Prognostic significance of low hepatic fat content in advanced chronic liver disease: MRI-PDFF insights

INTRODUCTION AND OBJECTIVES

The mechanisms of hepatic fat loss in late-stage metabolic dysfunction-associated fatty liver disease (MASLD) are enigmatic and the prognostic significance of low hepatic fat content (LHF) in chronic liver disease (CLD) is unknown. Proton density fat fraction (PDFF), measured by magnetic resonance imaging (MRI), is considered the most accurate noninvasive method for quantifying hepatic fat content. This study aimed to address these issues by evaluating PDFF.

PATIENTS AND METHODS

This is a single-center, retrospective study involving 762 patients with CLD, measuring liver stiffness (LS) using MR elastography and PDFF using MRI. LHF was defined as a PDFF ≤ 2.7 % and hepatic reserve function was assessed using the albumin-bilirubin (ALBI) score. Multivariate analysis explored associations between variables.

RESULTS

LHF was 27 % in the entire cohort, and PDFF was significantly decreased with LS ≥ 5.5 kPa (p < 0.05). On the multivariate analysis, low body mass index and ALBI score were independently associated with LHF (p < 0.05). In advanced CLD (n = 288), ALBI score and PDFF showed a significant negative correlation regardless of etiology (MASLD/non-MASLD: r= -0.613/-0.233), and the prevalence of LHF increased with progression of ALBI grade (p < 0.01 each). In addition, lower PDFF was associated with increased liver-related and all-cause mortality (p < 0.01), and Cox proportional hazards models extracted LHF as an independent prognostic factor, along with ALBI score and hepatocellular carcinoma (p < 0.05 each).

CONCLUSIONS

In ACLD, hepatic reserve dysfunction contributed to hepatic fat loss independent of nutritional status, suggesting that LHF may be a poor prognostic factor in all etiologies.

Evaluation of the effects of pemafibrate on metabolic dysfunction-associated steatotic liver disease with hypertriglyceridemia using magnetic resonance elastography combined with fibrosis-4 index and the magnetic resonance imaging-aspartate aminotransferase score

Background and Aim

In this retrospective study, we evaluated the effects of pemafibrate treatment in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) and hypertriglyceridemia using non-invasive stiffness-based models, including magnetic resonance elastography (MRE) combined with the fibrosis-4 (FIB-4) (MEFIB) index and the magnetic resonance imaging (MRI)-aspartate aminotransferase (AST) (MAST) score.

Methods

In total, 179 patients with MASLD treated with pemafibrate were enrolled. We evaluated the effects of 48-week pemafibrate treatment using the MEFIB index, which classifies patients based on the combination of liver stiffness measurement (LSM) on MRE and FIB-4 and the MAST score, which is calculated based on LSM on MRE, MRI-proton density fat fraction (MRI-PDFF), and AST levels.

Results

Pemafibrate treatment led to significant reduction in AST, alanine aminotransferase (ALT), and gamma-glutamyl transferase (GGT) (P = 0.011, <0.001, and <0.001, respectively) and significant improvements in triglyceride and high-density lipoprotein cholesterol levels (P < 0.001 and <0.001, respectively). The MRI-PDFF values were not significantly altered. However, a significant decrease in LSM on MRE was detected (P = 0.003). Evaluation of fibrosis using the MEFIB index and MAST score demonstrated significant improvement (P = 0.004 and <0.001, respectively). Changes in the MAST score showed positive correlation with changes in ALT and GGT levels (r = 0.821, P < 0.001, and r = 0.808, P < 0.001, respectively). Additionally, ALT and GGT levels at baseline were significantly associated with improvements in the MAST score (P < 0.001 and <0.001, respectively).

Conclusion

Pemafibrate led to improvements in the MEFIB index and MAST score, as well as liver function. It is a promising therapeutic agent for patients with MASLD and hypertriglyceridemia with the potential to reduce liver-related events.

Liver Disease-Related Sarcopenia: A Predictor of Poor Prognosis by Accelerating Hepatic Decompensation in Advanced Chronic Liver Disease

Background Sarcopenia is considered a prognostic factor for advanced chronic liver disease (ACLD) independent of liver function, but the underlying mechanisms are unknown. Here, we investigated whether sarcopenia contributed to hepatic decompensation and worsened prognosis. Methods This was a single-center retrospective study of 708 patients with chronic liver disease who underwent magnetic resonance elastography (MRE). Magnetic resonance imaging (MRI) was used to diagnose sarcopenia and hepatic decompensation (presence of ascites). Results The incidence of sarcopenia (29% overall) and age were significantly correlated to increased liver stiffness (LS) (p < 0.01 each), but age did not differ for LS ≥ 4 kPa. Rates of thrombocytopenia and varices increased at ≥4 kPa, and ascites (n = 52) accounted for 81% of patients with ≥6 kPa LS. Age, alcoholic liver disease, C-reactive protein, sodium level, and controlling nutritional status score were extracted as factors contributing to sarcopenia (all p < 0.05). In ACLD, sarcopenia was an independent predictor of ascites (p < 0.01), and in a follow-up analysis of 163 patients without ascites at baseline, the incidence of ascites in patients with sarcopenia was significantly higher, even after adjusting for LS and liver severity (p < 0.01). The Cox proportional hazards model indicated albumin-bilirubin score and sarcopenia as independent prognostic factors (p < 0.01 each). Conclusions In ACLD, both portal hypertension and liver disease-related sarcopenia were found to occur at ≥4 kPa. Sarcopenia was accompanied by mildly decreased sodium levels and contributed to the early development of ascites and poor prognosis, independent of liver function.

Communicating the External Beam Radiotherapy Experience (CEBRE) Discussion Guides: Real World Implementation and Evaluation

PURPOSE/OBJECTIVE(S)

Communicating about the radiotherapy treatment process can be difficult for patients and healthcare professionals. The "Communicating the External Beam Radiotherapy Experience" (CEBRE) and Communicating the Gynecologic Brachytherapy Experience (CoGBE) discussion guides use graphic narrative to explain external beam radiotherapy and gynecologic high-dose rate brachytherapy, respectively. The CEBRE, CoGBE, and CEBRE en Español guides have been available for free download since 10/2018, 6/2020, and 8/2021, respectively. This study aims to characterize how the guides are being implemented and used in practice.

MATERIALS/METHODS

Global downloads of the CEBRE, CoGBE, and CEBRE en Español guides were analyzed. Email addresses submitted at the time of download were used to contact study subjects. Duplicate emails, fake addresses, and expired emails were removed resulting in 500 individuals being invited to participate in the survey. A data collection web application survey was distributed on 1/27/23. Two reminders were sent prior to the survey closing on 2/13/23. The survey addressed how physicians or other radiotherapy team members use the CEBRE guides, where they are used, and how the guides can be improved. Likert-type data (1 = strongly disagree, 5 = strongly agree) are reported as median [interquartile range].

RESULTS

As of 10/16/22, the CEBRE guides (English) had been downloaded 602 times, CoGBE 86 times, and CEBRE en Español 63 times. 42/500 individuals responded to the survey for an 8% response rate. 40/42 (95%) of participants were healthcare providers with 35/40 (87.5%) radiation oncologists. 16/40 (40%) have used the CEBRE guides in some way. 6/16 (37.5%) "always use," 2/16 (12.5%) "often use," and 3/16 (18.8%) "sometimes use" the guides during consultation. 8/16 (50%) report using the guides for education of medical students, residents, and fellows. The 16 respondents that use the guides felt the guides were useful overall (5[5-5]), felt "very confident" using the guides (4.5[4-5]), and felt the guides "help patients prepare for their treatment" (5[4-5]). 40 respondents provided suggestions on additional language translations with 19/40 (48%) recommending translation into Mandarin, 6/40 (15%) into Cantonese, Portuguese, French and Arabic, and 5/40 (12.5%) into Haitian, Hindi, and Vietnamese.

CONCLUSION

The majority of respondents did not use the CEBRE guides which may be due to difficulty with implementation. However, respondents who use the guides are confident using them and rate them as useful for patients. These data, although limited by the low response rate, suggest that the CEBRE guides have accomplished the goal of facilitating patient-physician conversations. Moreover, there is an interest in translating the guides into additional languages other than Spanish. Due to the low response rate, definitive conclusions cannot be made from these data. Therefore, further research such as interviews and focus groups may be beneficial.

Mildly Low Serum Sodium Levels in Chronic Liver Disease: At Risk for Sarcopenia and Portal Hypertension

OBJECTIVE

Hyponatremia and sarcopenia in advanced chronic liver disease (ACLD) are both associated with portal hypertension (PHT) and worse prognosis. This study investigated their interrelationship.

METHODS

This retrospective study analyzed 751 patients with CLD who underwent magnetic resonance elastography (MRE) at Nippon Kokan Hospital (Kawasaki, Japan). Patients were classified and studied in five groups based on serum sodium (Na) levels: <135, 135-136, 137-138, 139-140, and >140 mEq/L. PHT was assessed by thrombocytopenia, varices, and ascites, and magnetic resonance imaging (MRI) data were used to diagnose sarcopenia.

RESULTS

The proportions of the five groups were 3/4/13/32/48 (%), and the mean liver stiffness (LS) was 6.6/5.7/4.2/3.2/3.2 (kPa), with significant progressive increases at Na < 139 (p< 0.01). The incidence of all PHT events and sarcopenia also increased at <139 (each p < 0.01). By contrast, the LS thresholds for predicting thrombocytopenia, varices, and ascites increased from 3.5 to 4.7 and 5.1, respectively, and were the same at 3.4 for low Na (<139) and sarcopenia (all p < 0.01). Multivariate analysis of factors associated with low Na identified LS and sarcopenia as independent factors (p < 0.05 both). In the Cox proportional hazards model, low Na was a significant prognostic factor in ACLD (hazard ratio (HR) 5.33, p < 0.01); however, the albumin-bilirubin (ALBI) score (HR 2.49) and sarcopenia (HR 4.03) were extracted in the multivariate analysis (p < 0.05 both).

CONCLUSIONS

Studies using MRE imaging showed that low Na levels in CLD are associated with worse prognosis, not only due to elevated LS (i.e., PHT) but also the strong association with sarcopenia.

