P6240The impact of stress myocardial blood flow as a very strong predictor for all-cause mortality, cardiovascular mortality and adverse cardiac and cerebrovascular event in hemodialysis population

Background

In the clinical setting, ischemic heart disease (IHD) is a major problem not only in general patients but also in regular hemodialysis (HD) patients. 13ammonia positron emission tomography (13NH3PET) is an established and excellent diagnostic device for IHD. Although coronary flow reserve is the most important index in IHD diagnosis, there are limited data about stress myocardial blood flow (MBF). We investigated the prognosis predictability of stress MBF in all-cause mortality, cardiovascular (CV) mortality and adverse cardiac and cerebrovascular event (MACCE).

Methods and results

A total 438 of HD patients who undergone 13NH3PET for suspected IHD were enrolled. 29 cases were excluded due to revascularization therapy in 60 days. In total we collected 409 eligible cases. All patients were undergone13NH3PET at Nagoya Radiological Diagnosis Foundation. Patients were divided into two group according to the median value of stress MBF levels; low stress MBF group (<2.12) and high stress MBF group (≥2.12). We followed up them up to 4.2 years (median 2.4 years) and collected their data. We evaluated their all-cause mortality, CV mortality and MACCE. Kaplan-Meyer analysis shows that intergroup difference in all-cause mortality (log rank p=0.001, hazard ratio [HR] 0.411, 95% confident interval [CI] 0.261–0.632), CV mortality (log rank p=0.002, HR 0.324, 95% CI 0.157–0.625) and MACCE (log rank p<0.001, HR 0.465, 95% CI 0.324–0.657). Multiple cox analysis that include established risk factors shows CFR is an independent risk factor for all-cause mortality (HR 0.261, 95% CI 0.154–0.442), CV mortality (HR 0.172, 95% CI 0.079–0.374) and MACCE (HR 0.329, 95% CI 0.213–0.503). As a result of the incremental value with C-index, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) when CFR added into a model with established risk factors, each indicator shows adding stress MBF on established risk factors improve the predictability in all-cause mortality, CV mortality and MACCE (all-cause mortality; NRI 0.642, p<0.001, IDI 0.091, p<0.001, CV mortality NRI 0.809, p<0.001, IDI 0.116, p<0.001, MACCE; NRI 0.646, p<0.001, IDI 0.072, p<0.001).

Conclusion

Considering prognosis of HD population, stress MBF is an important and independent predictor for all-cause mortality, CV mortality and MACCE. As a result of our investigation, stress MBF is one of most strong predictors in HD population.

P3529Prognostic impact of cohabitation status in hospitalized patients with acute heart failure

Background

The prevalence of heart failure (HF) in the elderly is steadily increasing, therefore, the prudent care and treatment according to individual's characteristics, comorbidities, or prognosis, should be prerequisite. Although cohabitations status in each elderly patient is different, an association of this condition with long-term prognosis remains to be identified definitively in Japan.

Purpose

The purpose of the present study was to examine the prognostic impact of cohabitation status on 3-year mortality among hospitalized acute HF patients.

Methods

The study population comprised a total of 817 individuals who were hospitalized for acute HF between November 2009 and December 2015, and was followed up for 3 years. We classified patients into three groups (cohabitation with spouse, cohabitation with another generation, and living alone). We evaluated relative predictive values between these three groups for 3-year mortality by Cox regression model.

Results

The median age was 79 (interquartile range 70–85) years, and 55.7% of the subjects were male. Median length of hospital stay was 16 (interquartile range 11–23) days. The distribution of three groups was cohabitation with spouse (50.9%), cohabitation with another generation (28.5%), and living alone (20.6%). The overall rate of 3-year mortality was 32.2% (n=263), 31.5% (n=131) in cohabitation with spouse, 38.2% (n=89) in cohabitation with another generation, and 25.6% (n=43) in living alone. Cohabitation with another generation was significantly related to the occurrence of 3-year mortality by univariate analysis (P<0.001). Age (84 years vs. 77 years), the frequency of female (69.1% vs. 33.4%), left ventricular ejection fraction (52.7% vs. 47.5%) were significantly greater, whereas body mass index (21.2 vs. 22.6), smoking status (27.0% vs. 53.4%), ischemic etiology (27.5% vs. 35.6%), and the prevalence of type 2 diabetes mellitus (32.2% vs. 41.4%) and atrial fibrillation (20.6% vs. 29.8%) were significantly (P<0.05) smaller in cohabitation with another generation than others. The ratio of home return and optimal medical therapy were similar between the 2 groups. Cohabitation with another generation was associated with higher relative risk of 3-year mortality than living alone [Hazard Ratio (HR) 1.65; 95% Confidence Interval (CI) 1.15–2.38, P=0.007], or cohabitation with spouse (HR 1.46; 95% CI 1.12–1.92, P=0.006). Multivariable Cox regression model, with adjustment for age, albumin, brain natriuretic peptide, and prior HF hospitalization, revealed that cohabitation with another generation was no longer significant.

Conclusion

Our present results suggest that cohabitation status affected on long-term prognosis in patients with HF, especially cohabitation with another generation posed as worst predictor. We should pay more attention to social factors including cohabitation status in the clinical practice.

P1959Impact of hemodialysis in patients undergoing bypass surgery for peripheral arterial disease - 10-year follow-up study

Background

Although lower extremities bypass surgery has been commonly performed as the standard option to treat peripheral artery disease (PAD) even in patients on hemodialysis (HD) as well as general population, poorer prognosis still remains major problems in this specific population. In this 10-year follow-up study, we investigated the impact of HD after surgical revascularization in patients with PAD.

