para-Selective dearomatization of phenols by I(i)/I(iii) catalysis-based fluorination

The regio- and enantio-selective dearomatization of phenols has been achieved by I(i)/I(iii) catalysis enabled fluorination. The process is highly para-selective, guiding the fluoride nucleophile to the distal C4 position of the substrate to generate fluorinated cyclohexadienones in an operationally simple manner. Extensive optimization has revealed key parameters that orchestrate enantioselectivity in this historically challenging transformation. A range of diversely substituted substrates are disclosed (20 examples, up to 92 : 8 e.r.) and the reaction displays efficiency that is competitive with the current state of the art in hydroxylation chemistry: this provides a preparative platform to enable OH to F bioisosterism to be explored. Finally, the utility of the products in accessing densely functionalized cyclic scaffolds with five contiguous stereocenters is disclosed together with crystallographic analyses to unveil fluorine-carbonyl non-covalent interactions.

Clinical Trials of Carbon Ion Radiotherapy for Early-Stage Breast Cancer

PURPOSE/OBJECTIVE(S)

Our institute conducted a clinical trial of curative partial breast irradiation using carbon ion radiotherapy (CIRT) to patients with stage 0 and I breast cancer since 2013. The purpose of this report is to evaluate treatment outcomes up to now.

MATERIALS/METHODS

To date, we have conducted three clinical trials and one advanced medical treatment (NIRS 9404 Comprehensive Research). The first study (UMIN000010848: commonly known as Breast I trial) was 4-split irradiation for stage I low-risk patients aged 60 years or older, and the next clinical study (UMIN000029478: commonly known as Breast II trial) was for Tis-1N0M0 cases of 2 cm or less. On the other hand, 4-split irradiation using standard adjuvant drug therapy according to risk combined with whole breast irradiation by X-ray, the latest clinical trial (UMIN000046859: commonly known as Breast III trial) is a single irradiation for Tis-1N0M0 patients aged 50 years or older. be. In each phase I, the dose increase test was performed, and in phase II, treatment was performed with the recommended dose determined in phase I. Advanced medical care was provided in parallel with breast I for stage I breast cancer that was difficult or rejected to participate in breast I trial.

RESULTS

By January 2023, 60 cases were enrolled. A total of 19 were enrolled In Breast I, 7 in Phase I, 12 in Phase II of the recommended dose of 60.0 Gy (RBE). A total of 14 were enrolled in the 9404 Comprehensive Research. A total of 17 were enrolled In Breast II, 5 cases in Phase I, 12 cases in Phase II of recommended dose 60.0 Gy (RBE). A total of 10 were enrolled in Breast III, 6 cases in Phase I, and 4 in Phase II of recommended dose 50.0 Gy (RBE). As acute adverse events, grade 2 of acute radiation dermatitis were observed in 1 case, grade 1 of acute radiation dermatitis was observed in 31 cases, and grade 1 of mastitis was observed in 6 cases. As a late adverse event, grade 3 of pneumonia of unknown causality were observed in one case, but there were no other problematic adverse events, and breast cosmetic outcome was excellent in all cases. Tumor disappearance after CIRT took 3 to 24 months. Local recurrence and axillary lymph node metastasis were observed in one high-risk case of advanced medical treatment who refused any other therapy. Two cases had ipsilateral intramammary metachronous breast cancer with different subtypes. To date, no other recurrences or metastases have been observed.

CONCLUSION

CIRT for early-stage breast cancer is expected to be effective with mild adverse events, and it is considered meaningful to continue research.

Clinical Outcomes of Carbon-Ion Radiotherapy for Large-Sized (≥4cm) Hepatocellular Carcinoma

PURPOSE/OBJECTIVE(S)

Radical treatment options for bulky unresectable locally advanced hepatocellular carcinoma (HCC) are limited. The purpose of this study is to evaluate the safety and efficacy of carbon-ion radiotherapy (C-ion RT) for bulky (≥4cm) locally advanced HCC.

MATERIALS/METHODS

We performed a retrospective cohort study of patients with bulky (≥4cm) locally advanced HCC treated by C-ion RT between April 2000 and March 2020 in our institution. The eligibility criteria for this study were: (1) the treatment protocols of 45.0-48.0 Gy/2 fractions or 52.8-60.0 Gy/4 fractions, which proven the safety and efficacy in the past clinical trials; (2) Tumors within 3 intrahepatic lesions and with a maximum tumor diameter of 4 cm or greater; (3) N0M0 status; (4) an Eastern Cooperative Oncology Group performance status of 0 to 2; (5) controllable ascites; (6) Child-Pugh grade was A or B. Overall survival (OS), progression-free survival (PFS), and local control rate (LC) were calculated by the Kaplan-Meier method, and Cox regression analysis was used for multivariate analysis. Adverse events were evaluated by CTCAE ver. 5.0. JMP® 12 (SAS Institute Inc., Cary, NC, USA) was used for all analyses. We defined p < 0.05 as statistically significant.

RESULTS

A total of 187 patients met the criteria and were evaluated. The median patient age was 73 years (range, 37-90), and 139 of 187 patients were male. Child-Pugh grade was A in 163 patients and B in 24. Modified albumin-bilirubin (mALBI) grade was 1 in 96 patients, 2a in 50, and 2b in 41. The number of HCV-related HCC cases was in 80, HBV in 32 and non-B and non-C in 75. In 51 patients, identification of vascular invasion to the first-order branch of the portal vein and/or major hepatic vein was confirmed. The median maximum tumor diameter was 5.1 cm (4.0-13.5 cm). In 76 patients, C-ion RT were treated for recurrence. With a median follow-up period of 25.9 months (range, 1.1-215.1), 2-year overall survival, progression-free survival and local control rates were 68.3% (95% confidence interval [CI], 64.7-72.0%), 39.0% (95% CI, 35.2 - 42.8%) and 86.7% (95% CI, 84.7 - 89.7%), respectively. Late adverse events were observed in 3 patients (1.6%) with Grade 3 liver dysfunction and in 3 patients (1.6%) with Grade 3 skin disorders, but there were no cases of Grade 4 or higher. Multivariate analysis of prognostic factors for overall survival revealed that mALBI grade in 2b(HR:3.13, 1.97-4.78, p<0.0001), tumor status in recurrent treatment (HR:1.50, 1.02-2.21, p = 0.039), the number of tumors in 2 or more (HR:2.16, 1.01-2.17, p = 0.045), and maximum tumor diameter in larger than 6 cm (HR:2.34, 1.50-3.61, p = 0.0001) were the predominant prognostic factors, while age, presence of vascular invasion, AFP and DCP were not.

CONCLUSION

The safety and efficacy of C-ion RT for bulky (≥4cm) locally advanced HCC was demonstrated. These results suggested that C-ion RT may be a new treatment option for locally advanced bulky HCC with no curative treatment options.

Long-Term Clinical Outcome of Carbon Ion Radio Therapy for Hepatocellular Carcinoma in the Caudate Lobe

PURPOSE/OBJECTIVE(S)

Surgical resection is the first-line treatment for hepatocellular carcinoma in the caudate lobe (caudate HCC), but it is often difficult due to the tumor's location. In addition, radiofrequency ablation and transcatheter arterial chemoembolization are also difficult for the same reason. This study aimed to evaluate the safety and efficacy of carbon-ion radiation therapy (C-ion RT) for caudate HCC.

MATERIALS/METHODS

We performed a retrospective cohort study of patients with hepatocellular carcinoma treated by C-ion RT between April 2000 and March 2020 in our institution. The eligibility criteria for this study were: (1) located mainly in the caudate lobe (2) the treatment protocols of 45.0-48.0 Gy/2 fractions or 52.8-60.0 Gy/4 fractions, which proved the safety and efficacy in the past clinical trials; (3) N0M0 status; (4) an Eastern Cooperative Oncology Group performance status (PS) of 0 to 2; (5) controllable ascites. The prescribed dose (Gy) used in this study is relative biological effectiveness (RBE) weighted dose. Overall survival (OS), progression-free survival (PFS), and local control rate (LC) were calculated by the Kaplan-Meier method. Adverse events were evaluated by NCI-CTCAE ver. 5.0. SPSS software version 27.0 (IBM Inc.) was used for all analyses. We defined p-value < 0.05 as statistically significant.

RESULTS

A total of 25 patients met the criteria and were evaluated. The median patient age was 73 years (range 58-89), and 21 of 25 patients were male. The number of patients with PS 0 was 22, PS 1 was 1, and PS 2 was 2. The number of HBV-related HCC cases was in 8, HCV-related HCC cases was in 11, and non-B and non-C cases was in 6. The median maximum tumor diameter was 3.0 cm (1.1-4.8 cm). In 6 patients, identification of vascular invasion to the main trunk of the portal vein and/or major hepatic vein was confirmed. The Child-Pugh (CP) grade was A in 21 patients and B in 4. The modified albumin-bilirubin (mALBI) grade 1 is in 17 patients, 2a in 4, 2b in 4. Prescribed doses were 45 Gy / 2 fr in 3 cases, 48 Gy / 2 fr in 12 cases, 52.8 Gy / 4 fr in 7 cases, and 60 Gy / 4 fr in 3 cases. With a median follow-up period of 43.6 months (range 0.3-85.0), 3-year OS, PFS, and LC were 74% (95% confidence interval [CI], 54.8-93.8%), 32% (95% CI, 11.8-51.4%), and 93% (95% CI, 79.4-106%), respectively. All patients had no Grade 2 or higher adverse events during the observation period.

CONCLUSION

The safety and efficacy of C-ion RT for caudate HCC were demonstrated. These results suggested that C-ion RT may be a promising treatment option for patients with caudate HCC.

Pioglitazone-incorporated microspheres alleviates cardiac dysfunction through macrophage polarization in a rat myocardial infarction model

 

Inflammatory processes are essential for the repair processes after myocardial infarction. Among inflammatory cells involved in this process, macrophages play a critical role through polarization in pro-inflammatory M1 or reparative M2 subtype. Pioglitazone, known as a treatment drug for diabetes mellitus, is reported to regulate macrophage polarization toward reparative M2 subtype. Poly L-lactic-co-glycolic acid (PLGA) has been widely accepted as the delivery carrier in drug delivery system (DDS).

Here, we aimed to validate the therapeutic effects and investigate the mechanisms of DDS-based treatment using pioglitazone to left ventricular remodeling after myocardial infarction.

Pioglitazone-incorporated PLGA microspheres (PGZ-MS) were prepared and the drug release profile was evaluated. The concentration of interleukin-10 secreted from murine bone marrow derived macrophages incubated with PGZ-MS was quantified in the culture supernatant. To validate the therapeutic potential of PGZ-MS in vivo, Sprague-Dawley rats were subjected to permanent left coronary artery ligation to induce myocardial infarction. Mock-MS (100 μg) or PGZ-MS (100 μg) was injected to the infarct region just after induction (n=9–11/group). Cardiac function and left ventricular size were assessed by echocardiography. At 28-day after surgery, rats were sacrificed, and excised hearts were evaluated histologically.

PGZ-MS released 1.8±0.3% of incorporated PGZ within 24 hours and 29.5±1.2% within 14 days indicating sustained release of PGZ in vitro. PGZ-MS augmented Interleukin-10 release from bone marrow derived macrophages, indicating polarization toward reparative M2 subtype. PGZ-MS significantly ameliorated cardiac function after myocardial infarction (fractional shortening: MI vs MI+Mock-MS vs MI+PGZ-MS, 24.4±1.1 vs 24.3±1.6 vs 32.2±1.4%; P=0.0035) with reverse remodeling (wall thickness: MI vs MI+Mock-MS vs MI+PGZ-MS, 0.69±0.12 vs 0.71±0.13 vs 1.06±0.09; P=0.03). Immunohistochemical analyses revealed that PGZ-MS enhanced macrophage polarization toward reparative M2 subtype (ratio of reparative M2 macrophages: 0.39±0.03 vs 0.42±0.02 vs 0.54±0.02; P=0.0004) and attenuated apoptosis of cardiomyocytes in the ischemic border zone (MI vs MI+Mock-MS vs MI+PGZ-MS, 2.6±0.2 vs 1.9±0.2 vs 1.2±0.2 cells/field; P=0.002).