Risk factors for persistent positive anticardiolipin antibodies in women with recurrent pregnancy loss

Antiphospholipid syndrome (APS) is an established cause of recurrent pregnancy loss (RPL). It is necessary to detect persistently positive antiphospholipid antibodies to diagnose APS. This study aimed to explore risk factors for persistent anticardiolipin (aCL) positivity. Women with a history of RPL or with a history of one or more intrauterine fetal deaths after 10 weeks underwent examinations to determine the causes of RPL, including antiphospholipid antibodies. If aCL-IgG or aCL-IgM antibodies were positive, retests were performed at least 12 weeks apart. Risk factors for persistent aCL antibody positivity were retrospectively investigated. The number and percentage of cases above the 99th percentile were 74/2399 (3.1%) for aCL-IgG, and 81/2399 (3.5%) for aCL-IgM. Of the initially tested cases, 2.3% (56/2399) for aCL-IgG and 2.0% (46/2289) for aCL-IgM were ultimately positive above the 99th percentile in retests. Retest values after 12 weeks were significantly lower than the initial values for both IgG and IgM immunoglobulin classes. Initial aCL antibody titers were significantly higher in the persistent-positive group than in the transient-positive group for both IgG and IgM immunoglobulin classes. The cut-off values for predicting persistent positivity of aCL-IgG antibodies and aCL-IgM antibodies were 15 U/mL (99.1 percentile) and 11 U/mL (99.2 percentile), respectively. The only risk factor for persistently positive aCL antibodies is a high antibody titer during the initial test. When the aCL antibody titer in the initial test exceeds the cut-off value, therapeutic strategies can be defined in subsequent pregnancies without waiting for 12 weeks.

Perme ICU Mobility Score as a comprehensive assessment tool of acute-phase rehabilitation is correlated with clinical outcomes in patients after cardiovascular surgery

Background

Early mobility therapy in the intensive care unit (ICU) is widely employed to improve the physical function and prognosis of patients with critically ill. On the other hand, patients who undergo cardiovascular surgery frequently suffer from disabilities after ICU care due to their cardiopulmonary conditions and treatments. However, few studies have reported the procedures and assessments of acute-phase rehabilitation in these patients. Recently, the Perme ICU Mobility Score (Perme Score) was developed as a reliable tool to assess comprehensive mobility status of patients in the ICU. We hypothesised that the Perme Score is a useful tool for assessing the mobility levels in the ICU and predicting clinical outcomes in patients undergoing acute-phase rehabilitation after cardiovascular surgery.

Purpose

To investigate the associations between the Perme Score within the second days after cardiovascular surgery and the patients' clinical outcomes, including physical function and the incidence of clinical events.

Methods

We studied 224 consecutive patients (34.4% female; aged 65±13 years) who were admitted to the ICU of a tertiary academic hospital after cardiac and/or major vascular surgery. Clinical characteristics including patient profiles, comorbidities, surgical details and APACHE II and SOFA scores were evaluated on ICU admission. The Perme Score contains categories on mental status, potential mobility barriers, muscle strength and mobility level, with higher scores indicating greater activity levels in the ICU. We assessed the Perme Score within the second days after the surgery. As a physical function at hospital discharge, we measured the six-minute walk distance (6MWD). The primary endpoint was a composite outcome of the number of all-cause mortality and/or all-cause unplanned readmission. We analysed the associations of the Perme Score with the 6MWD and the incidence of clinical events using multiple regression analysis and multivariate Poisson regression analysis, respectively.

Results

After adjusting for clinical confounding factors, a higher Perme Score was an independent factor of a higher 6MWD (Table 1). During the median follow-up period of 1.3 years, 51 cases of all-cause mortality/readmission occurred in 37 (16.5%) patients, with an incidence rate of 18.6/100 person-years. In the multivariate Poisson regression analysis, even after adjusting for the severity score in the ICU, a higher Perme Score was significantly and independently associated with lower rates of all-cause clinical events (adjusted incident rate ratio: 0.96, 95% confidence interval: 0.93–0.99, P=0.008, Figure 1).

Conclusions

The Perme Score within the second days after cardiovascular surgery is correlated with physical function at hospital discharge and the incidence of clinical events after discharge. Thus, a comprehensive assessment of acute-phase rehabilitation after cardiovascular surgery may be useful in predicting clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.

Cancer as a risk factor for physical dysfunction and poor prognosis in patients with cardiovascular disease

Introduction

The emerging interdisciplinary field of cardio-oncology is of interest to clinicians because a history of cancer or cancer treatment is considered a severe risk factor for cardiovascular disease (CVD). Both cancer and CVD can reduce skeletal muscle mass; together, they can lead to a poorer prognosis. However, it is unclear whether a patient's cancer history can lower physical function and lead to a poor prognosis with the coexistence of cancer history and physical dysfunction in patients with CVD. This study aimed to identify the relationship between cancer history and physical function, as well as the prognostic value of their combination, in patients with CVD.

Methods

We reviewed 3,640 patients with CVD (mean age, 67.9±13.5 years) who underwent physical-function tests (gait speed and 6-min walking distance [6MWD]). We performed multivariate linear regression analysis to assess potential associations between cancer history and physical-function tests in patients with CVD. Additionally, we used the Kaplan–Meier curve and Cox regression analyses to assess survival and prognostic significance for patients divided into four groups according to the presence or absence of cancer history and high or low physical function.

Results

In multivariate linear regression analysis, cancer history was independently associated with lower gait speed and 6MWD (gait speed, P=0.048 and 6MWD, P=0.040). A total of 581 deaths occurred over a median follow-up period of 3.08 years (interquartile range: 1.36–5.27). For all-cause mortality, patients with a history of cancer and reduced physical function were found to have a significantly higher mortality risk even after adjusting for several covariates (gait speed, HR: 1.66, P=0.003 and 6MWD, HR: 1.71, P=0.003).

Conclusion

Cancer history was correlated with physical dysfunction in patients with CVD. Moreover, the coexistence of cancer history and physical dysfunction resulted in poorer prognosis in patients with CVD.

Funding Acknowledgement

Type of funding sources: None.

Impact of small-airway disease on exercise intolerance and long-term outcomes in patients with heart failure and reduced or preserved ejection fraction

Introduction

Exercise intolerance in patients with heart failure (HF) is a strong indicator of a poor prognosis. As the respiratory impairment in HF patients, the small airway is reportedly more susceptible than central airways, which results in increased airway resistance and may cause poor outcomes. However, the impact of small-airway disease (SAD) on exercise intolerance and prognosis in patients with HF is still unclear.

Purpose

We investigated the associations between SAD and exercise intolerance in patients with HF, and the clinical significance of SAD for long-term clinical events with a reduced or preserved ejection fraction.

Methods

We reviewed 1015 patients with HF (mean age, 66.9±14.6 years; male, 64.5%) admitted for medical treatment. Patients with a prior history of chronic respiratory disease or an obstructive lung pattern – defined as the forced expiratory volume (%) in 1 s relative to &lt;70% forced vital capacity using spirometry – were excluded. Characteristics including HF aetiology, comorbidities conditions, medications, blood parameters, and echocardiographic variables were obtained from clinical records. All patients underwent spirometry at hospital discharge, and SAD was defined as the maximum mid-expiratory flow (%) relative to a &lt;60% predicted value. At hospital discharge, we measured 6-min walk distance (6MWD), and &lt;300 m was considered as exercise intolerance. The primary endpoint was a composite clinical event of all-cause death and/or unplanned readmission for HF. Multivariate logistic regression analysis was used to assess the association between SAD and exercise intolerance. The multivariate Cox proportional hazard model was used to clarify whether SAD was an independent predictor for the incidence of clinical events. We also performed subgroup analyses in each multivariate analysis based on a left ventricular ejection fraction (LVEF) of 40%.

Result

SAD was observed in 479 (47.2%) patients. LVEF subgroups included 458 (45.1%) and 518 (51.0%) patients with LVEF &lt;40% and ≥40%, respectively. After adjusting for clinical characteristics, SAD was independently associated with 6MWD &lt;300 m (Figure 1). Moreover, this association was consistently observed in the LVEF &lt;40% and ≥40% (Figure 1). During the median follow-up period of 1.5 years, all-cause death/readmission occurred in 431 patients (42.5%), and the incidence rate was 17.5/100 person-years. In the multivariate Cox proportional hazard model, SAD was independently associated with lower event-free survival rates in all patients and the LVEF &lt;40% subgroup, but not LVEF ≥40% subgroup (Figure 2A, B, and C, respectively).

Conclusion

This study is the first to reveal that SAD is associated with exercise intolerance in patients with HF regardless of LVEF. Moreover, SAD may have a predictive significance for long-term outcomes in patients with HF and subgroups with reduced, but not preserved ejection fraction.

Funding Acknowledgement

Type of funding sources: None.

O-015 Results of urological consultation in the setting of IVF clinic

Study question

In the management of male infertility, we investigated whether urological consultation could improve the live birth rate, and who should visit urologists in the setting of IVF clinic.

Summary answer

Urologic consultation resulted in improvement of semen quality and live birth rate with more IVF use in those with adverse semen parameters.

What is known already

Male factor infertility exists in about a half of infertility couples. This accounts for about 8% in male reproductive age. Therefore, ideally every male partner of infertility couples attempting conception should have a urological evaluation. However, it is not very easy to access urologists who specialized in reproductive medicine in Japan because we have very few of such urologists. One the other hand, a certain number of couples are wasting their time during IVF failure without urological evaluation.

Study design, size, duration

This is a single-institution retrospective study. We enrolled male partners of infertility couples who visited Kameda IVF clinic Makuhari, Chiba, Japan, between May 2016 and December 2020 and followed at least one year. Live birth rate and the frequency of IVF use were investigated according to semen quality and urological consultation status. Chi-square tests and T tests were used to compare the results between groups.

Participants/materials, setting, methods

Among 2225 couples who visited Kameda IVF clinic Makuhari, 803 male partners (Group A, 36.0%) were evaluated by urologists who were specialized in male reproductive medicine. Remaining 1422 patients did not (Group B, 64.0%). Lifestyle evaluation, physical examination, semen analyses, scrotal ultrasonography, blood test including sexual hormones and zinc concentration were performed in Group A. Semen analyses and lifestyle evaluation were performed in Group B. Urological treatments were done according to factors of male infertility.

Main results and the role of chance

Semen quality was worse in Group A as compared to Group B (sperm motility, 28.5±16.9% vs. 46.0±17.0%; total sperm count, 105±108 million/mL vs. 176±155; total motile sperm count, 34±49 vs.87±98; mean±S.D.; p = 0.0001, 0.0001, 0.0001, A vs. B, respectively). After urologic consultation and managements, sperm motility was improved to 34±18% (p = 0.001). Live birth rate in groups A and B were similar (56.0% vs. 57.2%), however couples who obtained a child in Group A used IVF more often than those in Group B (70% vs. 49.9%, p &lt; 0.001). Among those with adverse semen quality (total motile sperm count less than 15.6 million/mL, n = 472), 350 visited urologists (Group 1, 74.2%) and remaining 122 did not (Group 2, 25.8%). Live birth rate in Group 1 was significantly better than in Group 2 (65.3% vs. 54.1%, p = 0.0359). Use of IVF was significantly more frequent in Group 1 than Group 2 (79.3% vs. 63.6%, p = 0.0359) among who obtained a child. In those with better semen quality (motile sperm count &gt;50 million, n = 900), 119 visited urologist (31.1%, Group 3) and 781 did not (Group 4). Live birth rate and the use of IVF were not different between Groups 3 and 4 (51.1% vs.60.9%; 50.4% vs. 62.9%).

