Impact of dynamic parameter of trends in vital signs on the prediction of serious events in hospitalized patients -a retrospective observational study

Aim

Although early detection of patients' deterioration may improve outcomes, most of the detection criteria use on-the-spot values of vital signs. We investigated whether adding trend values over time enhanced the ability to predict adverse events among hospitalized patients.

Methods

Patients who experienced adverse events, such as unexpected cardiac arrest or unplanned ICU admission were enrolled in this retrospective study. The association between the events and the combination of vital signs was evaluated at the time of the worst vital signs 0-8 hours before events (near the event) and at 24-48 hours before events (baseline). Multivariable logistic analysis was performed, and the area under the receiver operating characteristic curve (AUC) was used to assess the prediction power for adverse events among various combinations of vital sign parameters.

Results

Among 24,509 in-patients, 54 patients experienced adverse events(cases) and 3,116 control patients eligible for data analysis were included. At the timepoint near the event, systolic blood pressure (SBP) was lower, heart rate (HR) and respiratory rate (RR) were higher in the case group, and this tendency was also observed at baseline. The AUC for event occurrence with reference to SBP, HR, and RR was lower when evaluated at baseline than at the timepoint near the event (0.85 [95%CI: 0.79-0.92] vs. 0.93 [0.88-0.97]). When the trend in RR was added to the formula constructed of baseline values of SBP, HR, and RR, the AUC increased to 0.92 [0.87-0.97].

Conclusion

Trends in RR may enhance the accuracy of predicting adverse events in hospitalized patients.

The impact of rare cancer and early-line treatments on the benefit of comprehensive genome profiling-based precision oncology

BACKGROUND

Comprehensive genome profiling (CGP) serves as a guide for suitable genomically matched therapies for patients with cancer. However, little is known about the impact of the timing and types of cancer on the therapeutic benefit of CGP.

MATERIALS AND METHODS

A single hospital-based pan-cancer prospective study (TOP-GEAR; UMIN000011141) was conducted to examine the benefit of CGP with respect to the timing and types of cancer. Patients with advanced solid tumors (>30 types) who either progressed with or without standard treatments were genotyped using a single CGP test. The subjects were followed up for a median duration of 590 days to examine therapeutic response, using progression-free survival (PFS), PFS ratio, and factors associated with therapeutic response.

RESULTS

Among the 507 patients, 62 (12.2%) received matched therapies with an overall response rate (ORR) of 32.3%. The PFS ratios (≥1.3) were observed in 46.3% (19/41) of the evaluated patients. The proportion of subjects receiving such therapies in the rare cancer cohort was lower than that in the non-rare cancer cohort (9.6% and 17.4%, respectively; P = 0.010). However, ORR of the rare cancer patients was higher than that in the non-rare cancer cohort (43.8% and 20.0%, respectively; P = 0.046). Moreover, ORR of matched therapies in the first or second line after receiving the CGP test was higher than that in the third or later lines (62.5% and 21.7%, respectively; P = 0.003). Rare cancer and early-line treatment were significantly and independently associated with ORR of matched therapies in multivariable analysis (P = 0.017 and 0.004, respectively).

CONCLUSION

Patients with rare cancer preferentially benefited from tumor mutation profiling by increasing the chances of therapeutic response to matched therapies. Early-line treatments after profiling increase the therapeutic benefit, irrespective of tumor types.

Evaluating the effects of hypoxic storage on platelet function and health using a novel storage system

BACKGROUND

Thousands of units of whole blood (WB) and blood components are transfused daily to treat trauma patients. Improved methods for blood storage are critical to support trauma-related care. The Hemanext ONE® system offers a unique method for hypoxic storage of WB, with successfully demonstrated storage of clinically viable RBCs. This work evaluated the system for the storage of WB, focusing on platelet health and function.

STUDY DESIGN AND METHODS

WB was collected from healthy donors and processed through the Hemanext ONE® system. Hemoglobin oxygen saturation (HbSO2) levels of WB were depleted to 10%, 20%, or 30% of total HbSO2 and then stored in PVC bags sealed in oxygen-impermeable bags (except for normoxic control) with samples collected on days 1, 7, and 14 post-processing. Flow cytometry assessed the activation and apoptosis of platelets. Clot dynamics were assessed based on aggregometry and thromboelastography assays, as well as thrombin generation using a calibrated-automated thrombogram method.

RESULTS

Hypoxic storage conditions were maintained throughout the storage period. Hypoxia triggered increased lactate production, but pH changes were negligible compared to normoxic control. Storage at 10% HbSO2 had a significant impact on platelet function, resulting in increased activation and reduced clot formation and aggregation. These effects were less significant at 20% and 30% HbSO2.

DISCUSSION

This study indicates that platelets are sensitive to hypoxic storage and suffer significant metabolic and functional deterioration when stored at or below 10% HbSO2.

Search for Antideuterons of Cosmic Origin Using the BESS-Polar II Magnetic-Rigidity Spectrometer

We searched for antideuterons (d[over ¯]'s) in the 4.7×10^{9} cosmic-ray events observed during the BESS-Polar II flight at solar minimum in 2007-2008 but found no candidates. The resulting 95% C.L. upper limit on the d[over ¯] flux is 6.7×10^{-5}  (m^{2} s sr GeV/n)^{-1} in an energy range from 0.163 to 1.100  GeV/n. The result has improved by more than a factor of 14 from the upper limit of BESS97, which had a potential comparable to that of BESS-Polar II in the search for cosmic-origin d[over ¯]'s and was conducted during the former solar minimum. The upper limit of d[over ¯] flux from BESS-Polar II is the first result achieving the sensitivity to constrain the latest theoretical predictions.