Methods

A total of 660 patients undergoing successfully bypass surgery were enrolled. Patients with acute limb ischemia were excluded. We compared 392 HD patients with 428 limbs and 268 non-HD (NHD) patients with 296 limbs during 10 years follow-up period. Primary endpoint was defined as major adverse cardiovascular events (MACE) including all-cause death, non-fatal myocardial infarction and stroke. Second endpoint was major adverse limb events (MALE) including any revascularization and major amputation. To minimize the differences of clinical characteristics between the two groups, propensity score adjusting with all baseline variables was performed.

Results

Prevalence of diabetes (53.3% vs. 35.2%), critical limb ischemia (77.5% vs. 52.1%) and infra-popliteal artery (48.2% vs. 19.6%) were higher in HD group compared to NHD group (p<0.0001 in all), inversely, age was younger in HD group than in NHD group (67±9 years vs. 71±9 years, p<0.0001). The 30-day mortality rate was comparable (3.1% in HD group vs. 1.5% in NHD group, p=0.19). The 10-year event-free survival rate for MACE was significantly lower in HD group compared to NHD group (45.3% vs. 67.4%, p<0.0001) and for MALE (60.0% vs. 80.0%, p=0.0007), respectively. After propensity score adjustment, the freedom rate from MACE was still lower in HD group compared to NHD group [45.6% vs. 67.6%, hazard ratio (HR) 1.89, 95% confidence interval (CI) 1.33–2.72, p=0.0003], however, the rate from MALE was statistically comparable between the two group (65.7% vs. 76.9%, 1.27, 95% CI 0.87–1.90, p=0.21). Furthermore, although the 10-year limb salvage rate was crudely lower in HD group compared to NHD group (80.6% vs. 91.6%, HR 1.57, 95% CI 1.05–2.40, p=0.0027), it was comparable after propensity score adjustment (89.4% vs. 90.1%, HR 1.09, 95% CI 0.59–1.88, p=0.79). Also, the mortality rate was consistently lower in HD patients (adjusted HR 2.37, 95% CI 1.62–3.50, p<0.0001).

Conclusion

The long-term freedom rate from MACE and mortality was markedly lower in HD patients compared to non-HD patients. However, the rate from MALE, especially limb salvage rate was similar between HD and NHD after adjustment for clinical characteristics. These results suggest that detection at the early stage of PAD may potentially improve the poor outcomes in this high risk population.

P4601Reduced exercise capacity and clinical outcomes following acute myocardial infarction

Background

Reduced exercise capacity is known to be an important predictor of poor prognosis and disability in patients with cardiovascular diseases and chronic heart failure, and even members of the general population. However, data about exercise capacity assessed by cardiopulmonary exercise testing (CPX) in acute myocardial infarction (AMI) patients who underwent primary percutaneous coronary intervention (PCI) is scarce. The purpose of this study is to assess the associated factors and clinical influence of exercise capacity measured by CPX in AMI patients.

Methods

Among 594 consecutive AMI patients who underwent primary PCI, we examined 136 patients (85.3% men, 64.9±11.9 years) who underwent CPX during hospitalization for AMI. CPX was usually performed five days after the onset of AMI. Reduced exercise capacity was defined as peak oxygen consumption (peak VO2) ≤12. Clinical outcomes including all-cause death, myocardial infarction, and hospitalization due to heart failure were followed.

Results

Among 136 patients, reduced exercise capacity (peak VO2 ≤12) was seen in 38 patients (28%). Patients with reduced exercise capacity were older, more likely to have hypertension, and had lower renal function. In echocardiography, patients with reduced exercise capacity had higher E/e' and larger left atria. Median follow-up term was 12 months (interquartile range: 9–22). The occurrence of composite endpoints of all-cause death, myocardial infarction, and hospitalization due to heart failure was significantly higher in patients with peak VO2≤12 than those with peak VO2>12 (p<0.001). Multivariate logistic analysis showed that E/e' (Odds ratio, 1.19, 95%, confidence interval 1.09 to 1.31, p<0.001) was an independent predictor of reduced exercise capacity (peak VO2≤12).

Cumulative incidence of clinical events

Conclusion

Diastolic dysfunction is associated with reduced exercise capacity following successful primary PCI in AMI patients and may lead to poorer clinical outcomes.

P1583The association of carotid atherosclerosis, protein-energy wasting and inflammation status with mortality in patients on haemodialysis

Background

Carotid atherosclerosis such as increased intima-media thickness (IMT) is associated with poor cardiovascular outcome. On the other hand, protein-energy wasting (PEW) or malnutrition, currently considered to be due to inflammatory process rather than poor nutritional intake, is highly prevalent in in chronic kidney disease (CKD) patients, particularly those on haemodialysis (HD). We investigated the association of carotid atherosclerosis, PEW and inflammation, and their joint role with prediction of mortality in chronic HD patients.

Methods

Carotid ultra-sound was performed in a total of 774 CKD patients stably undergoing HD therapy. Carotid atherosclerosis is defined as IMT>0.8mm as median value with hyperechoic plaque. Geriatric nutritional risk index (GNRI) which calculated from serum albumin levels, body weight and height as a surrogate marker of the PEW, and C-reactive protein (CRP) were measured at the same point. Patients were followed-up for 7 years.