In the present study, we confirmed that PGZ-MS could realize sustained release of pioglitazone which resulted in sustained effect of macrophage polarization and attenuated left ventricular remodeling accompanied with the amelioration of cardiac dysfunction and cardiomyocytes apoptosis. The strategy of DDS-based macrophage polarization might serve as a promising strategy in cardiac regenerative therapy for ischemic heart disease in the future.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grants-in-Aid for Scientific Research from the Ministry of Education, Science, Sports and Culture of Japan

Morphological and Proteomic Analyses of Soybean Seedling Interaction Mechanism Affected by Fiber Crosslinked with Zinc-Oxide Nanoparticles

Nanoparticles (NPs) enhance soybean growth; however, their precise mechanism is not clearly understood. To develop a more effective method using NPs for the enhancement of soybean growth, fiber crosslinked with zinc oxide (ZnO) NPs was prepared. The solution of ZnO NPs with 200 nm promoted soybean growth at the concentration of 10 ppm, while fibers crosslinked with ZnO NPs promoted growth at a 1 ppm concentration. Soybeans grown on fiber cross-linked with ZnO NPs had higher Zn content in their roots than those grown in ZnO NPs solution. To study the positive mechanism of fiber crosslinked with ZnO NPs on soybean growth, a proteomic technique was used. Proteins categorized in photosynthesis and secondary metabolism accumulated more in soybeans grown on fiber crosslinked with ZnO NPs than in those grown in ZnO NPs solution. Furthermore, significantly accumulated proteins, which were NADPH oxidoreductase and tubulins, were confirmed using immunoblot analysis. The abundance of NADPH oxidoreductase increased in soybean by ZnO NPs application. These results suggest that fiber crosslinked with ZnO NPs enhances soybean growth through the increase of photosynthesis and secondary metabolism. Additionally, the accumulation of NADPH oxidoreductase might relate to the effect of auxin with fiber crosslinked with ZnO NPs on soybean growth.

POS0532 DRUG RETENTION OF BIOLOGICS OR JAK INHIBITORS IN PATIENTS WITH DIFFICULT-TO-TREAT RHEUMATOID ARTHRITIS: RESULTS FROM THE ANSWER COHORT

Background

Difficult-to-treat rheumatoid arthritis (D2T RA) is defined as RA in which disease activity is uncontrolled despite the use of two or more biologics or Janus kinase inhibitors (JAKi) with different mechanisms of action (MOA).

Objectives

To explore the optimal treatment strategy for D2T RA, we evaluated the drug retention, efficacy, and reasons for discontinuation of biologics or JAKi used for patients with D2T RA in a longitudinal multicenter cohort.

Methods

RA patients with clinical disease activity index (CDAI) >10 despite the use of at least two biologics or JAKi with different MOA and further treated with biologics or JAKi were included. The drug retention rates of biologics (TNFi, IL-6Ri, and CTLA4-Ig) or JAKi were estimated at 12 months using the Kaplan-Meier method and adjusted for potential confounders (age, sex, disease duration, concomitant MTX and PSL use, and the number of switched biologics or JAKi) using Cox proportional hazards models.

Results

A total of 251 treatment courses (TCs) from 167 patients were included (TNFi: 97 TCs, IL-6Ri: 67 TCs, CTLA4-Ig: 27 TCs, JAKi: 60 TCs). Baseline characteristics showed no difference in age, sex, disease duration, ACPA positivity, CDAI, and concomitant MTX and PSL use between the four groups. Drug retention excluding non-toxic reasons and remission was significantly higher in patients treated with JAKi or IL-6Ri than in patients treated with TNFi or CTLA4-Ig (P=0.00172). Multivariate analysis using Cox proportional hazards models demonstrated that discontinuation of the drug was associated with the use of TNFi or CTLA4-Ig (HR: 3.29, 95%CI: 1.15-9.42, P=0.027) and concomitant PSL use (HR: 1.14, 95%CI: 1.04-1.26, P=0.0084). In terms of disease activity evaluated with CDAI, no difference was observed between the four groups at 3 months (P=0.90), at 6 months (P=0.77), and at 12 months (P=0.75).

Conclusion

In patients with D2T RA, JAKi or IL-6Ri may have treatment advantages compared with TNFi or CTLA4-Ig.

References

[1] EULAR definition of difficult-to-treat rheumatoid arthritis.

Nagy G, Roodenrijs NMT, Welsing PM, Kedves M, Hamar A, van der Goes MC, Kent A, Bakkers M, Blaas E, Senolt L, Szekanecz Z, Choy E, Dougados M, Jacobs JW, Geenen R, Bijlsma HW, Zink A, Aletaha D, Schoneveld L, van Riel P, Gutermann L, Prior Y, Nikiphorou E, Ferraccioli G, Schett G, Hyrich KL, Mueller-Ladner U, Buch MH, McInnes IB, van der Heijde D, van Laar JM.

Ann Rheum Dis. 2021 Jan;80(1):31-35.

[2] Prevalence and predictive factors of difficult-to-treat rheumatoid arthritis: the KURAMA cohort.

Watanabe R, Hashimoto M, Murata K, Murakami K, Tanaka M, Ohmura K, Ito H, Matsuda S.

Immunol Med. 2021 May 25:1-10.

Disclosure of Interests

Ryu Watanabe Speakers bureau: Eli Lilly, Mitsubishi Tanabe, Pfizer, Sanofi, AbbVie, Asahi Kasei, Eisai, Bristol-Myers Squibb, UCB Japan, Chugai, Janssen, Astellas, Nippon Shinyaku, Daiichi Sankyo, Gilead Sciences Japan, and Boehringer ingelheim., Tadashi Okano Speakers bureau: Asahi Kasei, Astellas, Abbvie, Amgen, Ayumi, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead Sciences, Janssen, Kyowa Kirin, Mitsubishi Tanabe, Novartis, Ono, Pfizer, Sanofi, Takeda, UCB, Grant/research support from: Asahi Kasei, Abbvie, Chugai, Eisai, Mitsubishi Tanabe, Shinsuke Yamada: None declared, Wataru Yamamoto: None declared, Koichi Murata Speakers bureau: Eisai Co., Ltd., Chugai Pharmaceutical Co., Ltd.; Asahi Kasei Pharma Corp.; and Mitsubishi Tanabe Pharma Co., and Daiichi Sankyo Co. Ltd., Kosaku Murakami: None declared, Kosuke Ebina Speakers bureau: AbbVie, Amgen, Asahi-Kasei, Astellas, Ayumi, Bristol-Myers Squibb, Chugai, Eisai, Eli Lilly, Janssen, Mitsubishi-Tanabe, Ono Pharmaceutical, Pfizer, Sanofi, and UCB Japan., Grant/research support from: AbbVie, Amgen, Asahi-Kasei, Astellas, Chugai, Eisai, Mitsubishi-Tanabe, Ono Pharmaceutical, Teijin Pharma, and UCB Japan, Yuichi Maeda Speakers bureau: Eli Lilly Japan K.K., Chugai Pharmaceutical Co. Ltd., Pfizer Inc., Bristol Myers Squibb, and Mitsubishi Tanabe Pharma Corporation., Sadao Jinno Speakers bureau: AbbVie G.K., Asahi Kasei Pharma., Bristol-Myers Squibb., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., Janssen Pharmaceutical K.K., and Mitsubishi Tanabe Pharma, and Ono Pharmaceutical Co, Iku Shirasugi: None declared, Yonsu Son: None declared, Hideki Amuro Speakers bureau: Chugai Pharmaceutical Co.,Ltd, Masaki Katayama: None declared, Ryota Hara: None declared, Kenichiro Hata Speakers bureau: AbbVie, Asahi-Kasei, Chugai, Janssen, Mitsubishi-Tanabe, Eisai, Ayaka Yoshikawa: None declared, Motomu Hashimoto Grant/research support from: Abbvie, Asahi-Kasei, Brystol-Meyers, Eisai, Eli Lilly, Novartis Pharma.

The difference in joint instability affects the onset of cartilage degeneration or subchondral bone changes

OBJECTIVE

It has been debated whether the onset of knee osteoarthritis is initiated in cartilage or subchondral bone. The purpose of this study was to clarify the effects of increasing or decreasing joint instability on cartilage degeneration and subchondral bone changes in knee OA by comparing different models of joint instability.

DESIGN

We used the anterior cruciate ligament transection (ACL-T) model and the destabilization of the medial meniscus (DMM) model. In addition, we created a controlled abnormal tibial translation (CATT) model and a controlled abnormal tibial rotation (CATR) model. We performed joint instability analysis, micro-computed tomography analysis, histological and immunohistological analysis in 4 and 6 weeks.

RESULTS

The CATT group suppressed joint instability in the ACL-T group (6 weeks; P = 0.032), and the CATR group suppressed joint instability in the DMM group (6 weeks; P = 0.032). Chondrocyte hypertrophy in the ACL-T and DMM groups was increased compared to the Sham group (6 weeks; [ACL-T vs Sham], P = 0.002, 95%CI [5.983-33.025]; [DMM vs Sham], P = 0.022, 95%CI [1.691-28.733]). In the subchondral bone, the BV/TV in the DMM and CATR groups was increased compared to the ACL-T and CATT groups (6 weeks; [DMM vs ACL-T], P = 0.002, 95%CI [7.404-37.582]; [DMM vs CATT], P = 0.014, 95%CI [2.881-33.059]; [CATR vs ACL-T], P = 0.006, 95%CI [4.615-34.793]; [CATR vs CATT], P = 0.048, 95%CI [0.092-30.270]).

CONCLUSIONS

This study showed that joint instability promotes chondrocyte hypertrophy, but subchondral bone changes were influenced by differences in ACL and meniscus function.

Favorable clinical response and drug retention of anti-IL-6 receptor inhibitor in rheumatoid arthritis with high CRP levels: the ANSWER cohort study

OBJECTIVE

Currently, biological disease-modifying anti-rheumatic drugs (bDMARDs) with different modes of action [tumour necrosis factor inhibitor (TNFi), interleukin-6 receptor inhibitor (IL-6Ri), or cytotoxic T-lymphocyte antigen 4-immunoglobulin (CTLA4-Ig)] are used in clinical practice to treat rheumatoid arthritis (RA). However, it is unclear which type of bDMARD is the most efficacious for a specific clinical situation. C-reactive protein (CRP) is an acute-phase reactant driven by IL-6 signalling. Here, we aimed to establish whether therapeutic efficacy differs between IL-6Ri and other bDMARDs with alternative modes of action in RA patients according to their CRP level.

METHOD

RA patients treated with bDMARDs were enrolled from an observational multicentre registry in Japan. Patients were classified into three groups according to baseline CRP tertiles. The overall 3 year retention rates of each bDMARD category were assessed. The Clinical Disease Activity Index (CDAI) was also assessed before and 3, 6, and 12 months after bDMARD initiation.

RESULTS

A total of 1438 RA patients were included and classified into three groups according to tertiles of baseline CRP levels (CRP¹, 0-0.3; CRP², 0.3-1.8; CRP³, 1.8-18.4 mg/dL). In CRP³, the overall 3 year drug retention rates were significantly higher for IL-6Ri than for TNFi and CTLA4-Ig (77.5 vs 48.2 vs 67.3, respectively). No significant difference was evident in terms of CDAI 12 months after bDMARD initiation in CRP¹-CRP³.

CONCLUSION

IL-6Ri may be a favourable therapeutic option over TNFi and CTLA4-Ig in RA patients with high CRP levels.

POS1482-HPR PAIN CATASTROPHIZING IS ASSOCIATED WITH RESIDUAL PAIN AFTER REACHING IMPROVED CONDITIONS OF SWOLLEN/TENDER JOINTS AND SERUM C-REACTIVE PROTEIN LEVEL

Background:

It has long been recognized that immune-mediated inflammatory diseases, such as rheumatoid arthritis (RA), are prone to coexist with depression due to the effects of cytokines, and that these two illnesses lead to an elevation in patients’ pain. However, we often encounter patients with RA who suffer from residual pain despite an improvement in disease activity and inflammation. The specific psychological factors associated with residual pain have not yet been clarified. In addition to the traditional psychological factors, such as depression and anxiety, we focused on pain catastrophizing due to the distortion of pain perception and explored its association with residual pain.

Objectives:

To examine whether psychological factors, such as pain catastrophizing, depression, and anxiety, are associated with self-reported pain visual analogue scale (pain-VAS) scores in RA patients with 1 or less on 28joints- swollen/tender counts (SJC/TJC) and CRP.

Methods:

This was a cross-sectional study of 290 RA outpatients (85% of whom were women) with scores of less than 1 on SJC, TJC, and CRP, with a median (IQR) age of 66 (57–73) years. The participants completed questionnaires, including pain VAS (0–100 mm), Pain Catastrophizing Scale (PCS, 0–52 scale), and Hospital Depression and Anxiety Scale (HADS, 0–42 scale). Using linear regression analyses, we analysed whether PC (PCS ≥30), depression (HADS-D ≥11), and anxiety (HADS-A ≥11) (independent variables) were associated with pain VAS scores (dependent variable). After univariate regression analysis, multivariate analysis adjusted for confounding factors was performed.

