HIGHLIGHTS

By using SPDE and solid-phase fluorescence derivatization in combination for AF analysis, fluorescence derivatization during cleanup was realized, leading to simplification of the pretreatment operation.

Five-year major adverse cardiac and cerebrovascular events of patients with lipid core abutting lumen (LCAL) on integrated-backscatter intravascular ultrasound undergoing PCI with current DES

Background

Percutaneous Coronary Intervention (PCI) using the new generation drug-eluting stent (DES) has been extremely reduced target lesion revascularization (TLR) in recent years. However, a high incidence of non-target lesion-related cardiovascular events in patients undergoing PCI is an important problem to be solved. According to the previous findings, patients with vulnerable plaques particularly have a high recurrence of cardiovascular events. Little studies, however, has been done to examine the relationship between plaque characteristics on intravascular imaging in a target lesion and non-target lesion-related cardiovascular events.

Purpose

The main objective of this study is to investigate the five-year major adverse cardiac and cerebrovascular events (MACCE) of patients with lipid core abutting lumen (LCAL) on integrated backscatter intravascular ultrasound (IB-IVUS) in a target lesion undergoing PCI with current DES.

Methods and results

Between February 2010 and September 2013, in total 780 patients with ischemic heart disease undergoing PCI, 166 target lesions in 166 consecutive patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) and stable angina pectoris (SAP) undergoing IVUS-guided PCI were studied.

Plaque characteristics in all target lesions were analyzed by three-dimensional IB-IVUS system using the mechanical IVUS catheter. Our previous study has found that LCAL which is defined as a lipid pool directly in contact with the lumen visualizes the thin fibrous cap of less than 75μm on optical coherence tomography (OCT). On the basis of this data, LCAL at minimal lumen area (MLA) site was identified.

In total, 39 patients had lesions with LCAL at MLA site (LCAL(+)), and 127 patients had those without LCAL (LCAL(−)).

The primary endpoint was defined as MACCE, including cardiovascular death, non-fatal myocardial infarction, non-fatal stroke and non-TLR for the new lesion during a median follow up of five years. The MACCE occurred significantly higher in the LCAL(+) than in the LCAL(−) (38.5% vs. 17.3%; p&lt;0.005). And the Kaplan-Meier estimates have shown that the cumulative incidence of MACCE was significantly higher in the LCAL(+) than in the LCAL(−) (log rank test, p=0.041). Additionally, after adjustment for confounders, gender, prior PCI and LCAL was the independent predictors for the MACCE of patients undergoing PCI with current DES.

Furthermore, after adding LCAL to a baseline model with established factors consisting of age, gender, diabetes mellitus, prior PCI and percentage lipid volume on IB-IVUS, the net reclassification (p&lt;0.002) and integrated discrimination improvement (p&lt;0.004) significantly improved compared to baseline model alone.

Conclusions

In this study, it has become clear that LCAL on IB-IVUS is likely to be a surrogate marker of MACCE in patients undergoing PCI with current DES.

Funding Acknowledgement

Type of funding source: None

Circulating presepsin (soluble CD14 subtype) as a novel marker of mortality in patients treated at medical cardiac intensive care units

Background

Presepsin, a subtype of soluble CD14, is an inflammatory marker, which largely reflects monocyte activation. The association between presepsin levels and mortality in patients treated at medical cardiac intensive care units (CICUs) remains poorly known.

Objective

We aimed to understand the prognostic value of presepsin levels on admission to medical CICUs for mortality.

Methods

We prospectively studied 1636 heterogeneous patients (median age; 71 years) treated at medical (non-surgical) CICUs. Patients with stage 5 chronic kidney disease (estimated glomerular filtration rate [eGFR] &lt;15 mL/min/1.73 m2) were excluded. Acute coronary syndrome was present in 46% of the patients, and acute decompensated heart failure in 36%. Upon admission, baseline plasma presepsin levels were measured. The primary endpoint was all-cause death.