Results

Declined GNRI and elevated CRP levels were independently associated with carotid atherosclerosis [odds ratio (OR) 0.96, 95% confidence interval (CI) 0.93–0.98, p=0.0082 and OR 1.30, 95% CI 1.04–1.64, p=0.019, respectively] accompanied with age (OR 1.03, 95% CI 1.01–1.05, p=0.0024) and hypertension (OR 1.78, 95% CI 1.12–2.91, p=0.013). During follow-up period (median of 67 months), 180 patients (23.3%) died. Carotid atherosclerosis [62.7% vs. 79.3% for 7-year survival rate, hazard ratio (HR) 1.57, 95% CI 1.12–2.16, p=0.0078], GNRI<91.2 as an established cut-off value (58.8% vs. 83.7%, HR 1.87, 95% CI 1.35–2.59, p=0.0002) and CRP>1.1 mg/l as a median value (65.8% vs. 88.6%, HR 2.87, 95% CI 2.00–4.22, p<0.0001) were identified as independent predictors of mortality after adjustment for other confounders. When patients were divided into groups according to number of these three risk factors, 7-year Kaplan-Meier survival rate was 92.7%, 91.1%, 56.8% and 37.2% among groups with no risk factor, any 1 risk factor, any 2 risk factors and all risk factors, respectively (p<0.0001 for trend). After adjustment for other confounders, patients with any 1, any 2 and all risk factors had 2.21-fold (95% CI 1.26–4.14), 5.44-fold (95% CI 3.13–10.1) and 7.19-fold (95% CI 3.67–14.6) higher risk for mortality compared to those without any risk factor, respectively (p<0.0001 for trend).

Conclusions

Presence of carotid atherosclerosis was closely associated with both declined GNRI and elevated CRP levels in CKD patients on HD. Combination of these predictors was also additively associated with an increasing risk of mortality. These results clearly manifested the so-called malnutrition, inflammation and atherosclerosis (MIA) syndrome in this high-risk population.

P2527Accumulative impact of poor nutrition and frailty on 1-year mortality among acute decompensated heart failure patients

Background

Several studies have proved that both poor nutrition (PN) and Frail are associated with poor prognosis among heart failure patients. However, it has not been fully revealed whether PN and frail could have impact on prognosis accumulatively.

Purpose

The purpose of the present study was to evaluate the impact of nutritional and Frailty status on 1-year mortality among hospitalized patients with acute decompensated heart failure (ADHF).

Methods

Study subjects comprised of 315 hospitalized patients with ADHF. To evaluate the nutritional and Frailty status, we calculated the controlling nutritional status (CONUT) score and the Study of Osteoporotic Fractures (SOF) index at hospital admission. PN and Frailty were defined as the CONUT score ≥5 and SOF index ≥2, respectively.

Results

z Sixty-nine subjects (21.9%) were died within 1-year. PN and Frailty were observed in 33.3% and 55.6% of study subjects, respectively. Both PN and Frailty were similarly related to the 1-year mortality by univariate cox regression analysis (Hazard Ratio (HR) 2.43, 95% confidence interval (CI) 1.51–3.91, p=0.0003: HR 3.13, 95% CI 1.83–5.66, p<0.0001, respectively).

Study subjects were classified into 4 groups according to the nutritional and frailty status: control (normal nutrition without Frailty, n=110), PN alone (PN without Frailty, n=30), Frailty alone (Frailty without PN, n=100), and PN + Frailty (PN with Frailty, n=75). The Kaplan-Meier event curves for 1-year all-cause mortality illustrated that subjects with PN + Frailty had a significantly higher mortality than in subjects with control, PN alone and Frailty alone (log rank p=0.0001, 0.0180, 0.0070, respectively).

As well as, cox regression analysis revealed that PN + Frailty showed significantly higher mortality than control, PN alone and Frailty alone. (HR 5.33, 95% CI 2.75–11.1, p<0.0001: HR 2.99, 95% CI 1.26–8.78, p=0.011: HR 2.07, 95% CI 1.21–3.61, p=0.008, respectively). Moreover, multivariate cox regression analysis also revealed that PN with Frailty was independently associated with 1-year mortality even after adjustment for age, body mass index, systolic blood pressure, and chronic kidney disease. (HR 3.40, 95% CI 1.69–7.32, adjusted p<0.001)

Kaplan-Meier curve for 1year mortality

Conclusions

The combination assessment consisted with nutrition and frailty could identify poor prognosis patients with ADHF.

P1582Prognostic value of C-reactive protein/albumin ratio for cardiovascular morbidity and mortality in end-stage renal disease patients with incident haemodialysis therapy

Background

Hypoalbuminemia, a manifestation of protein-energy wasting or malnutrition, is commonly observed in patients with end-stage renal disease (ESRD), and is associated with chronic inflammation and increasing cardiovascular (CV) risk. Recently, C-reactive protein (CRP)/albumin ratio at discharge is reportedly a well-predictor of mortality in severe sepsis or cancer patients.

We investigated prognostic value of the CRP/albumin ratio at just starting haemodialysis (HD) therapy for CV morbidity and mortality in patients with ESRD.