Results:

Patients reported a wide range of pain severity with a median (range) pain VAS score of 9 (0–96mm). The prevalence of anxiety and depression were 5.5% and 5.9%, respectively. Meanwhile, 24.1% of the patients experienced pain catastrophizing. Pain catastrophizing was associated with pain VAS scores in univariate and multivariate analyses (Table 1). The presence of anxiety and depression was not associated with pain VAS scores in any model. Multivariate analysis of other covariates showed that age, disease duration, and presence of SJC/TJC of joints other than the 28 joints were positively correlated with pain VAS scores.

Table 1.

Univariate and multivariate regression analysis for independent variables associated with pain-VAS scores

UnivariateMultivariate independent variablesModel 1*Model 2**Pain catastrophizingEstimate3.74.13.695%CI 0.7 to 6.61.1 to 7.00.5 to 6.6p-value0.0150.0060.021AnxietyEstimate3.74.40.595%CI -1.9 to 9.2 -1.0 to 9.9 -3.5 to 7.9p value0.1980.1080.453DepressionEstimate3.54.23.995%CI -1.9 to 8.9 -1.1 to 9.5 -1.9 to 8.7p-value0.2040.1190.210

The covariates in multivariate analysis are as follows: age, sex, body mass index, disease duration, Steinbrocker’s Stage, prednisolone dosage, biologic agents use, and presence of swollen joint counts/tender joint counts of joints other than the 28 joints.

*Model 1: each psychological independent variable and the above covariates.

**Model 2: all psychological independent variables and the above covariates.

Conclusion:

Pain catastrophizing was associated with pain VAS scores in RA patients with 1 or less on 28joints-SJC/TJC and CRP, emphasising that residual pain in the patients should be treated in a biopsychosocial framework focussing on pain catastrophizing.

Disclosure of Interests:

Tamami Yoshida: None declared, Motomu Hashimoto Speakers bureau: Mitsubishi Tanabe Pharma Corporation; Bristol-Myers Squibb; Eisai Co., Ltd.; and Eli Lilly and Company., Grant/research support from: Mitsubishi Tanabe Pharma Corporation; Bristol-Myers Squibb; Eisai Co., Ltd.; and Eli Lilly and Company., Kosaku Murakami Speakers bureau: Eisai Co., Ltd.; Chugai Pharmaceutical Co., Ltd.; Pfizer Inc.; Bristol-Myers Squibb; Mitsubishi Tanabe Pharma Co; UCB Japan Co., Ltd.; Daiichi Sankyo Co., Ltd.; and Astellas Pharma Inc., Consultant of: Eisai Co., Ltd.; Chugai Pharmaceutical Co., Ltd.; Pfizer Inc.; Bristol-Myers Squibb; Mitsubishi Tanabe Pharma Co; UCB Japan Co., Ltd.; Daiichi Sankyo Co., Ltd.; and Astellas Pharma Inc., Koichi Murata Speakers bureau: Eisai Co., Ltd. and Astellas Pharma Inc., Consultant of: Eisai Co., Ltd. and Astellas Pharma Inc., Kohei Nishitani Grant/research support from: Asahi-Kasei Pharma., Ryu Watanabe Speakers bureau: Mitsubishi Tanabe Pharma Co; Pfizer Inc.; Sanofi S.A.; AbbVie GK; Asahi Kasei Pharma; Eisai Co., Ltd.; Eli Lilly and Company; Bristol-Myers Squibb; and Janssen Pharmaceutical K.K., Teruhide Koyama: None declared, Ritei Uehara: None declared, Masao Tanaka Speakers bureau: AbbVie GK, Asahi Kasei Pharma., Astellas Pharma Inc., Ayumi Pharmaceutical Co., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., Janssen Pharmaceutical K.K., Mitsubishi Tanabe Pharma Co., Novartis Pharma K.K., Pfizer Inc., Taisyo Pharma., Ltd., UCB Japan Co., Ltd., Grant/research support from: AbbVie GK, Asahi Kasei Pharma., Astellas Pharma Inc., Ayumi Pharmaceutical Co., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., Janssen Pharmaceutical K.K., Mitsubishi Tanabe Pharma Co., Novartis Pharma K.K., Pfizer Inc., Taisyo Pharma., Ltd., UCB Japan Co., Ltd., Hiromu Ito Grant/research support from: Bristol-Myers Squibb, Eisai Co, Taisyo Pharma., and Mochida., Shuichi Matsuda: None declared

POS0544 INFLUENCE OF EATING HABITS ON FRAILTY AMONG PATIENTS WITH RHEUMATOID ARTHRITIS: KURAMA COHORT

Background:

Rheumatoid arthritis (RA) is a chronic inflammatory disorder that contributes to accelerating frailty, a clinical state of increased vulnerability due to declined physiological function. Although accumulating evidence suggests the importance of nutritional therapy for frailty in the general population, there is little evidence on dietary recommendations for preventing frailty in patients with RA.

Objectives:

The present study aimed to reveal clinical associations between frailty status, eating habits and RA disease activity.

Methods:

We conducted a cross-sectional study of 306 female outpatients enrolled from the KURAMA (Kyoto University Rheumatoid Arthritis Management Alliance) cohort database. The participants were classified into three groups (robust, prefrail and frail) according to simplified frailty scale (SOF index), and dietary data were collected using a self-reported food frequency questionnaire as previously reported. We performed multivariate logistic analyses for the presence of frailty/prefrailty with or without eating habits.

Results:

Frail group showed physical decline such as decreased skeletal muscle index, hand grip strength and walking speed, and DAS28-ESR in the frail group was significantly higher compared to that in the others. In multivariate logistic analysis, the presence of frailty/prefrailty was correlated with DAS28-ESR (OR 1.71, p=0.00004) and methotrexate use (OR 0.47, p=0.0097). Cochran-Armitage trend test also showed that the intake frequency of five ingredients (meat, fish, milk, fruits and vegetables) was inversely associated with the prevalence of frailty/prefrailty. In additional multivariate logistic analyses with dietary habits, habitual intake of fish (at least three times per week), rather than meat or other foods, was independently correlated with the presence of frailty/prefrailty (OR 0.33, p=0.00027).

Conclusion:

Our results suggest that habitual intake of fish, rather than meat or other foods, may be beneficial in preventing frailty among RA patients.

References:

[1]Ferrucci, L. & Fabbri, E. Inflammageing: chronic inflammation in ageing, cardiovascular disease, and frailty. Nat Rev Cardiol 15, 505-522, doi:10.1038/s41569-018-0064-2 (2018).

[2]Hernandez Morante, J. J., Gomez Martinez, C. & Morillas-Ruiz, J. M. Dietary factors associated with frailty in old adults: a review of nutritional interventions to prevent frailty development. Nutrients 11, doi:10.3390/nu11010102 (2019).

Table 1.

Multivariate logistic analysis for RA patients with prefrailty or frailty

variables including eating habitsFish + MeatAllOR (95% CI)P valueOR (95% CI)P valueDAS28-ESR1.78 (1.34 - 2.37)0.000031.73 (1.30 - 2.30)0.00009MTX use0.43 (0.23 - 0.79)0.00550.42 (0.23 - 0.78)0.0050Age (1 year)1.02 (1.00 - 1.05)0.0371.03 (1.01 - 1.06)0.0015PSL use1.23 (0.69 - 2.21)0.491.22 (0.67 - 2.20)0.51Duration of RA (1 year)1.00 (0.98 - 1.02)0.721.00 (0.98 - 1.02)0.84Body mass index1.00 (0.93 - 1.07)0.980.99 (0.92 - 1.07)0.85Biological agents use1.02 (0.60 - 1.72)0.941.04 (0.62 - 1.77)0.87Fish dish0.31 (0.17 - 0.55)0.000040.33 (0.18 - 0.61)0.00027Meat dish0.86 (0.49 - 1.50)0.600.89 (0.51 - 1.57)0.69Milk0.71 (0.41 - 1.24)0.23Vegetable0.95 (0.47 - 1.93)0.89Fruits0.77 (0.41 - 1.42)0.40Figure 1.

The prevalence of prefrailty or frailty for subjects by intake frequency

Acknowledgements:

We thank S. Nakagawa and M. Iida for technical assistance.

Disclosure of Interests:

Masao Katsushima: None declared, Hiroto Minamino: None declared, Mie Torii: None declared, Motomu Hashimoto Speakers bureau: M.H. receives grants and/or speaker fees from Bristol-Meyers, Eisai, Eli Lilly, and Tanabe Mitsubishi., Grant/research support from: M.H. belongs to the department financially supported by Nagahama City, Shiga, Japan, Toyooka City, Hyogo, Japan and five pharmaceutical companies (Tanabe-Mitsubishi, Chugai, UCB Japan, Ayumi and Asahi-Kasei).

KURAMA cohort study is supported by a grant from Daiichi Sankyo Co. Ltd., Wataru Yamamoto: None declared, Ryu Watanabe Grant/research support from: R.W. belongs to the department that is financially supported by Nagahama City, Shiga, Japan, Toyooka City, Hyogo, Japan and five pharmaceutical companies (Tanabe-Mitsubishi, Chugai, UCB Japan, Ayumi and Asahi-Kasei). KURAMA cohort study is supported by a grant from Daiichi Sankyo Co. Ltd., Kosaku Murakami: None declared, Koichi Murata Grant/research support from: K.M. belongs to the department that is financially supported by Nagahama City, Shiga, Japan, Toyooka City, Hyogo, Japan and five pharmaceutical companies (Tanabe-Mitsubishi, Chugai, UCB Japan, Ayumi and Asahi-Kasei).

KURAMA cohort study is supported by a grant from Daiichi Sankyo Co. Ltd., Masao Tanaka Grant/research support from: M.T. belongs to the department that is financially supported by Nagahama City, Shiga, Japan, Toyooka City, Hyogo, Japan and five pharmaceutical companies (Tanabe-Mitsubishi, Chugai, UCB Japan, Ayumi and Asahi-Kasei).

KURAMA cohort study is supported by a grant from Daiichi Sankyo Co. Ltd., Hiromu Ito Speakers bureau: H.I. receives a research grant and/or speaker fee from Bristol-Myers, Eisai, Mochida, Taisho, and Asahi-Kasei., Grant/research support from: H.I. belongs to the department that is financially supported by Nagahama City, Shiga, Japan, Toyooka City, Hyogo, Japan and five pharmaceutical companies (Tanabe-Mitsubishi, Chugai, UCB Japan, Ayumi and Asahi-Kasei). KURAMA cohort study is supported by a grant from Daiichi Sankyo Co. Ltd., Akio Morinobu Speakers bureau: A.M. has received speaking fees and/or research grants from Eli Lilly Japan K.K., Ono Pharmaceutical Co., Pfizer Inc., UCB Japan, AbbVie G.K., Asahi Kasei Pharma and Chugai Pharmaceutical Co. Ltd., Grant/research support from: A.M. has received speaking fees and/or research grants from Eli Lilly Japan K.K., Ono Pharmaceutical Co., Pfizer Inc., UCB Japan, AbbVie G.K., Asahi Kasei Pharma and Chugai Pharmaceutical Co. Ltd.

De Novo Genome Assembly of the Japanese Wheat Cultivar Norin 61 Highlights Functional Variation in Flowering Time and Fusarium-Resistant Genes in East Asian Genotypes

Bread wheat is a major crop that has long been the focus of basic and breeding research. Assembly of its genome has been difficult because of its large size and allohexaploid nature (AABBDD genome). Following the first reported assembly of the genome of the experimental strain Chinese Spring (CS), the 10+ Wheat Genomes Project was launched to produce multiple assemblies of worldwide modern cultivars. The only Asian cultivar in the project is Norin 61, a representative Japanese cultivar adapted to grow across a broad latitudinal range, mostly characterized by a wet climate and a short growing season. Here, we characterize the key aspects of its chromosome-scale genome assembly spanning 15 Gb with a raw scaffold N50 of 22 Mb. Analysis of the repetitive elements identified chromosomal regions unique to Norin 61 that encompass a tandem array of the pathogenesis-related 13 family. We report novel copy-number variations in the B homeolog of the florigen gene FT1/VRN3, pseudogenization of its D homeolog and the association of its A homeologous alleles with the spring/winter growth habit. Furthermore, the Norin 61 genome carries typical East Asian functional variants different from CS, ranging from a single nucleotide to multi-Mb scale. Examples of such variation are the Fhb1 locus, which confers Fusarium head-blight resistance, Ppd-D1a, which confers early flowering, Glu-D1f for Asian noodle quality and Rht-D1b, which introduced semi-dwarfism during the green revolution. The adoption of Norin 61 as a reference assembly for functional and evolutionary studies will enable comprehensive characterization of the underexploited Asian bread wheat diversity.

