[Analysis of the Tumor Immune Microenvironment of Colorectal Cancer by Deep Learning-Based Imaging Cytometry]

The tumor immune microenvironment(TIME)of colorectal cancer contains indicators of unique therapeutic outcomes for each cancer patient. Deep learning-based imaging cytometry(DL-IC), which can obtain objective and reproducible cell- related information in tissue sections, has attracted attention as an analytical method for clarifying this indicator. This study demonstrates the validation process of Cu-Cyto, one of DL-IC, regarding cell identification accuracy. Acquisition of"spatial structure"information in TIME is useful for biomarker retrieval and contributes to precision oncology.

Deep Learning-based Image Cytometry Using a Bit-pattern Kernel-filtering Algorithm to Avoid Multi-counted Cell Determination

BACKGROUND/AIM

In pathology, the digitization of tissue slide images and the development of image analysis by deep learning have dramatically increased the amount of information obtainable from tissue slides. This advancement is anticipated to not only aid in pathological diagnosis, but also to enhance patient management. Deep learning-based image cytometry (DL-IC) is a technique that plays a pivotal role in this process, enabling cell identification and counting with precision. Accurate cell determination is essential when using this technique. Herein, we aimed to evaluate the performance of our DL-IC in cell identification.

MATERIALS AND METHODS

Cu-Cyto, a DL-IC with a bit-pattern kernel-filtering algorithm designed to help avoid multi-counted cell determination, was developed and evaluated for performance using tumor tissue slide images with immunohistochemical staining (IHC).

RESULTS

The performances of three versions of Cu-Cyto were evaluated according to their learning stages. In the early stage of learning, the F1 score for immunostained CD8⁺ T cells (0.343) was higher than the scores for non-immunostained cells [adenocarcinoma cells (0.040) and lymphocytes (0.002)]. As training and validation progressed, the F1 scores for all cells improved. In the latest stage of learning, the F1 scores for adenocarcinoma cells, lymphocytes, and CD8⁺ T cells were 0.589, 0.889, and 0.911, respectively.

CONCLUSION

Cu-Cyto demonstrated good performance in cell determination. IHC can boost learning efficiencies in the early stages of learning. Its performance is expected to improve even further with continuous learning, and the DL-IC can contribute to the implementation of precision oncology.

Patients younger than 40 years with colorectal cancer have a similar prognosis to older patients

PURPOSE

Colorectal cancer (CRC) is a leading cause of cancer-related deaths worldwide. In recent years, the proportion of patients diagnosed with CRC at younger ages has increased. The clinicopathological features and oncological outcomes in younger patients with CRC remain controversial. We aimed to analyze the clinicopathological features and oncological outcomes in younger patients with CRC.

METHODS

We examined 980 patients who underwent surgery for primary colorectal adenocarcinoma between 2006 and 2020. Patients were divided into two cohorts: younger (< 40 years old) and older (≥ 40 years old).

RESULTS

Of the 980 patients, 26 (2.7%) were under the age of 40 years. The younger group had more advanced disease (57.7% vs. 36.6%, p = 0.031) and more cases beyond the transverse colon (84.6% vs. 65.3%, p = 0.029) than the older group. Adjuvant chemotherapy was administered more frequently in the younger group (50% vs. 25.8%, p < 0.01). Relapse-free survival and overall survival were similar between the groups at all stages. Moreover, in stages II and III they were also comparable, regardless of the administration of adjuvant chemotherapy.

CONCLUSIONS

Younger patients with CRC have a prognosis equivalent to that of older patients. Further studies are needed to establish the optimal treatment strategies for these patients.

Sudachitin and Nobiletin Stimulate Lipolysis via Activation of the cAMP/PKA/HSL Pathway in 3T3-L1 Adipocytes

Polymethoxyflavones are flavonoids that are abundant in citrus fruit peels and have beneficial effects on human health. Previous studies have demonstrated that the polymethoxyflavones, namely sudachitin and nobiletin, ameliorate obesity and diabetes in humans and rodents. Although nobiletin induces lipolysis in adipocytes, lipolytic pathway activation by sudachitin has not been clarified in adipocytes. In this study, the effect of sudachitin on lipolysis was elucidated in murine 3T3-L1 adipocytes. Glycerol release into the medium and activation of the cyclic AMP (cAMP)/protein kinase A (PKA)/hormone-sensitive lipase (HSL) pathway was evaluated in 3T3-L1-differentiated adipocytes. Treatment with sudachitin and nobiletin for 24 and 48 h did not induce cytotoxicity at concentrations of up to 50 μM. Sudachitin and nobiletin at concentrations of 30 and 50 μM increased intracellular cAMP and medium glycerol levels in 3T3-L1 adipocytes. Western blotting revealed that sudachitin and nobiletin dose-dependently increased protein levels of phosphorylated PKA substrates and phosphorylated HSL. Sudachitin- and nobiletin-induced glycerol release, phosphorylation of PKA substrates, and HSL phosphorylation were suppressed by pharmacological inhibition of adenylate cyclase and PKA. These findings indicated that sudachitin, similar to nobiletin, exerts anti-obesogenic effects, at least in part through the induction of lipolysis in adipocytes.

Cross-Sectional and Longitudinal Associations of Creatinine-to-Cystatin C Ratio with Sarcopenia Parameters in Older Adults

OBJECTIVES

Accumulating evidence from cross-sectional studies suggests that the serum creatinine-to-cystatin C ratio (CCR) may be a useful biomarker for sarcopenia. This study aimed to assess the cross-sectional and longitudinal associations of CCR with sarcopenia and its parameters in community-dwelling older adults.

DESIGN

Cross-sectional and longitudinal study.

SETTING AND PARTICIPANTS

This 6-year prospective cohort study included the repeated measurement data from 1,253 Japanese residents (662 males and 591 females) aged ≥65 years who underwent medical checkups in Kusatsu and Hatoyama, Japan. A total of 4,421 observations were collected.

MEASUREMENTS

The CCR was grouped into quartiles by sex (Q1-Q4) using Q4 as the reference category. Sarcopenia was defined according to the Asian Working Group for Sarcopenia 2019 algorithm. Skeletal muscle mass index (SMI) measured using segmental multifrequency bioelectrical impedance analysis, handgrip strength (HGS), usual gait speed (UGS), and maximal gait speed (MGS) were measured repeatedly as sarcopenia parameters. The association of the CCR with changes in sarcopenia, SMI, HGS, UGS, and MGS during the 6-year period were analyzed using a generalized linear mixed-effects model.

RESULTS

The prevalence of sarcopenia at baseline was 13.1% (11.9% in males and 14.5% in females). In a cross-sectional analysis, the CCR quartile was inversely associated with sarcopenia and was positively associated with SMI, HGS, and MGS (P for trend < 0.001). In a longitudinal analysis during the 6 years, a significant increase in sarcopenia in Q2 (B = 1.1% point/year; P = 0.026 for group-by-time interaction) and significant declines in SMI (B = -0.01 kg/m2/year; P = 0.044 for group-by-time interaction) and MGS (B = -0.008 m/sec/year; P = 0.041 for group-by-time interaction) in Q1 were observed compared with Q4. However, the dose-response relationship was significant only for MGS (P = 0.033 for trend). No significant group-by-time interaction was observed for HGS. CCR was not significantly associated with UGS either cross-sectionally or longitudinally.

CONCLUSIONS

CCR is a useful biomarker regarding the status of sarcopenia. It may be used for sarcopenia screening even in older adults whose physical function is difficult to assess. However, further longitudinal studies are needed to determine whether CCR can be a predictor of future sarcopenia.

Reduced Number and Immune Dysfunction of CD4+ T Cells in Obesity Accelerate Colorectal Cancer Progression

Obesity, a known risk factor for various types of cancer, reduces the number and function of cytotoxic immune cells in the tumor immune microenvironment (TIME). However, the impact of obesity on CD4+ T cells remains unclear. Therefore, this study aimed to clarify the impact of obesity on CD4+ T cells in the TIME. A tumor-bearing obese mouse model was established by feeding with 45% high-fat diet (HFD), followed by inoculation with a colon cancer cell line MC38. Tumor growth was significantly accelerated compared to that in mice fed a control diet. Tumor CD4+ T cells showed a significant reduction in number and an increased expression of programmed death-1 (PD-1), and decreased CD107a expression and cytokine such as IFN-γ and TNF-α production, indicating dysfunction. We further established CD4+ T cell-depleted HFD-fed model mice, which showed reduced tumor infiltration, increased PD-1 expression in CD8+ T cells, and obesity-induced acceleration of tumor growth in a CD4+ T cell-dependent manner. These findings suggest that the reduced number and dysfunction of CD4+ T cells due to obesity led to a decreased anti-tumor response of both CD4+ and CD8+ T cells to ultimately accelerate the progression of colorectal cancer. Our findings may elucidate the pathogenesis for poor outcomes of colorectal cancer associated with obesity.