Limitations, reasons for caution

This study is a single-institution, retrospective study in the setting of IVF clinic. There may be a selection bias since men first visit gynecologists. These could affect the study results.

Wider implications of the findings

In the setting of IVF clinic, urologic consultation resulted in improved semen quality and better live birth rate with the use of IVF, especially in those who have adverse semen parameters. The results of this study encourage patients to see urologists and physicians to introduce urologist to patients.

Trial registration number

not applicable

POS0728 ASSOCIATION BETWEEN TREATMENT GOAL ACHIEVEMENT AND GRIT PERSONALITY CHARACTERISTICS OF ATTENDING PHYSICIAN IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: A MULTICENTER CROSS-SECTIONAL STUDY

Background

In clinical practice for systemic lupus erythematosus (SLE), the concept of “treat to target” has been introduced with an established goal of reducing glucocorticoid dose as much as possible while controlling disease activity. Although it has been shown that various personality characteristics of patients with SLE affect their disease activity and damage, it is not clear whether the personality characteristics of attending physicians affect the outcomes of patients with SLE. Grit is a personality trait characterized by perseverance and passion for achieving long-term goals.

Objectives

This study aims to evaluate the relationship between attending physicians’ grit personality characteristics and treatment goal achievements in patients with SLE.

Methods

A cross-sectional study was conducted on 386 patients with SLE in five referral hospitals in Japan. The main exposure was the “perseverance” and “consistency” (scores 1-5) of the attending physicians, as measured by the Short Grit Scale, and the primary outcome was the achievement of the Lupus Low Disease Activity Score (LLDAS). Considering the clustering of achievement of LLDAS by each attending physician, the association between attending physician’s personality and LLDAS was analyzed by logistic regression with cluster robust variance estimation. Odds ratios to assess the relationship between perseverance and consistency and LLDAS were estimated with adjustment for confounders (age, sex, disease duration, hydroxychloroquine use, immunosuppressant use, and Systemic Lupus International Collaborating Clinics-Damage Index). We used multiple imputation to handle the uncertainty caused by missing values of potential confounders on the assumption of missing at random.

Results

The median age of the patients was 45 years (interquartile range[IQR],36-56), 88% were female, and the median disease duration was 152 months(IQR, 80-240). Thirty-seven doctors were in charge of the patients (1-79 patients/each doctor). The median age of the attending physicians was 40 years (IQR, 35-43), and 19% were female. The median perseverance and consistency scores of attending physicians were 3.1 (IQR, 3.0-3.5) and 3.3 (IQR, 2.8-3.8), respectively. Of the enrolled patients, 154 (40%) had achieved LLDAS. The attending physicians with a lower consistency score of <3 were more frequent in the patients who achieved LLDAS (40% vs. 29%, p=0.026). The lower consistency score of attending physicians was still related to LLDAS independently (adjusted odds ratio 1.63, 95% confidential interval 1.17-2.27). There was no association between the achievement of LLDAS and perseverance.

Conclusion

The grit personality characteristics of the attending physician may affect the achievement of treatment goals in patients with SLE.

Disclosure of Interests

KEN-EI SADA Speakers bureau: I received speaker’s fees from Glaxo Smith Kline K.K., Grant/research support from: I received a research grant from Pfizer Inc., Yoshia Miyawaki: None declared, Kenta Shidahara: None declared, Shoichi Nawachi: None declared, Yu Katayama: None declared, Yosuke ASANO: None declared, Keigo Hayashi: None declared, Keiji Ohashi: None declared, Eri Katsuyama: None declared, Takayuki Katsuyama: None declared, Mariko Narazaki: None declared, Yoshinori Matsumoto: None declared, Nao Oguro: None declared, Yuichi Ishikawa: None declared, Natsuki Sakurai: None declared, Chiharu Hidekawa: None declared, Ryusuke Yoshimi: None declared, Takanori Ichikawa: None declared, Dai Kishida: None declared, Yasuhiro Shimojima: None declared, Noriaki Kurita: None declared, Nobuyuki Yajima: None declared

POS1404 SHARED DECISION MAKING AND INTERNET USE FOR GATHERING HEALTH INFORMATION IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: A MULTICENTER CROSS-SECTIONAL STUDY

Background

It is well known that providing appropriate health information to patients with systemic lupus erythematosus (SLE) has an advantage in the treatment decision making process. In modern information society the growing popularity of smartphones and social networking services, patients have more access to online health information. However, there are concerns that Internet use may inversely affect the shared decision making (SDM) process with their attending physicians if they receive inaccurate information.

Objectives

This study aimed to investigate how online information gathering behavior affects SDM with their attending physicians.

Methods

In this cross-sectional study, information of 386 patients with SLE, which were enrolled from five Japanese institutions between June 2020 and August 2021, were analyzed. The main exposure was time spent on the Internet per day (excluding time used for working). It was divided into four categories (none, <1 hour, 1-2 hours, > 2 hours). Patients were asked to select the source of health care information they would like to access first and were categorized into physicians, the Internet, and other media sources (family and friends, healthcare professionals other than physicians, or TV and radio, etc.). Outcome was shared decision making measured via the 9-item Shared Decision Making Questionnaire (SDM-Q-9 [scores 0-100]). To assess the relationship between the time of Internet use and SDM, we fitted general linear models adjusted for age, gender, education level, household income, marital status, history of cancer, disease duration, and disease activity. Chained equations were used to impute missing values of covariates.

Results

This study ultimately employed 334 patients whose mean age and female ratio were 45.3 years (standard deviation 13.8) and 87.7%, respectively. 68.9% of the patients indicated that they would like to access their physicians first, and 19.5% indicated that they would like to access the Internet first. Compared to patients who chose their physician as their first access to health information, there was no difference in SDM-Q-9 among patients who chose the Internet, but patients who chose other media had significantly lower SDM-Q-9 (-7.7 point, 95% confident interval [CI] -14.4 to -0.92, P=0.026). Besides, SDM-Q-9 scores were significantly lower in patients who did not use the Internet compared to those who used it for more than two hours except for their work activities (-9.6, 95%CI -18.9 to -0.26, P=0.044).

Conclusion

The present study suggests that SDM between physicians and patients is positively rather than adversely associated with online information-gathering behavior. Rheumatologists also need to be aware that how patients prefer to access health information to establish a good physician-patient relationship for SDM. In addition, rheumatologists may need to introduce their patients to websites offering appropriate health information.

Disclosure of Interests

None declared

POS0822 HYPERTROPHIC PACHYMENINGITIS IN ANTINEUTROPHIL CYTOPLASMIC ANTIBODY-ASSOCIATED VASCULITIS: A MULTICENTER SURVEY IN JAPAN

Background

Hypertrophic pachymeningitis (HP), characterized by an inflammatory disorder indicating intracranial or spinal thickening of dura mater, is found to develop as a neurological involvement in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). Meanwhile, the previous studies focusing on HP in AAV have been reported as a single-institution study, and the analyses were performed in a small number of patients because HP is a rare neurological disorder. Therefore, neither etiological nor clinical characteristics of HP in AAV have been adequately elucidated.

Objectives

This study clarified the characteristics of HP in AAV by analyzing the information of multicenter study in Japan (Japan collaborative registry of ANCA-associated vasculitis: J-CANVAS).

Methods

We analyzed the clinical information from 541 Asian patients with AAV enrolled in J-CANVAS. Of them, newly diagnosed and relapsed AAV were included in 448 and 93, respectively. The epidemiological and clinical findings were compared between patients with and without HP. Clinical manifestations related to AAV were evaluated based on the Birmingham Vasculitis Activity Score version 3. To elucidate independent factors in HP development, logistic regression analyses were additionally performed.

Results

Of the total 541 patients (mean age: 71±14 years, M:F = 1:1.2), HP was demonstrated in 28 (5.17%), including 17 (3.79%) in newly diagnosed AAV and 11 (11.8%) in relapsed AAV. The classification of granulomatosis with polyangiitis (GPA) was significantly higher in patients with HP than those without HP (50% vs. 21%, p = 0.0007). In newly diagnosed AAV, patients with HP significantly had higher GPA classification and higher positivity for PR3-ANCA than those without HP (53% vs. 17%, p = 0.001; 29% vs. 9%, p = 0.015, respectively). Conversely, positivity for MPO-ANCA was significantly higher in patients with HP than those without HP in relapsed AAV (91% vs. 55%, p = 0.025), despite not significantly different in the classification of AAV. Headache and cranial neuropathies were significant neurological symptoms in patients with HP compared to those without HP (82% vs. 6.6%, p < 0.0001; 32% vs. 2.9%, p < 0.0001, respectively). Besides, ear, nose and throat (ENT) and mucous membranes/eyes were significantly higher involvements in patients with HP than in those without HP (54% vs. 26%, p = 0.003; 29% vs. 9%, p = 0.003, respectively). Moreover, higher complications of “conjunctive hearing loss” and “sudden visual loss”, which are included in the categories of ENT and mucous membranes/eyes involvement, respectively, were significantly indicated in patients with HP than those without HP (39% vs. 7.2%, p < 0.0001; 21% vs. 1.2%, p < 0.0001, respectively). Multivariable logistic regression analysis identified that ENT (odds ratio [OR] 1.28, 95% confident interval [CI] 1.09 to 1.49, p = 0.002) and mucous membranes/eyes involvement (OR 1.37, CI 1.14 to 1.65, p = 0.0006), as well as conjunctive hearing loss (OR 4.52, CI 1.56 to 13.05, p = 0.005) and sudden visual loss (OR 1.84, CI 1.12 to 3.00, p = 0.015), were independent related factors in patients with HP.

Conclusion

GPA could be significantly classified in patients with HP. Notably, patients with HP significantly showed higher positivity for PR3-ANCA than those without HP in newly diagnosed AAV. Furthermore, sudden visual loss and conjunctive hearing loss might be implicated in HP development.

Disclosure of Interests

None declared

AB0474 IMPACT OF HEALTH LITERACY ON TRUST IN PHYSICIANS AMONG PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: THE TRUMP2-SLE PROJECT

Background

Information technology has expanded the gap in patient health literacy (HL), and HL has various implications on the trust in patient-doctor relationship. Previously, only functional HL, the ability to interpret health information through reading and writing skills, has been studied in patients with SLE (1).