Pulmonary vein isolation for atrial fibrillation patients with reduced left ventricular ejection fraction

 

Background/Introduction Pulmonary vein isolation (PVI) is a cornerstone of curable treatment for atrial fibrillation (AF). Left ventricular (LV) ejection fraction (EF) occasionally improves after PVI in AF patients with reduced LVEF (rEF), the mechanism of which is not fully understood. CASTLE-AF trial have demonstrated that PVI with radiofrequency (RF) catheter for AF patients with rEF can reduce their mortality and heart failure. Nevertheless there are limited data about the clinical outcome of the PVI for patients with impaired LV function.

Purpose

This study was to evaluate the efficacy of PVI and improvement of LVEF after the procedure in AF patients with rEF.

Methods

A total of 2709 consecutive AF patients (age 65±39 y/o, male 67%) underwent their first PVI with cryoballoon or RF catheter in our facility from April 2014 to March 2019, and retrospectively analyzed. All the patients underwent echocardiogram before and half to one year after the procedure. Patients with LVEF under 40% before the PVI were selected (n=111) and divided into two groups based on whether there were specific etiologies of LV function impairment (group A) or not (group B).

Results

There were no significant difference in mean LVEF between group A (n=40) and group B (n=71) (32±6% vs 33±6%, p=0.12). The major etiology of rEF in group A were old myocardial infarction (n=20, 18%), hypertensive heart disease (n=6, 5.4%), and dilated cardiomyopathy (n=5, 4.5%). After mean follow-up of 2.7 years, there were no significant difference in clinical outcome after the procedure between two groups (1-year Kaplan–Meier event rate estimates; 72.2% vs 72.9%; p=0.85). The change amounts of LVEF after the PVI were significantly higher in group B (20±14%) compared to group A (2±10%) (p&lt;0.001). Multivariable Cox regression analysis revealed that age was the independent significant predictors of EF improvement over 10% in group B (p=0.048).

Conclusions

In AF patients with reduced LVEF, there were no significant difference in efficacy of PVI between those who have specific etiologies of LV function impairment other than AF and who have not. The improvement of LVEF after PVI was significantly larger in patients without specific etiologies compared to those with.

Funding Acknowledgement

Type of funding source: None

Secretion of equine chorionic gonadotropin and its association with supplementary corpus luteum formation and progesterone concentration in Hokkaido native pony recipient mares

The objectives of this study were to determine the plasma profile of equine chorionic gonadotropin (eCG) and its association with the formation of supplementary corpus luteum (CL) and plasma progesterone concentrations in embryo transfer Hokkaido native pony recipient mares. Blood samples and transrectal ultrasound examination of the reproductive tract were carried out weekly from the day of ovulation until week 32 of gestation (n = 4). Plasma concentrations of eCG and progesterone were measured by enzyme immunoassays. The eCG concentration was first detectable at week 5 for 2 mares and at week 6 for another 2 mares. Immediately after detection, the mean plasma eCG concentrations were observed to rise sharply and reach a peak at week 8. The concentrations then declined dramatically to a baseline (<0.5 IU/mL) by week 21. Plasma progesterone p=p concentrations increased in 2 phases. First, a sharp increase from 0.18 ± 0.05 ng/mL at ovulation to 15.9 ± 4.6 ng/mL at week 1 was observed, then a decrease to 9.69 ± 2.27 ng/mL by week 2, and maintained at this level until week 5 of gestation. The onset of the second rise occurred at week 6 and was observed to peak to 58.3 ± 21.8 ng/mL at week 10, then gradually declined to <10 ng/mL by week 26. The supplementary CLs were first detectable by pregnancy week 6 and 7 for 2 mares each. All supplementary and primary CLs regressed by week 26 for 3 mares and by week 30 for the remaining mare. The mean number of supplementary CL was 4.5 ± 0.8 and their formation in the right ovary (66.7%, 12/18) was higher (P < 0.05) than that in the left ovary (33.3%, 6/18). Among the mares, 1 mare that developed only 2 supplementary CL had 35% lower level of peak eCG and 65% lower concentration of peak progesterone compared with other 3 mares that had 5 or 6 supplementary CL. In conclusion, development of supplementary CL and blood concentrations of progesterone from around day 40 of gestation were associated with eCG concentration. The total number of supplementary CL formation in the present study in embryo transfer Hokkaido native pony recipient mares seemed higher than previously reported supplementary CL number in pregnant mares, with a greater rate in the right ovary than in left.

THU0107 OBESITY PREDICTS RESPONSE TO NOT ALL BUT CERTAIN BIOLOGICAL / TARGETED DISEASE MODIFYING ANTI-RHEUMATIC DRUGS FOR RHEUMATOID ARTHRITIS - RESULTS FROM KANSAI CONSORTIUM FOR WELL-BEING OF RHEUMATIC DISEASE PATIENTS (ANSWER COHORT)

Background:

A number of previous reports suggested that obesity is one of the baseline factors indicates refractory to biologic disease-modifying antirheumatic drugs (bDMARDs). However, difference of the significant responses appears on obesity patients depending on each kind of drug is yet unclear. However, it is yet unclear how the significant responses on obesity patients vary on each kind of drug.

Objectives:

To assess whether obesity affects clinical outcome in rheumatoid arthritis (RA) treated with each molecular-targeted agent including bDMARDs and tofacitinib.

Methods:

In Kansai consortium for well-being of rheumatic disease patients (ANSWER) cohort, which was the real-world retrospective cohort of clinical database for rheumatic diseases, RA patients who initiated biological / targeted disease modifying anti-rheumatic drugs were included and consecutively followed. Obesity was defined as BMI over than 25, and patients were divided between obese (“Ob”) and non-obese (“non-Ob”) patients. SDAI (simplified disease activity index) was compared between non-Ob and Ob at month 0, 3, 6, 9, 12 after the indicated drugs were administered. Using logistic regression analysis, odds ratio (OR) and their corresponding 95% confidence intervals (95% CIs) were further calculated to estimate achievement rate of SDAI remission defined as lower than 3.3 by obesity and other relevant clinical parameters. Once after the drugs were discontinued by any unfavorable reason, disease activities were no more scored and the Last Observation Carried Forward (LOCF) imputation method was used for SDAI at month 3 and thereafter.

Results:

A total of 1936 patients met in the inclusion criteria were under the analysis. In each drug, SDAI remission rate (non-Ob, Ob, p-value by Chi-square test) at month 12 was as follows; Infliximab (IFX, n=135): 43%, 38%, NS (not significant); Etanercept (ETN, n=188): 44%, 19%, p=0.0122; Adalimumab (ADA, n=169): 50%, 56%, NS; Golimumab (GLM, n=315): 36%, 30%, NS; Certolizumab pegol (CZP, n=131): 33%, 56%, p=0.0287; Tocilizumab (TCZ, n=423): 41%, 29%, p=0.0456; Abatacept (ABT, n=144): 26%, 23%, NS; Tofacitinib (TOF, n=69): 27%, 23%, NS. In multivariate analysis to predict SDAI remission at month 12, obesity was an independent protective factor in CZP (OR: 0.29, 95% CIs: 0.10 – 0.83), but was an independent risk factor in TCZ (OR: 1.9, 95% CIs: 1.01 – 3.61) irrespective of age, sex, disease duration, SDAI at month 0 or number of previous bDMARDs. Any other drug including ETN did not show significant result between non -Ob and Ob in the multivariate analysis.

Conclusion:

Obese patients were more resistant to TCZ but more effective in CZP than non-obese patients.

References:

[1]Ann Rheum Dis. 2018;77(10):1405-1412. Joint Bone Spine. 2019;86(2):173-183.

Disclosure of Interests:

Kosaku Murakami Speakers bureau: AbbVie, Eisai, and Mitsubishi Tanabe Pharma., Motomu Hashimoto Grant/research support from: Bristol-Myers Squibb, Eisai, and Eli Lilly and Company., Speakers bureau: Bristol-Myers Squibb and Mitsubishi Tanabe Pharma., Koichi Murata Grant/research support from: KMurata belong to a department that has been financially supported by four pharmaceutical companies (Mitsubishi-Tanabe, Chugai, AYUMI and UCB Japan)., Employee of: KMurata belong to a department that has been financially supported by four pharmaceutical companies (Mitsubishi-Tanabe, Chugai, AYUMI and UCB Japan)., Speakers bureau: KMurak has received speaking fees, and/or consulting fees from Eisai Co. Ltd, Chugai Pharmaceutical Co. Ltd., Pfizer Japan Inc, Bristol-Myers Squibb, Mitsubishi-Tanabe Pharma Corporation, UCB, Daiichi Sankyo Co. Ltd. and Astellas Pharma Inc., Wataru Yamamoto: None declared, Ryota Hara Speakers bureau: RH received a speaker fee from AbbVie, Masaki Katayama: None declared, Akira Onishi Speakers bureau: AO received a speaker fee from Chugai, Ono Pharmaceutical, Eli Lilly, Mitsubishi-Tanabe, Asahi-Kasei, and Takeda, Kengo Akashi: None declared, Koji Nagai: None declared, Yonsu Son: None declared, Hideki Amuro: None declared, Toru Hirano Grant/research support from: TH received a research grant and/or speaker fee from Astellas, Chugai, Nippon Shinyaku, Abbvie, Eisai, and Ono Pharmaceutical, Speakers bureau: TH received a research grant and/or speaker fee from Astellas, Chugai, Nippon Shinyaku, Abbvie, Eisai, and Ono Pharmaceutical, Kosuke Ebina Grant/research support from: KE has received research grants from Abbie, Asahi-Kasei, Astellas, Chugai, Eisai, Ono Pharmaceutical, and UCB Japan., Employee of: KE is affiliated with the Department of Musculoskeletal Regenerative Medicine, Osaka University, Graduate School of Medicine, which is supported by Taisho., Speakers bureau: KE has received payments for lectures from Abbie, Asahi-Kasei, Astellas, Ayumi, Bristol-Myers Squibb, Chugai, Eisai, Eli Lilly, Janssen, Mitsubishi-Tanabe, Ono Pharmaceutical, Sanofi, and UCB Japan., Kohei Nishitani Grant/research support from: KN belong to a department that has been financially supported by four pharmaceutical companies (Mitsubishi-Tanabe, Chugai, AYUMI and UCB Japan)., Masao Tanaka Grant/research support from: AbbVie, Asahi Kasei Pharma, Astellas Pharma, Ayumi Pharmaceutical, Chugai Pharmaceutical, Eisai, Mitsubishi Tanabe Pharma, Taisho Pharmaceutical, and UCB Japan.

, Speakers bureau: AbbVie, Asahi Kasei Pharma, Astellas Pharma, Bristol-Myers Squibb, Chugai Pharmaceutical, Eisai, Eli Lilly and Company, Janssen Pharmaceutical, Mitsubishi Tanabe Pharma, Novartis Pharma, Pfizer, Taisho Pharmaceutical, Takeda Pharmaceutical, and UCB Japan., Hiromu Ito: None declared, Koichiro Ohmura Grant/research support from: Astellas Pharma, AYUMI Pharmaceutical, Chugai Pharmaceutical, Daiichi Sankyo, Eisai, Japan Blood Products Organization, Mitsubishi Tanabe Pharma, Nippon Kayaku, Nippon Shinyaku, Sanofi, and Takeda Pharmaceutical., Speakers bureau: AbbVie, Actelion Pharmaceuticals Japan, Asahi Kasei Pharma, AYUMI Pharmaceutical, Bristol-Myers Squibb, Chugai Pharmaceutical, Eisai, Eli Lilly and Company, GlaxoSmithKline, Janssen Pharmaceutical, Mitsubishi Tanabe Pharma, Novartis Pharma, and Sanofi.