Effects of thienopyridine class antiplatelets on bleeding outcomes following robot-assisted radical prostatectomy

This study aimed to assess the effects of thienopyridine-class antiplatelet agents (including ticlopidine, clopidogrel, and prasugrel) on bleeding complications in patients who underwent robot-assisted radical prostatectomy. This cohort study used a database for robot-assisted radical prostatectomy at 23 tertiary centers nationwide between 2011 and 2022. Patients who received thienopyridines (thienopyridine group) were compared with those who received aspirin monotherapy (aspirin group). The primary outcome was the incidence of bleeding complications. High-grade complications were defined as Clavien-Dindo grade III or higher. The risks of these outcomes were evaluated using inverse probability of treatment weighted regression models. The study results demonstrated that thienopyridine therapy was associated with a higher risk of overall bleeding complications (OR: 3.62, 95%CI 1.54-8.49). The increased risks of the thienopyridine group were detected for low-grade bleeding complications (OR: 3.20, 95%CI 1.23-8.30) but not for high-grade bleeding complications (OR: 5.23, 95%CI 0.78-34.9). The increased risk of bleeding complications was not observed when thienopyridine was discontinued (OR: 2.52, 95%CI 0.83-7.70); however, it became apparent when it was continued perioperatively (OR: 4.35, 95%CI 1.14-16.61). In conclusion, thienopyridine increased the incidence of bleeding complications, particularly low-grade bleeding complications, following robot-assisted radical prostatectomy. These bleeding effects emerged when thienopyridine was continued perioperatively.

COVID-19 vaccine effectiveness against severe COVID-19 requiring oxygen therapy, invasive mechanical ventilation, and death in Japan: A multicenter case-control study (MOTIVATE study)

INTRODUCTION

Since the SARS-CoV-2 Omicron variant became dominant, assessing COVID-19 vaccine effectiveness (VE) against severe disease using hospitalization as an outcome became more challenging due to incidental infections via admission screening and variable admission criteria, resulting in a wide range of estimates. To address this, the World Health Organization (WHO) guidance recommends the use of outcomes that are more specific to severe pneumonia such as oxygen use and mechanical ventilation.

METHODS

A case-control study was conducted in 24 hospitals in Japan for the Delta-dominant period (August-November 2021; "Delta") and early Omicron (BA.1/BA.2)-dominant period (January-June 2022; "Omicron"). Detailed chart review/interviews were conducted in January-May 2023. VE was measured using various outcomes including disease requiring oxygen therapy, disease requiring invasive mechanical ventilation (IMV), death, outcome restricting to "true" severe COVID-19 (where oxygen requirement is due to COVID-19 rather than another condition(s)), and progression from oxygen use to IMV or death among COVID-19 patients.

RESULTS

The analysis included 2125 individuals with respiratory failure (1608 cases [75.7%]; 99.2% of vaccinees received mRNA vaccines). During Delta, 2 doses provided high protection for up to 6 months (oxygen requirement: 95.2% [95% CI:88.7-98.0%] [restricted to "true" severe COVID-19: 95.5% {89.3-98.1%}]; IMV: 99.6% [97.3-99.9%]; fatal: 98.6% [92.3-99.7%]). During Omicron, 3 doses provided high protection for up to 6 months (oxygen requirement: 85.5% [68.8-93.3%] ["true" severe COVID-19: 88.1% {73.6-94.7%}]; IMV: 97.9% [85.9-99.7%]; fatal: 99.6% [95.2-99.97]). There was a trend towards higher VE for more severe and specific outcomes.

CONCLUSION

Multiple outcomes pointed towards high protection of 2 doses during Delta and 3 doses during Omicron. These results demonstrate the importance of using severe and specific outcomes to accurately measure VE against severe COVID-19, as recommended in WHO guidance in settings of intense transmission as seen during Omicron.

[Testicular Malignant Sertoli Cell Tumor with Long-Term Survival After Pulmonary Metastasectomy: A Case Report]

A 45-year-old man was referred to our hospital with a complaint of right scrotal discomfort. With a diagnosis of testicular tumor, right orchiectomy was performed. The tumor was histologically diagnosed as malignant Sertoli cell tumor pT1N0M0. A pulmonary nodule appeared, 53 months after the operation, and increased in size there after. Thoracoscopic left upper lobectomy was performed 64 months after the operation, and the pathological diagnosis was metastasis of malignant Sertoli cell tumor. No recurrence has been observed for 94 months after the resection of the metastatic lesion.

Comparison of clinical outcomes of osimertinib and first-generation EGFR-tyrosine kinase inhibitors (TKIs) in TKI-untreated EGFR-mutated non-small-cell lung cancer with leptomeningeal metastases

BACKGROUND

Leptomeningeal metastases (LM) are devastating complications of epidermal growth factor receptor (EGFR)-mutated non-small-cell lung cancer (NSCLC). Although osimertinib, a third-generation EGFR-tyrosine kinase inhibitor (TKI), has better penetration into the central nervous system than first-generation EGFR-TKIs, data on the distinct activity of EGFR-TKIs in untreated advanced EGFR-mutated NSCLC with LM are lacking.

PATIENTS AND METHODS

We retrospectively reviewed patients treated with EGFR-TKIs for TKI-untreated common EGFR-mutated NSCLC with LM between July 2002 and July 2021 at the National Cancer Center Hospital. The patients were divided into two groups: patients treated with osimertinib (Osi group) and those treated with gefitinib or erlotinib [first-generation (1G)-TKI group].