Results

During a mean follow-up period of 44.6 months after admission, there were 323 (19.7%) deaths. Patients who died were older (median: 75 vs. 71 years, P&lt;0.0001); had higher levels of presepsin (194 vs. 110 pg/mL, P&lt;0.0001), B-type natriuretic peptide (BNP: 520 vs. 144 pg/mL, P&lt;0.0001), high-sensitivity C-reactive protein (hsCRP: 4.7 vs. 2.0 mg/L, P&lt;0.0001), and sequential organ failure assessment (SOFA) score (3 vs. 2, P&lt;0.0001); and had lower levels of eGFR (55 vs. 69 mL/min/1.73m2, P&lt;0.0001) and left ventricular ejection fraction (46% vs. 52%, P&lt;0.0001) than those of the survivors. Multivariate Cox regression analyses revealed presepsin levels as independent predictors of all-cause deaths when assessed as either continuous variables (relative risk [RR] 3.33 per 10-fold increment; P&lt;0.0001) or variables categorized according to quartiles (RR quartile 4 vs. 1, 3.60; P&lt;0.0001). Quartiles of presepsin levels were significantly (P&lt;0.0001) associated with increased risk of mortality (Figure). Adding presepsin levels to a baseline model that included established risk factors, BNP, and hsCRP further enhanced reclassification (P=0.009) and discrimination (P=0.0008) beyond that of the baseline model alone.

Conclusions

Circulating concentration of presepsin on admission may be a potent and independent predictor of mortality, and it may improve the risk stratification of patients admitted at medical CICUs.

Presepsin quartiles and mortality

Funding Acknowledgement

Type of funding source: None

Long-term survival of a patient with acute neonatal-onset metabolic encephalopathy with carbamoyl phosphate synthetase 1 deficiency

OBJECTIVE

Long-term survival of patients with neonatal-onset carbamoyl-phosphate synthetase 1 deficiency (CPS1D), an autosomal recessive disorder characterized by repeated, life-threatening hyperammonemia, is rare. We describe the diagnosis and clinical management of a teenager with neonatal-onset CPS1D who did not undergo therapeutic liver transplantation.

CASE REPORT

Following emergent neonatal therapy, the patient was diagnosed with CPS1D based on clinical, radiological, biochemical and genetic analyses. Her clinical course, neurobehavioral development and therapeutic interventions are presented and discussed.

RESULTS

Born from nonconsanguineous parents, the proband underwent phototherapy for neonatal jaundice, associated with acute encephalopathy, apnea and cerebral edema. Based on blood and urinary biochemical abnormalities, neonatal-onset CPS1D was diagnosed. Her hyperammonemia was corrected by hemodialysis, followed by sodium benzoate, L-arginine, levocarnitine and protein-free diet therapy. Because of a relapse and persistent neurobehavioral regression by age 1, a planned liver transplantation was cancelled. At age 10, sodium phenylbutyrate was substituted as ammonia scavenger. Genetic testing revealed compound heterozygote c.2359C>T (R787X) and c.236+6T>C variants of CPS1, confirming her diagnosis. Despite severe neurological sequelae, the patient is 16 and in stable condition.

CONCLUSIONS

Our case suggests that early hemodialysis and pharmacologic interventions for acute neonatal hyperammonemia can improve the prognosis of patients with neonatal-onset CPS1D.

P1512 Combination of mitral annular peak systolic and early diastolic velocities with early transmitral peak flow velocity: a new prognostic echo index in patients with acute coronary syndrome