Objectives

We examined how trust in physicians is affected by the broader concept of HL, including communicative HL, the ability to extract health information from communication to use, and critical HL, the ability to discern and use such information (2).

Methods

This cross-sectional study enrolled 362 SLE patients at 5 sites between June 2020 and August 2021. Three domains of HL (i.e., functional HL, communicative HL, and critical HL) were assessed using the 14-item FCCHL scale (range: 1-4 points for each domain). The outcomes were patients’ trust in their physicians and physicians in general and were measured using the Japanese version of the 5-item Wake Forest Physician Trust scales (range: 0-100 points for each scale). General linear models adjusted for age, gender, education, income, SLEDAI, disease duration, depression, and hours of Internet use were conducted. Subsequently, a series of general linear models were then fit to each of the three domains of HL to examine whether or not it was associated with the aforementioned covariates.

Results

The median age of the patients was 45 (interquartile range [IQR],34-55), 88% were female. The median value of SLEDAI was 4 ([IQR], 2-8), Trust in one’s physician was 80 ([IQR], 70-95) and trust in physicians generally was 65 ([IQR], 50-80). Trust in one’s physician increased with higher functional and communicative HL (per 1-pt increase, 3.2 [95%CI 0.7 to 5.9]; 5.4 [95%CI 1.6 to 9.3]). Trust in doctors generally increased with higher communicative HL and decreased with higher critical HL (per 1-pt increase, 6.8 [95% CI 2.0 to 12]; -6.7 [95% CI -12 to -1.9]). Lower functional HL was associated with older age and depression, while higher HL was associated with higher educational level. Higher communicative HL and critical HL were each associated with longer Internet use.

Conclusion

In patients with SLE, higher trust in one’s physician was associated with both functional and communicative HL, while higher trust in physicians generally was associated with higher communicative HL and lower critical HL. Our findings suggest that trusting relationships may be fostered by the encouragement of rheumatologists to cultivate patients’ ability to share their health problems with their physicians and family members and to obtain useful health information (i.e., communicative HL), rather than to improve their ability to discern health information (i.e., critical HL).

References

[1]Maheswaranathan M, Cantrell S, Eudy AM, Rogers JL, Clowse MEB, Hastings SN, et al. Investigating Health Literacy in Systemic Lupus Erythematosus: a Descriptive Review. Curr Allergy Asthma Rep. 2020;20(12):79.

[2]Ishikawa H, Takeuchi T, Yano E. Measuring functional, communicative, and critical health literacy among diabetic patients. Diabetes Care. 2008;31(5):874-9.

Disclosure of Interests

Nao Oguro: None declared, Nobuyuki Yajima: None declared, Yoshia Miyawaki: None declared, Ryusuke Yoshimi: None declared, Yasuhiro Shimojima: None declared, KEN-EI SADA Speakers bureau: He received speaker’s fees from Glaxo Smith

Kline K.K., Grant/research support from: He received a research grant from Pfizer Inc.,, Keigo Hayashi: None declared, Kenta Shidahara: None declared, Natsuki Sakurai: None declared, Chiharu Hidekawa: None declared, Dai Kishida: None declared, Takanori Ichikawa: None declared, Yuichi Ishikawa: None declared, Noriaki Kurita: None declared

Prevalence of metabolic dysfunction-associated fatty liver disease and its association with physical function in patients with acute coronary syndrome

Funding Acknowledgements

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

Background

It is widely known that patients with acute coronary syndrome (ACS) are at increased risk of nonalcoholic fatty liver disease (NAFLD), which is linked to sarcopenia and physical dysfunction. However, the relationship between metabolic dysfunction-associated fatty liver disease (MAFLD) and physical dysfunction remains unclear.

Purpose

The purpose of this study was to investigate the prevalence of MAFLD in patients with ACS to assess the relationship between MAFLD and muscle strength, walking speed, and 6-minute walking distance (6 MWD).

Methods

We reviewed patients with ACS who were assessed for hepatic steatosis using the fatty liver index, and the results were further assessed to determine the presence of MAFLD. Multiple regression analysis was used to examine the association between MAFLD and physical function.

Results

Among 479 enrolled hospitalized patients, MAFLD was identified in 234 (48.9%) patients. We conducted a multiple regression analysis in which MAFLD was independently associated with lower leg strength, gait speed, and 6 MWD (leg strength, P = 0.023; gait speed, P = 0.002 and 6 MWD, P = 0.017). Furthermore, having more metabolic impairment was still associated with lower physical function decline (leg strength, P for trend = 0.002; gait speed, P for trend = 0.019 and 6 MWD, P for trend = 0.003).

Conclusions

MAFLD is common in hospitalized patients with ACS, and most patients with MAFLD have many overlapping metabolic abnormalities. MAFLD is associated with impaired physical function, and the greater the number of overlapping metabolic abnormalities, the worse the motor function.

Skeletal muscle mass metrics as factors in the prognosis of heart failure patients

Funding Acknowledgements

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

Background

Sarcopenia is a chronic condition that is characterized by the loss of skeletal muscle mass with declining muscle strength and/or performance that occurs gradually with aging. It has been reported that sarcopenia is highly prevalent in patients with heart failure (HF) and is a poor prognostic factor. Therefore, it is important to accurately assess skeletal muscle mass in patients with HF. However, there are no reports that have simultaneously examined different skeletal muscle mass metrics as factors in the prognosis of HF patients.

Purpose

The purpose of this study is to examine if the different skeletal muscle mass metrics are associated with the prognosis of HF patients.

Methods

We examined a total of 869 patients with HF, aged ≥20 years (73 [63, 80] years; 537 males), who were admitted to our hospital and participated in an inpatient cardiac rehabilitation program. We used skeletal muscle mass index (SMI) as measured by bioelectrical impedance analysis (BIA), mid-upper arm circumference (MUAC), arm muscle circumference (AMC), and calf circumference (CC) as metrics of skeletal muscle mass. The primary outcome was all-cause deaths, and secondary outcome was HF readmission. To investigate the association between each skeletal muscle mass metric and prognosis, patients were divided into three groups according to the tertiles of SMI, MUAC, AMC, and CC. In addition, cumulative event rates of survival curves, Gray test, and Fine & Gray test were performed to evaluate the prognostic predictive capability.

Results

Over a median follow-up period of 0.9 years (interquartile 0.4–1.9) years, a total of 80 deaths and 195 HF readmissions occurred in the patients. Cumulative event rates of survival curves and Gray test showed that there was a significant decrease in all-cause mortality and HF readmission in the high MUAC group and high AMC group compared to their respective low groups (P &lt; 0.05). Fine & Gray test after multivariate adjustment showed significantly better prognosis in the high MUAC group and high AMC group compared to their respective low groups (All-cause mortality: high MUAC group, subdistribution hazard ratio [sHR] = 0.42, 95% confidence interval [CI] = 0.20-0.88, P &lt; 0.05; high AMC group, sHR = 0.34, 95%CI = 0.16-0.72 P &lt; 0.05, HF readmission: high MUAC group, sHR = 0.69, 95%CI = 0.47-1.00, P &lt; 0.05; high AMC group, sHR = 0.63, 95%CI = 0.43-0.93, P &lt; 0.05).

Conclusion

Patients with HF who maintained high MUAC and high AMC had a good prognosis. CC and SMI were not associated with the prognosis of HF patients. This suggests the importance of evaluating MUAC and AMC in HF patients.

Diagnosis and Pathogenesis of Sarcopenia in Chronic Liver Disease Using Liver Magnetic Resonance Imaging

Background Liver magnetic resonance imaging (MRI) is rarely used to evaluate sarcopenia. This study sought to develop new diagnostic criteria for MRI in Asians and investigate the relationship between adipopenia and sarcopenia using MRI proton density fat fraction (PDFF), which is correlated with body fat mass. Methodology This study included 512 patients with chronic liver disease (CLD) who underwent magnetic resonance elastography (MRE). The following parameters were assessed: paraspinal muscle area/height index (PSMI) measured at the level of the superior mesenteric artery and PDFF. The cutoff PSMI and PDFF values for the diagnosis of sarcopenia and adipopenia, respectively, were determined using receiver operating characteristic analysis of Asians with low body mass index. Results Among patients with CLD, the prevalence rates of sarcopenia and adipopenia were 25% and 17%, respectively. We found that sarcopenia increased from stage 3 fibrosis and was inversely correlated with steatosis grade. Multivariate analysis found that MRI-PDFF was associated with sarcopenia. The Kaplan-Meier method in cirrhosis (n = 122) showed that the non-sarcopenia, sarcopenia, and sarcopenia/adipopenia groups had three-year survival rates of 97%, 55% (p < 0.01), and 23%, respectively. The Cox proportional hazards model identified the Child-Pugh score and sarcopenia/adipopenia as independent prognostic factors. Conclusions The new diagnostic criteria for sarcopenia confirmed that the prognosis of cirrhosis can be stratified. Furthermore, sarcopenia with adipopenia was shown to be a phenotype of severe sarcopenia in cirrhosis, and screening for sarcopenia should include cases in the precirrhotic stage.

Congenital venous anomalies associated with retrocaval ureter: evaluation using computed tomography

BACKGROUND

Retrocaval ureter is a rare congenital anomaly resulting from anomalous development of inferior vena cava (IVC) and not from anomalous of the ureter. The anomaly always occurs on the right side due to regression of right supracardinal vein and persistence of right posterior cardinal vein. Retrocaval ureter tends to be associated with various vena cava anomalies because of the embryogenesis. We aimed to identify the prevalence of associated congenital venous anomalies (CVA) resulting from cardinal vein development in adults with retrocaval ureter using computed tomography (CT) images.

MATERIALS AND METHODS

The study included 22 adults with retrocaval ureter. We evaluated CT findings and determined the incidence of associated CVA using thin slice data sets from CT scanner with 64 or more detectors. We compared the prevalence of CVA in the retrocaval ureter group (mean age: 57±19 years) and in the control group of 6189 adults with normal ureter (mean age: 66±14 years).

RESULTS

In the retrocaval ureter group, 4 adults (18.2 %) had CVA including double IVC, right double IVC, preisthmic IVC with horseshoe kidney, and preaortic iliac confluence. One of 2 adults with preaortic iliac confluence had right double right IVC. In the control group, 49 adults (0.79%) had CVA including 37 double IVCe, 11 left IVCe, and 1 IVC interruption azygos continuation. Fifteen horseshow kidneys were found. The prevalence of associated CVA in the retrocaval ureter group was higher than that in the control group (p<0.001).

