Comparison of clinical effect of living alone between urban area and rural area in patient with acute coronary syndrome

Background and objective

Living alone is reported as an independent risk factor for worse clinical outcomes after percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). Manifestations of psychological stress such as depression and anxiety in patients living alone is thought to be associated with subsequent cardiovascular events. The impact of living alone on the psychological factors of patients may be differ depending on their living environment. However, comparison of the effects of living alone in different living environment on the prognosis of patients with ACS has not been reported.

Purpose

The aim of the present study was to compare the clinical effect of living alone on clinical outcomes in patients with ACS between urban area and rural area.

Methods

Data from a multi-center, observational study of consecutive patients who underwent emergency PCI for ACS between January 2012 and December 2016 were analyzed. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE). MACCE was defined as composite of cardiovascular death, ACS, and stroke.

Results

In this study, 1349 patients were enrolled and divided into two population according to their living environment: urban area population (n=417), and rural area population (n=932). In urban area population, 87 patients (20.9%) were living alone, and 330 (79.1%) were living together. In rural area population, 169 (18.1%) were living alone, and 763 (81.9%) were living together. There are no significant differences in baseline characteristics between the living alone group and the living together group in both urban area population and rural area population. During a median follow-up period of 2.1 years, Kaplan-Meier curves showed the living alone group had higher risk of MACCE than the living together group in urban area population (log-rank, p=0.01). On the other hands, there are no significant differences in the incidences of MACCE between two groups in rural area population (p=0.86). After adjustment for other covariates, the living alone was significantly associated with MACCE (hazard ratio [HR], 2.83; 95% confidential interval [CI], 1.16–6.91; p=0.02) compared with the living together group in urban area population. However, in rural area population, the living alone group was not significantly associated with MACCE (HR, 1.02; 95% CI, 0.66–1.57; p=0.92) compared with the living together group.

Conclusion

Living alone was significantly associated with worse clinical outcomes after emergency PCI of ACS in urban area but not in rural area.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Comparison of clinical outcomes between percutaneous coronary intervention for the de novo lesion versus in-stent restenosis lesion

Background and objective

Percutaneous coronary intervention (PCI) with metallic coronary stent (bare-metal stents [BMS] and drug-eluting stents [DES]) implantation is most frequently performed therapeutic procedures for coronary artery disease. In-stent restenosis (ISR) is a critical drawback of metallic coronary stents. Incidence of ISR has been reported in up to 30% after BMS implantation. The use of DES has greatly reduced the proportion of restenosis compared with the BMS. However, ISR still remains the primary concern after PCI even in the contemporary DES era, and thought to be associated with worse clinical outcomes. However, comparative data on ISR and de novo lesions are rare.

Purpose

The aim of the present study was to compare the clinical outcomes after PCI for the de novo lesion and the ISR lesion.

Methods

We performed a retrospective analysis of patients who underwent PCI between 2013 and 2020. The incidences of major adverse cardiac and cerebrovascular events (MACCE) and all-cause death were evaluated. MACCE was defined as composite of cardiovascular death, non-fatal myocardial infarction, and stroke.

Results

In this study, 1538 patients were enrolled and divided into two groups: PCI for de novo lesion group (n=1258, 81.8%), and PCI for ISR lesion group (n=280, 18.2%). Patients in the ISR lesion group were significantly older and had higher prevalence of hypertension, diabetes mellitus, dyslipidemia and chronic kidney disease than patients in the de novo lesion group. During a median follow-up period of 1.9 years, Kaplan-Meier curves showed no significant differences in the incidences of MACCE (log-rank, p=0.86) and all-cause death (p=0.84) between two groups. After adjustment for other covariates, PCI for ISR lesion were not significantly associated with MACCE (hazard ratio [HR], 1.10; 95% confidential interval [CI], 0.61–1.97; p=0.76) and all-cause death (HR, 0.93; 95% CI, 0.56–1.56; p=0.79)

Conclusion

PCI for the ISR lesion was not associated with worse clinical outcomes compared with PCI for the de novo lesion.

Funding Acknowledgement

Type of funding sources: None.

The relationship among extent of lipid-rich plaque, factors associated with a reduction of lipid-rich plaque and late lumen loss: a near-infrared spectroscopy and intravascular ultrasound study

Background

Near-infrared spectroscopy (NIRS) and intravascular ultrasound (IVUS) are useful imaging modalities to identify lipid-rich plaque (LRP) which is associated with an increased risk of future cardiovascular events in individuals undergoing PCI. Pathological studies have raised concerns that treating LRP with stents may impair vascular healing. However, the impact of stent implantation to LRP lesions was less known. Moreover, little information is available about changes in the extent of LRP at before and after PCI.

Purpose

The aim of this study was to investigate changes in LRP by NIRS between pre- and post-stent implantation, and to evaluate an association among impact of LRP by NIRS at pre- and post-stenting and late lumen loss (LLL) by angiography.

Methods

We studied 175 lesions in 149 patients who underwent PCI under NIRS-IVUS guidance and follow-up angiography at 8-month later from 2017 to 2020. Plaque characteristics on IVUS, the extent of LRP [defined as a long segment with a 4-mm maximum lipid core burden index (maxLCBI4mm)] on NIRS, and quantitative coronary angiography measurements were analyzed. We evaluated a change of the extent of LRP between pre- and post-stenting at index PCI procedure, and association between the extent of LRP and a 8-month LLL at follow-up coronary angiography. A large LRP was defined as maxLCBI4mm>400 at pre-stenting.

