Does parity matter in women's risk of dementia? A COSMIC collaboration cohort study

BACKGROUND

Dementia shows sex difference in its epidemiology. Childbirth, a distinctive experience of women, is associated with the risk for various diseases. However, its association with the risk of dementia in women has rarely been studied.

METHODS

We harmonized and pooled baseline data from 11 population-based cohorts from 11 countries over 3 continents, including 14,792 women aged 60 years or older. We investigated the association between parity and the risk of dementia using logistic regression models that adjusted for age, educational level, hypertension, diabetes mellitus, and cohort, with additional analyses by region and dementia subtype.

RESULTS

Across all cohorts, grand multiparous (5 or more childbirths) women had a 47% greater risk of dementia than primiparous (1 childbirth) women (odds ratio [OR] = 1.47, 95% confidence interval [CI] = 1.10-1.94), while nulliparous (no childbirth) women and women with 2 to 4 childbirths showed a comparable dementia risk to primiparous women. However, there were differences associated with region and dementia subtype. Compared to women with 1 to 4 childbirths, grand multiparous women showed a higher risk of dementia in Europe (OR = 2.99, 95% CI = 1.38-6.47) and Latin America (OR = 1.49, 95% CI = 1.04-2.12), while nulliparous women showed a higher dementia risk in Asia (OR = 2.15, 95% CI = 1.33-3.47). Grand multiparity was associated with 6.9-fold higher risk of vascular dementia in Europe (OR = 6.86, 95% CI = 1.81-26.08), whereas nulliparity was associated with a higher risk of Alzheimer disease (OR = 1.91, 95% CI 1.07-3.39) and non-Alzheimer non-vascular dementia (OR = 3.47, 95% CI = 1.44-8.35) in Asia.

CONCLUSION

Parity is associated with women's risk of dementia, though this is not uniform across regions and dementia subtypes.

Driving-Related Adverse Events in the Elderly Men: A Population-Based Prospective Cohort Study

OBJECTIVE

This study estimated the incidence of driving-related adverse events and examined the association of cognitive function with the risk of future driving-related adverse events in the elderly Korean male population.

METHODS

We analyzed 1,172 male drivers aged 60 years or older in the Korean Longitudinal Study on Cognitive Aging and Dementia (KLOSCAD). Using the data from Korean National Police Agency, we classified the participants into three groups: safe driving (drove for 2 years after baseline without a traffic accident or repeated violations), driving cessation (stopped driving), and risky driving (one or more traffic accidents or repeated violations). We estimated the incidences of driving cessation and risky driving, and examined the effect of cognitive function on their risks.

RESULTS

The incidence of driving cessation and risky driving in the Korean male drivers aged 60 years or older was 19.3 and 69.9 per 1,000 person-years respectively and increased in the late 80s. Drivers with better baseline Word List Memory Test scores showed less risky driving (OR=0.94, p=0.039).

CONCLUSION

Driving-related adverse events increased in late 80s, and better memory function was protective against these events.

The effects of hidden female smokers on the association between smoking and chronic obstructive pulmonary disease in Korean adults

OBJECTIVE

Smoking is an important causative factor of chronic obstructive pulmonary disease (COPD), and females are considered more susceptible to the effects of smoking than males. However, in previous Korean studies, the effects of sex differences on the association between smoking and COPD have been controversial. In this study, the effects of sex differences on the association between smoking and COPD and the effects of female hidden smokers on that association in Korean adults were investigated.

METHODS

Data were acquired from the Korea National Health and Nutrition Examination Surveys (KNHANES).

RESULTS

The multivariate logistic regression analysis showed that self-reported smoking status for ex-smoker and current smoker correlated with COPD (odds ratio, OR: 1.67 and OR: 2.41, respectively). Self-reported smoking status for ex-smoker and current smoker correlated with COPD in men (OR: 1.61, OR: 2.43, respectively). Female self-reported current smoking status correlated with COPD (OR: 2.52), but female ex-smoker status was not significantly correlated with COPD. The ratios of cotinine-verified to self-reported smoking rates were 1.95 for women and 1.07 for men.

CONCLUSION

The results of this study were that sex differences might affect the association between COPD and smoking and that female hidden smoking might affect the association between smoking and COPD in Korean adults.

Impact of overweight or obesity trajectory on health expenditure in Korea

BACKGROUND

This study aimed to identify the effect of the overweight or obesity (OWOB) trajectory on current health care expenditure in South Korea.

METHODS

Ten years of publicly released data (2002-12) were obtained in 2016 from a retrospective cohort of National Health Insurance System claims. This study included 51,844 adults (aged 30-59 years in 2002) and 21,196 elderly adults (aged ≥ 60 years in 2002).

RESULTS

Compared with adults who maintained normal weight (NW), higher yearly total health expenditures were estimated for adults who lost weight over the 10-year period: by 11.5% (95% confidence interval (CI): 0.18-22.96%) when changing from NW to underweight (UW) and 6.2% (95% CI: 0.47-12.01%) from OWOB to UW/NW. Elderly adults had higher health expenditures when they lost weight by 14.0% (95% CI: 0.37-27.70%) from NW to UW and 6.8% (95% CI: 0.13-13.51%) from OWOB to UW/NW compared with when they maintained NW.

CONCLUSIONS

These findings indicate the importance of early intervention to control OWOB, particularly because people in late adulthood have greater health care needs for reasons other than OWOB.

Trend in the Prevalence of Non-Daily Smoking and Their Relationship with Mental Health Using the Korea Health and Nutrition Examination Survey

Introduction: Non-Daily Smoking (NDS), which is increasingly prevalent worldwide, has not yet attracted as much attention as has daily smoking in Asia. The aims of this study were to identify trends in the prevalence of NDS and to compare characteristics by age, gender, and mental health indicators such as depression, suicidality, and alcohol consumption in South Korea. Methods: We included 33,806 adults (aged ≥ 19 years) who participated in the Korean National Health and Nutrition Examination Survey (KNHNES) from 2010 to 2015. The dataset includes self-reported medical history and questionnaires that explore depression, suicidality, and alcohol use, which are known to be highly related to smoking. We divided the respondents into four groups according to smoking status: Never Smoking (NS, N = 20,270); Past Smoking (PS = 6835); Daily Smoking (DS = 5927), who reported smoking every day; and Non-Daily Smoking (NDS = 774), who reported that they sometimes smoke. Results: Increased NDS prevalence is observed in most age groups in both male and female adults despite the prevalence of total smoking and daily smoking gradually decreasing. Depression and suicidality were significantly more prevalent in the NDS than the NS group (Depression Odds ratio, OR = 1.72, 95% Confidence interval, CI = 1.31–2.26; Suicidality OR = 3.14, 95% CI = 1.40–7.02). NDS is also associated with a higher frequency of binge drinking and alcohol use disorder than NS (OR = 4.17, 95% CI = 3.49–4.99). Conclusions: This study suggests that more concern is warranted for NDS given the increasing prevalence and characteristics of poor mental health in NDS respondents.

Epidemiological characteristics of subsyndromal depression in late life

OBJECTIVES

Subsyndromal depression is prevalent and associated with poor outcomes in late life, but its epidemiological characteristics have barely been investigated. The aim of this prospective cohort study is to compare the prevalence, incidence and risk factors of subsyndromal depression with those of syndromal depression including major and minor depressive disorders in community-dwelling elderly individuals.

METHODS

In a nationwide community-based study of randomly sampled Korean elderly population aged 60 years or older (N = 6640), depression was assessed with standardized diagnostic interviews. At baseline and at 2-year and 4-year follow-ups, the authors diagnosed subsyndromal depression by the operational criteria and syndromal depression by the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) diagnostic criteria. Multivariate logistic regression analyses were conducted to identify the risk factors for incident depression.

RESULTS

The age- and gender-adjusted prevalence rate of subsyndromal depression was 9.24% (95% confidence interval = [8.54, 9.93]), which was 2.4-fold higher than that of syndromal depression. The incidence rate of subsyndromal depression was 21.70 per 1000 person-years (95% confidence interval = [19.29, 24.12]), which was fivefold higher than that of syndromal depression. The prevalence to incidence ratio of subsyndromal depression was about half that of syndromal depression. The risk for subsyndromal depression was associated with female gender, low socioeconomic status, poor social support and poor sleep quality, while that of syndromal depression was associated with old age and less exercise.