RESULTS

Of the 967 patients, 71 were eligible, including 29 in the Osi group and 42 in the 1G-TKI group. The median progression-free survival (PFS) and overall survival (OS) in the Osi group were better than those in the 1G-TKI group (PFS: 16.9 months versus 8.6 months, P = 0.007, and OS: 26.6 months versus 20.0 months, P = 0.158). The LM-overall response rate (ORR) and LM-PFS were significantly better in the Osi group than in the 1G-TKI group (LM-ORR: 62.5% versus 25.7%, P = 0.007; LM-PFS: 23.4 months versus 12.1 months, P = 0.021). In the subgroup analysis of EGFR mutation status, LM-PFS for patients with exon 19 deletion was significantly longer in the Osi group than in the 1G-TKI group (32.7 months versus 13.4 months, P = 0.013), whereas those with L858R mutation in exon 21 did not differ between the two groups. In the multivariate analysis, osimertinib and exon 19 deletion were significant factors for better LM-PFS and OS.

CONCLUSION

Osimertinib can be more effective for untreated common EGFR-mutated NSCLC patients with LM, especially those with exon 19 deletion, compared to first-generation TKIs.

Left ventricular outflow tract obstruction caused by a congenital accessory mitral valve leaflet and treated by open-heart surgery in a young dog

A 3-month-old Shetland sheepdog presented with a loud ejection murmur and exercise intolerance. Echocardiography revealed an accessory mitral valve leaflet, characterised by a valve-like structure separate from the mitral valve seen in the subaortic region of the ventricular septum. The left ventricular outflow tract was partially obstructed with a pressure gradient of 12 mmHg. Accessory mitral valve leaflet resection and mitral valvuloplasty were performed during open-heart surgery. Histology performed on the membrane-like structures were indicative of fibrous connective tissues. Postoperative echocardiography confirmed removal of the valve-like structure with resolution of the left ventricular outflow tract obstruction. The pressure gradient was decreased to 4.6 mmHg. The dog was in good condition and no further treatment was required 5 months after surgery. Both cardiac troponin I and NT-proBNP were markedly decreased. In this dog, surgical resection combined with mitral valve plasty resolved the left ventricular outflow tract obstruction and the clinical signs.

[A Case of Intra-Abdominal Testicular Cancer Occurring from an Overlooked Intra-Abdominal Testis in Undescended Testicular Surgery]

Here, we report an adult case of intra-abdominal testicular cancer after surgical treatment of an undescended testis in infancy. A 36-year-old male patient was accidentally diagnosed with a tumor in the pelvic cavity by ultrasonographic examination. He had hematuria and the human chorionic gonadotropin beta subunit level was slightly elevated. T2-weighedmagnetic resonance imaging revealed a well-defined and highly intense mass. Since these findings suggested intra-abdominal testicular cancer, laparoscopic surgery was performed to remove the mass. Laparoscopy revealed an intra-abdominal tumor accompanied by a looping vas deferens entering the left inguinal canal. The distal part of the looping vas had already been removed from the external inguinal ring. The pathological findings revealed a pT1 seminoma. The patient has been recurrence-free for 12 months. The present case implies the importance of careful investigation and treatment for intra-abdominal testicular cancer, since intra-abdominal testis might have been overlooked at the time of surgery for undescended testis.

Association between regional cerebral oxygen saturation and outcome of patients with out-of-hospital cardiac arrest: An observational study

Aim

This study aimed to evaluate the association between cerebral oxygen saturation (StO2) and return of spontaneous circulation (ROSC) in patients with out-of-hospital cardiac arrest (OHCA).

Methods

We retrospectively evaluated the data of patients with OHCA to determine the association between ROSC and various StO2 parameters (initial_StO2, final_StO2, mean_StO2, and Δ_StO2 [=final_StO2-initial_StO2]). Time-domain near-infrared spectroscopy was used to determine absolute StO2 values.

Results

Of the 108 patients with OHCA, 23 achieved ROSC. Although initial_StO2 values did not differ between the groups, final_StO2, mean_StO2, and Δ_StO2 were higher in the ROSC group than in the non-ROSC group. The cut-off values for initial_StO2, mean_StO2, and Δ_StO2 as predictors of ROSC were 35%, 30%, and 5%, respectively. The odds ratio for ROSC had markedly increased in the Δ_StO2 ≥ 5% subgroup (19.70 [6.06-64.11], p < 0.001). When the change in StO2 (=d_StO2) at 8 min from the initiation of StO2 measurement was assessed, the d_StO2 ≥ 5% subgroup had a higher odds ratio for ROSC than the d_StO2 < 5% subgroup (5.8 [1.78-18.85], p = 0.002), and this tendency was maintained until 20 min. In the evaluation using a two-by-two contingency table with initial_StO2 and Δ_StO2 as two parameters, 61.9% of the patients fell under the categories of initial_StO2 < 35% and Δ_StO2 < 5% and had the lowest rate of ROSC achievement (4.6%). In the Δ_StO2 ≥ 5% subgroup, approximately-two-thirds of the patients achieved ROSC irrespective of the initial_StO2 (initial_StO2 ≥ 35%, 66.7%; initial_StO2 < 35%, 60.0%).

Conclusions

Initial_StO2 and Δ_StO2 were associated with the achievement of ROSC.

