Blood pressure and variability responses to the down-titration of antihypertensive drugs

OBJECTIVES

Several recent guidelines have proposed the gradual reduction of antihypertensive drugs for patients with well controlled blood pressure (BP). However, no studies have examined alterations in BP variability (BPV) during the down-titration of antihypertensives. This study aims to investigate changes in home BPV during the down-titration of antihypertensives.

METHODS

We analyzed 83 hypertensive patients who underwent down-titration of antihypertensives and had available home BP data during the down-titration. Down-titration was performed when home SBP was less than 120 mmHg, regardless of the clinic SBP. Primary exposure variable was the standard deviation (SD) of home BP.

RESULTS

Among 83 patients (mean age 66.3 ± 11.9 years; 45.8% men), down-titration led to increase home SBP (from 110.5 to 118.7 mmHg; P  < 0.001), and home DBP (from 68.8 to 72.8 mmHg; P  = 0.001) significantly. There were no significant differences in SDs of SBP [from 6.02 ± 3.79 to 5.76 ± 3.09 in morning, P  = 0.570; from 6.13 ± 3.32 to 6.63 ± 3.70 in evening, P  = 0.077; and from 6.54 (4.80, 8.31) to 6.37 (4.65, 8.76) in home SBP, P  = 0.464] and SDs of DBP during the down-titration of antihypertensive drugs.

CONCLUSION

Down-titration of antihypertensive drugs did not have notable impact on clinic BP and home BPV, while significantly increasing home BP. These findings provide important insights indicating that the potential concern related to an increase in BPV in the planned strategy of reducing antihypertensive drugs is not substantial.

Estimating meaningful change thresholds for Skin Pain-Numeric Rating Scale, Sleep-Numeric Rating Scale and Dermatology Life Quality Index in patients with prurigo nodularis

BACKGROUND

Prurigo nodularis (PN) is characterized by intensely itchy nodules/lesions and skin pain, which can have a substantial impact on health-related quality of life (HRQoL). Treatment benefits on such symptoms and impacts are best assessed in trials using patient-reported outcome (PROs) instruments such as Skin Pain Numerical Rating Scale (NRS), Sleep-NRS and Dermatology Life Quality Index (DLQI). However, no guidance exists for interpreting meaningful changes in scores using these PROs in patients with PN.

OBJECTIVES

The main objective was to derive within-patient (responder definition) and between-group improvement thresholds for interpreting Skin Pain-NRS, Sleep-NRS and DLQI total scores in patients with PN. The measurement properties of the three PROs were also evaluated.

METHODS

Intention-to-treat (ITT), blinded and pooled data were used from the Phase 3 PRIME (NCT04183335) and PRIME2 (NCT04202679) studies evaluating the efficacy of dupilumab in adult patients with PN. Anchor- and distribution-based methods were applied to derive responder definition and between-group thresholds for Skin Pain-NRS, Sleep-NRS and DLQI. Data were additionally used to examine the instrument measurement properties, including reliability, validity and responsiveness.

RESULTS

A total of 311 patients (mean age 49.5 years, 65.3% female) were included in the pooled ITT population. The within-patient improvement threshold for Skin Pain-NRS was estimated as 4.0 points, 2.0 points for Sleep-NRS and 9.0 points for DLQI total score. A 1.5-point improvement in Skin Pain-NRS scores, 1.0-point in Sleep-NRS and 4.0-point in DLQI indicated a between-group meaningful change. Adequate to good psychometric properties were demonstrated for all three instruments.

CONCLUSIONS

The results of this study can aid interpretation of Skin Pain-NRS, Sleep-NRS and DLQI scores in patients with PN in both clinical trials and clinical practice to better understand and treat PN-related skin pain and the impact of PN on sleep quality and HRQoL.

Harnessing Metabolic Indices as a Predictive Tool for Cardiovascular Disease in a Korean Population without Known Major Cardiovascular Event

Background

This study evaluated the usefulness of indices for metabolic syndrome, non-alcoholic fatty liver disease (NAFLD), and insulin resistance (IR), as predictive tools for cardiovascular disease in middle-aged Korean adults.

Methods

The prospective data obtained from the Ansan-Ansung cohort database, excluding patients with major adverse cardiac and cerebrovascular events (MACCE). The primary outcome was the incidence of MACCE during the follow-up period.

Results

A total of 9,337 patients were included in the analysis, of whom 1,130 (12.1%) experienced MACCE during a median follow-up period of 15.5 years. The metabolic syndrome severity Z-score, metabolic syndrome severity score, hepatic steatosis index, and NAFLD liver fat score were found to significantly predict MACCE at values above the cut-off point and in the second and third tertiles. Among these indices, the hazard ratios of the metabolic syndrome severity score and metabolic syndrome severity Z-score were the highest after adjusting for confounding factors. The area under the receiver operating characteristic curve (AUC) of the 10-year atherosclerotic cardiovascular disease (ASCVD) score for predicting MACCE was 0.716, and the metabolic syndrome severity Z-score had an AUC of 0.619.

Conclusion

The metabolic syndrome severity score is a highly reliable indicator and was closely associated with the 10-year ASCVD risk score in predicting MACCE in the general population. Given the specific characteristics and limitations of metabolic syndrome severity scores as well as the indices of NAFLD and IR, a more practical scoring system that considers these factors is essential to achieve greater accuracy in forecasting cardiovascular outcomes.

Effect of low sodium and high potassium diet on lowering blood pressure and cardiovascular events

Incorporating aggressive lifestyle modifications along with antihypertensive medication therapy is a crucial treatment strategy to enhance the control rate of hypertension. Dietary modification is one of the important lifestyle interventions for hypertension, and it has been proven to have a clear effect. Among food ingredients, sodium and potassium have been found to have the strongest association with blood pressure. The blood pressure-lowering effect of a low sodium diet and a high potassium diet has been well established, especially in hypertensive population. A high intake of potassium, a key component of the Dietary Approaches to Stop Hypertension (DASH) diet, has also shown a favorable impact on the risk of cardiovascular events. Additionally, research conducted with robust measurement methods has shown cardiovascular benefits of low-sodium intake. In this review, we aim to discuss the evidence regarding the relationship between the low sodium and high potassium diet and blood pressure and cardiovascular events.

Association between Estimated Pulse Wave Velocity and Incident Nonalcoholic Fatty Liver Disease in Korean Adults

Introduction

Nonalcoholic fatty liver disease (NAFLD) is associated with vascular dysfunction, one of the signs of which is arterial stiffness. Carotid-femoral pulse wave velocity (PWV), which is considered the gold standard measure of arterial stiffness, can be estimated using two commonly assessed clinical variables: age and blood pressure. This study aimed to evaluate the association between estimated PWV (ePWV) and the prevalence and incidence of NAFLD among Korean adults.

Methods

This study used data from the Ansan-Ansung cohort study, a subset of the Korean Genome and Epidemiology Study, and included 8,336 adult participants with and without NAFLD at baseline. The participants were subdivided into three tertile groups according to ePWV.

Results

At baseline, the prevalence of NAFLD was 10.5, 27.5, and 35.0% in the first (lowest), second, and third (highest) tertiles of ePWV, respectively. During the 18-year follow-up period, 2,467 (42.9%) incident cases of NAFLD were identified among 5,755 participants who did not have NAFLD at baseline. After adjustment for clinically relevant variables, participants in the second (adjusted hazard ratio [HR], 1.25; 95% confidence interval [CI], 1.12-1.40) and third (adjusted HR, 1.42; 95% CI, 1.24-1.64) tertiles of ePWV had a significantly higher risk of incident NAFLD than those in the first tertile.

Conclusion

Higher ePWV is independently associated with an elevated risk of NAFLD in the general population.

Electrocardiography score based on the Minnesota code classification system predicts cardiovascular mortality in an asymptomatic low-risk population

BACKGROUND

The use of a single abnormal finding on electrocardiography (ECG) is not recommended for stratifying the risk of cardiovascular (CV) events in low-risk general populations because of its low discriminative power. However, the value of a scoring system containing multiple abnormal ECG findings for predicting CV death has not been sufficiently evaluated.

METHODS

In a prospective community-based cohort study, 8417 participants without atherosclerotic CV diseases (ASCVDs) and any related symptoms were followed for 18 years. The standard 12-lead ECGs were recorded at baseline and the ECG findings were categorized using the Minnesota code classification. CV deaths were defined as death from myocardial infarction (MI), chronic ischemic heart disease, heart failure, fatal arrhythmia, cerebrovascular event, pulmonary thromboembolism, peripheral vascular disease and sudden cardiac arrest and identified using the Korean National Statistical Office (KOSTAT) database.

RESULTS

In a multivariate Cox proportional hazard (CPH) model, major and minor ST-T wave abnormalities, atrial fibrillation (AF), Q waves in the anterior leads, the lack of Q waves in the posterior leads, high amplitudes of the left and right precordial leads, left axis deviation and sinus tachycardia were associated with higher risks of CV deaths. The ECG score consisted of these findings showed modest predictive values represented by C-statistics that ranged from 0.632 to 760 during the follow-up and performed better in the early follow-up period. The ECG score independently predicted CV death after adjustment for relevant covariates in a multivariate model, and improved the predictive performance of the 10-year ASCVD risk estimator and a model of conventional risk factors including age, diabetes and current smoking. The combined ECG score (Harrell's C-index: 0.852, 95% confidence interval [CI], 0.828-0.876) composed of the ECG score and the conventional risk factors outperformed the 10-year ASCVD risk estimator (Harrell's C-index: 0.806; 95% CI, 0.780-0.833) and the model of the conventional risk factors (Harrell's C-index: 0.841, 95% CI, 0.817-0.865) and exhibited an excellent goodness of fit between the predicted and observed probabilities of CV death.

CONCLUSIONS

The ECG score could be useful to predict CV death independently and may add value to the conventional CV risk estimators regarding the risk stratification of CV death in asymptomatic low-risk general populations.

Prior bariatric surgery and risk of poor in-hospital outcomes in COVID-19: findings from a National Inpatient Sample

BACKGROUND

Obesity and obesity-related co-morbidities are risk factors for severe coronavirus disease 2019 (COVID-19).