Background

One of the novel echocardiographic indices reflecting left ventricular (LV) diastolic filling is the combination of mitral annular peak systolic (s’) and early diastolic velocities (e’) with early transmitral peak flow velocity (E); E/(e’ x s’). This index is reported to be useful to predict a prognosis of heart failure patients regardless of their LV ejection fraction (LVEF).Purpose: The aim of this study was to examine whether or not E/(e’ x s’) could predict cardiac events in patients with acute coronary syndrome (ACS).Methods: We studies consecutive ACS patients hospitalized in our institution between December 2009 and February 2012. They underwent echo examination within 7 days after admission. By use of Doppler tissue imaging, e’ and s’ were respectively calculated by averaging the peak velocities measured at both septal and lateral mitral annulus in 4-chamber view. The exclusion criteria were as follows: atrial fibrillation, significant valvular diseases and inadequate echo images. Cardiac events were defined as re-hospitalization due to recurrent ACS and/or heart failure, and cardiac mortality.Results: In total, 168 patients were eligible for this study (mean age 67 ± 11 years, mean LVEF 51.7 ± 10.3 %). Median follow-up period was 22.5 months. During the follow-up, cardiac events occurred in 27 patients (16.1%). Between the patients with cardiac events and those without, there were significant differences in LV end-systolic volume (44.2 ± 29.1 vs 33.2 ± 13.6 ml, p &lt; 0.05), LV mass index (122.4 ± 38.9 vs 107.5 ± 26.4 g/m², p &lt; 0.05), left atrial volume index (31.7 ± 9.2 vs 27.6 ± 9.4 ml/m², p &lt; 0.05), LVEF (45.7 ± 13.5 vs 52.9 ± 9.2 %, p &lt; 0.05), s’ (5.1 ± 1.6 vs 7.1 ± 1.7 cm/sec, p &lt; 0.001), e’ (4.8 ± 1.3 vs 6.0 ± 1.9 cm/sec, p &lt; 0.05), E/e’ (16.4 ± 6.6 vs 12.5 ± 4.9, p &lt; 0.05), E/(e’ x s’) (3.78 ± 2.52 vs 1.94 ± 1.08, p &lt; 0.001), and serum B-type natriuretic peptide (334.7 ± 420.1 vs 113.8 ± 177.2 pg/ml, p &lt; 0.05). While Cox proportional hazard multivariate analysis detected that E/(e’ x s’) and E/e’ were independent predictors of cardiac events, E/(e’ x s’) was more powerful than E/e’ (p = 0.0002 vs p = 0.0072). ROC analysis revealed that 2.35 of E/(e’ x s’) was the optimal cutoff values to predict cardiac events in ACS patients (AUC 0.79). Patients with E/(e’ x s’) &lt;2.35 had significantly better prognosis than the rest (p &lt; 0.0001, Log-rank; Figure)Conclusion: E/(e’ x s’) could be a useful echo marker to predict cardiac events in ACS patients.

Abstract P1512 Figure.

P1508 Left ventricular diastolic function plays a different role on mortality depending on the severity of systolic dysfunction in acute heart failure patients with reduced ejection fraction

Background

It remains to be clarified whether clinical significance of left ventricular (LV) diastolic function differs depending on the severity of LV systolic dysfunction in patients with acute heart failure (AHF). The aim of this study was to examine the prognostic role of LV diastolic function in AHF patients with various systolic dysfunction.Methods: We studied consecutive hospitalized AHF patients with LV ejection fraction (LVEF) &lt;50%. The exclusion criteria were as follows: atrial fibrillation, severe mitral regurgitation, and inadequate echo image quality. They underwent echocardiography on admission. The eligible patients (n = 289, 165 males, 76 ± 10 years) were divided into 4 groups based on LVEF and left atrial pressure (LAP) grade estimated as in the ESC guidelines: Group I (LVEF 40-49% (mildly reduced LVEF)/normal LAP, n = 28), II (mildly reduced EF/increased LAP, n = 38), III (LVEF &lt;40% (severely reduced LVEF)/normal LAP, n = 110), and IV (severely reduced LVEF/increased LAP, n = 113). Cardiac death was examined up to 60 months.Results: In total, 58 patients (20%) died because of cardiac events during the follow-up (mean 20 ± 19 months). In patients with mildly reduced LVEF, Group I showed significantly less cardiac death ratio than II (n = 1 vs 10, Group I vs II, p = 0.03). On the other hand, in patients with severely reduced LVEF, there was no significant difference in cardiac death ratio between Group III and IV (n = 23 vs 24, Group III vs IV, p = 0.80). That is, LAP grade was a prognostic marker when the patients had mild LV systolic dysfunction, whereas it did not contribute to the prediction of cardiac mortality when patients showed severely reduced LV systolic function. Group I showed significantly better prognosis than those with severe LV systolic dysfunction regardless of LAP grade (Group III, IV) (Group I vs III, p = 0.04; Group I vs IV, p = 0.04).Conclusions: LV diastolic function may have a different clinical significance depending on the severity of LV systolic dysfunction in AHF patients.