Changes of the subchondral bone microchannel network in early osteoarthritis

OBJECTIVE

We have identified a 3D network of subchondral microchannels that connects the deep zone of cartilage to the bone marrow (i.e., cartilage-bone marrow microchannel connectors; CMMC). However, the pathological significance of CMMC is largely unknown. Here, we quantitatively evaluated how the CMMC microarchitecture is related to cartilage condition, as well as regional differences in early idiopathic osteoarthritis (OA).

METHODS

Two groups of cadaveric female human femoral heads (intact cartilage vs early cartilage lesions) were identified, and a biopsy-based high-resolution micro-CT imaging was employed. Subchondral bone (SB) thickness, CMMC number, maximum and minimum CMMC size, and the CMMC morphology were quantified and compared between the two groups. The effect of joint's region and cartilage condition was examined on each dependent variable.

RESULTS

The CMMC number and morphology were affected by region of the joint, but not by cartilage condition. On the other hand, the minimum and maximum CMMC size was changed by both the location on the joint, as well as the cartilage condition. The smallest CMMC were consistently detected at the load-bearing region (LBR) of the joint. Compared to non-pathological subjects, the size of the microchannels was enlarged in early OA, most noticeably at the non-load-bearing region (NLBR) and the peripheral rim (PR) of the femoral head. Furthermore, subchondral bone thinning was observed in early OA as a localized occurrence linked with areas of partial chondral defect.

CONCLUSION

Our data point to an enlargement of the SB microchannel network, and a collective structural deterioration of SB in early idiopathic OA.

Dose-Response Relationships between Diet Quality and Mortality among Frail and Non-Frail Older Adults: A Population-Based Kyoto-Kameoka Prospective Cohort Study

OBJECTIVES

Although better diet quality is inversely associated with mortality risk, the association between diet quality and mortality remains unclear in frail and non-frail older adults. Thus, we aimed to examine this association in older Japanese adults.

DESIGN

A prospective cohort study.

SETTING AND PARTICIPANTS

We used the data of 8,051 Japanese older adults aged ≥65 years in the Kyoto-Kameoka study.

MESUREMENTS

Dietary intake was estimated using a validated food frequency questionnaire. Diet quality was evaluated by calculating the adherence scores to the Japanese Food Guide Spinning Top (range, 0 [worst] to 80 [best]), which were stratified into quartiles. Frailty status was assessed using the validated self-administered Kihon Checklist (KCL) and the Fried phenotype (FP) model. Survival data were collected between February 15, 2012 and November 30, 2016. Statistical analysis was performed using the multivariate Cox proportional hazard analysis and the spline model.

RESULTS

During the median 4.75-year follow-up (36,552 person-years), we recorded 661 deaths. After adjusting for confounders, compared with the bottom adherence score quartile, the top quartile was associated with lower hazard ratio (HR) of mortality in frailty (HR, 0.73; 95% confidence interval [CI], 0.54-1.00) and non-frailty, as defined by the KCL (HR, 0.72; 95% CI, 0.52-1.01). In the spline model, regardless of frailty status defined by the KCL and FP model, adherence score showed a strongly dose-dependent inverse association with mortality up to approximately 55 points; however, no significant differences were observed thereafter. This association was similar to the results obtained in individuals with physical, cognitive, and depression as domains of KCL in the spline model.

CONCLUSIONS

Our findings demonstrate an L-shaped association between diet quality and mortality in both frail and non-frail individuals. This study may provide important knowledge for improving poor diet quality in older individuals with frailty or domains of frailty.

Near-infrared ray catheter and indocyanine green via nephrostomy in delayed robotic reconstruction of injured ureter: A case report

Delayed surgical reconstruction of iatrogenic ureteral injuries is often a challenging procedure because spreading scar tissue impedes accurate identification and dissection of the injured ureter. We report a novel real-time navigation system using a ureteral near-infrared ray catheter (NIRC) and indocyanine green (ICG) via nephrostomy in delayed robot-assisted ureteral reconstruction. A female patient presented with complete obstruction of the right upper ureter after gynecological surgery with extensive lymphadenectomy. A nephrostomy tube was urgently placed, and surgical repair was performed. A straight NIRC was placed in the right ureter up to the obstruction point. ICG was administered via nephrostomy. Near-infrared light could clearly visualize the ureter and renal pelvis encased in scar tissue. The ureter and renal pelvis were dissected and successfully anastomosed. We found that near-infrared navigation using ureteral NIRC and ICG via nephrostomy was valuable for delayed laparoscopic reconstruction of the injured ureter.

Population‑based prostate‑specific antigen screening for prostate cancer may have an indirect effect on early detection through opportunistic testing in Kusatsu City, Shiga, Japan

Prostate cancer is the most common genitourinary cancer in men. Population-based serum prostate-specific antigen (PSA) testing is used to screen men for the early detection of asymptomatic prostate cancer. The present study compared the features of patients with prostate cancer in Kusatsu City, the only municipality in Shiga Prefecture of Japan to implement organized PSA screening, with those in other municipalities. The target population for organized PSA screening by mail invitation was men ≥50 years. Patients were pathologically diagnosed via prostate biopsy because of elevated serum PSA. This multicenter observational study was subsequently conducted in 14 hospitals. The following information was extracted from patient records: age, reason for PSA testing, initial PSA level, Gleason score, clinical stage, and place of residence. Risk classification was defined as low, intermediate, high, and advanced. Each patient was stratified according to their city/town. A total of 984 patients diagnosed with prostate cancer in Shiga in 2012 and 2017 were analyzed, of which 955 (97%) were opportunistically tested, with the remaining 29 (3%) assessed by organized screening. In Kusatsu, 93 patients were diagnosed, of whom 26 (28%) were detected by organized screening. By contrast, only three of 891 patients (0.3%) were detected by organized screening in other municipalities. Of patients in Kusatsu, cases identified by opportunistic testing had a higher initial PSA value (P=0.010) than those identified by organized screening. However, patients detected through opportunistic testing in Kusatsu City were younger (P=0.034), had a lower PSA value (P=0.001), and improved risk classification (P<0.001) than those in other municipalities. It was concluded that more patients were diagnosed with early-stage cancer by organized PSA screening. Furthermore, population-based PSA screening in Kusatsu City may have indirectly affected early detection, even by opportunistic testing.