OBJECTIVES

As bariatric surgery effectively addresses obesity-related conditions, we hypothesized that prior bariatric surgery may be associated with a reduced risk of severe COVID-19. Small-scale studies have suggested favorable outcomes; however, large-scale nationwide database studies are scarce.

SETTING

A retrospective analysis of the 2020 Healthcare Cost and Utilization Project National Inpatient Sample.

METHODS

All patients diagnosed with COVID-19 were examined and stratified by history of bariatric surgery. We performed 1:1 propensity score matching and compared patients with COVID-19 with and without prior bariatric surgery. The primary outcome was in-hospital mortality rate. Secondary outcomes included total hospital costs, length of hospital stay, and intensive treatment needs. Multivariate logistic regression analysis was performed to identify independent factors associated with in-hospital mortality.

RESULTS

In-hospital mortality rate was significantly lower in patients with prior bariatric surgery (6.2% versus 8.7%, P = .001). Furthermore, sepsis, acute kidney injury, and mechanical ventilation rates were significantly lower in patients with COVID-19 and prior bariatric surgery, resulting in a reduced need for intensive treatment (12.1% versus 14.9%, P = .005). The total hospitalization costs were lower, and the length of hospital stay was shorter in patients with prior bariatric surgery, demonstrating statistical significance. Old age, male sex, body mass index >50, and co-morbidities were significantly associated with in-hospital mortality in patients with COVID-19 and prior bariatric surgery.

CONCLUSIONS

Prior bariatric surgery was independently associated with decreased mortality and better in-hospital outcomes in patients hospitalized for COVID-19.

Dynamic Fixation versus Static Screw Fixation for Syndesmosis Injuries in Pronation External Rotation Ankle Fractures: A Retrospective Case Control Study

Introduction

The current standard treatment for ankle syndesmosis injury is static screw fixation. Dynamic fixation was developed to restore the dynamic function of the syndesmosis. The purpose of this study was to determine that which of static screw fixation and dynamic fixation is better for treatment of ankle syndesmosis injury in pronation-external rotation fractures.

Materials and methods

Thirty patients were treated with dynamic fixation (DF group) and 28 patients with static screw fixation (SF group). The primary outcome was Olerud-Molander Ankle Outcome Score. The secondary outcome were Visual Analogue Scale score and American Orthopedic Foot and Ankle Society score, radiographic outcomes, complications and cost effectiveness. To evaluate the radiographic outcome, the tibiofibular clear space, tibiofibular overlap, and medial clear space were compared using the pre-operative and last follow-up plain radiographs. To evaluate the cost effectiveness, the total hospital cost was compared between the two groups.

Results

There was no significant difference in primary outcome. Moreover, there were no significant difference in secondary outcome including Visual Analogue Scale score and American Orthopedic Foot and Ankle Society score and radiographic outcome. Two cases of reduction loss and four cases of screw breakage were observed in the SF group. No complication in the DF group was observed. Dynamic fixation was more cost effective than static screw fixation with respect to the total hospital cost.

Conclusion

Although dynamic fixation provided similar clinical and radiologic outcome, dynamic fixation is more cost effective with fewer complications than static screw fixation in ankle syndesmosis injury of pronation-external rotation fractures.

Clinical and life style factors related to the nighttime blood pressure, nighttime dipping and their phenotypes in Korean hypertensive patients

BACKGROUND

Non-dipping or reverse dipping patterns are known to be associated with adverse cardiovascular prognosis among the general population and clinical cohort. Few large sized studies have explored factors including sleep duration and sleep quality related to nighttime blood pressure (BP) and nocturnal dipping patterns.

METHODS

Among 5,360 patients enrolled  in Korean multicenter nationwide prospective Registry of ambulatory BP monitoring (KORABP), 981 subjects with complete data on sleep duration, sleep quality assessed using a 4-point Likert scale, and clinical variables were included in the analysis. Phenotypes of nighttime BP pattern were categorized as extreme dipper, dipper, non-dipper, and reverse dipper. Hypertension was defined as a 24-h ambulatory BPs were 130/80 mmHg or higher.

RESULTS

Among 981 subjects, 221 were normotensive, 359 were untreated hypertensive, and 401 were treated hypertensive. Age of the participants were 53.87 ± 14.02 years and 47.1% were female. In overall patients, sleep duration was 431.99 ± 107.61 min, and one to four points of sleep quality were observed in 15.5%, 30.0%, 30.4%, and 24.2%, respectively. Of the 760 hypertensive patients, extreme dipper, dipper, non-dipper, and reverse dipper were observed in 58 (7.63%), 277 (36.45%), 325 (42.76%), and 100 (13.16%), respectively. In multiple linear regression analysis, sleep duration (β = 0.0105, p < 0.001) and sleep quality (β = -0.8093, p < 0.001) were associated with nighttime systolic BP and sleep quality was associated with extent of nighttime systolic BP dipping (β = 0.7622, p < 0.001) in hypertensive patients. In addition, sleep quality showed positive association with dipper pattern (odds ratio [OR] = 1.16, 95% confidence interval [CI] = 1.03-1.30) and showed negative association with reverse dipper pattern (OR = 0.73, 95% CI = 0.62-0.86) in multiple logistic regression analyses.

CONCLUSION

When adjusted covariates, less sleep duration and poor sleep quality were positively associated with nighttime systolic BP. Additionally, sleep quality was the independent associated factor for dipper and reverse dipper phenotypes. The study also found that male sex, low estimated glomerular filtration rate, high ambulatory BP, low office BP, and poor sleep quality were associated with blunted nighttime SBP dipping.

Quantitative measurement of empathy and analysis of its correlation to clinical factors in korean patients with chronic diseases

BACKGROUND

Empathy is the core of the physician-patient relationship. The Consultation and Relational Empathy (CARE) measure is a useful tool for assessing patient-rated empathy. There have been scarce data on empathy in chronic disease patients in Korea. We aim to evaluate empathy using the Korean CARE measure in patients from various clinical environments and the factors influencing the degree of empathy in patients with chronic disease.

METHODS

Data were collected from patients with chronic diseases. Patients were from primary, secondary, and tertiary clinics. Characteristics of the patients, physicians, and disease status were collected. The difference in CARE score was studied according to the clinical factors.

RESULTS

A total of 162 patients with chronic diseases were included. About 60% of patients were male. The mean age was 62 years. They had an average number of 2.6 diseases. More than half of patients experienced overt cardiovascular disease. About half of them had a history of hospitalization due to cardiovascular disease. The overall average CARE score was 45.6 ± 7.0. The CARE score was not significantly different according to the characteristics of the patient, physician, or disease status. Regarding marital status, the CARE score was significantly lower for the small number of patients (n = 4, 2.5%) who refused to provide their marital status than for other groups. Except for four patients, there was no significant difference in the CARE score among married, unmarried, or divorced groups. This trend was maintained in hypertensive patients.

CONCLUSIONS

The Korean CARE measure could assess patient-rated empathy in various clinical practices. The empathy of patients was high regardless of multiple factors.

Association between D-dimer and long-term mortality in patients with acute severe hypertension visiting the emergency department

OBJECTIVE

High levels of D-dimer, a marker of thrombotic events, are associated with poor outcomes in patients with various cardiovascular diseases. However, there has been no research on its prognostic implications in acute severe hypertension. This study investigated the association between D-dimer levels and long-term mortality in patients with severe acute hypertension who visited the emergency department.

DESIGN AND METHOD

This observational study included patients with acute severe hypertension who visited the emergency department between 2016 and 2019. Acute severe hypertension was defined as a systolic blood pressure ≥ 180 mmHg or a diastolic blood pressure ≥ 100 mmHg. Among the 10,219 patients, 4,127 who underwent D-dimer assay were analyzed. The patients were categorized into tertiles based on their D-dimer levels at the time of emergency department admission.

RESULTS

Among the 4,127 patients with acute severe hypertension, 3.1% in the first (lowest) tertile, 17.0% in the second tertile, and 43.2% in the third (highest) tertile died within 3 years. After the adjustment for confounding variables, the third tertile of the D-dimer group (hazard ratio, 6.440; 95% confidence interval, 4.628-8.961) and the second tertile of the D-dimer group (hazard ratio, 2.847; 95% confidence interval, 2.037-3.978) had a significantly higher risk of all-cause mortality over 3 years than the first tertile of the D-dimer group.

CONCLUSIONS

D-dimer may be a useful marker for identifying the risk of mortality among patients with acute severe hypertension who visit the emergency department.

Safety evaluation of curative gastrectomy for gastric cancer patients who underwent liver transplantation: a comparative study with conventional gastrectomy for gastric cancer patients

BACKGROUND

We aimed to examine the technical and oncological safety of curative gastrectomy for gastric cancer patients who underwent liver transplantation.

METHODS

In this study, we compared the surgical and oncological outcomes of two groups. The first group consisted of 32 consecutive patients who underwent curative gastrectomy for gastric cancer after liver transplantation (LT), while the other group consisted of 127 patients who underwent conventional gastrectomy (CG). In addition, a subgroup analysis was performed to evaluate the impact of the background differences and the surgical outcomes on the involvement of a specialized liver transplant surgery team.

RESULTS

The mean operative time was significantly longer in the LT group (p < 0.05). Furthermore, there were more frequent cases of postoperative transfusion in the LT group compared to the CG group (p < 0.05). However, there were no significant differences in the overall complications between the groups (25.00 vs 23.62%, p = 0.874). The 5-year overall survival rates of the LT and CG groups were 76.7% and 90.1%, respectively (p < 0.05). The results of the subgroup analysis demonstrated no statistically significant difference in various early surgical outcomes, such as time to transfusion during surgery, first flatus, time to first soft diet, postoperative complications, hospital stay after surgery, and the number of harvested lymph nodes except for operation time.

CONCLUSIONS

Despite one's medical history of undergoing LT, our study demonstrated that curative gastrectomy could be a surgically safe treatment for gastric cancer. However, further study should be conducted to identify the reason gastric cancer patients who underwent liver transplant surgery have lower overall survival rate.