P6178The optimal point of CT-FFR measurement in comparison with invasive FFR

Background

Currently, invasive fractional flow reserve (FFR), has become a gold standard to select patients requiring revascularization. Coronary computed tomography angiography (CTA) -derived FFR (FFRCT/CT-FFR) can be used for the management of coronary artery disease, which would be a gatekeeper of invasive coronary angiography. In most of the previous report to evaluate the diagnostic performance of FFRCT/CT-FFR, FFRCT/CT-FFR value was measured at the same point as the invasive FFR. Clinically, FFRCT/CT-FFR should be measured without the information of invasive FFR. However, optimal measurement point for CT-FFR has not been established yet.

Purpose

To assess the optimal measurement point of CT-FFR in comparison with invasive FFR as a gold standard.

Methods

CTA images scanned at 70–99% of R-R interval with 320 slice CT were screened. In the de-novo lesions with invasive FFR data were included in this study. Since calcified lesions could affect CT-FFR value, severe calcified lesions on CTA were excluded from the analysis. The CT-FFR analysis was performed by 2 cardiologists blinded to the results of the invasive FFR using a standard desktop computer and dedicated software. CT-FFR values could be provided at any point from ostium of coronary artery to the distal with vessel diameter of 1.8mm. To determine the optimal point for measurement of CT-FFR, CT-FFR values were obtained at 3 points in each coronary artery; 1) at the same point as invasive FFR; 2) lowest CT-FFR at distal point of coronary artery; 3) at 2.0 cm distal to the lesion. The diagnostic performance at each point was compared with invasive FFR.

Results

Fifty vessels of 44 patients (average age 68 years, male were 32) were included. Average Agatston score was 279.4. There was significant correlation between CT-FFR at each point and invasive FFR. CT-FFR at the same point as invasive FFR showed the good correlation with invasive FFR (R=0.641, 95% CI= 0.041–0.127, p<0.0001). Compared to the lowest CT-FFR at distal (R=0.608, 95% CI= 0.069–0.160, p<0.0001), CT-FFR at 2.0 cm distal to the lesion (R=0.604, 95% CI= 0.007–0.061, p<0.0001) revealed better correlation with invasive FFR. Sensitivity, specificity, positive and negative predictive value at each point were 92.8 / 93.3 / 81.8; 75.0 / 57.1 / 94.2; 61.9 / 48.2 / 60.0; and 96.0 / 95.2 / 84.6, respectively. Diagnostic accuracy showed that CT-FFR at 2cm distal to the lesion (0.84) was similar to CT-FFR at the same point as invasive FFR (0.80), and it was better than far distal (0.68) to detect invasive FFR derived ischemia.

Conclusions

CT-FFR was feasible to detect invasive FFR derived ischemia at the same point.

CT-FFR at 2.0 cm distal to the lesion showed higher diagnostic performance compared with CT-FFR measured at the far distal. CT-FFR measurement at 2.0 cm distal to the lesion would be a optimal position clinically.

P6171Role of myocardial mass for identifying FFR-verified ischemia and determining therapeutic strategy

Background

Conventional noninvasive approach using coronary CT angiography (CTA) focusing on only coronary artery lesions remains mismatch in identifying functional ischemia and determining indication for coronary revascularization.

Purpose

We aimed to assess the usefulness of CT-verified myocardial mass for identifying FFR-verified myocardial ischemia and determining the indication of coronary revascularization after FFR examination.