Timing of Medium-Chain Triglyceride Consumption Modulates Effects in Mice with Obesity Induced by a High-Fat High-Sucrose Diet

The prevalence of obesity is increasing worldwide, and obesity can cause type 2 diabetes, atherosclerosis, hypertension, cardiovascular disease, and cancer. Intake of medium-chain triglycerides (MCTs) containing medium-chain fatty acids reduces body fat and insulin resistance in rodents and humans. This study aimed to determine how the timing of MCT consumption affects obesity and metabolic dysfunction induced in mice by a high-fat high-sucrose diet (HFHSD). Mice received an HFHSD with or without MCT (M-HFHSD) during either the active or rest phase for 9 weeks. Significant reduction in body weight, white adipose tissue (WAT) weight, and adipocyte size in epididymal WAT (eWAT) and improved insulin sensitivity in mice fed with M-HFHSD during the active but not the rest phase were observed. The consumption of M-HFHSD during both active and rest phases increased glucose tolerance. Phosphorylated Akt was more abundant in the gastrocnemius muscles and eWAT of M-HFHSD-fed mice than in those fed HFHSD during the active phase. The mRNA and protein expression of lipogenic genes increased in the eWAT of mice fed M-HFHSD compared with those fed HFHSD. Feeding with M-HFHSD during the active phase significantly increased the abundance of phosphorylated Ser563 and 660 of hormone-sensitive lipase and its upstream protein kinase A in eWAT. These results indicated that the timing of consumption modulates the effects of MCT on eWAT hypertrophy and glucose and lipid metabolism in mice.

Ketogenic diet containing medium-chain triglyceride ameliorates transcriptome disruption in skeletal muscles of rat models of duchenne muscular dystrophy

Duchenne muscular dystrophy (DMD) is a myopathy characterized by progressive muscle weakness caused by a mutation in the dystrophin gene on the X chromosome. We recently showed that a medium-chain triglyceride-containing ketogenic diet (MCTKD) improves skeletal muscle myopathy in a CRISPR/Cas9 gene-edited rat model of DMD. We examined the effects of the MCTKD on transcription profiles in skeletal muscles of the model rats to assess the underlying mechanism of the MCTKD-induced improvement in DMD. DMD rats were fed MCTKD or normal diet (ND) from weaning to 9 months, and wild-type rats were fed with the ND, then tibialis anterior muscles were sampled for mRNA-seq analysis. Pearson correlation heatmaps revealed a one-node transition in the expression profile between DMD and wild-type rats. A total of 10,440, 11,555 and 11,348 genes were expressed in the skeletal muscles of wild-type and ND-fed DMD rats the MCTKD-fed DMD rats, respectively. The MCTKD reduced the number of DMD-specific mRNAs from 1624 to 1350 and increased the number of mRNAs in common with wild-type rats from 9931 to 9998. Among 2660 genes were differentially expressed in response to MCTKD intake, the mRNA expression of 1411 and 1249 of them was respectively increased and decreased. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses suggested that the MCTKD significantly suppressed the mRNA expression of genes associated with extracellular matrix organization and inflammation. This suggestion was consistent with our previous findings that the MCTKD significantly suppressed fibrosis and inflammation in DMD rats. In contrast, the MCTKD significantly increased the mRNA expression of genes associated with oxidative phosphorylation and ATP production pathways, suggesting altered energy metabolism. The decreased and increased mRNA expression of Sln and Atp2a1 respectively suggested that Sarco/endoplasmic reticulum Ca²⁺-ATPase activation is involved in the MCTKD-induced improvement of skeletal muscle myopathy in DMD rats. This is the first report to examine transcription profiles in the skeletal muscle of CRISPR/Cas9 gene-edited DMD model rats and the effect of MCTKD feeding on it.

•

We evaluated the effects of an MCTKD on the global transcriptome of DMD rats.

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DMD rats are suitable models of human DMD for assessing transcriptome changes.

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MCTKD suppressed fibrosis and inflammatory pathways at the transcriptional level.

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MCTKD upregulated oxidative phosphorylation and ATP production pathways.

•

MCTKD might activate SERCA at the transcriptional level.

Suppressive effects of processed aconite root on dexamethasone-induced muscle ring finger protein-1 expression and its active ingredients

Processed aconite root (PA), the tuberous root of Aconitum carmichaelii prepared by autoclaving, is a crude drug used in Japanese traditional Kampo medicine and traditional Chinese medicine for the symptoms of kidney deficiency, that is related to the muscle atrophy in modern medicine. The objective of the present study is to evaluate the effectiveness of PA on muscle atrophy and to find its active ingredients using dexamethasone-induced muscle ring finger protein-1 (MuRF1) mRNA expression in murine myoblast C2C12 cells. Dexamethasone-induced MuRF1 expression was significantly suppressed by methanol-soluble part of boiling water extract of PA in a concentration-dependent manner with its IC₅₀ value of 1.5 mg/ml. By the activity-guided fractionations of PA extract using the partition between organic solvents and its aqueous solution, the activity of PA did not transfer into the fraction containing aconitine-type diterpenoid alkaloids but into BuOH layer. Then, we found higenamine and salsolinol as the active ingredients in PA. Higenamine and salsolinol significantly suppressed dexamethasone-induced MuRF1 expression, and their IC₅₀ values were 0.49 and 50 µM, respectively. The contents of higenamine and salsolinol in the decoctions of commercially available fourteen PA products are 0.12 and 14 µg/ml as the average values, and varied with the coefficient of variation (CV) values of 97 and 63%, respectively. Higenamine also significantly suppressed dexamethasone-induced mRNA expressions of muscle atrophy F-box protein (MAFbx)/atrogin1, casitas B-lineage lymphoma-b (Cbl-b), troponin, branched-chain amino acid aminotransferase 2 (BCAT2), and Bcl-2 binding and pro-apoptotic protein3 (Bnip3). Although the quality control of PA is regulated by the contents of diterpene alkaloids, salsolinol and higenamine can be used as the marker compounds to certificate the pharmacological activities of PA.

POS1471-HPR PAIN CATASTROPHIZING AND ITS ASSOCIATION WITH PAIN OF PATIENTS WITH RHEUMATOID ARTHRITIS IN A NON-INFLAMMATORY CONDITION

Background

Pain in rheumatoid arthritis (RA) is considered to be linked with non-inflammatory factors, including physical disabilities, psychiatric disorders, and pain catastrophizing (PC) (1.

Objectives

We investigated the role of PC in the possible link between physical disabilities and psychiatric disorders in RA patients in a non-inflammatory condition.

Methods

In this cross-sectional study, a total of 81 RA patients in a non-inflammatory condition were included; all patients had serum C-reactive protein levels <0.5 mg/dL, without any inflammatory joints. We examined the demographic and clinical data and administered the pain visual analog scale (VAS), the pain catastrophizing scale (PCS), the Health Assessment Questionnaire Disability Index (HAQ-DI), and the patient version of the Brief Scale for Psychiatric Problems in Orthopedic Patients (pBS-POP). A series of multivariate-adjusted multiple regression analyses were performed to examine the associations between PC and pain intensity, physical disabilities, and psychiatric disorders.

Results

We found associations between all the above-mentioned variables in separate models associated with HAQ-DI, pBS-POP, and PCS scores. However, in the model associated with pain VAS, the PCS score (β=0.34, p=0.0073) emerged as the only variable showing statistically significant association.

Conclusion

PC is associated with pain in RA patients in a non-inflammatory condition, and this association may be mediated through pathways involving physical disabilities and psychiatric disorders.

References

[1]Edwards RR, Giles J, Bingham CO, Campbell C, Haythornthwaite JA, Bathon J (2010) Moderators of the negative effects of catastrophizing in arthritis. Pain Med 11:591–599.

Table 1.