The whole blood transcriptional regulation landscape in 465 COVID-19 infected samples from Japan COVID-19 Task Force

Coronavirus disease 2019 (COVID-19) is a recently-emerged infectious disease that has caused millions of deaths, where comprehensive understanding of disease mechanisms is still unestablished. In particular, studies of gene expression dynamics and regulation landscape in COVID-19 infected individuals are limited. Here, we report on a thorough analysis of whole blood RNA-seq data from 465 genotyped samples from the Japan COVID-19 Task Force, including 359 severe and 106 non-severe COVID-19 cases. We discover 1169 putative causal expression quantitative trait loci (eQTLs) including 34 possible colocalizations with biobank fine-mapping results of hematopoietic traits in a Japanese population, 1549 putative causal splice QTLs (sQTLs; e.g. two independent sQTLs at TOR1AIP1), as well as biologically interpretable trans-eQTL examples (e.g., REST and STING1), all fine-mapped at single variant resolution. We perform differential gene expression analysis to elucidate 198 genes with increased expression in severe COVID-19 cases and enriched for innate immune-related functions. Finally, we evaluate the limited but non-zero effect of COVID-19 phenotype on eQTL discovery, and highlight the presence of COVID-19 severity-interaction eQTLs (ieQTLs; e.g., CLEC4C and MYBL2). Our study provides a comprehensive catalog of whole blood regulatory variants in Japanese, as well as a reference for transcriptional landscapes in response to COVID-19 infection.

Genetic mechanisms influencing COVID-19 susceptibility are not well understood. Here, the authors analyzed whole blood RNA-seq data of 465 Japanese individuals with COVID-19, highlighting thousands of fine-mapped variants affecting expression and splicing of genes, as well as the presence of COVID-19 severity-interaction eQTLs.

High-precision measurement of the W boson mass with the CDF II detector

The mass of the W boson, a mediator of the weak force between elementary particles, is tightly constrained by the symmetries of the standard model of particle physics. The Higgs boson was the last missing component of the model. After observation of the Higgs boson, a measurement of the W boson mass provides a stringent test of the model. We measure the W boson mass, M_W, using data corresponding to 8.8 inverse femtobarns of integrated luminosity collected in proton-antiproton collisions at a 1.96 tera-electron volt center-of-mass energy with the CDF II detector at the Fermilab Tevatron collider. A sample of approximately 4 million W boson candidates is used to obtain [Formula: see text], the precision of which exceeds that of all previous measurements combined (stat, statistical uncertainty; syst, systematic uncertainty; MeV, mega-electron volts; c, speed of light in a vacuum). This measurement is in significant tension with the standard model expectation.

Intraventricular pressure gradient: a promising tool to predict the post-infarction chronic congestive heart failure in rats

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction: Congestive heart failure (CHF), the main reason for morbidity and mortality, is considered a serious consequence of myocardial infarction (MI). The use of left ventricular end-diastolic pressure (LVEDP) as a chief indicator of CHF becomes limited because of the possible impairment of cardiac function and induced aortic valve damage during its recording. Echocardiography is the gold standard approach to diagnose structural myocardial dysfunction. However, its ability to predict chronic CHF following MI is still limited. Recently, intraventricular pressure gradient (IVPG) was presented as a non-invasive, highly sensitive preload-independent diastolic function parameter to assess cardiac function, especially during cardiomyopathy. However, there have not been any investigations demonstrating the feasibility of IVPG in the evaluation of post-infarction chronic CHF.

Purpose

This study aimed to investigate the utility of IVPG to assess the heart function in a rat model with chronic CHF following MI with evaluating its capacity to predict these changes.

Methods

Fifty male rats were included. MI was induced via ligation of the left anterior descending artery (LAD) at the level of the atrioventricular junction (MI animals, n = 35). Sham animals were subjected to the same left thoracotomy procedure without LAD ligation (Sham animals, n = 15). Transthoracic conventional echocardiography and colour M-mode echocardiography (CMME) for IVPG were performed in all animals 6 months post-surgery. The next day, animals were anesthetized, ventilated, and euthanized after the recording of hemodynamics. The heart weight, and lung and liver wet-to-dry weight ratios were recorded. J-tree cluster-analysis was performed based on ten echocardiographic variables indicative of CHF.