CONCLUSION

Subsyndromal depression should be validated as a clinical diagnostic entity, at least in late life, since it has epidemiological characteristics different from those of syndromal depression.

Evaluation of the Biofire FilmArray meningitis/encephalitis assay for the detection of Cryptococcus neoformans/gattii

OBJECTIVES

Cryptococcal meningitis (CM) remains an important cause of morbidity and mortality among immunocompromised patients. Laboratory diagnostics for CM includes antigen detection, staining and culture. Data on the performance of the Biofire® FilmArray® meningitis/encephalitis (ME) panel for detecting Cryptococcus neoformans/gattii is limited, with several reports describing false negativity for this target.

METHODS

A retrospective analysis of 1384 physician-ordered ME panel tests ordered between January 2017 to October 2018 was performed. ME panel results were compared to cerebrospinal fluid (CSF) cryptococcal antigen (CrAg) and CSF culture testing and clinical significance of cryptococcal detection was determined.

RESULTS

There were 34 patients positive for cryptococcal detection by either ME panel, CSF CrAg or CSF culture in 2.7% of CSF specimens tested (38/1384). Of the 34 patients positive for cryptococcal detection, 85.3% were human immunodeficiency virus positive (29/34). The ME panel detected 32/38 (84.2%) cryptococcal-positive specimens, culture detected 28/38 (73.7%) and CSF CrAg was positive in 37/38 specimens (97.4%). The ME panel had a sensitivity and specificity of 96.4% (95% CI 81.7-99.9%) and 99.6% (95% CI 99.2-99.9%) compared with culture, and 83.8% (95% CI 68.0-93.8%) and 99.9% (95% CI 99.6-100.0%) compared to CSF CrAg testing, respectively. CrAg titres were lower among ME panel-negative, culture-negative specimens compared with ME panel-positive, culture-negative specimens (reciprocal median end-point titres of 128 ± 60 vs. 1920 ± 1730, p 0.04). All five CrAg-positive, ME panel- and culture-negative specimens were obtained from previously treated CM patients.

DISCUSSION

The ME panel had high correlation with CSF culture and a somewhat lower correlation with CSF CrAg testing. The potential utility of using negative ME panel test results to predict culture sterility among patients undergoing treatment for CM warrants further study.

Loss of Functional Dentition is Associated with Cognitive Impairment

BACKGROUND

Although tooth loss is known to increase the risk of cognitive impairment and dementia, few studies have investigated the association between functional teeth including rehabilitated lost teeth and cognitive functionObjective:We investigated the associations of the numbers of functional teeth and functional occlusal units with cognitive impairment and cognitive function in late life.

METHODS

The current study was conducted as a part of the Korean Longitudinal Study on Cognitive Aging and Dementia (KLOSCAD), a community-based elderly cohort study. We analyzed 411 participants who have agreed with the additional dental exam. Geriatric psychiatrists and neuropsychologists administered the Consortium to Establish a Registry for Alzheimer's disease Assessment Packet Clinical and Neuropsychological Assessment Battery to all participants, and dentists examined their dental status.

RESULTS

Higher number of functional teeth (OR = 0.955, 95% CI = 0.914-0.997, p = 0.037) and higher number of functional occlusal units (OR = 0.900, 95% CI = 0.813-0.996, p = 0.042) were associated with lower odds of cognitive impairment. When we analyzed these relationships separated by the location of teeth, only the numbers of functional teeth (OR = 0.566, 95% CI = 0.373-0.857, p = 0.007) and functional occlusal units (OR = 0.399, 95% CI = 0.213-0.748, p = 0.004) in the premolar area were associated with lower odds of cognitive impairment.

CONCLUSION

Loss of functional teeth and functional occlusal units (especially in the premolar region) were associated with increased cognitive impairment.

Low Diastolic Blood Pressure and Cognitive Decline in Korean Elderly People: The Korean Longitudinal Study on Cognitive Aging and Dementia

OBJECTIVE

Cardiovascular diseases are representative risk factors for the onset of cognitive decline. The purpose of this study was to confirm the relationship between diastolic blood pressure and cognitive function in elderly people in Korea.

METHODS

Data from subjects who were enrolled in the prospective Korean Longitudinal Study on Cognitive Aging and Dementia were used in this study. Data from 701 subjects whose diastolic blood pressure range did not change (≤79 mm Hg or ≥80 mm Hg) over 2 years were analyzed. To analyze the differences in cognitive function between the groups at the 2-year follow-up, an analysis of covariance was performed with covariates, which were significantly different between the two groups, and the baseline cognitive function.

RESULTS

Significant differences were observed between the two groups, and the mean scores on the constructional praxis (η2=0.010) and word list recall tests (η2=0.018) in the diastolic blood pressure ≥80 mm Hg group were higher than those in the diastolic blood pressure ≤79 mm Hg group at the 2-year follow-up.

CONCLUSION

These results indicate that maintaining a DBP below 79 mm Hg presents a greater risk of cognitive decline in Korean elderly people.

THE EFFECTS OF SIMULATION-BASED EMPATHY ENHANCEMENT PROGRAM FOR CARER OF THE ELDERLY ON COUNSELLING

Empathy of the caregiver can influence both the caregiver’s performance and the receiver’s enhanced life. The aim of this study is to examine whether Simulation-based Empathy Enhancement program for the Carer of the Elderly (SEE-C) is effective in increasing care receivers’ session satisfaction and positive emotional change. We developed SEE-C by modifying the Dementia Live(TM) program and adding with a brief mindfulness. The effect on counselling was assessed using the Session Evaluation Questionnaire (SEQ), which is self-report tool asking the client about their experience with the session just ended. A total of 100 older adults living alone were interviewed by caregivers who experienced SEE-C (n=12) and by non-experienced (n=12). Participants in this study were randomly assigned to each of the two caregiver groups, and were interviewed about demographics, health and emotional status, and lifestyle using the same protocols. Analysis of covariance was conducted, controlling variables of age of subjects and caregivers’ months of career, which were found to differ significantly between the two groups. Among the four subcategories of SEQ, the experimental group reported significantly higher scores than the control group in three subcategories of session-depth (F(1, 96)=9.647, P=.002), session-smoothness (F(1, 96)=13.699, p<.001), emotion-positive (F(1, 96)=18.056, p<.001), with the exception of emotion-alertness (F(1, 96)=0.366, p=.546). These results suggest that SEE-C could have a positive impact on interviewing the elderly in terms of improving the capacity of the interviewer and raising the satisfaction of the interviewee.

THE EFFECTS OF SOCIAL NETWORK ON RESILIENCE OF COMMUNITY-DWELLING OLDER ADULTS LIVING ALONE

Resilience is one of the components for successful aging and is related to wellbeing in late life. Studies have shown that older people living alone have low resilience. However, most of these studies were mainly conducted on unhealthy participants. The aim of this study is to examine the factors that contribute to resilience of healthy older adults living alone. Older people living alone who are not subject to public health care service provided to the economically or physically challenged or depressed people were recruited. Data collected from 295 participants were used to conduct hierarchical multiple regression analyses, controlling demographic characteristics, level of cognitive and physical functions, and emotional status. A self-reported questionnaire, UCLA Loneliness Scale, Lubben Social Network Scale(LSNS), and Multidimensional Individual and Interpersonal Resilience Measure(MIIRM) were used to measure study variables. A hierarchical model accounted for 48.8% of the variance in resilience. In model 1(demographics), the religion(β=.178, p<.001) and the perceived economic status(β=-.176, p<.001) variables were significantly related to resilience. The subjective health(β=-.109, p=.038) in model 2(level of function) and the loneliness(β=-.379, p<.001) in model 3(emotional status) had a significant effect on resilience. In model 4, the size(β=-.115, p=.029) and the frequency(β=.160, p=.003) of social networks significantly predicted resilience. The results showed that protecting older adults’ social networks could lead to promote their health and wellbeing. What can be inferred from this finding is that even though the members are small, the social network they often have contact with is important for the resilience of older adults living alone.

Correction to: CD4 T cell count is positively associated with lumbar spine bone mass in HIV-infected men under the age of 50 years

Two sentences in the Discussion section were incorrect.

