Qualitative research concerning physiotherapy approaches to encourage physical activity in older adults with dementia

BACKGROUND

Physical exercise is known to improve the level of activities of daily living and physical function in people with dementia; however, symptoms of dementia often pose challenges when implementing physical therapy. This study aimed to elucidate how physiotherapists (PTs) engage with older adults with dementia to encourage exercise and participation in physical activity.

METHODS

In this qualitative study, four PTs working with older adults with dementia in long-term care facilities in Japan were recruited and interviewed. We used a modified grounded theory approach to assess how PTs engaged with older adults with dementia during physiotherapy sessions.

RESULTS

Based on PT responses, five categories of engagement were identified: "make structured preparations for clients to begin physical activity," "link exercise therapy to a client's daily life," "discover changes in daily life," "ascertain cognitive function," and "accommodate client differences." Concepts were derived under each category. The category "make structured preparations for clients to begin physical activity" served as a preceding stage for PTs to engage with older adults with dementia. PTs linked exercise therapy to each client's daily life activities to encourage voluntary participation in daily physical activity. PTs ensured the performance of routine patterns of movement and modified these movement patterns per clients' differing paces.

CONCLUSION

PTs provided exercise and movement training based on various degrees of client involvement and made structured preparations for clients to begin physical activity that were linked to exercise therapy. Our findings may prompt PTs to encourage older people with dementia to participate in physical therapy and benefit from exercise.

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.

Efficacy and safety of balloon pulmonary angioplasty for patients with chronic thromboembolic pulmonary hypertension comorbid to chronic obstructive pulmonary disease

Background

Balloon pulmonary angioplasty (BPA) would be promising treatment option for non-operable chronic thromboembolic pulmonary hypertension (CTEPH). However, BPA for CTEPH with Chronic obstructive pulmonary disease (COPD) might exacerbate ventilation perfusion mismatch. The aim is to evaluate the efficacy and safety of BPA for CTEPH with moderate or severe COPD.

Method

Data from 149 CTEPH patients were collected retrospectively who underwent BPA from March 2011 to June 2021. Patients were divided according to the comorbidity of COPD: a COPD group (defined as forced expiratory volume in one second (FEV1.0) / forced vital capacity (FVC)&lt;70% and FEV1.0&lt;80% predicted [n=32]) or a non-COPD group [n=101]. Mild COPD patients (n=16) were excluded. Hemodynamics and respiratory parameters were compared.

Results

Hemodynamics improved similarly in both group (percent decrease of pulmonary vascular resistance; −61.1±12.3% in a COPD group, −65.8±11.1% in a non-COPD group, p=N.S). Patients in a COPD group showed improved respiratory function and oxygenation with FEV1.0% from 61.8±7.0% to 66.5±10.2% (p=0.02), and partial pressure of arterial oxygen from 60.9±10.6mmHg to 69.3±13.6mmHg (p&lt;0.01). Higher vital capacity (r2=0.123, p=0.024), higher diffusing capacity for lung carbon monoxide (r2=0.308, p=0.028) at baseline were correlated with larger improvement of oxygenation after BPA in multivariate linear analyses. Lung injury per session was 1.6% in a COPD group.

Conclusion

The efficacy and safety of BPA for non-operable CTEPH with COPD were equivalent to those of patients without COPD. Oxygenation and FEV1.0% also improved in COPD patients. BPA might be considered even though patients comorbid COPD.

Funding Acknowledgement

Type of funding sources: None.

POS1349 IMMUNOGLOBULIN G4-RELATED KIDNEY DISEASE’S PREDISPOSITION TO CHRONIC RENAL DYSFUNCTION, COMPLICATIONS OF MALIGNANCY, AND MORTALITY: A LONG-TERM NATIONWIDE MULTICENTER STUDY IN JAPAN

Background

In immunoglobulin G4-related kidney disease (IgG4-RKD), persistent renal insufficiency may be observed despite the good initial response to glucocorticoids[1, 2]. However, its long-term prognosis in relation to renal function as well as malignancy and mortality has not been well clarified.

Objectives

To clarify the long-term renal prognosis, complications of malignancy, mortality, and factors related to those outcomes in IgG4-RKD.

Methods

We retrospectively reviewed the medical records of patients with IgG4-RKD diagnosed by the expert members of the IgG4-RKD working group in the Japanese Society of Nephrology. We investigated clinical, radiological, and histopathological features at baseline and course of renal function, complications of malignancy, and mortality during the long-term observation periods (median 71 months) in 75 patients. Using collected data, we calculated the crude incidence rates (IR) of chronic kidney disease (CKD) status, malignancy, and death. Cox regression analyses were performed to assess CKD-related factors. Additionally, we calculated the standardized incidence ratio (SIR) of malignancy and standardized mortality ratio (SMR) using national Japan statistics.

Results

Fifty-nine patients were male, and 16 were female (median age 70 years). At diagnosis, their median eGFR was 45.1 mL/min/1.73m2 (interquartile range [IQR] 28.6-69.9). Seventy-two patients (96%) were treated with prednisolone at a median initial dose of 30 (IQR 30-39) mg/day, leading to a reasonable initial improvement of renal function. The IR of CKD was 30.2/100 person-years, and 66.7% (50/75) of the patients showed CKD at the last visit. Age- and sex-adjusted Cox regression analyses indicated that lower eGFR (per 10 mL/min/1.73m2, hazard ratio [HR] 0.70, 95% confidence interval [CI] 0.61-0.80), pre-existing hypertension (HR 2.39, 95% CI 1.32-4.34), and wider areas with inflammation (>50% vs. <10%, HR 2.55, 95% CI 1.07-6.08) or fibrosis (>50% vs. <5%, HR 2.84, 95% CI 1.18-6.85) in the biopsied renal specimens at treatment initiation had a significant impact on the time to CKD. Eight patients (10.7%) died during follow-up due to malignancy, severe infection, cerebral hemorrhage, or myocardial infarction. The crude mortality rate was 1.76/100 person-years, and a SMR calculated according to national Japan statistics was 0.97 (95% CI 0.42-1.90). On the other hand, 15 patients were diagnosed as having malignancies during follow-up. The IR of malignancy was 3.71/100 person-years, and the SIR of malignancy was 1.80 (95% CI 1.03-2.93).

Conclusion

This study suggests that pre-treated renal insufficiency and extensive renal inflammatory and fibrotic lesions are related to CKD under glucocorticoid therapy in IgG4-RKD. Similarly with the whole IgG4-related disease, IgG4-RKD may have an increased incidence of malignancy but a mortality rate equivalent to the age- and sex-matched Japanese population.

References

[1]Saeki T et al. The clinical course of patients with IgG4-related kidney disease. Kidney Int. 2013 Oct;84(4):826-33.

[2]Mizushima I et al. Factors related to renal cortical atrophy development after glucocorticoid therapy in IgG4-related kidney disease: a retrospective multicenter study. Arthritis Res Ther. 2016 Nov 25;18(1):273.

Disclosure of Interests

None declared

POS0975 CLINICAL CHARACTERISTICS OF NONRADIOGRAPHIC AXIAL SPONDYLOARTHRITIS IN ASIAN COUNTRIES COMPARED TO OTHER REGIONS: RESULTS OF THE INTERNATIONAL CROSS-SECTIONAL ASAS-COMOSPA STUDY

Background:

Clinical characteristics of nonradiographic axial spondyloarthritis (nr-ax-SpA) are highly variable across patients, and may potentially vary across patient populations, particularly due to differing distributions of human leukocyte antigens (HLA) and other genetic factors. The majority of nr-ax-SpA studies have been conducted in Europe, the United States, and small studies are reported from Asia [1].

Objectives:

To delineate clinical characteristics of patients with nr-ax-SpA in Asian countries in comparison to other areas of the world.