Association of microscopic hematuria with long-term mortality in patients with hypertensive crisis

BACKGROUND

Microscopic hematuria is associated with increased risk of developing chronic kidney function impairment and even death. However, data on the long-term mortality risk associated with microscopic hematuria among patients with hypertensive crisis are scarce. We hypothesized that microscopic hematuria at initial presentation in patients with hypertensive crisis would be associated with increased long-term mortality.

METHODS

This retrospective study included patients admitted to the emergency department between 2016 and 2019 for hypertensive crisis (systolic blood pressure ≥ 180 mmHg or diastolic blood pressure ≥ 110 mmHg). Microscopic hematuria was defined as ≥ 3 red blood cells per high-power field on microscopic evaluation of urine.

RESULTS

Among 3595 patients, 1359 (37.8%) had microscopic hematuria. The 3-year all-cause mortality in patients with and without microscopic hematuria was 25.5% and 16.3%, respectively. After adjusting for confounding variables, patients with microscopic hematuria (adjusted HR, 1.30; 95% CI 1.10-1.54) showed a significantly higher risk of 3-year all-cause mortality than patients without microscopic hematuria. In a subgroup analysis based on the presence of proteinuria, microscopic hematuria was a significant predictor of all-cause mortality in patients without proteinuria (adjusted HR, 1.61; 95% CI 1.28-2.03) but not in patients with proteinuria.

CONCLUSION

Microscopic hematuria was a significant predictor of all-cause mortality in patients with hypertensive crisis. Our study suggests that microscopic hematuria can be a useful prognostic marker and may permit early detection of patients with an increased risk of death. Clinicians in the emergency department should consider screening for kidney function using urine analysis during the initial assessment of patients with hypertensive crisis.

Clinical implications of cardiac troponin-I in patients with hypertensive crisis visiting the emergency department

OBJECTIVES

Cardiac troponin-I (cTnI) is a representative marker of myocardial injury. Elevation of cTnI is frequently observed in patients with hypertensive crisis, but few studies have examined its prognostic significance in hypertensive crisis. We aimed to determine whether cTnI could predict all-cause mortality in patients with hypertensive crisis visiting the emergency department (ED).

METHODS

This observational study included patients aged ≥18 years who visited an ED between 2016 and 2019 for hypertensive crisis, defined as systolic blood pressure (BP) ≥180 mmHg and/or diastolic BP ≥110 mmHg. Among 6467 patients, 3938 who underwent a cTnI assay were analysed.

RESULTS

Among the 3938 patients, 596 (15.1%) had cTnI levels above the 99th percentile upper reference limit (elevated cTnI >40 ng/L) and 600 (15.2%) had cTnI levels between the detection limit (≥10 ng/L) and the 99th percentile upper reference limit (detectable cTnI). The 3-year all-cause mortality in the elevated, detectable and undetectable cTnI groups were 41.6%, 36.5% and 12.8%, respectively. After adjusting for confounding variables, elevated cTnI patients (adjusted hazard ratio [HR], 2.01; 95% confidence interval [CI], 1.61-2.52) and detectable cTnI patients (adjusted HR, 1.64; 95% CI, 1.32-2.04) showed a significantly higher risk of 3-year all-cause mortality than did patients with undetectable cTnI.

CONCLUSIONS

In patients with hypertensive crisis, elevated cTnI levels provide useful prognostic information and permit the early identification of patients with an increased risk of death. Moreover, putatively normal but detectable cTnI levels also significantly correlated with a higher risk of all-cause mortality. Intensive treatment and follow-up strategies are needed for patients with hypertensive crisis with elevated and detectable cTnI levels.Key messagesCardiac troponin-I level was an independent prognostic factor for all-cause mortality in patients with hypertensive crisis.Detectable but normal range cardiac troponin-I, which was considered clinically insignificant, also had a prognostic impact on all-cause mortality comparable to elevated cardiac troponin-I levels.

Association of anaemia with long-term mortality among patients with hypertensive crisis in the emergency department

BACKGROUND

Anaemia is frequent in patients with cardiovascular disease and is significantly associated with poor prognosis. However, the prognostic significance of anaemia in hypertensive crisis remains unknown. We conducted this study to determine whether anaemia is a risk factor for all-cause mortality in patients with hypertensive crisis visiting the emergency department (ED).

METHODS

This retrospective study included patients who visited the ED between 2016 and 2019 for hypertensive crisis, which was defined as systolic blood pressure ≥180 mmHg or diastolic blood pressure ≥110 mmHg. A total of 5,512 patients whose serum haemoglobin levels were checked were included in this study and were classified into three groups according to their serum haemoglobin levels at admission to the ED: moderate/severe anaemia (haemoglobin <11 g/dL), mild anaemia (haemoglobin 11 to <13 g/dL in men and 11 to <12 g/dL in women), and non-anaemia (haemoglobin ≥13 g/dL in men and ≥12 g/dL in women).

RESULTS

Among 5,512 patients, 665 (12.1%) and 668 (12.1%) were classified into the moderate/severe anaemia and mild anaemia groups, respectively. The three-year all-cause mortality rates in the moderate/severe anaemia, mild anaemia, and non-anaemia groups were 46.0, 29.2, and 12.0%, respectively. After accounting for relevant covariates, patients with moderate/severe anaemia group (hazard ratio [HR], 2.15; 95% confidence interval [CI], 1.75-2.64) and mild anaemia group (HR, 1.32; 95% CI, 1.07-1.63) had a higher risk of 3-year all-cause mortality than the non-anaemia group.

CONCLUSION

Anaemia is independently associated with 3-year all-cause mortality in patients with hypertensive crisis. A comprehensive therapeutic approach through more in-depth examination and close follow up are required for patients with hypertensive crisis with anaemia.KEY MESSAGESAnaemia is independently associated with 3-year all-cause mortality in patients with hypertensive crisis.A comprehensive therapeutic approach through more in-depth examination and close follow up are required for patients with hypertensive crisis with anaemia.

Augmented risk of ischemic stroke in hypertrophic cardiomyopathy patients without documented atrial fibrillation

Background

Ischemic stroke is a common complication in patients with hypertrophic cardiomyopathy (HCM) (1). Although atrial fibrillation (AF) is a well-established risk factor for ischemic stroke in HCM, the risk of ischemic stroke in patients with HCM without documented AF is less recognized (1, 2). This study aimed to determine the risk of ischemic stroke and identify its risk factors in patients with HCM without documented AF.

Methods

This nationwide population-based cohort study used the Korean National Health Insurance database. After excluding patients with a prior history of AF, thromboembolic events, cancer, or the use of anticoagulants, we identified 8,328 HCM patients without documented AF and 1:2 propensity score-matched 16,656 non-HCM controls. The clinical outcome was an incident ischemic stroke.

Results

During a mean follow-up of approximately 6 years, ischemic stroke occurred in 328/8,328 (3.9%) patients with HCM and 443/16,656 (2.7%) controls. Among individuals who developed ischemic stroke, the proportion of AF concomitantly detected accounted for 26.5% (87/328) and 5.8% (26/443) in the HCM and control groups, respectively. The overall incidence of ischemic stroke was 0.716/100 person-years in the HCM group, which was significantly higher than that in the control group (0.44/100 person-years) (HR 1.643; 95% CI, 1.424–1.895; P&lt;0.001, Figure 1). The subgroup analysis according to age, sex, and comorbidities (chronic heart failure, hypertension, dyslipidemia, and vascular disease) consistently demonstrated a higher risk of ischemic stroke in the HCM group (P for interaction &gt;0.05). In the HCM group, age ≥65 years (adjusted hazard ratio [HR] 2.741; 95% confidence interval [CI], 2.156–3.486; P&lt;0.001) and chronic heart failure (adjusted HR 1.748; 95% CI, 1.101–2.745; P=0.018) were independent risk factors for ischemic stroke. Overall incidence was 1.360/100 in patients with HCM aged ≥65 and 2.315/100 person-years years in those with chronic heart failure, respectively. Also, compared to controls aged &lt;65 years and without CHF, adjusted HR for ischemic stroke was 4.756 (95% CI 3.807–5.867) in patients with HCM aged ≥65 years and 2.539 (95% CI 1.638–3.936) in those with CHF, respectively (Figure 2).

Conclusions

Patients with HCM without documented AF are at a higher risk of ischemic stroke than the propensity score-matched general population. Age ≥65 years and chronic heart failure are two strong independent risk factors for ischemic stroke in this population.

Funding Acknowledgement

Type of funding sources: None.

Impact of estimated pulse wave velocity on cardiovascular outcomes in a general population

Background

Estimated pulse wave velocity (ePWV), a simple surrogate estimate of carotid-femoral pulse wave velocity which was gold standard for measuring aortic stiffness, has been demonstrated to predict cardiovascular (CV) outcome. However, there was limited data on its predictive capacity for CV outcomes in the general population. The study aim was to investigate the independent association between ePWV and CV outcomes in general population.

Methods

A total of 10,030 subjects aged between 40 and 69 years were followed over 18-year period in the Ansan-Ansung cohort study. Levels of ePWV, which was calculated from an equation based on age and mean blood pressure, were categorized according to quartiles. A major adverse cardiovascular event (MACE) was defined as a composite of myocardial infarction, coronary artery disease, stroke, heart failure, peripheral artery disease, and cardiovascular death.

Results

The incidence rates of CV death, and MACE were 7.0% and 22.1% in the fourth (highest) quartile of ePWV and 0.1% and 4.5% in the first (lowest) quartile of ePWV. After adjusting for relevant covariates, patients with third and fourth quartile of ePWV showed significantly higher risk of CV death (hazard ratio [HR] 3.92; 95% confidence intervals [CI] 1.09–14.15 in third quartile and HR 8.53; 95% CI 2.13–34.10 in fourth quartile), and MACE (HR 1.54; 95% CI 1.15–2.08 in third quartile and HR 1.56; 95% CI 1.05–2.32) compared to the reference of first (lowest) quartile of ePWV. However, there were no improvement of C statistic for CV death and MACE when adding ePWV to the Cox regression models with 10-year atherosclerotic cardiovascular disease (ASCVD) risk.

Conclusion

These results suggest that ePWV predicted CV death and MACE in general population. The value of ePWV, a simple and useful indicator of aortic stiffness, is expected to serve as a potential marker to identify high risk groups of CV event in general population.