P997Improving left atrial appendage occluder size determination by using 3-dimensional printing model of the left atrial appendage

Introduction

Given the complexity of left atrial appendage (LAA) structure, current 2D based LAA occluder (LAAO) size prediction system using transesophageal echocardiography (TEE) has limitations.

Objective

To assess the accuracy of LAAO size determination method by implantation simulation using a 3D printed model compared with a conventional method based on TEE.

Methods

We retrospectively reviewed 57 cases with percutaneous LAAO using Amplatzer Cardiac Plug and Amulet from 2014 to 2018. We excluded cases without cardiac CT (21 cases) or with peri-device leakage or inappropriate position of the device on six months follow up TEE (6 cases), or with paroxysmal atrial fibrillation (2 cases). We finally included 28 cases with anatomically and physiologically properly implanted LAAO, using the final size of the implanted devices as a standard for the size prediction accuracy. We generated 3D printing model from cardiac CT images. LAAO size was determined with device implantation simulation using 3D printing model and occluder devices (Figure C), and conventional 2D TEE measurements by two experienced cardiologists who were blinded to the size of the finally implanted device.

Results

The accuracy in size of 3D printed left atrium (LA) models, compared with CT image sources, were validated by measuring the distance between artifacts which were intentionally implanted to LA model during image processing. There was minimal bias (−0.11 mm) between 3D images and printed LA models (Figure A). As plotted in Figure B, LAAO sizing by implantation simulation with 3D printing model showed excellent agreement with actually implanted LAAO size (r=0.927; bias=0.7±2.5), while LAAO sizing by 2D TEE measurements remained poor (r=0.544; bias 2.3±6.7).

Conclusions

LAAO size determination by using 3D printing model of LAA showed excellent accuracy. A prospective study to evaluate the clinical utility of this method should be done in future.

P4758Label adherence of non-vitamin K antagonist oral anticoagulants and clinical outcomes in patients with atrial fibrillation: A nationwide study

Background

Dose adjustment of non-vitamin K antagonist oral anticoagulants (NOACs) is indicated in some patients with atrial fibrillation (AF), based on selected patient factors or concomitant medications.

Purpose

We assessed the frequency of label adherence of NOAC dosing among AF patients and the associations between off-label NOAC dosing and clinical outcomes in real-world clinical practice.

Methods

We evaluated 53,649 AF patients treated with a NOAC using Korean National Health Insurance Service database during the period from January 2013 to December 2016. NOAC doses were classified as either underdosed or overdosed, consistent with U.S. Food and Drug Administration labeling. Cox proportional hazards regression was performed to investigate the effectiveness and safety outcomes including stroke or systemic embolism, major bleeding, and all-cause mortality.

Results

Overall, 16,757 NOAC-treated patients (31.2%) were underdosed, 4,492 were overdosed (8.4%), and 32,400 (60.4%) were dosed appropriately according to drug labeling. Compared with patients with label adherence, those who were underdosed or overdosed were older (71±8 and 75±7 years of age vs. 70±9 years of age, respectively; p<0.001), more likely female (39% and 53% vs. 38%, respectively; p<0.001), and had higher CHA2DS2-VASc scores (4.6±1.7 and 5.3±1.7 vs. 4.5±1.8, respectively; p<0.001). NOAC overdosing was associated with increased risk for stroke or systemic embolism (5.76 vs. 4.03 events/100 patient-years, p<0.001), major bleeding (4.77 vs. 2.94 events/100 patient-years, p<0.001), and all-cause mortality (5.43 vs. 3.05 events/100 patient-years, p<0.001) compared with label-adherent use.

Figure 1

Conclusion

In routine clinical practice, a significant proportion (almost 2 in 5) of AF patients received NOAC doses inconsistent with drug labeling. NOAC overdosing is associated with increased risk for stroke or systemic embolism, major bleeding, and all-cause mortality in Asian patient with AF.

P1012Radiofrequency catheter ablation of accessory pathways at the site of prior valve surgery

Background

Radiofrequency catheter ablation (RFCA) for accessory pathways (APs) at the site of prior valve surgery remains challenging. We aimed to clarify the factors associated with successful RFCA for such APs.

Methods

Upon reviewing a RFCA registry and previous case reports, we included nine patients who underwent RFCA of APs at the site of prior valve surgery (total-VS group; age, 34.0 [24.5–45.0] years; men, 4/9) and 196 patients who underwent RFCA of APs with no history of valve surgery (no-VS group; age, 40.5 [23.0–54.0] years; men, 114/196). Electrophysiological features, procedural details, and outcomes were examined.

Results

AP exhibited decremental conduction in four of nine patients in the total-VS group. The number of RFCA attempts was significantly higher in the total-VS group than in the no-VS group (10.0 [4.5–14.5] vs 2.0 [1.0–3.0]; p<0.001). In four patients who underwent mitral valve surgery, successful RFCA was achieved using the transaortic approach, coronary sinus approach, or bipolar ablation. In three patients who underwent tricuspid valve surgery, successful RFCA was achieved using the above-prosthetics or trans-prosthetics approach. In two patients, RFCA failed. The trans-prosthetics approach and bipolar ablation technique were effective. The transaortic and coronary sinus approaches were occasionally effective. The transseptal approach was ineffective. Based on the success rate and accessibility, we suggest a stepwise approach to RFCA of APs at the site of prior mitral or tricuspid valve surgery (Figure).

Stepwise approach to AP at valve surgery

Conclusions

Successful RFCA of APs at the site of prior valve surgery can be achieved by detailed mapping of the areas both above and below the prosthetic valve, as well as by ensuring effective radiofrequency energy delivery using various catheter approaches and RFCA techniques.

P5660Clinical impact of polycythemia on cardiovascular outcome from the general population: a nationwide cohort study

Background

Although adverse effect of anemia had been reported, effect of polycythemia on cardiovascular outcome from the general population had not been revealed yet.

Methods

We included 451,107 subjects who received national health examinations from the Korean National Health Insurance Service-based National Sample Cohort from 2009–2013. Medical records were screened from January 2002 to investigate the subjects' disease-free baseline period. They were followed until December 2013. We divided male and female subjects into four categories each based on hemoglobin level (normal, moderate to severe and mild anemia, polycythemia) to assess each outcome.

Results

During 1,735,964 person·years, 12,107 major adverse cardiovascular and cerebrovascular events (MACCE), 862 incident acute myocardial infarction (MI), 5,850 incident ischemic stroke, and 2,430 incident atrial fibrillation (AF) were observed. Compared to normal hemoglobin range group, polycythemia group showed higher MACCE (HR=1.23 [1.12–1.35] in male, HR=1.79 [1.20–2.67] in female, each p<0.001), incident MI (HR=1.37 [1.05–1.79] in male, HR=3.46 [1.06–14.00] in female, each p<0.001), incident ischemic stroke (HR=1.27 [1.10–1.46] in male, HR=1.72 [1.02–2.91] in female, each p<0.001), and incident AF (HR=1.46 [1.21–1.74] in male, HR=2.13 [1.03–4.77] in female, each p<0.001). Each outcome was linearly increased with the increase of hemoglobin among subjects with polycythemia (p<0.001), and with the decrease of hemoglobin among subjects with anemia (each p<0.001, U-shaped relationship). These relationship was more profound in obese female younger than 60-year-old.

Conclusion

Not only anemia but also polycythemia were significantly associated with higher rate of MACCE including death, incident MI, ischemic stroke, and AF among the general population.

P1875Nonspecific intraventricular conduction delay is associated with future occurrence of atrial fibrillation in patients with structurally normal heart and sinus rhythm

Background

This study aimed to elucidate long-term prognosis of nonspecific intraventricular conduction delay (NIVCD) in patients with structurally normal heart.

Methods

We included 107,838 patients (age, 52.1±15.5 years; men, 46.8%) who underwent electrocardiography in outpatient clinics or medical checkup (model 1). NIVCD was defined as QRS duration ≥110 ms and incompatibility with bundle branch block. The patients with structurally normal heart and sinus rhythm were assigned to the NIVCD group and normal QRS group according to propensity score with matching variables of age, sex, hypertension, and diabetes (model 2), and additional PR interval (model 3). Baseline characteristics, electrocardiographic parameters, and clinical outcomes were compared in model 1, 2, and 3, respectively.

