Challenges of using body bags for COVID-19 deaths from the healthcare provider perspective - a qualitative study

BACKGROUND

During the COVID-19 pandemic, numerous issues regarding end-of-life care for COVID-19 patients have been discussed. Among these issues, challenges related to the use of body bags following the death of COVID-19 patients have been suggested. This study aimed to identify the challenges faced by healthcare professionals (HCPs) when using body bags after the death of patients infected with COVID-19 in medical settings.

METHODS

We conducted a qualitative descriptive study with semistructured in-depth interviews using inductive thematic analysis. From August to December 2021, we interviewed nurses and doctors who provided end-of-life care to COVID-19 patients focusing on their experiences with the use of body bags for the deceased.

RESULTS

Of the 25 interviewees who mentioned body bag use, 14 were nurses (56%) and 13 were women (52%). The mean interview length was 52.0 min (SD 9.6 min). Challenges associated with body bag use were classified into four themes with eight categories: preserving the dignity of the deceased, consideration for the bereaved saying a final goodbye to a loved one in a body bag, the physical and emotional impact on HCPs, and diverse opinions on body bag use.

CONCLUSION

Our findings include ethical concerns about the dignity of the deceased, empathy for the grief of bereaved families, and the emotional and physical distress experienced by HCPs struggling with the recommendation to use body bags based on limited evidence. The diverse perspectives of HCPs in this study highlight potential issues that developers should consider when formulating more appropriate and acceptable guidelines/guidance and policies.

Evaluation of preventive care for swallowing difficulty through policy changes in Japanese long-term care insurance: analysis of a nationwide claims dataset for long-term care insurance

BACKGROUND

Swallowing/feeding difficulty is a serious hidden health problem in the older population. Although oral intake services based on the degree of this difficulty have been provided and revised in Japanese public long-term care (LTC) insurance since 2006, their implementation has not been examined. We evaluated the impact of policy changes on these services.

METHODS

The nationwide database of LTC service uses in Japan was analysed for three oral intake services: Enhanced Oral Function in daycare facilities whose users were slightly disabled, Maintenance of Oral Ingestion and Transition to Oral Ingestion from tube feeding in residential facilities. Data were extracted for each June from 2015 to 2020 when monthly usage of these services was aligned and each June from 2009 to 2020 for the proportion of users according to LTC insurance certification. The major policy changes were the addition of municipal provision in Enhanced Oral Function and a requirement for multidisciplinary collaboration in Maintenance of Oral Ingestion in 2015. The impact of the medical fee reduction for developing percutaneous gastro-tubing to Transition to Oral Ingestion was also examined.

RESULTS

Between 2015 and 2020, the use of Enhanced Oral Function and Maintenance of Oral Ingestion increased and Transition to Oral Ingestion decreased, resulting in a total increase in use of 275,000 times or approximately 5,000 times per 100,000 among all older adults with LTC insurance certification. Concerning the proportion of users' disability status, the major users of Enhanced Oral Function in 2020 were slightly disabled and independent older adults (70%, up from 55% to 2009). Regarding the major users of Maintenance of Oral Ingestion between 2013 and 2020, care-need level 5 (most severe) decreased by 11%, whereas the total of care-need levels 4 and 3 increased by 9%. The use of Transition to Oral Ingestion, which had been declining, showed a further decline after reduction of the medical fee for percutaneous gastro-tubing in 2014.

CONCLUSIONS

Due to policy changes, Enhanced Oral Function and Maintenance of Oral Ingestion have increased in the number of use among slightly disabled persons. However, this increase may be insufficient given the hidden swallowing/feeding difficulty.

Development and assessment of a vaccine administration training course for medical students

BACKGROUND

Vaccine administration skills are very important for physicians, especially in the era of global pandemics. However, medical students have reported that practical sessions to develop these skills are insufficient. Therefore, the aim of our study was to develop a vaccination training course for medical students. We also examined its educational effectiveness.

METHODS

5th- and 6th-year medical students at the University of Tokyo were recruited to attend the vaccine administration training course in 2021. These students were our study participants. Our course consisted of an orientation part, which included a lecture on the indications, adverse events, and vaccination techniques of flu vaccines and practice on a simulator, and a main part in which the staff of the University of Tokyo Hospital were actually vaccinated. Before and after the main part of the course, study participants completed an online questionnaire that assessed their confidence in vaccine administration technique through a five-point Likert scale. We also surveyed their feedback about the course content and process. At the beginning and end of the main part, their technical competence in vaccination was assessed by two independent doctors. These doctors used a validated checklist scale (ranging from 16 to 80) and a global rating scale (ranging from 0 to 10). We used their mean scores for analysis. The quantitative data were analyzed through the Wilcoxon signed-rank test. For the qualitative data of the questionnaire, thematic analysis was conducted.

RESULTS

All 48 course participants participated in our study. Participants' confidence in vaccination technique (Z = -5.244, p < 0.05) and vaccination skill significantly improved (checklist rating: Z = -5.852, p < 0.05; global rating: Z = -5.868, p < 0.05). All participants rated the course as, "overall educational." Our thematic analysis identified four emerging themes: interest in medical procedures, efficacy of supervision and feedback, efficacy of "near-peer" learning, and very instructive course.

CONCLUSIONS

In our study, we developed a vaccine administration course for medical students, assessed their vaccination techniques and confidence in those techniques, and investigated their perceptions of the course. Students' vaccination skills and confidence improved significantly after the course, and they positively evaluated the course based on a variety of factors. Our course will be effective in educating medical students about vaccination techniques.

Current perception of social accountability of medical schools in Japan: A qualitative content analysis

INTRODUCTION

The concept of social accountability in medical schools is globally accepted, but data regarding Japanese medical schools are lacking and unclear. This study aimed to elucidate the perception of social accountability of medical schools in Japan and compare this to global frameworks.

METHODS

A document on Japanese medical accreditation standards (Basic Medical Education: Japanese Specifications WFME Global Standards for Quality Improvement) was used for this study. We included 45 medical schools in a qualitative content analysis done via inductive category formation. The documents were also assessed using the social obligation scale.

RESULTS

Three main categories and 15 categories were identified. The three main categories were as follows: Issues in society, Quality assurance of medical school, and Improvement of individual quality. Most categories were common to those in global frameworks, but some were characteristic of the Japanese context. The distribution of schools on the social obligation scale in six elements varied mainly 'from responsibility to responsiveness' or equal unless the elements were promoted by national policy.

CONCLUSIONS

The social accountability of Japanese medical schools is mostly common with the global frameworks. Our findings will help the social accountability of medical schools to become better understood and developed beyond contextual borders.

Axonal damage and astrocytosis are biological correlates of grey matter network integrity loss: a cohort study in autosomal dominant Alzheimer disease

Brain development and maturation leads to grey matter networks that can be measured using magnetic resonance imaging. Network integrity is an indicator of information processing capacity which declines in neurodegenerative disorders such as Alzheimer disease (AD). The biological mechanisms causing this loss of network integrity remain unknown. Cerebrospinal fluid (CSF) protein biomarkers are available for studying diverse pathological mechanisms in humans and can provide insight into decline. We investigated the relationships between 10 CSF proteins and network integrity in mutation carriers (N=219) and noncarriers (N=136) of the Dominantly Inherited Alzheimer Network Observational study. Abnormalities in Aβ, Tau, synaptic (SNAP-25, neurogranin) and neuronal calcium-sensor protein (VILIP-1) preceded grey matter network disruptions by several years, while inflammation related (YKL-40) and axonal injury (NfL) abnormalities co-occurred and correlated with network integrity. This suggests that axonal loss and inflammation play a role in structural grey matter network changes.

Key points

Abnormal levels of fluid markers for neuronal damage and inflammatory processes in CSF are associated with grey matter network disruptions.The strongest association was with NfL, suggesting that axonal loss may contribute to disrupted network organization as observed in AD.Tracking biomarker trajectories over the disease course, changes in CSF biomarkers generally precede changes in brain networks by several years.

Radiation-Induced Changes Associated with Obliteration of Brain AVMs after Repeat Radiosurgery

BACKGROUND AND PURPOSE

Radiation-induced changes can occur after stereotactic radiosurgery for brain AVMs, potentially causing symptomatic complications. We evaluated the incidence of such changes and the efficacy of repeat gamma knife radiosurgery for incompletely obliterated AVMs.

MATERIALS AND METHODS

We retrospectively evaluated 150 patients who underwent gamma knife radiosurgery for AVMs between 2002 and 2020; twenty-five underwent further radiosurgical procedures for incompletely obliterated AVMs. We recorded the median margin doses at the first (median, 20 Gy; range, 12-23 Gy; AVM volume, 0.026-31.3 mL) and subsequent procedures (median, 18 Gy; range, 12-23 Gy; AVM volume, 0.048-9.2 mL).

RESULTS

After the first treatment, radiologic radiation-induced changes developed in 48 (32%) patients, eight of whom had symptomatic changes. After repeat gamma knife radiosurgery, 16 of 25 patients achieved complete AVM obliteration (64%). The development of radiation-induced changes after the first treatment was significantly associated with successful obliteration by subsequent radiosurgery (OR = 24.0, 95% CI 1.20-483, P  = .007). Radiation-induced changes occurred in only 5 (20%) patients who underwent a second gamma knife radiosurgery, one of whom experienced transient neurologic deficits. Between the first and repeat gamma knife radiosurgery procedures, there was no significant difference in radiologic and symptomatic radiation-induced changes (P  = .35 and P  = 1.0, respectively).