Methods

A total of 1,548 ESRD patients were enrolled and were divided into quartiles according to CRP/albumin levels at initiation of HD; quartile 1 (Q1): <0.22, Q2: 0.23–0.54, Q3: 0.55–1.83 and Q4: >1.84. They were followed up for 10-year after starting HD therapy. Primary endpoint was CV events defined as hospitalization due to CV events such as cardiac disease, stroke and peripheral artery disease and CV death. We also evaluated the incremental value with C-index when CRP alone, albumin alone and the CRP/albumin ratio were added into a model with established risk factors.

Results

During follow-up period (median: 59 months), 512 cases experienced CV events (33.1%) including 165 cases of CV deaths (10.7%). Kaplan-Meier analysis shows that CV event-free survival rates for 10 years were 63.5%, 53.8%, 47.5% and 31.9% in Q1, Q2, Q3 and Q4, and that CV survival rates were 90.4%, 83.9%, 77.2% and 64.6% in Q1, Q2, Q3 and Q4, respectively (p<0.0001 in both). After adjustment for all baseline variables, elevated CRP/albumin ratio was identified as an independent predictor for CV events [hazard ratio (HR) 1.51, 95% confidence interval (CI) 1.11–2.07, p=0.0093 for Q2 vs. Q1, HR 1.79, 95% CI 1.33–2.42, p<0.0001 for Q3 vs. Q1and HR 2.27, 95% CI 1.70–3.07, p<0.0001 for Q4 vs. Q1, respectively]. As to CV mortality, similar results were obtained (HR 1.80, 95% CI 0.98–3.44, p=0.056 for Q2 vs. Q1, HR 2.56, 95% CI 1.45–4.71, p=0.0009 for Q3 vs. Q1 and HR 2.66, 95% CI 1.53–4.86, p=0.0004 for Q4 vs. Q1, respectively). Furthermore, adding the CRP/albumin ratio to a baseline model with established risk factors improved the C-index greater than that of CRP alone or albumin alone, respectively (0.715 from 0.692, p=0.0095 and from 0.683, p=0.0019)

Conclusion

The CRP/albumin ratio, which easily available from daily practice, could strongly stratify the risk of future CV morbidity and mortality in ESRD patients who need HD therapy.

P2434Digital zoom decreases radiation exposure dose up to 30% in percutaneous coronary intervention

Background

Interventional cardiology is gaining greater popularity worldwide with each passing year. Reduction of exposure dose is a very imminent and an important issue in cardiology procedure. Although a newer radiation reduction technique, device and procedure are very valuable and expected, we should consider about therapy technique, radiation technique, devices, and the way to protection. Digital zoom digitally enlarges images in real time by up to 2.5-fold at lower doses than those used with traditional field of view changes. In our phantom examination the average dose reduction of digital zoom was 27%.

Methods and results

This study is designated as single-center, retrospective, not-randomized, observation study. 2101 eligible cases were collected. We assigned the cases of PCI without the use of Digital zoom to the Conventional group and those involving the use of Digital zoom to the Digital zoom group. There were 806 patients in the Conventional group and 1195 in the Digital zoom group. Because we had begun using Digital zoom from January 2015 onwards, all patients in the Conventional group had undergone PCI from January 2013 to December 2014 and all patients in the Digital zoom group had undergone PCI from January 2015 to December 2016. In addition, we calculated the RAK/minute and DAP/minute for an accurate assessment. To minimize the difference of characteristics between two groups, propensity score including all baseline variables was performed. Furthermore, Predictors of radiation exposure were investigated using multivariable least square methods. Inter group differences were observed in DAP, RAK, DAP/min, and RAK/min (Digital zoom group vs conventional group: DAP, 16000 cGy cm2 [from 1st quartile to 3rd quartile; 10300–24400] vs 20700 [13400–29500], p<0.001; DAP/min, 557 cGy cm2/min [392–737] vs 782 [571–1010], p<0.01; RAK, 1590 Gy [990–2410] vs 1850 [1220–2720], p<0.01; RAK/min, 54.7 Gy/min [38.5–73.2] vs 71.2 [51.5–93.0], p<0.01). Even after propensity score matching, intergroup differences in DAP (810 cases), DAP/min (811 cases), RAK (746 cases), and RAK/min (744 cases) persisted. Furthermore, the least squares method showed that Digital zoom is an important predictor of DAP (β=0.17, p<0.01) and RAK (β=0.12, p<0.01).

Conclusion

Digital zoom is an old and cost-free technique, but one of most powerful reduction of exposure method. Propensity score adjustment and least square methods show that digital zoom is one of independent effective method.

P6243Impact of coronary flow reserve as an important predictor for major adverse cardiac and cerebrovascular event in hemodialysis patients even in patients without myocardial perfusion abnormality

Background

In the clinical setting, ischemic heart disease (IHD) is a major problem not only in general patients but also in regular hemodialysis (HD) patients. 13N-ammonia positron emission tomography (13NH3PET) is an established and excellent diagnostic test for IHD. We have reported about the predictability of coronary flow reserve (CFR) in poor prognosis in HD population. Some prior studies show that low CFR predicts poor prognosis for not only cardiovascular event but also all-cause mortality. Although it is well-known that CFR is an important predictor, there are limited data about CFR of patients without myocardial perfusion (MP) abnormality. We investigated the prognostic predictability of adverse cardiac and cerebrovascular event (MACCE) in HD patients without MP abnormality.