Results

In model 1, the frequencies of male and preexisting atrial fibrillation (AF) were significantly higher in the NIVCD group than in the normal QRS group. In model 2, sinus rate and PR interval were significantly slower and longer in the NIVCD group than in the normal QRS group. In model 3, cumulative incidence of AF was significantly higher in the NIVCD group than in the normal QRS group during follow-up of 8.8±2.9 years (Figure). NIVCD significantly increased risk of AF (hazard ratio, 2.571; 95% confidence interval, 1.074–6.156; p=0.034). NIVCD did not significantly increase risk of sick sinus syndrome, complete atrioventricular block, and heart failure.

Atrial fibrillation-free survival

Conclusions

NIVCD is associated with slow sinus rate and prolonged PR interval. NIVCD is an independent risk factor of AF in patients with structurally normal heart.

208Effect of hypertension duration and systolic blood pressure on dementia in patients with atrial fibrillation

Background

Atrial fibrillation (AF) is associated with a higher risk for cognitive impairment and dementia, with or without a history of clinical stroke. There are a paucity of data on the associations of hypertension duration and blood pressure (BP) level with risk of dementia in patients with AF.

Purpose

We examined associations of duration of hypertension and secondly, systolic blood pressure (SBP) levels with incidence of dementia among patients with AF.

Methods

We enrolled a total 196,388 patients aged ≥50 years who were newly diagnosed as AF and undergoing hypertension treatment from the Korean National Health Insurance Service database (2005–2016). Starting from AF diagnosis, participants were followed up until the date of dementia, death, or December 31, 2016. To incorporate the effect of BP level and hypertension duration changes over time on dementia incidence, we constructed time-updated multivariable Cox models in which BP levels and hypertension duration were updated at each participants' regular national health examination visits (at 0–7 years of follow-up). Similarly, age, BP medications, and health-related behaviors were included as time-varying covariates in these models.

Results

During 1,016,744 person-years of follow-up, there were 32,692 dementia events. A cubic spline curve using continuous hypertension duration measures suggested a linear association between increase of hypertension duration and dementia risk. One-year increase of hypertension duration increased the adjusted risk of dementia with a hazard ratio (HR) of 1.17 [95% confidence interval (CI) 1.13–1.22]. In patients with hypertension duration <6 years, SBP of ≥140 mmHg was significantly associated with higher dementia risk, compared to SBP of <130 mmHg (in patients with hypertension duration <3 years: adjusted HR 1.08, 95% CI 1.01–1.16; and in those with 3 ≤ hypertension duration <6 years: adjusted HR 1.13, 95% CI 1.07–1.20), whereas no significant association between SBP and dementia risk in those with hypertension duration ≥6 years.

SBP and dementia in different duration

Conclusion

In patients with AF, the increase of hypertension duration was strongly associated with increased risk of dementia. Uncontrolled SBP was also associated with higher dementia risk. But, this effect of SBP might be attenuated in patients with longer hypertension duration. These findings suggest more emphasis needed on BP control in AF patients with earlier phase of hypertension (duration <6 years).

Acknowledgement/Funding

The Korean Ministry of Education, Science and Technology (NRF-2017R1A2B3003303) and the Korean Ministry of Health & Welfare (HI16C0058, HI15C1200)

P5710Clinical applications of machine learning for prediction of incident atrial fibrillation from the general population: a nationwide cohort study

Background

To evaluate the ability of machine learning algorithms to predict incident atrial fibrillation (AF) from the general population using health examination items.

Methods

We included 483,343 subjects who received national health examinations from the Korean National Health Insurance Service-based National Sample Cohort (NHIS-NSC). We trained deep neural network model (DNN) of a deep learning system and decision tree model (DT) of a machine learning system using clinical variables and health examination items (including age, sex, body mass index, history of heart failure, hypertension or diabetes, baseline creatinine, and smoking and alcohol intake habits) to predict incident AF using a training dataset of 341,771 subjects constructed from the NHIS-NSC database. The DNN and DT were validated using an independent test dataset of 141,572 remaining subjects. C-indices of DNN and DT for prediction of incident AF were compared with that of conventional logistic regression model.

Results

During 1,874,789 person·years (mean±standard-deviation age 47.7±14.4 years, 49.6% male), 3,282 subjects with incident AF were observed. In the validation dataset, 1,139 subjects with incident AF were observed. The c-indices of the DNN and DT for incident AF prediction were 0.828 [0.819–0.836] and 0.835 [0.825–0.844], and were significantly higher (p<0.01) than conventional logistic regression model (c-index=0.789 [0.784–0.794]).

Conclusions

Application of machine learning using simple clinical variables and health examination items was helpful to predict incident AF in the general population. Prospective study is warranted to construct an individualized precision medicine.

64Risk of dementia in patients treated with non-vitamin k antagonist oral anticoagulant or warfarin for nonvalvular atrial fibrillation

Background

Evidence is accumulating that use of oral anticoagulants (OACs) decreases the risk of dementia in patients with atrial fibrillation (AF), but it is unclear if there is a difference between non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin in protecting against dementia.

Purpose

To compare the risk of dementia between patients taking either NOAC or warfarin using a nationwide cohort data covering the entire Korean population.

Methods

Using the Korean national health insurance service database, 68,984 new OAC users with non-valvular AF aged ≥50 years and no prior diagnosis of dementia were identified during the period of 2013–2016 (39,687 NOAC users and 29,297 warfarin users). Starting from OAC initiation, participants were followed up until the date of dementia, death, or December 31, 2016. We compared the rates of dementia in 1:1 propensity score-matched cohorts of NOAC (n=18,925) and warfarin users (n=18,925).

Results

During the 52,259 person-years of follow-up, there were 2,750 dementia events. Use of NOAC was associated with significant lower risk of dementia [hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.69–0.81], compared with warfarin. The risk reduction was prominent for vascular dementia (HR 0.60, 95% CI 0.52–0.71), whereas there was no significant difference in the risk of Alzheimer dementia (HR 0.92, 95% CI 0.83–1.02). Restricting the analyses to patients with no stroke diagnosis prior to OAC initiation (primary prevention) showed no significant difference between NOAC and warfarin in any types of dementia, but in the subgroup with prior stroke (secondary prevention), NOAC significantly reduced the risk of overall (HR 0.70, 95% CI 0.63–0.78) and vascular dementia (HR 0.59, 95% CI 0.49–0.69).

Subgroup analysis according to stroke Hx Patient N Overall dementia Alzheimer dementia Vascular dementia HR (95% CI) P for interaction HR (95% CI) P for interaction HR (95% CI) P for interaction Total 37,850 0.75 (0.69–0.81) 0.92 (0.83–1.02) 0.60 (0.52–0.71) Without prior stroke 24,773 0.90 (0.78–1.05) 0.948 0.98 (0.83–1.15) 0.235 0.85 (0.56–1.28) 0.863 With prior stroke 13,077 0.70 (0.63–0.78) 0.90 (0.79–1.03) 0.59 (0.49–0.69) CI, confidence interval; HR, hazard ratio.

KM curves of dementia incidence

Conclusion

In this propensity-weighted nationwide cohort of non-valvular AF patients, NOAC was associated with reduced risk of dementia, compared with warfarin. This association was the most pronounced for vascular dementia in patients with prior stroke.

Acknowledgement/Funding

The Korean Ministry of Education, Science and Technology (NRF-2017R1A2B3003303) and the Korean Ministry of Health & Welfare (HI16C0058, HI15C1200)

P345Catheter ablation for atrial fibrillation is associated with lower incidence of stroke, major bleeding and death: data from Korean health registries

Background

Compared with antiarrhythmic drug therapy, catheter ablation of AF reduces the number of AF episodes, prolongs the time in sinus rhythm, and improves quality of life. However, it is still unclear if catheter ablation for atrial fibrillation (AF) affects the prognosis or merely is a symptomatic treatment. Our objective was to compare long-term outcome regarding stroke, major bleeding and death in AF patients with and without ablation, and in relation to long-term exposure to anticoagulants.

Methods

We identified all 800,084 patients with a diagnosis of AF from 2006 to 2015 in the Korean national health insurance service database. During a 10-year period, 10,979 AF ablations were performed among 9,768 individuals. Propensity scores for the likelihood of AF ablation were obtained by logistic regression. Propensity score (PS) matching was used to construct two cohorts of equal size (n=9,768) with similar characteristics in 16 dimensions.