AB0197 INCREASED CIRCULATING ADIPONECTIN IS AN INDEPENDENT DISEASE ACTIVITY MARKER IN PATIENTS WITH RHEUMATOID ARTHRITIS: A CROSS-SECTIONAL STUDY USING THE KURAMA DATABASE

Background:

Adiponectin is a major adipokine with pleiotropic effects on inflammatory conditions including rheumatoid arthritis (RA). Adiponectin generally has anti-atherogenic effects, and its serum level inversely correlates with body mass index (BMI) and visceral fat area (VFA). On the other hand, several studies have indicated a deleterious role of adiponectin in RA progression [1]. Recently, both low BMI and increased serum adiponectin have been reported as poor prognostic factors of RA [2, 3]. However, large-scale surveys have not been done focusing on both BMI and serum adiponectin, and it is unclear which factor provides further contribution to RA disease activity. In addition, the effects of biological disease-modifying antirheumatic drugs (bDMARDs) and Janus kinase (JAK) inhibitors on serum adiponectin are largely unknown.

Objectives:

To clarify the relationship among serum adiponectin, body composition, current disease activity and therapeutic agents of RA.

Methods:

We conducted a cross-sectional study in RA patients under treatment with agents including bDMARDs and JAK inhibitors. A total of 351 subjects from the Kyoto University RA Management Alliance cohort (KURAMA) were enrolled. We classified the participants into five body composition groups (overweight with or without visceral adiposity, normal with or without visceral adiposity, and underweight), according to the cut-off points for obesity and visceral fat used in Japan: BMI, 18.5 kg/m2for underweight and 25.0 kg/m2for obesity, and VFA, 100 cm2for visceral adiposity. Differences of continuous variables among the five groups were assessed by the Steel-Dwass test or one-way analysis of variance (ANOVA). We adopted a multiple standardized linear regression model to analyze effects of serum adiponectin level on DAS28-ESR.

Results:

Serum adiponectin levels (20.9±12.5 vs. 14.7±8.4 µg/ml, p < 0.001) and DAS28-ESR (3.04±1.0 vs. 2.63±0.9,p= 0.017) in the underweight group were significantly higher than those in the others. In multiple regression analysis, serum adiponectin level, but not BMI, was positively correlated with DAS28-ESR (estimate = 0.0127,p= 0.0258). Subanalysis also showed that the use of bDMARD or JAK inhibitor did not have an obvious influence on circulating adiponectin.

Conclusion:

In the multiple regression analysis we revealed a positive and independent correlation between serum adiponectin and DAS28-ESR in Japanese RA patients. Thus, serum adiponectin is an potential marker reflecting high disease activity of RA regardless of current medications.

References:

[1]Frommer KW, Zimmermann B, Meier FM, Schroder D, Heil M, Schaffler A, et al. Adiponectin-mediated changes in effector cells involved in the pathophysiology of rheumatoid arthritis. Arthritis Rheum. 2010;62(10):2886-99.

[2]Kaufmann J, Kielstein V, Kilian S, Stein G, Hein G. Relation between body mass index and radiological progression in patients with rheumatoid arthritis. Journal of Rheumatology. 2003;30(11):2350-5.

[3]Ebina K, Fukuhara A, Ando W, Hirao M, Koga T, Oshima K, et al. Serum adiponectin concentrations correlate with severity of rheumatoid arthritis evaluated by extent of joint destruction. Clin Rheumatol. 2009;28(4):445-51.

Acknowledgments:

We would like to thank to Ms. Sumie Nakagawa for management of blood specimens, Ms. Noriko Kitayama and Ms. Maki Yoneyama for support of the patients. We also thank Drs. Takao Fujii, Chicashi, Terao, Masahide Hamaguchi, Hiroyuki Yoshitomi, and Masahiro Ishikawa for their thoughtful comments.

Disclosure of Interests:

Masao Katsushima: None declared, Motomu Hashimoto Grant/research support from: Bristol-Myers Squibb, Eisai, and Eli Lilly and Company., Speakers bureau: Bristol-Myers Squibb and Mitsubishi Tanabe Pharma., Mirei Shirakashi: None declared, Tamami Yoshida: None declared, Wataru Yamamoto: None declared, Kosaku Murakami Speakers bureau: AbbVie, Eisai, and Mitsubishi Tanabe Pharma., Koichi Murata Grant/research support from: KMurata belong to a department that has been financially supported by four pharmaceutical companies (Mitsubishi-Tanabe, Chugai, AYUMI and UCB Japan)., Employee of: KMurata belong to a department that has been financially supported by four pharmaceutical companies (Mitsubishi-Tanabe, Chugai, AYUMI and UCB Japan)., Speakers bureau: KMurak has received speaking fees, and/or consulting fees from Eisai Co. Ltd, Chugai Pharmaceutical Co. Ltd., Pfizer Japan Inc, Bristol-Myers Squibb, Mitsubishi-Tanabe Pharma Corporation, UCB, Daiichi Sankyo Co. Ltd. and Astellas Pharma Inc., Kohei Nishitani Grant/research support from: KN belong to a department that has been financially supported by four pharmaceutical companies (Mitsubishi-Tanabe, Chugai, AYUMI and UCB Japan)., Masao Tanaka Grant/research support from: AbbVie, Asahi Kasei Pharma, Astellas Pharma, Ayumi Pharmaceutical, Chugai Pharmaceutical, Eisai, Mitsubishi Tanabe Pharma, Taisho Pharmaceutical, and UCB Japan.

Speakers bureau: AbbVie, Asahi Kasei Pharma, Astellas Pharma, Bristol-Myers Squibb, Chugai Pharmaceutical, Eisai, Eli Lilly and Company, Janssen Pharmaceutical, Mitsubishi Tanabe Pharma, Novartis Pharma, Pfizer, Taisho Pharmaceutical, Takeda Pharmaceutical, and UCB Japan., Hiromu Ito: None declared, Shuichi Matsuda: None declared

OP0025 DRUG RETENTION OF 7 BIOLOGICS AND TOFACITINIB IN BIOLOGICS-NAÏVE AND BIOLOGICS-SWITCHED PATIENTS WITH RHEUMATOID ARTHRITIS -THE ANSWER COHORT STUDY

Background:

EULAR recommendation announced that biological disease-modifying antirheumatic drugs (bDMARDs) and janus kinase inhibitors (JAKi) are considered as equivalent in the treatment of rheumatoid arthritis (RA). However, we still lack reliable evidence of direct comparison between these agents’ retention, which may reflect both effectiveness and safety.

Objectives:

The aim of this multi-center (7 university-related hospitals), retrospective study is to clarify retention rates and reasons for discontinuation of 7 bDMARDs and tofacitinib (TOF), one of the JAKi, in both bDMARDs-naïve and bDMARDs-switched cases.

Methods:

This study assessed 3,897 patients and 4,415 treatment courses of with bDMARDs and TOF from 2001 to 2019 (2,737 bDMARDs-naïve patients and 1,678 bDMARDs-switched patients [59.5% switched to their second agent], female 82.3%, baseline age 57.4 years, disease duration 8.5 years; rheumatoid factor positivity 78.4%; DAS28-ESR 4.3; concomitant prednisolone [PSL] 6.1 mg/day [42.4%] and methotrexate [MTX] 8.5 mg/week [60.9%]). Treatment courses included abatacept (ABT; n=663), adalimumab (ADA; n=536), certolizumab pegol (CZP; n=226), etanercept (ETN; n=856), golimumab (GLM; n=458), infliximab (IFX; n=724), tocilizumab (TCZ; n=851), and TOF (n=101/only bDMARDs-switched cases). Reasons for discontinuation were classified into four categories by each attending physician: 1) lack of effectiveness, 2) toxic adverse events, 3) non-toxic reasons, and 4) remission. Retention rates of each discontinuation reason were estimated at 36 months using the Kaplan-Meier method and adjusted for potential clinical confounders (age, sex, disease duration, concomitant PSL and MTX, starting date and number of switched bDMARDs) using Cox proportional hazards modeling.

Results:

Adjusted drug retention rates for each discontinuation reason were as follows: lack of effectiveness in the bDMARDs-naïve group (from 70.8% [CZP] to 85.1% [ABT]; P=0.001 between agents) and the bDMARDs-switched group (from 52.8% [CZP] to 78.7% [TCZ]; P<0.001 between agents). Toxic adverse events in the bDMARDs-naïve group (from 86.9% [IFX] to 96.3% [ABT]; P<0.001 between agents) and the bDMARDs-switched group (from 81.1% [ADA] to 95.4% [ETN]; P=0.01 between agents). Finally, overall retention rates excluding discontinuation for non-toxic reasons or remission ranged from 64.2% (IFX) to 82.0% (ABT) (P<0.001 between agents) in the bDMARDs-naïve group (figure a) and from 44.2% (ADA) to 66.8% (TCZ) (P<0.001 between agents) in the bDMARDs-switched group (figure b).

Conclusion:

Remarkable differences were observed in drug retention of 7 bDMARDs and TOF between bDMARDs-naïve and bDMARDs-switched cases.

Disclosure of Interests:

Kosuke Ebina Grant/research support from: KE has received research grants from Abbie, Asahi-Kasei, Astellas, Chugai, Eisai, Ono Pharmaceutical, and UCB Japan., Employee of: KE is affiliated with the Department of Musculoskeletal Regenerative Medicine, Osaka University, Graduate School of Medicine, which is supported by Taisho., Speakers bureau: KE has received payments for lectures from Abbie, Asahi-Kasei, Astellas, Ayumi, Bristol-Myers Squibb, Chugai, Eisai, Eli Lilly, Janssen, Mitsubishi-Tanabe, Ono Pharmaceutical, Sanofi, and UCB Japan., Toru Hirano Grant/research support from: TH received a research grant and/or speaker fee from Astellas, Chugai, Nippon Shinyaku, Abbvie, Eisai, and Ono Pharmaceutical, Speakers bureau: TH received a research grant and/or speaker fee from Astellas, Chugai, Nippon Shinyaku, Abbvie, Eisai, and Ono Pharmaceutical, Yuichi Maeda Grant/research support from: YM received a research grant and/or speaker fee from Eli Lilly, Chugai, Pfizer, Bristol-Myers Squibb, and Mitsubishi-Tanabe, Speakers bureau: YM received a research grant and/or speaker fee from Eli Lilly, Chugai, Pfizer, Bristol-Myers Squibb, and Mitsubishi-Tanabe, Wataru Yamamoto: None declared, Motomu Hashimoto Grant/research support from: Bristol-Myers Squibb, Eisai, and Eli Lilly and Company., Speakers bureau: Bristol-Myers Squibb and Mitsubishi Tanabe Pharma., Koichi Murata Grant/research support from: KMurata belong to a department that has been financially supported by four pharmaceutical companies (Mitsubishi-Tanabe, Chugai, AYUMI and UCB Japan)., Employee of: KMurata belong to a department that has been financially supported by four pharmaceutical companies (Mitsubishi-Tanabe, Chugai, AYUMI and UCB Japan)., Speakers bureau: KMurak has received speaking fees, and/or consulting fees from Eisai Co. Ltd, Chugai Pharmaceutical Co. Ltd., Pfizer Japan Inc, Bristol-Myers Squibb, Mitsubishi-Tanabe Pharma Corporation, UCB, Daiichi Sankyo Co. Ltd. and Astellas Pharma Inc., Tohru Takeuchi Grant/research support from: TT received a research grant from Chugai, CoverLetter and a speaker fee from Astellas, Chugai, Eisai, Mitsubishi-Tanabe, Abbvie, Bristol-Myers Squibb, Ayumi, Daiichi Sankyo, Eisai, Takeda, and Asahi-Kasei, Employee of: TT is affiliated with a department that is financially supported by six pharmaceutical companies (Mitsubishi-Tanabe, Chugai, Ayumi, Astellas, Eisai, and Takeda), Hideyuki Shiba: None declared, Yonsu Son: None declared, Hideki Amuro: None declared, Akira Onishi Speakers bureau: AO received a speaker fee from Chugai, Ono Pharmaceutical, Eli Lilly, Mitsubishi-Tanabe, Asahi-Kasei, and Takeda, Kengo Akashi: None declared, Ryota Hara Speakers bureau: RH received a speaker fee from AbbVie, Masaki Katayama: None declared, Keiichi Yamamoto: None declared, Atsushi Kumanogoh Grant/research support from: AK received a research grant and/or speaker fee from Mitsubishi-Tanabe, Chugai, Eisai, Asahi-Kasei, Astellas, Abbvie, Bristol-Myers Squibb, Ono Pharmaceutical, and Pfizer, Speakers bureau: AK received a research grant and/or speaker fee from Mitsubishi-Tanabe, Chugai, Eisai, Asahi-Kasei, Astellas, Abbvie, Bristol-Myers Squibb, Ono Pharmaceutical, and Pfizer, Makoto Hirao Speakers bureau: MHirao received a speaker fee from Astellas, Ono Pharmaceutical, Eli Lilly, Mitsubishi-Tanabe, Pfizer, Ayumi, and Takeda

Myositis with sarcoplasmic inclusions in Nakajo-Nishimura syndrome: a genetic inflammatory myopathy

AIMS

Nakajo-Nishimura syndrome (NNS) is an autosomal recessive disease caused by biallelic mutations in the PSMB8 gene that encodes the immunoproteasome subunit β5i. There have been only a limited number of reports on the clinicopathological features of the disease in genetically confirmed cases.