CONCLUSIONS

Radiation-induced changes after the first gamma knife radiosurgery were associated with AVM obliteration after a repeat procedure. The risk of symptomatic radiation-induced changes did not increase with retreatment. When the first procedure fails to achieve complete AVM obliteration, a favorable outcome can be achieved by a repeat gamma knife radiosurgery, even if radiation-induced changes occur after the first treatment.

Providing End-of-Life Care for Patients Dying of COVID-19 and Their Families in Isolated Death During the Pandemic in Japan: The Providing End-of-life Care for COVID-19 Project

BACKGROUND

Death resulting from COVID-19 in a hospital during the pandemic has meant death in isolation. Although many health care providers (HCPs) have struggled with end-of-life (EOL) care for these patients, the various strategies across hospitals are not well known.

RESEARCH QUESTION

What EOL care did HCPs give patients dying of COVID-19 and their families in hospitals during the COVID-19 pandemic? What were the key themes in care?

STUDY DESIGN AND METHODS

This qualitative study used individual, semistructured, internet, and face-to-face interviews. We recruited HCPs who provided EOL care to patients with COVID-19 dying in hospitals and their families. Purposive sampling was used through the academic networks at the School of Public Health, Kyoto University. Anonymized verbatim transcripts were analyzed thematically.

RESULTS

Fifteen doctors and 18 nurses from 23 hospitals in 13 regions across Japan participated; 16 participants (48%) were women, with an age range of 20 to 59 years (most were 30-39 years of age). Participants described 51 strategies, including providing physical and psychological-spiritual care, making connections, providing death care, and arranging care environments and bereavement care for patients and their families. Four themes emerged as prominent efforts in COVID-19 EOL care: maintaining relationships with isolated patients, connecting patients and families, sharing decision-making in isolation, and creating humanistic episodes.

INTERPRETATION

Proper application and awareness of the four themes may help HCPs to implement better EOL care. To compensate for limited memories resulting from isolation and rapid progression of the disease, communicating and creating humanistic episodes are emphasized. ICU diaries and the HCPs' arrangements based on cultural funerary procedures could be provided as grief care for the family and to build trust. EOL education and building partnerships among palliative care staff and nonmedical personnel on a regular basis may enhance the capacity to deliver the necessary support for EOL care.

Impact of amino acid 233 in Tax on bovine leukemia virus infection in Japanese Black cattle

Bovine leukemia virus (BLV) is an economically important pathogen that both causes fatal enzootic bovine leukosis (EBL) and reduces lifetime milk production, reproductive efficiency, carcass weight, and longevity in dairy cows. The virus can be divided into two categories based on the amino acid at position 233 in Tax protein, which activates viral transcription and probably plays crucial roles in leukemogenesis. We recently reported that early-onset EBL in Japanese Black (JB) cattle was frequently caused by L233-Tax-carrying virus. This study examined the impact of BLV infection, the proviral load (PVL), and amino acid 233 in Tax on the outcomes of JB cattle. We measured PVL in cattle enrolled between February 2016 and December 2018, determined the Tax type of the isolates, and performed follow-up until March 2022. The results demonstrated that BLV infection increased the risk of involuntary culling and mortality in JB cattle in a PVL-dependent manner. Infection with L233-Tax-carrying virus increased the likelihood of mortality by 1.6-fold compared with the effects of P233-Tax-carrying virus infection. Intrauterine and perinatal infections were frequently caused by L233-Tax-carrying virus, and these infections were likely to influence the early onset of EBL in JB cattle. Conversely, breeding cows infected with P233-Tax-carrying virus were often eliminated by involuntary culling. These findings indicate that amino acid 233 in Tax has importance in terms of preventing economic loss attributable to EBL in JB cattle.

Clinical features and lipid profiles of plaque erosion over lipid rich plaque versus fibrous plaque

Backgrounds and aims

Plaque erosion (PE) which is one of the most common causes of acute coronary syndrome (ACS) can occur over fibrous plaque or lipid-rich plaque (LRP) according to pathological reports. Whereas in plaque rupture (PR) the main cause of ACS, underlying plaque is basically LRP with thin fibrous cap. We aimed to investigate the clinical features and lipid profiles of PE with or without LRP in comparison to PR.

Methods

A total of 165 statin-naïve patients with ACS who underwent percutaneous coronary intervention using optical coherence tomography and met the criteria for PR or PE were included. LRP was defined as a plaque with lipid having the maximal lipid arc (&gt;180°). Culprit lesions were categorized into the PR, PE with/without LRP [PE(LRP), PE(Fibrous), respectively).

Results

The prevalence of PR, PE(LRP), and PE(Fibrous) was 104 (63.0%), 42 (25.5%), and 19 (11.5%), respectively. Patients with PR and PE(LRP) had significantly higher peak creatine kinase (1338, 1733, 214 U/L, respectively, P&lt;0.01) and more prevalence of ST-elevation myocardial infarction (71.2, 78.6, 21.1%, respectively, P&lt;0.01) than PE(Fibrous).

Overall, the levels of the various lipid profiles were mostly comparable between PE(Lipid) and PR but different in PE(Fibrous). The levels of small-dense low-density lipoprotein cholesterol was significantly greater in PR and PE(LRP) than in PE(Fibrous) (39.0, 36.6, 25.7 mg/dL, respectively, P=0.02).

Conclusion

PE(LRP) had substantially different clinical features and lipid profiles compared to PE(Fibrous) showing some similarity to those of PR.

Funding Acknowledgement

Type of funding sources: None.

MR Imaging Detection of CNS Lesions in Tuberous Sclerosis Complex: The Usefulness of T1WI with Chemical Shift Selective Images

BACKGROUND AND PURPOSE

CNS lesions of tuberous sclerosis complex are diagnosed mainly by T2WI, FLAIR, and sometimes T1WI with magnetization transfer contrast. The usefulness of T1WI with chemical shift selective images was recently reported in focal cortical dysplasia type IIb, which has histopathologic and imaging features similar to those of tuberous sclerosis complex. We investigated the usefulness of the T1WI with chemical shift selective images in detecting CNS lesions of tuberous sclerosis complex.

MATERIALS AND METHODS

We retrospectively reviewed 25 consecutive patients with tuberous sclerosis complex (mean age, 11.9 [SD, 8.9] years; 14 males) who underwent MR imaging including T1WI, T1WI with magnetization transfer contrast, T1WI with chemical shift selective, T2WI, and FLAIR images. Two neuroradiologists assessed the number of CNS lesions in each sequence and compared them in 2 steps: among T1WI, T1WI with magnetization transfer contrast and T1WI with chemical shift selective images, and among T2WI, FLAIR, and T1WI with chemical shift selective images. We calculated the contrast ratio of the cortical tubers and of adjacent normal-appearing gray matter and the contrast ratio of radial migration lines and adjacent normal-appearing white matter in each sequence and compared them.

RESULTS

T1WI with chemical shift selective images was significantly superior to T1WI with magnetization transfer contrast for the detection of radial migration lines and contrast ratio of radial migration lines. There was no significant difference between T1WI with chemical shift selective images and T1WI with magnetization transfer contrast for the detection of cortical tubers and the contrast ratio of the cortical tubers. Both T2WI and FLAIR were statistically superior to T1WI with chemical shift selective images for the detection of cortical tubers. T1WI with chemical shift selective images was significantly superior to T2WI and FLAIR for the detection of radial migration lines.

CONCLUSIONS

The usefulness of T1WI with chemical shift selective images in detecting radial migration lines was demonstrated. Our findings suggest that the combination of T1WI with chemical shift selective images, T2WI, and FLAIR would be useful to evaluate the CNS lesions of patients with tuberous sclerosis complex in daily clinical practice.

De-Training Effects Following Leucine-Enriched Whey Protein Supplementation and Resistance Training in Older Adults with Sarcopenia: A Randomized Controlled Trial with 24 Weeks of Follow-Up

OBJECTIVES

This study aimed to evaluate the effectiveness of de-training after a combined intervention of leucine-enriched whey protein supplementation and resistance training on skeletal muscle mass and strength in older adults with sarcopenia.

DESIGN

A randomized controlled trial.

SETTING

A community in Hyogo, Japan.

PARTICIPANTS

The study included older adults aged ≥ 65 years who were screened for sarcopenia at the Care Center from, a community in Hyogo, Japan. The participants were randomly allocated to one of three groups: whey protein supplementation after resistance training (RT + PRO; n = 27), resistance training only (RT; n = 27), and whey protein supplementation only (PRO; n = 27).

INTERVENTIONS

An intervention program was conducted over a period of 24 weeks. The program included RT and/or PRO supplementation twice a week for 24 weeks, followed by a de-training period for another 24 weeks. PRO supplementation included 11.0 g of protein and 2,300 mg of leucine. The total energy and protein intake amounts for the participants in all groups were controlled to achieve at least 30 kcal/kg ideal body weight (IBW)/day and 1.2 g/kg IBW/day, respectively, during the intervention and de-training periods.

MEASUREMENTS

The primary outcomes, such as mean change of appendicular skeletal muscle mass index (ΔASMI), and secondary outcomes, such as handgrip strength (ΔHGS), were measured at baseline, the end of intervention, and at 12 and 24 weeks of de-training.