Results

Patients who had undergone catheter ablation were younger (57.2 vs. 65.6 years, P<0.001) and healthier (mean CHA2DS2-VASc scores 2.5±1.7 vs. 3.6±2.1, P<0.001) than other patients with AF. Mean follow-up was 5.5±3.1 years. After propensity score matching, in the ablated group, 472 patients suffered ischemic stroke/systemic embolism (SE) compared with 1,682 in the matched non-ablated (annual rates 2.92 vs. 1.10%, P<0.001). Major bleeding occurred in 439 and 1,219 patients in ablated and non-ablated (annual rates 2.07 vs. 1.01%, P<0.001). A total of 306 ablated and 1,439 non-ablated patients died (annual rates 2.31 vs. 0.69%, P<0.001). After multivariable adjustments, catheter ablation was associated with lower risk of ischemic stroke [hazard ratio (HR) 0.51, 95% confidence interval (CI) 0.38–0.67), lower risk of major bleeding (HR 0.65, 95% CI 0.57–0.75) and with lower mortality risk (HR 0.39, 95% CI 0.34–0.46). The reduction of stroke/SE and mortality was observed after AF ablation regardless thromboembolic risk. Major bleeding was reduced only among patients with CHA2DS2-VASc score ≥2 (HR 0.70, 95% CI 0.59–0.84).

Conclusion

We found a strong association between ablation and survival. Ablation may be associated with lower incidence of ischemic stroke and major bleeding in patients with AF. The reduction of stroke/SE and mortality was observed regardless thromboembolic risk after AF ablation. But the risk of major bleeding was reduced only in patients with high thromboembolic risk factors.

P1027The risk of dementia and catheter ablation for atrial fibrillation: a nationwide cohort study

Background

Atrial fibrillation (AF) is associated with all forms of dementia, including Alzheimer's disease. Catheter ablation of AF reduces the number of AF episodes, prolongs the time in sinus rhythm, and improves quality of life. However, it is still unclear if catheter ablation for AF improve cognitive function and prevent dementia. Our objective was to compare long-term outcome regarding dementia and type of dementia in AF patients with and without ablation, and about long-term exposure to anticoagulants.

Methods

We identified all 801,701 patients with a diagnosis of AF from 2006 to 2015 in the Korean national health insurance service database. During ten years, 10,979 AF ablations were performed among 9,768 individuals. Propensity scores for the likelihood of AF ablation were obtained by logistic regression. Propensity score (PS) matching was used to construct two cohorts of equal size (n=9,768) with similar characteristics in 16 dimensions.

Results

Patients who had undergone catheter ablation were younger (57.2 vs. 65.6 years, P<0.001) and healthier (mean CHA2DS2-VASc scores 2.5±1.7 vs. 3.6±2.1, p<0.001) than other patients with AF. Mean follow-up was 5.5±3.1 years. After propensity score matching, in the ablated group, 184 patients suffered dementia compared with 650 in the matched non-ablated (annual rates 0.42 vs. 1.08%, P<0.001). While a total of 134 ablated and 379 non-ablated patients had Alzheimer disease (annual rates 0.31 vs. 0.62%, p<0.001), 40 ablated and 191 non-ablated patients had vascular disease (annual rates 0.09 vs. 0.31%, p<0.001). After multivariable adjustments, catheter ablation was associated with lower risk of dementia (hazard ratio [HR] 0.46, 95% confidence interval [CI] 0.37–0.58), lower risk of Alzheimer disease (HR 0.61, 95% CI 0.46–0.79) and lower risk of vascular dementia (HR 0.27, 95% CI 0.19–0.38). Although the reduction of dementia and Alzheimer disease was observed after AF ablation regardless of thromboembolic risk, vascular dementia was reduced only among patients with CHA2DS2-VASc score ≥2 (HR 0.29, 95% CI 0.20–0.42).

The risk of dementia, RFCA vs. no-RFCA Type Propensity score matched ablation group vs. no ablation group adjusted HR (95% CI) P-value Overall dementia 0.46 (0.37–0.58) <0.001 Alzheimer dementia 0.61 (0.46–0.79) <0.001 Vascular dementia 0.27 (0.19–0.38) <0.001

Conclusion

Ablation may be associated with a lower incidence of dementia and both type of dementia in patients with AF. This finding appears more pronounced in patients with high thromboembolic risk factors.

Association of Up-Regulated Plasma Adiponectin With Risk of Incident Depression in a Community-Dwelling Elderly Population

OBJECTIVE

Despite robust interest in the association between inflammation and depression, anti-inflammatory markers have been scarcely investigated as predictors of the future risk of depression. The aim of this study is to determine whether up-regulation of plasma adiponectin, an anti-inflammatory adipokine, precedes and predicts the development of depression in the elderly.

METHODS

This prospective cohort study was launched in 2005. Among 1,000 participants who were randomly sampled from community-dwelling individuals 65 years or older, 633 euthymic individuals without prior history of depressive disorders were enrolled for a baseline evaluation and follow-up after 5 years. Incident clinically significant depression, including major and minor depressive disorders (by DSM-IV criteria), subsyndromal depression (by operational criteria), and euthymia after antidepressant treatment, was assessed by clinical interviews.

RESULTS

Baseline plasma adiponectin values were divided into tertiles (low tertile: ≤ 5.685 μg/mL, middle tertile: 5.686-10.367 μg/mL, high tertile: ≥ 10.368 μg/mL). Among the 261 euthymic individuals who responded to the 5-year follow-up evaluation, 17 developed incident depression (7 from the high tertile, 8 from the middle tertile, and 2 from the low tertile). The risk of incident depression was much higher in the high tertile group than in the low tertile group after adjusting for age, sex, body mass index, burden of chronic medical illnesses, and Mini-Mental State Examination score (odds ratio = 10.64; 95% CI, 1.21-93.84; P = .033).

CONCLUSIONS

Up-regulation of plasma adiponectin may precede the onset of clinically significant depression in the elderly, and thus plasma adiponectin level is a potential candidate marker for the risk of depression.

Anhedonia and Dysphoria Are Differentially Associated with the Risk of Dementia in the Cognitively Normal Elderly Individuals: A Prospective Cohort Study

OBJECTIVE

We investigated the impact of depressed mood (dysphoria) and loss of interest or pleasure (anhedonia)on the risk of dementia in cognitively-normal elderly individuals.

METHODS

This study included 2,685 cognitively-normal elderly individuals who completed the baseline and 4-year follow-up assessments of the Korean Longitudinal Study on Cognitive Aging and Dementia. We ascertained the presence of dysphoria and anhedonia using the Mini International Neuropsychiatric Inventory. We defined subjective cognitive decline as the presence of subjective cognitive complaints without objective cognitive impairments. We analyzed the association of dysphoria and anhedonia with the risk of cognitive disorders using multinomial logistic regression analysis adjusted for age, sex, education, Cumulative Illness Rating Scale score, Apolipoprotein E genotype, and neuropsychological test performance.

RESULTS

During the 4-year follow-up period, anhedonia was associated with an approximately twofold higher risk of mild cognitive impairment (OR=2.09, 95% CI=1.20-3.64, p=0.008) and fivefold higher risk of dementia (OR=5.07, 95% CI=1.44-17.92, p=0.012) but was not associated with the risk of subjective cognitive decline. In contrast, dysphoria was associated with an approximately twofold higher risk of subjective cognitive decline (OR=2.06, 95% CI=1.33-3.19, p=0.001) and 1.7-fold higher risk of mild cognitive impairment (OR=1.75, 95% CI=1.00-3.05, p=0.048) but was not associated with the risk of dementia.

CONCLUSION

Anhedonia, but not dysphoria, is a risk factor of dementia in cognitively-normal elderly individuals.

Impact of Mild Cognitive Impairment on Mortality and Cause of Death in the Elderly

BACKGROUND

Mild cognitive impairment (MCI) is a cognitive state that lies on the continuum between normal aging and dementia, and the prevalence of MCI is higher than dementia. However, the risk for mortality of people with MCI has been far less studied than that of people with dementia, and the population attributable risk percent (PAR%) of death attributable to MCI has not been estimated yet.

OBJECTIVE

To investigate the impact of MCI on mortality and the cause of death in the elderly, and to estimate the PAR% of deaths attributable to MCI.