Methods

A total 438 of HD patients who underwent 13NH3PET for suspected IHD were enrolled. All patients were underwent 13NH3PET at our facility. After we excluded patients whose summed stress score (SSS) >3, we identified 182 eligible patients. Patients were divided into two group according to the median value of CFR; low CFR group (≤2.405) and high CFR group (>2.405). We followed up them up to 4.2 years (median 2.4 years) and collected their data. We evaluated their major adverse cardiac cerebrovascular event. We performed Kaplan-Meyer analysis and multivariable cox regression models. Furthermore, we evaluated the incremental value with C-index, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) when CFR added into a model with established risk factors.

Results

There were intergroup difference in baseline characteristics: age, gender, prior CVD and diabetes. Kaplan-Meyer analysis shows statistically intergroup difference [log rank p=0.04, hazard ratio (HR) 0.54, 95% confidential interval (CI) 0.30–0.97]. Multivariable cox regression model for MACCE shows CFR is an independent risk factor (p=0.04, HR 0.54, 95% CI 0.30–0.97). As regarding model discrimination, all of C-index (0.82 vs 0.80, p=0.23), NRI (0.51, p<0.01) and IDI (0.03, p=0.03) were greatest in a predicting model with established risk factors plus CFR.

Conclusions

The low CFR group had poor prognosis in MACCE comparing to the high CFR group. CFR would be an independent risk factor for MACCE. Adding CFR on conventional risk factors could more accurately predict MACCE in HD patients, even in patients without MP abnormality.

Combined ultrasound and Sestamibi scintigraphy provides accurate preoperative localisation for patients with primary hyperparathyroidism

INTRODUCTION

Minimally invasive parathyroidectomy has advantages over the traditional bilateral neck exploration for the surgical treatment of primary hyperparathyroidism. It requires accurate localisation of the parathyroid pathology prior to surgery. The best method of preoperative localisation in a district general hospital setting is not well understood.

METHODS

All patients who underwent parathyroidectomy for primary hyperparathyroidism from 2008 to 2016 were identified from a prospectively maintained database. Operative findings were correlated with radiological and histological results. Sensitivity and specificity of ultrasound, sestamibi scintigraphy and the two together were calculated for diagnostic precision and compared.

RESULTS

One hundred and eighty-four patients met the inclusion criteria, of whom 81.5% had a histological diagnosis of a parathyroid adenoma. Ultrasound had higher sensitivity than sestamibi scintigraphy. Used together, ultrasound and sestamibi scintigraphy performed better than either ultrasound or sestamibi scintigraphy alone (P< 0.001). Twenty-two of 184 cases had no lesion located by either ultrasound or sestamibi scintigraphy preoperatively. Where neither ultrasound nor sestamibi scintigraphy located the lesion, additional computed tomography led to the excision of parathyroid pathology in one in ten patients.

CONCLUSION

The combination of ultrasound and sestamibi scintigraphy provides the highest sensitivity of preoperative localisation. This approach led to a high success rate of minimally invasive parathyroidectomy. Where preoperative localisation is not achieved with ultrasound or sestamibi scintigraphy, computed tomography adds little additional benefit. In this setting other modalities of localisation such a selective venous sampling, intraoperative methylene blue or intraoperative parathyroid hormone levels could be considered.

Associations of Skeletal Muscle Mass, Lower-Extremity Functioning, and Cognitive Impairment in Community-Dwelling Older People in Japan

OBJECTIVE

We examined whether skeletal muscle mass and lower extremity functioning are closely associated with multiple cognitive domains, including global cognition, memory, attention, executive functioning, and processing speed, in community-dwelling older Japanese adults.

DESIGN

A cross-sectional, population-based community study.

SETTING

This study was conducted among community-living older people enrolled in the Obu Study of Health Promotion for the Elderly.

PARTICIPANTS

Participants comprised 5,104 adults (≥ 65 years, mean age: 71 years).

MEASUREMENTS

Data from 4273 participants were analyzed. Appendicular skeletal muscle mass was estimated from bioelectrical impedance analysis and expressed as appendicular skeletal muscle mass index (ASMI). Lower-extremity functioning was assessed by the Five-Times-Sit-to-Stand test (FTSS) and Timed Up and Go test (TUG). Cognitive functions were assessed by the Mini Mental State Examination, word list memory, Trail Making Test parts A and B, and Symbol Digit Substitution Task. Logistic regression analysis were performed to calculate odds ratios (ORs) of cognitive impairment in various domains among skeletal muscle mass, lower-extremity functioning levels adjusted for important demographic variables, and comorbidities.

RESULTS

Participants with lower ASMI and slower FTSS and TUG groups had lower cognitive functioning scores than did participants with higher ASMI and faster FTSS and TUG. The slowest quartiles (Q4) of FTSS and TUG were significantly associated with impaired global functioning (MMSE score < 24) compared to the fastest quartile (Q1) after multivariate adjustment (FTSS, OR = 1.46, 95% confidence interval (CI) = 1.12-1.90; TUG, OR = 1.65, 95% CI = 1.25-2.17). In other dimensions of cognitive functioning, FTSS and TUG were significantly associated with all cognitive impairment in the full adjustment model.

CONCLUSION

Lower-extremity functioning, rather than skeletal muscle mass, is closely related to multiple cognitive domains. This study suggests that maintaining lower-extremity functioning, rather than skeletal muscle mass, may be required for detecting and preventing cognitive impairment.

Decision tree analysis for factors associated with dental caries in school-aged children in Japan

OBJECTIVE

Our study aimed to elucidate the interactive relationship between factors associated with dental caries in school children using decision tree analysis.