METHODS

We studied clinical and pathological features of three NNS patients who all carry the homozygous p.G201V mutations in PSMB8. Patients' muscle specimens were analysed with histology and immunohistochemistry.

RESULTS

All patients had episodes of typical periodic fever and skin rash, and later developed progressive muscle weakness and atrophy, similar to previous reports. Oral corticosteroid was used for treatment but showed no obvious efficacy. On muscle pathology, lymphocytes were present in the endomysium surrounding non-necrotic fibres, as well as in the perimysium perivascular area. Nearly all fibres strongly expressed MHC-I in the sarcolemma. In the eldest patient, there were abnormal protein aggregates in the sarcoplasm, immunoreactive to p62, TDP-43 and ubiquitin antibodies.

CONCLUSIONS

These results suggest that inflammation, inclusion pathology and aggregation of abnormal proteins underlie the progressive clinical course of the NNS pathomechanism.

Oral steroid decreases the progression of joint destruction of large joints in the lower extremities in rheumatoid arthritis

To identify the risk factors for destruction of large joints in the lower extremities in patients with rheumatoid arthritis (RA) during a 4-year follow-up period in a prospective study.We enrolled consecutive patients who participated in both 2012 and 2016. Clinical data, disease activity, and types of medication were collected in 2012. Standard anteroposterior radiographs of weight-bearing joints (hips, knees, and ankles) were taken in 2012 and 2016. Radiographic progression was defined as progression in the Larsen grade or the need for joint arthroplasty or arthrodesis. The association between baseline characteristics and the incidence of radiographic progression was statistically assessed.A total of 213 patient were enrolled, and, after exclusion, 186 patients were analyzed. Sixty 9 patients (37.1%) showed radiographic progression in 1 of the large joints in the lower extremities. Multivariate regression analysis showed that radiographic progression was associated with older age, higher disease activity, and the presence of radiographic destruction at the baseline. The lower dosage of oral prednisolone was a significant risk factor compared with higher dosage when used.Patients with the risk factors should be followed closely to limit the progression of large joint destruction in the lower extremities.

P5593The association of recurrence and bleeding events with mortality after venous thromboembolism: from the COMMAND VTE Registry

Background/Introduction

Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), has a long-term risk for recurrence, which can be prevented by anticoagulation therapy. The duration of anticoagulation therapy after VTE should be based on the balance between risks of recurrent VTE and bleeding. However, there is uncertainty about the impact of these events on subsequent mortality.

Purpose

We sought to evaluate the impact of recurrent VTE events and bleeding events on subsequent mortality in patients with VTE in a large retrospective observational database in Japan.

Methods

We evaluated the association of recurrent VTE and major bleeding with mortality among 3026 patients in the COMMAND VTE Registry. We estimated the risks of recurrent VTE events and major bleeding events for subsequent all-cause death with the multivariable Cox proportional hazard model. We incorporated the recurrent VTE events and major bleeding events during follow-up into the multivariable Cox model as time-updated covariates together with the clinically-relevant 16 risk-adjusting factors. We expressed the adjusted risks of each covariate as hazard ratios (HR) and their 95%confidence intervals (CI). Furthermore, to assess the risks of recurrent PE and recurrent DVT events for subsequent all-cause death respectively, we divided recurrent VTE events into recurrent PE (PE with or without DVT) and recurrent DVT (DVT only), and incorporated these events as well as major bleeding events into the multivariable Cox model as time-updated covariates.

Results

In the current study population, the mean age was 67 years, 61% were women, and mean body weight and body mass index were 57.9 kg and 23.2 kg/m2, respectively. During the median follow-up period of 1,218 days, 763 patients died, 225 patients developed recurrent VTE events, and 274 patients developed major bleeding events. The time-updated multivariable Cox proportional hazard model revealed that both the recurrent VTE events and the major bleeding events were strongly associated with subsequent mortality risk (recurrent VTE events: HR 3.24, 95% CI 2.57–4.08, P<0.001; major bleeding events: HR 3.53, 95% CI 2.88–4.31, P<0.001). Both the recurrent PE events and the recurrent DVT events were associated with subsequent mortality risk with the numerically greater magnitude of effect with the recurrent PE events than with the recurrent DVT events (recurrent PE events: HR 4.42, 95% CI 3.28–5.95, P<0.001; recurrent DVT events: HR 2.42, 95% CI 1.75–3.36, P<0.001).

Conclusions

In the real-world patients with VTE, both recurrent VTE events and major bleeding events were strongly associated with subsequent mortality risk with the comparable effect size. Recurrent PE and recurrent DVT events were also associated with increased risks for mortality, although the magnitude of the effect on mortality was numerically greater with the recurrent PE events than with the recurrent DVT events.

Acknowledgement/Funding

Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

P1918Comparison of the clinical outcome of pulmonary vein isolation with cryoballoon and radiofrequency ablation for atrial fibrillation with pulmonary vein triggers

Background

Pulmonary vein isolation (PVI) using radiofrequency (RF) or cryoballoon (CB) has been an established treatment for atrial fibrillation. PVI using RF is the most common method with a rather complex technique of a point-by-point tissue heating and navigation of electro-anatomical-guided mapping system, and PVI with CB is also the common method with a relatively simple technique of freezing balloon occlusion. These 2 types of ablation are comparable in terms of the efficacy of the PVI procedure.

Purpose

The data on the clinical outcome of each AF type with PV triggers has been limited. We compared the outcome of success rate between RF and CB group with respect to each AF type, and further assessed the efficacy of pulmonary vein isolation for AF patients with the origin of only PV.

Methods

A total of 3402 AF patients (age 64±11; 2463 males) underwent initial PVI from May 2009 to July 2018 (PAF: 67%, non-PAF: 37%). Radiofrequency using irrigation-tip catheter was employed to 1796 patients since May 2009 (RF-PAF: 55%, RF-non-PAF: 45%). Second-generation cryoballoon was employed to other 1606 patients since September 2014 (CB-PAF: 81%, CB-non-PAF: 19%). In CB group, PV touch-up ablation with RF was needed for 113 patients (7%) (CB-PAF: 6%, CB-non-PAF: 13%; p<0.001). After PVI, additional ablation for non-PV foci was undergone after the induction by using isoproterenol infusion and rapid atrial pacing (RF-AF: 34%, CB-AF: 32%; p=0.107).

Results

In all PAF patients, AF free survival rate was significantly superior in CB group (2-years Kaplan-Meir event rate, CB 83.2%, RF 75.2%; log-rank p<0.001). The percentage of patients with non-PV foci was almost equivalent in both group (CB 30%, RF 31%, p=0.644). And in PAF patients with only PV-foci, AF free survival rate was significantly superior in CB group (2-years Kaplan-Meir event rate, CB 85.0%, RF 78.8%; log-rank p<0.001). On the other hand, in all non-PAF patients, AF free survival rate was almost equivalent in both non-PAF group (2-years Kaplan-Meir event rate, CB 65.5%, RF-non-PAF 70.0%; log-rank p=0.9). The percentage of patients with non-PV foci was almost equivalent in both group (CB 40%, RF 39%, p=0.731), And in non-PAF patients with only PV-foci, AF free survival rate was almost equivalent in both non-PAF group (2-years Kaplan-Meir event rate, CB 69.7%, RF 73.0%; log-rank p=0.376).

Conclusions

Our study showed better outcome of PVI with CB for PAF patients with PV triggers, and indicated the non-inferiority of PVI with CB for non-PAF patients with PV triggers to PVI with RF.

P6380The impact of coronary artery disease to predict mortality and neurological outcome in post-cardiac arrest patients

Background

Some studies reported that performing coronary angiography (CAG) for patients with out-of-hospital cardiac arrest (OHCA) is effective for the prognosis and neurological outcome. However, the impact of complexity of coronary artery disease (CAD) on CAG findings has not been evaluated sufficiently.

Purpose

We sought to investigate the complexity of CAD to predict the prognosis and neurological outcome in patients with OHCA.

Methods

A total of 1382 out-of-hospital cardiac arrest patients were transferred to our critical care center, of which 252 cardiovascular arrest patients achieving the return of spontaneous circulation (ROSC) were extracted from the institutional consecutive database between January 2015 and December 2018. Among those patients, we performed CAG for 160 patients. To predict mortality in hospital and neurological outcome at 30 days, we investigated basic patients' characteristics, pre-hospital information, coronary anatomical angiographical findings.

Results

Ventricular fibrillation (VF) (P=0.001), younger age (P=0.007), pre-hospital ROSC (P<0.001) and normal coronary artery on CAG findings (P=0.014) were associated with low 30-days mortality in hospital. VF (P=0.003), younger age (P=0.004), pre-hospital ROSC (P<0.001), bystander cardiopulmonary resuscitation (CPR) (P=0.043) and normal coronary artery (P=0.001) were associated with good neurological outcome (cerebral-performance-category (CPC) =1 or 2) at 30 days. We further investigated 100 patients who had any coronary artery stenosis on CAG findings. Among these patients, 55 patients (55.0%) had multi-vessel coronary artery disease and 29 patients (29.0%) had at least a chronic total occlusion lesion. VF survivor (P=0.035), without previous history of CAD (P=0.008), pre-hospital ROSC (P=0.013), and Syntax score (P=0.002) were associated with low 30-days mortality. In multivariate analysis, Syntax score (OR 0.94; 95% confidence interval (CI) 0.88–0.99; P=0.042) was independent predictor of mortality. Bystander CPR (P=0.001), pre-hospital ROSC (P<0.001) were associated with good neurological outcome at 30 days. Bystander CPR (OR 5.92; 95% CI 2.01–17.5; P<0.001) and pre-hospital ROSC (OR 9.22; 95% CI 3.34–25.5; P<0.001) were predictive for good neurological outcome.

Conclusions

OHCA patients with any coronary stenosis had high mortality and bad neurological outcome in comparison with those who had normal coronary arteries. OHCA patients with CAD had complex lesions such as multi-vessel disease or chronic total occlusion lesions. The coronary complexity in patients with OHCA was a predictor of in-hospital 30-days mortality. However, pre-hospital care such as bystander CPR and pre-hospital ROSC were the most important to achieve good neurological outcome at 30 days in the present study.

P3847Deep vein thrombosis in upper extremities: clinical characteristics, management strategies and long-term outcomes from the COMMAND VTE Registry

Background/Introduction

Pulmonary embolism (PE) is caused by blockage of pulmonary arteries by thrombus. The sources of thrombus are thought to be mostly veins in lower extremities, whereas deep vein thrombosis (DVT) in upper extremities rarely occurs spontaneously. Recent studies reported that DVT in upper extremities might have significant complications, and DVT in upper extremities could be increasing. However, there is a paucity of data on patients with DVT in upper extremities, leading to uncertainty in optimal treatment strategies including anticoagulation therapy.

Purpose

We sought to evaluate the clinical characteristics, management strategies, and long-term outcomes of patients with DVT in upper extremities in a large observational database in Japan.

Methods

The COMMAND VTE Registry is a multicenter registry enrolling 3027 consecutive patients with acute symptomatic venous thromboembolism (VTE) objectively confirmed by imaging examination or by autopsy among 29 centers in Japan between January 2010 and August 2014. The current study population consisted of 2498 patients with DVT in upper or lower extremities, after excluding 381 patients with PE only, 144 patients who had thrombus in locations other than upper or lower extremities, and 4 patients with DVT in both upper and lower extremities. The study patients were divided into 2 groups: patients with DVT in upper extremities and patients with DVT in lower extremities. We compared the clinical characteristics, management strategies and long-term outcomes between the 2 groups.

Results

There were 74 patients (3.0%) with upper extremities DVT and 2498 patients (97%) with lower extremities DVT. Patients with upper extremities DVT more often had active cancer at diagnosis (58%) and central venous catheter use (22%). The proportion of concomitant PE at diagnosis was lower in patients with upper extremities DVT than in those with lower extremities DVT (14% and 51%, P<0.001). Discontinuation of anticoagulation therapy was more frequent in patients with upper extremities DVT (63.8% and 29.8% at 1-year, P<0.001). The cumulative 3-year incidence of recurrent VTE was not different between the 2 groups (9.8% and 7.4%, P=0.43) (Figure). After adjusting confounders, the risks of upper extremities DVT relative to lower extremities DVT for recurrent VTE remained insignificant (HR 0.94, 95% CI 0.36–2.01, P=0.89).