METHODS

Data came from 7,315 elderly subjects aged ≥60 years without dementia from two cohort studies with diagnostic assessments of MCI at baseline. Deaths among participants were confirmed through the nationwide mortality database of Statistics Korea.

RESULTS

MCI increased the risk of mortality in a multivariate Cox proportional model adjusting for age, sex, education, smoking, alcohol drinking, chronic illness, depression, vascular components, and cohort (hazard ratio = 1.59, 95% confidence interval 1.30, 1.94). PAR% of death attributable to MCI was 10.7% for age 65-74 years, 16.0% for age 75-84 years, and 24.2% for age ≥85 years. In the elderly with MCI, mortality risks from cerebrovascular disease, respiratory disease, and external causes were higher than in the cognitively normal elderly.

CONCLUSIONS

Our results suggest that the mortality risk of MCI in Asian countries may be comparable to that in Western countries, and MCI can contribute to the death of the elderly as much as dementia.

Normal-But-Low Serum Folate Levels and the Risks for Cognitive Impairment

OBJECTIVE

This study aimed to examine the association between normal-but-low folate levels and cognitive function in the elderly population using a prospective cohort study.

METHODS

We analyzed 3,910 participants whose serum folate levels were within the normal reference range (1.5-16.9 ng/mL) at baseline evaluation in the population-based prospective cohort study named the "Korean Longitudinal Study on Cognitive Aging and Dementia." The association between baseline folate quartile categories and baseline cognitive disorders [mild cognitive impairment (MCI) or dementia] was examined using binary logistic regression analysis adjusting for confounding variables. The risks of incident MCI and dementia associated with the decline of serum folate level during a 4-year follow-up period were examined using multinomial logistic regression analysis.

RESULTS

The lowest quartile group of serum folate (≥1.5, ≤5.9 ng/mL) showed a higher risk of cognitive disorders than did the highest quartile group at baseline evaluation (odds ratio 1.314, p=0.012). Over the 4 years of follow-up, the risk of incident dementia was 2.364 times higher among subjects whose serum folate levels declined from the 2nd-4th quartile group to the 1st quartile than among those for whom it did not (p=0.031).

CONCLUSION

Normal-but-low serum folate levels were associated with the risk of cognitive disorders in the elderly population, and a decline to normal-but-low serum folate levels was associated with incident dementia. Maintaining serum folate concentration above 5.9 ng/mL may be beneficial for cognitive status.

CD4 T cell count is inversely associated with lumbar spine bone mass in HIV-infected men under the age of 50 years

HIV-infected men under the age of 50 years had a lower bone mass compared to that of HIV-uninfected men. Lower CD4 T cell counts, independent of whether antiretroviral therapy (ART) was used, were associated with lower BMD. HIV-infected patients with low CD4 T cell counts may need follow-up and intervention regarding bone health, including younger patients.

INTRODUCTION

HIV-infected patients have a low bone mineral density (BMD) owing to multifactorial interaction between common osteoporosis risk factors and HIV-related factors, including chronic inflammation and ART. Although HIV infection and ART might affect bone metabolism, little data is available for patients aged under 50 years. We aimed to investigate the association of HIV infection-induced low CD4 T cell counts and ART with BMD in men aged under 50 years.

METHODS

We performed an age- and body mass index-matched case-control study. BMD values of HIV-infected and HIV-uninfected men (< 50 years) were compared, and HIV-infected men were stratified by CD4 T cell counts and ART use.

RESULTS

After adjusting confounders, HIV-infected men with CD4 T cell counts ≥ 500 cells/μL (n = 28) and < 500 cells/μL (n = 139) had lower BMD at the femoral neck (FN, p < 0.001) and total hip (TH, p < 0.001) than HIV-uninfected men (n = 167). HIV-infected men with CD4 T cell counts < 500/μL had lower BMD at the lumbar spine (LS, p = 0.034) than those with counts of ≥ 500 cells/μL, but not at FN and TH. The CD4 T cell count (γ = 0.169, p = 0.031) was positively correlated with BMD at LS. There was no significant difference in the BMD (p = 0.499-> 0.999) between the ART-naïve (n = 75) and ART-user group (n = 92).

CONCLUSIONS

Despite their relatively younger age, HIV-infected men had a lower BMD than HIV-uninfected men. Lower CD4 T cell counts, irrespective of ART, might result in lower bone mass.

Abstract OT2-04-02: A phase 3 study of post-lumpectomy radiotherapy to whole breast + regional lymph nodes vs whole breast alone for patients with pN1 breast cancer treated with taxane-based chemotherapy (KROG 1701): Trial in progress

Background

In patients with early stage breast cancer, regional nodal irradiation (RNI) is added to whole breast irradiation (WBI) in order to control microscopic regional disease and to prevent systemic spread of cancer. According to recent randomized trials (MA.20 and EORTC 22922-10925), prophylactic RNI was associated with improvement in disease-free survival (DFS) in the patients with high-risk node negative or pN1 breast cancer. However, systemic agents now known to improve loco-regional control, such as taxane or endocrine therapy, were prescribed to a small percentage of patients in the studies. The benefit of RNI found in the previous studies might be attributed to incorporation of less effective systemic treatments. The impact of prophylactic RNI in pN1 breast cancer should be evaluated in the patients receiving modern systemic treatment. The current study was conducted to compare the effect of post-lumpectomy WBI vs WBI plus RNI on DFS in pN1 breast cancer patients who received adjuvant taxane-based chemotherapy.

Methods

This study is a multicenter, phase 3, randomized controlled non-inferiority trial (NCT03269981). Eligibility criteria are ≥ 20 years female; pathologically proven invasive carcinoma of the breast; one to three positive axillary lymph nodes (pN1) in pathologic specimen; receiving breast-conserving surgery followed by taxane-based chemotherapy; having adjuvant endocrine therapy or anti-HER2 treatment according to molecular subtype of tumor. Patients are randomly assigned in a 1:1 ratio to receive WBI or WBI plus RNI. Patient randomization was stratified by molecular subtype of tumor (i.e. luminal A/luminal B/luminal HER2/HER2-enriched/triple-negative) and methods of axillary management (i.e. sentinel lymph node biopsy/axillary lymph node dissection). The primary outcome is DFS. The secondary outcomes include DFS according to molecular subtype, treatment-related toxicity, and patient's quality of life per EORTC QLQ-C30 and QLQ-BR23. Patients will be followed for survival and disease recurrence for seven years. A total of 1,926 patients are planned to be enrolled, with recruitment initiated in April 2017. As of June 2018, a total of 236 patients were enrolled.

Acknowledgement

This study was supported by a grant from the National R&D Program for Cancer Control, Ministry of Health & Welfare, Republic of Korea (grant number: HA17C0043010018).

Citation Format: Kim H, Park W, Choi DH, Ahn SJ, Kim SS, Kim ES, Lee JH, Lee KC, Kim JH, Lee H-S, Kim JH, Kim MY, Park HJ, Kim K, Song SH, Kwon J, Lee IJ, Kim TH, Kim TG, Chang AR, Cho O, Jeong BK, Ha B, Lee J, Ki Y. A phase 3 study of post-lumpectomy radiotherapy to whole breast + regional lymph nodes vs whole breast alone for patients with pN1 breast cancer treated with taxane-based chemotherapy (KROG 1701): Trial in progress [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-04-02.

Abstract P5-07-10: The prognostic significance of estrogen formation as a consequence of aromatase expression in tumor microenvironment

Estrogen synthesis via aromatase in adipose tissue has an important role in progression of postmenopausal breast cancer. The increased local concentrations of estrogen in breast cancer via aromatase overexpression within the tumor tissue have been demonstrated by some investigators. Although aromatase inhibitor is the standard endocrine therapy for postmenopausal breast cancer patients, it is not uncommon for patients to have poor compliance to the drugs due to their side effects. This research is based on the hypothesis that if aromatase expression is related to prognosis and if therapeutic effect varies depending on the degree of aromatase expression, then this study may be able to suggest a new guideline in terms of choosing between aromatase inhibitors and tamoxifen.

Methods: 154 postmenopausal breast cancer patients who underwent surgery and aromatase inhibitor therapy in Busan Paik Hospital, Inje University from January 2005 to December 2010 were enrolled. Patients with DCIS or stage IV breast cancer were excluded. Patients' clinicopathological data were collected and TMA blocks were created for immunohistochemistry studies to examine aromatase expression.