Funding Acknowledgement

Type of funding sources: None.

Influence of concomitant percutaneous transluminal angioplasty with percutaneous coronary intervention on outcomes in patients with stable lower extremity artery disease

Background

Patients with stable lower extremity artery diseases (LEAD) frequently present with coronary artery diseases; thus, concomitant percutaneous transluminal angioplasty (PTA) at the time of percutaneous coronary intervention (PCI) is often performed. We investigated the influence of concomitant PTA on both cardiovascular (CV) and limb outcomes in the Korean National Health Insurance Service registry.

Methods

Among 78,185 patients undergoing PCI between 2012 and 2015, 6,563 patients (279 for the PTA+PCI group vs. 6,284 for the PCI group) suffering from stable LEAD without limb ischemia were included. Major adverse CV events (MACEs) were defined as a composite of CV death, myocardial infarction (MI) and coronary revascularization. Patients were followed for at least 3 years.

Results

After 1:5 propensity score matching was conducted, 279 patients in the PTA+PCI group and 1,385 patients in the PCI group were compared. The risk of all-cause death was higher in the PTA+PCI group than in the PCI group, whereas the risks of MACE, MI, revascularization, stroke, CV death and bleeding event were not different between the 2 groups in the matched cohort. In contrast, the risks of end-stage renal diseases and unfavorable limb outcomes were higher in the PTA+PCI group than in the PCI group (Figure 1). Mediation analyses revealed that amputation and repeat Percutaneous transluminal angioplasty after discharge significantly mediated the association between the concomitant PTA and all-cause death (Figure 2).

Conclusions

CPTA at the time of PCI is not associated with an increased risk of CV events but may increase the risk of all-cause death by increasing unfavorable renal and limb outcomes in patients with stable LEAD.

Funding Acknowledgement

Type of funding sources: None.

Clinical characteristics and prognosis of patients with very severe acute hypertension visiting the emergency department

Background

Data regarding very severe acute hypertension, a serious problem in emergency departments (EDs), are scarce. We investigated the clinical characteristics, practice patterns, and long-term prognoses of patients presenting to the ED with very severe acute hypertension.

Methods

Cross-sectional study data were obtained from a single regional emergency medical center, including patients aged ≥ 18 years who were admitted to the ED between January 2016 and December 2019 for very severe acute hypertension, which was defined as systolic blood pressure of > 220 mmHg and/or diastolic blood pressure of > 120 mmHg. The patients were classified into two groups based on the presence or absence of hypertension-mediated organ damage (HMOD).

Results

Among 1,391 patients with very severe acute hypertension in the ED, half of the them (50.2%) had a previous medical history of hypertension, and 547 (39.3%) had acute HMOD. The overall 3-month, 1-year, and 3-year mortality rates were 5.2%, 11.9%, and 17.3%, respectively. In particular, patients with HMOD had a significantly higher mortality rate at each time point than those without HMOD. Among patients with HMOD, acute ischemic stroke was the most common (28.7%). Moreover, intravenous antihypertensive drugs were significantly more prescribed in patients with HMOD than in those without HMOD (79.0% vs. 22.2%, P < 0.001), but there were no differences in oral antihypertensive drugs between the two groups.

Conclusions

Patients with very severe acute hypertension had poor long-term clinical prognoses. Clinicians should be continuously monitoring and providing appropriate treatment and close follow-up for patients with very severe acute hypertension.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40885-022-00208-3.

Association of Dipstick Proteinuria with Long-Term Mortality among Patients with Hypertensive Crisis in the Emergency Department

Proteinuria, frequently observed in hypertensive crisis, is a risk factor for cardiovascular and all-cause mortality in patients with hypertension. Here we investigated the association between proteinuria and all-cause mortality in patients with a hypertensive crisis in the emergency department (ED). This retrospective study included patients admitted to the ED of a tertiary referral center between 2016 and 2019 with hypertensive crisis (systolic blood pressure ≥ 180 mmHg or diastolic blood pressure ≥ 110 mmHg); 3599 patients with an assay for proteinuria were included in this study. Proteinuria was defined as a trace or more protein on a urine dipstick test. Proteinuria was present in 1964 (54.6%) of 3599 patients. At 3 years, crude all-cause mortality rates were 10.8% for patients with negative proteinuria, 21.7% for those with trace proteinuria, 29.0% for those with proteinuria (1+), 32.0% for those with proteinuria (2+), and 35.4% for those with proteinuria (≥3+). After adjusting for age, sex, blood pressure, and comorbid conditions, the hazard ratio (95% confidence interval) for dipstick proteinuria was 1.91 (1.53–2.37) for those with trace proteinuria, 2.32 (1.85–2.91) for those with proteinuria (1+), 2.40 (1.86–3.10) for those with proteinuria (2+), and 2.40 (1.78–3.24) for those with proteinuria (≥3+) compared to the reference of negative proteinuria. In patients with hypertensive crisis, dipstick proteinuria was a significant predictor of all-cause mortality, and the risk of all-cause mortality increased in a dose-dependent manner according to its degree. Moreover, even trace proteinuria was associated with an increased risk of mortality. The dipstick urine test could be used as a simple and useful method for risk assessment of all-cause mortality in patients with hypertensive crisis.

A comparative study of laparoscopic near-total and total gastrectomy for patient nutritional status and quality of life using a propensity score matching analysis

BACKGROUND

Previous studies of LNTG had small sample sizes and short follow-up periods and did not evaluate quality of life after LNTG. We aimed to compare surgical, oncological, nutritional outcomes, and quality of life of patients after laparoscopic near-total and total gastrectomy (LNTG and LTG, respectively).

METHODS

We retrospectively collected and analyzed data of 167 and 294 patients who underwent LNTG and LTG, respectively, for treatment of upper or middle third gastric cancer between January 2008 and December 2018. After propensity score matching, the surgical, oncological, and nutritional outcomes of 324 patients were analyzed. Moreover, we measured quality of life after surgery using a postgastrectomy syndrome scale.

RESULTS

The operation time and the length of hospital stay was significantly shorter in the LNTG group than in the LTG group. In addition, patients with anastomotic complications were fewer in the LNTG group. No significant difference was found in the 5-year overall survival rate between the two groups. However, patients in the LNTG group had a significantly smaller body weight loss after 3 months postoperatively. Furthermore, patients in the LNTG group had significantly healthier albumin and cholesterol than those in the LTG group. The mean scores on the postgastrectomy symptom scale at 3, 6, and 12 months postoperatively were higher in the LNTG group than in the LTG group.

CONCLUSION

LNTG is a surgically safe and oncologically favorable method compared with LTG. Furthermore, patients who underwent LNTG had improved nutritional status and quality of life than those who underwent LTG.

Associations between Choriocapillaris Flow on Optical Coherence Tomography Angiography and Cardiovascular Risk Profiles of Patients with Acute Myocardial Infarction

We evaluated the association between macular perfusion assessed via optical coherence tomography angiography (OCTA) and the cardiovascular risk profiles of patients with acute myocardial infarction (AMI). Patients with AMI who underwent comprehensive ophthalmological examinations and retinal OCTA were evaluated retrospectively. Retinal OCTA was performed for each patient within 3 days of admission. Quantitative analyses of the vessel density (VD) of the superficial capillary plexus (SCP) layers, deep capillary plexus layers (DCP), and choriocapillaris were performed after image processing. The 10-year risk of atherosclerotic cardiovascular disease (ASCVD), Global Registry of Acute Coronary Events (GRACE) score, reduction of atherothrombosis for continued health (REACH) score, and thrombolysis in myocardial infarction (TIMI) risk score were assessed. Sixty patients were included. VD in SCP and DCP was not associated with a 10-year ASCVD risk; however, choriocapillaris flow void features were significantly correlated with the 10-year ASCVD risk: decreased count, increased average size, and increased signal void area were correlated with increased 10-year ASCVD risk, GRACE score, REACH score, and TIMI risk score. In the multivariate analysis, a 10-year ASCVD risk (adjusted odds ratio [OR], 1.04; 95% confidence interval [CI], 1.01–1.08) and brain natriuretic peptide (adjusted OR, 1.00; 95% CI, 1.00–1.01) were significantly associated with the highest tertile of the average size of the choriocapillaris. Choriocapillaris flow void features measured using OCTA were associated with cardiovascular risk profiles in patients with AMI. OCTA may be used as an indicator of cardiovascular risk profiles and could improve cardiovascular risk assessments.

Impact of the estimated glomerular filtration rate on long-term mortality in patients with hypertensive crisis visiting the emergency department

Background

The association between renal function and all-cause mortality in patients with hypertensive crisis remains unclear. We aimed to identify the impact of estimated glomerular filtration rate (eGFR) on all-cause mortality in patients with hypertensive crisis visiting the emergency department (ED).

Methods

This retrospective study included patients aged ≥18 years admitted to the ED between 2016 and 2019 for hypertensive crisis (systolic blood pressure ≥180 mmHg and/or diastolic blood pressure ≥110 mmHg). They were classified into four groups according to the eGFR at admission to the ED: ≥90, 60–89, 30–59, and <30 mL/min/1.73 m².

Results

Among the 4,821 patients, 46.7% and 5.8% had an eGFR of ≥90 and <30 mL/min/1.73 m², respectively. Patients with lower eGFR were older and more likely to have comorbidities. The 3-year all-cause mortality rates were 7.7% and 41.9% in those with an eGFR ≥90 and <30 mL/min/1.73 m², respectively. After adjusting for confounding variables, those with an eGFR of 30–59 (hazard ratio [HR], 1.93; 95% confidence interval [CI], 1.47–2.54) and <30 mL/min/1.73 m² (HR, 2.35; 95% CI, 1.71–3.24) had significantly higher 3-year all-cause mortality risks than those with an eGFR of ≥90 mL/min/1.73 m². Patients with an eGFR of 60–89 mL/min/1.73 m² had a higher mortality (21.1%) than those with an eGFR of ≥90 mL/min/1.73 m² (7.7%); however, the difference was not significant (HR, 1.21; 95% CI, 0.94–1.56).