Methods:

Utilizing the ASAS-COMOSPA data, an international cross-sectional observational study of SpA patients, we analyzed information on demographics, disease characteristics, comorbidities, and risk factors. Patients were classified by region: Asia (China, Japan, Singapore, South Korea, and Taiwan), and non-Asian countries (Europe, Americas, and Africa); patient characteristics, including diagnosis and treatment, were compared.

Results:

Among 3984 SpA patients included in the study, 1094 were from centers in Asian countries, and 2890 from other regions. 112/780 (14.4%) of axial SpA patients in Asian countries were nr-ax-SpA, substantially less than in other countries (486/1997, 24.3%). Nr-ax-SpA patients in Asian countries compared to nr-ax-SpA in other countries were more likely male (75.9 vs 47.1%), have onset (22.8 vs 27.8 years) and diagnosis (27.2 vs 34.5 years) at younger age, and experience less diagnostic delay (1.88 vs 2.92 years) (Table 1). Nr-ax-SpA patients in Asian countries have higher prevalence of positive HLA-B27 (90.6% vs 61.9%) and fewer peripheral signs such as arthritis, enthesitis, or dactylitis (53.6% vs 66.3%) but have similar rate of extra-articular manifestations (psoriasis, IBD, or uveitis) and co-morbidities. Disease activity, functional impairment, and inflammation on MRI were less in nr-ax-SpA patients in Asian countries. NSAIDs response was higher and use of methotrexate and b-DMARDs were lower among nr-ax-SpA in Asian countries.

Conclusion:

Among axial SpA patients, substantially lower frequency of nr-ax-SpA was observed in Asian countries compared to other regions of the world. Nr-ax-SpA patients in Asian countries were predominantly male, and had younger disease onset with higher HLA-B27 positivity rate and less peripheral signs, and better response to NSAIDs. These results offer an opportunity to improve both early diagnosis and treatment of nr-ax-SpA patients in Asian countries.

Table 1.

Characteristics of nonradiographic axial SpA in Asia versus non-Asian regions

VariablesAsianon-Asian regionsp valueN112486Age at disease diagnosis, yrs27.2 [21.1, 39.6]34.5 [27.7, 41.7]<0.001Diagnostic delay, yrs1.88 [0.27, 5.56]2.92 [0.59, 9.58]0.011Male (%)85 (75.9)229 (47.1)<0.001Sacroiliitis on MRI among tested (%)49 (67.1)341 (82.2)0.005HLA B27 positivity among measured (%)96 (90.6)273 (61.9)<0.001Inflammatory Back Pain (%)107 (95.5)478 (98.4)0.076Arthritis, enthesitis, or dactylitis (%)60 (53.6)322 (66.3)0.016Psoriasis (%)12 (10.7)82 (16.9)0.142Uveitis (%)20 (17.9)81 (16.7)0.870Inflammatory bowel disease (%)5 (4.5)27 (5.6)0.817Elevated CRP (%)37 (33.0)213 (43.8)0.048Physician global assessment (0-10)2.0 [1.0, 5.0]2.0 [1.0, 4.0]0.741Patient global assessment (0-10)3.0 [1.0, 6.0]4.0 [2.0, 6.0]0.012ASDAS-CRP1.40 [0.95, 2.08]1.97 [1.21, 2.78]<0.001BASFI0.8 [0.05, 2.65]2.9 [0.8, 5.6]<0.001Good response to NSAIDs (%)80 (71.4)272 (56.0)0.004Methotrexate use (%)18 (16.1)134 (27.6)0.016Biological DMARDs use (%)27 (24.1)191 (39.3)0.004

References:

[1]López-Medina C, Ramiro S, van der Heijde D, et al. Characteristics and burden of disease in patients with radiographic and non-radiographic axial Spondyloarthritis: a comparison by systematic literature review and meta-analysis. RMD Open. 2019 Nov 21;5(2): e001108.

Acknowledgements:

This study was conducted under the umbrella of the International Society for Spondyloarthritis Assessment (ASAS) and COMOSPA study was supported by unrestricted grants from Pfizer, AbbVie and UCB.

Disclosure of Interests:

Keisuke Ono: None declared, Mitsumasa Kishimoto Speakers bureau: AbbVie, Amgen-Astellas BioPharma, Asahi-Kasei Pharma, Astellas, Ayumi Pharma, BMS, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Janssen, Kyowa Kirin, Novartis, Ono Pharma, Pfizer, Tanabe-Mitsubishi, Teijin Pharma, and UCB Pharma, Consultant of: AbbVie, Amgen-Astellas BioPharma, Asahi-Kasei Pharma, Astellas, Ayumi Pharma, BMS, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Janssen, Kyowa Kirin, Novartis, Ono Pharma, Pfizer, Tanabe-Mitsubishi, Teijin Pharma, and UCB Pharma, Sho Fukui: None declared, Satoshi Kawaai: None declared, Gautam A. Deshpande: None declared, Kazuki Yoshida Consultant of: OM1, Inc., Grant/research support from: Corrona, LLC, Naomi Ichikawa: None declared, Yuko Kaneko Speakers bureau: AbbVie, Astellas, Ayumi, Bristol-Myers Squibb, Chugai, Eisai, Eli Lilly, Hisamitsu, Jansen, Kissei, Pfizer, Sanofi, Takeda, Tanabe-Mitsubishi, and UCB, Taku Kawasaki: None declared, Kazuo Matsui: None declared, Mitsuhiro Morita: None declared, Kurisu Tada: None declared, Naoho Takizawa: None declared, Naoto Tamura: None declared, Atsuo Taniguchi: None declared, Yoshinori Taniguchi: None declared, Shigeyoshi Tsuji: None declared, Shigeto Kobayashi: None declared, Masato Okada: None declared, Clementina López-Medina: None declared, Anna Moltó Consultant of: AbbVie, Pfizer, MSD, Novartis, Gilead, Lilly and UCB, Grant/research support from: AbbVie, Pfizer, MSD, Novartis, Gilead, Lilly and UCB, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, Bayer, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma, Employee of: Imaging Rheumatology bv. (Director), Maxime Dougados: None declared, Yoshinori Komagata: None declared, Tetsuya Tomita: None declared, Shinya Kaname: None declared.

Physical therapy processes-interactions between a physical therapist and an older client with dementia

Background: In Japan, the population aging rate highlights the need to examine various care provisions for older adults with dementia, including physical therapy. However, despite its positive effects, there are also many challenges associated with providing physical therapy for older adults with dementia.Objective: This qualitative case study examined the interactions between a physical therapist and a patient with dementia and the process by which physical therapy was provided to her.Methods: This study utilized a modified grounded theory approach to analyze the interview of one physical therapist, a woman with four years of clinical experience who specializes in physical therapy for older adults who provided a 20-minute physical therapy session to her client, a woman in her 80s with dementia who sought to maintain her ability to perform activities of daily living and preserve her independence. Data were collected in January 2017.Results: Fifteen concepts that represent aspects of the services that the therapist provided to her client were identified. Five distinct categories were derived: 1) foundations of the relationship; 2) understanding individual factors; 3) supporting execution of functional activities; 4) assessing cognitive function; and 5) support to ensure safety in daily living.Conclusion: Physical therapists help older adults with dementia execute functional activities, which helps ensure their safety and independence, and fosters strong therapist-client relationships. Future studies should interview multiple physical therapists to generate additional concepts. Further, quantifying these concepts and developing tools to assess clients will improve care provision and inform physical therapists with limited experience in treating patients with dementia.

Longitudinal assessment of anti-Müllerian hormone after cesarean section and influence of bilateral salpingectomy on ovarian reserve

OBJECTIVE

This study aimed to compare longitudinal changes in ovarian reserve markers after cesarean section (CS) with and without bilateral salpingectomy (BS).

STUDY DESIGN

We prospectively enrolled women >35 weeks' gestation scheduled for CS alone or CS + BS and obtained blood samples for anti-Müllerian hormone prior to surgery and at 3 and 6 months after surgery. At the 3-month visit, we similarly performed transvaginal ultrasound for antral follicle count.