Results

Based on the cluster analysis, animals were joined into two clusters; CHF+ (n = 22) and named MI/HF+, and CHF- (n = 28) that was joined from sham (n = 15), and MI/HF- (n = 13). MI/HF+ presented the most severe anatomical and echocardiographic changes indicative of CHF with significant reduction of all IVPG indices and impairment of the hemodynamics. The IVPG indices were significantly (P&lt; 0.0001) correlated with the anatomical and echocardiographic findings, LVDP, LVEDP, HR, -dP/dtmin, and Tau. Meanwhile, LVSP was only significantly correlated with apical IVPG (R = 0.677, P = 0.022). dP/dtmax was significantly correlated with total IVPG, basal IVPG, and apical IVPG (R = 0.797, P = 0.017, R = 0.724, P = 0.003, and R = 0.652, P = 0.026 ; respectively). Moreover, total, basal, mid-to-apical, mid-, and apical IVPG were significant (P&lt; 0.0001) predictors of chronic CHF following MI.

Conclusion

Compared to the structural, and functional indices of conventional echocardiography, IVPG derived from CMME could provide a substantial non-invasive tool to diagnose and predict CHF after long-term MI.

Profiling the tackle and its injury characteristics in premier New Zealand club rugby union players over a complete season

Objectives

RugbySmart is a safe tackle technique education programme. Our objective was to identify whether the RugbySmart-recommended safe tackle technique was exhibited by club rugby players and whether tackle-related injuries showed poor tackle technique characteristics.

Methods

The prospective cohort design enabled 28 senior club based amateur male rugby union players from New Zealand to be followed over 18 matches in the 2017 rugby season. Game video analysis by three analysts provided categorisation of tackle technique into type, approach, foot contact, leading foot and rear foot position, face and head position. Injuries were diagnosed by the same sports medicine physician.

Results

In the 18 matches, 28 players completed a combined total of 3006 tackles, with only six tackle-related injuries sustained. Notable findings included: (1) forwards complete more tackles than backs; (2) shoulder tackles were the most prevalent tackle; (3) good tackle technique as promoted by RugbySmart was demonstrated in 57.9% of all tackles and (4) of the six tackle-related injuries, two occurred despite RugbySmart desired tackle techniques.

Conclusion

This is the first study to investigate whether players were performing the recommended ‘safe tackle technique’ proposed by New Zealand Rugby’s RugbySmart programme. As two of six tackle-related injuries occurred despite the RugbySmart preferred technique being performed, further technique analysis and a larger sample are needed to determine what techniques reduce risk of injury during tackles. As only 57.9% of tackles were performed with RugbySmart head and foot positions, further research and education regarding tackle technique recommendations are needed.

Adequate Protein Intake on Comprehensive Frailty in Older Adults: Kyoto-Kameoka Study

OBJECTIVES

Defining an adequate protein intake in older adults remains unresolved. We examined the association between calibrated protein intake and comprehensive frailty by sex in the Kyoto-Kameoka study.

DESIGN

Cross-sectional study of baseline data.

SETTING AND PARTICIPANTS

The study included 5679 Japanese participants aged 65 years or older.

METHODS

Calibration coefficients were estimated from food frequency questionnaires and 7-day dietary records as a reference. Comprehensive frailty was evaluated using the 25-item Kihon Checklist (KCL) and defined as a total KCL score of ≥7points. Sex-specific calibrated protein intakes were presented as % of energy, per kg of actual body weight (BW), and per kg of ideal BW.

RESULTS

Multiple logistic regression analysis showed that calibrated protein intake is inversely associated with comprehensive frailty. The association between protein intake and comprehensive frailty was also evaluated using curve fitting with non-linear regression, a weak U-shaped association was found in males and an L-shaped association in females. Men had a low prevalence of frailty at a calibrated protein intake of 15-17% energy from protein, 1.2 g/kg actual BW/day, or 1.4 g/kg ideal BW/day, and women had a low prevalence of frailty at 17-21% energy from protein or 1.6 g/kg ideal BW/day, with the prevalence of frailty remaining unchanged at higher protein intakes. Meanwhile, the inverse relationship between protein intake per ABW and frailty showed a gradual decrease at 1.4 g/kg ABW/day for protein in women.

CONCLUSIONS AND IMPLICATIONS

A non-linear relationship was found between calibrated protein intake and frailty, with a U-shaped association in men and an L-shaped association in women. Adequate protein intake in healthy Japanese older adults was higher than the current recommended daily allowance.

Hybridization of Bogoliubov Quasiparticles between Adjacent CuO_{2} Layers in the Triple-Layer Cuprate Bi_{2}Sr_{2}Ca_{2}Cu_{3}O_{10+δ} Studied by Angle-Resolved Photoemission Spectroscopy

Hybridization of Bogoliubov quasiparticles (BQPs) between the CuO_{2} layers in the triple-layer cuprate high-temperature superconductor Bi_{2}Sr_{2}Cu_{2}Cu_{3}O_{10+δ} is studied by angle-resolved photoemission spectroscopy (ARPES). In the superconducting state, an anticrossing gap opens between the outer- and inner-BQP bands, which we attribute primarily to interlayer single-particle hopping with possible contributions from interlayer Cooper pairing. We find that the d-wave superconducting gap of both BQP bands smoothly develops with momentum without an abrupt jump in contrast to a previous ARPES study. Hybridization between the BQPs also gradually increases in going from the off nodal to the antinodal region, which is explained by the momentum dependence of the interlayer single-particle hopping. As possible mechanisms for the enhancement of the superconducting transition temperature, the hybridization between the BQPs as well as the combination of phonon modes of the triple CuO_{2} layers and spin fluctuations represented by a four-well model are discussed.