Multiple linear regression analysis of factors associated with each outcome

OutcomeVariablesß95% CIP valuePain VASAge0.044-0.32 to 0.510.66Sex (female)0.0089-4.65 to 5.090.93Stage0.0092-4.34 to 4.700.94Disease duration0.19-0.13 to 0.880.14HAQ-DI0.23-0.23 to 1.760.13pBS-POP0.038-1.06 to 1.450.76PCS0.340.13 to 0.810.0073pBS-POPAge-0.18-0.15 to 0.000.046Sex (female)-0.0081-0.95 to 0.860.93Stage-0.033-0.97 to 0.710.77Disease duration0.10-0.053 to 0.140.40Pain VAS0.033-0.037 to 0.0500.76HAQ-DI0.410.10 to 0.450.0026PCS0.310.02 to 0.160.0088HAQ-DIAge0.160.01 to 0.200.029Sex (female)0.14-0.10 to 2.100.93Stage0.17-0.06 to 2.000.77Disease duration0.220.017 to 0.250.025Pain VAS0.14-0.01 to 0.090.76pBS-POP0.290.15 to 0.700.0026PCS0.260.03 to 0.190.0088PCSAge-0.10-0.42 to 0.120.27Sex (female)-0.21-6.77 to -0.600.02Stage-0.082-4.10 to 1.830.45Disease duration-0.13-0.53 to 0.140.25Pain VAS0.280.06 to 0.350.0073pBS-POP0.300.28 to 1.850.0087HAQ-DI0.360.23 to 1.500.0080

ß: standardized regression coefficient; CI: confidence interval; HAQ-DI: Health Assessment Questionnaire Disability Index; pBS-POP: the patient version of the Brief Scale for Psychiatric Problems in Orthopedic Patients; PCS: Pain Catastrophizing Scale; VAS: visual analog scale

Disclosure of Interests

None declared

Albumin and Derived Neutrophil-to-Lymphocyte Ratio is a Novel Prognostic Factor for Patients with Esophageal Squamous Cell Carcinoma

BACKGROUND

Multidisciplinary treatment combining neoadjuvant treatment (NAT) and surgery has slightly improved the prognosis of patients with esophageal squamous cell carcinoma (ESCC). Although various biomarkers targeting nutrition and inflammation are associated with cancer prognosis, most studies have focused on conditions prior to NAT. Developing real-time and sensitive biomarkers that monitor changes in systemic conditions during NAT is important. We established a novel nutritional and inflammatory index, represented as the albumin to derived neutrophil-to-lymphocyte ratio (Alb-dNLR), and calculated the change in Alb-dNLR (ΔAlb-dNLR) during neoadjuvant chemotherapy (nCT). In this study, we aimed to evaluate whether ΔAlb-dNLR is associated with prognosis in patients with ESCC.

METHODS

We investigated 172 patients who underwent nCT before esophagectomy between April 2010 and March 2018. The dNLR was calculated as the ratio of neutrophil count to (white blood cell count - neutrophil count), Alb-dNLR was calculated by dividing the serum albumin level by the dNLR, and ΔAlb-dNLR was evaluated by dividing the post-Alb-dNLR by the pre-Alb-dNLR. Patients were divided into 'high' and 'low' groups according to the ΔAlb-dNLR.

RESULTS

Thirty-nine patients (22.7%) had a low ΔAlb-dNLR (≤ 0.8), and the 5-year overall survival (OS) rates in patients with low and high ΔAlb-dNLR were 38.1% and 53.6%, respectively (p = 0.0072). Multivariate analyses demonstrated that estimated blood loss (p = 0.044), pathological T stage (p = 0.0005), pathological N stage (p = 0.017), and ΔAlb-dNLR (p = 0.005) were independent prognostic factors for OS.

CONCLUSIONS

ΔAlb-dNLR is a useful prognostic factor for OS in patients with ESCC receiving nCT.

Combination of extramural venous invasion and lateral lymph node size detected with magnetic resonance imaging is a reliable biomarker for lateral lymph node metastasis in patients with rectal cancer

PURPOSE

Pathological extramural venous invasion (EMVI) is defined as the active invasion of malignant cells into veins beyond the muscularis propria in colorectal cancer. It is associated with poor prognosis and increases the risk of disease recurrence. Specific findings on MRI (termed MRI-EMVI) are reportedly associated with pathological EMVI. In this study, we aimed to identify risk factors for lateral lymph node (LLN) metastasis related to rectal cancer and to evaluate whether MRI-EMVI could be a new and useful imaging biomarker to help LLN metastasis diagnosis besides LLN size.

METHODS

We investigated 67 patients who underwent rectal resection and LLN dissection for rectal cancer. We evaluated MRI-EMVI grading score and examined the relationship between MRI-EMVI and LLN metastasis.

RESULTS

Pathological LLN metastasis was detected in 18 cases (26.9%), and MRI-EMVI was observed in 32 cases (47.8%). Patients were divided into two cohorts, according to LLN metastasis. Multivariate analyses demonstrated that higher risk of LLN metastasis was significantly associated with MRI-EMVI (P = 0.0112) and a short lateral lymph node axis (≥ 5 mm) (P = 0.0002). The positive likelihood ratios of MRI-EMVI alone, LLN size alone, and the combination of both factors were 2.12, 4.84, and 16.33, respectively. Patients negative for both showed better 2-year relapse-free survival compared to other patients (84.4% vs. 62.1%, P = 0.0374).

CONCLUSIONS

MRI-EMVI was a useful imaging biomarker for identifying LLN metastasis in patients with rectal cancer. The combination of MRI-EMVI and LLN size can improve diagnostic accuracy.

A Combined Assessment Method of Phase Angle and Skeletal Muscle Index to Better Predict Functional Recovery after Acute Stroke

OBJECTIVES

We aimed to investigate whether combination assessment of phase angle (PhA) and skeletal muscle index (SMI), was a possible predictor of physical function at discharge from the hospital in patients with acute stroke.

RESEARCH METHODS AND PROCEDURES

In this retrospective cohort study that was conducted from May 2020 and July 2021, we determined PhA and SMI using bioimpedance analysis (BIA) in patients with acute stroke. Patients were classified as normal, low PhA + SMI group, pre-sarcopenia (low SMI only), and dynapenia (low PhA only) using cut-off points (men: SMI < 7.0 kg/m2, PhA < 4.05 degrees; women: SMI < 5.7 kg/m2, PhA < 3.55 degrees). The main outcome was physical function based on functional independence measure motor (FIM-motor) score at discharge. Multiple regression analysis was used to determine the association between low PhA + SMI and FIM-motor score.

RESULTS

We included 244 patients (161 men; mean age, 73.9 years). low PhA + SMI was found in 21 (8.6%) patients. Multiple regression analysis showed that low PhA + SMI was independently associated with the FIM-motor score at discharge (β= -0.099, 95%CI: -0.193,-0.005, p = 0.039). The PhA cutoff values for determining good functional results using receiver operating characteristic (ROC) curves were 5.36 for men (sensitivity = 0.769, specificity = 0.586, area under the curve [AUC] = 0.682), and 3.85 for women (sensitivity = It was 0.881, specificity = 0.481, AUC). Further, pearson correlation coefficient showed that PhA was significantly related to FIM-motor score in patients with mild or moderately severe stroke (mild: r = 0.472, p < 0.001; moderate: r = 0.524, p < 0.001).

CONCLUSIONS

Combination of low PhA and SMI values at baseline, was an independent predictor of physical function at discharge in patients with acute stroke. The findings highlighted the importance of measuring PhA and SMI using BIA in patients with acute stroke.

Albumin-Derived NLR Score is a Novel Prognostic Marker for Esophageal Squamous Cell Carcinoma

BACKGROUND

Multidisciplinary treatment for esophageal squamous cell carcinoma (ESCC) has improved outcomes, but the prognosis for ESCC remains poor. Nutritional and inflammatory indicators are reported to be associated with cancer prognosis. The combination of albumin and the derived neutrophil-to-lymphocyte ratio (Alb-dNLR) score was established to measure the immune system and nutritional status. The authors hypothesized that the Alb-dNLR score could be a new reliable prognostic factor for ESCC patients.

METHODS

The study evaluated 269 patients who underwent esophagectomy between April 2010 and March 2018, including 185 patients who received neoadjuvant chemotherapy. The Alb-dNLR score was calculated using serum albumin and the dNLR. The dNLR was calculated as neutrophils to (leukocyte-neutrophil count). The cutoff values of the albumin and dNLR for overall survival (OS) were determined using the receiver operating characteristic curve. Patients were divided into "high" and "low" groups according to the Alb-dNLR score.

RESULTS

A high Alb-dNLR score was found in 61 cases (22.7%). The 5-year OS was 34% in the high Alb-dNLR group and 66.2% in the low Alb-dNLR group (p < 0.0001). The 5-year cause-specific survival (CSS) was 51.5% in the high Alb-dNLR group and 74.7% in the low Alb-dNLR group (p < 0.0001). Multivariate analyses demonstrated that the Alb-dNLR score was an independent prognostic factor for OS (hazard ratio [HR], 2.198; 95% confidence interval [CI], 1.460-3.263; p = 0.0002) and CSS (HR, 1.733; 95% CI, 1.035-2.835; p = 0.0371).

CONCLUSIONS

The Alb-dNLR score is an extremely useful, easy-to-use parameter to predict OS and CSS for ESCC patients.

Non-driving older adults living in a rural hilly area are at high risk for poor physical function

Background

While some studies have found an association between built environments and physical function, it is unclear whether living in a hilly area is associated with poor physical function among older adults, and whether this association varies by car driving status. This cross-sectional study investigated the association between hilliness and physical function in community-dwelling older adults and whether it varied according to their car driving status.