Results

Mean age was 64.5 years old, and 123 (82%) patients were male. The prevalence of large LRP was 51% and median plaque burden at minimum lumen area was 81%. The extent of LRP at culprit lesion significantly decreased from pre- to post-stenting (median maxLCBI4mm [interquartile range (IQR)]: 407 [199, 580] to 133 [13, 319], p<0.001) (Figure 1). In multivariable liner regression analysis, independent predictors for the reduction of LRP were a pre-stenting LRP (β coefficient = −57.0, 95% confidence interval (CI) [−65.1 to −48.8], p<0.001) and plaque burden (β coefficient = −30.0, 95% CI [−56.6 to −3.4], p<0.001), respectively. On the other hands, patient comorbidities, lipid profile and inflammatory markers were not associated with the reduction of LRP (all p>0.05). Median LLL at follow-up angiogram was 0.17 [0.07–0.35] mm. Both the extent of pre- and post-stenting LRP were not associated with LLL (r=0.018, p=0.80 and r=0.022, p=0.76, respectively) (Figure 2). In addition, there was no significant difference in LLL between the post-stenting large and non-large LRP (median [IQR] 0.18 [0.08–0.35] vs. 0.17 [0.07–0.35]; P=0.95).

Conclusions

This study showed coronary stent implantation significantly reduced the NIRS-derived LRP in patients undergoing PCI. Although the extent of pre-stenting LRP and IVUS plaque burden predicted the reduction of LRP, the extent of pre- and post-stenting LRP were not associated with LLL. These findings suggest that stent implantation for LRP, even in a large LRP, is safe and does not affect LLL.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Scatter plotsFigure 2. CENTRAL Figure

Coronary lipid-rich plaque characteristics with acute coronary syndrome and chronic coronary syndrome: a near infrared spectroscopy and intravascular ultrasound study

Background

Asians have a much lower incidence of adverse coronary events than Caucasians, and the characteristics of vulnerable plaque might be different among the ethnics.

Purpose

The aim of this study was to investigate the clinical characteristics of lipid-rich plaque (LRP) in the Asian population and we also aimed to distinguish the characteristics of an acute coronary syndrome (ACS) culprit lesion and a chronic coronary syndrome (CCS) culprit lesion. Furthermore, we evaluated the association between lipid core burden index (LCBI) and cardiovascular risk factors, lipid profiles, and inflammatory biomarkers, as determined in vivo by near infrared spectroscopy intravascular ultrasound (NIRS-IVUS) imaging in patients undergoing percutaneous coronary intervention (PCI).

Methods

We evaluated 207 patients (ACS, n=75; CCS, n=132) who underwent PCI under NIRS-IVUS. Plaque characteristics and the extent of LRP [defined as a long segment with a 4-mm maximum LCBI (maxLCBI4mm)] on NIRS in de-novo culprit and non-culprit segments were analyzed.

Results

The mean age was 65 years old and 82% of patients were male. The ACS culprit lesions had a significantly higher maxLCBI4mm (median [interquartile range (IQR)]: 533 [385–745] vs. 361 [174–527], p<0.001) than the CCS culprit lesions. Whereas, no significant difference was seen in maxLCBI4mm between ACS and CCS non-culprit lesion segments (246 [53, 342] vs. 185 [37, 350], p=0.47) (Figure 1). Receiver-operating characteristic analysis showed that the NIRS maxLCBI4mm could distinguish the ACS culprit segment from the CCS culprit segment, with a sensitivity of 73% and a specificity of 69% (c-statistic = 0.69; p<0.001, cut-off value of max LCBI4mm = 408) (Figure 2). On multivariate logistic analysis, a large LRP (defined as maxLCBI4mm ≥400) was the strongest independent predictor of the ACS culprit segment (odds ratio, 3.87; 95% confidence interval, 1.95–8.02). In non-culprit segments, 19.8% of patients had at least one large LRP without a small lumen. No significant correlation was found between the extent of LRP and circulating lipid profiles and inflammatory makers biomarkers (hs-CRP, IL-6, TNF-α) in both the culprit and non-culprit lesion segments, whereas the extent of LRP was positively correlated with IVUS plaque burden (r=0.24, p<0.001).

Conclusions

We confirmed that NIRS-IVUS plaque assessment could be useful to differentiate ACS from CCS culprit lesions, and that a threshold maxLCBI4mm ≥400 was clinically suitable in Japanese patients. No systemic surrogate markers were found to be associated with the extent of LRP by NIRS in culprit and non-culprit segments. Consequently, we believe that direct intravascular evaluation of coronary plaque characteristics remains important for identification of high-risk LRP.

Funding Acknowledgement

Type of funding sources: None. Figure 1. The difference of maxLCBI4mmFigure 2. ROC curve

Clinical outcomes of patients with diffuse coronary artery disease following physiology-guided treatment strategy: insights from AJIP registry

Background

Physiology-guided treatment strategy improves clinical outcomes of patients with coronary artery disease. However, it has not been fully evaluated whether such guideline-based strategy is useful for patients with diffuse coronary artery disease as well, which is known to be one of the major factors affecting morbidity and mortality.

Purpose

The aim of this study was to clarify clinical outcomes of patients with diffuse coronary artery disease whose treatment strategy was based on coronary physiology.

Methods

From an international multicentre registry of iFR-pullback, consecutive 1067 patients (1185 vessels) with stable angina were included in whom coronary lesions were deferred or revascularized according to the iFR cutoff: 0.89. The physiological pattern of disease was classified according to the iFR-pullback recording as predominantly physiologically diffuse (n=463) or predominantly physiologically focal (n=722). Major adverse cardiovascular events (MACEs), defined as a composite of cardiac death, non-fatal myocardial infarction, and ischemia-driven target lesion revascularization during follow-up period, were compared between diffuse and focal groups, in both deferred and revascularized groups, respectively.

Results

Mean age was 67.1±10.7 years and 75.8% of patients were men. Median iFR was 0.88 (interquartile range: 0.80 to 0.92). At a median follow-up period of 18 months, no significant differences in MACEs were found between diffuse and focal groups, in both iFR-based deferred and revascularized groups. In the deferred group (n=480), MACEs occurred in 6.9% patients (15/217) in the diffuse group and 8.0% patients (21/263) in the focal group (p=0.44). In the revascularized group (n=705), MACEs occurred in 8.9% patients (22/246) in the diffuse group and 7.2% patients (33/459) in the focal group (p=0.49).

Conclusions

Despite potentially higher risks in patients with diffuse coronary artery disease, clinical outcomes of those patients were comparable to those of patients without diffuse disease, as long as treatment strategy was based on the physiology guidance, which is globally recommended by international guidelines.

