Gender differences in patterns of relationship between body mass index and AF incidence

Background

Obesity is reportedly associated with the new incidence of atrial fibrillation (AF). However, gender differences in patterns of relationship between body mass index (BMI) and the risk of AF are unknown.

Methods

We analyzed 21,382 middle-aged Japanese subjects (10923 men, 10459 women) without AF from a cohort of employees undergoing annual health examinations, with a follow-up period of 4.8±3.7 years. We examined the relationship between BMI at baseline to AF incidence in unadjusted and adjusted analyses. This relationship was also studied using linear and quadratic models.

Results

AF had developed in 137 subjects (119 men; mean age, 54.4±8.2 years; incidence, 2.19 and 0.38 per 1000 person-years in men and women, respectively). In multivariable Cox proportional-hazard models, increasing age (hazard ratio [HR], 2.72 per year; 95% CI, 2.22 to 3.33; P<0.001), male gender (HR, 3.28; 95% CI, 1.86 to 5.76; P<0.001) and BMI (HR, 1.08; 95% CI, 1.02 to 1.15; P=0.007) were associated with the new incidence of AF in all cohorts. The shape of the BMI-incident AF relationship showed a linear association in women and a J-shaped association in men. (Figure) In particular, a U-shaped relationship was observed in young men aged 40–49, with increased risk among those with higher BMI and with very low BMI. In analyses adjusted for comorbidities and risk factors for CV disease, the U-shaped AF incidence versus BMI curves were not attenuated, suggesting that other genetic or congenital factors may mediate this relationship.

Conclusion

Our results indicate that the shape of the BMI-incident AF relation differs by sex and in particular a U-shaped relationship was observed in young men.

Patterns of relation among BMI and AF

Funding Acknowledgement

Type of funding source: None

Predictors of in-hospital mortality in patients with acute myocardial infarction due to unprotected left main trunk lesion: insight from the Tokyo Cardiovascular Care Unit network multicenter registry

Background

Acute myocardial infarction (AMI) due to unprotected left main trunk (LMT) lesion remains a clinical challenge because it requires prompt and efficient revascularization in catastrophic clinical presentation. However, predictors of in-hospital prognosis in patients with LMT-AMI are still not fully understood.

Purpose

To examine the predictors of in-hospital mortality in patients with LMT-AMI.

Methods

From 20,257 AMI patients in the Tokyo Cardiovascular Care Unit network registry (comprising 72 hospitals) from 2013 to 2017, we identified 371 (1.8%) eligible LMT-AMI patients without a history of coronary artery bypass grafting (CABG) and divided them into two groups: 254 survivors and 117 non-survivors. Measured variables included patient demographics, vital signs, laboratory data on admission, and in-hospital treatment. The outcome was in-hospital mortality. We performed a multivariable logistic regression analysis for in-hospital mortality with adjustment for the following 9 potential confounders, based on previous studies: (1) age, (2) sex, (3) Killip class, (4) ST elevation, (5) wide QRS (>120 msec), (6) the Thrombolysis in Myocardial Infarction (TIMI) grade on initial coronary angiography, (7) number of vessels with significant stenosis other than LMT, (8) renal dysfunction on admission, and (9) plasma glucose on admission.

Results

Overall, mean age was 70.6±11.8 years and 81.9% were male. ST-elevation myocardial infarction accounted for 61.8%. Cardiac arrest was observed in 102 (33.6%) patients. Percutaneous coronary intervention and CABG were performed in 302 (81.8%) and 63 (17.0%) patients, respectively. Intra-aortic balloon pumping and veno-arterial extracorporeal membranous oxygenation were used in 288 (77.8%) and 81 (21.9%) patients, respectively. In-hospital mortality was 31.5%. Multivariable logistic regression analysis showed that higher in-hospital mortality was significantly associated with Killip class IV (adjusted odds ratio 3.41 [95% confidence interval 1.36–8.56]; reference: Killip I), TIMI grade 0 (3.51 [1.22–10.14]; reference: TIMI grade 3), renal dysfunction (estimated glomerular filtration <60 mL/min/1.73m2; 6.48 [2.53–16.57]), and high plasma glucose on admission (>150 mg/dl; 3.64 [1.33–9.97]). Age, sex, ST-elevation, wide QRS, and multi-vessel disease were not significantly associated with in-hospital mortality.

Conclusions

LMT-AMI remains life-threatening in the current era of widely available revascularization. Our results showed that haemodynamic compromise, no coronary flow, renal dysfunction, and high plasma glucose on admission were strong predictors of in-hospital mortality after LMT-AMI. Given the high cardiac arrest rate, more aggressive therapeutic measures including mechanical circulatory support may be required to improve the prognosis of LMT-AMI.