Methods

Data were collected from 633 participants aged 60 years and older living in Okinoshima Town, Shimane prefecture, Japan, in 2018. Physical function was objectively assessed; &lt; 1.0 m/s was defined as poor walking speed, and hilliness was measured by mean land slope within a 1000-meter network buffer zone around each participant's home using geographic information system. Logistic regression examined whether hilliness was associated with poor walking speed adjusted for sex, age, body mass index, current smoking, current alcohol consumption, exercise habits, current chronic disease, and living arrangements. A stratified analysis by car driving status was also conducted.

Results

A total of 159 (25.1%) participants had poor walking speed. After adjusting for all confounders, hilliness was positively associated with poor walking speed (OR = 1.07, 95% CI, 1.02-1.12). The stratified analysis by car driving status showed that living in a hilly area was positively associated with poor walking speed among non-drivers (OR = 1.10, 95% CI, 1.03-1.17), though there were no associations among drivers (OR = 1.00, 95% CI 0.92-1.08).

Conclusions

Our study found that a hilly environment was associated with poor walking speed in community-dwelling older adults in Japan. Moreover, car driving status potentially modified the relationship between living in a hilly environment and poor walking speed.

Key messages

Older adults living in a hilly environment were more likely to have poor walking speed, compared to those living in less hilly area. The stratified analysis by car driving status showed that non-driving older adults living in a rural hilly environment may be at high risk for poor physical function.

Environmental Factors Affecting Cognitive Function Among Community-dwelling Older Adults

Background

Although neighborhood environmental factors have been found to be associated with cognitive decline, few longitudinal studies have focused on their effect among older adults living in rural areas. This longitudinal study aimed to investigate the effect of neighborhood environmental factors on cognitive decline among rural older adults.

Methods

The data of 503 older adults aged &gt; 60 years who were living in Unnan City in Japan and had participated in two surveys conducted between 2014 and 2018 were analyzed. Cognitive function was assessed using the Cognitive Assessment for Dementia, iPad version 2. Elevation, hilliness, residential density, and proximity to a community center were measured using geographic information system. Logistic regression examined the effect of each neighborhood environmental factor (in quartiles: Q1-Q4) on cognitive decline.

Results

A total of 57 (11.3%) participants demonstrated a decrease in cognitive function at follow up. Elevation (Odds ratio (OR): 3.37, 95% Confidence Interval (CI): 1.11-10.20 for Q3 vs. Q1; OR: 5.43, 95% CI: 1.89-15.56 for Q4 vs. Q1) and hilliness (OR: 3.45, 95% CI: 1.46-8.11 for Q4 vs. Q1) were associated with a higher likelihood of cognitive decline. Residential density and distance to a community center were not associated with cognitive decline.

Conclusions

Elevated and hilly environments may increase risk of cognitive decline among rural older adults.

Key messages

Residents in mountainous regions tend to have limited accessibility to various living centers. Those who live in elevated and hilly areas within the mountainous regions may have further limited accessibility and availability of locations where they can interact with others.

Low serum chloride level gives renin-angiotensin system inhibitor a prognostic impact in heart failure patients with preserved ejection fraction

Background

Hypochloremia is associated with a poor prognosis of heart failure (HF) patients. This phenomenon is sustained even in HF with preserved ejection fraction (HFpEF). Serum chloride level is known to be affected by serum renin secretion; however, this relationship is one of the least investigated field in HF patients. Renin-angiotensin system (RAS) inhibitor is recommended as a first-line medication for HF patients with reduced left ventricular ejection fraction, but no prior studies of RAS inhibitors have achieved to improve the prognosis of HFpEF patients.

Purpose

We investigated the relationship between baseline serum chloride level and the prognostic impact of RAS inhibitor in HFpEF patients.

Methods

This is an observational study including 1,913 consecutive patients who admitted to hospital due to worsening of HF and discharged alive in a single university hospital. After excluding patients who received regular hemodialysis and whose left ventricular ejection fraction were under 50%, 506 HFpEF patients were ultimately analyzed. They were categorized into tertiles by serum chloride levels at discharge (T1: −100 mEq/L, T2: 101–104 mEq/L, T3: 105- mEq/L), and patients in each category were further divided into subgroups depending on the prescription of RAS inhibitor at discharge (RAS inhibitor group and Non-RAS inhibitor group). The primary endpoint of this study was death from any cause.

Results

During the observation period with 479 days of median follow-up, 77 (15.2%) died. Patients in the RAS inhibitor group had significantly better prognosis than those in the Non-RAS inhibitor group in T1 category (Log-rank: p=0.003, Figure). In contrast, there was no statistical difference in the mortality between the RAS inhibitor group and Non-RAS inhibitor group in T2 and T3 categories (Log-rank: p=0.15, p=0.81, respectively, Figure). Multivariate Cox regression analysis in T1 category revealed that taking RAS inhibitor at discharge was independently associated with a lower mortality rate, even after the adjustment of diverse covariates (hazard ratio: 0.40, 95% confidence interval: 0.20–0.80).

Conclusion

In this observational study, the administration of RAS inhibitor was associated with an improved prognosis of HFpEF patients only in low serum chloride level at discharge. Therapeutic strategy focusing on the chloride level may be one of the promising options to find the light on a unintervenable prognosis of HFpEF.

Funding Acknowledgement

Type of funding sources: None.

Prognostic advantage of optimal medical therapy is not cancelled in hospitalized heart failure patients receiving regular hemodialysis

Background

As the first-line medications, renin-angiotensin-aldosterone system inhibitor (RAASi) and β-blocker provide prognostic benefits in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF). However, the negative inotropic effect of these drugs may destabilize the hemodynamics during hemodialysis (HD) and become prognostically controversial in patients receiving regular HD. Indeed, prior studies have reported the cancellation of the favorable prognostic effects of RAASi and β-blocker in patients with HD. However, it is totally unknown whether the guideline-directed medical therapy affects the prognosis in HF patients receiving regular HD.

Purpose

We aimed to evaluate the prognostic impact of RAASi and β-blocker on the cardiovascular (CV) events in HF patients on regular HD.

Methods

This observational study initially included 1,930 consecutive patients who were hospitalized due to HF and discharged alive. Of these, 151 patients who received regular HD were ultimately analyzed. They were classified into 3 groups depending on the prescribing medications at discharge; patients who received none of RAASi or β-blocker (None group: N=19), either RAASi or β-blocker (Either group: N=56), and both RAASi and β-blocker (Both group: N=76). The primary endpoint was a composite of CV death and readmission due to HF.

Results

During the observation period of median 501 (interquartile range: 197–954) days, the primary endpoint occurred in 61 patients (40%). Kaplan-Meier analysis showed the highest rate of composite endpoint in the None group (log-rank for trend: p&lt;0.001, Figure). After adjusting for covariates of age, sex, LVEF, and systolic blood pressure and heart rate at discharge, the hazard ratio (HR) for a composite endpoint was significantly lower in the Either group or Both group than that in the None group [HR: 0.19, 95% confidence interval (CI): 0.08–0.45; HR: 0.16, 95% CI: 0.06–0.42, respectively].

Conclusions

The prescription of RAASi or β-blocker at discharge was associated with lower adverse CV event rates in patients on regular HD who were hospitalized for HF. In order to improve long-term prognosis of HF patients on HD, we should consider the prescription of RAASi or β-blocker for them if hemodynamics during HD is affordable.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Heart failure re-hospitalization differently affects the following mortality in patients with reduced, mid-range and preserved LVEF

Introduction

The recent advances in the treatment for heart failure with reduced ejection fraction (HFrEF) have been remarkable, while no therapy has convincingly improved the prognosis in HF patients with preserved (HFpEF) and mid-range (HFmrEF) ejection fraction. Frequent decompensations of HF lead to progressive deterioration of cardiac and renal function, and quality of life. Hence, prior studies have reported that the mortality of HFrEF patients increases as hospitalization for HF repeats. However, it is still unclear whether this trend applies for HFpEF and HFmrEF patients.

Purpose

We aimed to compare the prognostic impact of re-hospitalization due to HF on cardiovascular death (CVD) among HFrEF, HFmrEF and HFpEF patients.

Methods

This observational study included 1,930 consecutive patients who were hospitalized for worsening of HF and discharged alive. Of them, patients who have never or have not been hospitalized for HF at least last 2 years, were finally analyzed. Patients were consisted of the population with HFrEF (EF&lt;40%, n=421), HFmrEF (EF 40–49%, n=202) and HFpEF (EF&gt;50%, n=291). Patients in each EF-classified population were divide into 2 subgroups based on whether patients were re-hospitalized for HF during the observational period, respectively. The primary endpoint of this study was CVD.