Methods

We examined 244 vessels with intermediate stenoses (50 to 90% stenosis visually on CTA) in 216 patients (mean age 69.2±9.2, 166 men) who underwent both coronary CTA and invasive FFR. In addition to coronary stenosis severity and plaque characteristics on visual, minimal lumen diameter (MLD), minimal lumen area (MLA), plaque volume, the entire myocardial volume of the target vessel (MTV) and that exposed to ischemia (FFR ≤0.80) (myocardial volume of ischemia: MVI) were evaluated. Additionally, therapeutic strategy after FFR was recorded.

Results

Of 244 vessels, myocardial ischemia (FFR ≤0.80) was shown in 99 (40.6%). MTV was larger in the patients with FFR-verified ischemia than those without (53.3±19.2 vs. 41.5±21.6, P<0.001); MLA, plaque burden (PB) and percentage of aggregated plaque volume (%APV) were also associated with ischemia. The area under the curves (AUCs) of MLA, PB, %APV, and MTV were 0.69, 0.67, 0.64, and 0.71, respectively. Addition of MTV to a model with coronary stenosis on visual, MLA, PB, and %APV improved C-index (from 0.72 to 0.79, P<0.01), net reclassification improvement (NRI) (0.71, P<0.01), and integrated discrimination improvement (IDI) (0.10, P<0.01). Of 99 vessels with FFR ≤0.80, MVI was larger in the vessels with early revascularization after FFR than those without (38.8 vs. 29.1, P=0.01).

Conclusions

The measurement of myocardial mass improves the diagnostic performance of coronary CTA for the identification of coronary arteries with FFR-verified ischemia. Furthermore, it is associated with therapeutic strategy for the diseased vessels after FFR examination.

P2240CTA derived plaque characteristics and cardiac events in deferred lesions by invasive FFR

Background

Fractional flow reserve (FFR) based strategy for coronary artery disease (CAD) is widely accepted. However, cardiac events could occur at deferred lesions after FFR. We previous reported that CT derived high risk plaque (HRP) and residual stenosis were the independent predictors of cardiac events.

Purpose

The purpose of this study was to investigate if plaque characteristics on CTA could predict cardiac events in deferred lesions after FFR.

Methods

We included 211 vessels of 193 patients who were deferred revascularization after CTA and invasive FFR. The presence of HRP and the stenosis grading on CTA were analyzed.

Results

Median follow-up period after CTA was 623 days (IQR 302–945). HRP and obstructive stenosis were detected in 58 (27.5%) and 87 (41.2%) lesions, respectively. Cardiac events were occurred in 10 lesions at 440±167 days in average (range: 150–770 days). Multivaliate cox hazard regression analysis revealed that HRP (HR8.01, p=0.0032) and obstructive stenosis with ≥70% (HR 34.93, p<0.0001) were the independent predictors of cardiac events after adjusted for age, sex, and FFR≤0.8. Of 21 lesions with both HRP and obstructive stenosis, 29% lesions resulted in cardiac events in 2 years.

Conclusions

Even in the deferred lesions by invasive FFR, lesions with HRP and obstructive stenosis showed high rate of cardiac events. These lesions should be treated with intensive medical therapy to prevent cardiac events.

P1806Diagnosis of isolated cardiac sarcoidosis using FDG-PET/CT on the basis of new guidelines

Introduction

Sarcoidosis is a systemic inflammatory disease which can involve any organs. The reported prevalence of isolated cardiac sarcoidosis (CS) varies widely because of the lack of an agreed definition of isolated CS (iCS). ICS was newly defined in the new guidelines for CS by Japanese Circulation Society.

Purpose

We aimed to examine the diagnostic accuracy of 18F-FDG PET/CT and the ratio of iCS in the whole CS by reviewing the patients with suspected CS undergoing the whole-body and cardiac FDG PET/CT scans.