RESEARCH DESIGN

Cross-sectional study Methods: Participants were recruited from public primary schools (9-12 years, 4th to 6th grade) and junior high schools (12-13 years, 1st grade) in Japan. A total of 1775 students (928 boys and 847 girls) were analyzed. Questionnaire survey, oral examination, and saliva test were performed. Multiple logistic regression and decision tree analysis were performed.

RESULTS

Multiple logistic regression showed an association between dental caries and toothpaste use, dental attendance and the presence of Streptococcus mutans. Decision tree analysis showed that students with non-regular dental attendance were at a significantly higher risk of dental caries at the late stage of primary school. At the early stage of primary school, high levels of Streptococcus mutans and male sex were factors associated with dental caries. In students with low levels of Streptococcus mutans, using toothpaste occasionally was associated with a high risk of dental caries.

CONCLUSIONS

In early primary school years, S. mutans may be a useful screening and diagnostic tool for dental caries. In students with high levels of S. mutans, sex may be associated with dental caries. Furthermore, in students with low levels of S. mutans, regular use of toothpaste should be encouraged, and in late primary school years, regular dental attendance should be encouraged to prevent dental caries.

Low-noise 750 MHz spaced ytterbium fiber frequency combs

We demonstrate two low-noise 750 MHz ytterbium fiber frequency combs that are independently stabilized to a continuous-wave laser. A bulk electro-optic modulator and a single-stack piezo-electric transducer are employed as fast actuators for stabilizing the respective cavity length to heterodyne beat notes. Both combs exhibit in-loop fractional frequency instabilities of ∼10^-18 at 1 s. To the best of our knowledge, this is the first demonstration of tightly phase-locked (<1  rad root mean square phase noise integrated from 0.1 Hz to 10 MHz) fiber frequency combs with 750 MHz fundamental repetition rate.

Implementing a standardised discharge analgesia guideline to reduce paediatric post tonsillectomy pain

OBJECTIVES

To reduce readmission for pain control post-paediatric tonsillectomy.

INTRODUCTION

Paediatric tonsillectomy is a common procedure in the UK. Uncontrolled pain at home is a common reason for re-admission and therefore adequate analgesic control following paediatric tonsillectomy is vital for a smooth post-operative recovery. Analgesic regimens at a district general hospital in England were audited and a standardised protocol was subsequently implemented.

METHODS

A retrospective audit from September 2014 to August 2015 was completed. Discharge analgesic regimens and readmission rates post-tonsillectomy for recurrent tonsillitis in 2-17 year-old children were studied in a large general hospital in the United Kingdom. A standardised weight-based algorithm was used to dose scheduled regular paracetamol for 2 weeks. Second cycle prospective audit ran from December 2015 to November 2016.

RESULTS

In cycle 1, 151 children (mean age, 7.9 years) underwent tonsillectomy for tonsillitis, 25 (16.6%) of whom were readmitted. 12 (7.9%) experienced postoperative haemorrhage, 13 (8.6%) required pain control, and one (1.2%) had infection. The discharging analgesic regimen varied widely and often included purchase of over-the-counter ibuprofen and paracetamol. In cycle 2, 118 children (mean age, 8.8 years) underwent tonsillectomy, 17 (14.4%) were readmitted; 12 (10.2%) had post-operative haemorrhage, 0 needed pain control, 5 (4.2%) had other problems. There was a significant reduction in readmission for pain control (p = 0.0027) from 7.3% to 0% in the study. There was no significant change in overall readmission rate (16.6%-14.4%) or postoperative haemorrhage rate (8.9% overall).

DISCUSSION

Analgesia prescription post tonsillectomy varies widely and over the counter prescriptions of ibuprofen and paracetamol is based on age rather than weight with patients receiving inadequate analgesic doses. A readily available standardised postoperative analgesic protocol can significantly reduce readmission rates for pain control following paediatric tonsillectomy.

The Role of Venom Haemorrhagin in Spontaneous Bleeding in Bothrops jararaca Envenoming

Thirty-eight patients bitten by Bothrops jararaca were investigated. Twenty-six had signs of local or systemic haemorrhage. Twenty-two of these had incoagulable blood, and these patients were found to have low fibrinogen levels (mean 0.17 ± 0.03 g/1), thrombocytopenia, very high thrombin-antithrombin III complex (850 ± 184 pg/1) and D-dimer (170 ± 44 μg/ml) antigen levels. Serum venom haemorrhagin levels were significantly higher in patients with clinical signs of haemorrhage (36.4 ± 6.4 ng/ml) than those without (11.7 ± 3.7 ng/ml; p <0.002). Twelve out of 13 patients with thrombocytopenia were bleeding. High levels of thrombomodulin (22.3 ± 1.5 ng/ml) and haemorrhagin (35.7 ± 7.7 ng/ml) were detected in these 12 patients, suggesting vascular endothelial damage. Haemorrhagin levels also correlated inversely with platelet count in these patients. It was concluded that thrombocytopenia is one of the main causes of bleeding inB. jararaca victims, possibly as a result of venom haemorrhagin activity.