RESULTS

Compared to baseline, ASMI and HGS increased significantly at the end of the intervention period in the RT+PRO group (ASMI and HGS, p < 0.01); however, there were no significant differences in ΔASMI and ΔHGS between each group. At 24 weeks of the de-training period, ΔASMI and ΔHGS were higher in the RT + PRO group than in the RT group (p < 0.05 and p < 0.01, respectively).

CONCLUSION

We demonstrated that combined intervention of RT and PRO showed long-term maintenance in treating sarcopenia than RT only at 24 weeks after de-training. Therefore, PRO intake after RT may be useful in the treatment of sarcopenia in older adults.

Examination of the acute efficacy and safety about aggressive use of tolvaptan for early rising after admission in super-elder patients with congestive heart failure

Background

From August 2015, for shortening of hospitalization period through efficient medical care in acute phase, we had introduced a unique clinical pathway (PATH) for congestive heart failure (CHF) cases. In PATH, since immediate taking of Tolvaptan, which is an strong oral diuretic and approver for use in the treatment of CHF cases since 2010 in Japan, after admission is specified, early diuresis makes it possible to achieve early rising from bed and streamline each medical care such as oxygen inhalation, continuous infusion, and urethral catheterization. Early rising from bed is particularly important for super-elder CHF patients who merge often frail. On the other hand, for super-elder CHF patients, it is feared that aggressive use of Tolvaptan may frequently cause dehydration, renal damage caused by it, or hypernatremia, which is a peculiar side effect about the drug.

Purpose

In this study, we examined the usefulness and safety of active use of Tolvaptan by introducing PATH in patients with super-elder CHF patients.

Methods

We set up three groups, NE group consist of 37 CHF cases (90 years old or over) who admitted in our hospital before (without) introduction of PATH between April 2014 and July 2015, PE group consist of 130 CHF cases (90 years old or over) and PY group consist of 466 CHF cases (under 90 years old) who ware admitted with introduction of PATH between August 2015 and July 2020. And in each group, we investigated various medical conditions in their acute phase after admission and the incidence of adverse events related to oral administration of tolvaptan, and examined the differences between three groups.

Results

Between NE group and PE group, there were no significant differences in mean age, pre-hospital living status, or clinical status at admission (Figure 1). But due to lean and efficient CHF care, the average length of hospitalization period was significantly shorter in PE group. And, in PE group, each medical care was performed as efficiently as in PY group, but the progression of renal damage or hypernatremia that required unscheduled discontinuation of tolvaptan use occurred more frequently in PE group (Figure 2).

Conclusions

Aggressive Tolvaptan use through our unique clinical pathway for congestive heart failure cases seemed to be useful even in super-elder patients. Although we thought that the safety of active use of tolvaptan for super-elder patients was well tolerated considering the results of this study, the incidence of adverse events such as hypernatremia was clearly higher in super-elder patients than in non-super-elder patients. It seemed that we should pay close attention to the clinical data of super-elder patients after introduction of tolvaptan.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Contributions of small dense LDL and oxidized LDL on the formation of neoatherosclerosis in patients under statin treatment

Aim

In-stent neoatherosclerosis (NA) has emerged as an important contributing factor to late stent failure and cardiovascular events. The aim of this study was to investigate whether lipid markers are associated with NA using optical coherence tomography (OCT) after percutaneous coronary intervention (PCI) in patients with coronary artery disease under well-controlled low density lipoprotein cholesterol (LDL-c) on statin treatment.

Methods

We enrolled consecutive 115 patients under statin treatment who underwent PCI with current-generation drug-eluting stent for acute and chronic coronary syndrome. OCT image and various lipid markers were obtained at 1-year for scheduled research assessment. NA was defined as a lipid laden neointima or calcified neointima. Both small dense LDL-c (sd-LDL-c) and remnant lipoprotein cholesterol (RL-c) were measured using direct homogenous assay.

Results

During an average follow-up of 13 months, NA was observed in 14 (13.6%) patients. Not LDL-c but sd-LDL-c, Malondialdehyde-modified LDL (MDA-LDL) as oxidized LDL and (RL-c) were significantly higher in patients with NA. The optimal threshold values of sd-LDL-c, MDA-LDL and RL-c for predicting NA according to receiver operating characteristics analysis were 32.3 mg/dl, 91.0 U/L, and 3.3 mg/dL, respectively. On multivariate logistic regression analysis, sd-LDL-c (≥32.3 mg/dL) and MDA (≥91.0 U/L) were significantly associated with NA (odds ratio [OR]:13.62, p=0.016, OR: 12.68, p=0.01, respectively).

Conclusions

In statin-treated patients, sd-LDL-c and MDA-LDL but not LDL-c might be useful biomarkers to identify the formation of NA at 1 years after PCI. Aggressive reduction of these atherogenic LDL may have a potential to prevent the formation of NA.

Funding Acknowledgement

Type of funding sources: None.

Higher plasma level of small dense low-density lipoprotein cholesterol in ST-segment-elevation myocardial infarction patients with plaque rupture

Aim

The aim of this study was to compare small dense low-density lipoprotein cholesterol (sd-LDL-c) and various lipid markers between patients exhibiting plaque rupture (PR) in the culprit lesions evaluated by optical coherence tomography (OCT) imaging and those without PR in ST-segment elevation myocardial infarction (STEMI) patients.

Methods

We studied consecutive 60 de novo culprit lesions in 60 patients with STEMI who underwent pre-intervention OCT. PR was defined as a plaque containing a cavity that had overlying residual fibrous caps. Plasma sd-LDL-c was measured directly by homogeneous assay at the time of primary percutaneous coronary intervention.

Results

The patients were classified into PR (n=40, 66.7%) or non-PR (n=20, 33.3%). There were no significant differences in low-density lipoprotein cholesterol (LDL-c), non-high-density lipoprotein cholesterol (non-HDL-c) and pre-admission statin therapy between two groups (135.1±38.0 mg/dL vs 129.2±43.8 mg/dL; p=0.35, 157.1±37.4 mg/dL vs 143.0±37.7 mg/dL; p=0.24, 15.0% vs 20.0%; p=0.93). However, sd-LDL-c level was significantly higher in patients with PR than those with non-PR (44.0±18.1 mg/dL vs 28.0±9.3 mg/dL; p=0.0005). On multiple logistic regression analysis, sd-LDL-c was an independent predictor of PR (odds ratio, 1.14 per 1 mg/dL; p=0.0063).

Conclusion

Sd-LDL-c was significantly associated with PR of the culprit lesion in patients with STEMI.

Funding Acknowledgement

Type of funding sources: None.

Examination about more realistic prognosis evaluation method, how long the patients with congestive heart failure can spend at home

Background

From August 2015, for efficient medical care in congestive heart failure (CHF) cases, we had introduced a unique clinical pathway (PATH) provided the immediate use of Tolvaptan and comprehensive education by multi-disciplinary staff after admission. And by introduction of PATH, we confirmed the shortening effect of hospitalization period with CHF and the suppressive effect of readmission with CHF after discharge. But since almost CHF patients repeat hospitalization and discharge due to change of their medical condition, the investigation for only first readmission rate after discharge is not enough to assess the entire long clinical course of CHF. Recently we found one report about evaluation method for CHF clinical prognosis, how long CHF patients can stay healthy at their own home after discharge within a certain period. This evaluation method is considered to take into account the long clinical course of CHF.

Purpose

We investigated whether the CHF patients introduced PATH on admission could stay longer at their home than CHF patients without PATH.

Methods

Between April 2014 and July 2019, 471 CHF cases, who ware admitted in our hospital at first and could be followed up for at least 1 month after discharge, ware enrolled. We divided them to two groups, PATH- group before introducing PATH (until July 2015, 142 cases), and PATH+ group applied PATH (after August 2015, 329 cases). Between both groups, we investigated the readmission rate (RR) with CHF and the total period (TP) that patients could spend at home within1, 3, 6 and 12month after discharge.

Results

There were no significant differences in mean age, pre-hospital living status, or clinical status at admission between the two groups. On the other hand, due to efficient CHF care, the average length of hospital stay was significantly shorter (figure1). RR within 1, 3, 6 and 12 months after discharge ware all lower in PATH+ group. And TP within 1, 3, 6 and 12 months after discharge ware all longer in PATH+ group (figure2).

Conclusion

By introducing our unique clinical pathway for congestive heart failure cases requiring hospitalization, we could confirm not only the improvement of their conventional clinical prognosis index but also the improvement of their new and more realistic clinical prognosis index after discharge.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

A Japanese Multicenter Study on PET and Other Biomarkers for Subjects with Potential Preclinical and Prodromal Alzheimer's Disease

BACKGROUND

PET (positron emission tomography) and CSF (cerebrospinal fluid) provide the "ATN" (Amyloid, Tau, Neurodegeneration) classification and play an essential role in early and differential diagnosis of Alzheimer's disease (AD).

OBJECTIVE

Biomarkers were evaluated in a Japanese multicenter study on cognitively unimpaired subjects (CU) and early (E) and late (L) mild cognitive impairment (MCI) patients.