Funding Acknowledgement

Type of funding source: None

Combined impact of residual inflammatory risk and chronic kidney disease on long-term clinical outcomes in patients undergoing percutaneous coronary intervention

Background

Inflammatory status pre-percutaneous coronary intervention (PCI) and post-PCI has been reported not only associated with poor prognosis, but also to impair renal function. Statins reduce cardiovascular events by lowering lipids and have anti-inflammatory impacts, but residual inflammatory risk (RIR) exists. It remains unclear that the synergistic effect of RIR and chronic kidney disease (CKD) on long-term clinical outcome in stable coronary artery disease (CAD) patients undergoing PCI in statin era.

Aim

The aim of this study was to investigate the long-term combined impact of RIR evaluating hs-CRP at follow-up and CKD among stable CAD patients undergoing PCI in statin era.

Methods

This is a single-center, observational, retrospective cohort study assessing consecutive 2,984 stable CAD patients who underwent first PCI from 2000 to 2016. We analyzed 2,087 patients for whom hs-CRP at follow-up (6–9 months later) was available. High residual inflammatory risk was defined as hs-CRP >0.6 mg/L according to the median value at follow up. Patients were assigned to four groups as Group1 (high RIR and CKD), Group2 (low RIR and CKD), Group3 (high RIR and non-CKD) or Group4 (low RIR and non-CKD). We evaluated all-cause death and major adverse cardiac events (MACE), defined as a composite of cardiovascular (CV) death, non-fatal myocardial infarction (MI) and non-fatal stroke.

Results

Of patients (83% men; mean age 67 years), there were 299 (14.3%) patients in group 1, 201 (9.6%) patients in group 2, 754 (36.1%) patients in group 3, and 833 (39.9%) patients in group 4. The median follow-up period was 5.2 years (IQR, 1.9–9.9 years). In total, 189 (frequency, 16.1%) cases of all-cause death and 128 (11.2%) MACE were identified during follow-up, including 53 (4.6%) CV deaths, 27 (2.4%) MIs and 52 (4.8%) strokes. The rate of all-cause death and MACE in group 1 was significantly higher than other groups (p<0.001, respectively). There was a stepwise increase in the incidence rates of all-cause death and MACE. After adjustment for important covariates, the presence of high RIR and/or CKD were independently associated with higher incidence of MACE and higher all-cause mortality. (shown on figure).

Conclusion

The presence of both high RIR and CKD conferred a synergistic adverse effect on the risk for long-term adverse cardiac events in patients undergoing PCI.

Kaplan-Meier curve

Funding Acknowledgement

Type of funding source: None

The effect of underweight on mid-term outcome following transcatheter aortic valve implantation: an insight from multicenter registry

Background

Obesity has the adverse prognostic impact in the general population, whereas paradoxical effect of obesity has been reported in patients with heart failure. Several studies have suggested the same obesity paradox in patients undergoing transcatheter aortic valve implantation (TAVI), however, they included limited number of underweight patients.

Purpose

The aim of this study was to clarify the effect of underweight on outcome following TAVI.

Methods

We retrospectively analyzed consecutive 1,027 patients undergoing TAVI between April 2010 and June 2019. The patients were categorized according to body mass index (BMI) as follows: underweight (<18.5 kg/m2, n=150), normal weight (18.5 to 25 kg/m2, n=657), and overweight (>25 kg/m2, n=220). BMI was defined as body weight (kg) divided by the square of body height (m) measured at the hospital admission. We compared the short- and mid-term outcome after TAVI among three groups, and all clinical events were accordance with Valve Academic Research Consortium-2 criteria.

Results

Underweight patients were more often female, and had a higher prevalence of hypertension, dyslipidemia, peripheral artery disease, anemia, and hypoalbuminemia. They also presented lower ejection fraction, smaller aortic valve area, and higher surgical risk score. In procedural findings, device unsuccess and major vascular complication more occurred in underweight patients, but 30-day mortality was equivalent among three groups. The mid-term survival of the underweight was inferior to the other two groups (figure).In the multivariate analysis, female (hazard ratio [HR] 0.52, 95% confidence interval [CI] 0.37–0.73, P=0.0002), atrial fibrillation (HR 2.22, 95% CI 1.56–3.17, P<0.0001), albumin value (HR 0.37 per 1-g/dl increase, 95% CI 0.25–0.55, P<0.0001), Society of Thoracic Surgeons score (HR 1.06 per 1% increase, 95% CI 1.02–1.06, P=0.0039), 30-day combined endpoint (HR 2.12, 95% CI 1.33–3.38, P=0.0017), and underweight (HR 1.59, 95% CI 1.04–2.37, P=0.026) were associated with the survival after TAVI.

Conclusion

The underweight had a worse mid-term prognosis, representing the obesity paradox in the TAVI population.

Kaplan-Meier curves

Funding Acknowledgement

Type of funding source: None

Effectiveness of an app for perinatal home visitation by nurses in preventing infant abuse in Japan

Background

In Japan, public health nurses provide home visitation with pregnant women who are at high risk for child maltreatment, but its effectiveness in preventing child maltreatment has not been evaluated because contents and quality of home visitation vary from municipality to municipality. This study aims to evaluate whether the tablet app developed to standardize and assist perinatal home visitation by public health nurses is effective in preventing child maltreatment.

Methods

An intervention study was conducted in 2018 in Adachi City, Tokyo, Japan. Public health nurses at two public health centers used the tablet app when they support high-risk pregnant women through home visitation and interviews, while public health nurses at the other three public health centers provided support as in the past. Because two public health centers were different in usage of the app, the treatment group was further divided into two groups: active and inactive. As fatal abuse among infants, frequency of shaking and smothering was assessed as an outcome through a self-reported questionnaire at the 4-month health check, and compared between the active treatment group, inactive treatment group, and control group, using multiple logistic regression (N = 5,651).

Results

Prevalence of infant abuse was 0.82% in the active treatment group, 1.34% in the inactive treatment group, and 1.50% in the control group. When adjusted for parental demographics and parenting situations, mothers in the active treatment group were less likely to shake or smother their baby than those in the control group (Odds ratio: 0.51, p = 0.093).