Results

During the observation period, Kaplan-Meier analysis showed that patients who were re-hospitalized for HF had higher event rate of CVD in HFrEF group (Log-rank p=0.008, Figure). Even after adjusting with multivariate covariates including age, sex, EF, brain natriuretic peptide and estimated glomerular filtration rate, re-hospitalization for HF was an independent predictor for CVD in HFrEF group (HR: 1.95, 95% CI: 1.11–2.86, p=0.029). However, in HFmrEF group and HFpEF group, there was no significant difference in the rates of CVD between 2 subgroups divided whether patients were re-hospitalized for HF or not (p=0.91, p=0.34, respectively).

Conclusion

Re-hospitalization for HF affected the CVD rate in HFrEF group, but not in HFmrEF and HFpEF groups. The prevention of re-hospitalization for HF is important particularly in HFrEF patients in order to improve cardiovascular mortality.

Funding Acknowledgement

Type of funding sources: None.

P–192 Efficacy of postponement of intracytoplasmic sperm injection timing after spindle visualization for Metaphase I oocytes

Study question

Does postponement of intracytoplasmic sperm injection (ICSI) timing after spindle visualization for Metaphase I (MI) oocytes improve developmental outcomes of embryos?

Summary answer

Postponement of ICSI timing after spindle visualization for MI oocytes improves blastocyst utility rates.

What is known already

Immature oocytes are generally considered poor developmental outcomes. Meanwhile, the timing of ICSI adjusted by using spindle visualization can improve clinically utilized embryos and live birth rates, but these outcomes remain inferior to those of mature oocytes. In in vitro maturation culture, nuclear maturation is thought to occur before the completion of cytoplasmic maturation, and in immature oocytes, synchronization of nuclear and cytoplasmic maturation may be insufficient for ICSI immediately after spindle visualization.

Study design, size, duration

Data for this retrospective cohort study were obtained 672 oocytes retrieved under mild stimulation cycles using letrozole, in patients aged younger than 39 years between April 2017 and October 2020.Written informed consent was obtained from all patients. This study was approved by the institutional review board.

Participants/materials, setting, methods

As a control group, 464 MetaphaseIIoocytes that underwent ICSI immediately after visualization of the spindle were used. In group A, 103 MI oocytes underwent ICSI immediately after the first polar body release and spindle visualization, and in group B, 105 oocytes underwent ICSI 2–3 hours after spindle visualization. The primary outcomes were fertilization rates, degeneration, cleavage, embryo blastocyst formation, and utility rates. Outcomes were compared among the three groups.

Main results and the role of chance

The baseline fertilization rates of each group (control, A, B) were 82.3% (382/464), 73.8% (76/103), and 83.8% (88/105), respectively. The rate was significantly lower in group A than in the control group (P &lt; 0.05), and also tended to be lower in group A than in group B, although the difference was not significant. There was no significant difference in abnormal fertilization rates, oocyte degeneration rates, cleavage rates, and blastocyst formation rates among the three groups. [control, A, B: abnormal fertilization rate: 4.3% (20/464), 8.7% (9/103), 4.8% (5/105); oocyte degeneration rates: 3.0% (14/464), 1.9% (2/103), 3.8% (4/105); cleavage rates: 95.6% (307/321), 93.8% (61/65), 98.7% (74/75); blastocyst formation rates: 58.6% (177/302), 51.7% (31/60), 55.4% (41/74), respectively]. The blastocyst utility rates of control group and group B were significantly higher than in group A [41.7% (126/302), 45.9% (34/74), 26.7% (16/60), respectively] (P &lt; 0.05). There were no significantly different outcomes between the control group and group B.

Limitations, reasons for caution

The optimal timing of ICSI for MI oocyte cannot be determined by the presence or absence of spindles. In addition, the postponement duration we set was based on reports which reported on final oocyte maturation, and further investigation is needed to establish the optimal ICSI timing for MI oocytes.

Wider implications of the findings: In MI oocytes, postponement of ICSI timing after spindle visualization is essential for synchronization of the nucleus and cytoplasmic maturation.

Trial registration number

none

P–609 The chances of one live birth rates after first ART cycle in minimal stimulation cycle IVF with letrozole only and natural cycle IVF

Study question

Are one live birth rates (LBRs) similar in minimal stimulation cycle IVF with letrozole only and natural cycle IVF for the first ART cycle?

Summary answer

LBRs after first ART cycle in minimal stimulation cycle IVF with letrozole only are superior to natural cycle IVF.

What is known already

The addition of letrozole to gonadotropins in ovarian stimulation (OS) may reduce the risk of OHSS, but there is no significant difference were reported in ongoing pregnancy rate or number of oocytes retrieved in the letrozole + FSH group compared to the FSH only. No differences were also reported in clinical pregnancy rates or number of mature oocytes in the additional of letrozole in an GnRH antagonist protocol group compared to the GnRH antagonist group. There are no previous study comparing LBRs after first ART cycle in minimal stimulation cycle IVF with letrozole and natural cycle IVF.

Study design, size, duration

Data for this retrospective cohort study were obtained 643 women, 30–39 years of age started their first ART cycle at one private fertility clinic between January 2016- December 2019.

Participants/materials, setting, methods

A total of 643 women were scheduled their first oocyte retrieval cycle. 118 women started with letrozole (LE) and 525 women started natural cycle (NC). The main strategy for OS in our center is minimal stimulation and natural cycle IVF. Patients consulted with gynecologists to determine their treatment plan based on patients’ preference or their menstrual cycle. All pregnancies generated from oocyte retrieval during the first IVF cycle including fresh and frozen-thaw cycles were registered.

Main results and the role of chance

The number of retrieved oocytes and the normal fertilization rates were significantly higher in the LE than NC (4.4 vs 3.4, 77.6% vs 71.1%), p &lt; 0.05 respectively). There was no significant difference in the clinical pregnancy rates (CPRs) per embryo transfer (ET) (fresh cleavage stage ET: 32.9% vs 28.0%, frozen-thaw blastocyst ET: 39.4% vs 44.9% ns). However, the CPRs and LBRs per oocyte retrieval (OR) were significantly higher in the LE group (39.0% vs 28.6, 33.9% vs 21.9%, p &lt; 0.05 respectively). In a subsequent regression analyses, LBRs per OR of LE was significantly higher than NC as well. (adjusted OR = 1.63 (95% CI: 1.02–2.58, p = 0.041).

Limitations, reasons for caution

The strength of the present study was the use of a large cohort of women who underwent minimal stimulation IVF with letrozole only. Although our results are promising, limited by retrospective cohort study. These interpretations prompted the need for a perspective cohort study to evaluate the efficacy of letrozole.

Wider implications of the findings: When comparing minimal stimulation IVF with letrozole only and natural cycle IVF, we found significantly higher LBRs per OR in minimal stimulation IVF with letrozole only, despite similar CPRs per ET.

Trial registration number

none

Risk Factors for Outlet Obstruction in Patients with Diverting Ileostomy Following Rectal Surgery

Objectives:

Anastomotic leakage is one of the most severe complications of rectal cancer surgery. A diverting ileostomy was constructed for the purpose of reducing anastomotic failure risk. Outlet obstruction (OO) is one of the complications of diverting stoma that results in a lack of fecal discharge from the stoma. Detailed etiologies and preventive measures for outlet obstruction have not yet been identified.

Methods:

We studied 125 patients who underwent rectal resection, anastomosis, and elective ileostomy. We evaluated the incidence of outlet obstruction and looked for any relationship between perioperative factors and outlet obstruction.

Results:

Outlet obstruction was detected in 20 cases (16.0%). Outlet obstruction occurred 9 days after surgery in most cases. Inserting a decompressing tube improved obstructive symptoms in 4 days. Patients were divided into two cohorts according to the occurrence of outlet obstruction. Postoperative hospital stay was longer in the outlet obstruction group (19 vs. 15 days; p = 0.0003). A multivariate analysis identified that younger patients, a postoperative thicker rectus abdominis muscle at the stoma passage and high output syndrome were independent risk factors for outlet obstruction.

Conclusions:

Younger patients, a postoperative thicker rectus abdominis muscle at stoma passage and high output syndrome were independent risk factors for outlet obstruction.

A multicenter cohort study of osimertinib compared with afatinib as first-line treatment for EGFR-mutated non-small-cell lung cancer from practical dataset: CJLSG1903

Background

FLAURA, the prospective trial of osimertinib as a first-line therapy compared with first-generation epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs), did not show superior survival benefit for osimertinib in either the subgroup of Asians or the subgroup with the L858R mutation. In addition, the superiority of osimertinib compared with second-generation EGFR-TKI is thus far unclear.

Patients and methods

We reviewed the clinical data of all consecutive patients who were treated with osimertinib or afatinib as first-line therapy between May 2016 and October 2019 from 15 institutions in Japan. We defined the groups based on first-line EGFR-TKI as the afatinib group and the osimertinib group. Outcomes included time to discontinuation of any EGFR-TKI (TD-TKI), overall survival (OS), and time to treatment failure, with propensity score analysis carried out as an exploratory analysis in the survival and subgroup analyses.