MEASUREMENTS

A total of 38 (26 CU, 7 EMCI, 5 LMCI) subjects with the age of 65-84 were enrolled. Amyloid-PET and FDG-PET as well as structural MRI were acquired on all of them, with an additional tau-PET with 18F-flortaucipir on 15 and CSF measurement of Aβ1-42, P-tau, and T-tau on 18 subjects. Positivity of amyloid and tau was determined based on the positive result of either PET or CSF.

RESULTS

The amyloid positivity was 13/38, with discordance between PET and CSF in 6/18. Cortical tau deposition quantified with PET was significantly correlated with CSF P-tau, in spite of discordance in the binary positivity between visual PET interpretation and CSF P-tau in 5/8 (PET-/CSF+). Tau was positive in 7/9 amyloid positive and 8/16 amyloid negative subjects who underwent tau measurement, respectively. Overall, a large number of subjects presented quantitative measures and/or visual read that are close to the borderline of binary positivity, which caused, at least partly, the discordance between PET and CSF in amyloid and/or tau. Nine subjects presented either tau or FDG-PET positive while amyloid was negative, suggesting the possibility of non-AD disorders.

CONCLUSION

Positivity rate of amyloid and tau, together with their relationship, was consistent with previous reports. Multicenter study on subjects with very mild or no cognitive impairment may need refining the positivity criteria and cutoff level as well as strict quality control of the measurements.

Multidose evaluation of 6,710 drug repurposing library identifies potent SARS-CoV-2 infection inhibitors In Vitro and In Vivo

The SARS-CoV-2 pandemic has caused widespread illness, loss of life, and socioeconomic disruption that is unlikely to resolve until vaccines are widely adopted, and effective therapeutic treatments become established. Here, a well curated and annotated library of 6710 clinical and preclinical molecules, covering diverse chemical scaffolds and known host targets was evaluated for inhibition of SARS-CoV-2 infection in multiple infection models. Multi-concentration, high-content immunocytofluorescence-based screening identified 172 strongly active small molecules, including 52 with submicromolar potencies. The active molecules were extensively triaged by in vitro mechanistic assays, including human primary cell models of infection and the most promising, obatoclax, was tested for in vivo efficacy. Structural and mechanistic classification of compounds revealed known and novel chemotypes and potential host targets involved in each step of the virus replication cycle including BET proteins, microtubule function, mTOR, ER kinases, protein synthesis and ion channel function. In the mouse disease model obatoclax effectively reduced lung virus load by 10-fold. Overall, this work provides an important, publicly accessible, foundation for development of novel treatments for COVID-19, establishes human primary cell-based pharmacological models for evaluation of therapeutics and identifies new insights into SARS-CoV-2 infection mechanisms.

Significance

A bioinformatically rich library of pharmacologically active small molecules with diverse chemical scaffolds and including known host targets were used to identify hundreds of SARS-CoV-2 replication inhibitors using in vitro, ex vivo, and in vivo models. Extending our previous work, unbiased screening demonstrated a propensity for compounds targeting host proteins that interact with virus proteins. Representatives from multiple chemical classes revealed differences in cell susceptibility, suggesting distinct dependencies on host factors and one, Obatoclax, showed 90% reduction of lung virus loads in the mouse disease model. Our findings and integrated analytical approaches will have important implications for future drug screening and how therapies are developed against SARS-CoV-2 and other viruses.

Terahertz-field-induced polar charge order in electronic-type dielectrics

Ultrafast electronic-phase change in solids by light, called photoinduced phase transition, is a central issue in the field of non-equilibrium quantum physics, which has been developed very recently. In most of those phenomena, charge or spin orders in an original phase are melted by photocarrier generations, while an ordered state is usually difficult to be created from a non-ordered state by a photoexcitation. Here, we demonstrate that a strong terahertz electric-field pulse changes a Mott insulator of an organic molecular compound in κ-(ET)₂Cu[N(CN)₂]Cl (ET = bis(ethylenedithio)tetrathiafulvalene), to a macroscopically polarized charge-order state; herein, electronic ferroelectricity is induced by the collective intermolecular charge transfers in each dimer. In contrast, in an isostructural compound, κ-(ET)₂Cu₂(CN)₃, which shows the spin-liquid state at low temperatures, a similar polar charge order is not stabilized by the same terahertz pulse. From the comparative studies of terahertz-field-induced second-harmonic-generation and reflectivity changes in the two compounds, we suggest the possibility that a coupling of charge and spin degrees of freedom would play important roles in the stabilization of polar charge order.

Promotion in solid phase reaction of Pt/SiOx bilayer film by electron-orbital-selective-excitation

A thermally impossible positive free energy reaction can proceed by electron-orbital-selective excitation. When the Si 2p core level is photo-excited in Pt/SiO_x bilayer films, Coulomb repulsion at the final two-hole state localized in the valence band by an interatomic Auger transition induces dissociation of the O atom and formation of a Si–Pt bond. Consequently, Pt₂Si silicide is formed by a positive free energy reaction. Under a single particle excitation of the valence band, low probability of the coexistence of the two-hole state for picosecond order suppresses to allow the reaction to proceed.

A thermally impossible positive free energy reaction can proceed by electron-orbital-selective excitation.

Comparison of Two Evacuation Shelter Operating Policies and the Role of Public Health Nurses after the Great East Japan Earthquake: A Qualitative Study

This study describes shelter operations by public health nurses (PHNs) in Kesennuma City, located near the epicenter of the Great East Japan Earthquake, which occurred on March 11, 2011. The data were semi-structured interviews with 10 PHNs, 2 nutritionists, and 2 general administrators conducted from July 2013 to January 2014. All transcripts were analyzed using the constructivist grounded theory approach. We identified two operating methods for shelters: shelters stationed by PHNs in the Old City, and shelters patrolled by PHNs in the merged district. These methods were compared using four themes. In emergency situations, "operational periods," a predetermined short term for a leader to perform his/her duties responsibly, could be adopted for relatively small organizations on the frontline. PHNs must not only attempt to operate shelters on their own but also encourage residents to manage the shelters as well. Moreover, human resource allocation should be managed independently of personal factors, as strong relationships between shelter residents would sometimes disturb the flexibility of the response. Even when a situation requires PHNs to stay in shelters, frequent collecting of information and updating the plan according to response progress will help to maintain effective shelter operations.

Platelet volume indices correlate to severity of heart failure and have prognostic value for both cardiac and thrombotic events in patients with congenital heart disease

Introduction

Patients with heart failure are reported to have activated platelets leading to thrombotic events. Consequently, immature giant platelets are produced, and platelet distribution width (PDW) and mean platelet volume (MPV) increase. These platelet indices are easily, reasonably, and safely available by routine blood test and recently have been proposed as potential markers of cardiac events. However, little is known about the usefulness of platelet indices in patients with congenital heart disease (CHD).

Purpose

To test whether the hypothesis that PDW and MPV correlate to the severity of heart failure and have prognostic value in both future heart failure-related admission and thrombosis formation in patients with CHD.

Methods

We performed a retrospective, single-centre study that included 400 patients with CHD (median age, 34 years [range: 12–76]; 49% males; 35% single ventricular morphology), who were admitted in our institute between April 2014 and June 2017. We reviewed patients' medical records to assess their clinical information including medical history, blood sample data, and echocardiologic parameters. At first, we assessed the correlation between platelet indices and patients' clinical parameters. Next, we compared platelet indices before and after treatment for heart failure. Finally, using logistic regression and Kaplan-Meier analyses, we assessed prognostic factors of future heart failure-related admission and thrombosis formation.

Results

In multivariate analysis, a significant correlation was found between PDW and logBNP (brain natriuretic peptide) (p&lt;0.001), haemoglobin (p=0.01), D-dimer (p=0.019), Fontan operation (p&lt;0.001) and male sex (p&lt;0.001); as well as between MPV and logBNP (p&lt;0.001), D-dimer (p&lt;0.001) and Fontan operation (p=0.002). Throughout treatment of heart failure, significant reduction was found both in PDW (average value before treatment = 14.2, after treatment = 13.2, p=0.002) and MPV (before = 11.2, after = 10.8, p=0.004). In multivariate logistic regression analysis, predictors of future heart failure-related admissions were PDW (hazard ratio [HR]: 1.365; 95% confidence interval [CI]: 1.005–1.768), MPV (HR: 1.472; 95% CI: 1.055–2.052), age (HR: 1.063; 95% CI: 1.010–1.119), and SpO2 under 85% (HR: 5.089; 95% CI: 1.350–19.18). Using the same analysis, predictors of thrombotic formation were PDW (HR: 1.998; 95% CI: 1.461–2.630), MPV (HR: 1.792; 95% CI: 1.155–2.781), logBNP (HR: 1.196, 95% CI: 1.085–1.320), D-dimer (HR: 1.024; 95% CI: 1.007–1.042) and male sex (HR: 3.071; 95% CI: 1.079–8.737). In addition, during median follow-up of 28 months, the Kaplan-Meier analysis showed an improvement in both heart failure and thrombosis-free survival in the low PDW, as well as the low MPV group.

Conclusion

Platelet volume indices correlate to severity of heart failure and have prognostic value for both cardiac and thrombotic events in patients with congenital heart disease.