Results: The recurrence has occured in 7 patients (6.9%). Stage, tumor size and number of lymph node metastasis were related to increased risk of recurrence (p=0.051, 0.043, 0.001). The aromatase expression in cancer cells had significant correlation with clinical stage (p=0.041). There was also a positive correlation between Ki67 and aromatase expression in cancer tissue (p=0.006). However, aromatase expression in cancer, stromal, and adipose tissue had no relationship with recurrence (p=0.410, 0.627, 0.552).

Correlation between clinicopathologic factors and aromatase expression (Linear by linear association and Spearman's correlation coefficient test)Site of aromatase expressionERPRKi67P53BMIStageIn Cancer0.6060.5920.0060.4510.9560.041In Stroma0.2200.4710.5840.3290.3670.229In Adipose0.9880.2650.1590.1170.7701.000

Conclusions: Aromatase expression in cancer cells was correlated with clinical stage. This implies that aromatase expression might have a role of prognostic marker in addition to role of treatment indicator. There was no direct correlation between aromatase expression and recurrence.

Citation Format: Kim TH, Lee A, Han JW, Jung SJ, Byun K-D. The prognostic significance of estrogen formation as a consequence of aromatase expression in tumor microenvironment [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-07-10.

Gait Variability Can Predict the Risk of Cognitive Decline in Cognitively Normal Older People

BACKGROUND

The aim of this study was to investigate the association of gait speed and gait variability, an index of how much gait parameters, such as step time, fluctuate step-to-step, with risk of cognitive decline in cognitively normal elderly individuals. While high gait variability is emerging as an early indicator of dementing illnesses, there is little research on whether high gait variability predicts cognitive decline in cognitively normal elderly who have no evidence of cognitive impairment.

METHODS

In this 4-year prospective cohort study on 91 community-dwelling cognitively normal elderly individuals without cerebral ischemic burden or Parkinsonism, we evaluated gait speed and step time variability using a tri-axial accelerometer placed on the center of body mass, and diagnosed mild cognitive impairment (MCI) according to the International Working Group on MCI. We performed Kaplan-Meier analysis with consecutive log-rank testing for MCI-free survival by cohort-specific tertiles of gait speed; hazard ratios (HR) of incident MCI were estimated using Cox proportional hazards regression analysis adjusted for age, sex, education level, Cumulative Illness Rating Scale score, GDS score, and presence of the apolipoprotein E ε4 allele.

RESULTS

Out of the 91 participants in the baseline assessment, 87 completed one or more 2-year follow-up assessments, and the median duration of follow-up was 47.1 months. Kaplan-Meier curves of incident MCI show evident differences in risk by gait variability group (χ2 = 9.64, p = 0.002, log-rank test). Mean MCI-free survival in the high variability group was 12% shorter than in the mid-to-low tertile group (47.4 ± 1.74 [SD] vs. 54.04 ± 0.52 months), while it was comparable between gait speed groups (51.59 ± 0.70 vs. 50.64 ± 1.77 months; χ2 = 1.16, p = 0.281). In multivariate analysis, subjects with high gait variability showed about 12-fold higher risk of MCI (HR = 11.97, 95% CI = 1.29-111.37) than those with mid-to-low variability. However, those with slow gait speed showed comparable MCI risk to those with mid-to-high speed (HR = 5.04, 95% CI = 0.53-48.18).

CONCLUSIONS

Gait variability may be a better predictor of cognitive decline than gait speed in cognitively normal elderly individuals without cerebral ischemic burden or Parkinsonism.

Is Dementia More Fatal Than Previously Estimated? A Population-based Prospective Cohort Study

Dementia increases the risk of mortality (ROM) in the elderly and estimates of hazard ratio (HR) of dementia for mortality have ranged from 1.7 to 6.3. However, previous studies may have underestimated ROM of dementia due to length bias, which occurs when failing to include the persons with rapidly progressive diseases, who died before they could be included in the study. This population-based prospective cohort study conducted on 6,752 randomly sampled Koreans, aged 60 years or older (the Korean Longitudinal Study on Cognitive Aging and Dementia). Cognitive disorders were evaluated at baseline and 2-year follow-up using the Korean version of the Consortium to Establish a Registry for Alzheimer's Disease Assessment Packet (CERAD-K), and prevalent and incident cases of dementia were identified. The participants' deaths were confirmed through the National Mortality Database of Statistics Korea. We compared the ROM between prevalent and incident dementia, and estimated HR of dementia for mortality using Cox proportional hazards model. Of the 5,097 responders to the 2-year follow-up assessment, 150 participants had dementia from the baseline (prevalent dementia), and 95 participants developed dementia during the 2-year follow-up period (incident dementia). The ROM of participants with incident dementia was about 3 times higher than the ROM of those with prevalent dementia (HR = 3.04, 95% confidence interval [CI] = 1.34-6.91). Compared to cognitively normal participants at both the baseline and 2-year follow-up assessments, the ROM of those with incident dementia approximately 8 times higher (HR = 8.37, 95 % CI = 4.23-16.54). In conclusion, the ROM of dementia using prevalent cases was underestimated due to length bias, and dementia may be much more fatal than previously estimated. In clinical settings, the ROM of dementia warrants the attention of physicians, particularly in recently incident dementia cases.

Experiences of caregivers of people with dementia in a Korean dementia simulation program

OBJECTIVES

Experiencing dementia-related challenges in a dementia simulation program can be useful for caregivers to understand perspectives of people with dementia possibly leading to improvement in the quality of care and positive outcomes in caregivers and people with dementia. Previous studies about dementia simulation programs have been conducted in Western countries and no research has been conducted in Asian countries. The purpose of this qualitative study was to explore experiences of caregivers of people with dementia who participated in a Korean dementia simulation program.

METHODS

A descriptive phenomenological study using thematic analysis with ATLAS.ti 8 software was used. A total of 28 Korean caregivers were interviewed about two weeks after participating in the Korean dementia simulation program that was modified from a program developed in USA by considering Korean cultures.

RESULTS

Three key themes with seven subthemes emerged. The present study demonstrated that participation in the program helped caregivers have more empathy, affected their care strategies positively leading to emotional and social benefits on the care dyads, and increased awareness in possible changes due to aging and the risk of dementia.

CONCLUSIONS

The present study was the first study that demonstrated caregivers' positive experiences in and benefits from participation in a dementia simulation program in an Asian country. Caregivers in the other Asian countries may have similar benefits from participation in dementia simulation programs.

Depressive symptoms and suicidal behaviours in adolescent non-daily smokers compared to daily smokers and never-smokers in Korea: National cross-sectional study

INTRODUCTION

We aimed to investigate the association of non-daily smoking with depressive symptoms and suicidal behaviours among adolescents by analysing data from the 2016 Korean Youth Risk Behavior Web-based Survey (KYRBWS), a national school-based survey.

METHODS

We analysed data from a nationally representative sample of Korean adolescents aged 12-18 years (n = 65,528). We investigated the risks of depressive symptoms, suicide ideation, plan and attempt in adolescent non-daily smokers using multiple logistic regression analyses after adjusting for confounding factors. Taking into account the trajectory of smoking patterns in adolescents, we assessed all analyses with stratification by early (aged 12-15) and late (aged 16-18) adolescents.

RESULTS

Among early adolescents, non-daily smokers were more likely to have depressive symptoms, suicide ideation and plan compared with never smokers and even more likely to have depressive symptoms compared with daily smokers. Among late adolescents, non-daily smokers had higher risks of depressive symptoms, suicide ideation, plan and attempt than never smokers, whereas the risk for suicide attempts was lower than daily smokers.

CONCLUSIONS

Our findings suggest that non-daily smoking in adolescents was associated with risks for depressive symptoms and suicidal behaviours, and the association was more prominent in early adolescents. Careful attention on the mental health of adolescent non-daily smokers is needed because this is an increasing and easily overlooked group.

Note: Double-layered polyimide film heater with low magnetic field generation

We designed a double-layered polyimide film heater where the direction of the injection current of each layer is opposite to that of the other layer to reduce the magnetic field. The width of the heater is 0.125 mm and the resistance is 21.2 Ω. This specially designed heater successfully demonstrated temperature controllability within 10 mK for an atomic cell in an atom spin gyroscope while minimizing the generation of the magnetic field to within 1 nT.