Funding Acknowledgement

Type of funding source: None

Effect of air pollution on acute heart failure hospitalization differ across specific heart failure populations

Introduction

Several report showed the association between ambient air pollution including particular matter under 2.5um (PM2.5) and increasing rate of hospitalization for heart failure. However, these report analyzed mainly cross-sectional, epidemiological data, thus the reports regarding association between vulnerability to PM2.5 and specific populations in acute heart failure (AHF) were scarce.

Purpose

1. To analyze the association between air pollution and rate of hospitalization for AHF

2. To analyze whether the vulnerability to air pollution differ between specific populations in AHF. Methods

A case-cross over analysis was conducted to 4980 consecutive patients registered for multicenter acute heart failure registry in 2017 in our city Japan. This registry enrolled patients transferred to cardiovascular care unit (80 institutions) via emergency medical services across our city area. Logistic regression analysis were conducted to estimate percentage changes in the rate of acute heart failure hospitalization associated with per 1μg/m3 PM2.5 concentration increase. We also conducted subgroup analysis for patients stratified by age, gender, comorbidities, left ventricular ejection fraction, and clinical scenario.

Results

An increase in 1 μg/m3 PM2.5 concentration corresponded to 2.9% (95% CI 1.2–4.6%) increase in AHF hospitalization. Patients with age younger than 75, without prior heart failure hospitalization, without history of hypertension, without anemia, and with reduced ejection fraction were more susceptible to increase in PM2.5 concentration (Figure).

Conclusions

Increase in PM2.5 concentration was associated with increased rate of AHF hospitalization. Effect of PM2.5 may differ across specific AHF subpopulations.

Figure 1

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Tokyo Metropolitan Government

The impact of low diastolic blood pressure on 30-day mortality of patients with acute myocardial infarction

Background

It is known that low diastolic blood pressure (DBP) is associated with long-term cardiovascular events after acute myocardial infarction (AMI). However, the impact of low diastolic blood pressure on short-term outcome has not yet been well investigated.

Methods and results

We included 15,208 patients who were hospitalized for AMI and registered in the Tokyo CCU network registry between 2013 and 2016. Thirty-day in-hospital mortality rate was 4.8% (728/15,208). To assess the relationship between DBP at the time of admission and 30-day mortality non-linearly, spline regression model was applied with the stratification of the cohort according to tercile of systolic blood pressure (SBP, low:≤122 mmHg, intermediate:123–148 mmHg, high:≥149 mmHg) and J-curve phenomenon was observed in the low and high SBP groups. In multivariate logistic regression analysis, adjusted odds ratio of the lowest quintile of DBP (≤64 mmHg) was 1.65 (95% CI:1.02–2.66) in low SBP group and 4.55 (95% CI:1.72–12.00) in high SBP group.

Conclusion

Low DBP was associated with increased 30-day in-hospital mortality rate after AMI even in patients with high SBP.

Funding Acknowledgement

Type of funding source: None

The suppressive effect on CD4 T cell alloresponse against endothelial HLA-DR via PD-L1 induced by anti-A/B ligation

While donor-specific human leukocyte antigen (HLA) antibodies are a frequent cause for chronic antibody-mediated rejection in organ transplantation, this is not the case for antibodies targeting blood group antigens, as ABO-incompatible (ABO-I) organ transplantation has been associated with a favorable graft outcome. Here, we explored the role of CD4 T cell-mediated alloresponses against endothelial HLA-D-related (DR) in the presence of anti-HLA class I or anti-A/B antibodies. CD4 T cells, notably CD45RA-memory CD4 T cells, undergo extensive proliferation in response to endothelial HLA-DR. The CD4 T cell proliferative response was enhanced in the presence of anti-HLA class I, but attenuated in the presence of anti-A/B antibodies. Microarray analysis and molecular profiling demonstrated that the expression of CD274 programmed cell death ligand 1 (PD-L1) increased in response to anti-A/B ligation-mediated extracellular signal-regulated kinase (ERK) inactivation in endothelial cells that were detected even in the presence of interferon-γ stimulation. Anti-PD-1 antibody enhanced CD4 T cell proliferation, and blocked the suppressive effect of the anti-A/B antibodies. Educated CD25⁺ CD127^- regulatory T cells (edu.T_regs ) were more effective at preventing CD4 T cell alloresponses to endothelial cells compared with naive T_reg ; anti-A/B antibodies were not involved in the T_reg -mediated events. Finally, amplified expression of transcript encoding PD-L1 was observed in biopsy samples from ABO-I renal transplants when compared with those from ABO-identical/compatible transplants. Taken together, our findings identified a possible factor that might prevent graft rejection and thus contribute to a favorable outcome in ABO-I renal transplantation.