Conclusions

It possibly suggests that the tablet app developed to assist perinatal home visitation by public health nurses was effective in preventing infant abuse.

Key messages

An intervention study was conducted at public health centers in Adachi City, Tokyo, Japan, using the tablet app developed to standardize and assist perinatal home visitation by public health nurses. The finding suggested that the tablet app may be effective in preventing shaking and smothering among 4-month old infants.

Prevention of dental caries by eating vegetables at the beginning of a meal in Japanese children

Backgrounds

Dental caries is still a worldwide serious problem among children. Previous studies showed that higher consumption of vegetables prevents dental caries. Eating order habits, such as eating vegetables at the beginning of a meal, called “Vege-first”, may increase the amount of vegetable consumption, and in turn, prevent dental caries. We used cross-sectional data in our previous study to show the association between “Vege-first” and dental caries. However, the causal relationship of “Vege-first” on dental caries is not clear. The aim of this study to investigate the effect of “Vege-first” on dental caries, using cohort data of Japanese elementary students.

Methods

We used cohort data from 2015 to 2016 by the Adachi Child Health Impact of Living Difficulty (A-CHILD) study, a population-based study of all first- and Second- grade students in Adachi City, Tokyo, Japan. The number of DMFT (decayed, missed due to decay, and filled teeth) in 2016 was used as an outcome. Poisson regression analyses were applied to determine the independent association between keeping the “Vege-first” habit over one year and the number of DMFT in 2016 after controlling for the effects of a child's sex, parental marital status, socioeconomic status, and child's dental caries status in 2015.

Results

Of 3,164 valid participants, 45.0% had dental caries and 6.3% kept the “Vege-first” habit. Children who kept the “Vege-first” habit had fewer DMFTs in 2016 than children who did not (p < 0.001). After controlled for covariates, children with having a continuous “Vege-first” habit were still significantly and independently decreased the number of DMFT in 2016 (Incidence-rate ratios=0.87 (95% confidential interval [0.75-0.98])).

Conclusions

This study showed that having the continuous “Vege-first” habit was associated with preventive dental caries even after accounting for socioeconomic status. Health policy introducing the “Vege-first” habit may be effective to prevent pediatric dental caries.

Key messages

The practice of eating vegetables at the beginning of a meal, called “Vege-first” may increase vegetable consumption and reduce dental caries. The continuous habit of 'Vege-first' was effective in preventing a child’s dental caries even if after accounting for socioeconomic status.

Preventing postpartum depression using an educational video on infant crying

Background

Perception of and reactive behaviors towards infant crying is one of the modifiable risk factors for postpartum depression. The aim of this study was to examine the impact of watching an educational video on infant crying within 1 week of age after delivery at maternity wards to reduce the prevalence of postpartum depressive symptoms at 1 month after giving birth.

Methods

Study design was a cluster randomized controlled trial (UMIN000015558). The intervention hospitals were randomly assigned, stratified by area and function of the hospital. Participants included 47 obstetrics hospitals or clinics out of 150 hospitals or clinics in Osaka Prefecture, Japan. In total, 44 hospitals or clinics completed the trial and 2,601 (intervention group=1,040, control group=1,561) caregivers responded to the questionnaire on postpartum depression. Mothers in the intervention group watched a 11-minute educational video, within 1 week of age, during hospitalization at maternity wards. Primary outcome in this study was postpartum depression assessed by the Edinburgh Postnatal Depression Scale as 9+, and assessed via questionnaire at a 1-month health checkup.

Results

In the intervention group, 142 (13.7%) mothers reported postpartum depression compared to 250 (16.0%) in the control group. Intention-to-treat analysis showed no significant difference in the prevalence of postpartum depression between the groups. However, among young mothers (<25 years old), the analysis showed a 67% reduction in postpartum depression (OR:0.33, 95%CI:0.15-0.72).

Conclusions

Watching an educational video on infant crying did not reduce postpartum depression at 1 month after giving birth, but it was effective for young mothers aged less than 25 years old. It may be easier to introduce our approach to any opportunity for meeting mothers during perinatal period because it does not require specialized manpower and a significant amount of time for the intervention.

Key messages

The educational video on infant crying, “Baby Doesn't Stop Crying,” had no effect in preventing postpartum depressive symptoms. Among young mothers aged <25 years, the educational video had a protective effect on postpartum depressive symptoms, which was not observed for mothers aged ≥25 years.

[BCR-ABL1-positive myelodysplastic syndrome with neutropenia and anemia treated successfully with imatinib mesylate]

An 81-year-old female was referred to our hospital with progressive neutropenia and anemia of unknown etiology. We performed a bone marrow biopsy which was notable for hypercellularity, multinucleated megakaryocytes and hypo-granular neutrophils with 2.6% blasts. A diagnosis of myelodysplastic syndrome with multilineage dysplasia (MDS-MLD) was made. Karyotype analysis revealed a t (9;22)(q34;q11.2) BCR-ABL1 fusion with no additional chromosomal abnormalities. BCR-ABL1 was also detected in transcripts from peripheral blood cells as well as in polynuclear leukocytes via FISH. Within one year, her peripheral blood neutrophil count had declined to 403/µl; further analysis was notable for increasing dysplasia including enlarged platelets and hypo-granular neutrophils. Platelet counts gradually increased over time and reached 100×10⁴/µl. A second bone marrow examination revealed similar cell morphology and the BCR-ABL1 translocation. Her condition deteriorated and blood transfusions were required. Treatment with low doses of the tyrosine kinase inhibitor (TKI), imatinib mesylate (100 mg), was initiated. Thereafter, both the neutropenia and anemia resolved gradually, platelet counts returned to normal levels, and dysplasia eventually disappeared. Detection of the BCR-ABL fusion in mRNA decreased to < 0.0007% (IS%) after 16 months of treatment. Several cases of BCR-ABL1-positive myelodysplastic syndrome treated with TKIs have been reported. Our results suggest that complete hematologic recovery in response to imatinib mesylate suggests a critical role for the BCR-ABL1 fusion in the pathogenesis of this disease.

