Changes in chronic myeloid leukemia treatment modalities and outcomes after introduction of second-generation tyrosine kinase inhibitors as first-line therapy: a multi-institutional retrospective study by the CML Cooperative Study Group

This study investigated changes in treatment modalities and outcomes of chronic myeloid leukemia in the chronic phase (CP-CML) after the approval of second-generation tyrosine kinase inhibitors (2G-TKIs) for first-line therapy. Patients were grouped into those who underwent TKI therapy up to December 2010 (imatinib era group, n = 185) and after January 2011 (2G-TKI era group, n = 425). All patients in the imatinib era group were initially treated with imatinib, whereas patients in the 2G-TKI era group were mostly treated with dasatinib (55%) or nilotinib (36%). However, outcomes including progression-free survival, overall survival, and CML-related death (CRD) did not differ significantly between groups. When stratified by risk scores, the prognostic performance of the ELTS score was superior to that of the Sokal score. Even though both scoring systems predicted CRD in the imatinib era, only the ELTS score predicted CRD in the 2G-TKI era. Notably, the outcome of patients classified as high-risk by ELTS score was more favorable in the 2G-TKI era group than in the imatinib era group. Thus, expanding treatment options may have improved patient outcomes in CP-CML, particularly in patients classified as high-risk by ELTS score.

Disease burden and treatment satisfaction in patients with prurigo nodularis in Japan

Prurigo nodularis (PN) is a chronic inflammatory skin disorder with a high disease burden. In this cross-sectional, web-based survey, Global Questions (GQ), the Numerical Rating Scales (NRS) for pruritus, burning sensation and sleep disturbance, the Short-Form-8 (SF-8) Health Survey, Dermatology Life Quality Index (DLQI), Patient Health Questionnaire 9 (PHQ-9), Work Productivity and Activity Impairment (WPAI), and Treatment Satisfaction Questionnaire for Medication-9 (TSQM-9) scores were used to assess the current disease burden and treatment satisfaction among patients with PN in Japan. In total, 97 patients were included (55.7% male, median age 51 years, median duration of PN 36 months). Based on GQ scores, 35.1% of patients had mild disease, 50.5% moderate, and 14.4% severe disease. Disease burden increased as the severity of PN increased, as indicated by worsening of pruritus NRS scores and quality of life (DLQI, PHQ-9, WPAI presenteeism, work productivity loss, and activity impairment scores). Patients with comorbid atopic dermatitis (AD) also had more intense pruritus than those without AD. Mean ± standard deviation TSQM-9 scores for effectiveness, convenience, and global satisfaction were 54.7 ± 18.1%, 62.4 ± 15.2%, and 57.4 ± 15.9%, respectively. TSQM-9 scores were lowest in patients receiving the most intensive guideline-directed treatment (i.e., topical corticosteroids + systemic oral corticosteroids or cyclosporine), highlighting an unmet need for more effective treatment options for patients with PN. In summary, Japanese patients with PN reported increased disease burden and reduced treatment satisfaction with increased disease severity, despite the use of guideline-recommended therapies.

Real-world data of MDS and CMML in Japan: results of JALSG clinical observational study-11 (JALSG-CS-11)

We conducted a multicenter, prospective observational study of acute myeloid leukemia (AML), myelodysplastic syndromes (MDS), and chronic myelomonocytic leukemia (CMML) in Japan. From August 2011 to January 2016, we enrolled 6568 patients. Herein, we report the results for MDS (n = 2747) and CMML (n = 182). The percentage of patients aged 65 years or older was 79.5% for MDS and 79.7% for CMML. The estimated overall survival (OS) rate and cumulative incidence of AML evolution at 5 years were 32.3% (95% confidence interval: 30.2-34.5%) and 25.7% (23.9-27.6%) for MDS, and 15.0% (8.9-22.7%) and 39.4% (31.1-47.6%) for CMML. Both diseases were more common in men. The most common treatment for MDS was azacitidine, which was used in 45.4% of higher-risk and 12.7% of lower-risk MDS patients. The 5-year OS rate after treatment with azacitidine was 12.1% (9.5-15.1%) for of higher-risk MDS patients and 33.9% (25.6-42.4%) for lower-risk patients. The second most common treatment was erythropoiesis-stimulating agents, given to just 20% of lower-risk patients. This is the first paper presenting large-scale, Japanese data on survival and clinical characteristics in patients with MDS and CMML.

Correlation Analysis of Clinician- and Patient-Reported Outcomes Among Japanese Adults with Atopic Dermatitis

INTRODUCTION

Atopic dermatitis (AD) is a chronic relapsing condition with high disease burden and impact on health-related quality of life (HRQoL). Correlations between clinician- and patient-reported outcomes tend to be poor, and limited data in Asian patients are available.

METHODS

ADDRESS-J was a prospective, non-interventional, longitudinal study that evaluated the real-world effectiveness and safety of AD treatment in Japanese adults (aged 20-59 years) with moderate-to-severe AD. Three clinician-reported AD severity outcomes (Investigator's Global Assessment, Eczema Area and Severity Index, and body surface area affected), three dermatological patient-reported outcomes (Patient-Oriented Eczema Measure, Dermatology Life Quality Index, and Worst Itch Numerical Rating Scale), and two general HRQoL patient-reported outcomes (5-dimension EuroQoL questionnaire and EuroQol Visual Analog Scale) were collected at baseline and every 3 months throughout the 24-month observation period. Four biomarkers were also analyzed when available (thymus and activation-regulated chemokine [TARC], lactate dehydrogenase [LDH], total immunoglobulin E [IgE], and peripheral blood eosinophil counts [PB EOS]). Spearman's correlation coefficients were calculated using all available pooled data from baseline through 24 months.

RESULTS

Correlations between the three clinician-reported outcomes were high/very high (Spearman's correlation coefficients 0.76-0.92); those between the three dermatological patient-reported outcomes were moderate (0.53-0.64), and those between the clinician-reported and dermatological patient-reported outcomes were low/moderate (0.37-0.51). Correlations between the general HRQoL patient-reported outcomes and the clinician-reported and dermatological patient-reported outcomes were negligible-moderate (0.26-0.60). Biomarker correlations with the clinician-reported and dermatological patient-reported outcomes were low/moderate for TARC and LDH (0.44-0.63), but negligible/low for PB EOS and total IgE (0.01-0.41).

CONCLUSIONS

These results show that clinician- and patient-reported outcomes do not necessarily correlate well in Japanese adults with AD. This highlights the importance of including patient-reported outcomes when assessing disease severity/impact, planning treatment, and assessing response to treatment.