Conclusions

Renal impairment is common in patients with hypertensive crisis who visit the ED. A strong independent association was observed between decreased eGFR and all-cause mortality in these patients. eGFR provides useful prognostic information and permits the early identification of patients with hypertensive crisis with an increased mortality risk. Intensive treatment and follow-up strategies are needed for patients with a decreased eGFR who visit the ED.

Comparison of Standard D2 and Limited Lymph Node Dissection in Elderly Patients with Advanced Gastric Cancer

BACKGROUND

Knowledge on the optimal extent of lymphadenectomy among elderly patients with advanced gastric cancer is limited. This study was designed to compare standard D2 and limited lymphadenectomy for evaluating the appropriate extent of lymphadenectomy.

PATIENTS AND METHODS

We retrospectively reviewed patient's data based on a prospectively collected gastric cancer registry. The inclusion criteria were age above 75 years and histologically confirmed stage II or more advanced gastric cancer. In this study, 103 patients who underwent limited lymph node dissection and 134 patients who underwent standard D2 lymph node dissection were included to evaluate surgical and oncological outcomes using propensity score matching (PSM) analysis.

RESULTS

The mean age after PSM was approximately 78 years in both groups. The Charlson Comorbidity Index was 5.81 ± 0.87 and 5.75 ± 0.76, respectively, and 12.5% of the patients in both groups had American Society of Anesthesiologists scores of more than 3. The limited lymphadenectomy group showed a shorter operation time and fewer retrieved lymph. However, other surgical outcomes and pathological data were not significantly different between the groups. No postoperative mortality within 30 days was observed. There were no significant differences in overall complications between the groups. The 3-year overall survival rates of the limited and standard lymphadenectomy groups were 58.3% and 73.6%, respectively. The 3-year recurrence-free survival rate of the limited lymphadenectomy group was lower than that of the standard lymphadenectomy group; however, the difference was not statistically significant.

CONCLUSIONS

Standard D2 lymphadenectomy has better oncological outcomes in elderly patients with advanced gastric cancer.

Sex Differences in Long-Term Mortality of Patients with Hypertensive Crisis Visiting the Emergency Department

Background: There are limited data on sex difference in patients with hypertensive crisis. We investigated sex differences in characteristics and long-term mortality in patients with hypertensive crisis visiting the emergency department (ED). Materials and Methods: This cross-sectional study at a tertiary referral center included patients ≥18 years of age who were admitted to the ED between 2016 and 2019 with hypertensive crisis, defined as systolic blood pressure ≥180 mmHg and/or diastolic blood pressure ≥110 mmHg. Results: Among the 6,467 patients who visited the ED with hypertensive crisis, 3,131(48.4%) were women. Women were older and less likely to have acute hypertension-mediated organ damage than men. The 3-year all-cause mortality did not differ between women and men (16.9% in women and 17.2% in men, p = 0.738). After adjusting for age and comorbidities, the 3-year all-cause mortality was significantly higher in men than in women (hazard ratio [HR], 1.14; 95% confidence interval [CI], 1.01-1.29; p = 0.031). In particular, among patients ≥50 years of age, the 3-year all-cause mortality was significantly higher in men than in women (HR, 1.14; 95% CI, 1.01-1.29; p = 0.038); however, it was not different according to sex among patients 18-49 years of age. Moreover, the 3-year all-cause mortality was significantly higher in men than in women among patients with hypertensive urgency (HR, 1.59; 95% CI, 1.34-1.90; p < 0.001), which was reversed in patients with hypertensive emergency (HR, 0.71; 95% CI, 0.60-0.84; p < 0.001). Conclusions: Men ≥50 years of age with hypertensive crisis, men with hypertensive urgencies, and women with hypertensive emergencies have a high risk of all-cause mortality. Thus, it is necessary to consider sex differences when predicting subsequent prognosis and determining the appropriate treatment for patients with hypertensive crisis.

Early Clinical Outcomes of the Morbidly Obese Patients Who Underwent Laparoscopic Sleeve Gastrectomy by Gastric Cancer Surgeons: the Analysis of Fifty Consecutive Cases

Purpose

The number of bariatric surgeries performed at our tertiary hospital has gradually increased since the national health insurance began to cover their expenses in January of 2019. This study examined the early surgical outcomes of laparoscopic sleeve gastrectomy (LSG) performed by experienced gastric cancer surgeons.

Materials and Methods

We retrospectively reviewed and analyzed data from 50 patients who underwent LSG between November of 2018 and April of 2020 at the Asan Medical Center by 1 of 5 experienced surgeons each of whom performed approximately 100-300 cases of gastrectomy annually. The age, body mass index (BMI), weight, presence of comorbidities, operation time, hospital stay after surgery, postoperative complications, postoperative excess weight loss (EWL), and resolution of comorbidities were examined.

Results

The mean age, BMI, and weight were 37.29±9.77 years, 37.12 kg/m², and 102.00 kg, respectively. The mean operation time and postoperative length of hospital stay were 109.59±35.88 and 5.06±1.20 days, respectively. Two patients (4.00%) had early postoperative complications and postoperative leakage; bleeding and stenosis were not reported. The EWL after 1 and 6 months of operation was 26.55% and 60.34%, respectively. The resolution of diabetes, hypertension, and dyslipidemia after 6 months of operation was 88.89%, 54.54%, and 50.00%, respectively.

Conclusion

LSG is safe and effective when performed by an experienced gastric cancer surgeon; however, a long-term follow-up of patients is required.

Influence of changes in body fat on clinical outcomes in a general population: a 12-year follow-up report on the Ansan-Ansung cohort in the Korean Genome Environment Study

BACKGROUND

The impact of the changes in the obesity status on mortality has not been established; thus, we investigated the long-term influence of body fat (BF) changes on all-cause deaths and cardiovascular outcomes in a general population.

METHODS

A total of 8374 participants were observed for 12 years. BF was measured at least two times using a bioimpedance method. The causes of death were acquired from the nationwide database. A major adverse cardiovascular event (MACE) was defined as a composite of myocardial infarction, coronary artery disease, stroke, and cardiovascular death. Standard deviations (SDs) were derived using a local regression model corresponding to the time elapsed between the initial and final BF measurements (SD_T) and were used to standardize the changes in BF (ΔBF/SD_T).

RESULTS

The incidence rates of all-cause death, cardiovascular death, and MACE were the highest in the participants with ΔBF/SD_T <-1 and lowest in the participants with ΔBF/SD_T ≥1. Multivariate Cox proportional hazard models adjusted for relevant covariates, including baseline obesity and physical activity, showed that the risks of all-cause deaths (hazard ratio [HR] 0.58; 95% confidence intervals [CI] 0.53-0.64), cardiovascular deaths (HR 0.63; 95% CI 0.51-0.78) and MACEs (HR 0.68; 95% CI 0.62-0.75) decreased as ΔBF/SD_T increased. Subgroup analyses showed that existing cardiovascular diseases weakened the associations between higher ΔBF/SD_T and better outcomes, while high physical activity and exercise did not impact the associations.

CONCLUSION

Increasing BF was associated with a lower risk of all-cause death, cardiovascular death, and MACE in the general population.Key messagesIncreasing body fat is associated with a lower risk of all-cause death, cardiovascular death, and major cardiovascular adverse events in a low-risk ageing general population, independently of physical activity, underlying cardiovascular disease burden, changes in muscle mass, and baseline obesity status.Fatness measured at baseline requires adjustment for the changes in fatness during the follow-up to reveal its impact on the clinical outcomes.

Granulocyte colony-stimulating factor reduces the endoplasmic reticulum stress in a rat model of diabetic cardiomyopathy

Prolonged endoplasmic reticulum (ER) stress contributes to the apoptosis of cardiomyocytes, which leads to the development of diabetic cardiomyopathy. Previously, we reported that the granulocyte colony-stimulating factor (G-CSF) reduces the cardiomyocyte apoptosis in diabetic cardiomyopathy; however, the precise mechanisms associated with this process are not yet fully understood. Therefore, in this study, we investigated whether the mechanism of the anti-apoptotic effect of G-CSF was associated with ER stress in a rat model of diabetic cardiomyopathy. Diabetic cardiomyopathy was induced in rats using a high-fat diet combined with the administration of a low-dose of streptozotocin. Diabetic rats were treated with G-CSF or saline for 5 days. Cardiac function was evaluated using serial echocardiography before and 4 weeks after treatment. The rate of cardiomyocyte apoptosis and the expression levels of proteins related to ER stress, including glucose-regulated protein 78 (GRP78), caspase-9, and caspase-12 were analyzed in the cardiac tissue. G-CSF treatment significantly reduced cardiomyocyte apoptosis in the diabetic myocardium and downregulated the expression levels of these proteins in diabetic rats treated with low-dose streptozotocin when compared to that in rats treated with saline. In addition, G-CSF treatment significantly downregulated the expression levels of proteins related to ER stress, such as GRP78, inositol-requiring enzyme-1α (IRE-1α), and C/EBP homologous protein (CHOP) in H9c2 cells under high glucose (HG) conditions. Moreover, G-CSF treatment significantly improved the diastolic dysfunction in serial echocardiography assessments. In conclusion, the anti-apoptotic effect of G-CSF may be associated with the downregulation of ER stress.

Nanoscale lattice dynamics in hexagonal boron nitride moiré superlattices

Twisted two-dimensional van der Waals (vdW) heterostructures have unlocked a new means for manipulating the properties of quantum materials. The resulting mesoscopic moiré superlattices are accessible to a wide variety of scanning probes. To date, spatially-resolved techniques have prioritized electronic structure visualization, with lattice response experiments only in their infancy. Here, we therefore investigate lattice dynamics in twisted layers of hexagonal boron nitride (hBN), formed by a minute twist angle between two hBN monolayers assembled on a graphite substrate. Nano-infrared (nano-IR) spectroscopy reveals systematic variations of the in-plane optical phonon frequencies amongst the triangular domains and domain walls in the hBN moiré superlattices. Our first-principles calculations unveil a local and stacking-dependent interaction with the underlying graphite, prompting symmetry-breaking between the otherwise identical neighboring moiré domains of twisted hBN.