CONCLUSIONS

Retrocaval ureter is frequently associated with CVA. Various CVA with retrocaval ureter could happen because of abnormal development of not only the right posterior or supra cardinal vein but also other cardinal veins.

A Case of Hepatitis C-Related Decompensated Cirrhosis Observed by MRI Imaging Data During Treatment With Direct-Acting Antiviral Agents

Sofosbuvir/velpatasvir therapy can safely treat hepatitis C virus (HCV)-related decompensated cirrhosis and has been shown to improve liver function at an early stage. However, the pathophysiology of the liver during treatment remains unclear. In this case report, we analyzed hepatic morphology on magnetic resonance imaging during the treatment period and confirmed that liver function and malnutrition were greatly improved with the elimination of HCV, and that rapid hemodynamic changes were occurring in the liver.

Associations between kidney function and outcomes following cardiac rehabilitation in patients with heart failure

Background

Kidney dysfunction is considered one of the most prevalent comorbidities in patients with heart failure (HF). A combination of HF and kidney dysfunction is associated with peripheral muscle impairment, exercise intolerance, and poor prognosis. Conversely, cardiac rehabilitation (CR) for HF patients has been recognized to improve their clinical outcomes. However, the impact of kidney function on responses to CR in patients with HF is still unclear.

Purpose

This study aimed to investigate the associations between baseline kidney function and outcomes following CR including changes in physical function and prognosis in HF patients.

Methods

We reviewed a total of 3,727 patients who were admitted for HF treatment and underwent comprehensive CR during hospitalization. In addition to clinical characteristics, we assessed the kidney function using estimated glomerular filtration rate (eGFR) based on serum creatinine level at hospital discharge as baseline. The quadriceps strength (QS) and 6-minute walk distance (6MWD) were measured as muscle strength and functional capacity, respectively, at baseline. We also remeasured these parameter 5 months after hospital discharge in patients who participated in outpatient CR. The association between participation in outpatient CR and composite outcome of all-cause death and/or unplanned readmission were assessed using the multivariate Cox proportional hazard models in a subgroup of baseline eGFR. We also compared the changes in QS and 6MWD (ΔQS and Δ6MWD) between the eGFR stages.

Results

During the median follow-up period of 1.9 years, all-cause death/readmission occurred in 1604 (43.0%) patients, and their rate of incidence was 20.9/100 person-years. Out of studied patients, 1,585 (42.5%) patients participated in outpatient CR that was significantly associated with lower incidences of all-cause clinical events in patients with both eGFR ≥60 (adjusted hazard ratio [HR]: 0.73, 95% confidence interval [CI]: 0.60–0.89, P=0.002) and eGFR &lt;60 (adjusted HR: 0.88, 95% CI: 0.78–0.99, P=0.045), but those with an eGFR &lt;60 showed significant interaction between CR participation and adverse clinical events (interaction P&lt;0.035, Figure 1). Among the outpatient CR participants, QS and 6MWD were significantly higher after 5-month CR than those at baseline (P&lt;0.001, respectively), but the low baseline eGFR correlated with low ΔQS and Δ6MWD (trend P&lt;0.001, respectively) even after adjustment for clinical confounding factors (Figure 2).

Conclusions

Although the outcomes following CR is affected by baseline kidney function, outpatient CR is significantly associated with the positive change in physical function and better prognosis in HF patients with low kidney function.

Funding Acknowledgement

Type of funding sources: None.

Associations of severity of liver damages with physical function and prognosis in patients with heart failure

Funding Acknowledgements

Type of funding sources: None.

Introduction

Heart failure (HF) and liver dysfunction often coexist because of complex cardiohepatic interactions, which adversely affects prognosis. However, the association between liver dysfunction and physical dysfunction, and between coexistence of both and prognosis in HF patients remains unclear.

Purpose

We evaluated the associations of severity of liver damage and physical function and prognosis in patients with HF.

Methods

The study population consisted of 895 patients with HF (mean age, 69.4 ± 14.2 years) who underwent liver function test using model for end-stage liver disease excluding international normalized ratio (MELD-XI) score and physical function test (grip strength, leg strength, gait speed, and 6-minute walking distance [6MWD]). The associations between MELD-XI score and physical function were assessed by multivariate linear regression model analysis. Moreover, we investigated the prognostic value of coexistence of liver dysfunction and physical dysfunction. The endpoint was all-cause mortality.

Results

After adjusting for covariates, MELD-XI score was independently associated with lower grip strength, leg strength, gait speed, and 6MWD (P &lt; 0.001). In addition, hierarchical multivariate linear regression analysis revealed that adding MELD-XI scores or BNP explained additional variance in the physical function measures. The MELD-XI score added to the clinical model was significantly more predictive of physical function (grip strength, change in F: 27.105, P &lt; 0.001; leg strength, change in F: 33.980, P &lt; 0.001; gait speed, change in F: 22.826, P &lt; 0.001; 6MWD, change in F: 59.193, P &lt; 0.001) than BNP added to the clinical model. Eighty-six deaths occurred over a median follow-up period of 1.67 years (interquartile range: 0.62 – 3.04). Patients with high MELD-XI score and reduced physical function were found to have significantly higher mortality risk even after adjusting for several covariates (grip strength, hazard ratio [HR] = 3.80 [95% confidence interval (CI) = 2.04 – 7.08], P &lt; 0.001; leg strength, HR = 4.65 [95% CI = 2.47 - 8.75], P &lt; 0.001 and gait speed, HR = 2.49 [95% CI = 1.43 - 4.33], P = 0.001; 6MWD, HR = 5.48 [95% CI = 2.88 - 10.41], P &lt; 0.001).

Conclusions

Liver dysfunction was correlated with reduced physical function. Moreover, the coexistence of lower physical function and liver dysfunction considerably affected prognosis in patients with HF.

Abstract Figure. Kaplan–Meier survival curves

Low skeletal muscle density combined with muscle dysfunction predicts adverse events after adult cardiovascular surgery

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): This study was supported by the Grant for Japan Society for the Promotion of Science (JSPS) KAKENHI.

Introduction

Although muscle dysfunction is widely known as a poor prognostic factor in patients with cardiovascular disease, no study has examined whether the addition of low skeletal muscle density (SMD) assessed by computed tomography (CT) to muscle dysfunction is useful.

Purpose

The present study aimed to examine whether SMDs can strengthen the predictive ability of muscle dysfunction for adverse events in patients who underwent cardiovascular surgery.

Methods

We retrospectively reviewed 853 patients (median age: 69 years, 65.1% male) aged ≥40 years who had preoperative CT for risk management purposes and muscle dysfunctions measured during postoperative cardiac rehabilitation. Muscle dysfunctions were determined from weakness (low grip strength) and slowness (slow gait speed) based on the Asia Working Group for Sarcopenia. Low SMD based on transverse abdominal CT images was defined as a mean Hounsfield unit of the psoas muscle &lt;45. To examine the complementary prognostic value for all-cause deaths, all-cause events, and cardiovascular-related events when low SMDs were added to four patterns of muscle dysfunction (weakness only, slowness only, weakness or slowness, and weakness and slowness), the continuous net reclassification improvement (cNRI) and integrated discrimination improvement (IDI) index were calculated.

Results

For all definitions of muscle dysfunction, the addition of SMDs was shown to significantly improve the cNRI (estimates: 0.377 to 0.468 for all-cause death, 0.220 to 0.248 for all-cause events, 0.308 to 0.322 for cardiovascular-related events) and IDI (estimates: 0.005 to 0.011 for all-cause death, 0.005 to 0.010 for all-cause events, 0.009 to 0.012 for cardiovascular-related events) in all analyses. Low SMDs combined with muscle dysfunctions were associated with the highest risk of all-cause death (Figure 1: A-D). Patients with neither low SMDs nor muscle dysfunction had the lowest risk of all-cause events and cardiovascular-related events (Figure1: E-L).

Conclusion

The predictive ability of muscle dysfunction for adverse events was consistently increased by addition of SMDs in patients who underwent cardiovascular surgery. Our results suggest that when CT is performed for any clinical investigation, the addition of the organic assessment of skeletal muscle can strengthen the diagnostic accuracy of muscle wasting.

Abstract Figure 1

[Pathogenic and Compensatory Mechanisms in Epidermis of Sphingomyelin Synthase 2-Deficient Mice]

Sphingomyelin (SM) is a constituent of cellular membranes, while ceramides (Cer) produced from SM on plasma membranes serve as a lipid mediator that regulates cell proliferation, differentiation, and apoptosis. In the skin, SM also is a precursor of Cer, an important constituent of epidermal permeability barrier. We investigated the role of epidermal SM synthase (SMS)2, an isoform of SMS, which modulates SM and Cer levels on plasma membranes. Although SMS2-knockout (SMS2-KO) mice were not neonatal lethal, an ichthyotic phenotype with epidermal hyperplasia and hyperkeratosis was evident at birth, which persisted until 2 weeks of age. These mice showed abnormal lamellar body morphology and secretion, and abnormal extracellular lamellar membranes in the stratum corneum. These abnormalities were no longer evident by 4 weeks of age in SMS2-KO mice. Our study suggests that (1) exposure to a dry terrestrial environment initiates compensatory responses, thereby normalizing epidermal ichthyotic abnormalities and (2) that a nonlethal gene abnormality can cause an ichthyotic skin phenotype.

Correlation between respiratory muscle weakness and frailty status as risk markers for prognosis in patients with cardiovascular disease

Background

Respiratory muscle weakness (RMW), frequently observed in patients with cardiovascular disease (CVD), is documented as a predictor for exercise intolerance and poor prognosis. On the other hand, frailty is commonly associated with disease condition, leading to increased risk of morbidity and mortality. Although the developmental mechanism of RMW and frailty is partly similar, the relationship between these statuses remains unclear.

Purpose

We aimed to investigate the correlation between RMW and frailty and its impact on prognosis in patients with CVD.

Methods

We studied 771 consecutive patients (68.5±13.1 years, 256 females) who were hospitalized for CVD treatment and underwent cardiac rehabilitation during hospitalization. Patients who received thoracic surgery within the last 3 months or could not perform respiratory function test were excluded from this study. As patient characteristics, we obtained body mass index, comorbidity conditions, smoking history, blood examinations, echocardiographical variables, and lung function from medical database. The frailty status on admission was assessed using frailty score consisting of 5 items including gait speed, nutrition/shrinking, physical activity, forgetfulness, and emotions/exhaustion, and patients who had 3 items were defined as frailty. We also measured maximal inspiratory pressure (PImax) as respiratory muscle strength at hospital discharge, and RMW was defined with PImax &lt;70% of predicted value. Primary end-point was all-cause clinical events including all-cause death and/or unplanned readmission after hospital discharge. We examined the prevalence of RMW and frailty and the correlation between these statuses. The relationships of RMW with the clinical events for each presence or absence of frailty were also investigated using multivariate Cox proportional hazard models.