TRIAL REGISTRATION

UMIN Clinical Trials Registry (UMIN-CTR) Identifier UMIN000022623.

Comparison of standardized prophylactic high-dose and intrathecal methotrexate for DLBCL with a high risk of CNS relapse

The efficacy of high-dose methotrexate (HD-MTX) for central nervous system (CNS) relapse prophylaxis in patients with high-risk diffuse large B-cell lymphoma (DLBCL) is controversial. We compared the prophylactic effects of HD-MTX and intrathecal methotrexate (IT-MTX) on CNS relapse in high-risk DLBCL, in a multicenter retrospective study. A total of 132 patients with DLBCL at high risk of CNS relapse who received frontline chemotherapy and IT-MTX from 2003 to 2013 (n = 34) or HD-MTX from 2014 to 2020 (n = 98) were included. After a median follow-up of 52 months (range: 9-174), 11 patients had isolated CNS relapse: six (6.1%) in the HD-MTX group and five (14.7%) in the IT-MTX group. The median time until CNS relapse was 38 months (range: 11-122), and the cumulative incidence of CNS relapse at 3 years was 3.9% in the HD-MTX group and 6.1% in the IT-MTX group (P = 0.93). Similar results were obtained after adjusting for background factors using propensity score-matched analysis (4.5% HD-MTX vs. 7.6% IT-MTX, P = 0.84). The CNS relapse rate in HD-MTX-treated patients was equivalent to that in IT-MTX patients, demonstrating that HD-MTX was not superior to IT-MTX in preventing CNS relapse.

Real-world data of AML in Japan: results of JALSG clinical observational study-11 (JALSG-CS-11)

This report covers acute myeloid leukemia (AML) results from a multicenter, prospective observational study of AML, myelodysplastic syndromes, and chronic myelomonocytic leukemia in Japan. From August 2011 to January 2016, 3728 AML patients were registered. Among them, 42% were younger than 65, and the male-to-female ratio was 1.57:1. With a median follow-up time of 1807 days (95% confidence interval [CI]: 1732-1844 days), the estimated 5-year overall survival (OS) rate in AML patients (n = 3707) was 31.1% (95% CI: 29.5-32.8%). Trial-enrolled patients had a 1.7-fold higher OS rate than non-enrolled patients (5-year OS, 58.9% [95% CI: 54.5-63.1%] vs 35.5% [33.3-37.8%], p < 0.0001). Women had a higher OS rate than men (5-year OS, 34% [95% CI; 31.4-36.7%] vs 27.7% [25.7-29.7%], p < 0.0001). The OS rate was lower in patients aged 40 and older than those under 40, and even lower in those over 65 (5-year OS for ages < 40, 40-64, 65-74, ≥ 75: 74.5% [95% CI; 69.3-79.0%] vs 47.5% [44.4-50.6%] vs 19.3% [16.8-22.0%] vs 7.3% [5.5-9.4%], respectively). This is the first paper to present large-scale data on survival and clinical characteristics in Japanese AML patients.

Prognostic significance of the CFA ratio for newly diagnosed acute myeloid leukemia: A multicenter retrospective study

The CFA ratio, calculated using pretreatment C-reactive protein (CRP), fibrinogen, and albumin levels (CRP × fibrinogen/albumin), was previously reported to be a significant prognostic factor for acute myeloid leukemia (AML). This multicenter retrospective study evaluated the prognostic value of the CFA ratio in 328 adult patients with newly diagnosed AML from April 2000 to March 2018. The median age was 49.5 years (range, 15-75 years), and 60.7% of the population were males. According to the European LeukemiaNet (ELN) risk classification, 67 patients (20.4%) were in the favorable-risk group, 197 patients (60.1%) in the intermediate-risk group, and 58 patients (17.7%) in the adverse-risk group. The median CFA ratio was 1.07 (0-67.69). Based on the calculated cutoff CFA ratio of 1.44, the cohort included 176 and 152 patients with low and high CFA ratios, respectively. At a median follow-up of 91.2 months, the 7-year overall survival (OS) and disease-free survival (DFS) rates were 51.2% and 48.6%, respectively, in the overall cohort. The 7-year OS rates were 61.7% and 39.0% in the low and high CFA ratio groups, respectively (p < 0.001). The 7-year DFS rates were 58.1% and 37.0% in the low and high CFA ratio groups, respectively (p = 0.004). In univariate analysis, age ≥50 years, male sex, ELN risk class, and comorbidities were associated with poor OS. Age, ELN risk class, comorbidities, and high CFA ratio were associated with poor OS in multivariate analysis. Subgroup analysis revealed that the CFA ratio was significant in the intermediate and adverse ELN risk classes. These findings indicate the prognostic significance of the CFA ratio in AML.

Evaluating the usefulness of the Atopic Dermatitis Control Tool for assessing disease control in individuals with atopic dermatitis in Japan

An online questionnaire assessed atopic dermatitis (AD)-related patient-reported outcome measures [including the Atopic Dermatitis Control Tool (ADCT)] in 5546 patients with AD. Spearman’s rank correlation coefficients showed that total ADCT scores had strong correlations with established AD assessment tools (including the DLQI, POEM and WI-NRS). ADCT subitem scores also had moderate correlations with the other AD assessment tools, except for Q4 (sleep) with the Global Questions assessment tool. This demonstrates that ADCT scores can effectively characterize multidimensional AD disease burden.

Management and Risk Factors for Pleural Effusion in Japanese Patients with Chronic Myeloid Leukemia Treated with First-line Dasatinib in Real-world Clinical Practice

Objective Pleural effusion (PE) is a common adverse event that occurs during dasatinib therapy for chronic myeloid leukemia (CML). However, the pathomechanism of PE and appropriate management of Asian patients with CML have not been elucidated. This study investigated the incidence rate, risk, and appropriate management of PE in Asian patients with CML treated with dasatinib. Methods We retrospectively collected data on patients in the chronic phase of CML who received first-line dasatinib therapy and were registered in the CML-Cooperative Study Group database. Patients We identified 44 cases of PE in a series of 89 patients and analyzed previously reported risk factors and effective management of PE. Results A univariate analysis revealed that age, diabetes mellitus, chronic renal failure, hypertension, the history of cardiovascular events, and dasatinib dose were significantly associated with PE. A multivariate analysis revealed that age ≥65 years old was the only independent risk factor for PE. Dasatinib dose reduction and switching to a tyrosine kinase inhibitor showed a statistically significant difference in effectively reducing PE volume compared to single diuretic use. Conclusion Although further studies are warranted, our observations showed that advanced age is a significant risk factor for PE, and tyrosine kinase inhibitor dose reduction or replacement of dasatinib may be an effective management strategy for PE in Asian CML patients who received first-line treatment with dasatinib in real-world clinical practice.