RESULTS

We enrolled 50 women; 30 underwent CS only and 20 underwent CS + BS. Although anti-Müllerian hormone level increased over 6 months of follow-up in both groups, no clinically important differences in the geometric mean (interquartile range) (ng/mL) were observed at any timepoint (baseline [0.69 {0.36-1.21} {CS only} vs 0.49 {0.32-2.10} {CS + BS}, p = 0.64]; 3 months [1.35 {0.58-3.13} vs 1.45 {1.04-2.25}, p = 0.79]; and 6 months [1.74 {0.93-4.45} vs 2.60 {1.41-5.10}, p =0.27]). Similarly, we detected no difference in antral follicle count.

CONCLUSION

BS at the time of CS does not have a negative impact on ovarian reserve 6 months after surgery.

IMPLICATION

While our results provide reassuring data that bilateral salpingectomy for permanent contraception at the time of cesarean section does not impact ovarian reserve, longer adequately powered studies are needed.

Patients' need for information on permanent contraception during a cesarean section: A cross-sectional questionnaire survey

AIM

The present study aimed to explore the need for information about permanent contraception in Japanese women with repeated cesarean sections (CS).

METHODS

The present, cross-sectional survey used a self-administered questionnaire mailed to women with a second or later CS at Tokyo Metropolitan Tama Medical Center between March 2010 and December 2017. Those who were pregnant, had given birth less than 1 year before the survey or had an hysterectomy were excluded.

RESULTS

The present study analyzed 284 patients (60 with permanent contraception, 224 without permanent contraception). Forty-eight (80%) of women with permanent contraception, and 135 (60%) of women without permanent contraception believed that information on permanent contraception was needed before CS. Among women without permanent contraception, significantly fewer women obtained adequate information of permanent contraception from their healthcare workers before a CS compared with women with permanent contraception (8% vs. 71%, p < 0.001). A higher rate of unreliable contraceptive use (41%) and unintended pregnancies (4%) after the latest CS were found among the women without permanent contraception.

CONCLUSIONS

A large portion of the study cohort wished they had received information on permanent contraception before CS; however, the patients without permanent contraception had limited access to this information. Adequate information about permanent contraception should be provided to women planning a CS to enable them to make an informed decision with respect to the treatment.

Association between Oral Frailty and Dietary Variety among Community-Dwelling Older Persons: A Cross-Sectional Study

OBJECTIVE

To examine the association between the severity of oral frailty (OF), which is one of the comprehensive oral functions evaluated, and dietary variety in community-dwelling older persons.

DESIGN

Cross-sectional study.

SETTING

Community-based.

PARTICIPANTS

A total of 769 community-dwelling older persons aged 65 and over.

INTERVENTIONS

We examined basic demographic information, functional status, cognitive status, depressive symptoms, medical history, and oral functions of the participants.

MEASUREMENTS

OF was defined by 1-2 and 3 or more of 6 items of oral function evaluation in the pre-oral frailty and oral frailty groups, respectively. Dietary variety was assessed using the dietary variety score (DVS). The participants were categorized into 3 groups for evaluation: those with a low score (0-2), medium score (3-5), and high score (≥6). Ordinal logistic regression analysis was performed to examine the association between OF and DVS.

RESULTS

The rate of OF in the participants was 21.6%, and its severity was significantly associated with DVS after adjusting for potential confounders (Pre-OF; adjusted odds ratio [OR] = 1.687, 95% confidence interval [CI] = 1.219-2.335, OF; adjusted OR = 2.857, 95% CI = 1.489-5.484).

CONCLUSION

The severity of OF was significantly associated with DVS in community-dwelling older persons. This suggests that DVS may be useful in understanding the effects of OF on the nutritional status. Further longitudinal studies are needed to elucidate the association between OF and DVS.

Fruit and Vegetable Consumption and Incident Frailty in Older Adults: A Systematic Review and Meta-Analysis

Background: There is limited evidence regarding associations between fruit and vegetable consumption and incident frailty risk among older people. Objectives: The objective of this study was to conduct a systematic review and meta-analysis regarding the association between fruit and vegetable consumption and incident frailty risk among older adults. Methods: A systematic search of the literature was conducted according to the PRISMA guidelines using PubMed in January 2021 for studies that prospectively examined risk of incident frailty in relation to fruit and vegetable consumption in older adults aged 60 and older. Methodological quality and heterogeneity were assessed. Odds ratios (OR) were pooled using random-effects or fixed-effects meta-analysis, depending on the presence of heterogeneity. Results: Among three studies included in this review, data of four cohorts were provided by two studies and used in meta-analysis. The highest fruit and vegetable consumption was significantly associated with lower risk of incident frailty compared with the lowest consumption (pooled OR=0.38, 95%CI=0.24-0.59, p=<0.001). Conclusions: This study provided the pooled evidence that high fruit and vegetable consumption may be beneficial for preventing the development of frailty in older adults. Increasing fruit and vegetable consumption can be a relevant strategy to prevent frailty.

The assessment of lung function and residual hypoxemia after balloon pulmonary angioplasty for patients with chronic thromboembolic hypertension

Background

It has been reported that balloon pulmonary angioplasty (BPA) could dramatically improve hemodynamics in patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, some patients have shown poor response in oxygenation and lung function even after BPA. The aim of our study was to evaluate the efficacy of BPA using clinical indicators and to investigate lung function and residual hypoxemia.

Method

Consecutive 103 patients who underwent BPA from September 2011 to August 2018 were enrolled. We evaluated hemodynamics with right heart catheterization, respiratory function test, arterial blood gas examination, and exercise capacity with 6 minute-walk-distance (6MWD).

Result

At the median 12-month follow-up after the final BPA session, following examination findings were significantly improved. Mean pulmonary artery pressure (39.0±8.2mmHg, 23.2±8.4mmHg, p&lt;0.001), Pulmonary vascular resistance (782±378 dynes / sec / cm-5, 331±187 dynes / sec / cm-5, p&lt;0.001), 6 MWD (310±94 m, 363±119 m, p&lt;0.001), PaO2 (63.1±15.8 mmHg, 68.5±13.6 mmHg, p=0.044),%VC (88.5±17.1, 91±16.3, p=0.036). However, the following examination findings did not improve after BPA. Oxygen desaturation during 6MWD test (−11.9±6.3, 12±7.9, p=0.65), %DLCO (64.2 17.1, 61.3 16.8, p=0.147).

Conclusion

BPA could dramatically improve hemodynamics and exercise tolerance. However, arterial oxygenation was not normalized after BPA. Moreover, oxygen desaturation in exercise, and %DLCO were almost unchanged. These observations might suggest the remaining arteriopathy in capillary level of pulmonary artery, but further research is needed.

Funding Acknowledgement

Type of funding source: None

Influence of caffeine intake on intravenous adenosine-induced fractional flow reserve

Background

This study evaluated whether caffeine abstention is required before fractional flow reserve (FFR) measurement by intravenous adenosine triphosphate (ATP) administration in Japanese patients.

Methods and results

This study was a subanalysis of a previously published study and a total of 208 intermediate lesions that underwent FFR measurements were enrolled for this analysis. Hyperemia was induced by continuous intravenous ATP infusion at 150μg/kg/min (IVATP150) and 210μg/kg/min (IVATP210), and by intracoronary administration of nicorandil 2mg (ICNIC2mg) as a reference standard. The degree of change in the FFR value both after IVATP150 and after IVATP210, as compared with the FFR value after ICNIC2mg was similar between the caffeine and non-caffeine groups (−0.04±0.05 vs. −0.04±0.07, and 0.00±0.02 vs. 0.01±0.02, respectively). In patients who consumed caffeine before the FFR measurement, the degree of FFR change was independent of the time interval (&lt;12 hours, 12–24 hours, and 24–48 hours) between caffeine intake and catheterization both after IVATP150 and ICNIC2mg and after IVATP210 and ICNIC2mg.