The association between eating vegetables at start of meal and dental caries among Japanese children

Background

Dental caries is still serious problem among Japanese children. Previous studies suggested that higher consumption of vegetables prevent dental caries. Eating order habit, such as eating vegetables at start of meal, called “Vege-first”, may increase the amount of vegetable consumption, and in turn, prevent dental caries. However, no published studies have examined the impact of “Vege-first” habit on dental caries. The aim of this study to investigate the association between “Vege-first” and dental caries among Japanese children.

Methods

We used the 2015 cross-sectional data from the Adachi Child Health Impact of Living Difficulty (A-CHILD) study, a population-based study of all first-grade students in Adachi City, Tokyo, Japan. The number of DMFT (decayed, missed due to decay, and filled teeth) was used as an outcome. Poisson regression analyses were applied to determine the independent association between “Vege-first” habit and the number of DMFT after controlling for the effects from child’s sex, parents’ marital status, socioeconomic status, and frequency of tooth brushing, drinking sweet beverages, and snacking.

Results

Of 3,689 valid Japanese children participants, 38.2% had DMFT and 11.6% were having the “Vege-first” habit. The number of DMFT decreased linearly with “Vege-first” habit (p &lt; 0.001). After controlled for covariates, the number of DMFT was still significantly and independently decreased with “Vege-first” habit (prevalence ratio=0.89 (95% confidential interval [0.81-0.98])).

Conclusions

This study showed that having the “Vege-first” habit was associated with dental caries even accounting for socioeconomic status, dental health behavior, and dietary habits. Health policy introducing “Vege-first” habit may be effective to prevent pediatric dental caries.

Key messages

Eating habit which vegetables at start of meal called “Vege-first” may increase the amount of vegetable consumption and possibly reduce dental caries. The habituation of Vege-first was likely to reduce child’s dental caries even accounting for socioeconomic status, dental health behavior and dietary habits.

Combined effect of adverse childhood experiences and young age on self-harm ideation after birth

Background

Suicide among postpartum women is a new and emerging issue in developed countries. However, little is known about the combined effect of risk factors on self-harm ideation, although various risk factors have been found. The aim of this study is to examine the combined effect of maternal adverse childhood experiences and maternal age on self-harm ideation among postpartum women.

Methods

The study comprised a cross-sectional study of 8,074 mothers participating in a 3-month health checkup between September 2013 and August 2014 in City A, Prefecture A, Japan. Main outcome was self-harm ideation assessed using the Edinburgh Postnatal Depression Scale (EPDS), item 10. Possible risk factors were maternal adverse childhood experiences (ACEs), maternal characteristics, relationship with husband/partner (e.g., feelings when pregnancy was confirmed), household characteristics, child characteristics (e.g., age, sex, birth weight), and postpartum characteristics, and postpartum depression status other than self-harm ideation.

Results

Postpartum women with 3 or more ACEs and younger age (&lt;25 years old) were 10.3 times more likely than those with no ACEs and older age to have self-harm ideation (95%CI=5.3-20.2). This combined effect was also found in first-time mothers (OR = 7.6, 95%CI=3.2-17.9).

Conclusions

Postpartum women with 3 or more ACEs and who were younger than 25 years old were at a high risk for self-harm ideation. Providing prevention strategies aimed at mothers with multiple risk factors, especially younger age and ACEs, is warranted.

Key messages

Mothers with 3 or more ACEs and younger age had a high self-harm ideation risk. Providing prevention strategies for mothers with multiple risk factors is warranted.

P2861Elevated cc chemokine receptor 2 expression and higher migratory activity of monocytes in atrial fibrillation patients with progressive structural remodeling

Background

Inflammation in atrial tissue underlies structural remodeling of left atrium, which is a hallmark of atrial fibrillation (AF). Activated monocytes mediate inflammation; however, the role of monocytes in AF pathogenesis has not been extensively examined. In this study, we thus investigated the association between structural remodeling of left atrium, represented by left atrial dimension (LAD), and characteristics of peripheral monocytes in patients with AF.

Methods

Blood samples were collected from patients undergone catheter ablation between July 2017 and October 2018, including AF patients (n=152) and paroxysmal supraventricular tachycardia (PSVT) patients, which serves as a control non-AF group (n=22). AF patients were further divided into two groups by the median of LAD (normal LAD group: LAD <40 mm, n=77, large LAD group: LAD ≥40 mm, n=75). Peripheral blood mononuclear cells (PBMC) were isolated to analyze monocyte subsets by flow cytometry. In a subset of patients, we further isolated monocytes from PBMC by using magnetic bead-based negative selection method then gene products associated with inflammation or monocyte functions were evaluated. We also examined migratory activity of monocytes toward monocyte chemotactic protein-1, a ligand for CC chemokine receptor 2 (CCR2), using a modified Boyden chamber method. Finally, we performed immunofluorescence staining of monocytes and macrophages in left atrial appendages resected from patients underwent coronary bypass graft surgery (CABG) complicated by AF.

Results

There were no differences in age, body mass index and high-sensitivity C-reactive protein levels among three groups, including non-AF, normal LAD and large LAD groups, except that more female subjects were included in non-AF group. We found that proportions of classical CD14++CD16- and nonclassical CD14+CD16++ monocytes were higher (non-AF: 71.2±7.3% vs. AF: 75.5±8.3%, p<0.05) and lower (non-AF: 16.4±5.9% vs. AF: 13.2±5.5%, p<0.05), respectively, in all AF patients compared with those in non-AF group, while no significant difference was observed between normal and large LAD groups. In monocytes from large LAD group, mRNA levels of CCR2, a receptor to mediate monocyte chemotaxis, were significantly higher compared to those in normal LAD group (Figure A, p<0.05). Furthermore, monocytes isolated from large LAD group exhibited higher migratory capacity compared to normal LAD group (Figure B, p<0.01). Finally, higher monocyte/macrophage infiltrations to left atrial appendages were implicated in patients with large LAD, shown by immunofluorescence staining.