Cryo-EM structures of human zinc transporter ZnT7 reveal the mechanism of Zn2+ uptake into the Golgi apparatus

Zinc ions (Zn2+) are vital to most cells, with the intracellular concentrations of Zn2+ being tightly regulated by multiple zinc transporters located at the plasma and organelle membranes. We herein present the 2.2-3.1 Å-resolution cryo-EM structures of a Golgi-localized human Zn2+/H+ antiporter ZnT7 (hZnT7) in Zn2+-bound and unbound forms. Cryo-EM analyses show that hZnT7 exists as a dimer via tight interactions in both the cytosolic and transmembrane (TM) domains of two protomers, each of which contains a single Zn2+-binding site in its TM domain. hZnT7 undergoes a TM-helix rearrangement to create a negatively charged cytosolic cavity for Zn2+ entry in the inward-facing conformation and widens the luminal cavity for Zn2+ release in the outward-facing conformation. An exceptionally long cytosolic histidine-rich loop characteristic of hZnT7 binds two Zn2+ ions, seemingly facilitating Zn2+ recruitment to the TM metal transport pathway. These structures permit mechanisms of hZnT7-mediated Zn2+ uptake into the Golgi to be proposed.

Is neonatal uterine bleeding responsible for early-onset endometriosis?

BACKGROUND

It has been hypothesized that the origin of early-onset endometriosis could be from endometrial mesenchymal stem cells (eMSCs) in neonatal uterine blood (NUB). There is no information on the possible mechanistic basis linking an association between NUB/neonatal endometrium and development of early-onset endometriosis. In this study we performed a series of experiments to clarify the mechanistic link between NUB and/or neonatal endometrium and development of early-onset endometriosis.

METHODS

We retrospectively collected postmortem neonatal endometria (n = 15) and prospectively collected NUB (n = 18) of female babies for the analysis of different biological markers including eMSCs. Immunohistochemical analysis of neonatal endometria was performed to examine the expression patterns of ovarian steroid receptors (ER/PGR), decidualization (prolactin, IGFBP1), pre-decidualization (Glycodelin A, α-SMA), proliferation (Ki-67 index), vascularity (CD31 + cells), immunocompetent CD68+, CD45+, CD56 + cells and some putative markers of eMSCs. Cell transfer method and immunocytochemistry were used to investigate the eMSCs and/or endometrial cells in NUB.

RESULTS

Immunohistochemical analysis of postmortem neonatal endometria revealed variable staining response to ER/PGR, decidual markers, and substantial proliferative and angiogenic activity. A moderate to strong immunoexpression of Glycodelin-A was found in both neonatal and adult endometria. The tissue infiltration of CD56+, CD45 + and CD68 + immunocompetent cells was significantly low in neonatal endometria than that in adult endometria (p = 0.0003, p < 0.0001, p = 0.034, respectively). No eMSCs or even endometrial cells were detected in NUB. However, a variable expression of some phenotypes of eMSCs (CD90/CD105) was found in neonatal endometria.

CONCLUSIONS

Based on our serial experiments we did not find any supporting evidence for the role of NUB in early-onset endometriosis. Neonatal endometria showed variable expression of ovarian steroid receptors, decidualization, and a substantial amount of proliferative and angiogenic activity. As an alternative mechanism, a significantly less tissue accumulation of immunocompetent cells in neonatal endometria may explain the survival of ER + and PGR + cells should they make entry into the pelvis and consequent development of early endometriosis with the onset of ovarian function. Future study with large sample size and application of modified technological tools is warranted to test the NUB hypothesis and to clarify their biological or clinical significance.

TRIAL REGISTRATION

not applicable.

Silicon chambers for enhanced incubation and imaging of microfluidic droplets

Droplet microfluidics has become a powerful tool in life sciences, underlying digital assays, single-cell sequencing or directed evolution, and it is making foray in physical sciences as well. Imaging and incubation of droplets are crucial, yet they are encumbered by the poor optical, thermal and mechanical properties of PDMS, a material commonly used in microfluidics labs. Here we show that Si is an ideal material for droplet chambers. Si chambers pack droplets in a crystalline and immobile monolayer, are immune to evaporation or sagging, boost the number of collected photons, and tightly control the temperature field sensed by droplets. We use the mechanical and optical benefits of Si chambers to image ≈1 million of droplets from a multiplexed digital assay - with an acquisition rate similar to the best in-line methods. Lastly, we demonstrate their applicability with a demanding assay that maps the thermal dependence of Michaelis-Menten constants with an array of ≈150 000 droplets. The design of the Si chambers is streamlined to avoid complicated fabrication and improve reproducibility, which makes Si a complementary material to PDMS in the toolbox of droplet microfluidics.

Clinical management of second-generation tyrosine kinase inhibitor therapy in patients with newly diagnosed chronic myeloid leukemia in the chronic phase, focusing on age and dose effects

ABL1-tyrosine kinase inhibitors (TKIs) are an established treatment choice for patients with chronic myeloid leukemia in the chronic phase (CML-CP). However, effects of TKI dose modification have not been well investigated. In this study, we retrospectively analyzed 178 patients with newly diagnosed CML-CP who were treated with dasatinib or nilotinib, focusing on age and dose effects. Efficacy as measured by cumulative major molecular response (MMR) and molecular response 4.5 rates did not differ significantly between the younger group and elderly group. Elderly patients who started nilotinib at a reduced dose had similar or better efficacy outcomes (including cumulative MMR and continuation ratios) than other groups, and elderly patients who started dasatinib at a reduced dose had the lowest MMR ratio and longest MMR duration. Effects of dose modification based on age and TKI selection can be attributed to flexible management of TKI therapy in real-world practice, but further studies are required to validate the findings of this study.

Regional Difference in the Impact of COVID-19 Pandemic on Domain-Specific Physical Activity, Sedentary Behavior, Sleeping Time, and Step Count: Web-Based Cross-sectional Nationwide Survey and Accelerometer-Based Observational Study

BACKGROUND

Physical activity (PA) and sedentary behavior (SB) have been affected by the COVID-19 pandemic and its restrictive environments, such as social distancing and lockdown measures. However, regional differences in the changes in domain-specific PA and SB in response to the COVID-19 pandemic are not clearly understood.

OBJECTIVE

This study aimed to examine regional differences in domain-specific PA and SB, as well as sleeping time in response to the COVID-19 pandemic in Japan.