Conclusion

When compared with the FFR value after ICNIC2mg, the degree of change in the FFR value both after IVATP150 and after IVATP210 remained similar regardless of caffeine intake. Strict caffeine abstention before intravenous ATP-induced FFR measurement may not be required in clinical practice.

Funding Acknowledgement

Type of funding source: None

Microvasculopathy evaluated by dual-energy computed tomography in chronic thromboembolic pulmonary hypertension and pulmonary arterial hypertension

Background

It has been previously reported that poor subpleural perfusion (PSP) in dual-energy computed tomography (DE-CT) might suggest the microvasculopathy in patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, it remains unclear whether pathological findings of microvasculopathy in CTEPH and pulmonary arterial hypertension (PAH) are equivalent. The aim is to evaluate the microvasculopathy in CTEPH and PAH by using clinical parameters and DE-CT.

Methods

We retrospectively reviewed PSP (defined as subpleural spaces either not or minimally perfused in all segments) of consecutive treatment-naïve 89 CTEPH patients and 20 PAH patients who underwent DECT from Feb. 2015 to Dec. 2019.

We also evaluated hemodynamic parameters and DE-CT parameters including quantitative evaluation of pulmonary blood volume (PBV) which was calculated as the average of entire lung iodine density.

Results

PSP was observed in 49.4% of patients in CTEPH group versus 5.0% in PAH group (p&lt;0.01).

There were no significant differences in hemodynamics and lung PBV between CTEPH group and PAH group (mean pulmonary arterial pressure; 36.4±10.4mmHg vs 38.3±8.5mmHg p=0.464, pulmonary vascular resistance; 700±388dyne*sec/cm5 vs 805±440 dyne*sec/cm5 p=0.288, lung PBV; 24.9±6.4 Hounsfield Unit vs 22.0±6.6 Hounsfield Unit p=0.06, respectively), however diffusing capacity for carbon monoxide (%DLCO/VA) was significantly lower (69.5±16.8% vs 45.7±23.7% p&lt;0.01) in PAH group.

Conclusion

PSP in DE-CT, which was observed more frequently in patients with CTEPH, might suggest the different mechanism of microvasculopathy from PAH in patients with CTEPH. Microvasculopathy in CTEPH would be diffuse very distal thrombosis. DE-CT is effective modality to detect microvasculopathy of diffuse distal thrombosis in patients with CTEPH.

DECT, Poor subpleural perfusion

Funding Acknowledgement

Type of funding source: None

Influence of obesity and epicardial fat on the progression of electrical and structural remodeling in a canine obese rapid atrial pacing model

Background

Metabolic syndrome is a cluster of conditions including obesity, insulin resistance, hypertension, and abnormal cholesterol, which increases the cardiovascular risk. Metabolic syndrome or obesity has been reported to provide systemic inflammation and oxidative stress. Increased epicardial fat volume is a manifestation of obesity or metabolic syndrome. Those systemic and local conditions related to obesity or metabolic syndrome have been linking to the risk of atrial fibrillation (AF). The underlying mechanisms of obesity linking epicardial fat to AF progression have not been fully examined.

Purpose

To investigate the impact of obesity linked to epicardial fat on electrophysiologic and anatomical AF substrates.

Methods

Twenty dogs aged 3 years were divided into four groups (n=5 per each): normal diet for over 20 weeks (control group [median body weight: 12.0 kg]), rapid atrial pacing (RAP) for last 4–15 (median 8) weeks during a normal diet for the same period (RAP group [10.5 kg]), high-fat diet (HFD) maintained for over 20 weeks without RAP (MetS group [16.0 kg]), and RAP for last 4–12 (median 6) weeks during HFD maintained for 24 weeks (MetS-RAP group [17.0 kg]), respectively. Activation/voltage maps of the atria during sinus rhythm were created with Ensite NavX mapping system. The effective refractory period (ERP) at 5 left atrial (LA) and pulmonary vein (PV) sites (LA appendage [LAA], LA body, right and left superior PVs, and inferior PV), and AF inducibility by burst LAA pacing were determined. At study completion, hearts were excised for histopathological and gene expression analyses.

Results

The LA pressure was more significantly increased in MetS than the MetS-RAP, RAP, and control groups (22.5 [17–28.8] mmHg vs. 14.0 [10.5–16.3] mmHg, 10.5 [7.4–17.2] mmHg and 10.7 [9.6–13.5] mmHg, respectively, P&lt;0.05). The LA/PV ERP at a basic cycle length of 400 ms was shorter in the MetS-RAP and RAP than MetS and control groups (118±39 ms and 122±44 ms vs. 136±18 ms and 155±39 ms, respectively, P&lt;0.05). Short duration AF was more induced in the MetS and MetS-RAP than RAP and control groups (3 [0–5.5] sec and 2 [0.5–3.5] sec vs. 0 [0–4.5] sec and 0 [0–0] sec, P&lt;0.05). Histological examinations showed the fatty infiltration extending from epicardial fat increased more in the Mets and Mets-RAP than RAP and control groups (Figure). The Fibronectin 1 and collagen I/III mRNA levels increased more in the MetS-RAP and AF than MetS and control groups.

Conclusions

AF vulnerability was associated with increased LA pressures and fibrofatty infiltration from epicardial fat in the MetS group, and with fibrofatty infiltration from epicardial fat with subtle fibrosis in the MetS-RAP group. This suggested that fibrofatty infiltration and epicardial fat plays an important role in AF pathogenesis in obese patients.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Grant-in-Aid for Scientific Research (KAKENHI)

Efficacy of interventional treatment for patients with chronic thromboembolic pulmonary hypertension with microvasculopathy

Background

The existence of microvasculopathy in chronic thromboembolic pulmonary hypertension (CTEPH) had been suggested. However, the impact of microvasculopathy for pathophysiology had been unknown. Recently dual-energy computed tomography (DECT) can produce a sensitive iodine distribution map in lung fields to quantify lung perfusion, which may indicate the existence of microvasculopathy according to poor subpleural perfusion.

This study aimed to examine the therapeutic efficacy of interventional treatment (pulmonary endarterectomy or/and balloon pulmonary angioplasty) in CTEPH with microvasculopathy.

Methods

We retrospectively reviewed poor subpleural perfusion (defined as subpleural spaces either not or minimally perfused in all segments) and hemodynamics of 70 consecutive CTEPH patients who underwent DECT before and after interventional therapy from January 2014 to January 2020.

Patients were divided according to poor subpleural perfusion in DECT images before treatment: a microvasculopathy group (MV group, n=37) or a non-microvasculopathy group (Non-MV group, n=33).

We evaluated clinical parameters as WHO functional class (WHO-Fc), 6-min walk distance, respiratory function test, cardiopulmonary exercise test, hemodynamic parameters, and DECT parameters at baseline and after the treatments. DECT parameters as quantitative evaluation of pulmonary blood volume (PBV) calculated as the average of entire lung iodine density.

Results

After interventional treatments, WHO-Fc improved in 33 patients in MV group, and 27 patients in Non-MV group (p=0.50).

In MV group, baseline mean pulmonary arterial pressure (mPAP), pulmonary vascular resistance (PVR) and VE/VCO2 slope were higher (38.3±9.3 vs. 33.2±10.8 mmHg p=0.04, 818±394 vs. 539±289 dyne*sec/cm5 p&lt;0.01 and 43.7±11.3 vs. 35.2±6.9 p&lt;0.01, respectively) and PBV were lower (43.7±11.3 vs. 35.2±6.9 Hounsfield Unit p&lt;0.01) After the treatments, mPAP, PVR, VE/VCO2 slope and PBV showed almost equivalent between the groups (19.5±4.1 vs. 20.6±5.1 mmHg p=0.35, 272±111 vs 251±109 dyne*sec/cm5 p=0.42, 29.2±6.3 vs. 26.0±6.1 p=0.06 and 27.1±6.6 vs. 29.6±6.6 Hounsfield Unit p=0.13).