Phase I/II study of adding intraperitoneal paclitaxel in patients with pancreatic cancer and peritoneal metastasis

BACKGROUND

Intraperitoneal chemotherapy using paclitaxel is considered an experimental approach for treating peritoneal carcinomatosis. This study aimed to determine the recommended dose, and to evaluate the clinical efficacy and safety, of the combination of intravenous gemcitabine, intravenous nab-paclitaxel and intraperitoneal paclitaxel in patients with pancreatic cancer and peritoneal metastasis.

METHODS

The frequencies of dose-limiting toxicities were evaluated, and the recommended dose was determined in phase I. The primary endpoint of the phase II analysis was overall survival rate at 1 year. Secondary endpoints were antitumour effects, symptom-relieving effects, safety and overall survival.

RESULTS

The recommended doses of intravenous gemcitabine, intravenous nab-paclitaxel and intraperitoneal paclitaxel were 800, 75 and 20 mg/m² respectively. Among 46 patients enrolled in phase II, the median time to treatment failure was 6·0 (range 0-22·6) months. The response and disease control rates were 21 of 43 and 41 of 43 respectively. Ascites disappeared in 12 of 30 patients, and cytology became negative in 18 of 46. The median survival time was 14·5 months, and the 1-year overall survival rate was 61 per cent. Conversion surgery was performed in eight of 46 patients, and those who underwent resection survived significantly longer than those who were not treated surgically (median survival not reached versus 12·4 months). Grade 3-4 haematological toxicities developed in 35 of 46 patients, whereas non-haematological adverse events occurred in seven patients.

CONCLUSION

Adding intraperitoneal paclitaxel had clinical efficacy with acceptable tolerability.

The Background of Calculating CAVI: Lesson from the Discrepancy Between CAVI and CAVI0

Arterial stiffness is a good predictor of cardiovascular events. As a substitute for elastic modulus representing stiffness, pulse wave velocity (PWV) has been used for over a century as it is easy to measure; however, PWV is known to essentially depend on blood pressure at the time of measurement. The cardio-ankle vascular index (CAVI) is a relatively new index of global arterial stiffness of the origin of the aorta to the ankle arteries. The characteristic feature is its independency from blood pressure at the measuring time. Recently, a variant index CAVI₀ was proposed, which was claimed to be a more accurate arterial stiffness index than CAVI, considering independency from blood pressure. The purpose of this review is to evaluate the properties of CAVI more precisely by comparing with CAVI₀, and to confirm the true meaning of CAVI as an index of arterial stiffness. First, the properties of PWV depending on the blood pressure and the variation of PWV values in the cardiac cycle were analyzed. Then, we attempted to clarify the point at which the PWV, adopted in CAVI or in CAVI₀, was measured in cardiac cycle. A comprehensive comparison of the clinical data of CAVI and CAVI₀ showed that CAVI is more appropriate than CAVI_0. In conclusion, CAVI is reconfirmed to be a reliable and useful index of blood pressure-independent arterial stiffness composed of both organic and functional stiffness.

Scoliosis, diabetes mellitus and total laminectomy at the 4th lumbar vertebra are independent risk factors for post-laminectomy fracture around the isthmus

OBJECTIVE

We aimed to identify the risk factors and clinical outcomes for post-laminectomy fracture around the isthmus, which can cause back pain or radiculopathy.

METHODS

We performed a retrospective cohort study involving all patients who underwent laminectomy splitting the spinous process for lumbar spinal stenosis between 2010 and 2014. The primary outcome measure was post-laminectomy fracture around the isthmus. Clinical outcomes were evaluated based on reoperation rate. To evaluate risk factors for fracture, the following parameters were collected: (1) patient characteristics and concomitant diabetes mellitus, (2) lumbar scoliosis and sagittal alignment parameters, and (3) surgical data, such as rate of total laminectomy. Logistic regression analysis was performed to identify the independent risk factors for post-laminectomy fracture.

RESULTS

Twelve of the 92 patients suffered a post-laminectomy fracture around the isthmus. Logistic regression analysis revealed that diabetes mellitus (odds ratio [OR]: 15.41; 95% confidence interval [CI]: 2.93-80.98; P=0.001), L4 total laminectomy (OR: 14.68; 95% CI: 1.51-142.76; P=0.021), and lumbar scoliosis (OR: 5.72; 95% CI: 1.16-28.21; P=0.032) were independent risk factors. The fracture group included 2 patients (16.7%) who required reoperation at the decompression level for recurrent leg pain, whereas the non-fracture group included 2 (2.5%) who underwent reoperation at a level different from the index procedure.

CONCLUSIONS

Post-laminectomy fractures around the isthmus were significantly associated with scoliosis, diabetes mellitus, and total laminectomy at L4. Total laminectomy at L4 is best avoided to reduce the risk of post-laminectomy fracture in patients with scoliosis or diabetes mellitus.