Deep learning based low-cost high-accuracy diagnostic framework for dementia using comprehensive neuropsychological assessment profiles

BACKGROUND

The conventional scores of the neuropsychological batteries are not fully optimized for diagnosing dementia despite their variety and abundance of information. To achieve low-cost high-accuracy diagnose performance for dementia using a neuropsychological battery, a novel framework is proposed using the response profiles of 2666 cognitively normal elderly individuals and 435 dementia patients who have participated in the Korean Longitudinal Study on Cognitive Aging and Dementia (KLOSCAD).

METHODS

The key idea of the proposed framework is to propose a cost-effective and precise two-stage classification procedure that employed Mini Mental Status Examination (MMSE) as a screening test and the KLOSCAD Neuropsychological Assessment Battery as a diagnostic test using deep learning. In addition, an evaluation procedure of redundant variables is introduced to prevent performance degradation. A missing data imputation method is also presented to increase the robustness by recovering information loss. The proposed deep neural networks (DNNs) architecture for the classification is validated through rigorous evaluation in comparison with various classifiers.

RESULTS

The k-nearest-neighbor imputation has been induced according to the proposed framework, and the proposed DNNs for two stage classification show the best accuracy compared to the other classifiers. Also, 49 redundant variables were removed, which improved diagnostic performance and suggested the potential of simplifying the assessment. Using this two-stage framework, we could get 8.06% higher diagnostic accuracy of dementia than MMSE alone and 64.13% less cost than KLOSCAD-N alone.

CONCLUSION

The proposed framework could be applied to general dementia early detection programs to improve robustness, preciseness, and cost-effectiveness.

Comparison of Perioperative Renal Function Between Epidural and Intravenous Patient-Controlled Analgesia After Living-Donor Hepatectomy: A Retrospective Study

BACKGROUND

Sympathetic blockade associated with epidural analgesia was reported to be a risk factor for acute kidney injury (AKI) following liver resection. The purpose of this study was to compare the incidence of AKI after living-donor hepatectomies according to the type of patient-controlled analgesia (PCA).

METHODS

A total of 316 patients after living-donor hepatectomy were retrospectively analyzed; 148 patients in the epidural PCA group and 168 patients in the intravenous (IV) PCA group were evaluated. AKI was defined as an increase in serum creatinine ≥0.3 mg/dL, ie, 1.5-fold from the baseline, or a reduction in the urine output in the first 48 hours after surgery, based on the Acute Kidney Injury Network criteria. Logistic regression analysis was performed to identify the independent risk factors for AKI after living-donor hepatectomy.

RESULTS

Baseline characteristics were similar between the 2 groups except the age. Volumes of fluids and colloids administered intraoperatively were greater in the epidural PCA group (P < .001 and P = .006, respectively). The incidence of AKI did not show significant differences between the 2 groups (8.1% vs 7.1%; P = .747). In multivariate analysis, preoperative serum alanine transaminase level ≥50 U/L was identified as a risk factor for postoperative AKI. However, epidural PCA failed to be a risk factor for postoperative AKI.

CONCLUSIONS

The type of PCA did not affect the incidence of postoperative AKI after living-donor hepatectomy. Despite significant differences in the postoperative hemodynamics, the incidence of AKI was similar between 2 groups.

Risk Factors for Dropout From the Liver Transplant Waiting List of Hepatocellular Carcinoma Patients Under Locoregional Treatment

BACKGROUND

In new organ allocation policy, patients with hepatocellular carcinoma (HCC) experience a 6-month delay in being granted Model for End-Stage Liver Disease exception points. However, it may not be fair for patients at risk of early progression of HCC.

METHODS

All patients who were diagnosed as United Network for Organ Sharing (UNOS) stage 1 or 2 of HCC between January 2004 and December 2012 were included. Patients who received surgical resection or liver transplant (LT) as a primary treatment and who did not receive any treatment for HCC were excluded. Patients with baseline Model for End-Stage Liver Disease score ≥22 were also excluded because they have a higher chance of receiving LT. Patients who developed extrahepatic progression within 1 year were considered as high-risk for early recurrence after LT.

RESULTS

A total of 586 patients were included. Mean (SD) age was 59.9 (10.3) years and 409 patients (69.8%) were men. The cumulative incidence of estimated dropout was 8.9% at 6 months; size of the maximum nodule (≥3 cm) and nonachievement of complete response were independent factors. Extrahepatic progression developed in 16 patients (2.7%) within 1 year; size of the maximum nodule (4 cm) and alpha-fetoprotein level (>100 ng/mL) were independent predictors.

CONCLUSIONS

The estimated dropout rate from the waiting list within 6 months was 8.9%. Advantage points might be needed for patients with maximum nodule size ≥3 cm or those with noncomplete response. However, in patients with maximum nodule size ≥4 cm or alpha-fetoprotein level >100 ng/mL, caution is needed.

Depression Plays a Moderating Role in the Cognitive Decline Associated With Changes of Brain White Matter Hyperintensities

OBJECTIVE

In the elderly, depression and white matter hyperintensities (WMH) are common and associated with cognitive impairment. This study investigated the possible interactions between depression and WMH in their influences on cognition of the elderly.

METHODS

Using multiple neuropsychological tests, we evaluated the cognitive function of 122 community-dwelling elders with depression at baseline between November 2008 and February 2009. Major depressive disorder, dysthymic disorder, and minor depressive disorder were diagnosed according to DSM-IV criteria. Subsyndromal depressive disorder was operationally defined using a modification of DSM-IV criteria. We visually rated WMH severity according to the modified Fazekas scale and calculated WMH volume using an automated method. We defined WMH (+) as having a score of 2 or higher on the modified Fazekas scale. In the 3-year follow-up study, baseline participants were reassessed between November 2011 and February 2013 with the same methodology.

RESULTS

Baseline depression was associated with a decline over 3 years in the Categorical Verbal Fluency Test (VFT) (P = .001), Word List Memory Test (WLMT) (P = .019), Trail Making Test A (TMT-A) (P = .018), and Mini-Mental State Examination (MMSE) (P = .017), while baseline WMH (+) was associated with a decline in WLMT (P = .039) only. An increase of WMH volume over 3 years was associated with a decline in the performances of VFT (P = .044), WLMT (P = .044), Word List Recall Test (P = .040), Word List Recognition Test (P = .036), and TMT-A (P = .001) over the same period only in the subjects with depression at baseline.

CONCLUSIONS

Depressive disorder and WMH are interactively associated with the poor performance of multiple cognitive functions. Depressive disorder may moderate the cognitive decline associated with the changes of brain WMH.

Differential effects of completed and incomplete pregnancies on the risk of Alzheimer disease

OBJECTIVE

To investigate the effects of completed pregnancy with childbirth and incomplete pregnancy without childbirth on the late-life cognition and the risk of Alzheimer disease (AD) in women.

METHODS

Using the pooled data of 3,549 women provided by 2 population-based cohort studies, we conducted logistic regression analyses to examine retrospectively the associations of completed and incomplete pregnancy with the risks of mild cognitive impairment and AD. For women without dementia, we also conducted analyses of covariance to examine the associations of completed and incomplete pregnancy with Mini-Mental State Examination (MMSE) score.

RESULTS

Grand multiparous women who experienced ≥5 completed pregnancies showed an ≈1.7-fold higher risk of AD than those who experienced 1 to 4 completed pregnancies (odds ratio [OR] 1.68, 95% confidence interval [CI] 1.04-2.72), while those who had incomplete pregnancies showed half the level of AD risk compared with those who never experienced an incomplete pregnancy (OR 0.43, 95% CI 0.24-0.76 for 1 incomplete pregnancy; OR 0.56, 95% CI 0.34-0.92 for ≥2 incomplete pregnancies). In women without dementia, the grand multiparous had worse MMSE scores than those with 1 to 4 completed pregnancies (p < 0.001), while those who experienced ≥1 incomplete pregnancies had better MMSE scores than those who never experienced an incomplete pregnancy (p = 0.008).

CONCLUSIONS

Grand multiparity was associated with high risk of AD, while incomplete pregnancy was associated with low risk of AD in late life.