Results

A total of 554 patients were enrolled. Data on 326 patients in the osimertinib group, and 224 patients in the afatinib group were analyzed. TD-TKI adjusted by propensity score in the afatinib and osimertinib groups was 18.6 months (95% confidence interval 15.8 to 22.0) and 20.5 months (95% confidence interval 13.8 to not reached), respectively, without significant difference (P = 0.204). OS adjusted by propensity score favored the afatinib group with a significant difference (P = 0.018). Subgroup analysis with propensity score showed that patients with L858R and without brain metastasis had superior survival benefit with afatinib compared with osimertinib (P < 0.001).

Conclusions

TD-TKI in the afatinib group was not significantly prolonged compared with the osimertinib group in the practical data. In the exploratory analysis of patients with L858R-mutated non-small-cell lung cancer without brain metastasis, afatinib showed more benefit in OS over osimertinib.

•

The large-scale practical data of 550 patients who were treated with osimertinib or afatinib as first-line therapy were analyzed.

•

The superiority of osimertinib compared with afatinib could not be demonstrated in all populations.

•

Osimertinib therapy showed effectiveness in patients with brain metastasis.

•

Afatinib therapy showed potential benefit in patients with L858R mutation and without brain metastasis.

A phase II study of the safety of olanzapine for oxaliplatin based chemotherapy in coloraectal patients

Olanzapine has exhibited efficacy as an antiemetic agent when used with 5-HT₃ receptor antagonists, dexamethasone, and NK₁ receptor antagonists for patients receiving highly emetogenic chemotherapy. In addition, several studies have reported the efficacy or safety of olanzapine in patients receiving moderately emetogenic chemotherapy, including carboplatin, irinotecan, and oxaliplatin. However, no reports of olanzapine use have focused on patients receiving oxaliplatin-based chemotherapy. Therefore, we analyzed the safety of antiemetic therapy using olanzapine, palonosetron, aprepitant, and dexamethasone in colorectal cancer patients undergoing oxaliplatin-based chemotherapy. This study was a prospective phase II single-institution study of 40 patients (median age 60 years, 23 patients were male). The primary endpoint was the incidence of adverse events, and the exploratory endpoints were the rate of chemotherapy-induced nausea and vomiting. Almost all patients (90%) had a performance status of 0. All patients received the scheduled antiemetic therapy. The most common adverse event was somnolence (n = 7 patients, 17.5%). All adverse events were grade 1. Thirty-six patients were included in the exploratory analysis of efficacy. No patients experienced vomiting during the first 120 h after chemotherapy, and complete response and complete control were both 86.1%. The rate of total control was 55.6% during the same time period. Olanzapine use with 5-HT₃ receptor antagonists, dexamethasone, and NK₁ receptor antagonists was safe for colorectal cancer patients receiving oxaliplatin-based chemotherapy.

Clinical significance of late diastolic tissue doppler parameters after onset of STEMI: from the view point of the timing of the echocardipography

Background

The early transmitral flow velocity (E) divided by the early diastolic velocity of the mitral valve annulus (e') is referred to as the “E/e' ratio,” is useful even for ST elevation acute myocardial infarction (STEMI). However, the role of late diastolic velocity (a') which reveals the atrial function for STEMI is still unclear.

Objectives

We evaluated the clinical usefulness of tissue Doppler including atrial function for a first-time STEMI by long time follow up. Furthermore, we evaluated the meaning of each parameters by performing immediately after PCI or 2 weeks later.

Methods

We treated consecutive 571 first-time STEMI patients by immediate PCI within 12 hours after onset, and we examined 270 patients at immediately after PCI (GroupA, 65 years, 250 male) and 301 patients at 2 weeks after onset (GroupB, 64 years, 243 male). We examined trans mitral flow and TDI, then defined E/e' as LV filling pressure and A/a' as left atrial function. We followed them for a long time (&gt;5 years). The primary end point (PE) was cardiac death or re-admission for heart failure (HF).

Results

We followed the patients in Group A for 10 years, Group B for 5 years. PE occurred in 64 patients in GroupA during 10 years, and 45 patients in GroupB during 5 years. We analyzed the univariate and multivariate Cox hazard analyses and we compared e' and a', E/e' and A/a' (Table). In GroupA, a' and A/a' were the independent predictors, on the other hand neither a' nor A/a' were the predictors in GroupB. E/e' was an independent predictor both in GroupA and B.

Conclusion

TDI parameters have different meanings by the timing of echocardiography after onset of a first-time STEMI. These results demonstrated that atrial dysfunction immediately after onset of STEMI suggests the poor prognosis after STEMI.

Cox Hazard Proportional Analysis

Funding Acknowledgement

Type of funding source: None

The prognostic impact of catheter ablation for atrial fibrillation after heart failure hospitalization on long-term mortality – Propensity-score matching analysis

Background

In the last two decades, catheter ablation (CA) for atrial fibrillation (AF) including pulmonary vein isolation (PVI) has been developed as a standard and effective treatment for atrial fibrillation (AF). In patients with chronic heart failure with reduced left ventricular ejection fraction (LVEF) (HFrEF), PVI CA for AF dramatically improves LVEF, resulting in better clinical prognoses. On the contrary, there still has been no data that PVI CA for AF improves the prognosis in heart failure patients with preserved LVEF (HFpEF).

Purpose

The aim of this study was to evaluate the prognostic impact of PVI CA for AF after the hospitalization due to decompensation of heart failureHF, focusing on LVEF.

Methods

From the database including 1,793 consecutive patients who were hospitalized due to congestive HF, we ultimately analyzed 624 AF patients who were discharged alive. They were assigned into two groups due that PVI CA for AF procedure done after the index hospitalization for HF; the PVI CA group (n=62) and Non-PVI CA group (n=562). For the two groups, we performed propensity-score (PS) matching using variables as follows: age, sex, LVEF, brain natriuretic peptide (BNP), blood urea nitrogen (BUN) and estimated glomerular filtration rate (eGFR) at discharge. Further analysis was performed separately in HFrEF (LVEF &lt;50%) and HFpEF (LVEF &gt;50%). The primary endpoint of this study was death from any cause.

Results

In unmatched patients, Kaplan-Meier analysis showed that patients in the PVI CA group had a significantly lower all-cause mortality than those in the Non-PVI CA group during 678 median follow-up period (Log-rank test: P=0.003, Figure A). In 96 PS-matched patients, patients in the PVI CA group still had lower mortality rate than those in the Non-PVI CA group (hazard ratio 0.28, 95% confidence interval 0.09–0.86, p=0.018, Figure B). When the whole study population was classified into HFrEF and HFpEF, HFrEF patients who received PVI showed a significantly lower mortality than those who did not (p=0.007); whereas, in HFpEF patients, PVI CA for AF did not make statistical difference in all-cause mortality (p=0.061).

Conclusions

In this observational study, PVI CA for AF may improve the mortality in HF patients with reduced LVEF. However, the prognostic impact of PVI CA for AF was not observed in HF patients with preserved LVEF.

Funding Acknowledgement

Type of funding source: None

Insufficient lipid lowering therapy could not bring favorable prognostic effect in high risk patients who were functionally deferred percutaneous coronary intervention

Introduction

Deferral of percutaneous coronary intervention (PCI) of a functionally insignificant stenosis is associated with favorable long-term prognoses. However, previous reports revealed that patients with fractional flow reserve (FFR) 0.81–0.85 had higher cardiovascular adverse event rates than those with FFR &gt;0.85. Numbers of large clinical trials established the lower, the better strategy for low-density lipoprotein cholesterol (LDL-C) management for patients after PCI. However, in the real clinical practice, the achievement rate of target LDL-C is often insufficient in patients with atherosclerotic risk factors who were functionally deferred PCI.

Purpose

We aimed to examine optimal LDL-C management for patients with intermediate coronary stenosis deferred PCI by FFR measurement.

Methods

This observational study included 293 consecutive patients with coronary stenosis deferred PCI due to greater FFR than 0.80. We separately analyzed 90 patients with 0.81–0.85 of FFR and 203 patients with &gt;0.85. Patients in each group were further classified into 2 groups based on LDL-C level at one year after FFR measurement; the Lower LDL-C group (&lt;100 mg/dL) and the Higher LDL-C group (&gt;100 mg/dL). The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE) including death, non-fatal myocardial infarction, ischemic stroke, heart failure hospitalization and unplanned revascularization.

Results

Patients with FFR 0.81–0.85 had a significantly higher MACCE rate than those with FFR &gt;0.85 (hazard ratio (HR): 1.77, 95% confidence interval (CI): 1.02–3.07, p=0.043). In patients with FFR 0.81–0.85, the Lower LDL-C group (n-=53) had a significantly lower rate of the primary endpoint than the Higher LDL-C group (HR: 0.41, 95% CI: 0.18–0.97, Log-rank p=0.036, Figure A). Whereas, there was no significant difference in the event rate between 2 groups in patients with FFR &gt;0.85 (Log-rank p=0.42, Figure B).