Conclusions

Monocytes in AF patients with enlarged left atrium expressed higher CCR2 mRNA and were more active in chemotaxis to MCP-1, suggesting the proactive roles of activated monocytes in the pathogenesis of arterial remolding in AF.

P4654Clinical and electrocardiographic features of restrictive cardiomyopathy in children

Introduction

Restrictive cardiomyopathy (RCM) is a rare myocardial disease with an impaired diastolic function and poor prognosis. The mean survival duration after a diagnosis of RCM is reported to be around 2 years in children and most need heart transplantations.

Purpose

This study aimed to determine the 12-lead electrocardiogram (ECG) diagnostic criteria of RCM based on the initial diagnostic electrocardiogram.

Methods

ECGs in pediatric cardiomyopathy patients were collected from 15 institutes in Japan between 1979 and 2013. We compared the ECG findings, especially of the P wave, in RCM patients between the cardiomyopathy group and healthy children group separately for each gender and the age. The ECGs in the healthy group were obtained from school heart screening in Japan of first-graders, and seventh-graders. Statistical significance was determined as p<0.001.

Results

Among 376 registered cardiomyopathy patients, 63 had hypertrophic cardiomyopathy (HCM) (36%), 91 (24%) dilated cardiomyopathy (DCM), 106 (28%) a left ventricular myocardial noncompaction (LVNCs), 25 (7%) restrictive cardiomyopathy (RCM), 14 (4%) arrhythmogenic right ventricular cardiomyopathy (ARVC), and 5 (1%) other cardiomyopathies. Of the 25 RCM patients (9.9±3.4 years old, F:M=11:14), 36% were discovered during school heart screening. The first onset was an abnormal ECG in 9, symptoms of heart failure in 6, respiratory tract infections in 3, syncope in 1, and 6 with other. Of those patients, 2 (8%) had a family history of RCM, 24 (92%) no family history. A genetic diagnosis was performed in 5 of the 25 cases, and 3 had genetic abnormalities related to RCM. The mean follow-up period was 65±95 months (mean±standard deviation). During follow up, 19 patients (76%) survived, 6 (24%) died, 7 (28%) had heart transplantations, and 3 (12%) were waiting for heart transplantations with a left ventricular assist device.

The P wave was bimodal in lead I or biphasic in lead V1 in 15 patients (93%), and 13 (81%) patients had both variations. We evaluated the duration and amplitude of the first and second component of the P wave as P1 and P2. The number of control and RCM patients (control/RCM), duration of P1+P2, and sum total absolute value of the amplitude of P1+P2 in lead V1 were 8350/5, 90±9/116±10ms, and 72±28/528±278μV in first grade boys, 8423/3, 91±10/120±22ms, and 66±28/326±229μV in first grade girls, 8943/1, 97±1/100ms, and 71±31/328μV in seventh grade boys, and 9183/5, 98±11/112±10ms, and 55±27/315±56μV in seventh grade girls. Although the number of patients in the RCM group was small, sum total absolute value of the amplitude of P1+P2 in lead V1 showed a significant difference in any group.

Conclusion

The ECG in children with RCM exhibits P wave abnormalities in almost all patients. In particular, not the P wave interval but P wave shape in I and V1 and the sum total absolute value of the amplitude of P1+P2 in lead V1 were observed differences.

Alkali Attack on Anion Exchange Membranes with PVC Backing and Binder: II Prediction of Electrical and Mechanical Performances from Simple Optical Analyses

Performance of anion exchange membranes (AEMs), including polyvinyl chloride (PVC) as backing and binder, decreases during a repetitive cleaning-in-place (CIP) treatment using alkali. In this study, we have systematically performed two optical analyses, relative total visible (VIS) reflectance and handheld X-ray fluorescence (XRF), for alkali-attacked commercially available AEM (Neosepta^® AMX, Tokyo, Japan) with different NaOH immersion conditions (0–1.0 M NaOH at 40–80 °C for 0–168 h). The VIS reflectance and XRF data were then compared with the electrical and mechanical performances (i.e., membrane resistance, proton rejection, amount of fixed-charge sites, and Young’s modulus) of the alkali-attacked AMXs. The result indicated that there are clear linear relationships between their performances and both VIS reflectance and XRF data especially at 40 °C, indicating both optical analyses have a good possibility as a quick diagnosis-in-place (DIP) to predict the resulting performance of the alkali-attacked AMXs. In addition, we also found a clear linear relationship between VIS reflectance and XRF data, so that polyene formations through dehydrochlorination of PVC during alkali attack is one of dominant mechanisms for the performance reduction of the alkali-attacked AMX at 40 °C. These results are promising to be useful for the analysis of ion exchange membranes (IEMs) used in real commercial processes on-site in future.

Long-term clinical impact of serum albumin in coronary artery disease patients with preserved renal function

BACKGROUND AND AIMS

Low serum albumin level is reportedly associated with worse clinical outcomes in patients with chronic kidney disease (CKD). However, associations between decreased serum albumin level and outcomes in non-CKD patients with coronary artery disease (CAD) remain unclear. Therefore, we aimed to evaluate the prognostic value of serum albumin concentrations in stable CAD patients with preserved renal function.

METHODS AND RESULTS

We studied 1316 patients with CAD and preserved renal function (estimated glomerular filtration rate ≥60 mL/min/1.73 m²) who underwent their first PCI between 2000 and 2011 and had data available for pre-procedural serum albumin. Patients were assigned to quartiles based on pre-procedural albumin concentrations. The incidence of major adverse cardiac events (MACE), including all-cause death and non-fatal myocardial infarction, was evaluated. Mean albumin concentration was 4.1 ± 0.4 g/dL. During the median follow-up of 7.5 years, 181 events occurred (13.8%). Kaplan-Meier curves revealed that patients with decreased serum albumin concentrations showed a higher event rate for MACE (log-rank, p < 0.0001). Using the highest tertiles (>4.3 g/dL) as reference, adjusted hazard ratios were 1.97 (95% CI, 1.12-3.55), 1.77 (95% CI, 0.99-3.25), and 1.19 (95% CI, 0.68-2.15) for serum albumin concentrations of <3.9, 3.9-4.0, and 4.1-4.3 g/dL, respectively. Decreased serum albumin concentration was associated with MACE even after adjusting for other independent variables (HR, 2.21 per 1-g/dL decrease; 95% CI, 1.37-3.56, p = 0.001).