Results

RMW and frailty were defined in 163 (33.5%) and 126 (28.7%) patients, respectively, and 95 patients (12.4%) among them showed an overlap of both statuses (Figure 1). Frailty was detected as a significant indicator of RMW after adjusting for confounding factors (adjusted odds ratio: 1.57, 95% CI: 1.12–2.19, P=0.009). Over the median follow-up periods of 1.2 years, all-cause clinical events occurred in 154 patients (20.0%). RMW was significantly and independently associated with increased incidence of all-cause clinical events in patients with both non-frailty (adjusted hazard ratio [HR]: 1.64, 95% CI: 1.09–2.46, P=0.017) and frailty (adjusted HR: 1.97, 95% CI: 1.14–3.42, P=0.015) even after adjusting for clinical confounding factors (Figure 2).

Conclusions

This study is the first to demonstrate that RMW correlated to frailty in patients with CVD, and 12.4% of patients had overlap status. Moreover, RMW was significantly associated with an increased risk of all-cause clinical events in patients with CVD and frailty.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Japan Society for the Promotion of Science Grant-in-Aid

THU0052 RELATIONSHIP BETWEEN INTERFERON-Γ-PRODUCING IMMUNOCOMPETENT CELLS AND DISEASE ACTIVITY IN ADULT-ONSET STILL’S DISEASE

Background:

In the acute phase of adult-onset Still’s disease (AOSD), elevated levels of proinflammatory cytokines including interferon-γ (IFN-γ) are shown. Moreover, IFN-γ impacts on activating macrophages which play a crucial role in the pathogenesis of AOSD. Natural killer (NK) cells and T helper cells are in charge of secreting IFN-γ in the innate and adaptive immune systems of disease, respectively. However, the features of their IFN-γ-producing variation depending on disease activity are still uncertain in AOSD.

Objectives:

We investigated characteristics of IFN-γ-producing CD4+T cells and NK cells in patients with AOSD.

Methods:

Twenty-four patients in the acute phase of AOSD (active AOSD), 8 of them after treatment (remission), and 12 healthy controls (HC) were recruited in this study. Peripheral blood mononuclear cells and serum samples were provided from them for the experimental analysis. Flow cytometry was used for analyzing CD4+T cells, CD4+regulatory T cells (Tregs), NK cells, and their intracellular IFN-γ expression levels as well as suppression assay of Tregs. The serum concentration of interleukin-18 (IL-18) was measured using commercially available ELISA kit. Relationship between the analyzed data and clinical findings related to disease activity were statistically evaluated.

Results:

IFN-γ expression in CD4+T cells was significantly higher in active AOSD than in HC (p < 0.05). Tregs also significantly indicated higher expression of IFN-γ in active AOSD than in HC (p < 0.0001); and moreover, Tregs were significantly impaired in their suppression ability (p < 0.05). In both CD4+T cells and Tregs, expression of IFN-γ was significantly correlated with serum ferritin levels in active AOSD (p < 0.05). IFN-γ expression in CD4+T cells was significantly higher in patients with splenomegaly than those without that (p < 0.05). The proportion of NK cells was significantly lower in active AOSD than in HC (p < 0.005), whereas IFN-γ expression in NK cells was significantly higher in active AOSD than in HC (p < 0.0005). The number of NK cells and IFN-γ-expressing NK cells had inverse relationship with serum ferritin levels in active AOSD (p < 0.05 and p < 0.005, respectively). Increased number of NK cells and their decreased expression of IFN-γ were significantly demonstrated in remission (p < 0.05). In the analyses of NK cell subsets, lower expression of IFN-γ in CD56brightNK cells and higher that in CD56dimNK cells were significantly indicated in active AOSD than HC (p < 0.05). In remission, IFN-γ expression was significantly decreased in CD56dimNK cells (p < 0.05) despite no significant recovery of that in CD56brightNK cells (p = 0.311). Meanwhile, increased expression of IFN-γ in CD56brightNK cells was demonstrated in only patients who were treated with biologics. Although serum levels of IL-18 were significantly higher in active AOSD than in remission and HC; however, they had no significant correlations with any analyzed data.

Conclusion:

CD4+T cells and NK cells promote IFN-γ expression in the acute phase of AOSD. Meanwhile, increased expression of IFN-γ in CD4+T cells and decreased number of NK cells were correlated with serum ferritin levels, suggesting that they are indicators of disease activity. Furthermore, high disease activity may impact on the alteration of IFN-γ-producing balance in two distinct population of NK cells, and the plasticity of Tregs leading to defect in suppression ability.

Disclosure of Interests:

None declared

P6331Influence of dynapenia and obesity on prognoses of elderly heart failure patients

Background

In elderly people, a decline in activities of daily living is more closely associated with low muscle strength (dynapenia) than with low muscle mass. Moreover, the combination of low muscle strength and obesity (dynapenic obesity) is associated with a higher risk of mortality than dynapenia or obesity alone, but its influence on prognosis is still unknown in elderly heart failure (HF) patients. To clarify these relationships may contribute to the development of rehabilitation programs for elderly HF patients and the improvement their prognoses in the future.

Purpose

We aimed to investigate the influence of dynapenia and obesity on prognoses of elderly HF patients.

Methods

We evaluated 1006 elderly HF patients aged ≥65 years (76.5±6.9 years, 579 males) who were admitted to our hospital and participated in an inpatient cardiac rehabilitation program. We assessed patients' characteristics, including body mass index (BMI) and handgrip strength during hospitalization. Patients with low handgrip strength (<26 kg and <18 kg in males and females, respectively) and high BMI (≥25 kg/m2) were considered to have dynapenia and obesity, respectively. Moreover, patients fulfilling the above two criteria (dynapenia, obesity) were considered to have dynapenic obesity. Patients were divided into four groups: normal, dynapenia only, obesity only, and dynapenic obesity. We compared survival rates among the four groups using the Kaplan-Meier method and log-rank test. To identify predictors for all-cause mortality, we performed Cox regression analysis.

Results

During the 8-year follow-up period, 228 patients (21.2%) died. Eight-year cumulative incidences of mortality were 35.4%, 26.0%, 62.6%, and 33.1% in the normal, obesity only, dynapenia only, and dynapenic obesity groups, respectively. Significantly lower survival rates were observed in the dynapenia only group than in the other 3 groups (log-rank: 28.893, P<0.001). Cox regression analysis, after adjusting for age and sex, showed significantly poor prognosis in the dyanapenia only group than in the other 3 groups (normal group, hazard ratio [HR] = 0.684, 95% confidence interval [CI] = 0.488–0.959, P=0.028; obesity only group, HR = 0.330, 95% CI = 0.182–0.598, P<0.001; dynapenic obesity group, HR = 0.390, 95% CI = 0.206–0.739, P=0.004).

Conclusion

Elderly HF patients with dynapenia alone had poor prognoses. Obesity may have protective effects on the survival of dynapenia patients with HF.

P1901Use of direct thrombin inhibitor on the day of atrial fibrillation ablation decreases incidence of silent cerebral ischemia detected by magnetic resonance imaging

Background

There is increasing evidence to use direct oral anticoagulants (DOACs) in atrial fibrillation (AF) ablation. Uninterrupted use of DOACs is recommended for peri-procedural anticoagulation; the ways of choosing and/or using DOACs depend on physicians' decisions and preferences. Uninterrupted dabigatran (DAB), a direct thrombin inhibitor, reportedly decreased the risk of major bleeding (MB) in AF ablation, compared to uninterrupted warfarin (NEJM 2017; 376:1627). Among DOACs, only regular-dose of DAB (150 mg b.i.d.), showed superiority to warfarin for preventing ischemic thromboembolism (TE) in patients with non-valvular AF, implicating the powerful anti-thrombotic agent. DAB may decrease the potential risk of procedure-related TE.

Purpose

To evaluate whether use of DAB on the day of AF ablation decreases the prevalence of silent cerebral ischemia (SCI) detected by magnetic resonance imaging (MRI).

Methods

414 AF patients on DOACs were enrolled and admitted on the day before AF ablation. Among 354 patients on factor Xa inhibitors (rivaroxaban, apixaban, and edoxaban), the original DOACs were switched to DAB (150 mg b.i.d.) on the day of the procedure in 172 patients (Group D); the treatment remained unchanged in 182 patients (Group non-D). In both groups, DOACs were continuously used throughout the procedure. After propensity-score matching, procedure-related parameters/events and the incidence of MRI-detected SCI were compared between Group D (n=134) and Group non-D (n=134). These parameters in patients originally taking DAB, used without interruption during the procedure (uninterrupted DAB, n=55), were also compared to Group D (n=55) after propensity-score matching.

Results

Baseline activated clotting time (ACT) before initial heparin injection was increased in Group D vs. Group-non-D (179±25* vs. 146±23 sec, *p<0.05 vs. Group non-D). The time to achieve optimal ACT (>300 sec) was shorter in Group D (34±29* vs. 43±32 min). The amounts of heparin needed to achieve optimal ACT and the total amount of heparin used during the procedure were unchanged between Group D and Group non-D. The incidence of SCI decreased in Group D (13.1%* vs. 21.9%), suggesting the potential anti-thrombotic efficacy of DAB. No MB or symptomatic TE events were observed in either group. Baseline ACT, the time to achieve ACT >300 sec, and the incidence of SCI in Group D were comparable to those in uninterrupted DAB (183±38 vs. 181±32 sec, 39±31 vs. 42±28 min, and 14.5% vs. 16.4%, respectively). No MB or symptomatic TE events were observed either in Group D or uninterrupted DAB.

Conclusions

Temporarily switching to DAB from the other DOACs and using it on the day of procedure enable us to achieve optimal ACT quickly and decrease the incidence of SCI, showing similar potential anti-thrombotic efficacy to uninterrupted DAB. Use of DAB on the day of AF ablation also benefits from the availability of its antidote in the case of MB during the procedure.

P2514Pupillary area predicts all-cause mortality in patients with cardiovascular disease

Background

Autonomic dysfunction is among the most important pathophysiological factors involved in the high mortality rate associated with cardiovascular disease (CVD). Autonomic function is generally evaluated by heart rate variability, which is obtained by Holter electrocardiography. However, the measurement of heart rate variability requires continuous electrocardiographic monitoring for 24 h, which is time consuming and not always feasible. The pupillary area is controlled by the autonomic nervous system; however, limited data are available regarding the utility of the pupillary area for predicting prognosis in patients with CVD.