Conclusion

Uncontrolled LDL-C level was associated with higher MACCE rate in patients who were deferred PCI due to FFR 0.81–0.85. These results suggested that even in patients who were deferred PCI, those with coronary artery stenosis of lower FFR value should receive strict LDL-C lowering therapy with close monitoring.

Figure 1

Funding Acknowledgement

Type of funding source: None

Serial echocardiographical assessment for urgent control of rapid atrial fibrillation in acute heart failure

Objectives

Doppler echocardiography is a well-recognized technique for noninvasive evaluation; however, little is known about its efficacy in patients with rapid atrial fibrillation (AF) accompanied by acute decompensated heart failure (ADHF). The aim of this study was to explore the usefulness of serial echocardiographical assessment for rapid AF patients with ADHF.

Patients

A total of 110 ADHF patients with reduced ejection fraction (HFrEF) and rapid AF who were admitted to the CCU unit and received landiolol treatmentto decrease the heart rate (HR) to &lt;110 bpm and change HR (ΔHR) of &gt;20% within 24 hours were enrolled.

Interventions

Immediately after admission, the patients (n=110) received landiolol, and its dose was increased to the maximum; then, we repeatedly performed echocardiography. Among them, 39 patients were monitored using invasive right heart catheterization (RHC) simultaneously with echocardiography.

Measurements and main results

There were significant relationships between Doppler and RHC parameters through the landiolol treatment (Figure, baseline–max HR treatment). We observed for the major adverse events (MAE) during initial hospitalization, which included cardiac death, HF prolongation (required intravenous treatment at 30 days), and worsening renal function (WRF). MAE occurred in 44 patients, and logistic regression analyses showed that the mean left atrial pressure (mLAP)-Doppler (odds ratio = 1.132, 95% confidence interval [CI]: 1.05–1.23, p=0.0004) and stroke volume (SV)-Doppler (odds ratio = 0.93, 95% confidence interval [CI]: 0.89–0.97, p=0.001) at 24 hours were the significant predictors for MAE, and multivariate analysis showed that mLAP-Doppler was the strongest predictor (odds ratio = 1.16, 95% CI: 0.107–1.27, p=0.0005) (Table).

Conclusions

During the control of the rapid AF in HFrEF patients withADHF, echocardiography was useful to assess their hemodynamic condition, even at bedside.

Doppler for rapid AF of ADHF

Funding Acknowledgement

Type of funding source: None

Maternal fish oil supplementation ameliorates maternal high-fructose diet-induced dyslipidemia in neonatal mice with suppression of lipogenic gene expression in livers of postpartum mice

Maternal fructose consumption during pregnancy and lactation is associated with metabolic dysregulation in offspring. We tested the hypothesis that fish oil (FO) supplementation during pregnancy and lactation improves fructose-induced metabolic dysregulation in postpartum dams and offspring mice. We therefore aimed to determine the effects of FO supplementation on metabolic disruption in neonatal mice and dams induced by a maternal high-fructose diet (HFrD). The weight of the offspring of dams fed with HFrD on postnatal day 5 was significantly low, but this was reversed by adding FO to the maternal diet. Feeding dams with HFrD significantly increased plasma concentrations of triglycerides, uric acid, and total cholesterol, and decreased free fatty acid concentrations in offspring. Maternal supplementation with FO significantly suppressed HFrD-induced hypertriglyceridemia and hyperuricemia in the offspring. Maternal HFrD induced remarkable mRNA expression of the lipogenic genes Srebf1, Fasn, Acc1, Scd1, and Acly in the postpartum mouse liver without affecting hepatic and plasma lipid levels. Although expression levels of lipogenic genes were higher in the livers of postpartum dams than in those of nonmated mice, HFrD feeding increased the hepatic lipid accumulation in nonmated mice but not in postpartum dams. These findings suggest that although hepatic lipogenic activity is higher in postpartum dams than nonmated mice, the lipid consumption is enhanced in postpartum dams during pregnancy and lactation. Maternal FO supplementation obviously suppressed the expression of these lipogenic genes. These findings coincide with reduced plasma triglyceride concentrations in the offspring. Therefore, dietary FO apparently ameliorated maternal HFrD-induced dyslipidemia in offspring by suppressing maternal lipogenic gene expression and/or neonatal plasma levels of uric acid.

Environmental factors and physical activity among youth in rural Japan: a 1-year prospective study

Background

Although moderate-to-vigorous physical activity (MVPA) has multiple health benefits, current global activity levels among children are quite low. Environmental influences on MVPA levels among children and adolescents in rural areas are unclear. The present study examined if environmental factors were associated with MVPA in children and adolescents in rural Japan.

Methods

Two school-based serial surveys were conducted in 2017 and 2018 for 1,461 children and adolescents (10-14 years old) in Unnan City, Japan. If meeting the WHO recommended MVPA levels: at least 60 minutes/day was assessed via the Japanese translation of the WHO Health Behaviour in School-aged Children survey questionnaire. Environmental factors, namely habitable land area, population size, and population density were calculated for each individuals' residential town, and categorized into three levels (small, medium, and large). Logistic regression was used to determine odds ratios (OR) and 95% confidence intervals (CI) of engaging in the recommended level of MVPA after 1 year by each environmental factor, adjusting for sex, school grades, body mass index, screen time, preference for PA, and MVPA level at baseline.

Results

Only 22.4% of children and adolescents were engaging in the recommended MVPA levels in 2018. Engaging in the recommended level of MVPA after 1 year was significantly associated with medium (OR = 1.63; 95%CI, 1.08-2.46) and large (OR = 1.69; 95%CI, 1.15-2.47) compared to small habitable areas, and with medium (OR = 1.01; 95%CI, 0.61-1.67) and large (OR = 1.75; 95%CI, 1.09-2.81) compared to small population size. Population density was not associated with MVPA.

Conclusions

This prospective study found that habitable area and population size were positively associated with MVPA at 1-year follow-up in rural Japan. In rural areas, habitable land areas and population size itself may be a better predictor for MVPA among children than population density.

Key messages

Habitable area and population size was positively associated with physical activity among children and adolescents in rural Japan. Population density as an environmental factor was not associated with physical activity.

Daytime Dynamo Electrodynamics With Spiral Currents Driven by Strong Winds Revealed by Vapor Trails and Sounding Rocket Probes

We investigate the forces and atmosphere-ionosphere coupling that create atmospheric dynamo currents using two rockets launched nearly simultaneously on 4 July 2013 from Wallops Island (USA), during daytime Sq conditions with ΔH of -30 nT. One rocket released a vapor trail observed from an airplane which showed peak velocities of >160 m/s near 108 km and turbulence coincident with strong unstable shear. Electric and magnetic fields and plasma density were measured on a second rocket. The current density peaked near 110 km exhibiting a spiral pattern with altitude that mirrored that of the winds, suggesting the dynamo is driven by tidal forcing. Such stratified currents are obscured in integrated ground measurements. Large electric fields produced a current opposite to that driven by the wind, believed created to minimize the current divergence. Using the observations, we solve the dynamo equation versus altitude, providing a new perspective on the complex nature of the atmospheric dynamo.

Influence of an SGLT2 inhibitor, tofogliflozin, on the resting heart rate in relation to adipose tissue insulin resistance

AIMS

To examine the effects of a sodium-glucose co-transporter 2 (SGLT2) inhibitor, tofogliflozin, on resting heart rate by exploring baseline factors that independently influenced changes in the resting heart rate.

METHODS

Data on 419 participants in tofogliflozin phase 2/3 trials were analysed. Changes in resting heart rate from baseline to week 24 were analysed using an analysis of covariance (ANCOVA) model with groups (tofogliflozin/placebo) as a fixed effect and baseline values as covariates. The antilipolytic effect was evaluated as adipose tissue insulin resistance (Adipo-IR) and was calculated as the product of fasting insulin and free fatty acid. Multivariate analysis evaluated independent factors for changes in resting heart rate from baseline to week 24.

RESULTS

Of the participants, 58% were men, and mean age, HbA_1c , BMI and resting heart rate were 57.6 years, 65 mmol/mol (8.1%), 25.5 kg/m² and 66 bpm, respectively. At week 24, adjusted mean difference vs. placebo in the change from baseline was -2.3 bpm [95% confidence interval (CI) -4.6, -0.1] with tofogliflozin. Changes in resting heart rate were positively correlated with changes in Adipo-IR, whereas reductions in HbA_1c , body weight and blood pressure were similar independent of changes in resting heart among quartiles of resting heart rate change. On multivariate analysis, higher baseline resting heart rates and Adipo-IR values were significantly associated with greater reductions in resting heart rate.

CONCLUSIONS

Tofogliflozin corrected resting heart rate levels in accordance with baseline levels. Correction of high resting heart rates may be attributed to improved adipose tissue insulin resistance, leading to correction of hyperinsulinaemia.