Suitable reference gene selection for gene expression studies in knee osteoarthritis synovium using quantitative PCR analysis

Osteoarthritis (OA) is the leading cause of musculoskeletal disability in the elderly. Insights into the biological features of OA are obtained by characterization of the molecular features by gene expression profiling using reverse transcription-quantitative PCR (RT-qPCR). However, it has recently become evident that the use of suitable reference genes is required for appropriate normalization of this technique. Here total RNA was isolated from the synovium of 18 men and 20 women who underwent total knee arthroplasty for knee OA (KOA). We validated the expression stability of 7 candidate housekeeping genes (ACTB, B2M, GAPDH, HPRT1, RPL13A, SDHA, and YWHAZ) in the synovium of KOA with 3 commonly used algorithms (geNorm, NormFinder, and BestKeeper). Additionally, we evaluated expression profiles of the steroid hormone receptor (AR, ESR1, ESR2, GR, MR, and PR) and proinflammatory cytokines (IL1B and IL6) genes in the synovium and their correlations with the risk factors of KOA, using the most and least stable housekeeping genes for comparison. Results showed that HPRT1 was the most stable gene, whereas B2M was the least stable. RT-qPCR analysis revealed sexually dimorphic expression of AR, IL1B, and IL6; intercorrelations between steroid hormone receptor expression levels and female-specific correlations of IL1B expression with ESR1 and PR expression, IL6 expression with ESR1 and GR expression, and body mass index with AR and PR expression; and the choice of the least stable reference gene altered several correlations and statistical significances. In conclusion, HPRT1 was identified as the suitable reference gene for normalization in the OA synovium.

Systematic review of cure and recurrence rates following minimally invasive parathyroidectomy

Background

The majority of patients with primary hyperparathyroidism (PHPT) have a single overactive adenoma. Advances in preoperative imaging and surgical adjuncts have given rise to minimally invasive parathyroidectomy (MIP), with lower complication rates in comparison with bilateral neck exploration. Misdiagnosis and undertreatment of multiglandular disease, leading to potentially higher recurrence rates, remains a concern. This study evaluated risks of long‐term (1 year or more) recurrence following ‘targeted’ MIP in PHPT.

Methods

Multiple databases were searched for studies published between January 2004 and March 2017, looking at long‐term outcomes (1 year or more) following targeted MIP for PHPT. English‐language studies, with at least 50 patients and a mean follow‐up of 1 year, were included.

Results

A total of 5282 patients from 14 studies were included. Overall mean recurrence and cure rates were 1·6 (range 0–3·5) and 96·9 (95·5–100) per cent respectively. Mean follow‐up was 33·5 (1–145) months. When intraoperative parathyroid hormone (PTH) measurements were not done, cure rates were higher (99·3 per cent versus 98·1 per cent with use of intraoperative PTH measurement; P < 0·001) and recurrence rates lower (0·2 versus 1·5 per cent respectively; P < 0·001).

Conclusion

Targeted MIP for a presumed single overactive adenoma was associated with very low recurrence rates, without the need for intraoperative PTH measurement when preoperative imaging studies were concordant. Targeted MIP should be encouraged.

The plasmonic properties of gold nanoparticle clusters formed via applying an AC electric field

An external electric AC field with a field strength ranging from 10 V mm-1 to 30 V mm-1 and a frequency ranging from 0.1 kHz to 1 MHz was applied to suspensions of gold nanoparticles (Au NPs) to control their plasmonic properties. Apparent differences in the UV-vis spectra of the Au NPs were observed between the spectra with and without the field application. The characteristic red color of the Au NP suspension darkened; this suggested that the application of the AC field caused the aggregation of the Au NPs. In addition, the sizes of the Au NP clusters in suspension formed by the AC field application depended on the frequency of the applied field. The surface-enhanced Raman scattering (SERS) effects of Au NP clusters were examined by comparing the difference in Raman intensities obtained at 30 V mm-1 and in a frequency range of 0.1 kHz to 1 MHz. The application of a low-frequency field at 0.1 kHz caused a rapid aggregation of the Au NPs, resulting in low Raman intensities of the probe molecules. Conversely, high-frequency applications between 1 kHz and 1 MHz successfully enhanced the Raman intensities of the molecules in suspension. The strong correlation of the optical/sensing properties with the Au NP clustering states reveals that the application of an AC electric field is a powerful tool for control over the plasmonic properties.

Medial and lateral laxity in knees with advanced medial osteoarthritis

OBJECTIVE

An increase in coronal laxity is recognized as a risk factor for progression of knee osteoarthritis (OA). The purpose of this study was to evaluate coronal laxity, which was defined as the angular motion from the neutral, unloaded (baseline) position to the loaded position, in patients with advanced medial knee OA.

METHOD

Preoperative coronal laxity was assessed using radiographs in patients with medial knee OA undergoing total knee arthroplasty by applying a force of 150 N with an arthrometer. A consecutive series of 211 knees with OA and 40 normal control knees were examined. A knee with OA was defined as clinically "balanced" when the difference between medial and lateral laxity was 3° or less. Values are expressed as median [25^th, 75^th percentile].

RESULTS

The laxity was 4° [3, 5] from the baseline on the medial side and 3° [2, 4] on the lateral side. The distribution of medial and lateral laxity indicated that 90% (189/211) of patients fell within 3°. The equivalence test showed that the medial and lateral laxity was similar, with an equivalence margin of 3° (P < 0.001). In the control knees, the laxity was 3° [2, 4] from the baseline on the medial side and 2° [2, 4] on the lateral side. The differences between the knees with advanced OA and the controls were significant (P = 0.005, medial; P = 0.006, lateral).

CONCLUSION

This study showed that a clinically balanced knee was maintained even in patients with advanced medial knee OA.