Methods

We retrospectively reviewed 74 consecutive patients undergoing 18F-FDG PET/CT from 2013 to 2018 (mean age 60±14 years, 37 male) without the initiation of corticosteroid. Myocardial FDG uptake in CS was defined as a “focal” or “focal on diffuse” pattern. Systemic sarcoidosis (sCS) and iCS were diagnosed according to guidelines for the diagnosis and treatment of CS by Japanese Circulation Society. In short, iCS was diagnosed clinically when no clinical findings of sarcoidosis in any other organs and FDG uptake in heart were shown in addition to the following three of four criteria: high-grade atrioventricular block or fatal ventricular arrhythmia, structural abnormality, left ventricular contractile dysfunction, and delayed Gadolinium enhancement of myocardium on MRI.

Results

Of 31 patients with extra-cardiac sarcoidosis, 10 already met the diagnostic criteria of sCS before undergoing 18F-FDG PET/CT and 11 was newly diagnosed as sCS after FDG PET/CT. Of the remaining 43 without extra-cardiac sarcoidosis, 18 had FDG uptake in heart. Of 18 with FDG uptake in heart, iCS was diagnosed in 7, and sCS in 3 with extra-cardiac uptake of FDG as well as myocardium. Finally, 24 and 7 patients met the criteria of sCS and iCS based on the guideline, respectively. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of FDG PET/CT for CS including sCS and iCS were 90, 87, 88, 85, and 92%, respectively.

Conclusion

The ratio of iCS on the basis of new guidelines for diagnosis and treatment of CS was 22% of the whole CS.

P4620Circulating concentration of presepsin improves early prediction of short-term mortality in patients treated at medical cardiac intensive care units

Background

Presepsin, a subtype of soluble CD14, is an inflammatory marker, which largely reflects monocytic activation. Presepsin appears to be an accurate diagnostic marker of sepsis, but its clinical significance remains unclear in cardiovascular disease.

Purpose

This prospective study aimed to investigate the predictive value of plasma presepsin levels on admission to medical (non-surgical) cardiac intensive care units (MCICUs) for short-term mortality.

Methods

We examined 1560 patients hospitalized in MCICUs and measured the baseline plasma presepsin levels at admission.

Results

Acute coronary syndrome was present in 46% of the patients, and acute decompensated heart failure in 36%. Before MCICUs admission, emergent coronary angiography or percutaneous coronary intervention was performed in 36%, mechanical ventilation was required for respiratory insufficiency in 2.1%, and intraaortic balloon pumps were needed for hemodynamic instability in 8.9%. During 6 months after admission, there were 113 (7.2%) deaths. Patients who died were older (median: 77 vs. 71 years, P<0.0001); had higher levels of presepsin (263 vs. 119 pg/mL, P<0.0001), B-type natriuretic peptide (BNP: 696 vs. 186 pg/mL, P<0.0001), high-sensitivity troponin T (hsTnT: 81 vs. 47 pg/mL, P=0.004), and high-sensitivity C-reactive protein (13.8 vs. 2.2 mg/L, P<0.0001); and had lower levels of estimated glomerular filtration rate (50 vs. 65 mL/min/1.73m2, P<0.0001) and left ventricular ejection fraction (43% vs. 51%, P<0.0001) than those of the survivors. In the multivariate Cox regression analysis, higher levels of presepsin (P=0.0002), BNP (P=0.04), and hsTnT (P=0.009) were all independent predictors of 6-month deaths. Quartiles of presepsin levels were associated with higher mortality rates within 6 months after admission (Table). Adding presepsin levels to a baseline model that included established risk factors, BNP, and hsTnT further enhanced reclassification (P=0.004) and discrimination (P=0.003) beyond that of the baseline model.

Mortality rates according to presepsin Presepsin quartile 1st 2nd 3rd 4th P value ≤80 pg/mL 81–124 pg/mL 125–232 pg/mL >232 pg/mL 1-month mortality 0.8% 2.0% 3.3% 8.0% <0.0001 6-month mortality 0.8% 3.8% 8.2% 16.3% <0.0001

Conclusions

Presepsin levels at admission could improve the prediction of short-term mortality in patients hospitalized at MCICUs.