Diffusing capacity for carbon monoxide (%DLCO/VA) did not improve after treatment in both groups (MV group: 59.5±13.1 to 58.8±11.9% p=0.43. Non-MV group: 77.8±13.4% to 70.5±10.8% P&lt;0.01).

Conclusion

Hemodynamics, pulmonary perfusion, exercise capacities significantly improved after the treatments in spite of the existence or absence of microvasculopathy. However, DLCO which might indicate the existence of microvasculopathy did not improve. Interventional treatments could not improve microvasculopathy because of their limit of accessibilities.

Funding Acknowledgement

Type of funding source: None

Survival in patients with chronic thromboembolic pulmonary hypertension in the modern management era

Background

The management of non-operable chronic thromboembolic pulmonary hypertension (CTEPH) has recently evolved with the availability of balloon pulmonary angioplasty (BPA) and pulmonary vasodilators. We launched BPA program since 2011. The aim was to analyze survival and treatment efficacy in the modern management era.

Method and result

We retrospectively reviewed data from 143 consecutive CTEPH patients diagnosed in our university from January 2011 (i.e. after the availability of BPA) to December 2019. Forty-one patients underwent PEA, in these 25 patients underwent additional BPA (Hybrid group) and other patients were treated with only PEA (PEA group). Ninety patients underwent BPA (BPA group), remaining 12 patients had not undergone any interventional treatments. The 1- and 5-year survival rates of operated patients (n=41) were 97.4% and 90.0%, compared to96.9% and 86.9% in not-operated patients (n=102), respectively (p=0.579) (Figure). There was no death in Hybrid group. Percent decrease of pulmonary vascular resistance in PEA group, Hybrid group, BPA group were −75.4±9.9%, −74.3±11.8%, −56.3±22.2%, respectively (p&lt;0.01, one-way ANOVA). Absolute decrease of mean pulmonary artery pressure in each groups were −20.3±9.5mmHg, −24.5±8.8mmHg, −16.4±9.2mmHg, respectively (p&lt;0.01, one-way ANOVA).

Conclusion

There was no longer significant difference of long-term survival between operated and not-operated CTEPH. Moreover, Hybrid approach might have the potential to lead notable improvement in the prognosis of CTEPH. BPA and PEA would be mutually complementary therapies in the modern management era.

Figure 1

Funding Acknowledgement

Type of funding source: None

Combined pre- and post-capillary pulmonary hypertension defined by new criteria is worse prognosis group in patients with heart failure

Background

The 6th World Symposium on Pulmonary Hypertension suggested major revision about definition of pulmonary hypertension (PH) as mean pulmonary artery pressure (mPAP) &gt;20 mmHg. The definitions of two subsets of PH due to left heart disease (PH-LHD) also revised. The aim of this study was to investigate clinical characteristics and outcomes of subsets of PH-LHD defined by new criteria.

Methods

We analyzed 701 patients admitted for symptomatic heart failure (NYHA ≥2) and underwent right heart catheterization at compensated stage between 2007 and 2016. These patients were divided into 4 groups as follows: (i) Isolated post-capillary PH (Ipc-PH); mPAP &gt;20 mmHg and pulmonary artery wedge pressure (PAWP) &gt;15 mmHg and pulmonary vascular resistance (PVR) &lt;3 WU, (ii) Combined pre- and post-capillary PH (Cpc-PH); mPAP &gt;20 mmHg and PAWP &gt;15 mmHg and PVR ≥3 WU, (iii) pre-capillary PH; mPAP &gt;20 mmHg and PAWP ≤15 mmHg, (iv) no PH; mPAP ≤20 mmHg. Kaplan-Meier curves were applied to investigate whether each groups predict heart failure (HF) death or HF readmission.

Results

The study patients were divided into Ipc-PH (n=268), Cpc-PH (n=54), Pre-capillary PH (n=112), and no PH (n=267). Cpc-PH was significantly associated with HF death or HF readmission as compared to other groups (Figure).

Conclusions

Cpc-PH defined by new criteria was significantly associated with poor long-term clinical outcomes, which suggests new criteria of two subsets of PH-LHD could be strict risk stratification for symptomatic heart failure.

Figure1. Kaplan-Meier curves.

Funding Acknowledgement

Type of funding source: None

Nivolumab treatment beyond progressive disease in advanced non-small cell lung cancer

PURPOSE

This study evaluated the efficacy and safety of nivolumab treatment beyond progressive disease (PD) in non-small cell lung cancer (NSCLC).

PATIENTS/METHODS

Medical records of consecutive patients with advanced NSCLC who received nivolumab between December 2015 and December 2018 were reviewed. Clinical outcomes of three groups of eligible patients who received nivolumab as a second-line treatment after PD were compared based on Response Evaluation Criteria in Solid Tumors v1.1. We conducted subgroup analyses in patients with and without new lesions at first PD.

RESULTS

Twenty-eight patients continued nivolumab treatment beyond PD (TBP). Post PD, 46 patients switched to other anti-cancer treatment (OAT), and 21 received no further anti-cancer treatment (NAT). There were no significant differences in overall survival (OS) or survival post progression (SPP) between TBP and OAT groups (OS: 15.6 vs. 13.4 months, P = .40, SPP: 12.2 vs. 9.3 months, P = .42). Subgroup analyses indicated that among patients without new lesions at first PD, SPP was longer in the TBP than in the OAT groups (12.6 vs. 9.3 months, P = .22, HR: 0.64; 95% CI 0.31‒1.31). The frequency of immune-related adverse events leading to discontinuation during nivolumab beyond PD was equivalent to that for pre-PD (10.7 vs. 12.6%).

CONCLUSIONS

No significant benefits were associated with continuation of nivolumab for advanced NSCLC patients. Continuation of nivolumab beyond PD could be a more useful option in patients without new lesions at first PD. Treatment-related toxicities require attention during nivolumab treatment not only before PD but also beyond PD.

AB1050 CLINICAL IMPLICATIONS OF ULTRASONOGRAPHY (US) IN DIAGNOSIS AND MONITORING DISEASE ACTIVITY OF RELAPSING POLYCHONDRITIS (RP) AND COMPARATIVE INVESTIGATION BY US BETWEEN AURICLE OF RP, REPEATED TRAUMA, CELLULITIS AND HEALTHY SUBJECT

Objectives:

To assess the clinical implications of ultrasonography (US) in monitoring disease activity and diagnosis of relapsing polychondritis (RP).

Methods:

Firstly, auricular (n=5) and nasal (n=1) chondritis of six patients with RP were assessed by US before and after treatments. The relationship between US findings and serum markers were evaluated. Moreover, the comparisons of US findings between the auricle of patients with RP (n=5), repeated trauma (n=5), cellulitis (n=2) and healthy subjects (n=5) were also assessed.

Results:

US finding before treatment showed low-echoic swollen auricular and nasal cartilage with increased power Doppler signals (PDS) in all cases of RP. US findings corresponded to biopsy findings. After treatment, the swollen ear and nose completely resolved. Then, US findings also showed dramatic reductions in swollen cartilage with the decrease in PDS. Although serum markers completely improved, US finding remained in 1 of 6 cases, and this case showed flare due to PSL tapering. Finally, RP could be differentiated from the damage of repeated trauma and cellulitis by the presence or absence of PDS and subperichondrial serous effusion.

Conclusion:

US of auricular and nasal cartilage in RP possibly facilitates evaluation of auricular lesions and monitoring of disease activity, especially when we consider the treatment response and the timing of drug tapering.

Disclosure of Interests:

None declared

SAT0520 CONTROVERSY ON DIAGNOSIS AND TREATMENT OF ADULT PATIENTS WITH SAPHO SYNDROME: MULTI-DISCIPLINARY INTERNATIONAL SURVEY

Background:

Synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) is a rare disease involving skin and skeleton, with a potentially complicated and severe course, optimal management of which seems to require a collaborative rheumatology and dermatology care. Diagnostic criteria for SAPHO remain preliminary and lack validation. There are no evidence-based treatment algorithms in SAPHO due to lack of clinical trials in this rare medical condition.