CONCLUSION

Decreased serum albumin concentration independently predicted worse long-term prognosis in non-CKD patients after PCI. Pre-procedural serum albumin concentration could offer a useful predictor for patients with CAD and preserved renal function.

Bonhoeffer-van der Pol Oscillator Model of the Sino-Atrial Node: A Possible Mechanism of Heart Rate Regulation

A Bonhoeffer-van der Pol equation with a stable limit cycle is proposed as a model of the pacemaker in the sino-atrial node to exptain heart rate regulation. Standard tools, such as the phase transition curve in nonlinear dynamic system theory, are used to analyze the model and results are compared with other studies on experiments with dogs.

Relationships Among Valued Action, Behavioral Activation, Avoidance, and Reinforcement in a Sample of College Students

Behavioral activation is a validated intervention for depression, which helps depressed people re-engage overt behaviors to facilitate contacts with reinforcing environmental contingencies and subsequent reductions in depression. Moreover, behavioral activation deals with values that are based on acceptance and commitment therapy. However, there is no empirical study that examines the role of behavior in line with values in behavioral activation. This study examined the role of behavior in line with values in behavioral activation by examining the association between behavior in line with values and variables of behavioral activation intervention targets, as well as the mediating effect of behavioral commitment. Japanese versions of the Personal Values Questionnaire II, the Behavioral Activation for Depression Scale, the Environmental Reward Observation Scale, and the Center for Epidemiological Studies Depression were completed by 292 Japanese undergraduate students ( M age = 19.2 yr., SD = 1.7; 65 men, 226 women, 1 unknown). Results indicated that behavior in line with values was associated with focused, goal-directed activation and completion of scheduled activities, which were mediated by behavioral commitment to values.

Varied clinical course of aplastic crisis in hereditary spherocytosis

This study is the first to report a familial case involving differing clinical courses of aplastic crisis triggered by parvovirus B19 in two patients with HS, although similar eosin-5-maleimide-binding test and sodium dodecylsulfate-polyacrylamide gel electrophoresis results had been obtained for both. One patient had short-term mild symptoms, whereas the other patient developed severe anemia that required blood transfusion, experienced fever for 13 days, and did not have any rash. The severity of aplastic crisis is reported to be correlated with the severity of the underlying hemolytic anemia; the present findings show that the severity of infection should also be considered as an important predictive factor of the severity of aplastic crisis.

Endoscopic ultrasound-guided celiac ganglia neurolysis vs. celiac plexus neurolysis: a randomized multicenter trial

BACKGROUND AND STUDY AIMS

No prospective comparison of endoscopic ultrasonography-guided direct celiac ganglia neurolysis (EUS - CGN) vs. EUS-guided celiac plexus neurolysis (EUS - CPN) has been reported. The aim of the current study was to compare the effectiveness of EUS - CGN and EUS - CPN in providing pain relief from upper abdominal cancer pain in a multicenter randomized controlled trial.

PATIENTS AND METHODS

Patients with upper abdominal cancer pain were randomly assigned to treatment using either EUS - CGN or EUS - CPN. Evaluation was performed at Day 7 postoperatively using a pain scale of 0 to 10. Patients for whom pain decreased to ≤ 3 were considered to have a positive response, and those experiencing a decrease in pain to ≤ 1 were considered to be completely responsive. Comparison between the two groups was performed using intention-to-treat analysis. The primary endpoint was the difference in treatment response rates between EUS - CGN and EUS - CPN at postoperative Day 7. Secondary endpoints included differences in complete response rates, pain scores, duration of pain relief, and incidence of adverse effects.

RESULTS

A total of 34 patients were assigned to each group. Visualization of ganglia was possible in 30 cases (88 %) in the EUS - CGN group. The positive response rate was significantly higher in the EUS - CGN group (73.5 %) than in the EUS - CPN group (45.5 %; P = 0.026). The complete response rate was also significantly higher in the EUS - CGN group (50.0 %) than in the EUS - CPN group (18.2 %; P = 0.010). There was no difference in adverse events or duration of pain relief between the two groups.

CONCLUSIONS

EUS - CGN is significantly superior to conventional EUS - CPN in cancer pain relief.

CLINICAL TRIAL REGISTRATION

http://www.umin.ac.jp/ctr/index.htm (ID: UMIN-000002536).

Preoperative routine evaluation of bilateral adrenal glands by endoscopic ultrasound and fine-needle aspiration in patients with potentially resectable lung cancer

BACKGROUND AND STUDY AIMS

The aim of the current study was to assess the detection rate of the right adrenal gland and the diagnostic ability of endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) for the diagnosis of adrenal metastasis in potentially resectable lung cancer.

PATIENTS AND METHODS

This retrospective cohort study included a consecutive series of 150 patients undergoing EUS/EUS - FNA for staging of lung cancer. The detection rate of the right adrenal gland by EUS and the diagnostic accuracies of computed tomography (CT), positron emission tomography-CT (PET-CT), and EUS/EUS - FNA for the diagnosis of adrenal metastasis were evaluated.

RESULTS

The right adrenal gland was visualized by EUS in 131 patients (87.3 %); the left adrenal gland was visualized in all patients. Findings suggestive of metastasis in either one of the adrenal glands or in both were observed in 6 patients (4.0 %) by CT, in 5 patients (3.3 %) by PET-CT, and in 11 patients (7.3 %) by EUS. EUS - FNA was performed simultaneously in the 11 patients, and in 4 patients the diagnosis of metastasis was established. The accuracy for the diagnosis of adrenal metastasis was 100 % for EUS/EUS - FNA, 96.0 % for CT, and 97.0 % for PET-CT (P = 0.1146).

CONCLUSIONS

As well as the left adrenal gland, the right adrenal gland was also usually visible by EUS. EUS/EUS - FNA provided an accurate diagnosis of adrenal metastasis, although the prevalence of adrenal metastasis was relatively low in these patients with potentially resectable lung cancer.