METHODS

A web-based cross-sectional nationwide survey and an accelerometer-based longitudinal observation were conducted. In the web-based survey, we recruited 150 Japanese men and 150 Japanese women for each of the following age groups: 20s, 30s, 40s, 50s, 60s, and 70s (n=1800). A total of 1627 adults provided valid responses to web-based surveillance from June to July 2020. Participants were recruited from urban (Greater Tokyo Area, n=1028), urban-rural (regional core cities, n=459), or rural (regional small and medium cities, n=140) areas. They answered sociodemographic and health-related questions and retrospectively registered the PA data of their average day before and during the COVID-19 pandemic in a web-based PA record system. In the accelerometer-based observation, PA and step count data were obtained using a triaxial accelerometer on people living in urban (n=370) and rural (n=308) areas.

RESULTS

Before the COVID-19 pandemic, there were no significant differences between these 3 regions in the time spent sleeping, staying at home, working or studying, and exercising (P>.05). By contrast, people living in urban areas had a longer duration of SB and transportation and a shorter duration of moderate-to-vigorous PA and lying or napping time compared with people living in rural areas (P>.05). During the COVID-19 pandemic, a significant decrease was observed in transportation time in urban (-7.2 min/day, P<.001) and urban-rural (-2.0 min/day, P=.009) areas but not in rural (-0.4 min/day, P=.52) areas. The moderate-to-vigorous PA was decreased in urban (-31.3 min/day, P<.001) and urban-rural (-30.0 min/day, P<.001) areas but not in rural areas (-17.3 min/day, P=.08). A significant increase was observed in time spent sleeping in urban (+22.4 min/day, P<.001) and urban-rural (+24.2 min/day, P<.001) but not in rural areas (+3.9 min/day, P=.74). Lying or napping was increased in urban (+14.9 min/day, P<.001) but not in rural areas (-6.9 min/day, P=.68). PA and step count obtained using an accelerometer significantly decreased in urban (P<.05) but not in rural areas (P>.05).

CONCLUSIONS

The effect of the COVID-19 pandemic on PA and SB was significantly dependent on living area, even in a single country. The effects of PA and SB were greater in the Greater Tokyo Area and regional core cities but were not observed in regional small and medium cities in Japan.

Dose-Response Relationships between Diet Quality and Mortality among Frail and Non-Frail Older Adults: A Population-Based Kyoto-Kameoka Prospective Cohort Study

OBJECTIVES

Although better diet quality is inversely associated with mortality risk, the association between diet quality and mortality remains unclear in frail and non-frail older adults. Thus, we aimed to examine this association in older Japanese adults.

DESIGN

A prospective cohort study.

SETTING AND PARTICIPANTS

We used the data of 8,051 Japanese older adults aged ≥65 years in the Kyoto-Kameoka study.

MESUREMENTS

Dietary intake was estimated using a validated food frequency questionnaire. Diet quality was evaluated by calculating the adherence scores to the Japanese Food Guide Spinning Top (range, 0 [worst] to 80 [best]), which were stratified into quartiles. Frailty status was assessed using the validated self-administered Kihon Checklist (KCL) and the Fried phenotype (FP) model. Survival data were collected between February 15, 2012 and November 30, 2016. Statistical analysis was performed using the multivariate Cox proportional hazard analysis and the spline model.

RESULTS

During the median 4.75-year follow-up (36,552 person-years), we recorded 661 deaths. After adjusting for confounders, compared with the bottom adherence score quartile, the top quartile was associated with lower hazard ratio (HR) of mortality in frailty (HR, 0.73; 95% confidence interval [CI], 0.54-1.00) and non-frailty, as defined by the KCL (HR, 0.72; 95% CI, 0.52-1.01). In the spline model, regardless of frailty status defined by the KCL and FP model, adherence score showed a strongly dose-dependent inverse association with mortality up to approximately 55 points; however, no significant differences were observed thereafter. This association was similar to the results obtained in individuals with physical, cognitive, and depression as domains of KCL in the spline model.

CONCLUSIONS

Our findings demonstrate an L-shaped association between diet quality and mortality in both frail and non-frail individuals. This study may provide important knowledge for improving poor diet quality in older individuals with frailty or domains of frailty.

Association of the interaction between physical activity and sitting time with mortality in older Japanese adults

PURPOSE

To examine how physical activity (PA) and sitting time (ST) are associated with mortality in older Japanese adults.

METHODOLOGY

We used the data of 10 233 older Japanese adults aged ≥65 years who provided valid responses to the International Physical Activity Questionnaire-Short Form (IPAQ-SF) by a mail survey. Both PA and ST were assessed using the IPAQ-SF. The results were classified into high or low categories using ≥3.0 metabolic equivalent PA (150 min/week) and ST (300 min/day) into the following four groups: High PA (HPA)/Low ST (LST), HPA/High ST (HST), Low PA (LPA)/LST, and LPA/HST. Mortality data were collected from July 30, 2011, to November 30, 2016. We assessed the interaction of PA and ST status with the risk of all-cause mortality using the multivariable Cox proportional-hazards model.

RESULTS

A total of 1014 people were recorded to have died during a median follow-up period of 5.3 years (51 553 person-years). After adjustment for confounders, the risk of mortality was higher in the LPA/HST group than in all other groups (HPA/LST: reference; HPA/HST group: hazard ratio [HR] 0.86 (95% confidence interval [CI]: 0.66 to 1.12); LPA/LST group: HR 1.09 (95% CI: 0.88 to 1.35); LPA/HST group: HR 1.36 (95% CI: 1.10 to 1.67); and multiplicative interaction: HR 1.44 (95% CI: 1.07 to 1.94)).

CONCLUSIONS

The risk of mortality associated with LPA/HST depends on the level of PA, duration of ST, and their interaction with each other. Our results may be useful in ameliorating the adverse effects leading to mortality in individuals with lower PA, by reducing ST.

Outcomes of adolescents and young adults with chronic-phase chronic myeloid leukaemia treated with tyrosine kinase inhibitors

INTRODUCTION

Few studies have reported the outcomes of adolescents and young adults (AYAs) with chronic-phase chronic myeloid leukaemia (CML-CP) on tyrosine kinase inhibitors (TKIs).

MATERIALS AND METHODS

We retrospectively analysed the clinical features, treatment response, and long-term outcomes of 42 AYA patients, in comparison to older patients. The initial therapies of AYA patients between 2001 and 2016 included imatinib (n = 24), dasatinib (n = 13) and nilotinib (n = 5).