AB1198 DECREASING OF TOTAL AND UNILATERAL KNEE ARTHROPLASTIES DUE TO RHEUMATOID ARTHRITIS BUT INCREASING IN OSTEOARTHRITIS IN OUR INSTITUTES IN LAST DECADE OF SUPER-AGING SOCIETY

Background:

The rate of elderly people over 65 year-old increased from 22.1 % in 2008 to 27.7% in 2017 in Japan, also from 27.1 % to 32.3 % in our super-aging area1, 2. The number of total and unilateral knee arthroplasty (TKA, UKA) have increased annually in all over the world according to the larger population of elderly people due to osteoarthritis (OA)3. In fact, the numbers of primary TKA predicted increasing from six hundred fifty-six thousand cases at 2010 to one million three hundred seventy-six thousand cases at 2020 in USA4. In the other hand, rheumatoid arthritis (RA) therapy have been remarkably improved from starting to use biologic agents since 2003 in Japan5. The rate of orthopaedic surgery may reflect trends in disease severity and drug management of RA5.

Objectives:

The aim of study is to reveal the rate of TKA, including UKA and revision TKA in elderly people in our super-aging area of Japan.

Methods:

We surveyed the number and cause of primary and revision TKA and UKA in our institutes using the data of diagnosis procedure combination and the record of surgeries in the last decade.

Results:

Figure 1.

Table 1.2008-122013-17TimesOsteoarthritis15652252*1.3Rheumatoid arthritis13181*0.6Trauma155Osteonecrosis of femoral condylar2041*2.1Revision21391.9Total17382418*1.4*p< 0.05

Conclusion:

The number and rate of primary TKA/UKA due to RA decreased year by year because of progression of modern medication therapy. In the other hand, in case of OA increased because of increasing of elderly people affected by knee OA in the super-aging society.

References:

[1]National Institute of Population and Social Security Research. Japanese Mortality Database, 2018.http://www.ipss.go.jp/

[2]Yamagata prefecture, Health and longevity Promotion Section. Rate of elderly people in Yamagata prefecture, 2018.http://www.pref.yamagata.jp/ou/kikakushinko/020052/tokei/jinkel.html

[3]Annual report 2017 of replacement arthroplasty in Japan. The Japanese Society For Replacement Arthroplasty The Japan Arthroplasty Register.https://jsra.info/jar-report.html

[4]Kurtz SM, et al. J Bone Joint Surg Am. 96: 624-30, 2014.

[5]Momohara S, et al. J Rheumatol. 41:862-5, 2014.

Disclosure of Interests:

None declared

Correction to: Comprehensive genetic analyses using targeted next-generation sequencing and genotype-phenotype correlations in 53 Japanese patients with osteogenesis imperfecta

The original article has been corrected.

Efficacy of guselkumab in a subpopulation with pustulotic arthro-osteitis through week 52: an exploratory analysis of a phase 3, randomized, double-blind, placebo-controlled study in Japanese patients with palmoplantar pustulosis

Background

Previous studies of guselkumab have demonstrated clinical benefits in patients with plaque‐type psoriasis, generalized pustular psoriasis, erythrodermic psoriasis and palmoplantar pustulosis (PPP).

Objective

The aim of this exploratory analysis of a double‐blind, multicenter, placebo‐controlled, phase 3 study in Japanese patients with PPP was to evaluate the efficacy of guselkumab in the subset of patients with pustulotic arthro‐osteitis (PAO).

Methods

Patients were randomized to receive guselkumab 100 or 200 mg at weeks 0, 4, 12 and every 8 weeks, or placebo with cross‐over to guselkumab 100 or 200 mg at week 16 (placebo group). Efficacy endpoints were changes from baseline in magnetic resonance imaging (MRI) score, EuroQOL‐5 dimensions (EQ‐5D) index score, EQ‐5D pain/discomfort dimension score and C‐reactive protein (CRP, mg/L) level in all PAO patients through week 52. Data from both guselkumab groups were combined and presented as results for a single overall guselkumab group.

Results

Among 159 patients with PPP, 66 with PAO were randomized across treatment groups. For patients with MRI data for all regions assessed, the proportion of patients in the guselkumab group with PAO characterized as severe decreased from 23.8% (10/42) at baseline to 5.4% (2/42) at week 52. The mean (SD) change from baseline at week 52 in EQ‐5D index score was 0.20 (0.17) among PPP patients with PAO and 0.15 (0.17) among those without PAO in the guselkumab group. Among all PAO patients, the proportions with an EQ‐5D pain/discomfort dimension score of no or slight pain/discomfort in the guselkumab group increased from baseline to week 52 [33.3% (7/21) vs. 87.5% (35/40)]. The mean (SD) CRP levels decreased in all PAO patients in the guselkumab group at week 52 compared to baseline [−1.71 (8.16) mg/L].

Conclusion

Guselkumab treatment showed beneficial outcomes for PAO signs and symptoms in Japanese patients with PPP.