Objectives:

This study aimed to investigate the current practice in the diagnosis and treatment of SAPHO syndrome among the international rheumatology and dermatology communities.

Methods:

We conducted a survey among the members of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) combining international rheumatologists and dermatologists as well as members of the Japanese and Israeli Societies of Rheumatology.

Results:

A total of 78 physicians participated in the survey: rheumatologists (83%, n=65), dermatologists (11.5%, n=9), and orthopedics (3.8%, n=3). SAPHO was considered a subtype of spondylarthritis by 48.7% (n=38), a subtype of psoriatic arthritis by 19.2% (n=15), a separate entity by 25.6% (n=20), and a subtype of reactive arthritis by 6.4% (n=5). Palmoplantar pustulosis was the most prevalent cutaneous manifestation (n=44, 56.4%) and anterior chest pain - the most prevalent osteoarticular manifestation (n=66, 84.6%). The majority (84.6%, n=66) voted for the update of the present diagnostic criteria by Khan 1994. Magnetic resonance imaging was considered the preferred imaging modality for the diagnosis of SAPHO by 41% (n=32). Conduction of bone biopsy for diagnosis of non-infectious osteitis was supported only by 10.3% (n=8). Patient-reported outcomes were considered the most appropriate measure for the assessment of disease activity by 47.4% (n=37). The treatment approach was overall similar among the rheumatology and dermatology communities, including non-steroidal anti-inflammatory drugs, bisphosphonates, conventional disease-modifying anti-inflammatory drugs, and biologics (Table 1).

Table 1.

Preferences in the treatment choice of SAPHO

Treatment% of respondersNSAIDs76.6%Glucocorticoids32.5%Conventional DMARDs57.1%Bisphosphonates48.1%Anti-TNF biologic therapy75.3%Other biologic therapy20.8%Antibiotic14.3%Tonsillectomy5.1%Isotretinoin5.2%Topical therapy10.4%Intra-articular steroid injection7.8%

Legend: NSAIDs – non-steroidal anti-inflammatory drugs; DMARDs – disease modifying anti-rheumatic drugs

Conclusion:

Our study underlines the controversy on diagnosis and treatment of SAPHO syndrome among specialists in rheumatology and dermatology and emphasizes an unmet need for update and validation of diagnostic criteria and treatment approach.

Acknowledgments:

GRAPPA, Japanese Society of Rheumatology, Israeli Society of Rheumatology

Disclosure of Interests:

Victoria Furer: None declared, Mitsumasa Kishimoto: None declared, Shigeyoshi Tsuji Grant/research support from: Eli Lilly, Speakers bureau: AbbVie, Asahi Kasei, Chugai, Daiichi Sankyo, Eli Lilly, Eisai, Mitsubishi Tanabe, Celgene, and Novartis Pharma K.K., Yoshinori Taniguchi: None declared, Yoko Ishihara: None declared, Tetsuya Tomita Consultant of: Eli Lilly and Company, Ori Elkayam Speakers bureau: AbbVie, BMS, Pfizer, Roche, Sanofi-Aventis, Novartis, Jansen

FRI0503 VALIDATION OF THE 2019 ACR/EULAR CLASSIFICATION CRITERIA FOR IGG4-RELATED DISEASE IN A JAPANESE KIDNEY DISEASE COHORT: A MULTI-CENTER RETROSPECTIVE STUDY BY THE IGG4-RELATED KIDNEY DISEASE (IGG4-RKD) WORKING GROUP OF THE JAPANESE SOCIETY OF NEPHROLOGY

Background:

The 2019 ACR/EULAR classification criteria for IgG4-RD have recently been published1). In the criteria, patients with an inclusion criteria score of >20 without exclusion criteria are classified as having IgG4-RD.

Objectives:

To validate the 2019 ACR/EULAR classification criteria for IgG4-RD in a Japanese kidney disease cohort.

Methods:

The study involved Japanese patients diagnosed as having kidney disease between April 2012 and May 2019, for whom sufficient clinical information and data on serum IgG4 values and/or immunohistological staining for IgG4 in renal biopsy samples were known. These patients were classified as having IgG4-RKD or non-IgG4-RKD (mimickers) based on the 2019 ACR/EULAR classification criteria for IgG4-RD, and the results were evaluated by expert opinion.

Results:

Among 105 included patients, the expert panel diagnosed 55 as having true IgG4-RKD and 50 as mimickers. The final diagnoses among the mimickers were vasculitis (n=11), idiopathic tubulointerstitial nephritis (TIN) (n=5), drug-induced TIN (n=5), Sjögren’s syndrome (n=4) and others. Among the 55 true IgG4-RKD patients, 4 had exclusion criteria, and 50 of the remaining 51 had an inclusion criteria score of ≥20 points (sensitivity 90.9%). On the other hand, 49 of the 50 mimickers were classified as having non-IgG4-RKD (specificity 98.0%) (Table 1).

Table 1.

General characteristics and prevalence of individual items of true IgG4-RKD and non-IgG4-RKD (mimicker)

IgG4-RKD(true IgG4-RKD)(n=55)Non-IgG4-RKD(mimicker)(n=50)PAge at diagnosis,mean ±SD (years)69.9 ± 9.456.7 ± 17.4<0.001Male (%)76.4440.001Elevated serum IgG454/55 (98.2%)18/50 (36.0%)<0.001Serum IgG4 (mg/dl), mean±SD1028 ± 796226 ± 261<0.001Dense IgG4+Plasma cells (>10/hpf) in the kidney biopsy48/51 (94.1%)13/40 (32.5%)<0.001Storiform fibrosis in the kidney biopsy28/51 (54.9%)3/50 (6%)<0.001Hypocomplementemia39/55 (70.1%)7/42 (16.7%)<0.001Renal pelvis thickening/soft tissue5/55 (9%)1/50 (2%)0.20Bilateral renal cortex low-density areas29/55 (52.7%)7/50 (14.0%)<0.001Exclusion criteria present4/55 (7.3%)22/50 (44%)<0.001Total inclusion criteria points >20 without exclusion criteria50/55 (90.9%)1/50 (2%)<0.001

Conclusion:

The 2019 ACR/EULAR classification criteria for IgG4-RD showed good agreement with expert classification in this Japanese kidney disease cohort.

References:

[1] Wallace ZS, et al. The 2019 American College of Rheumatology/European League Against Rheumatism classification criteria for IgG4-related disease. Ann Rheum Dis. 79:77-87, 2020

Disclosure of Interests:

None declared

AB1031 DYSKERATOTIC CELLS IN PERSISTENT PRURITIC SKIN LESIONS AS A PROGNOSTIC FACTOR IN ADULT-ONSET STILL’S DISEASE

Background:

Adult-onset Still’s disease (AOSD), a systemic inflammatory disorder, is characterized by high fever, evanescent rash, arthritis, and hyperferritinaemia. AOSD is also reported to be associated with other skin lesions, including persistent pruritic papules and plaques.

Objectives:

This study aimed to assess the significance of dyskeratotic skin lesions in Japanese AOSD patients.

Methods:

We retrospectively assessed the histology of persistent pruritic skin lesions and evanescent rashes and the relationship between dyskeratotic cells, serum markers, and outcomes in 20 Japanese AOSD patients, comparing AOSD histology with that of dermatomyositis (DM), drug eruptions, and graft-versus-host disease (GVHD).

Results:

Persistent pruritic lesions were characterized by scattered single keratinocytes with an apoptotic appearance confined to the upper layer of the epidermis and horny layer without inflammatory infiltrate. In contrast to AOSD, the histology of DM, drug eruption, and GVHD demonstrated dyskeratotic cells in all layers of the epidermis with inflammatory infiltrate. AOSD with evanescent rash showed no dyskeratotic cells. The dyskeratotic cells in pruritic AOSD lesions stained positive for ssDNA and terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling, indicating apoptosis. Serum IL-18 was significantly higher in AOSD patients with dyskeratotic cells than those without, and generally required higher doses of glucocorticoids, immunosuppressants, and biologic agents. Two of ten AOSD patients with dyskeratotic cells died from haemophagocytic lymphohistiocytosis.