RESULTS

In AYA patients, the peripheral blood (PB) white blood cell count and percentage of blasts at the diagnosis were significantly higher, haemoglobin levels were lower and the spleen size was larger. The major molecular response (MMR), event-free survival (EFS) and overall survival (OS) rates were comparable. A sub-analysis comparing imatinib to second-generation TKIs as the initial therapy also showed that their prognosis was comparable.

DISCUSSION

In conclusion, the tumour burden at the diagnosis of CML-CP is higher in AYA patients; however, their prognosis was not worse in comparison to older patients treated with TKIs. KEY MESSAGESFew studies have reported the outcomes of adolescents and young adults (AYAs) with chronic-phase chronic myeloid leukaemia (CML-CP) on tyrosine kinase inhibitors (TKIs). This study showed the tumour burden at the diagnosis of CML-CP is higher in AYA pa tients; however, their prognosis was not worse in comparison to older patients treated with TKIs. Understanding the biological and non-biological features of AYA patients with CML-CP on TKI therapy is essential for better management and to improve the outcomes.

Impact of BNP level in patients with heart failure on major bleeding events after percutaneous coronary intervention

Aims

The Academic Research Consortium for High Bleeding Risk (ARC-HBR) presents a bleeding risk assessment in antithrombotic therapy for patients post percutaneous coronary intervention (PCI). In Japanese patients, heart failure (HF), peripheral vascular disease, and frailty are established as bleeding risk factors in addition to ARC-HBR. However, it is unknown whether left ventricular function or severity of HF is associated with HBR. The aim of this study was to investigate the association between the severity of HF measured by BNP and future bleeding events after PCI.

Methods

Clinical Deep Data Accumulation System (CLIDAS), a multicenter database with 7 tertiary medical hospitals in JAPAN, was developed to collect data directly for patient characteristics, medications, laboratory test, physiological test, cardiac catheterization and PCI treatment in electronic medical records using Standardized Structured Medical Information eXchange Extended Storage (SS-MIX). This retrospective analysis using CLIDAS database included 7160 patients who underwent PCI during April 2014 and March 2020 in the participating hospitals and also who have completed 3-year follow-up were divided into two groups: No HF (n=6645) and HF (n=515). HF patients were furthermore divided based on high BNP (≥100 pg/ml) group (n=384) and low BNP (&lt;100 pg/ml) group (n=131). Primary outcome was defined as bleeding events according to the moderate and severe bleeding in the GUSTO classification. In addition, secondary endpoint was major adverse cardiovascular events (MACE) defined as a composite of cardiac death, myocardial infraction and stroke.

Results

Multivariable Cox regression adjusted for age, sex, BMI, acute coronary syndrome, hypertension, diabetes, dyslipidemia, chronic kidney disease, hemodialysis, previous PCI, previous coronary artery bypass grafting, prior myocardial infraction, prior stroke, prior atrial fibrillation, prior PVD, left main trunk disease, multivessel disease, and anticoagulants use showed that HF with high BNP was significantly associated with bleeding events (hazard ratio [HR], 1.66; 95% confidence interval [CI], 1.10–2.50), MACE (HR, 2.16; 95% CI, 1.60–2.90), and all-cause death (HR, 1.74; 95% CI, 1.30–2.33), but not HF with low BNP.

Conclusions

The CLIDAS real-world database revealed that HF with high BNP was associated with future bleeding events, suggesting that bleeding risk might be altered depending on severity of HF.

Funding Acknowledgement

Type of funding sources: None.

Hyperuricemia predicts worse prognosis in patients with chronic coronary syndrome after percutaneous coronary intervention: insights from Japanese real-world database using a storage system

Background

The relationship between hyperuricemia (HUA) and cardiovascular disease was observed in some epidemiological studies. However, the association between HUA and chronic coronary syndrome (CCS) after percutaneous coronary intervention (PCI) is not fully elucidated.

Purpose

The purpose of this study was to investigate the prognostic impact of HUA in patients with CCS after PCI.

Methods

This study is a retrospective, multicenter, observational study. We developed the Clinical Deep Data Accumulation System (CLIDAS), which consists of 6 university hospitals and the national cardiovascular center in Japan, directly obtains clinical data including patients background, laboratory data, echocardiogram, electrocardiogram, cardiac catheterization report, prescription, and long-term outcome from electronic medical records. A total of 9936 consecutive patients after PCI were analyzed. Of them, 5138 patients with CCS after PCI during April 2013 and March 2019 were analyzed, and divided into HUA group (patients with HUA at baseline, n=1724) and non-HUA group (patients without HUA at baseline, n=3414). HUA was defined as a serum uric acid levels ≥7.0 mg/dL for men or ≥6.0 mg/dL for women and/or taking urate-lowering drugs. The primary outcome was the major cardiovascular events (MACE) defined as being the composite of cardiovascular death, myocardial infarction, and hospitalization for heart failure.

Results

The median follow-up duration was 910 days (interquartile range: 307–1479 days). The proportion of male (78% vs. 78%) and age (71±11 vs. 71±10) were similar between the HUA and the non-HUA groups. The prevalence of hypertension (87% vs. 82%), atrial fibrillation (9% vs. 5%), and history of previous hospitalization for heart failure (15% vs. 6%) and baseline creatinine value (1.8±2.3 vs. 1.5±2.0 mg/dL) were significantly higher in the HUA group. In contrast, the prevalence of diabetes (43% vs. 48%) was significantly lower in the HUA group. The incidence of MACE was significantly higher in the HUA group than in the non-HUA group (13.1% vs. 6.4%, log rank P&lt;0.001). Multivariate Cox regression analyses revealed that hyperuricemia was significantly associated with MACE (hazard ratio 1.50, 95% confidence interval 1.22–1.84, P&lt;0.001) after controlling for other cardiovascular risk factors.

Conclusion

The real-world database CLIDAS revealed that hyperuricemia was significantly associated with the increase of MACE in patients with CCS after PCI. This result sheds light on the significant role of urate in prediction of prognosis, suggesting the possibility of new therapeutic approaches using urate-lowering drugs or SGLT2 inhibitors for the CCS patients.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Jichi Medical University, Tochigi, Japan, and Kowa Co., Ltd

Combined use of two frailty tools in predicting mortality in older adults

We aimed to verify the combined use of two frailty tools in predicting mortality in older adults. We used the data of 10,276 Japanese older adults (aged ≥ 65 years) who provided valid responses to two frailty assessment tools in a mail survey in Japan’s Kyoto‒Kameoka Prospective cohort study. Frailty status was categorized into four groups depending on the validated frailty screening index and Kihon Checklist, respectively: Non-frailty (n = 5960), Physical frailty (n = 223), Comprehensive frailty (n = 2211), and Combination (n = 1882) groups. Mortality data were collected between July 30, 2011, and November 30, 2016. We assessed the relationship between frailty status and all-cause mortality risk using multivariate Cox proportional hazards models. During a median follow-up of 5.3 years, we recorded 1257 deaths. After adjusting for confounders, the Combination group had the highest mortality risk compared with the other groups [Non-frailty: reference; Physical frailty: hazards ratio [HR], 0.99 (95% confidence interval [CI] 0.58 to 1.70); Comprehensive frailty: 1.91 (1.63 to 2.23); Combination: 2.85 (2.44 to 3.22)]. People who are positive for frailty in both instruments have a higher risk of death than those who are positive to one model.