312 EFFECTS OF TRANSFORMING GROWTH FACTOR ALPHA AND INSULIN-LIKE GROWTH FACTOR 1 SUPPLEMENTATION ON IN VITRO MATURATION OF CANINE OOCYTES

Although in vitro maturation (IVM) of oocytes has been successfully established for many species, the efficiency of IVM in canine oocytes is still very low. As growth factors have been shown to promote oocyte maturation in some species, we investigated whether use of transforming growth factor α (TGF-a) and insulin-like growth factor 1 (IGF-1) might overcome the difficulties of achieving meiotic maturation in cultured canine cumulus-oocyte complexes (COC). Ovaries were obtained from bitches at 6 months to 7 years of age by ovariohysterectomy and were sliced repeatedly to release COC. In the first experiment, the COC were cultured at 38.8°C for 48 h in 5% CO2 in air in medium 199 supplemented with either TGF-a (0, 1, 10, or 100 ng mL–1) or IGF-1 (0, 0.5, 5, 10, or 50 µg mL–1). In the second experiment, the synergistic effect of TGF-a and IGF-1 was investigated by culturing COC in medium 199 supplemented with both TGF-a (0, 1, 10, or 100 ng mL–1) and IGF-1 (0, 0.5, 5, 10, or 50 µg mL–1). At the end of the culture period, the oocytes were denuded of cumulus cells by pipetting with a fine bore glass pipette; the denuded oocytes were then fixed in Carnoy's solution and stained with Hoechst 33342. The nuclear configuration and chromatin morphology of the oocytes were evaluated under confocal laser scanning microscopy. The cells were assigned to 1 of the following meiotic stages: germinal vesicle (GV), germinal vesicle breakdown (GVBD), metaphase I (MI), or metaphase II (MII). Data were analysed by ANOVA with Fisher's PLSD test. In experiment 1, no significant difference were observed in the rates of cells maturing to the MI and MII stages, but that in the 10 ng mL–1 of TGF-a group (56.3%) were larger than in the other treatment groups (38.8–51.0%). The frequencies of MII stage cells in the 5, 10, and 50 µg mL–1 of IGF-1 treatment groups (9.8, 13.3, and 12.2%, respectively) were significantly higher than in the 0.5 µg mL–1 of IGF-1 group and the control group (5.3 and 2.2%, respectively). In experiment 2, the frequency of MI and MII cells in the control, 1 ng mL–1 of TGF-a plus 0.5 µg mL–1 of IGF-1, 10 ng mL–1 of TGF-a plus 5 µg mL–1 of IGF-1, 10 ng mL–1 of TGF-a plus 10 µg mL–1 of IGF-1, and 100 ng mL–1 of TGF-a plus 50 µg mL–1 of IGF-1 group were 44.1, 36.1, 63.5, 70.8, and 50.8%, respectively. The frequency of MII cells in the control group and the same treatment groups were 2.8, 7.2, 10.4, 15.3, and 10.8%, respectively. Both frequencies in the 10 ng mL–1 of TGF-a plus 10 µg mL–1 of IGF-1 group were significantly higher than in the control group. The TGF-a may act in a paracrine fashion on the surrounding granulosa cells, and IGF-1 may play multiple roles in cellular metabolism, proliferation, growth, and differentiation in canine oocyte maturation, as has been reported for many other species. In conclusion, these results demonstrate that a synergistic effect between TGF-a and IGF-1 produces an increased rate of in vitro maturation to the MI and MII stages in canine oocytes.

Mandibular reconstruction using a poly(L-lactide) mesh combined with autogenous particulate cancellous bone and marrow: a prospective clinical study

The purpose of this study was to evaluate the stability and viability of mandibular bone regeneration using a poly(L-lactide) (PLLA) mesh and autogenous particulate cancellous bone and marrow (PCBM). Sixty-two procedures were undertaken at eight hospitals (22 malignant tumours, 30 benign tumours, five cysts, two osteomyelitis, two trauma, and one atrophy of the alveolar ridge); the success rate was 84%. The follow-up period was between 9 and 200 months (mean 88.2 months). Consequently, bone regeneration at 6 months postoperation was excellent in 35 cases (57%), good in 17 cases (27%), and poor in 10 cases (16%). In six of the 'poor' cases, the PLLA mesh was removed due to local infection early after surgery. Bone resorption>20% was observed in only one of 46 cases with a follow-up term of >1 year. There were no signs of any other adverse effects except in one case where a section of the tray broke off late in the follow-up period. It is concluded that this method is stable and effective due to favourable morphological and functional recovery and low invasiveness. It may thus be a useful alternative procedure for mandibular reconstruction.