Kaplan-Meier event curves for recurrence

Conclusions

The prevalence of patients with DVT in upper extremities was 3.0% in the current large-scale real-world registry. Patients with DVT in upper extremities more often had active cancer at diagnosis and central venous catheter use as a transient risk factor for VTE, and less often had concomitant PE. Patients with DVT in upper extremities had similar long-term risk for recurrent VTE as those with DVT in lower extremities despite shorter duration of anticoagulation.

Acknowledgement/Funding

Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

P3846The association between statin prescription, recurrent venous thromboembolism and bleeding events: from the COMMAND VTE Registry

Background

Statin prevents occurrence and recurrence of atherosclerotic events. With regard to venous thromboembolism (VTE), a randomized controlled trial suggested that statin reduced occurrence of VTE, whereas its usefulness as secondary prevention of VTE remains to be elucidated.

Purpose

This study aimed to assess the association between statin prescription, recurrent VTE and bleeding events in patients with VTE.

Methods

The COMMAND VTE Registry is a multicentre registry enrolling consecutive 3027 patients with acute symptomatic VTE among 29 centres in Japan. We divided the cohort into the patients who were prescribed statin (N=437) and those not (N=2590), and compared the two groups. We assessed hazard ratios (HRs) of those with statin relative to those without for long-term clinical outcomes (recurrent symptomatic VTE and International Society of Thrombosis and Hemostasis [ISTH] major bleeding). Because the durations of anticoagulation therapy were widely different between the two groups, we constructed Cox's proportional hazard model incorporating status of anticoagulation during the follow-up period as a time-varying covariate. Also, because the incidences of death were strikingly different between the two groups due to the difference in the prevalence of active cancer, we used Fine-Gray's subdistribution hazard model in the presence of competing risks. We incorporated clinically relevant factors into these two models as covariates (10 factors for recurrent VTE and 11 for major bleeding).

Results

The statin group was significantly older than the non-statin group (statin 71.2±11.8 vs. non-statin 66.5±15.8, P<0.001). The prevalence of active cancer in the statin group was less than one-half of that in the non-statin group (12% vs. 25%, P<0.001), and the cumulative 3-year incidence of death was significantly lower in the statin group than in the non-statin group (12.8% vs. 26.1%, log-rank P<0.001). The table shows the adjusted HRs of the statin group relative to the non-statin group. The HRs of the statin group relative to non-statin group for recurrent VTE were significantly low, but those for major bleeding were insignificant.

Adjusted hazard ratios Outcome measures Model 1 P value Model 2 P value Adjusted HR [95% CI] Adjusted HR [95% CI] Recurrent VTE 0.59 [0.36–0.98] 0.042 0.53 [0.32–0.89] 0.02 Major bleeding 0.87 [0.60–1.24] 0.43 0.997 [0.69–1.43] 0.99 Model 1 derived from Cox's model with time-varying covariate of anticoagulation status. Model 2 derived from Fine-Gray's model.

Study flowchart

Conclusions

Prescription of satin was associated with significantly low risks for recurrent VTE, whereas that was not for major bleeding events. Statin could be a potential treatment option for secondary prevention of VTE.

P2266The predictor of mortality and neurological outcome in out-of-hospital cardiac arrest patients with non-ST-segment elevation

Background

The prognosis of patients with out-of-hospital cardiac arrest (OHCA) remains poor. Coronary artery disease (CAD) is the most frequent cause of OHCA. The prompt evaluation and revascularization for coronary artery in OHCA patients with ST-segment elevation are recommended because they often have CAD. However, OHCA patients without ST-segment elevation also have any coronary stenosis in the non-negligible proportion. The predictor of mortality and neurological outcome in OHCA patients with no ST-segment elevation has not been sufficiently elucidated.

Purpose

We sought to investigate the predictor of mortality and neurological outcome at 30 days in OHCA patients without ST-segment elevation.

Methods

A total of 1382 out-of-hospital cardiac arrest patients were transferred to our critical care center, of which 252 cardiovascular arrest patients achieving the return of spontaneous circulation (ROSC) were extracted from the institutional consecutive database between January 2015 and December 2018. Among those patients, 183 patients' electrocardiogram after ROSC were without ST-segment elevation. We performed coronary angiography (CAG) for 103 patients, who were eligible for final analysis. To predict mortality in hospital and neurological outcome at 30 days, we investigated basic patients' characteristics, pre-hospital information, post-hospital care.

Results

Any coronary stenosis was founded in 50 patients (48.5%). Male (P=0.007), older age (P<0.001), past history of coronary artery disease (CAD) (P=0.037) and diabetes mellitus (P=0.087) were associated with coronary artery stenosis on CAG findings. Age (OR 1.05; 95% confidence interval (CI) 1.02–1.08; P<0.001), male (OR 5.33; 95% CI 1.37–20.7; P<0.001) were independent predictors of coronary artery stenosis. Among those who had stenosis, 34 patients (68.0%) survived and 27 patients (54.0%) achieved good neurological outcome (cerebral-performance-category (CPC) =1 or 2) at 30 days. Successful revascularization by percutaneous coronary intervention (PCI) was not associated with low mortality (P=0.77). Past history of CAD (P=0.014) and high Syntax score (P=0.030) were associated with mortality. Bystander cardiopulmonary resuscitation (CPR) (P-0.021), pre-hospital ROSC (P<0.001) was more frequent in patients with good neurological outcome. Pre-hospital ROSC (OR 14.7; 95% CI 3.1–69.3; P<0.001) was independently predictive for good neurological outcome.

Conclusions

Successful PCI for OHCA patients with no ST-segment elevation was not a predictor of mortality. CAD past history and complex CAD was associated with mortality. Pre-hospital information such as pre-hospital ROSC was important to achieve good neurological outcome.

P1919The assessment of the application and the efficacy of pulmonary vein isolation with cryoballoon for non-paroxysmal atrial fibrillation

Background

Pulmonary vein isolation (PVI) using second generation cryoballoon (CB) ablation has become an established treatment for paroxysmal atrial fibrillation (PAF) patients. On the other hand, PVI with radiofrequency (RF) has been an established treatment for non-PAF patients, in addition to PAF patients.

Purpose

The data on second generation CB ablation for non-PAF patients is limited. We assessed the application of PVI with CB for non-PAF patients and compared the outcomes of success rate, radiational time, and procedural time.

Methods

A total of 2632 AF patients (age 64±10; 1873 males) underwent initial PVI from September 2014 to June 2018. Second-generation CB was employed to 1587 patients (CB-PAF: 80%, CB-non-PAF: 20%) and RF using irrigation-tip catheter was employed to other 1045 patients (RF-PAF: 40%, RF-non-PAF: 60%). In CB group, PV touch-up ablation with RF was needed for 113 patients (7%) (CB-PAF: 6%, CB-non-PAF: 13%; p<0.001). After PVI, additional ablation for non-PV foci was undergone after the induction by using ISP infusion and rapid atrial pacing.

Results

AF free survival rate was almost equivalent in both non-PAF group (2-years Kaplan-Meir event rate, CB-non-PAF 66.3%, RF-non-PAF 69.8%; log-rank p=0.297). There was significantly difference in procedural time (CB-non-PAF 132±56min, RF-non-PAF: 189±52min, p<0.001), and radiation time (CB-non-PAF: 47±40min, RF-non-PAF: 75±31min, p<0.001). The percentage of patients with non-PV foci was significantly higher in CB group (CB-non-PAF 41%, RF-non-PAF 54%, p<0.001), and after excluding the patients with non-PV foci, AF free survival rate was almost equivalent in both group (2-years Kaplan-Meier event rate, CB-non-PAF 75.4%, RF-non-PAF 78.8%; log-rank p=0.577). On the other hand, in patients in CB, AF free survival rate was significantly superior in PAF group (2-years Kaplan-Meir event rate, CB-PAF 83.3%, CB-non-PAF 65.2%; log-rank p<0.001). There was significantly difference in procedural time (CB-PAF: 117±47min, CB-non-PAF: 132±56min, p<0.001), and radiation time (CB-PAF: 38±22min, CB-non-PAF: 46±27min, p<0.001). The percentage of patients with non-PV foci was significantly higher in non-PAF group (CB-PAF 30%, CB-non-PAF 41%, p<0.001), and after excluding the patients with non-PV foci, AF free survival rate was also significantly superior in PAF group (2-years Kaplan-Meier event rate, CB-PAF 85.1%, CB-non-PAF 69.8%; log-rank p<0.001).

Conclusions

For non-PAF patients with PV triggers, PVI with CB might be non-inferior to PVI with RF. Our study showed the efficacy of CB in terms of the shortening of procedural time, and the reduction of radiational exposure. PVI with CB for non-PAF patients was inferior to that for PAF patients.

P6461The long-term clinical comparisons of symptomatic patients of pulmonary embolism with and those without deep vein thrombosis: from the COMMAND VTE Registry

Background

Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), has significant morbidity and mortality. Acute PE, in particular, is fatal if we miss it, and symptomatic patients of PE sometimes have concomitant DVT.

Purpose

This study compared the risk of mortality in symptomatic patients of PE with and those without DVT in the long term.

Methods

The COMMAND VTE Registry is a multicenter registry enrolling consecutive 3027 patients with acute symptomatic VTE objectively confirmed by imaging examination or by autopsy among 29 centers in Japan between January 2010 and August 2014. Patients with both PE and DVT (N=1334) were regarded as PE patients, and the current study population consisted of 1715 PE patients and 1312 DVT patients.

Results

There were 1203 symptomatic patients of PE, including 381 without and 822 with DVT. In our cohort, the mean age was 67.9±14.9 years, 63% was female, 44% had hypertension, 12% diabetes mellitus, 5% history of VTE. There were 20% of active cancer. Baseline characteristics were well matched except for dyslipidemia (18% vs. 23%, p=0.021) and atrial fibrillation (8% vs. 5%, p=0.045). Patients without DVT had a more severe clinical presentation compared to those with DVT, including hypoxemia, shock and arrest. Moreover, Initial parenteral anticoagulation therapy in the acute phase was administered less frequently in patients without DVT (89% vs. 96%, P=0.0001). Two groups received thrombolysis (20% vs. 26%, P=0.18) and mechanical supports (Ventilator 14% vs. 5%, p<0.001, PCPS 5% vs. 3%, p<0.001, respectively). During follow-up, 93 (8%) patients experienced recurrent VTE events and 98 (8%) major bleeding events, and 323 (27%) patients died. The most frequent cause of death was cancer (11%). There were a significant differences in the cumulative incidences of all-cause death between the groups (32% vs. 24%, P=0.006), whereas there was significant difference in VTE-related death (13% vs. 4%, p<0.001). Estimated freedom rates from death for patients of PE without and those with DVT were as follows: 88% vs 99% at 10-day, 86% vs 95% at 1-month, 75% vs 83% at 1-year, and 64% vs 71% at 5-year, respectively.

Landmark analysis

Conclusions

In symptomatic patients of PE, there was a difference in mortality between groups, but no difference in recurrent VTE. Patients without DVT had a more severe clinical presentation compared to those with DVT, and many VTE-related deaths in the acute phase. The one-month mortality rate differed statistically between groups, but there was no significant difference in long-term survival beyond one month. Most of deaths were due to underlying diseases, mainly cancer, and less commonly due to VTE in the long term.

Acknowledgement/Funding

Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

P2770Clinical characteristics and outcomes of venous thromboembolism according to patients with versus without atrial fibrillation: from the COMMAND VTE Registry

Background/Introduction

Oral anticoagulants are widely used for the treatment and second prevention of venous thromboembolism (VTE) and stroke prevention in atrial fibrillation (AF). VTE and AF are common diseases and these sometimes might coexist. However, there are few reports about the relationship between VTE and AF.

Purpose

We sought to evaluate the clinical characteristics and outcomes in VTE patients with AF.

Methods

The COMMAND VTE Registry is a multicenter registry enrolling consecutive 3027 patients with acute symptomatic VTE objectively confirmed by imaging examination or by autopsy among 29 centers in Japan between January 2010 and August 2014. The current study population consisted of 129 patients with AF (AF group) and 2898 patients without AF (non-AF group). We compared the clinical characteristics, management strategies and long-term outcomes between the 2 groups.