Clinical, pathological, and therapeutic features of newly diagnosed prostate cancer predominantly detected by opportunistic PSA screening: A survey of Shiga Prefecture, Japan

BACKGROUND

In all the prefectures of Japan, with the exception of Shiga Prefecture, more than half of local governments have an organized prostate-specific antigen (PSA) screening system in place. However, in the Shiga Prefecture, only a single city performed PSA screening over the time period of this survey. The purpose of the present study was to determine the clinical, pathological, and therapeutic features of newly diagnosed prostate cancer in localities where a formally organized screening system was almost entirely absent.

METHODS

A multicenter observational study was conducted in the Shiga Prefecture, which has the lowest rate of population-based PSA-screening in Japan. Patients' age, initial PSA, reasons for PSA testing, Gleason score, clinical stage, and primary treatments were surveyed. We stratified patients according to the reasons for PSA measurement, and compared the differences between groups subject to organized versus opportunistic screening.

RESULTS

In the 2 years 2012 and 2017, 984 newly diagnosed prostate cancer patients were analyzed. Of these, 954 (97%) were opportunistically tested (i.e., not as part of an organized screening system), with the remaining 29 (3%) measured as part of an organized screening program. Patients in the former group exhibited a higher initial PSA value than in the organized screening group (median: 11.49 vs. 5.67 ng/ml). They also had worse clinical features, including higher Gleason score and TNM stage. More patients in the organized screening group were treated curatively than in the nonorganized screening group in terms of the primary treatment. The results were similar in a subanalysis of the patients of age 50-69 years.

CONCLUSIONS

Organized PSA screening contributes to increasing the number of patients diagnosed with early-stage cancer who can be treated curatively.

Influence of renal dysfunction on clinical outcomes in elderly patients with atrial fibrillation: a subanalysis of the phase 3, randomized, placebo-controlled ELDERCARE-AF trial

Background

Renal dysfunction is common in elderly patients with atrial fibrillation (AF) and is thought to be associated with increased risk of thromboembolic and bleeding events. Once-daily low-dose (15 mg) edoxaban was superior to placebo in preventing stroke or systemic embolic events (S/SEE) without significantly increasing major bleeding events in very elderly (≥80 years) non-valvular AF (NVAF) patients in whom standard oral anticoagulant therapy at approved doses was inappropriate (ELDERCARE-AF trial). Little is known about how renal dysfunction affects the effects of low-dose edoxaban in these patients.

Purpose

We used prespecified subgroup analysis to investigate the relation between renal function (assessed by creatinine clearance, CrCl) and the efficacy and safety of edoxaban in elderly NVAF patients.

Methods

ELDERCARE-AF patients were divided into 3 subgroups according to baseline CrCl: normal renal function/mild dysfunction (CrCl &gt;50 mL/min), moderate renal dysfunction (CrCl ≥30 to ≤50 [“30–50”] mL/min) and severe renal dysfunction (CrCl ≥15 to &lt;30 [“15–30”] mL/min). Primary efficacy and safety endpoints were annualized incidence of S/SEE and ISTH-defined major bleeding, respectively.

Results

Of 984 patients randomized to edoxaban 15 mg or placebo (each group N=492), 681 completed the trial. The 303 discontinuations were due to withdrawal of consent (n=158), death (n=135), or other causes (n=10). Discontinuation rate was the same in the edoxaban and placebo groups. S/SEE incidence in patients with CrCl &gt;50, 30–50 and 15–30 mL/min was 2.0%, 1.3% and 3.5%, respectively, in edoxaban, and 4.4%, 4.6% and 9.7%, respectively, in placebo. In those with CrCl 30–50 and 15–30 mL/min, it was significantly lower in edoxaban than in placebo (adjusted hazard ratio [HR], 0.30 [95% CI, 0.10–0.91], p=0.03; and 0.33 [95% CI, 0.16–0.71], p&lt;0.01, respectively). Incidence of major bleeding in patients with CrCl &gt;50, 30–50 and 15–30 mL/min was 1.0%, 1.8% and 6.2%, respectively, in edoxaban, and 0.9%, 1.5% and 2.4%, respectively, in placebo. Incidence of major bleeding in those with CrCl 15–30 mL/min was higher in edoxaban but not significantly (adjusted HR, 2.53 [95% CI, 0.96–6.72], p=0.062). Incidence of gastrointestinal bleeding in patients with CrCl 15–30 mL/min was 4.3% in edoxaban and 1.6% in placebo (adjusted HR, 2.61 [95% CI, 0.79–8.68], p=0.12). Incidence of all-cause death in patients with CrCl &gt;50, 30–50 and 15–30 mL/min was 5.8%, 6.8% and 15.2%, respectively, in edoxaban, and 7.0%, 6.3% and 15.5%, respectively, in placebo (no significant intergroup differences).

Conclusions

Incidence of S/SEE, major bleeding and all-cause death increased with declining renal function in elderly NVAF patients. Edoxaban 15 mg remained superior to placebo in preventing S/SEE, even in those with moderate to severe renal dysfunction. Incidence of major bleeding in patients with severe renal dysfunction was higher (non-significantly) with edoxaban than with placebo.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi-Sankyo Co., Ltd.

Nivolumab with carboplatin, paclitaxel, and bevacizumab for first-line treatment of advanced nonsquamous non-small-cell lung cancer

BACKGROUND

This international, randomized, double-blind phase III study (ONO-4538-52/TASUKI-52) evaluated nivolumab with bevacizumab and cytotoxic chemotherapy as first-line treatment for nonsquamous non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Between June 2017 and July 2019, this study enrolled treatment-naïve patients with stage IIIB/IV or recurrent nonsquamous NSCLC without sensitizing EGFR, ALK, or ROS1 alterations. They were randomly assigned in a 1 : 1 ratio to receive nivolumab or placebo in combination with carboplatin, paclitaxel, and bevacizumab every 3 weeks for up to six cycles, followed by nivolumab/placebo with bevacizumab until progressive disease or unacceptable toxicity. The primary endpoint was progression-free survival (PFS) assessed by an independent radiology review committee (IRRC).