Differentiation between superficial and deep lobe parotid tumors by magnetic resonance imaging: usefulness of the parotid duct criterion

BACKGROUND

The location of a parotid tumor affects the choice of surgery, and there is a risk of damaging the facial nerve during surgery. Thus, differentiation between superficial and deep lobe parotid tumors is important for appropriate surgical planning.

PURPOSE

To evaluate the usefulness of using the parotid duct, in addition to the retromandibular vein, for differentiating between superficial and deep lobe parotid tumors on MR images.

MATERIAL AND METHODS

Magnetic resonance images of 42 parotid tumors in 40 patients were reviewed to determine whether the tumor was located in the superficial or deep lobe. In each case, the retromandibular vein and the parotid duct were used to locate the tumor. The parotid duct was only used in cases where the tumor and the duct were visualized on the same image.

RESULTS

Using the retromandibular vein criterion, 71% of deep lobe and 86% of superficial lobe tumors were correctly diagnosed, providing an accuracy of 81%. However, the accuracy achieved when using the parotid duct criterion was 100%, although it could be applied to only 28 of the 42 cases. Based on these results, we defined the following diagnostic method: the parotid duct criterion is first applied, and for cases in which it cannot be applied, the retromandibular vein criterion is used. The accuracy of this method was 88%, which was better than that achieved using the retromandibular vein criterion alone.

CONCLUSION

The parotid duct criterion is useful for determining the location of parotid tumors. Combining the parotid duct criterion with the retromandibular vein criterion might improve the diagnostic accuracy of parotid tumor location compared to using the latter criterion alone.

Increased risk of exacerbating gastrointestinal disease among elderly patients following treatment with calcium channel blockers

BACKGROUND AND OBJECTIVE

Calcium channel blockers (CCBs) have been widely used for the treatment of hypertension and angina pectoris. It is presumed that CCBs decrease the lower esophageal sphincter pressure and as a result, the risk of gastrointestinal disease may be increased. Since the prevalence of gastrointestinal diseases has increased in elderly patients, it is possible that treatment with CCBs may have contributed to this increase. Therefore, we considered that the risk of exacerbating gastrointestinal disease among elderly patients by CCBs can be estimated by using the prescription ratio of antisecretory drugs as an outcome.

METHOD

We hypothesized that patients who are prescribed CCBs would increase the use of antisecretory drugs involving H(2)-receptor antagonists and proton pump inhibitors (PPIs). From January 2001 to December 2005, a dynamic retrospective cohort study was performed at three community pharmacies in Nagasaki city, Japan, to assess the use of antisecretory drugs following treatment with CCBs among elderly patients. The correlation of initiation of antisecretory drugs treatment to maintenance therapy with PPIs was determined by the Cox proportional hazards model.

RESULTS

The proposed study includes 303 patients prescribed CCBs and 258 controls. During the study period, 138 patients prescribed CCBs and 66 controls were initiated by giving antisecretory drugs; the hazard ratio was 1.40 (95% confidence interval 1.21-1.63). Eighty two patients taking CCBs and 32 controls were initiated by the maintenance therapy with PPIs; the hazard ratio was 1.48 (95% confidence interval 1.21-1.83).

CONCLUSION

Patients who simultaneously initiated the use of antisecretory drugs with CCBs could not be found. Therefore, antisecretory drugs have not been used to prevent the gastrointestinal diseases caused by CCBs. The results obtained in this study suggest that the risk of gastrointestinal disease could be increased by long-term treatment with CCBs for elderly patients.