Funding Acknowledgement

Type of funding source: None

Our unique clinical pathway for congestive heart failure cases required admission achieved a dramatic reduction of their hospitalization period and a significant reduction of readmission with heart fa

Background

In recent years, the number of elderly congestive heart failure (CHF) cases has been increasing in Japan with the aging of the population. This tendency is particularly remarkable in rural areas where our facilities are located. After admission with CHF, the hospitalization period (PE) was prolonged due to various complications unique to the elderly, and re-exacerbation of CHF occurred shortly after discharge. Approximately 30% of them were readmitted within one year. From August 2015, for shortening of PE and reduction of CHF readmission through the efficiency of CHF treatment and comprehensive patient education, we had introduced a unique clinical pathway (PATH) that provided the immediate use of Tolvaptan and comprehensive education by multi-disciplinary staff after admission.

Purpose

In this study, we verified whether the improvement of clinical prognosis were achieved by introduction of PATH.

Methods

Between April 2014 and July 2019, 635 CHF cases (764 admissions) ware enrolled. We divided them to two groups, N-group before introducing PATH (198 cases, 262 admissions) and P-group applied PATH (437 cases, 502 admission). Between both groups, we compared the various acute care situation, PE and readmission rate with CHF within 1 year after discharge.

Results

There were no differences between P and N-group in mean age, distribution of underlying illness or daily activity level before admission. There ware not also differences about left ventricle function by echocardiography and various blood test data at admission. The enforcement rate of continuous infusion and the rate of urinary catheter placement were significantly lower in the P-group (71 vs 88%; p&lt;0.0001, 52 vs 63%; p&lt;0.01, respectively). And their enforcement duration was significantly shorter in P-group (4.6±5.3 vs 10.5±9.6 days; p&lt;0.0001, 6.3±7.9 vs 12.8±13.1 days; p&lt;0.0001 respectively). The enforcement rate of cardiac rehabilitation was significantly higher in group P (94 vs 84%; p&lt;0.0001), and the starting time of rehabilitation was significantly earlier (2.9±1.5 vs 6.3±4.8th illness day; p&lt;0.0001). As a result, the average HP was significantly shorter in group P (16.5±13.4 vs 28.6±24.1 days, p&lt;0.0001). The readmission rate with CHF within one year after discharge was significantly lower in group P (23 vs 36%; p&lt;0.001).

Conclusion

By the introduction of our original clinical pathway for congestive heart failure, the efficiency of medical care was achieved and the mean hospitalization period was widely shortened. In addition, by the through comprehensive patient education by multi-disciplinary staff involved in the pathway, the self-restraint life style after discharge seemed to be maintained and the readmission with worsening of heart failure was significantly suppressed.

Funding Acknowledgement

Type of funding source: None

Early vascular healing following bioresorbable-polymer sirolimus-eluting stent implantation in comparison with durable-polymer everolimus-eluting stent: sequential optical coherence tomography study

Background

Orsiro ultrathin-strut bioresorbable-polymer sirolimus-eluting stent (BP-SES) might facilitate early vascular healing responses that seems to be associated with improved long-term clinical outcomes. We compared the early vascular healing responses to BP-SES and Xience durable-polymer everolimus-eluting stent (DP-EES) in patients with chronic coronary syndrome (CCS) using optical coherence tomography (OCT).

Methods

A total of 40 patients with CCS receiving OCT-guided PCI were included. 20 patients were assigned to BP-SES, and 20 to DP-EES. OCT was performed immediately after stent placement (post-procedure) and at 1 month follow-up. Struts were recorded as uncovered if any part was visibly exposed in the lumen or covered if a layer of tissue covered all reflecting surfaces. The incidence of intrastent thrombus (IS-Th) and irregular protrusion (IRP) were also assessed.

Results

At 1 month, the percentage of uncovered struts was significantly lower in the BP-SES compared with the DP-EES (2.8±1.6% vs. 5.8±1.8%, respectively; p&lt;0.001), and that of malapposed struts was similar between both groups (2.5±3.1% vs. 2.4±2.2%; p=0.76). There were no differences in the incidence of IS-Th (65.0% vs. 55.0% at post-procedure; p=0.54, 30.0% vs. 35.0% at 1 month; p=0.75) and IRP (30.0% vs. 25.0% at post-procedure; p=0.74). IRP had completely resolved at 1 month in both groups.

Conclusion

Early vascular healing response to Orsiro BP-SES implantation was revealed in CCS patients at 1 month compared with Xience DP-EES. Orsiro BP-SES may have a potential to shorten the dual antiplatelet therapy duration.

Funding Acknowledgement

Type of funding source: None

Early vascular responses to ultrathin biodegradable polymer sirolimus-eluting stent for the treatment of st-elevation myocardial infarction

Background

Recent clinical study suggests newer-generation drug-eluting stents (DES) that combine ultrathin strut and nano-coating with biodegradable polymers sirolimus-eluting stent (BP-SES) could improve long-term clinical outcomes in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) over current generation DES. However, safety profiles in very early phase have not been systematically addressed.

Objective and method

We exploratory investigate early vascular response following BP-SES implantation in patients with STEMI to reveal mechanism of the favorable clinical outcomes in recent studies using frequency domain-optical coherence tomography (FD-OCT).

Consecutive twenty patients with STEMI who underwent FD-OCT immediately after primary PCI and were eligible for follow-up FD-OCT at 2 weeks after implantation were enrolled between June 2018 and November 2019.

Results

Twenty patients (age 62.7±11.3 years, male 85.0%) were enrolled with frequencies of hypertension (45.0%), diabetes mellitus (35.0%), dyslipidemia (55.0%) and smoking (80.0%). Aspiration catheter were used in all patients, and 1.13±0.34 stents were used. Only one patient (5.0%) received chronic antiplatelet therapy with aspirin prior to the onset of STEMI. All patients started to receive prasugrel as thienopyridine from this event and continued dual antiplatelet therapy for 2 weeks.

The percentage of uncovered struts significantly decreased from post-procedure to 2W follow-up (69±18% post-procedure versus 30±11% at 2W follow up, p&lt;0.0001). Malapposed struts also decreased (5.6±5.7% post-procedure versus0.9±1.2% at 2W follow up, p&lt;0.0001).The average protrusion area of athero-thrombotic burden numerically decreased (0.37±0.19 at post-procedure versus 0.34±0.14 mm2 at 2W follow up, p=0.19) and its volume showed similar tendency (10.60±6.40 at post-procedure versus 9.36±5.14 mm3 at 2W follow up, p=0.19).

Conclusion(s)

This study firstly elucidated very early vascular responses following ultrathin strut BP-SES implantation in STEMI patients, showing early progression of strut coverage and resolution of athero-thrombotic materials. This technology may have a potential to overcome the current generation DESs in this clinical setting.

Thrombus, uncovered and malapposed struts

Funding Acknowledgement

Type of funding source: None

Atrial Fibrillation is related with higher in-hospital morality in acute myocardial infarction (AMI) patients from K-ACTIVE registry

Background

The prognostic significance of atrial fibrillation (AF) on in-hospital mortality in acute myocardial infarction (AMI) patients is not fully understood in Japanese patients.

Methods

To elucidate the clinical significance of AF on in-hospital mortality in AMI patients, we analyzed the Japanese observational prospective multicenter registry of acute myocardial infarction (K-ACTIVE: Kanagawa ACuTe cardio Vacular rEgistry), which spans October 2016 to December 2019.

Results

A total of 3482 patients included 336 patients with AF and 3146 patients with sinus rhythm. Table 1 shows patient baseline characteristics. Patients with AF were significantly older than those with sinus rhythm (75 vs 67, P&lt;0.0001). Prevalence of hypertension and hemodialysis were significantly greater in patients with AF than patients with sinus rhythm while prevalence of dyslipidemia and smoking were significantly less in patients with AF than patients with sinus rhythm. Table 2 shows characteristics of AMI. There were no significant difference in prevalence of STEMI, area of MI, Peak CK/CK-MB and prevalence of multivessel disease. However, patients with AF showed lower systolic blood pressure, faster heart rate, worse Killip category, greater prevalence of OHCA. Need of mechanical support including IABP/ECMO were greater in patients with AF than patients with sinus rhythm. In-hospital mortality was significantly higher in patients with AF than in patients with sinus rhythm (Figure, 10.4% versus 5.2%, P=0.0005). This trend didn't change even after adjustment with age and sex (Odds ratio 1.6 95% confidence interval 1.1–2.4, P=0.02).

Conclusion

AF was associated with higher in-hospital mortality in Japanese AMI patients.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This work was supported by JSPS KAKENHI Grant Number JP15K09101.

A case of systemic lupus erythematosus in which Cushing's syndrome caused by adrenal adenoma accidentally occurred during long-term maintenance therapy with corticosteroids

A 30-year-old female patient had been administered 5-mg/day prednisolone for systemic lupus erythematosus. She developed hypertension, dyslipidemia, moon face, central obesity, hypertrichosis, and impaired glucose tolerance. Although iatrogenic Cushing syndrome was initially suspected, we made a diagnosis of Cushing syndrome caused by a right adrenal adenoma, on the basis of the endocrine function test result and imaging findings. After surgery, the Cushingoid signs disappeared. Autoimmune diseases are often treated with corticosteroids; therefore, a differential diagnosis of primary Cushing syndrome should be made adequately.

MRI Findings of Immune Checkpoint Inhibitor-Induced Hypophysitis: Possible Association with Fibrosis

BACKGROUND AND PURPOSE

Hypophysitis is one of the well-known adverse effects of immune checkpoint inhibitors. Immune checkpoint inhibitor-induced hypophysitis frequently causes irreversible hypopituitarism, which requires long-term hormone replacement. Despite the high frequency and clinical significance, characteristic MR imaging findings of immune checkpoint inhibitor-induced hypophysitis have not been established. In the present study, we aimed to review and extract the MR imaging features of immune checkpoint inhibitor-induced hypophysitis.