Accelerometer-Determined Intensity and Duration of Habitual Physical Activity and Walking Performance in Well-Functioning Middle-Aged and Older Women: A Cross-Sectional Study

BACKGROUND

The association of physical activity (PA) intensities and duration spent in those activities with different walking tasks remains unclear.

OBJECTIVES

To examine the association between the duration of PA intensities and three walking speeds (usual walking speed, maximal walking speed and zig-zag walking speed).

DESIGN

Multiple linear regression analysis was used to estimate the association of age, BMI, maximum knee extension strength, light PA, moderate PA and vigorous PA with walking speeds.

SETTING

University lab.

PARTICIPANTS

Eighty-six older women (67 ± 7 years).

MEASUREMENTS

PA was measured for 30 consecutive days using the Lifecorder-EX accelerometer. Exercise intensity was categorized as light (levels 1-3), moderate (levels 4-6) and vigorous (levels 7-9) based on the manufacturer algorithms. Usual straight walking speed (20 m), maximal straight walking speed (20 m) and zig-zag walking speed tests (10 m) were performed by each participant.

RESULTS

For the usual straight walking speed model (R2 = 0.296, SEE = 0.15 m/s), the significant predictors were BMI, knee extension strength, light PA and vigorous PA. For the maximal straight walking speed model (R2 = 0.326, SEE = 0.20 m/s), only age was a significant predictor. For the zig-zag walking speed model (R2=0.417, SEE = 0.14 m/s), age and maximum knee strength were significant predictors in the model.

CONCLUSIONS

Overall, the results of this study suggest that vigorous PA and maximal knee extension strength are two important factors that are associated with different walking speeds in older women.

Gastrectomy with or without omentectomy for cT3–4 gastric cancer: a multicentre cohort study

Background

Omentectomy is performed widely for locally advanced gastric cancer to prevent disease recurrence. However, its clinical benefit is unknown.

Methods

This retrospective cohort study compared the outcome of gastrectomy with preservation of the omentum (GPO) and gastrectomy with resection of the omentum (GRO) among patients with cT3–T4 gastric cancer who underwent gastrectomy between 2006 and 2012 in one of five participating institutions. A consensus conference identified 28 variables potentially associated with outcome after gastrectomy for the estimation of propensity scores, and propensity score matching (PSM) was undertaken to control for possible confounders. Postoperative surgical outcomes, overall survival and disease recurrence were compared between GPO and GRO.

Results

A total of 1758 patients were identified, of whom 526 remained after PSM, 263 in each group. Median follow-up was 4·9 (i.q.r. 3·1–5·9) years in the GRO group and 5·0 (2·5–6·8) years in the GPO group. The incidence of postoperative complications of Clavien–Dindo grade III or more was significantly higher in the GRO group (17·5 versus 10·3 per cent; P = 0·016). Five-year overall survival rates were 77·1 per cent in the GRO group and 79·4 per cent in the GPO group (P = 0·749). There were no significant differences in recurrence rate or pattern of recurrence between the groups.

Conclusion

Overall survival and disease recurrence were comparable in patients with cT3–4 gastric cancer who underwent GPO or GRO.

Impact of Fat-Free Adipose Tissue on the Prevalence of Low Muscle Mass Estimated Using Calf Circumference in Middle-Aged and Older Adults

Previous studies proposed calf circumference cutoff values for predicting dual-energy X-ray absorptiometry (DXA)-derived low muscle mass. However, DXA-derived appendicular lean mass (aLM) includes non-skeletal muscle components such as the appendicular fat-free component of adipose tissue fat cells (aFFAT). The purpose of this study was to compare the calf circumference method of classification before (Model #1) and after (Model #2) eliminating the influence of FFAT in healthy Japanese adults (50 to 79 years; mean age 70 (SD 7) years). Model 1, and Model 2 for classifying low muscle mass had a sensitivity of 78% and 64%, specificity of 76% and 75%, positive predictive value of 31% and 28%, and negative predictive value of 96% and 93%, respectively. Appendicular fat-free component of adipose tissue has the potential to influence the ability of calf circumference to accurately classify individuals with low muscle mass. Consideration should be made when using this as a screening tool for low muscle mass.

Decreased CT-number in the pancreatic parenchyma is a reliable imaging biomarker of the presence of malignancies in patients with high-risk intraductal papillary mucinous neoplasm

BACKGROUND

Intraductal papillary mucinous neoplasm (IPMN) is a premalignant cystic neoplasm of the pancreas and is frequently detected in imaging investigations. A proportion of the patients with IPMN develop malignancies including high-grade dysplasia and invasive carcinoma. To predict the presence of malignancies in IPMN, constant imaging follow-up is usually required. Pancreatic steatosis (PS) has been recently identified as a facilitating factor for pancreatic cancer, and can be predicted through computed tomography (CT). We hypothesized that the CT-number of the pancreatic parenchyma could be a new reliable imaging biomarker for IPMN patients.

METHODS

Eighty-six patients undergoing pancreatectomy for IPMN were investigated. Using preoperative CT, the pancreatic index (PI) was calculated by dividing the CT-number of the pancreas by that of the spleen.

RESULTS

Malignancies were pathologically detected in 63 cases (73.3%). Patients were divided into two cohorts according to the presence of malignancies and were compared for various factors including the PI scores. The comparison of the two cohorts detected significant differences in two parameters (CA19-9 and PI score), and the PI score was the most sensitive biomarker to predict the presence of malignancies in patients showing high-risk stigmata of IPMN.

CONCLUSIONS

Pancreatic CT-number is an additional reliable imaging biomarker in distinguishing patients with IPMN having malignancies when investigating the patients showing high-risk stigmata.

Outcome of maintenance systemic chemotherapy with drug-free interval for metastatic urothelial carcinoma

OBJECTIVE

Aiming to achieve long-term disease control, maintenance systemic chemotherapy (MSC) with a 1-3-month drug-free interval is continued in selected patients. We report our experience of MSC for metastatic urothelial carcinoma (UC).

METHODS

Of 228 metastatic UC patients treated with systemic chemotherapy, 40 (17.5%, 40/228) had continuously undergone MSC. Data on the regimen, cycle number, and reason for the discontinuation of MSC were also collected. We analyzed OS from the initiation of MSC until death or the last follow-up, using the log-rank test to assess the significance of differences.

RESULTS

The median number of cycles of chemotherapy was 6, and the responses were CR in 6, PR in 20, SD in 13, and PD in 1 before MSC. Gemcitabine plus CDDP or carboplatin was mainly performed as MSC (70%, 28/40). MSC was repeated quarterly in 30 (75%, 30/40), every two months in 8 (20%, 8/40), and with other intervals in 2 (5%, 2/40). Overall, a median of 3.5 cycles (range: 1-29) of MSC was performed. The reason for the discontinuation of MSC was PD in 24 (60%, 24/40), favorable disease control in 9 (22.5%, 9/40), and myelosuppression in 3 (7.5%, 3/40), and for other reasons in 2 (5%, 2/40). MSC was ongoing in 2 (5%, 2/40). The median OS was 27 months from the initiation of MSC. PS0 (P = 0.0169), the absence of lung metastasis (P = 0.0387), and resection of the primary site (P = 0.0495) were associated with long-term survival after MSC.

CONCLUSIONS

In selected patients, long-term systemic chemotherapy could be performed with a drug-free interval. Our maintenance strategy with cytotoxic drugs may become one of the treatment options for long-term disease control.

Ketogenic diet induces skeletal muscle atrophy via reducing muscle protein synthesis and possibly activating proteolysis in mice

Ketogenic diets (KD) that are very high in fat and low in carbohydrates are thought to simulate the metabolic effects of starvation. We fed mice with a KD for seven days to assess the underlying mechanisms of muscle wasting induced by chronic starvation. This diet decreased the weight of the gastrocnemius (Ga), tibialis anterior (TA) and soleus (Sol) muscles by 23%, 11% and 16%, respectively. The size of Ga, TA, Sol muscle fibers and the grip strength of four limbs also significantly declined by 20%, 28%, 16% and 22%, respectively. The muscle atrophy-related genes Mafbx, Murf1, Foxo3, Lc3b and Klf15 were upregulated in the skeletal muscles of mice fed with the KD. In accordance with the reduced expression of anabolic genes such as Igf1, surface sensing of translation (SUnSET) analyses of fast-twitch Ga, TA and Sol muscles revealed that the KD suppressed muscle protein synthesis. The mRNA expression of oxidative stress-responsive genes such as Sod1 was significantly increased in all muscles examined. In addition to hypercorticosteronemia, hypoinsulinemia and reduced IGF-1, oxidative stress might also be involved in KD-induced muscle atrophy. Feeding mice with a KD is a novel experimental animal model of muscle-wasting induced by chronic starvation.