RESULTS

Overall, 550 patients from Japan, Korea, and Taiwan were randomized; of these patients, 273 and 275 received the nivolumab and placebo combinations, respectively. In the present preplanned interim analysis with a median follow up of 13.7 months, the IRRC-assessed median PFS was significantly longer in the nivolumab arm than in the placebo arm (12.1 versus 8.1 months; hazard ratio 0.56; 96.4% confidence interval 0.43-0.71; P < 0.0001). The PFS benefit was observed across all patients with any programmed death-ligand 1 (PD-L1) expression levels including PD-L1-negative patients. The IRRC-assessed objective response rates were 61.5% and 50.5% in the nivolumab and placebo arms, respectively. The incidence of treatment-related adverse events of grade 3 or 4 was comparable between the two arms; treatment-related adverse events leading to death were observed in five and four patients in the nivolumab and placebo arms, respectively.

CONCLUSION

The TASUKI-52 regimen should be considered a viable new treatment strategy for treatment-naïve patients with advanced nonsquamous NSCLC.

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Table 1.

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

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

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

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

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

Conclusion:

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

Disclosure of Interests:

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

POS0824 THE LONG-TERM CLINICAL COURSE OF MUSCULAR VASCULITIS DEPENDING ON THE ANTI-NEUTROPHIL CYTOPLASMIC ANTIBODY STATUS: A RETROSPECTIVE OBSERVATIONAL STUDY

Background:

Skeletal muscle is known as one of the organ involvements of primary systemic vasculitis.1,2 Muscle inflammation is detected by magnetic resonance imaging, and necrotizing vasculitis is proved by muscle biopsy.3 As with systemic vasculitis or single organ vasculitis, glucocorticoid (GC) and immunosuppressants are used in its treatment.4 There are not many reports about muscular vasculitis, and its long-term clinical course after initial treatment, including the rates of relapse and mortality, remains unclear.

Objectives:

To identify the predictors of relapse and mortality in patients with muscular vasculitis, especially focusing on the status of anti-neutrophil cytoplasmic antibody (ANCA).

Methods:

We retrospectively reviewed patients diagnosed with necrotizing vasculitis with muscle involvements in our hospital between 2004 and 2020. In all cases, muscular vasculitis was identified by muscle biopsy or magnetic resonance imaging. To focus on the clinical features of muscular vasculitis, we excluded patients with such severe organ involvements as cardiovascular, abdominal, cerebral, severe renal, and severe pulmonary involvements. We compared the 5-year cumulative incidence of relapse, the overall survival rate, and the dose of GC over 5 years between the ANCA-positive and ANCA-negative groups. A relapse was defined as any new or worsened state of disease activity requiring an escalation of GC dose. Gray’s method was used for assessing the cumulative incidence of relapse. The log-rank test was used for assessing overall survival. The Mann-Whitney U test was used for assessing the dose of GC. The possible factors for relapse in 5 years in a univariate analysis were selected for a multivariate analysis using the Cox proportional hazards model.

Results:

Forty-nine patients were enrolled. The median age of onset was 77 (69-82) years and 71.4% were women. There were 30 ANCA-positive patients (90.0% with anti-myeloperoxidase) and 19 ANCA-negative patients. The median age and the number of patients with renal involvements were higher in the ANCA-positive group than in the ANCA-negative group (73.0 ± 9.29 years vs. 79.5 ± 20.28 years, p=0.0062 and 7/30 [23.3%] vs. 0/19 [0.0%], p=0.034, respectively). The Birmingham Vasculitis Activity Score (ver. 3), the induction dose of GC, and the rate of immunosuppressants use were not significantly different between the two groups. During the observational period, 24 patients relapsed. The 5-year cumulative incidence of relapse was significantly higher in the ANCA-positive group than in the ANCA-negative group (p=0.026) (Figure 1). The Cox proportional hazards model revealed that the presence of ANCA was an independent risk factor for relapse (hazard ratio: 3.15; 95% confidence interval 1.06–9.38; p=0.040). During the observational period, 9 patients died (3 died from cancer, 1 from interstitial pneumonia, 1 from cerebral hemorrhage, 1 from infection, and 3 from unknown reasons). The ANCA-positive group exhibited a higher mortality rate than the ANCA-negative group without a statistical significance (p=0.12). The 5-year cumulative dose of GC was larger in the ANCA-positive group than in the ANCA-negative group without a statistical significance (14786 [11246–19138] mg vs. 10088 [7129–12634] mg, p=0.12).

Conclusion:

In muscular vasculitis, the presence of ANCA is an independent risk factor for long-term relapse. Stratified treatment depending on the ANCA status may reduce the relapse rate and the occurrence of side effects of GC in patients with muscular vasculitis.

References:

[1]Kitching AR et al. Nat Rev Dis Primers 2020; 6(1): 71.

[2]Hernández-Rodríguez J et al. J Autoimmun 2014; 48-49: 84-9.

[3]Ushiyama S et al. Rheumatol Int 2020; 40(10): 1667-74.

[4]Ganeshanandan LR et al. Semin Arthritis Rheum 2020; 50(3): 503-8.

Disclosure of Interests:

None declared