Here, the authors investigate the lattice dynamics of twisted hexagonal boron nitride layers via nano-infrared spectroscopy, showing local and stacking-dependent variations of the optical phonon frequencies associated to the interaction with the graphite substrate.

Clinical Characteristics and Predictors of All-Cause Mortality in Patients with Hypertensive Urgency at an Emergency Department

Hypertensive urgency is characterized by an acute increase in blood pressure without acute target organ damage, which is considered to be managed with close outpatient follow-up. However, limited data are available on the prognosis of these cases in emergency departments. We investigated the characteristics and predictors of all-cause mortality in Korean emergency patients with hypertensive urgency. This cross-sectional study included patients aged ≥18 years who visited an emergency tertiary referral center between January 2016 and December 2019 for hypertensive urgency, which was defined as a systolic blood pressure of ≥180 mmHg and a diastolic blood pressure of ≥110 mmHg, or both, without acute target organ damage. The 1 and 3 year all-cause mortality rates were 6.8% and 12.1%, respectively. The incidence of emergency department revisits and readmission after 3 months and 1 year was significantly higher in non-survivors than in survivors. In a multivariate analysis, age ≥ 60 years (hazard ratio (HR), 16.66; 95% CI, 6.20-44.80; p < 0.001), male sex (HR, 1.54; 95% CI, 1.22-1.94; p < 0.001), history of chronic kidney disease (HR, 2.18; 95% CI, 1.53-3.09; p < 0.001), and proteinuria (HR, 1.94; 95% CI, 1.53-2.48; p < 0.001) were independent predictors of 3 year all-cause mortality. The all-cause mortality rate of hypertensive urgency remains high despite the increased utilization of antihypertensive medications. Old age, male sex, history of chronic kidney disease, and proteinuria were poor prognostic factors for all-cause mortality in patients with hypertensive urgency.

Human leukocyte antigen class-I variation is associated with atopic dermatitis: A case-control study

Atopic dermatitis (AD) is a common immune-medicated skin disease. Previous studies have explored the relationship between Human Leukocyte Antigen (HLA) allelic variation and AD with conflicting results. The aim was to examine HLA Class I genetic variation, specifically peptide binding groove variation, and associations with AD. A case-control study was designed to evaluate HLA class I allelic variation and binding pocket polymorphisms, using next generation sequencing on 464 subjects with AD and 388 without AD. Logistic regression was used to evaluate associations with AD by estimating odds ratios (95% confidence intervals). Significant associations were noted with susceptibility to AD (B*53:01) and protection from AD (A*01:01, A*02:01, B*07:02 and C*07:02). Evaluation of polymorphic residues in Class I binding pockets revealed six amino acid residues conferring protection against AD: A9F (HLA-A, position 9, phenylalanine) [pocket B/C], A97I [pocket C/E], A152V [pocket E], A156R [pocket D/E], B163E [pocket A] and C116S [pocket F]. These findings demonstrate that specific HLA class I components are associated with susceptibility or protection from AD. Individual amino acid residues are relevant to protection from AD and set the foundation for evaluating potential HLA Class I molecules in complex with peptides/antigens that may initiate or interfere with T-cell responses.

Antifungal activity of streptavidin C1 and C2 against pathogens causing Fusarium wilt

Fusarium wilt is caused by the soil-inhabiting fungus Fusarium oxysporum ff. spp. and is one of the most devastating plant diseases, resulting in losses and decreasing the quality and safety of agricultural crops. We recently reported the structures and biochemical properties of two biotin-binding proteins, streptavidin C1 and C2 (isolated from Streptomyces cinnamonensis strain KPP02129). In the present study, the potential of the biotin-binding proteins as antifungal agent for Fusarium wilt pathogens was investigated using recombinant streptavidin C1 and C2. The minimum inhibitory concentration of streptavidin C2 was found to be 16 µg ml^-1 for inhibiting the mycelial growth of F. oxysporum f.sp. cucumerinum and F. oxysporum f.sp. lycopersici, while that of streptavidin C1 was found to be 64 µg ml^-1 . Compared with the nontreated control soil, the population density of F. oxysporum f.sp. lycopersici in the soil was reduced to 49·5% and 39·6% on treatment with streptavidin C1 (500 µg ml^-1 ) and C2 (500 µg ml^-1 ), respectively. A greenhouse experiment revealed that Fusarium wilt of tomato plants was completely inhibited on soil drenching using a 50-ml culture filtrate of the streptavidin-producing strain KPP02129.

Clinical significance of subclinical atherosclerosis in retinal vein occlusion

Retinal vein occlusion (RVO) is associated with atherosclerotic cardiovascular risk factors; however, its association with the specific markers of subclinical atherosclerosis has not yet been established. To investigate this association, we compared 70 patients with RVO to 70 age- and sex-matched patients without RVO. Low-density lipoprotein cholesterol (LDL-C) levels and brachial-ankle pulse wave velocity (baPWV) were significantly higher in the RVO group than in the control group. Carotid plaques (54.3% vs. 28.6%, p = 0.004) were more frequent in the RVO group. Multivariate logistic regression analysis showed that the presence of carotid plaques (odds ratio [OR]: 3.15, 95% confidence interval [CI] 1.38–7.16, p = 0.006), as well as smoking, LDL-C level, and baPWV were associated with RVO. Additionally, a multinomial logistic regression model showed that the presence of carotid plaques (OR: 3.94, 95% CI 1.65–9.41, p = 0.002) and LDL-C level were associated with branch RVO, whereas smoking and baPWV were associated with central RVO. In conclusion, RVO was associated with subclinical atherosclerosis markers, including carotid plaques and baPWV. These results support the hypothesis that atherosclerosis contributes to the etiology of RVO and suggest the evaluation of subclinical atherosclerosis in patients with RVO.

Predictors of the Effects of Flow Diversion in Very Large and Giant Aneurysms

BACKGROUND AND PURPOSE

The treatment paradigm for very large and giant aneurysms has recently changed to flow diversion, in light of the results of the Pipeline for Uncoilable or Failed Aneurysms trial. However, the effects of flow diversion were definitely unknown. We explored this topic and identified the predictors of such effects.

MATERIALS AND METHODS

We retrospectively reviewed 51 patients with unruptured aneurysms admitted to our institution for flow diversion between February 2014 and August 2019. Patients were categorized into an effect group (no filling or remnant entry) and a no-effect group (subtotal or total filling). We evaluated the aneurysm size and shape, incorporation vessel, parent artery stenosis and curvature, stagnation of contrast medium within the aneurysm, use of balloon angioplasty, and intra-aneurysm thrombus as potential predictors of the effects of flow diversion.

RESULTS

The effect group comprised 34 patients (66.7%, 34/51; no filling, 35.3%, 18/51; and remnant entry, 31.4%, 16/51). The no-effect group comprised 17 patients (33.3%, 17/51; subtotal filling, 29.4%, 15/51; and total filling, 3.9%, 2/51). An incorporation vessel and balloon angioplasty were independent risk factors for the no-effect group in multivariate logistic regression analyses (OR = 0.13 and 0.05; 95% confidence intervals, 0.02-0.62 and 0.00-0.32; P values, .021 and .004, respectively).

CONCLUSIONS

Flow diversion is effective for very large and giant aneurysms, but the outcomes require further improvement. The results of this study show that an incorporated vessel and excessive balloon angioplasty might compromise flow diversion. This finding can help improve the outcomes of flow diversion.

Totally laparoscopic total gastrectomy using the modified overlap method and conventional open total gastrectomy: A comparative study

BACKGROUND

Although several methods of totally laparoscopic total gastrectomy (TLTG) have been reported. The best anastomosis technique for LTG has not been established.

AIM

To investigate the effectiveness and surgical outcomes of TLTG using the modified overlap method compared with open total gastrectomy (OTG) using the circular stapled method.

METHODS

We performed 151 and 131 surgeries using TLTG with the modified overlap method and OTG for gastric cancer between March 2012 and December 2018. Surgical and oncological outcomes were compared between groups using propensity score matching. In addition, we analyzed the risk factors associated with postoperative complications.

RESULTS

Patients who underwent TLTG were discharged earlier than those who underwent OTG [TLTG (9.62 ± 5.32) vs OTG (13.51 ± 10.67), P < 0.05]. Time to first flatus and soft diet were significantly shorter in TLTG group. The pain scores at all postoperative periods and administration of opioids were significantly lower in the TLTG group than in the OTG group. No significant difference in early, late and esophagojejunostomy (EJ)-related complications or 5-year recurrence free and overall survival between groups. Multivariate analysis demonstrated that body mass index [odds ratio (OR), 1.824; 95% confidence interval (CI): 1.029-3.234, P = 0.040] and American Society of Anaesthesiologists (ASA) score (OR, 3.154; 95%CI: 1.084-9.174, P = 0.035) were independent risk factors of early complications. Additionally, age was associated with ≥ 3 Clavien-Dindo classification and EJ-related complications.

CONCLUSION

Although TLTG with the modified overlap method showed similar complication rate and oncological outcome with OTG, it yields lower pain score, earlier bowel recovery, and discharge. Surgeons should perform total gastrectomy cautiously and delicately in patients with obesity, high ASA scores, and older ages.

Nicotinamide Improves Delayed Tooth Eruption in Runx2+/- Mice

Patients with cleidocranial dysplasia (CCD) caused by mutations in RUNX2 have severe dental anomalies, including delayed or absent eruption of permanent teeth. This requires painful and expensive surgical/orthodontic intervention because of the absence of medicine for this condition. Here, we demonstrate that nicotinamide, a vitamin B3 and class III histone deacetylase inhibitor, significantly improves delayed tooth eruption in Runx2^+/- mice, a well-known CCD animal model, through the restoration of decreased osteoclastogenesis. We also found that Csf1 mRNA and protein levels were significantly reduced in Runx2^+/- osteoblasts as compared with wild type whereas RANKL and OPG levels had no significant difference between wild type and Runx2^+/- osteoblasts. The nicotinamide-induced restoration of osteoclastogenesis of bone marrow-derived macrophages in Runx2^+/- mice was due to the increased expression of RUNX2 and CSF1 and increased RANKL/OPG ratio. RUNX2 directly regulated Csf1 mRNA expression via binding to the promoter region of the Csf1 gene. In addition, nicotinamide enhanced the RUNX2 protein level and transacting activity posttranslationally with Sirt2 inhibition. Taken together, our study shows the potential and underlying molecular mechanism of nicotinamide for the treatment of delayed tooth eruption by using the Runx2^+/- murine model, suggesting nicotinamide as a candidate therapeutic drug for dental abnormalities in patients with CCD.