Evaluation of standard treatments for managing adult Japanese patients with inadequately controlled moderate-to-severe atopic dermatitis: Two-year data from the ADDRESS-J disease registry

Atopic dermatitis (AD), a chronic relapsing inflammatory skin disease with a high disease burden, is one of the most common dermatological conditions in Japan. Herein, we report the disease profiles and current AD treatment during 2‐year management of Japanese adults with moderate‐to‐severe AD. ADDRESS‐J was a prospective, longitudinal, observational study that evaluated real‐world effectiveness and safety of current AD treatments of adult patients with moderate‐to‐severe AD (Investigator's Global Assessment score 3 or 4) in Japan. The maximum follow‐up period was 2 years. Among 300 patients enrolled, 288 had ≥1 post‐baseline evaluation and were analyzed (mean age, 35.5 years; 60.1% male). Almost all patients (99.7%) received topical therapy; the most commonly used therapy was topical corticosteroids of the second‐highest potency (86.5%) (e.g., 0.1% mometasone furoate) followed by medium‐potency topical corticosteroids (50.3%) (e.g., 0.05% clobetasol butyrate). At month 12 of the study, 10.4% of patients had Investigator's Global Assessment 0/1, similarly at month 24 (10.8%). A total of 132 patients (45.8%) had ≥1 AD flare‐up during the observation period, with the majority of first flares occurring within the first year of the study. Various physician‐ and patient‐reported outcomes improved considerably during the first 3 months of the study, with only minor changes after this time. In this cohort, 16.7% of patients had skin infections requiring treatment; 7.3% had adverse events (AE) potentially related to treatment; 1.7% had serious AE; and 1.0% had treatment discontinuations due to AE. Limitations include missing data at later timepoints and the inclusion criteria limiting generalizability. In summary, this analysis of the ADDRESS‐J study showed that some patients with moderate or severe AD respond to conventional therapies, while others do not. For those with inadequately controlled moderate‐to‐severe AD, the newly emerged systemic agents, such as biologics, may provide a potential strategy for long‐term disease management.

Direct Capture and Amplification of Small Fragmented DNAs Using Nitrogen-Mustard-Coated Microbeads

Circulating cell-free DNA (cfDNA) has been implicated as an important biomarker and has been intensively studied for "liquid biopsy" applications in cancer diagnostics. Owing to its small fragment size and its low concentration in circulation, cfDNA extraction and purification from serum samples are complicated, and the extraction yield affects the precision of subsequent molecular diagnostic tests. Here, we report a novel approach using nitrogen-mustard-coated DNA capture beads (NMD beads) that covalently capture DNA and allow direct subsequent polymerase chain reaction (PCR) amplification from the NMD bead without elusion. The complex DNA extraction and purification processes are not required. To illustrate the diagnostic use of the NMD beads, we detected short DNA fragments (142 bp) that were spiked into fetal bovine serum (as a model serum sample). The spiked DNAs were captured directly from serum samples and detected using real-time PCR at concentrations as low as 10 fg/mL. We anticipate that this DNA capture bead technique has the potential to simplify the preanalytical processes required for cfDNA detection, which could significantly expand the diagnostic applications of liquid biopsy.

Ultrahigh strength and shear-assisted separation of sliding nanocontacts studied in situ

The behavior of materials in sliding contact is challenging to determine since the interface is normally hidden from view. Using a custom microfabricated device, we conduct in situ, ultrahigh vacuum transmission electron microscope measurements of crystalline silver nanocontacts under combined tension and shear, permitting simultaneous observation of contact forces and contact width. While silver classically exhibits substantial sliding-induced plastic junction growth, the nanocontacts exhibit only limited plastic deformation despite high applied stresses. This difference arises from the nanocontacts’ high strength, as we find the von Mises stresses at yield points approach the ideal strength of silver. We attribute this to the nanocontacts’ nearly defect-free nature and small size. The contacts also separate unstably, with pull-off forces well below classical predictions for rupture under pure tension. This strongly indicates that shearing reduces nanoscale pull-off forces, predicted theoretically at the continuum level, but not directly observed before.

To understand and predict friction, it is crucial to observe sliding at the nanoscale to uncover the mechanisms at play. Here, the authors show that nano-contacts exhibit strength near the ideal limit, and find that pull-off forces predicted by continuum models are reduced by shearing.

Are the Physical and Cognitive Functions of Older Adults Affected by Having a Driver's License?-A Pilot Study of Suburban Dwellers

Previous studies have frequently reported that those with a driver’s license have better physical and cognitive functions than those without. However, there are many people in the world who do not need or who cannot have a driver’s license. We hypothesized that if the non-driver’s license group had the same or better physical and cognitive functioning as the driver’s license group, they could lead healthy lives without the risk of functional decline or loss of functioning due to surrendering their licenses or giving up driving. The subjects were 47 community-dwelling older adults. We measured their physical function and cognitive function and performed psychological assessment via the following tests: grip strength, Timed Up and Go test, walking speed, Five Times Sit to Stand test, Functional Reach test, Two-Step Test, Mini-Mental State Examination, Trail Making Test, Modified Falls Efficacy Scale, Geriatric Depression Scale, and University of California Los Angeles Loneliness Scale. In previous studies, it has been said that having a driver’s license provides good physical, cognitive, and psychological functions. However, in this study, loneliness and executive function were strongly influenced by age and sex, and no direct relationship to a driver’s license was suggested. Rather, non-driver license holders may be relieved because there is no risk of accidents due to driving, and there is no possibility of a suddenly decline in physical or cognitive function due to revocation of a driver’s license.

Difference of compliance rates for the recommendations in Japanese Guideline on Febrile Neutropenia according to respondents’ attributes: the second report on a questionnaire survey among hematology-oncology physicians and surgeons

Purpose

The Japanese Society of Medical Oncology (JSMO) published a guideline (GL) on febrile neutropenia (FN) in 2017. This study aims to identify promoting factors and disincentives for complying with GL recommendations according to attributes of doctors providing chemotherapy.