MATERIALS AND METHODS

This retrospective international multicenter study comprised 20 patients with melanoma who were being treated with immune checkpoint inhibitors and clinically diagnosed with immune checkpoint inhibitor-induced hypophysitis. Three radiologists evaluated the following MR imaging findings: enlargement of the pituitary gland and stalk; homogeneity of enhancement of the pituitary gland; presence/absence of a well-defined poorly enhanced area and, if present, its location, shape, and signal intensity in T2WI; and enhancement pattern in contrast-enhanced dynamic MR imaging. Clinical symptoms and hormone levels were also recorded.

RESULTS

Enlargement of the pituitary gland and stalk was observed in 12 and 20 patients, respectively. Nineteen patients showed poorly enhanced lesions (geographic hypoenhancing lesions) in the anterior lobe, and 11 of these lesions showed hypointensity on T2WI. Thyrotropin deficiency and corticotropin deficiency were observed in 19/20 and 12/17 patients, respectively, which persisted in 12/19 and 10/12 patients, respectively, throughout the study period.

CONCLUSIONS

Pituitary geographic hypoenhancing lesions in the anterior lobe of the pituitary gland are characteristic and frequent MR imaging findings of immune checkpoint inhibitor-induced hypophysitis. They reflect fibrosis and are useful in distinguishing immune checkpoint inhibitor-induced hypophysitis from other types of hypophysitis/tumors.

Associations between urinary 6-sulfatoxymelatonin excretion and diabetic vascular complications or arteriosclerosis in patients with type 2 diabetes

AIMS/INTRODUCTION

There are limited reports on the association between melatonin levels and vascular complications in patients with type 2 diabetes. The aim of this study was to determine the association between urinary 6-sulfatoxymelatonin, which is a urinary metabolite of melatonin, and diabetic vascular complications or arteriosclerosis in patients with type 2 diabetes.

MATERIALS AND METHODS

This retrospective study included patients (167 patients with type 2 diabetes and 27 patients without diabetes adjusted for age and sex) admitted to the hospital who underwent measurement of urinary 6-sulfatoxymelatonin. The urinary 6-sulfatoxymelatonin/creatinine ratio (6-SMT) was calculated.

RESULTS

The natural logarithmically scaled 6-SMT level (Ln 6-SMT) was significantly lower in type 2 diabetes patients (1.9 ± 1.1) compared with patients without diabetes (2.8 ± 1.0, P < 0.001). Multivariate linear regression analysis identified duration of diabetes, smoking status, urinary albumin-to-creatinine ratio, retinopathy and coronary heart disease as factors that could influence Ln 6-SMT levels in type 2 diabetes patients (R²  = 0.232, P < 0.001). Ln 6-SMT was associated with decreased odds of diabetic retinopathy, even after adjustment for various confounding factors (odds ratio 0.559, 95% confidence interval 0.369-0.846, P = 0.006). Similarly, Ln 6-SMT was associated with decreased odds of coronary heart disease (odds ratio 0.442, P = 0.030).

CONCLUSIONS

Our results showed the presence of low levels of Ln 6-SMT in type 2 diabetes patients relative to patients without diabetes. Furthermore, Ln 6-SMT is an independent risk factor of diabetic retinopathy and coronary heart diseases. These findings suggest that 6-SMT could be a useful biomarker for the prediction of micro- and macrovasculopathies in patients with type 2 diabetes.

Factors secreted from dental pulp stem cells show multifaceted benefits for treating experimental temporomandibular joint osteoarthritis

OBJECTIVE

Temporomandibular joint osteoarthritis (TMJOA) is a degenerative disease characterized by progressive cartilage degeneration, abnormal bone remodeling, and chronic pain. In this study, we aimed to investigate effective therapies to reverse or suppress TMJOA progression.

DESIGN

To this end, we performed intravenous administration of serum free conditioned media from human exfoliated deciduous teeth stem cells (SHED-CM) into a mechanical-stress induced murine TMJOA model.

RESULTS

SHED-CM administration markedly suppressed temporal muscle inflammation, and improved bone integrity and surface smoothness of the destroyed condylar cartilage. Moreover, SHED-CM treatment decreased the number of IL-1β, iNOS, and MMP-13 expressing chondrocytes, whereas it specifically increased PCNA-positive cells in the multipotent polymorphic cell layer. Notably, the numbers of TdT-mediated dUTP nick end labeling (TUNEL)-positive apoptotic chondrocytes in the SHED-CM treated condyles were significantly lower than in those treated with DMEM, whereas the proteoglycan positive area was restored to a level similar to that of the sham treated group, demonstrating that SHED-CM treatment regenerated the mechanical-stress injured condylar cartilage and subchondral bone. Secretome analysis revealed that SHED-CM contained multiple therapeutic factors that act in osteochondral regeneration.

CONCLUSIONS

Our data demonstrated that SHED-CM treatment promoted the regeneration and repair of mechanical-stress induced mouse TMJOA. Our observations suggest that SHED-CM has potential to be a potent tissue-regenerating therapeutic agent for patients with severe TMJOA.

FRI0097 EFFECTS OF BIOLOGICAL DISEASE-MODIFYING ANTI-RHEUMATIC DRUG TREATMENT ON PHYSICAL ACTIVITY, MUSCLE POWER, AGILITY AND INHIBITION OF FALL IN PATIENTS WITH RHEUMATOID ARTHRITIS -THE 2-YEAR RESULTS

Background:

Treatment with biological DMARDs (bDMARDs) rapidly improves signs and symptoms in patients with rheumatoid arthritis (RA). The efficacy of these bDMARDs was evaluated using composite measures or biomarkers used in daily clinical practice or clinical studies. Although a rapid improvement in composite measures or biomarkers is important in the treatment of RA, the primary goal of treatment is improvement of long-term health-related quality of life (HR-QOL) [1]. HR-QOL is evaluated based on physical functions (PF) such as muscle power and agility. We reported the 1-year results of our study presented at EULAR 2019 [2]. The present study was conducted to investigate the 2-year results of our study by including more patents than those included in the previous one.

Objectives:

This study was aimed at investigating the efficacy of bDMARDs with respect to PF and fall risk in RA patients.

Methods:

At our institute, in addition to routine rheumatology evaluation, periodic evaluation of physical function is performed by staff members in our rehabilitation center in RA patients in whom the first bDMARD treatment was initiated in Oct. 2015–Feb. 2018. In total, 41 cases were registered in this study. Evaluation of PF included evaluation of muscle power [grasping power (GP) and knee extension power (KEP)]; agility [time up and go test (TUG) and 10-m walking time (10 mW)]; and a questionnaire using modified HAQ, portable fall risk index [3], and the 25-question geriatric locomotive function scale (locomo25) [4] at baseline (BL), which implies the time at the initiation of bDMARD treatment, i.e., 1, 3, 6, 12, and 24 months. Disease activity of RA was evaluated at the same time points. Although 2 years had elapsed from BL in 37 patients, 13 patients dropped out from the evaluation of physical function owing to cessation of bDMARD treatment, rejection of evaluation for physical function, or major joint surgery performed in a patient. The results of 24 patients who completed the evaluation at 24 months were investigated in this study.

Results:

Baseline characteristics of the 24 patients were as follows: mean age 60.8 years, RA duration 12.3 years, mean SDAI 19.0, and mean CRP level 2.1 mg/dl. The bDMARDs used in the study were abatacept in 7 patients, adalimumab in 4 patients, tocilizumab in 4 patients, golimumab in 4 patients, etanercept in 3 patients, certolizumab in 1 patient, and an infliximab biosimilar in 1 patients. Data are presented as mean values at BL and at 1, 3, 6, 12, and 24 months (Fig.1). SDAI and CRP levels were significantly improved at and after 1 month. GP and KEP were significantly improved at and after 3 and 6 months. TUG and 10 mW results were significantly improved at and after 3 and 6 months. Modified HAQ results were significantly improved at and after 3 months. Locomo25 scores were significantly improved at and after 1 month. Portable fall risk index values were significantly improved at and after 12 months.

Conclusion:

Although there was a rapid improvement in the signs and symptoms of RA after the initiation of bDMARD treatment, improvement in PF was slightly delayed. Significant improvement of muscle power and agility was achieved after 3–6 months onward. Inhibition of fall risk was achieved at and after 12 months after the initiation of bDMARD treatment. These results suggest that physiotherapy plays a vital role in RA patients who undergo treatment with bDMARDs to gain more rapid improvement of PF.

References:

[1]Smolen JS et al. Ann Rheum Dis, 2016.

[2]Hirano Y et al. Ann Rheum Dis, suppl. 2, 2019.

[3]Toba K et al. Jpn J Geriat, 2005.

[4]Seichi A at al. J Orthop Sci, 2012.