Morphological Analysis of Trafficking and Processing of Anionic and Cationic Liposomes in Cultured Cells

Liposomes, artificial phospholipid vesicles, have been developed as a non-viral drug delivery system to allow contained agents to be efficiently delivered to target sites via systemic circulation. Liposomes have been used as a gene transfer tool with cultured cells; however, their precise trafficking and processing remain uncertain. Furthermore, liposomes with different surface charges are known to exhibit distinct properties. The purpose of the current study was to elucidate the intracellular trafficking and processing of liposomes with anionic and cationic surface charges from a morphological view point. We found that cationic liposomes (CLs) were more effectively taken by the cells than anionic liposomes (ALs). Confocal laser scanning microscopy and transmission electron microscopy demonstrated distinct intracellular localization and processing patterns of ALs and CLs. ALs and their contents were localized in lysosomes but not in cytosol, indicating that ALs are subjected to the endosome-lysosome system. In contrast, contents of CLs were distributed mainly in the cytosol. CLs appear to disturb the cell membrane and then collapse to release their contents into the cytosol. It is feasible that the contents of CLs enter the cytosol directly rather than via the endosome-lysosome system.

Ultrasound-Guided Fine-Needle Aspiration Biopsy for Breast Tumors: Needle Guide versus Freehand Technique

Background

We retrospectively studied whether a needle guide is necessary when performing ultrasound-guided fine-needle aspiration biopsy (US-FNAB) in patients with breast tumors.

Methods

A total of 47 patients (50 lesions) with breast tumors underwent US-FNAB with a needle guide and 127 patients (143 lesions) underwent the procedure without a needle guide (freehand biopsy). The diagnoses obtained by US-FNAB were compared with the surgical findings.

Results

The sensitivity of freehand biopsy for tumors <3 cm in diameter was significantly higher than that of the needle guide technique.

Conclusions

We recommend performing US-FNAB without a needle guide (freehand biopsy) in order to maximize the correct preoperative diagnosis rate, especially in patients with tumors <3 cm in diameter.

Thyroid Cancer in Uremic Patients

Background

The combination of thyroid cancer and secondary uremic hyperparathyroidism has thus far been reported in only 25 cases.

Methods

Here we report our experience of 19 patients with secondary hyperparathyroidism who underwent parathyroidectomy.

Results

Thyroid nodules were present in five patients (26.3%), including one with a benign nodule and four with papillary thyroid cancer (21.1%).

Conclusion

Our experience suggests that, in order to make a correct diagnosis, clinicians should consider the possibility of thyroid cancer in uremic patients with secondary hyperparathyroidism.

Accessory Breast Cancer: A Case Report and Review of the Japanese Literature

The case of a 31-year-old woman with accessory breast cancer in the left axilla is described. She had noticed a swelling in the left axilla during her three pregnancies. The preoperative diagnosis of accessory breast cancer was made on the basis of ultrasound-guided fine-needle aspiration biopsy (US-FNAB) and clinical history. She was treated by wide local resection and regional lymph node dissection. Although cancer originating from accessory breast tissue has been reported very rarely, knowledge of this disorder may facilitate the correct diagnosis of axillary tumors. US-FNAB is a useful and simple technique for the tissue diagnosis of axillary tumors.

Intrathyroid Thyroglossal Duct Cyst Simulating a Thyroid Nodule

A case of intrathyroid thyroglossal duct cyst is reported. A 50-year-old woman presented with a right lateral neck mass that was clinically indistinguishable from a thyroid nodule. Ultrasound-guided fine-needle aspiration biopsy (US-FNAB) revealed normal-looking squamous cells. Right thyroid lobectomy was performed and microscopic examination revealed a cyst lined by squamous epithelium that was consistent with a thyroglossal duct cyst. The lesion was completely surrounded by normal thyroid tissue. Our experience suggests that intrathyroid thyroglossal duct cyst should be remembered in the differential diagnosis of a thyroid nodule. Detection of benign squamous cells by US-FNAB may be useful for ruling out the possibility of a cystic thyroid tumor.

Co-expression of the calcitonin receptor gene in the hypothalamic kisspeptin neurons in female rats

Purpose

Hypothalamic kisspeptin neurons are considered to play a critical role in regulating mammalian reproduction and integrating humoral and neuronal inputs that control gonadotropin‐releasing hormone (GnRH)/gonadotropin release. The present study aimed to investigate the upstream regulator candidates for kisspeptin neurons.

Methods

Visualized kisspeptin neurons that were taken from the arcuate nucleus (ARC) of Kiss1‐tdTomato rats were subjected to next‐generation sequencing (NGS) analysis. In situ hybridization (ISH) for the calcitonin receptor gene (Calcr) was performed throughout the whole forebrain of ovariectomized wild‐type female rats that had been implanted with a negative feedback level of estrogen, because the Calcr expression was evident in the ARC kisspeptin neurons from the NGS analysis. Then, a double ISH was performed for the Calcr and kisspeptin gene (Kiss1) in the brain regions, containing either the anteroventral periventricular nucleus (AVPV) or ARC of the female rats.

Results

The NGS analysis revealed that the Calcr was highly expressed in the ARC kisspeptin neurons. It was found that the Calcr was co‐expressed in 12% and 22% of the Kiss1‐expressing cells in the ARC and AVPV, respectively.

Conclusion

The present study suggests that calcitonin receptor signaling could be involved in the regulation of reproductive function through the direct control of the ARC and/or AVPV kisspeptin neurons, and then GnRH/gonadotropin release.