Association between immunotherapy biomarkers and glucose metabolism from F-18 FDG PET

OBJECTIVE

To assess associations between parameters derived from F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) and mRNA expression levels of immune checkpoint biomarkers such as programmed death receptor 1 (PD-1), programmed death-ligand 1 (PD-L1), cytotoxic T-lymphocyte antigen 4 (CTLA-4) as well as tumor mutation burden (TMB) in non-small cell lung cancer (NSCLC) patients.

PATIENTS AND METHODS

Integrated data were downloaded from Genomic Data Common Data Portal. Clinical, mRNA-seq, and whole exome-seq data of lung adenocarcinoma and squamous cell carcinoma from The Cancer Genome Atlas (TCGA) database were analyzed. TMB was defined as the total number of somatic missense mutations per megabase of the genome examined. Expression levels of PD-1, PD-L1, CTLA4 mRNA and TMB were collected. Correlations between imaging parameters of glucose metabolism and the expression levels of genomic biomarkers from cancers were evaluated. Bonferroni correction (adjusted p<0.0027) was applied to reduce type 1 error.

RESULTS

Of 31 NSCLC cases, 11 cases were adenocarcinoma (LUAD) and 20 were squamous cell carcinoma (LUSC). In linear regression analysis, texture parameters such as low gray-level run emphasis (LGRE, R2=0.48, p<0.0001), short run low gray-level emphasis (SRLGE, R2=0.45, p<0.0001) and long run low gray-level emphasis (LRLGE, R2=0.41, p=0.0001) derived from gray-level run length matrix (GLRLM) showed remarkable correlation with PD-L1 mRNA expression. Expression of PD-1, CTLA-4, and TMB failed to show any significant correlation with parameters of the F-18 FDG PET/CT.

CONCLUSIONS

Texture parameters derived from PET, known to indicate glucose uptake distribution, were correlated with expression of PD-L1 mRNA but not with expression of PD-1, CTLA-4 and TMB. Thus, tumoral heterogeneity could be a surrogate marker for the identification of PD-L1 level in NSCLC.

A later menopausal age is associated with a lower prevalence of physical frailty in community-dwelling older adults: The Korean Frailty and Aging Cohort Study (KFACS)

OBJECTIVES

The aim of this study was to determine whether age at menopause is associated with physical frailty.

METHODS

This was a cross-sectional study that included 1264 women (70-84 years) from the Korean and Aging Cohort Study (KFACS) who had records of their ages at menarche and their ages at menopause and had experienced a natural menopause. We used Fried criteria to assess physical frailty status. The ages at menopause and menarche were collected using self-reported questionnaires.

RESULTS

The prevalence of physical frailty decreased by 5.3 % with each year of increase in age at menopause after adjusting for age, marital status, years of education, diabetes mellitus, hypertension, polypharmacy, hospitalizations, falls, and hormone replacement therapy (p = 0.005). The prevalence of frailty significantly decreased by 4.1 % when the reproductive span increased by a year (p = 0.019).

CONCLUSIONS

This study found that a later menopausal age was associated with a lower risk of frailty using Fried criteria. In addition, it showed that a longer reproductive span was associated with a lower prevalence of frailty.

Comparison Between Redo Endoscopic Treatment and Surgery in Patients with Locally Recurrent Gastric Neoplasms

BACKGROUND

Treatment of locally recurrent gastric neoplasms after endoscopic resection remains challenging. We investigated the efficacy and safety of treatment options for recurrent gastric neoplasms localized to the scar of previous endoscopic submucosal dissection (ESD).

METHODS

The clinicopathological characteristics and treatment outcomes of patients who underwent endoscopic treatment or surgery for recurrent gastric neoplasms between June 2010 and May 2017 were retrospectively reviewed.

RESULTS

Of the 92 patients included, 74 underwent endoscopic treatment (51 redo ESD, 23 argon plasma coagulation [APC] ablation) and 18 underwent surgery. The redo ESD procedure time was significantly longer than that of the primary ESD (31.0 versus 22.0 min, p = 0.018). Overall, adverse events occurred in 11 patients (12.0%), with the incidence being significantly higher in the surgery group (27.8% versus 8.1% in the endoscopic treatment group, p = 0.036). Local recurrence-free survival rates were 81.1% for the endoscopic treatment group (86.3% and 69.6% for redo ESD and APC groups, respectively) and 100% for the surgery group (log rank p = 0.033). Logistic regression analysis showed that tumor size > 12.5 mm (odds ratio [OR] 5.14, 95% confidence interval [CI] 1.25-26.9, p = 0.032) and tumors located in the upper two-thirds of the stomach (OR 4.43, 95% CI 1.27-16.8, p = 0.023) were associated with non-curative resection after redo ESD.

CONCLUSIONS

Endoscopic treatment could be an effective and safe alternative to surgery for selected patients with gastric neoplasms recurring at the scar of previous ESD. Especially, patients having small lesions located in the distal part of the stomach could be a good candidate for redo ESD.

Comparative outcomes of robot-assisted minimally invasive versus open esophagectomy in patients with esophageal squamous cell carcinoma: a propensity score-weighted analysis

Robots are increasingly used in minimally invasive surgery. We evaluated the clinical benefits of robot-assisted minimally invasive esophagectomy (RAMIE) in comparison with the conventional open esophageal surgery. From 2012 to 2016, 371 patients with esophageal squamous cell carcinoma underwent an Ivor Lewis or McKeown procedure at our institution. Of these, 130 patients underwent laparoscopic gastric conduit formation followed by RAMIE, whereas 241 patients underwent conventional esophageal surgery, including laparotomy and open esophagectomy (OE). We compared the short- and long-term clinical outcomes of these patients using the propensity score-based inverse probability of treatment weighting technique (IPTW). Among the early outcomes, the OE group showed a higher incidence of pneumonia (P = 0.035) and a higher requirement for vasopressors (P = 0.001). Regarding the long-term outcomes, all-cause mortality was significantly higher (P = 0.001) and disease-free survival was lower (P = 0.006) in the OE group. Wound-related problems also occurred more frequently in the OE group (P = 0.020) during the long-term follow-up. There was no statistical intergroup difference in the recurrence rates (P = 0.191). The Cox proportional-hazard analysis demonstrated that wound problems (HR 0.16, 95% CI 0.02-0.57; P = 0.017), pneumonia (HR 0.23, 95% CI 0.06-0.68; P = 0.019), and use of vasopressors (HR 0.14, 95% CI 0.08-0.25; P = 0.001) were independent predictors of mortality. RAMIE could be a better surgical option for selected patients with esophageal squamous cell carcinoma.

Optimal proximal resection margin distance for gastrectomy in advanced gastric cancer

BACKGROUND

The conventional guidelines to obtain a safe proximal resection margin (PRM) of 5-6 cm during advanced gastric cancer (AGC) surgery are still applied by many surgeons across the world. Several recent studies have raised questions regarding the need for such extensive resection, but without reaching consensus. This study was designed to prove that the PRM distance does not affect the prognosis of patients who undergo gastrectomy for AGC.

AIM

To investigate the influence of the PRM distance on the prognosis of patients who underwent gastrectomy for AGC.

METHODS

Electronic medical records of 1518 patients who underwent curative gastrectomy for AGC between June 2004 and December 2007 at Asan Medical Center, a tertiary care center in Korea, were reviewed retrospectively for the study. The demographics and clinicopathologic outcomes were compared between patients who underwent surgery with different PRM distances using one-way ANOVA and Fisher’s exact test for continuous and categorical variables, respectively. The influence of PRM on recurrence-free survival and overall survival were analyzed using Kaplan-Meier survival analysis and Cox proportional hazard analysis.

RESULTS

The median PRM distance was 4.8 cm and 3.5 cm in the distal gastrectomy (DG) and total gastrectomy (TG) groups, respectively. Patient cohorts in the DG and TG groups were subdivided into different groups according to the PRM distance; ≤ 1.0 cm, 1.1-3.0 cm, 3.1-5.0 cm and > 5.0 cm. The DG and TG groups showed no statistical difference in recurrence rate (23.5% vs 30.6% vs 24.0% vs 24.7%, P = 0.765) or local recurrence rate (5.9% vs 6.5% vs 8.4% vs 6.2%, P = 0.727) according to the distance of PRM. In both groups, Kalpan-Meier analysis showed no statistical difference in recurrence-free survival (P = 0.467 in DG group; P = 0.155 in TG group) or overall survival (P = 0.503 in DG group; P = 0.155 in TG group) according to the PRM distance. Multivariate analysis using Cox proportional hazard model revealed that in both groups, there was no significant difference in recurrence-free survival according to the PRM distance.

CONCLUSION

The distance of PRM is not a prognostic factor for patients who undergo curative gastrectomy for AGC.

Interleukin-1β Stimulates the Production of Extracellular Matrix in Cultured Human Peritoneal Mesothelial Cells

Objective

To investigate the effect of interleukin-1β (IL-1β) on the production of extracellular matrix in cultured human peritoneal mesothelial cells (HPMCs).

Design

Cultured HPMCs were treated with or without IL-1β. Cell morphology was observed. The expression of fibronectin, α1(I) procollagen, and transforming growth factor-β1 (TGFβ1) mRNAs was measured by Northern blot analysis. The cell surface expression of fibronectin and type I collagen was evaluated by immunofluorescent staining. Fibronectin and type I collagen in culture supernatant were measured by inhibition ELISA.