Conclusion:

Persistent pruritic AOSD skin lesions are characterized by dyskeratotic cells with apoptotic features, involving the upper layers of the epidermis. There may be a link to elevated IL-18. This dyskeratosis may be a negative prognostic indicator.

Disclosure of Interests:

None declared

Bone strength of the proximal femur in healthy subjects with ossification of the posterior longitudinal ligament

We compared the bone strength measured via quantitative computed tomography-based finite element method (QCT/FEM) between healthy adults with and without ossification of the posterior longitudinal ligament (OPLL). No statistically significant difference was observed in the bone strength between healthy adults with and without OPLL. Hyperostosis of the posterior longitudinal ligament in OPLL may not be associated with the systemic bone strength.

INTRODUCTION

Although patients with OPLL have been reportedly associated with increased level of bone mineral density (BMD) using dual-energy X-ray absorptiometry (DXA), little is known about the bone strength in OPLL subjects. The aim of this study is to investigate the bone strength measured via QCT/FEM in healthy subjects with OPLL using the medical check-up data, including whole-body CT scans.

METHODS

We examined 796 participants (529 men and 267 women) who underwent CT scans in a single health center between January 2008 and May 2009. We identified OPLL in whole spine and divided the subjects into two groups: non-OPLL and OPLL groups. We calculated the predicted bone strength (PBS) of the proximal femur using QCT/FEM and examined the bone mineral status of the calcaneus using quantitative ultrasound (QUS). We compared the PBS and the QUS parameters between the non-OPLL and OPLL groups.

RESULTS

Seventy-four subjects (9.3%; 57 men and 17 women) were diagnosed with OPLL in the whole spine. The OPLL group was significantly older than the non-OPLL group. No statistically significant difference was observed in the PBS and the QUS parameters between the non-OPLL and OPLL groups in both sexes. Furthermore, no statistically significant difference was noted in the PBS and the QUS parameters between two groups in age- and gender-matched analysis.

CONCLUSIONS

Our results suggest that hyperostosis of the posterior longitudinal ligament in OPLL may not be associated with bone strength and bone mineral status at the extremities.

Development of Professional Care Program for Nurses in Dementia Wards and Its Educational Effects

PURPOSE

To develop an education program for nurses specializing in dementia care, and to investigate its effects.

METHODS

An intervention study of nurses was conducted using a quasi-experiment with 3 randomly assigned groups. Participants were 51 nurses from a psychiatric hospital dementia ward, divided into an intervention program group (17 nurses), a knowledge-acquisition-only group (16 nurses), and a usual-care group (18 nurses) as controls. The program group intervention comprised 3 frameworks: motivation for achieving the task, acquisition of professional knowledge required for dementia care, and sharing of successful experiences based on professional knowledge. The knowledge-acquisition-only group received only the acquisition of professional knowledge framework, and the usual-care group received only the usual-care framework. The intervention period was 3 months.

RESULTS

Post-intervention, the program group had a significantly greater sense of self-efficacy associated with professional knowledge and significantly greater self-efficacy associated with practice compared with the knowledge-acquisition-only and the usual-care groups. Professional knowledge was acquired by 80% of the program group, compared with 70% of the knowledge-acquisition-only group. A co-occurrence network diagram of the multivariate analysis results produced by text mining of the descriptive data indicated that nurses provided care for symptoms specific to different diseases based on their pathological mechanisms.

CONCLUSION

Program implementation led to the acquisition of deeper knowledge and greater self-efficacy by sharing expertise-based practices and successful experiences, compared with desk-based learning in a single workshop lecture, suggesting the program's usefulness in clinical practice.

Relationship between the precursors of high grade serous ovarian cancer and patient characteristics: decreased incidence of the p53 signature in pregnant women

Objective

To investigate the relationship between the precursors of high grade serous ovarian cancer (HGSOC) and the characteristics of patients with a low HGSOC risk in terms of the effects of pregnancy.

Methods

We prospectively examined consecutive cases in which the bilateral fallopian tubes were removed during benign gynecological or obstetric surgery and assessed the relationship between the patient characteristics, including parity and pregnancy, and the incidence of HGSOC precursors. All the fallopian tubes were examined by applying the Sectioning and Extensively Examining the Fimbriated End (SEE-FIM) Protocol.

Results

Of the 113 patients enrolled, 67 were gynecological and 46 were obstetric. The p53 signature was identified in 21 patients. No other precursors were identified. In a comparison of the p53 signature-positive and negative groups, parous women and pregnant women were significantly fewer in the p53 signature-positive group (53% vs. 86%, p=0.002, 10% vs. 47%, p=0.001, respectively). Current pregnancy was also associated with a significantly lower incidence of the p53 signature after multivariate adjustment (odds ratio [OR]=0.112; 95% confidence interval [95% CI]=0.017–0.731; p=0.022). Among gynecological patients, parous women were fewer in the p53 signature-positive group on univariate (47% vs. 73%, p=0.047) and multivariate analysis (OR=0.252; 95% CI=0.069–0.911; p=0.036). No other characteristics were associated with p53 signature positivity.

Conclusions

The incidence of the p53 signature was significantly lower in parous women and pregnant women. This decreased incidence of early phase serous carcinogenesis may be one of the possible mechanisms underlying HGSOC risk reduction among parous women.

P5022Dual-energy CT was effective to evaluate of microvasculopathy in chronic thromboembolic pulmonary hypertension

Background

The existence of microvasculopathy in patients with chronic thromboembolic pulmonary hypertension (CTEPH) had been suggested. However, the impact of microvasculopathy for pathophysiology had been unknown. Recently dual-energy CT (DECT) can produce a sensitive iodine distribution map as blood perfusion in lung fields to quantify lung perfusion, also can suggest the existence of microvasculopathy according to poor subpleural perfusion which was published previously.

Methods

We retrospectively reviewed poor subpleural perfusion (defined as subpleural spaces either not or minimally perfused in all segments) and hemodynamics of 83 treatment-naïve CTEPH patients who underwent DECT from February 2014 to Jan 2019. Patients were divided according to poor subpleural perfusion: a microvasculopathy group (n=44) or a non-microvasculopathy group (n=39).

We assessed cardiopulmonary exercise test, right heart catheterization and DECT parameters as quantitative evaluation of pulmonary blood volume (PBV). PBV was calculated as the average of entire lung iodine density.

Results

PBV value in non-microvasculopathy group showed significant inverse correlation with pulmonary vascular resistance (PVR) (y = 14236 x-1.028 r=−0.530, p<0.01).

PBV, SvO2, and %DLCO/VA were significantly lower (22.0 vs. 26.4, p<0.01, 61.3 vs. 66.0, p<0.01, and 59.2 vs 75.9 p<0.01), and systolic pulmonary arterial pressure, PVR, VE/VCO2 slope, BNP were higher (69.3 vs 60.6 p=0.04, 834 vs 586 p<0.01, 45.5 vs. 37.8, p=0.02, and 440 vs 122 p=0.04) in microvasculopathy group, while the other parameters were similar between the two groups.

Multivariate analysis revealed that %DLCO/VA was the only predictor of microvasculopathy (OR,0.895 [95% CI, 0.835 - 0.960]; P<0.01).

Conclusion

Pulmonary blood flow of patients in non-micorvasculopathy group showed inverse correlation with PVR. DECT was effective to assess the microvasculopathy in CTEPH. In our experience, less than 60% of non-operable CTEPH patients have microvasculopathy.

P6468Balloon pulmonary angioplasty for patients with symptomatic chronic thromboembolic disease without pulmonary hypertension

Background

Chronic thromboembolic disease (CTED) is characterised by thromboembolic stenosis and obstruction of pulmonary arteries without pulmonary hypertension. The treatment approach for symptomatic patients with CTED is still controversial. It has been reported the efficacy of surgical endarterectomy for patients with CTED, however that of balloon pulmonary angioplasty (BPA) for non-operable CTED has not been well established.