Impact of screening with thyroid ultrasonography in myasthenia gravis patients

OBJECTIVES

This study was conducted to screen thyroid abnormality evaluated with ultrasonography (US) in patients with myasthenia gravis (MG) and investigate further when malignancy is suspected.

METHODS

Thyroid screening using US was conducted in 162 patients with MG. In cases where malignancy was suspected, further investigations were performed.

RESULTS

Abnormal US findings were detected in 125 of 162 patients with MG (72 patients with nodules, 74 patients with cysts, 27 patients with diffuse findings such as enlargement, atrophy, a hypoechoic pattern or a heterogenous echoic pattern, and 28 patients with calcification). From among these 125 subjects, 30 patients underwent further examinations such as needle aspiration cytology. As a result, six patients (3.7% of 162 cases) were positive for papillary carcinoma. The size of the carcinoma in three patients was <10 mm, yet the stage of thyroid carcinomas was high (stage III or IVa) in all six cases.

CONCLUSIONS

Our data suggest that the prevalence of thyroid carcinoma in cases of MG may be higher than that of the general population. Furthermore, in patients with MG, there is a possibility that the stage of the carcinoma is higher even when the carcinoma is of a very small size. Patients with MG, when diagnosed, should be advised to undergo US screening of the thyroid because most cases of thyroid carcinoma are highly curable.

Combined endobronchial and endoscopic ultrasound-guided fine needle aspiration for mediastinal nodal staging of lung cancer

BACKGROUND

Recently, transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has been evaluated for mediastinal nodal staging (N staging) of lung cancer, as this technique is less invasive than mediastinoscopy and possibly more accurate than 18F-fluorodeoxyglucose positron emission tomography with computed tomography (PET-CT). However, EUS-FNA does not provide access to pretracheal and hilar lymph nodes. More recently, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been introduced as a novel technique for accessing pretracheal and hilar lymph nodes. Although the combined endoscopic approach of EUS-FNA and EBUS-TBNA is presumably more accurate than PET-CT, only a few reports have quantitatively evaluated its diagnostic ability. Therefore, we prospectively assessed the diagnostic yield of this combined endoscopic approach for mediastinal N staging of lung cancer.

METHODS

A consecutive series of 120 patients with suspected resectable lung cancer on CT findings underwent PET-CT and combined EUS-FNA/EBUS-TBNA. The accuracy and other diagnostic indices of the combined approach in mediastinal N staging were compared with those of PET-CT.

RESULTS

Among the enrolled patients, a final pathological N stage was established in 110 patients. The accuracy of the combined approach using EUS-FNA and EBUS-TBNA was significantly higher than that of PET-CT (90.0 % vs. 73.6 %; P < 0.0001). The sensitivity, specificity, and positive and negative predictive values were respectively 71.8 %, 100 %, 100 %, and 86.6 % for the combined approach vs. 47.4 %, 87.5 %, 66.7 %, and 75.9 % for PET-CT.

CONCLUSIONS

The combined endoscopic approach using EUS-FNA and EBUS-TBNA provided excellent diagnostic performance. Therefore, this approach is strongly recommended before surgery or mediastinoscopy to avoid futile thoracotomy and surgical intervention.

Carbon dioxide insufflation vs. conventional saline irrigation for peroral video cholangioscopy

BACKGROUND AND STUDY AIMS

Recent studies have evaluated the efficacy of peroral cholangioscopy (POCS) for diagnosis of biliary diseases. In order to obtain clear images with POCS, saline irrigation, which is performed to replace yellow bile, is carried out for an extended duration. The aim of this study was to evaluate the feasibility of replacing saline irrigation with CO₂ insufflation during POCS.

PATIENTS AND METHODS

A total of 36 patients who had bile duct lesions and were due to undergo POCS were enrolled in the study. Of these patients, 18 underwent POCS using saline irrigation followed by CO₂ insufflation, and 18 patients underwent the reverse approach. The two methods were compared with regard to the time required to obtain a clear endoscopic image and the quality of the images.

RESULTS

The median time required to obtain a clear endoscopic image using CO₂ insufflation (5.0 min) was significantly shorter than that required for saline irrigation (22.5 min; P < 0.001). The quality of the endoscopic images obtained was similar in 27 cases. However, CO₂ insufflation provided better images in four cases that showed an abundance of mucin or biliary sludge, and saline irrigation was superior to CO₂ insufflation in five cases that showed severe stricture with bleeding and tall papillary lesions.

CONCLUSIONS

CO₂ insufflation during POCS can reduce procedure time and simplify cholangioscopy. The overall image quality was similar to that obtained with conventional saline irrigation.

Endoscopic hemostasis using covered metallic stent placement for uncontrolled post-endoscopic sphincterotomy bleeding

Severe bleeding following endoscopic biliary sphincterotomy (EBS) can sometimes be difficult to manage, resulting in the need for an invasive intervention. The aim of this study was to retrospectively evaluate the feasibility and efficacy of endoscopic hemostasis using covered self-expandable metallic stents (SEMSs) for severe post- EBS bleeding. Eleven patients with bile duct stones underwent standard EBS using a standard sphincterotome-based technique at 4 endoscopic units of a university-affiliated hospital and a general hospital. Monotherapy or combined therapy were used to achieve hemostasis with either balloon tamponade, hypertonic saline epinephrine injection, or endoclip placement. When active bleeding could not be controlled, covered SEMSs were placed across the major papilla. Emergency endoscopy was performed on the day of admission or the subsequent day (ranging from 6 to 35 h after admission). Bleeding was classified as mild in 6 cases (54.5 %) and moderate in 5 (45.5 %). A covered SEMS 10mm in diameter and 6 cm long was placed across the papilla. After placement, complete hemostasis was achieved. The mean duration of stent placement was 8.2 days (range 5–10 days), and the SEMS was successfully removed in all cases. Although the present study has the limitations of a small sample size and lack of control patients, covered SEMS placement for endoscopic hemostasis may be useful in selected patients with uncontrolled post-EBS bleeding.