Methods

A questionnaire survey was conducted with SurveyMonkey™ for physician members of the Japanese Association of Supportive Care in Cancer and relevant academic organizations. Each question had four options (always do, do in more than half of patients, do in less than half, do not at all) and a free description form. Responses were analyzed according to the respondents’ attributes.

Result

Seven hundred eighty-eight out of retrieved 801 responses were available for analysis. Multivariable analysis demonstrated that the percentage of GL users was higher among women and Japanese Society of Clinical Oncology members. The overall compliance rate was higher among women, JSMO members, and board-certified medical oncologists. Internists emphasized the significance of collecting blood cultures at FN onset, and surgeons stressed the importance of G-CSF prophylaxis. Hematologists were less likely to adhere to recommendations on risk assessment of FN by the Multinational Association of Supportive Care in Cancer score and administration of gammaglobulin products. However, those are acceptable due to the characteristics of their practice. Eight recommendations had no difference in compliance rates between users and non-users, some of whose statements were ambiguous and discretionary.

Conclusion

Women were more likely to use and adhere to GL. The recommendations should be developed considering the characteristics of specialty and subspecialty and avoiding ambiguity and discretionary statements.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-022-06834-9.

Adequate Protein Intake on Comprehensive Frailty in Older Adults: Kyoto-Kameoka Study

OBJECTIVES

Defining an adequate protein intake in older adults remains unresolved. We examined the association between calibrated protein intake and comprehensive frailty by sex in the Kyoto-Kameoka study.

DESIGN

Cross-sectional study of baseline data.

SETTING AND PARTICIPANTS

The study included 5679 Japanese participants aged 65 years or older.

METHODS

Calibration coefficients were estimated from food frequency questionnaires and 7-day dietary records as a reference. Comprehensive frailty was evaluated using the 25-item Kihon Checklist (KCL) and defined as a total KCL score of ≥7points. Sex-specific calibrated protein intakes were presented as % of energy, per kg of actual body weight (BW), and per kg of ideal BW.

RESULTS

Multiple logistic regression analysis showed that calibrated protein intake is inversely associated with comprehensive frailty. The association between protein intake and comprehensive frailty was also evaluated using curve fitting with non-linear regression, a weak U-shaped association was found in males and an L-shaped association in females. Men had a low prevalence of frailty at a calibrated protein intake of 15-17% energy from protein, 1.2 g/kg actual BW/day, or 1.4 g/kg ideal BW/day, and women had a low prevalence of frailty at 17-21% energy from protein or 1.6 g/kg ideal BW/day, with the prevalence of frailty remaining unchanged at higher protein intakes. Meanwhile, the inverse relationship between protein intake per ABW and frailty showed a gradual decrease at 1.4 g/kg ABW/day for protein in women.

CONCLUSIONS AND IMPLICATIONS

A non-linear relationship was found between calibrated protein intake and frailty, with a U-shaped association in men and an L-shaped association in women. Adequate protein intake in healthy Japanese older adults was higher than the current recommended daily allowance.

Dupilumab efficacy in chronic rhinosinusitis with nasal polyps from SINUS-52 is unaffected by eosinophilic status

Background

The human monoclonal antibody dupilumab blocks interleukin (IL)‐4 andIL‐13, key and central drivers of type 2 inflammation. Dupilumab, on background mometasone furoate nasal spray (MFNS), improved outcomes in the phase III SINUS‐52 study (NCT02898454) in patients with severe chronic rhinosinusitis with nasal polyps (CRSwNP). This posthoc analysis of SINUS‐52 examined whether eosinophilic status of CRSwNP was a predictor of dupilumab efficacy.

Methods

Patients were randomized 1:1:1 to dupilumab 300 mg every 2 weeks (q2w) until week 52; dupilumab 300 mg q2w until Week 24, then 300 mg every 4 weeks until week 52; or placebo (MFNS) until week 52. Coprimary endpoints were change from baseline in nasal polyps score (NPS), nasal congestion (NC), and Lund‐Mackay score assessed by CT (LMK‐CT) at week 24. Patients (n = 438) were stratified by eosinophilic chronic rhinosinusitis (ECRS) status according to the Japanese Epidemiological Survey of Refractory Eosinophilic Rhinosinusitis algorithm.

Results

Dupilumab significantly improved NPS, NC, and LMK‐CT scores versus placebo at week 24 in all ECRS subgroups (p < 0.001), with improvements maintained or increased at week 52 (p < 0.001). There was no significant interaction between ECRS subgroup (non‐/mild or moderate/severe) and dupilumab treatment effect for all endpoints at weeks 24 and 52 (p > 0.05), except LMK‐CT at week 24 (p = 0.0275). Similar results were seen for the secondary endpoints. Dupilumab was well tolerated across all ECRS subgroups.

Conclusion

Dupilumab produced consistent improvement in symptoms of severe CRSwNP irrespective of ECRS status. Therefore, blood eosinophil level may not be a suitable biomarker for dupilumab efficacy in CRSwNP.

A questionnaire survey on evaluation for penetration and compliance of the Japanese Guideline on Febrile Neutropenia among hematology-oncology physicians and surgeons

PURPOSE

The Japanese Society of Medical Oncology published a guideline (GL) on febrile neutropenia (FN) in 2017. The study's purpose is to reveal how widely GL penetrated among physicians and surgeons providing chemotherapy.

METHODS

A questionnaire survey was conducted with SurveyMonkey™ for members of the Japanese Association of Supportive Care in Cancer and relevant academic organizations. Each question had four options (always do, do in more than half of patients, do in less than half, do not at all) and a free description form. Responses were analyzed with statistical text-analytics.

RESULT

A total of 800 responses were retrieved. Major respondents were experts with more than 10-year experience, physicians 54%, and surgeons 46%. Eighty-seven percent of respondents knew and used GL. Forty-eight percent assessed FN with Multinational Association of Supportive Care in Cancer (MASCC) score "always" or "more than half." Eighty-one percent chose beta-lactam monotherapy as primary treatment in high-risk patients. Seventy-seven percent did oral antibacterial therapy in low-risk patients ambulatorily. Seventy-eight percent administered primary prophylactic G-CSF (ppG-CSF) in FN frequency ≥ 20% regimen. Fifty-nine percent did ppG-CSF for high-risk patients in FN frequency 10-20% regimen. Ninety-seven percent did not use ppG-CSF in FN frequency < 10% regimen. The medians of complete and complete plus partial compliance rates were 46.4% (range 7.0-92.8) and 77.8% (range 35.4-98.7). The complete compliance rates were less than 30% in seven recommendations, including the MASCC score assessment.