Results

The AF group was older (mean age: 75.3 vs. 66.8 years, P<0.001), and more often had co-morbidities such as hypertension (54.3% vs. 37.7%, P<0.001), diabetes mellitus (20.2% vs. 12.4%, P=0.01), chronic kidney disease (28.7% vs. 18.5%, P=0.004), heart failure (28.7% vs. 18.5%, P=0.004), history of stroke (20.2% vs. 8.4%, P<0.001), and history of major bleeding (12.4% vs. 7.4%, P=0.04) compared with the non-AF group, whereas there were no significant differences in the proportions of active cancer at diagnosis (18.6% vs. 23.2%, P=0.23) and pulmonary embolism at presentation (64.3% vs. 56.3%, P=0.07). The proportion of anticoagulation therapy beyond acute phase was not significantly different (94% vs. 93%, P=0.60), while the cumulative discontinuation rates of anticoagulation therapy was significantly lower in the AF group (26.9% vs. 43.4% at 3 years, Log-rank P=0.03). The cumulative 5-year incidences of recurrent VTE and major bleeding were not significantly different (Recurrent VTE: 7.6% vs. 10.6%, Log-rank P=0.89; Major bleeding: 18.6% vs. 11.8%, Log-rank P=0.07). After adjusting for potential confounders, the risks of the AF group relative to the non-AF group for recurrent VTE and major bleeding remained insignificant (HR 1.19, 95% CI 0.54–2.28, P=0.64; HR 1.28, 95% CI 0.73–2.06, P=0.37). The cumulative 5-year incidence of all-cause death was significantly higher in the AF-group (49.1% vs. 28.6%, Log-rank P<0.001). After adjusting for potential confounders, the risks of the AF group relative to the non-AF group for all-cause death remained significant (HR 1.63, 95% CI 1.23–2.15, P<0.001). The proportion of deaths due to cancer was lower in the AF group (30% vs. 55%, P<0.001), while the proportion of cardiac deaths was higher in the AF group (16.1% vs. 4.0%, P<0.001).

The outcomes of VTE patients with AF

Conclusions

The risks for recurrent VTE between patients with AF and those without AF were not significantly different, although patients with AF received longer-term anticoagulation therapy, whereas the risks for major bleeding tended to be higher in patients with AF.

Acknowledgement/Funding

Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

Controlling joint instability after anterior cruciate ligament transection inhibits transforming growth factor-beta-mediated osteophyte formation

OBJECTIVE

Abnormal joint instability contributes to cartilage damage and osteophyte formation. We investigated whether controlling joint instability inhibited chronic synovial membrane inflammation and delayed osteophyte formation and examined the role of transforming growth factor-beta (TGF-β) signaling in the associated mechanism.

DESIGN

Rats (n = 94) underwent anterior cruciate ligament (ACL) transection. Anterior tibial instability was either controlled (CAM group) or allowed to continue (SHAM group). At 2, 4, and 8 weeks after surgery, radiologic, histopathologic, immunohistochemical, immunofluorescent, and enzyme-linked immunosorbent assay examinations were performed to evaluate osteophyte formation and TGF-β signaling.

RESULTS

Joint instability increased cartilage degeneration score and osteophyte formation, and cell hyperplasia and proliferation and synovial thickening were observed in the synovial membrane. Major findings were increased TGF-β expression and Smad2/3 following TGF-β phosphorylation in synovial membarene, articular cartilage, and the posterior tibial growth plate (TGF-β expression using ELISA: 4 weeks; P = 0.009, 95% CI [260.1-1340.0]) (p-Smad2/3 expression density: 4 weeks; P = 0.024, 95% CI [1.67-18.27], 8 weeks; P = 0.034, 95% CI [1.25-25.34]). However, bone morphogenetic protein (BMP)-2 and Smad1/5/8 levels were not difference between the SHAM model and the CAM model.

CONCLUSIONS

This study showed that the difference between anterior tibial instability caused a change in the expression level of TGF in the posterior tibia and synovial membrane, and the reaction might be consequently involved in osteophyte formation.

Distinct biomarkers for different bones in osteoporosis with rheumatoid arthritis

Background

Rheumatoid arthritis (RA) is known to cause secondary osteoporosis and fragility fractures. This study aimed to identify biomarkers predictive of bone mineral density (BMD) change at three anatomical sites in patients with RA.

Methods

We conducted a prospective longitudinal study in patients with RA. In 2012, we recruited 379 patients from an RA cohort, 329 of whom underwent evaluation of blood and urine biomarkers together with measurement of BMD in the lumbar spine, proximal femur, and distal forearm. The BMD in these three regions was reassessed in 2014. We performed multivariate linear regression analysis to identify those factors associated with BMD change.

Results

The averages of age, body mass index, and disease activity score in 28 joints (DAS28) at baseline were 63.2 (minimum to maximum, 32–85), 21.3 (12.3–30.0), and 3.2 (0.1–5.9), respectively. Univariate analysis showed that the annual BMD change was significantly associated with the use of steroid, bisphosphonate (BP) or vitamin D (VitD), and serum homocysteine in the lumber spine; DAS28, the use of BP or VitD, CRP, and anti-cyclic citrullinated peptide antibody (ACPA) in the proximal femur; and the dosage of MTX, the use of BP or VitD, and serum tartrate-resistant acid phosphatase 5b (TRACP-5b) in the distal forearm, respectively.

Conclusions

Predictive biomarkers for BMD change in RA patients differ at each anatomical site. Practitioners should treat each anatomical site with different markers and prescribe osteoporosis drugs to prevent fractures for RA patients.

Association between Sarcopenia and Overactive Bladder in Elderly Diabetic Patients

OBJECTIVES

To determine the association between sarcopenia and overactive bladder (OAB) in elderly diabetic patients using the Japanese version of SARC-F called SARC-F-J.

DESIGN

Cross-sectional study.

SETTINGS AND PARTICIPANTS

The study included 329 elderly diabetic patients (aged ≥65 years) who regularly visited the outpatient clinic at Community hospital in Japan.

MEASUREMENTS

The condition of OAB was evaluated using the OAM symptom score, which involves a self-administered questionnaire, and sarcopenia was evaluated using the self-administered SARC-F-J questionnaire comprising five items. The odds ratio for OAB due to sarcopenia was calculated using multiple logistic regression analysis, with OAB as the dependent variable and sarcopenia as the explanatory variable.

RESULTS

A total of 329 patients (186 males, 143 females) were included for analysis in the present study. Of these patients, 22.9% had sarcopenia and 18.7% had OAB. After adjusting the variables, the odds ratio for OAB due to sarcopenia was 4.46 (95% confidence interval [CI], 1.14-17.36, P = 0.031) and 2.09 (95% CI, 0.52-8.26, P = 0.293) for males and females, respectively.

CONCLUSION

This study found that sarcopenia was significantly associated with OAB in elderly diabetic male patients based on SARC-F-J. Moreover, the possibility of the development of OAB should be considered during the medical examinations of elderly diabetic male patients with sarcopenia.

Structural features of two major nucleolar organizer regions (NORs), Nor-B1 and Nor-B2, and chromosome-specific rRNA gene expression in wheat

The reference genome sequence of wheat 'Chinese Spring' (CS) is now available (IWGSC RefSeq v1.0), but the core sequences defining the nucleolar organizer regions (NORs) have not been characterized. We estimated that the total copy number of the rDNA units in the wheat genome is 11 160, of which 30.5%, 60.9% and 8.6% are located on Nor-B1 (1B), Nor-B2 (6B) and other NORs, respectively. The total length of the NORs is estimated to be 100 Mb, corresponding to approximately 10% of the unassembled portion of the genome not represented in RefSeq v1.0. Four subtypes (S1-S4) of the rDNA units were identified based on differences within the 3' external transcribed spacer regions in Nor-B1 and Nor-B2, and quantitative PCR indicated locus-specific variation in rDNA subtype contents. Expression analyses of rDNA subtypes revealed that S1 was predominantly expressed and S2 weakly expressed, in contrast to the relative abundance of rDNA subtypes in the wheat genome. These results suggest a regulation mechanism of differential rDNA expression based on sequence differences. S3 expression increased in the ditelosomic lines Dt1BL and Dt6BL, suggesting that S3 is subjected to chromosome-mediated silencing. Structural differences were detected in the regions surrounding the NOR among homoeologous chromosomes of groups 1 and 6. The adjacent regions distal to the major NORs were expanded compared with their homoeologous counterparts, and the gene density of these expanded regions was relatively low. We provide evidence that these regions are likely to be important for autoregulation of the associated major NORs as well as silencing of minor NORs.

Subatomic structure of hyper-sweet thaumatin D21N mutant reveals the importance of flexible conformations for enhanced sweetness

One of the sweetest proteins found in tropical fruits (with a threshold of 50 nM), thaumatin, is also used commercially as a sweetener. Our previous study successfully produced the sweetest thaumatin mutant (D21N), designated hyper-sweet thaumatin, which decreases the sweetness threshold to 31 nM. To investigate why the D21N mutant is sweeter than wild-type thaumatin, we compared the structure of the D21N mutant solved at a subatomic resolution of 0.93 Å with that of wild-type thaumatin determined at 0.90 Å. Although the overall structure of the D21N mutant resembles that of wild-type thaumatin, our subatomic resolution analysis successfully assigned and discriminated the detailed atomic positions of side-chains at position 21. The relative B-factor value of the side-chain at position 21 in the D21N mutant was higher than that of wild-type thaumatin, hinting at a greater flexibility of side-chain at 21 in the hyper-sweet D21N mutant. Furthermore, alternative conformations of Lys19, which is hydrogen-bonded to Asp21 in wild-type, were found only in the D21N mutant. Subatomic resolution analysis revealed that flexible conformations at the sites adjacent to positions 19 and 21 play a crucial role in enhancing sweet potency and may serve to enhance the complementarity of electrostatic potentials for interaction with the sweet taste receptor.

Cytological observation of chromosome breakage in wheat male gametophytes caused by gametocidal action of Aegilops triuncialis-derived chromosome 3Ct

In this study, we investigated the chromosome breakage caused by gametocidal (Gc) chromosome 3C^t and its interaction with the suppressor gene Igc1 (inhibitor of gametocidal gene 1) on wheat chromosome 3B. We demonstrated cytologically that patterns of 3C^t-induced chromosomal fragmentation in microspores differed from patterns observed for other Gc genes. Uninuclear microspores of the monosomic 3C^t addition line had high frequencies of micronuclei, possibly explaining its low fertility. Chromosome fragmentation was observed in prometaphase and metaphase of the first pollen mitosis in the monosomic 3C^t addition line. Patterns of chromosome fragmentation were different from those previously reported for Gc chromosomes 2S of Aegilops speltoides, 4S^sh of Ae. sharonensis and 2C^cy of Ae. cylindrica; many chromosome fragments were observed in prometaphase of the first pollen mitosis in the monosomic 3C^t addition plants. In anthers at the binuclear stage, many microspores at the uninuclear stage coexisted with normally developed microspores.

Outcomes of patients receiving a massive transfusion for major trauma

BACKGROUND

The benefits of high transfusion ratios (plasma to red blood cells and platelets to red blood cells) on survival in injured patients who receive massive transfusions remain uncertain. This study aimed to assess the association between transfusion ratios and adverse events and survival in patients undergoing massive transfusion for major trauma.

METHODS

A retrospective observational study was conducted on patients who had major trauma using a Japanese national administrative database. The associations between transfusion ratios and outcomes (in-hospital mortality and incidence of adverse events) were analysed using a non-linear logistic generalized additive model (GAM). In a logistic generalized estimating equation model, adjusted for patient and hospital-level confounders, transfusion ratios were included as continuous or categorical variables (low, transfusion ratio 0·75 or less; intermediate, over 0·75 to 1·25; high, over 1·25).

RESULTS

Some 1777 patients were included in the analysis, of whom 602 died in hospital. GAM plots of the transfusion ratios for in-hospital mortality demonstrated a downward convex unimodal curve. In-hospital mortality was similar with increasing transfusion ratios for plasma (adjusted odds ratio (OR) 1·13, 95 per cent c.i. 0·82 to 1·55; P = 0·446) and platelets (adjusted OR 0·84, 0·66 to 1·08; P = 0·171). Both plasma to red blood cell ratio (adjusted OR 1·77, 1·32 to 2·37; P < 0·001) and platelet to red blood cell ratio (adjusted OR 1·71, 1·35 to 2·15; P < 0·001) were significantly associated with a higher incidence of adverse events. No significant differences in in-hospital mortality were observed between the three transfusion categories (low, medium and high).

CONCLUSION

In this study, transfusion strategies with high plasma to red blood cell and platelet to red blood cell ratios did not have survival benefits, but were associated with an increase in adverse events.