Disclosure of Interests:

Yuji Hirano Speakers bureau: Tanabe-Mitsubishi, Pfizer, Eisai, Abbie, Chugai, Bristol-Meyers, Jansen, Astellas, UCB, Eli-Lilly, Asahikasei, Daiichi-Sankyo, Amgen, Ayako Morisaka: None declared, Hironobu Kosugiyama: None declared, Shiori Inuzuka: None declared, Takeshi Kamiya: None declared, Hiroyuki Mori: None declared, Naohito Morishima: None declared, Tomoji Ishikawa: None declared

Association of long-term care needs, approaching death and age with medical and long-term care expenditures in the last year of life: An analysis of insurance claims data

AIM

This study aimed to examine whether long-term care needs, approaching death and age were associated with the use of medical and long-term care resources (care/service use and expenditures) in the last year of life among older Japanese individuals.

METHODS

Using data on insurance claims and death certificates, we described the use of medical and long-term care resources in the last year of life by residents of Soma City in Japan aged ≥65 years who died between September 2006 and October 2009. Using a generalized estimating equation, we examined whether long-term care needs, approaching death and age were associated with resource use during each 3-month period in the last year of life.

RESULTS

Resource use in medical and long-term care among 882 non-survivors and 8504 survivors were analyzed. Analyses for the non-survivors showed statistically significant associations between: (i) severe long-term care needs and greater service use in outpatient care, higher expenditures for outpatient care and higher expenditures for in-home/facility services; (ii) approaching death and greater use in both inpatient care and facility services; and (iii) being aged 65-74 years and greater service use in outpatient/in-hospital care and in-home/facility services, higher expenditures in outpatient/inpatient care, and lower expenditures for in-home/facility services.

CONCLUSIONS

The present study showed that severe long-term care needs and approaching death, rather than advancing age, were significantly and independently associated with greater use of resources in both medical and long-term care services. Geriatr Gerontol Int 2020; 20: 277-284.

P17 In-hospital mortality and clinical features of Japanese patients with acute myocardial infarction diagnosed by universal definition in real world from kanagawa-acute cardiovascular registry (K-ACTIVE)

Background

Cardiac troponin (cTn) has been used as the preferred biomarker of myocardial injury for diagnosis of acute myocardial infraction (AMI) by universal definition. A large number of patients formerly classified by creatine kinase (CK) as unstable angina with the WHO criteria in Japan are now diagnosed by cTn as non-ST elevation myocardial infarction (NSTEMI). In this report, we aimed to understand its prevalence and clinical features of AMI diagnosed by using universal definition and the WHO criterial in real world. 

Method

This registry is a cross-sectional study of 53 facilities in Kanagawa prefecture of Japan. 4372 AMI patients were enrolled who received primary percutaneous coronary intervention (PCI) between October 1, 2015 and January 29, 2019. Patients were divided into 3 groups, 3268 patients with ST elevation myocardial infarction (STEMI), 628 patients with NSTEMI patients who satisfied the WHO criteria with CK elevation beyond twice upper limit of normal (NSTEMI + CK), and 476 patients with NSTEMI who didn’t satisfy the WHO criteria without CK elevation (NSTEMI-CK).

Result

Baseline clinical characteristics of the study patients are shown in Table 1. In-hospital mortality was significantly lower in patients with NSTEMI-CK (1.9%) than in STEMI (6.0%, P &lt; 0.001) and NSTEMI + CK (5.3%, P &lt; 0.004) (Figure 1). Kaplan-Meier analyses for 0-30 days of cardiac death are shown in Figure 2. From day 0, the Kaplan-Meier curves began to diverge in favor of NSTEMI-CK for up to 30 days.

Conclusion

AMI patients showed distinct clinical features depends on the type. We should be aware of the difference for the diagnosis of AMI by using universal definitions.

Table 1. 　 STEMI (n = 3268) NSTEMI + CK (n = 628) NSTEMI-CK (n = 476) STEMI vs NSTEMI + CK P value STEMI vs NSTEMI-CK P value NSTEMI + CK vs NSTEMI-CK P value Age(years) 68(59-77) 69(61-78) 70(61-79) 　 　 　 Male 76% 77% 75% 0.54 0.74 0.47 Concomitant diseases 　 　 　 　 　 　 Hypertention 65.4% 70.5% 69.3% 0.013 0.097 0.65 Diabetes 33.5% 36.5% 37.3% 0.15 0.11 0.78 Dyslipidemia 56.1% 61.2% 61.3% 0.018 0.03 0.96 Hemodialysis 2.3% 2.1% 6.8% 0.86 &lt;0.001 0.01 Smoking 66.3% 63.1% 64.6% 0.13 0.48 0.62 Atrial fibrillation 9.6% 10.7% 14.4% 0.57 0.04 0.23 Previous MI 8.3% 17.3% 15.7% &lt;0.001 &lt;0.001 0.47 In-hospital mortality 6.0% 5.3% 1.9% 0.49 &lt;0.001 0.004

Abstract P17 Figure 1. 2.

P3615The number of coronary risk factors and mortality in patients with acute myocardial infarction from Japanese nation-wide real-world database

Background

Hypertension, diabetes, dyslipidemia and smoking are so-called coronary risk factors for coronary heart disease, which were established by extensive epidemiological research. However, in Japanese patients with acute myocardial infarction (AMI), the impact of number of coronary risk factors on in-hospital morality has not been elucidated.

Methods

The Japan Acute Myocardial Infarction Registry (JAMIR) is a nationwide real-world database integrated form 10 regional registries. We examined the association between number of coronary risk factors and in-hospital mortality from this JAMIR registry.

Results

The data were obtained from total of 20462 AMI patients (mean age, 68.8±13.3 years old; 15281 men, 5181 women). Figure 1 shows the prevalence of each coronary risk factors stratified by sex and decade. The prevalence of hypertension became higher with the advanced age while the prevalence of smoking became lower with the advanced age. Prevalence of diabetes and dyslipidemia were highest in middle age. Majority (76.9%) of the patients with AMI had at least 1 of these coronary risk factors and, 23.1% had none of them. Overall, except women under 50, number of coronary risk factor was relatively less in older age (Figure 2). In-hospital mortality by sex and decades was shown in figure 3. In-hospital mortality rates were 10.7%, 10.5%, 7.2%, 5.0% and 4.5% with 0, 1, 2, 3 and 4 risk factors, respectively (Figure 4A). After adjusting age and sex, there was an inverse association between the number of coronary risk factors and in-hospital mortality (adjusted odds ratio [1.68; 95% CI, 1.20–2.35] among individuals with 0 vs. 4 risk factors, Figure 4B).

Conclusion

In the present study of Japanese patients with AMI, who received modern medical treatment, in-hospital mortality was inversely related to the number of coronary risk factors.

Acknowledgement/Funding

Grant-in-Aid for Scientific Research

Large Enhancement of Thermoelectric Efficiency Due to a Pressure-Induced Lifshitz Transition in SnSe

The Lifshitz transition, a change in Fermi surface topology, is likely to greatly influence exotic correlated phenomena in solids, such as high-temperature superconductivity and complex magnetism. However, since the observation of Fermi surfaces is generally difficult in the strongly correlated systems, a direct link between the Lifshitz transition and quantum phenomena has been elusive so far. Here, we report a marked impact of the pressure-induced Lifshitz transition on thermoelectric performance for SnSe, a promising thermoelectric material without a strong electron correlation. By applying pressure up to 1.6 GPa, we have observed a large enhancement of the thermoelectric power factor by more than 100% over a wide temperature range (10-300 K). Furthermore, the high carrier mobility enables the detection of quantum oscillations of resistivity, revealing the emergence of new Fermi pockets at ∼0.86  GPa. The observed thermoelectric properties linked to the multivalley band structure are quantitatively reproduced by first-principles calculations, providing novel insight into designing the SnSe-related materials for potential valleytronic as well as thermoelectric applications.

α-PD-1 therapy elevates Treg/Th balance and increases tumor cell pSmad3 that are both targeted by α-TGFβ antibody to promote durable rejection and immunity in squamous cell carcinomas

BACKGROUND

Checkpoint blockade immunotherapy has improved metastatic cancer patient survival, but response rates remain low. There is an unmet need to identify mechanisms and tools to circumvent resistance. In human patients, responses to checkpoint blockade therapy correlate with tumor mutation load, and intrinsic resistance associates with pre-treatment signatures of epithelial mesenchymal transition (EMT), immunosuppression, macrophage chemotaxis and TGFβ signaling.

METHODS

To facilitate studies on mechanisms of squamous cell carcinoma (SCC) evasion of checkpoint blockade immunotherapy, we sought to develop a novel panel of murine syngeneic SCC lines reflecting the heterogeneity of human cancer and its responses to immunotherapy. We characterized six Kras-driven cutaneous SCC lines with a range of mutation loads. Following implantation into syngeneic FVB mice, we examined multiple tumor responses to α-PD-1, α-TGFβ or combinatorial therapy, including tumor growth rate and regression, tumor immune cell composition, acquired tumor immunity, and the role of cytotoxic T cells and Tregs in immunotherapy responses.