Results

Interleukin-1β induced morphologic change in HPMCs from a cuboidal epithelioid shape into an elongated fibroblastoid shape. The elongated cells were positive for cytokeratin although they had a fibroblastoid appearance. Treatment of HPMCs with IL-1β resulted in increased expression of both fibronectin and α1(I) procollagen mRNA in dose- and time-dependent manners. Immunofluorescent staining showed strong and diffuse cytoplasmic expression of fibronectin and type I collagen in the cells treated with IL-1β, whereas only weak perinuclear cytoplasmic staining was noted in the cells on media alone. The concentrations of secreted fibronectin and type I collagen in culture supernatant were significantly higher in the cells treated with IL-1β than in the control cells. IL-1β also stimulated the expression of TGFβ1 mRNA. However, IL-1β-induced fibronectin mRNA expression was only partially blocked by neutralizing anti-TGFβ antibody.

Conclusion

Interleukin-1β stimulated the production of extracellular matrix in cultured HPMCs along with the induction of morphologic changes. This may play a role in the development of peritoneal fibrosis caused by peritonitis or bioincompatible dialysate in continuous ambulatory peritoneal dialysis patients.

The Association of Gait Speed and Frontal Lobe among Various Cognitive Domains: The Korean Frailty and Aging Cohort Study (KFACS)

OBJECTIVE

The aim of this study was to determine how gait speed and frontal lobe functionsin community-dwelling older adults in Korea.

DESIGN

This was a cross-sectional study.

SETTING

The study used data from the Korean Frailty and Aging Cohort Survey (KFACS), a multi-center longitudinal study addressing 10 centers across urban, rural, and suburban communities in Korea, between 2016 and 2017.

PARTICIPANTS

A total of 1552 older adults who underwent both gait speed tests and cognitive functions tests during the investigation of the KFACS.

MEASUREMENTS

Gait speed was assessed by asking participants to walk from a starting point to a point 4 meters away at a normal gait. Cognitive functions were evaluated using various standardized cognitive functions tests.

RESULTS

Gait speed was slower when participants were older or less educated The percentage of women, higher BMI, people with lower incomes, singles, smokers, and drinkers was high in the slower gait group. Also, all cognitive function scores were low and depression score was high in the group with slower walking speed. The slower walking speed showed low physical activity score and high prevalence of hypertension, osteoarthritis and osteoporosis. Among the seven cognitive functions (MMSE, memory, TMT, Recall, Recognition, digit span, and Fab), only TMT showed no significant difference between different gait speed groups. The other six cognitive functions showed higher results in the fastest gait speed group (T3), Participants in middle gait speed group (T2) also showed higher results in five of the seven cognitive function scores as well (Memory, Recall, Recognition, digit span, and Fab).

CONCLUSION

In this study, we found correlation between the slower gait speeds and the decrease in cognitive function, and especially the frontal lobe dysfunction was most prominent of all cognitive dysfunctions.

P4390Sex-specific association between secondhand smoke exposure and metabolic syndrome in 118,609 Korean never-smokers verified by both self-reported questionnaire and cotinine

Background

No study has reported the relationship between secondhand smoke (SHS) exposure and metabolic syndrome (MetS) in self-reported never-smokers verified by nicotine metabolite.

Purpose

The aim of this study is to determine the relationship between SHS exposure and MetS in self-reported and cotinine-verified never-smokers.

Methods

A total of 118,609 self-reported and cotinine-verified never-smokers (38,385 men; age 34.8±7.1 years) who participated in Kangbuk Samsung Health Study (KSHS) and Kangbuk Samsung Cohort study (KSCS) between 2011 and 2016 were included. Cotinine-verified never-smoker was defined as individuals having urinary cotinine <50 ng/mL. SHS exposure was defined as having experienced passive smoking indoors at home or the workplace.

Results

The prevalence of SHS exposure in the overall population was 22.6%, with rates of 27.4% for males and 20.3% for females (p<0.001). The overall prevalence of MetS was 6.8%; the prevalence in males was higher than that in females (10.7% versus 4.9%, p<0.001). In both males and females, the prevalence of MetS in group with SHS exposure was higher than that in group without SHS exposure (11.3% versus 10.4%, p=0.010 for males; 5.8% versus 4.6%, p<0.001 for females). However, there was significant gender interaction for the relationships between SHS exposure and MetS (p for interaction=0.010). A multivariate regression model was adjusted for the baseline variables including age, body mass index, frequency of alcohol drinking and vigorous exercise, blood urea nitrogen, creatinine, uric acid, total cholesterol, LDL cholesterol, and hsCRP. The results showed that SHS exposure only in females was associated with MetS (odds ratio [95% confidence interval], 1.17 [1.06, 1.29] for females; 1.02 [0.94, 1.11] for males). In particular, females with SHS exposure of ≥1 hours/day, ≥3 times/week, and ≥10 years increased the prevalence of MetS compared to those without SHS exposure (1.21 [1.02, 1.45], 1.30 [1.14, 1.49], and 1.12 [0.99, 1.28], respectively.

Conclusions

This study showed that the SHS exposure in females was significantly associated with MetS in self-reported never-smokers with low urinary cotinine levels (<50 ng/mL), suggesting that more active anti-smoking programs in the home and public are needed to reduce the risk of MetS.

4947Association between secondhand smoke exposure and diabetes mellitus in 131,724 Korean never smokers using self-reported questionnaire and cotinine: gender differences

Background

No study has reported the relationship between secondhand smoke (SHS) exposure and diabetes mellitus in self-reported never-smokers verified by nicotine metabolite.

Purpose

The aim of this study is to determine the relationship between SHS exposure and diabetes mellitus in self-reported and cotinine-verified never-smokers.

Methods

A total of 131,724 self-reported and cotinine-verified never-smokers (42,681 men; age 35.0±7.1 years) enrolled in Kangbuk Samsung Health Study (KSHS) and Kangbuk Samsung Cohort study (KSCS) between 2011 and 2016 were included. Cotinine-verified never-smoker was defined as individuals having urinary cotinine <50 ng/mL. SHS exposure was defined as having experienced passive smoking indoors at home or the workplace. Diabetes mellitus was defined as having a fasting blood glucose level of ≥7.0mmol/L, hemoglobin A1C ≥6.5% or taking anti-diabetic medication(s).

Results

The frequency of diabetes mellitus in the overall population was 1.6%; the frequency in males was higher than that in females (2.2% versus 1.3%, p<0.001). The overall frequency of SHS exposure was 22.9%, with rates of 27.6% for males and 20.7% for females (p<0.001). The frequency of diabetes mellitus in group with SHS exposure was higher than that in group without SHS exposure only in females (1.8% versus 1.2%, p<0.001 for females; 2.2% versus 2.2%, p=0.956 for males). There was significant gender interaction for the relationships between SHS exposure and diabetes mellitus (p for interaction <0.001). A multivariate regression model was adjusted for the baseline variables including age, waist circumference, body mass index, frequency of alcohol drinking and vigorous exercise, systolic blood pressure, blood urea nitrogen, creatinine, uric acid, total cholesterol, HDL cholesterol, LDL cholesterol, triglyceride, and hsCRP. Only in females, SHS exposure was significantly associated with diabetes mellitus (odds ratio [95% confidence interval], 1.40 [1.20, 1.65] for females; 1.00 [0.85, 1.19] for males). Higher frequency and longer duration of SHS exposure were also significantly associated with diabetes mellitus (p<0.001) for all trends). In particular, females with SHS exposure of ≥1 hours/day, ≥3 times/week, and ≥10 years increased the risk of diabetes mellitus 51–64% above that for those without SHS exposure (1.64 [1.25, 2.13], 1.51 [1.21, 1.87], and 1.59 [1.30, 1.95], respectively.

Conclusions

This study showed that the SHS exposure in females was significantly associated with diabetes mellitus in self-reported never-smokers verified by urinary cotinine and this association was proportional to the frequency and duration of SHS exposure. These findings suggest the importance of banning smoking in the home and public to reduce the risk of diabetes mellitus.

Acknowledgement/Funding

None

Independent effect of physical activity and resting heart rate on the incidence of atrial fibrillation in the general population

While physical activity (PA) may influence resting heart rate (RHR), and a low RHR may be a risk factor for atrial fibrillation (AF), controversy exists regarding the association between PA and development of AF. Using data from a Korean, prospective population cohort, we investigated the independent effect of PA and RHR on the incidence of AF in the general population. A total of 8,811 participants aged 40-69 years were analyzed. Total PA assessed based on questionnaires was divided into quartiles, with the lowest to the highest being Q1, Q2, Q3, and Q4. During a median follow-up of 139 months, AF developed in 167 participants (1.9%). Q3 of total PA was associated with a significantly lower risk of AF than Q1 even after adjusting for RHR as a covariate, but Q4 was not. The risk of AF was higher in participants with RHR < 60 bpm than in those with RHR 70-85 bpm, and the significance persisted after adjusting for PA as a covariate. This study showed that a moderate amount of total PA was associated with a lower risk of incident AF independent of RHR and that low RHR was an independent risk factor for AF in the general Korean population.

Role of EphA2-PI3K signaling in vasculogenic mimicry induced by cancer-associated fibroblasts in gastric cancer cells

Although erythropoietin-producing human hepatocellular receptor A2 (EphA2) signaling serves an important role in the tumor microenvironment, its contribution to vasculogenic mimicry (VM) formation in gastric cancer cells remains unclear. The aim of the present study was to investigate the role of EphA2 in VM formation induced by cancer-associated fibroblasts (CAFs). The conditioned medium of CAFs (CAF-CM) was prepared from 12 patients with gastric adenocarcinoma. VM was evaluated by the number of tubules and intersections in gastric cancer cells following CAF-CM treatment. The role of EphA2-phosphoinositide 3-kinase (PI3K) in VM was investigated using EphA2-targeted small interfering (si)RNAs (siEphA2), EphA2 inhibitors and PI3K-inhibitors. CAF-CM-induced VM formation was significantly associated with high protein expression levels of EphA2. EphA2 inhibitor and siEphA2 manipulation significantly decreased VM formation by CAF-CM. In siEphA2 cells, decreased expression levels of VM-associated proteins were observed. CAF-CM-induced VM formation was blocked by the PI3K-inhibitor. In conclusion, CAFs facilitate VM formation via EphA2-PI3K signaling in gastric cancer cells. Thus, EphA2-PI3K signaling may be required for CAF-promoted VM formation during gastric tumorigenesis.