Purpose

We aimed to investigate whether pupillary area can be used as a novel prognostic marker in patients with CVD.

Methods

We retrospectively reviewed 1342 consecutive Japanese patients hospitalized for CVD. The study was performed in accordance with the tenets of the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of our University Hospital. The pupillary area measurement was performed on both eyes at least 7 days after hospitalization for CVD using a portable videopupillography system (Iriscorder Dual C10641; Hamamatsu Photonics, Hamamatsu, Japan) consisting of a goggle-shaped measurement portion with a charge-coupled device camera and a control portion with a video monitor and microcomputer with software for data analysis. After securing the goggles on the patient's face and fully covering the patient's eyes, a 5-minute period was allowed for dark adaptation. All patients were tested once between 09:00 and 12:00 h. The primary outcome of this study was all-cause mortality, and the endpoint time was calculated as the number of days from the date of pupillary area measurement up to three years. We performed the Kaplan–Meier and log-rank tests and multivariable Cox regression analysis to evaluate the prognostic predictive capability of the pupillary area.

Results

The study population had a mean age of 65±13 years, and 69.4% of the patients were male. The median of the pupillary area was 18.5 mm2 (interquartile range: 13.3–23.4 mm2). Over a median follow-up period of 1.9 years (interquartile range: 1.0–3.0 years), a total of 114 deaths occurred in the patient population. The Kaplan–Meier and log-rank tests revealed that all-cause mortality was significantly higher in the small pupillary area group than in the large pupillary area group (P<0.0001, Figure). Furthermore, Cox regression analysis indicated that the pupillary area was an independent predictor of mortality (Hazard ratio: 0.96; 95% confidence interval: 0.93–0.98; P=0.006) even after adjusting for several preexisting prognostic factors.

Kaplan-Meire Curve

Conclusion

The pupillary area can be an independent predictor of prognosis in patients with CVD, and our observations suggest that the assessment of the pupillary area can be useful as a new noninvasive prognostic predictor in patients with CVD.

298Change in respiratory muscle strength predicts clinical events in patients with chronic heart failure

Background

Respiratory muscle weakness, frequently observed in patients with chronic heart failure (CHF), has been documented as a predictor for poor prognosis. Several studies have reported that respiratory muscle training increases respiratory muscle strength and consequently improves exercise tolerance and quality of life in these patients. However, the relationship between the change in respiratory muscle strength and prognosis is still unclear.

Purpose

We aimed to investigate whether the change in respiratory muscle strength following cardiac rehabilitation predicts the incidence of clinical events in CHF patients.

Methods

We studied 348 patients with CHF who were hospitalized because of decompensated heart failure and received 5-month cardiac rehabilitation during hospitalization and after hospital discharge. Clinical characteristics including aetiology of heart failure, comorbidity conditions, medications, blood examination and echocardiographic variables were obtained from clinical records. We also measured maximal inspiratory pressure (PImax) as respiratory muscle strength at hospital discharge and 5 months later. The change of PImax (ΔPImax) between the 5-month observation period was examined. We followed up the patients after the observation period and investigated the incidence of all-cause mortality or all-cause unplanned readmission. In statistical analysis, patients were divided into two groups based on the median value of ΔPImax. We compared the event-free survival rate between the two groups using the Kaplan-Meier method with a log-rank test. We also performed the Cox proportional hazard model to clarify whether the ΔPImax was an independent predictor for the incidence of clinical events.

Results

Over a median follow-up of 1.6 years, 121 patients (34.8%) died or readmitted, and their rate of incidence was 21.7/100 person-years. The higher ΔPImax was associated significantly with a higher rate of event-free survival (Log-rank: 8.085, P=0.004, Figure 1). In univariate Cox proportional hazard model, ΔPImax was a significant predictor for the all-cause mortality/readmission (unadjusted hazard ratio for PImax increase of 10 cmH2O: 0.842, 95% CI: 0.763 - 0.931, P=0.001). Even after adjustment for clinical confounding factors including baseline PImax, ΔPImax remained significant and independent predictor for the all-cause mortality/readmission (adjusted hazard ratio for PImax increase of 10 cmH2O: 0.862, 95% CI: 0.763 - 0.974, P=0.017, Figure 2).

Conclusion

This study is the first to demonstrate that the change in respiratory muscle strength following cardiac rehabilitation independently predicts the incidence of clinical events in patients with CHF. The increase in PImax of 10 cmH2O was associated significantly with a 14% decrease in the rate of all-cause mortality or readmission.

Acknowledgement/Funding

JSPS KAKENHI JP16K16442

P3106Atrial fibrillation is not associated with the responses to exercise training in heart failure patients with preserved ejection fraction

Background

Atrial fibrillation (AF) is known as a common arrhythmia in heart failure patients with preserved left ventricular ejection fraction (HFpEF). Several studies have reported that HFpEF patients with AF show lower exercise tolerance and poorer prognosis as compared with those with sinus rhythm (SR). On the other hand, exercise training is documented to improve peripheral muscle function and exercise tolerance in HFpEF patients. However, the relationship between AF status and outcomes due to exercise training is still unclear in these patients.

Purpose

We aimed to investigate the influence of AF on the responses to outcomes with exercise training in HFpEF patients.

Methods

We studied 426 patients with HFpEF who received 5-month cardiac rehabilitation including exercise training during hospitalization and after hospital discharge. As clinical characteristics, we obtained body mass index, disease aetiology, comorbidity conditions, blood examination and echocardiographic variables from medical records. We also measured isometric quadriceps strength (QS) and 6-minute walk distance (6MWD) as peripheral muscle strength and exercise tolerance, respectively. The QS and 6MWD were assessed at hospital discharge as the baseline and 5 months later. AF status was determined by the presence on electrocardiogram at baseline 6MWD or medical history of AF during hospitalization. In statistical analysis, we compared baseline clinical characteristics, QS and 6MWD between the rhythm status (SR group or AF group). We also examined the changes in QS and 6MWD from baseline to the 5-month observation period (ΔQS and Δ6MWD) and compared them between the 2 groups using analysis of covariance with adjustment for baseline clinical confounding factors.

Results

At baseline, 289 patients (68%) were in SR, and 111 patients (26%) had AF. The AF was associated significantly with older age (P<0.001) and lower levels of estimated glomerular filtration rate (P=0.013), QS (P<0.001) and 6MWD (P<0.001) at baseline. The QS increased significantly from 25.2±11.0 kg at baseline to 30.8±13.0 kg after 5-month cardiac rehabilitation in the SR group, and from 21.1±8.3 kg to 26.0±9.4 kg in the AF group (P<0.001, respectively). The 6MWD also increased significantly from 394.8±129.2 to 463.5±133.5 meters in the SR, and from 343.7±107.9 to 403.0±114.5 meters in the AF (P<0.001, respectively). There were no significant differences in ΔQS and Δ6MWD between the SR and AF groups even after adjustment for clinical confounding factors including baseline QS or 6MWD (Figure).

Conclusions

The AF status in HFpEF patients was associated with older age, lower peripheral muscle function and also lower exercise tolerance at baseline, but not associated with the responses to exercise training.

Acknowledgement/Funding

JSPS KAKENHI JP16K16442

P1717The clinical impact of intra-aortic balloon pumping for acute coronary syndrome from Mie ACS registry

Background

Intra-Aortic Balloon Pumping (IABP) was widespread used in cases of Acute Coronary Syndrome (ACS) at daily clinical situation in Japan, even though the efficacy of IABP in AMI patients with cardiogenic shock was not proved. The aim of this study was to investigate the efficacy of IABP use in ACS patients in Japan.

Methods

We investigated 2-year all-cause-mortality of 2,660 enrolled ACS patients including 358 patients with IABP and 2,302 patients without IABP from Mie ACS registry.

Results

We compared a 1:1 propensity score-matched cohort of 426 ACS patients with or without IABP (n=213, respectively). 2-year mortality was significantly higher in patients with IABP than without IABP (p=0.02, Figure A). In addition, IABP usage was independent predictor of mortality with hazard ratio of 1.6 by multivariate analysis. However, 2-year mortality was not statistically different between 2 groups only when analyzed patients with shock (p=0.60, Figure B).

Figure 1

Conclusion

IABP was not commonly recommended in ACS patients. However, IABP was might as well used in some situation especially in shock.

P2659Difference of prognostic impact of Killip classification in ACS patients with or without hemodialysis

Background

Cardiovascular deaths are more frequently in hemodialysis (HD) patients compared to general population. However, difference of prognosis of acute coronary syndrome (ACS) patients with or without HD were not well evaluated.

Purpose

The purpose of this study was to evaluate the clinical and prognostic characteristics of ACS patients with HD compared to that of ACS patients without HD.

Methods

We investigated 3427 ACS patients including 63 HD and 3364 non-HD patients between 2013 and 2017 using date from Mie ACS registry, a retrospective and multicenter registry. The primary outcome was defined as all-cause mortality.

Results

HD patients showed significantly higher prevalence of diabetes mellitus, past treatment of coronary artery disease, history of myocardial infarction and Killip ≥2 compared to non-HD patients (p<0.05, respectively). During the follow-up periods (median 719 days), 425 (12.4%) patients experienced all-cause death. HD patients demonstrated the higher all-cause mortality rate compared to that of non-HD patients during the follow-up (11.9% versus 38.1%, p<0.001, chi square). Kaplan Meier survival curves demonstrated that HD and non-HD patients with Killip 1 showed similar 30-day mortality, and Killip ≥2 patients also showed similar prognosis (Left side of figure). On the other hand, all cause mortality at 2 years were higher in Killip 1 HD patients compared to Killip 1 non-HD patients and similar between Killip 1 HD patients and Killip ≥2 non-HD patients in the 30 days landmark analysis (Right side of figure). In addition, cox regression analyses for all cause mortality demonstrated that HD was a strongest independent prognostic factor not of 30-day mortality but of after 30-day mortality with hazard ratio of 4.09 (95% confidential interval: 2.32–7.21, p<0.001).

Figure 1

Conclusion

Careful management are required in chronic phase for ACS patients with HD even in Killip 1 classification.

Subjective Evaluation of Denture Adhesives: A Multicenter Randomized Controlled Trial

INTRODUCTION

Many reports show that denture adhesives improve the retention and stability of dentures. However, few randomized controlled trials have examined the effects of denture adhesives.

OBJECTIVE

This 10-center randomized controlled trial with parallel groups involving 200 edentulous patients wearing complete dentures aimed to evaluate the effects of short-term use of cream and powder denture adhesives.