Method

We started aggressive BPA protocol for non-operable CTED patients who suffered from symptom with NYHA class II, III, and IV or limitation of exercise in spite of mean pulmonary artery pressure (mPAP) <25 mmHg since February 2014. We evaluated subjective symptoms, hemodynamic parameters by right heart catheter, and exercise capacity by cardiopulmonary exercise test at baseline and after the last BPA session.

Results

Twenty-three patients with CTED (68.7±10.5 years-old, 7 male) had undergone BPA. In these, 7 patients had received pulmonary vasodilators previously. After 2.9±1.3 sessions of BPA, Further improvement was observed in hemodynamics such as mPAP (21.6±2.3 to 17.1±2.6 mmHg, p<0.01), pulmonary vascular resistance (278±80 to 198±63 dyne/s/cm–5, p<0.01), which were accompanied with improved peak VO2 (14.6±4.4 to 17.4±4.2 ml/min/kg, p<0.01), VE/VCO2 slope (39.6±14.6 to 30.2±6.0, p=0.01), and functional class (I/II/III/IV; 0/10/12/1 to 9/12/2/0, p<0.01) (Table). All patients were tolerable, and no severe complication regarding to BPA.

Table 1 Variables Baseline After BPA (3 month) P value NYHA class (I / II / III / IV) 0 / 10 / 12 / 1 9 / 12 / 2 / 0 <0.01 Mean PAP (mmHg) 21.6±2.3 17.1±2.6 <0.01 PVR (dyne/sec/cm–5) 278±80 198±63 <0.01 6 MWD (m) 354±93 382±96 0.09 Peak VO2 (ml/min/kg) 14.6±4.4 17.4±4.2 <0.01

Conclusion

BPA may have the potential to achieve further improvement of exercise capacity and symptoms in CTED patients with acceptable risk, therefore BPA should be considered as a treatment option for symptomatic patients with non-operable CTED.

P5504Comparison of in-hospital clinical outcomes of acute myocardial infarction between nonagenarians and octogenarians: a propensity-score matched analysis

Background

Acute myocardial infarction (AMI) in the very elderly is associated with high morbidity and mortality. Because the majority of study population in clinical researches focusing on the very elderly with AMI were octogenarians, clinical evidences regarding AMI in nonagenarians are sparse. The aim of the present study was to compare in-hospital clinical outcomes of AMI between octogenarians and nonagenarians.

Methods

We included consecutive 415 very elderly (≥80 years) patients with AMI, and divided into the nonagenarian group (n=38) and the octogenarian group (n=377). Clinical characteristics and in-hospital outcomes were compared between the 2 groups. Furthermore, we used propensity-score matching to find the matched octogenarian group (n=38).

Results

Percutaneous coronary interventions (PCI) to the culprit of AMI were similarly performed between the nonagenarian (86.8%) and octogenarian (87.0%) groups The incidence of in-hospital death in the nonagenarian group (13.2%) was similar to that in the octogenarian group (14.6%) (P=0.811). The length of hospital stay was significantly shorter in the nonagenarian group (7.4±4.2 days) than that in the octogenarian group (15.4±19.4 days) (P<0.001). After using the propensity-score matching, the incidence of in-hospital death was less in the nonagenarian group (13.2%) than in the matched octogenarian group (21.1%) without reaching statistical significance (P=0.361). The length of hospitalization was significantly shorter in the nonagenarian group (7.4±4.2 days) than in the matched octogenarian group (17.8±37.0 days) (P=0.01).

Clinical outcomes Nonagenarian group (n=38) Octogenarian group (n=377) P value In-hospital death, n (%) 5 (13.2) 55 (14.6) 0.811 Length of hospital stay (days) 7.4±4.2 15.4±19.4 <0.001 Length of CCU stay (days) 3.3±2.5 4.7±5.1 0.109 LVEF (%) 48.2±9.2 50.8±13.7 0.152 Peak CPK (U/L) 1424.8±1580.8 1640.1±2394.4 0.912 CCU indicates Coronary care unit; LVEF, Left ventricular ejection fraction; CPK, Creatine kinase.

Flow-chart

Conclusions

The in-hospital mortality of nonagenarians with AMI was comparable to that of octogenarians with AMI. In-hospital outcomes in nonagenarians with AMI may be acceptable as long as acute medical management including PCI to the culprit of AMI is performed.

Acknowledgement/Funding

None

Score-Based and Nutrient-Derived Dietary Patterns Are Associated with Depressive Symptoms in Community-Dwelling Older Japanese: A Cross-Sectional Study

OBJECTIVES

This study evaluated associations of score-based and nutrient-derived dietary patterns with depressive symptoms in community-dwelling older Japanese.

DESIGN

Cross-sectional study.

SETTING

Community-based.

PARTICIPANTS

982 community-dwelling adults aged 65 years or older.

MEASUREMENTS

Score-based pattern was assessed by using dietary variety score (DVS), which covers 10 food group items in Japanese meals. Nutrient-derived dietary patterns were identified by using reduced rank regression (RRR), with folate, vitamin C, magnesium, calcium, iron, and zinc intakes as response variables. Depressive symptoms were assessed with the Geriatric Depression Scale. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for these dietary patterns in multivariate logistic regression analyses with potential confounders. The lowest consumption category was used as the reference group.

RESULTS

The prevalence of depressive symptoms was 13.5%. Higher DVS was associated with fewer depressive symptoms (OR=0.52, 95% CI=0.27-1.03 for the highest vs the lowest DVS; P for trend=0.031). The first RRR dietary pattern score was characterized by high intakes of fish, soybean products, potatoes, most vegetables, mushrooms, seaweeds, fruits, and green tea and a low intake of rice and was inversely associated with the prevalence of depressive symptoms (OR=0.53, 95% CI=0.30-0.92; P for trend=0.030).

CONCLUSION

Greater dietary variety and a dietary pattern characterized by high intakes of fish, soybean products, potatoes, most vegetables, mushrooms, seaweeds, fruit, and green tea and a low intake of rice were consistently associated with lower prevalence of depressive symptoms in community-dwelling older Japanese. Therefore, both patterns identified the components of dietary habits essential to depression prevention.

[Effects of a fall intervention program for elderly patients with dementia based on person-centered care on care staff]

AIM

This study aimed to clarify the effects of a fall prevention intervention that focused on the characteristics of falls among elderly patients with dementia and was based on person-centered care in geriatric facilities on care staff.

METHODS

This study was conducted between May 2016 and January 2017, and the subjects were classified into two groups: the intervention group, consisting of members who had participated in a three-month education training program, and the control group, consisting of members who provided the usual care. The study period was nine months divided as follows: training period (three months), fall prevention practice (three months), and follow-up period (three months). The quality of care was measured using the Nursing Quality Indicator for Preventing Falls (NQIPFD), and the assessment scale of health care professionals' recognition of the successful Interdisciplinary Team Approach in Health Care Facilities for the Elderly was also used. In total, the care staff members were evaluated four times: once to obtain baseline values before training, and again after the training period, after the fall prevention practice, and after the follow-up period. The results were analyzed using an analysis of variance (fixed factors = group and time, random factor = subjects, and covariance = years of experience working at the geriatric facility and type of job).

RESULTS

There were 50 care staff subjects in the intervention group and 69 people in the control group. The results of the analysis of variance indicated that there was a significant difference in the NQIPFD between baseline 68.60 (±9.09) and follow-up 70.02 (±9.88) in the intervention group. With regard to the differences by intervention, the effect size of the dementia knowledge scale scores was 0.243 higher than the others, which was significant (p<0.01).

CONCLUSIONS

The results showed that the participation of care staff in a fall intervention program to support elderly patients with dementia based on person-centered care significantly improved the NQIPFD and other measured factors. These findings suggest that the program fostered positive effects among the care staff.