RESULTS

We show that α-PD-1 therapy is ineffective in establishing complete regression (CR) of tumors in all six SCC lines, but causes partial tumor growth inhibition of two lines with the highest mutations loads, CCK168 and CCK169. α-TGFβ monotherapy results in 20% CR and 10% CR of established CCK168 and CCK169 tumors respectively, together with acquisition of long-term anti-tumor immunity. α-PD-1 synergizes with α-TGFβ, increasing CR rates to 60% (CCK168) and 20% (CCK169). α-PD-1 therapy enhances CD4 + Treg/CD4 + Th ratios and increases tumor cell pSmad3 expression in CCK168 SCCs, whereas α-TGFβ antibody administration attenuates these effects. We show that α-TGFβ acts in part through suppressing immunosuppressive Tregs induced by α-PD-1, that limit the anti-tumor activity of α-PD-1 monotherapy. Additionally, in vitro and in vivo, α-TGFβ acts directly on the tumor cell to attenuate EMT, to activate a program of gene expression that stimulates immuno-surveillance, including up regulation of genes encoding the tumor cell antigen presentation machinery.

CONCLUSIONS

We show that α-PD-1 not only initiates a tumor rejection program, but can induce a competing TGFβ-driven immuno-suppressive program. We identify new opportunities for α-PD-1/α-TGFβ combinatorial treatment of SCCs especially those with a high mutation load, high CD4+ T cell content and pSmad3 signaling. Our data form the basis for clinical trial of α-TGFβ/α-PD-1 combination therapy (NCT02947165).

α-PD-1 therapy elevates Treg/Th balance and increases tumor cell pSmad3 that are both targeted by α-TGFβ antibody to promote durable rejection and immunity in squamous cell carcinomas

BACKGROUND

Checkpoint blockade immunotherapy has improved metastatic cancer patient survival, but response rates remain low. There is an unmet need to identify mechanisms and tools to circumvent resistance. In human patients, responses to checkpoint blockade therapy correlate with tumor mutation load, and intrinsic resistance associates with pre-treatment signatures of epithelial mesenchymal transition (EMT), immunosuppression, macrophage chemotaxis and TGFβ signaling.

METHODS

To facilitate studies on mechanisms of squamous cell carcinoma (SCC) evasion of checkpoint blockade immunotherapy, we sought to develop a novel panel of murine syngeneic SCC lines reflecting the heterogeneity of human cancer and its responses to immunotherapy. We characterized six Kras-driven cutaneous SCC lines with a range of mutation loads. Following implantation into syngeneic FVB mice, we examined multiple tumor responses to α-PD-1, α-TGFβ or combinatorial therapy, including tumor growth rate and regression, tumor immune cell composition, acquired tumor immunity, and the role of cytotoxic T cells and Tregs in immunotherapy responses.

RESULTS

We show that α-PD-1 therapy is ineffective in establishing complete regression (CR) of tumors in all six SCC lines, but causes partial tumor growth inhibition of two lines with the highest mutations loads, CCK168 and CCK169. α-TGFβ monotherapy results in 20% CR and 10% CR of established CCK168 and CCK169 tumors respectively, together with acquisition of long-term anti-tumor immunity. α-PD-1 synergizes with α-TGFβ, increasing CR rates to 60% (CCK168) and 20% (CCK169). α-PD-1 therapy enhances CD4 + Treg/CD4 + Th ratios and increases tumor cell pSmad3 expression in CCK168 SCCs, whereas α-TGFβ antibody administration attenuates these effects. We show that α-TGFβ acts in part through suppressing immunosuppressive Tregs induced by α-PD-1, that limit the anti-tumor activity of α-PD-1 monotherapy. Additionally, in vitro and in vivo, α-TGFβ acts directly on the tumor cell to attenuate EMT, to activate a program of gene expression that stimulates immuno-surveillance, including up regulation of genes encoding the tumor cell antigen presentation machinery.

CONCLUSIONS

We show that α-PD-1 not only initiates a tumor rejection program, but can induce a competing TGFβ-driven immuno-suppressive program. We identify new opportunities for α-PD-1/α-TGFβ combinatorial treatment of SCCs especially those with a high mutation load, high CD4+ T cell content and pSmad3 signaling. Our data form the basis for clinical trial of α-TGFβ/α-PD-1 combination therapy (NCT02947165).

Strange metal from a frustration-driven charge order instability

Interparticle interactions are self-conflicting rather than cooperative on particular lattices. When such geometrical frustration occurs, charge ordering (CO) can be destabilized into non-trivial charge states such as the recently observed charge glass (CG). A more extreme case is the frustration-induced quantum melting of the CO that has been theoretically proposed. Here, we report d.c. charge transport and noise spectroscopy measurements for a triangular-lattice organic conductor situated close to the CO or CG. Our experiments demonstrate that these materials can host a strange metal with unusual charge dynamics, which we attribute to frustration-induced fluctuations of the CO or CG. Our results also show that the anomalous charge fluctuations can freeze into an insulating state when uniaxial stress is applied, which reduces the geometrical frustration. The present observations suggest the existence of the frustration-induced quantum melting of charges analogous to spin liquids.

Abstract P1-06-11: Microsatellite instability in triple negative breast cancers

Background:Microsatellite instability (MSI) is a phenotype resulting from defect in mismatch repair genes. The Food and Drug Administration approved anti-programmed death 1 (PD-1) immune checkpoint inhibitor for any solid tumor with MSI-high (MSI-H). Some tumors had good response to PD-1 blockade and it is a promising treatment for a part of refractory breast cancers. Our goal was to determine the frequency of MSI in triple negative breast cancer (TNBC), one of the most clinically aggressive subtypes.

Patients and Methods:This study included 228 patients with primary TNBC underwent resection without neoadjuvant chemotherapy between January 2004 and December 2014. Genomic DNA was extracted from formalin-fixed and paraffin-embedded tissue. Tumor and control DNA were amplified by polymerase chain reaction at the following 5 microsatellite markers: NR-21, BAT-26, BAT-25, NR-24, MONO-27. We classified the tumors as microsatellite stable(MSS), MSI-low or MSI-H.

Results: The mean age of patients was 59 years (range: 30-89) and all were women. T1 tumors were 57.9% and N0 were 67.5%. Meanwhile, the tumors with nuclear grade 3 were 66.2% and high Ki-67 (&gt; 30%) were 66.7%. Among the 228 tumors, 222 tumors (97.4%) revealed MSS, of which 6 (2.6%) revealed MSI and 2 (0.9%) were MSI-H. Among the MSI tumors, T and N factor were showed as follows: T1: 2 tumors, T2: 3 tumors, T3: 1 tumor, N0: 5 tumors and N1: 1 tumor. Of two MSI-H tumors, one showed T1N0 and another showed T2N0. The both of them showed nuclear grade 3, high Ki-67 (&gt; 30%) and had common following instable markers: NR-21, BAT-26 and BAT-25.

Conclusions: Our results demonstrated that the frequency of MSI-H was 0.9% (2/228). MSI might not be useful as a biomarker for immune check point inhibitors. MSI should be combined with another biomarker such as tumor mutational burden in TNBC.

Citation Format: Kurata K, Kubo M, Mori H, Kawaji H, Motoyama Y, Kuroki L, Yamada M, Kaneshiro K, Kai M, Nakamura M. Microsatellite instability in triple negative breast cancers [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-06-11.

Abstract P4-06-22: Transcription factor T-bet and PD-L1 expression in tumor microenvironment of triple-negative breast cancer

Background: Many analyzes regarding immunotherapies using checkpoint blockade has made it clear that tumor infiltrating lymphocytes (TILs) plays an important role in treating cancers with high levels of somatic mutations such as triple-negative breast cancer (TNBC). We reported the relationship between TILs and PD-L1 expression, and revealed that high-TILs/positive-PD-L1 expression population in TNBC was associated with better prognosis (Oncotarget 2017). However, its molecular mechanism is still unclear. Meanwhile, T-box transcription factor 21 (T-bet) which regulates effecter T-cells activation is derived by stimulation of T-cell receptor and IL-12. Activated T-cells work as antitumor lymphocytes by enhancing the production of cytokines such as INFγ. We focused on T-bet and examined the function of activated T-cells.

Patients and Methods: This study included 242 patients with primary TNBC who underwent resection without neoadjuvant chemotherapy at our three hospitals between January 2004 and December 2014. The immunohistochemistry scoring for CD8 and T-bet expression on TILs was defined as ≥30 per 0.00625mm2. PD-L1 positivity was defined as ≥1% of tumor cells staining positive for PD-L1.

Results: Of the 242 TNBC, CD8 on TILs was expressed as positive in 127 (52.5%) tumors, T-bet on TILs was expressed as positive in 67 (27.7%) tumors, and PD-L1 expression on tumor cells was expressed as positive in 99 (40.9%) tumors. T-bet expression was significantly correlated with CD8 expression (P&lt;0.0001) and PD-L1 expression (P=0.0004). There was no significant difference in recurrence free survival (RFS) and overall survival (OS) regardless of CD8 or PD-L1expression level. Meanwhile, the patients with T-bet-positive tumors had a longer OS, compared to those with T-bet-negative tumors (P = 0.13 in RFS and P = 0.047 in OS). The multivariate analysis revealed that T-bet expression on TILswas an independent and positive prognostic factor for OS(HR = 0.5, 95%CI 0.1-0.9, P = 0.035).

Conclusion: OS was significantly longer among patients with high T-bet expressing TNBC. These results may validate the significance of T-bet as a biomarker for various immunotherapies in TNBC.

Citation Format: Mori H, Kubo M, Kai M, Kurata K, Kawaji H, Kaneshiro K, Motoyama Y, Kuroki R, Yamada M, Nishimura R, Okido M, Oda Y, Nakamura M. Transcription factor T-bet and PD-L1 expression in tumor microenvironment of triple-negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-06-22.