METHODS

Patients were allocated into 2 cream- and powder-type adhesive groups and 1 control group. Intervention groups were treated with the 2 adhesives (1 each), and the control group received saline solution. Adhesive or control was applied to the denture-mucosal surface for 4 d, and data at baseline and after day 4 of intervention (i.e., 8 meals) were obtained. Patient satisfaction was evaluated with a 100-mm visual analog scale. Oral health-related quality of life was measured with the Japanese version of the Oral Health Impact Profile for Edentulous Patients. Perceived chewing ability was evaluated by a questionnaire regarding ease of chewing and swallowing food. Between-group comparisons were performed with Kruskal-Wallis tests with the Mann-Whitney U test adjusted by Bonferroni correction. Within-group comparisons of pre- and postintervention measurements were performed with the Wilcoxon signed-rank test. Intention-to-treat analysis was also performed.

RESULTS

Between-group comparisons showed no significant differences for general satisfaction or Oral Health Impact Profile for Edentulous Patients. However, significant differences in satisfaction with various denture functions with cream- and powder-type adhesives were seen in pre- and postintervention comparisons (P < 0.05). Significant differences were also observed for perceived chewing ability of hard foods (P < 0.05).

CONCLUSION

These results suggest that although denture adhesives do not invariably improve denture function, they do affect subjective evaluations and possibly chewing of hard foods. Therefore, the effects of denture adhesive use are insufficient to resolve any fundamental dissatisfaction with dentures ( ClinicalTrials.gov NCT01712802 ).

KNOWLEDGE TRANSFER STATEMENT

The results of this study suggest that denture adhesives should be applied under certain conditions; however, an appropriate diagnosis is important before application. These practice-based data provide information to establish evidence-based guidelines for applying denture adhesives.

Craniofacial penetration by a wooden stick

INTRODUCTION

Penetrating craniofacial injuries caused by stick-like foreign bodies occur as a result of accidents particularly in children, and often lead to significant morbidity.

CASE SUMMARY

We describe a 5-year-old boy who sustained facial trauma after falling on a wooden stick which penetrated his left cheek. At the initial visit, his vital and neurological signs were normal. However, the stick had penetrated the frontal lobe to a depth of 3cm via the orbital cavity and the anterior skull base. The stick was successfully removed while visualizing the anterior skull base in an endoscopic transethmoidal approach. A follow-up examination one year after the accident demonstrated normal visual acuity and ocular motility, with no diplopia, tearing or pain.

DISCUSSION

Penetrating facial injuries caused by stick-like objects carry a significantly higher risk of serious neurological involvement. Even if penetrating facial injuries sometimes appear trivial, the external injury site is often insufficient to determine the position of the object within the head. Although the cheek is a rare entry site for intracranial injuries, the extent of damage should be assessed fully before attempting removal.

C-reactive Protein Can Predict Patients with Cirrhosis at a High Risk of Early Mortality after Acute Esophageal Variceal Bleeding

Objective The aim of this study was to identify patients with a high risk of early mortality after acute esophageal variceal bleeding by measuring the C-reactive protein (CRP) level. Methods We retrospectively evaluated 154 consecutive cirrhotic patients admitted with acute esophageal variceal bleeding. Differences between categorical variables were assessed by the chi-square test. Continuous variables were compared using the Mann-Whitney U-test. Multivariate logistic regression analyses consisting of clinical laboratory parameters were performed to identify risk factors associated with the 6-week mortality. The discriminative ability and the best cut-off value were assessed by a receiver-operating characteristic (ROC) curve analysis. Results Child-Pugh C patients showed a significantly higher 6-week mortality than Child-Pugh A or B patients (38% vs. 6%, p<0.0001). The 6-week mortality in Child-Pugh C patients was associated with the age (p<0.0001), etiology of cirrhosis (p=0.003), hepatocellular carcinoma (p=0.0003), portal vein thrombosis (p=0.005), baseline creatinine (p=0.0001), albumin (p=0.001), white blood cell count (p=0.038), baseline CRP [p=0.0004; area under the ROC (AUROC)=0.765; optimum cut-off value at 1.30 mg/dL] and bacterial infection (p=0.019). We determined that CRP ≥1.30 mg/dL was an independent predictor for 6-week mortality in Child-Pugh C patients [odds ratio (OR)=8.789; 95% confidence interval (CI): 2.080-47.496; p=0.003], along with a creatinine level of 0.71 mg/dL (OR=17.628; 95% CI: 2.349-384.426; p=0.004) (73% mortality if CRP ≥1.30 mg/dL vs. 19% if CRP<1.30 mg/dL, p<0.0001). Conclusion In Child-Pugh C patients with esophageal variceal bleeding, a baseline CRP ≥1.30 mg/dL can help identify patients with an increased risk of mortality.

Phase Angle Is a Useful indicator for Muscle Function in Older Adults

AIM

Phase angle (PhA) can be determined through bioelectrical impedance analysis and is a unique variable for skeletal muscle. The objective of this study was to evaluate the relationship between PhA and muscle mass/quality in older adults. In addition, we attempted to determine the cutoff value of PhA for poor muscle function.

METHODS

Community-dwelling Japanese older men (n=285, 81.1±7.1 years) and women (n=724, 80.4±6.8 years) participated in this study and were classified into four groups based on the Asian Working Group for Sarcopenia (normal, presarcopenia, dynapenia, and sarcopenia). We measured PhA using bioelectrical impedance analysis, muscle quantity and quality indicators using ultrasonography, muscle strength, and physical performance and compared them in four groups. We also tried to determine the cutoff value of PhA for poor muscle function.

RESULTS

We found a significant difference in PhA among the four groups in men (P<0.05), and the dynapenia (3.61±0.75°) and sarcopenia groups (3.40±0.74°) showed significantly lower values than the normal group (4.50±0.86°) (P<0.05), but not the presarcopenia group (4.12±0.85°). In women, a significant difference was also observed among the four groups (P<0.05), and the dynapenia (3.41±0.65°) and sarcopenia groups (3.31±0.66°) showed significantly lower measures than the normal group (4.14±0.71°) (P<0.05), but not the presarcopenia group (4.07±0.51°). The receiver-operating characteristic curve analysis indicated the best cutoff value of PhA (men: 4.05°, women: 3.55°) to discriminate sarcopenia and dynapenia from normal and presarcopenia.

CONCLUSION

These findings suggest that PhA is a useful indicator for muscle function.

Plasma Amino Acid Concentrations Are Associated with Muscle Function in Older Japanese Women

BACKGROUND

Although several previous studies have found benefits for amino acid supplementation in terms of muscle function, the role of plasma amino acid concentrations on sarcopenia are not well addressed yet.

OBJECTIVE

The aim of this study was to compare the amino acid concentrations at each stage of sarcopenia (normal, pre-sarcopenia, dynapenia, and sarcopenia) in community-dwelling older Japanese adults.

SETTING AND SUBJECTS

Community-dwelling older Japanese women (n=232, 79.4±7.0 years) participated in this study.

MEASUREMENTS

We measured plasma amino acid concentrations, 5-m walking speed, grip strength, and skeletal muscle mass using a bioelectrical impedance data acquisition system and compared them among participants at each stage of sarcopenia.

RESULTS

The proportions of normal, pre-sarcopenia, dynapenia, and sarcopenia patients were 40.5% (n=94), 12.1% (n=28), 26.3% (n=61), and 21.1% (n=49), respectively. Significant differences were observed for concentrations of leucine, branched-chain amino acid (BCAAs), and essential amino acid (EAAs) among the four groups (p<0.05), and the dynapenia and sarcopenia groups showed significantly lower concentrations of leucine than the normal group (p<0.05).

CONCLUSIONS

This study indicated a positive relationship between plasma leucine, BCAA and EAA concentrations and muscle function. A longitudinal study is needed to determine the causal relationship between leucine/BCAA concentrations and muscle function.

Fibroblast growth factor 13 regulates glioma cell invasion and is important for bevacizumab-induced glioma invasion

Glioblastoma has the poorest prognosis, and is characterized by excessive invasion and angiogenesis. To determine the invasive mechanisms, we previously used two glioma cell lines (J3T-1 and J3T-2) with different invasive phenotypes. The J3T-1 showed abundant angiogenesis and tumor cell invasion around neovasculature, while J3T-2 showed diffuse cell infiltration into surrounding healthy parenchyma. Microarray analyses were used to identify invasion-related genes in J3T-2 cells, and the expressed genes and their intracellular and intratumoral distribution patterns were evaluated in J3T-2 cell lines, human glioma cell lines, human glioblastoma stem cells and human glioblastoma specimens. To determine the role of the invasion-related genes, invasive activities were evaluated in vitro and in vivo. Fibroblast growth factor 13 (FGF13) was overexpressed in J3T-2 cells compared to J3T-1 cells, and in human glioma cell lines, human glioblastoma stem cells and human glioblastoma specimens, when compared to that of normal human astrocytes. Immunohistochemical staining and the RNA-seq (sequencing) data from the IVY Glioblastoma Atlas Project showed FGF13 expression in glioma cells in the invasive edges of tumor specimens. Also, the intracellular distribution was mainly in the cytoplasm of tumor cells and colocalized with tubulin. Overexpression of FGF13 stabilized tubulin dynamics in vitro and knockdown of FGF13 decreased glioma invasion both in vitro and in vivo and prolonged overall survival of several xenograft models. FGF13 was negatively regulated by hypoxic condition. Silencing of FGF13 also decreased in vivo bevacizumab-induced glioma invasion. In conclusion, FGF13 regulated glioma cell invasion and bevacizumab-induced glioma invasion, and could be a novel target for glioma treatment.

Carotid intima media thickness in a girl with sitosterolemia carrying a homozygous mutation in the ABCG5 gene

BACKGROUND

Sitosterolemia is a rare lipid metabolism disorder that involves storage of plant sterols. This disease is associated with atherosclerosis, but detailed vascular endothelial assessment is difficult.

CASE PRESENTATION

We report a 5-year-old girl with sitosterolemia who presented with xanthomas at 23 months of age. Her total cholesterol was 868 mg/dL, and her plasma sitosterol level was 9.48 mg/dL. Direct sequencing detected a homozygous mutation in gene ABCG5 (p.Arg389His). Echocardiographic examination revealed that the carotid artery intima media thickness (cIMT) was 0.4 mm with heterogenous hyperechogenicity inside the arterial wall. She was treated using dietary therapy and ezetimibe, which effectively lowered her sitosterol levels. After 3 years of treatment, her cIMT was stable in diameter and arterial wall echogenicity had improved.

CONCLUSIONS

Sitosterolemia is a unique disorder in which it is difficult to avoid premature atherosclerosis because of high sitosterol levels. cIMT measurement with arterial wall assessment may improve management.