CONCLUSION

GL is estimated to be widely utilized, but some recommendations were not followed, presumably due to a mismatch with actual clinical practices in Japan.

Fungal biomarker monitoring and CT scans for early detection of invasive fungal disease in neutropenic hematological patients

OBJECTIVES

By using data from the CEDMIC trial (n = 413), we conducted a post-hoc analysis of the diagnostic value of biomarker monitoring and chest computed tomography (CT) scans for the early detection of invasive fungal disease (IFD) in neutropenic hematological patients.

METHODS

IFDs were defined in accordance with the EORTC/MSG definition with some modifications. Biomarkers such as Aspergillus galactomannan (GM) and (1→3)-β-D-glucan (βDG) were measured weekly.

RESULTS

The positive predictive value (PPV) of GM and βDG in cases of high-risk treatment were 0.70 and 0.69, while those in low-risk treatment were 0.08 and 0, respectively. All of the positive biomarkers that were measured before the development of fever in low-risk treatment were false positives. The proportion of patients who had abnormal chest CT findings was 19% in persistent fever at 4-6 days, 57% at 7 days or later and 36% in recurrent fever. Sixty-nine percent of the patients who had abnormal findings at 7 days or later did not have abnormalities at 4-6 days.

CONCLUSIONS

Afebrile screening of biomarkers in low-risk treatment is not useful. Chest CT should be reevaluated in persistent fever lasting for 7 days or longer even in patients who did not have abnormalities within 6 days.

The relationships among the pulse rate, use of beta-blockers, and prognosis in patients with ischemic heart disease in a real-world database using a storage system

Background

The use of β-blockers has the effect of improving the prognosis of patients with ischemic heart disease (IHD). One of the underlying mechanisms is a decrease in the cardiac load due to a reduction in the heart rate.

Purpose

To clarify the relationships among the pulse rate, the use of β-blockers, and the prognosis in patients with IHD in a multicenter study using a storage system.

Methods

The Clinical Deep Data Accumulation System (CLIDAS) collects (1) basic patient information, prescriptions, and laboratory data from electronic medical records from the Standardized Structured Medical Information eXchange (SS-MIX2) standard storage, and (2) the results of physiological tests, cardiac catheterization, and cardiac catheter intervention reports from the SS-MIX2 extended storage. 8540 cases who underwent cardiac catheterization from 6 university hospitals and the national cardiovascular center in Japan were registered (male: 77%, average age: 70.2 years). We evaluated these patients' pulse rate at admission and at the discharge of cardiac catheterization in 6,598 patients. We divided the pulse rates at discharge into quartiles (Q1: &lt;60, Q2: 60–66, Q3: 67–75, Q4: ≥76 bpm), and we analyzed the relationship between the pulse rate and the prognosis by dividing the patients into the stable angina group (n=2,631) and the acute coronary syndrome (ACS) group (n=2,394). Regarding the use of β-blockers, we compared the pulse rates of the patients taking carvedilol (n=1,728) and those taking bisoprolol (n=2,761) at admission and discharge. Major adverse cardiovascular events (MACE) were defined as cardiovascular death, non-fatal myocardial infarction, unstable angina, heart failure, stroke, and other hospitalized cardiovascular events.

Results

A total of 600 MACEs occurred during an average observation period of 890 days. The incidence of cardiovascular events was significantly higher in the Q4 patients in the stable angina group (hazard ratio 1.79, 95% confidence interval 1.32–2.41, but there was no significant difference among the four pulse rate subgroups in the ACS group. The bisoprolol-treated patients had lower pulse rates at discharge (67.4±12.2 vs. 68.8±11.8 bpm, p&lt;0.001) and a lower percentage of patients in the Q4 group (21.2 vs. 24.9%, p=0.005) compared to the carvedilol-treated patients. The pulse rate at admission was similar in the bisoprolol- and carvedilol-treated patients (74.3±19.3 vs. 73.2±29.5 bpm, p=0.328).

Conclusion

In a real-world database using a storage system, a pulse rate of ≤75 bpm was associated with a good prognosis in patients with ACS. Compared to carvedilol, bisoprolol was associated with a decreased pulse rate at discharge.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Kowa Company, Ltd.

Clinical Deep Data Accumulation System (CLIDAS) reveals lipid paradox in guideline-defined high risk Japanese patients after PCI

Background

Japanese clinical guidelines recommend a stratification of the risks and LDL-cholesterol (LDL-C) treatment goals for patients with coronary artery disease after percutaneous coronary intervention (PCI), i.e. &lt;100 mg/dL for normal risk patients and &lt;70 mg/dL for high risk patients; however, less is known about the association between baseline LDL-C values and long-term prognosis.

Purpose

To investigate the association between LDL-C goals and baseline LDL-C levels in relation to major adverse cardiovascular events (MACE) among high-risk patients after PCI, using a real-world database.

Methods

We developed the Clinical Deep Data Accumulation System (CLIDAS) that acquires clinical data directly from hospital information system, and implemented the system in 6 university hospitals and the national cardiovascular center in Japan. The CLIDAS database accumulates data regarding patient background, laboratory data, prescriptions, electrocardiogram, echocardiogram, PCI report, and long-term prognosis. We retrospectively analyzed 8540 consecutive patients who underwent PCI during April 2014 and March 2020 in participating hospitals, and classified them into the normal risk group (n=3712, 43%) and the high risk group [n=4828, 57%, with any of acute coronary syndrome (ACS), familial hypercholesterolemia (FH), or diabetes with additional risk factor(s)], for which LDL-C goals are &lt;100 mg/dL and &lt;70 mg/dL, respectively, according to the Japanese Atherosclerosis Society guidelines or the diagnosis and prevention of atherosclerotic cardiovascular diseases. The primary outcome was the time to first occurrence of MACE, a composite of cardiovascular death, stroke, myocardial infarction, and coronary revascularization in associations with baseline LDL-C levels and patient background.

Results

Proportion of male (77% vs. 77%) and age (71±11 vs. 70±11) were similar between 2 groups. The prevalence of ACS at the index PCI (0% vs. 62%), FH (0% vs. 2%), hypertension (61% vs. 86%), diabetes (11% vs. 67%), dyslipidemia (73% vs. 84%), hemodialysis (4% vs. 9%), peripheral artery disease (5% vs. 9%), smoking (16% vs. 30%), and prescription of statins (79% vs. 86%) were significantly higher in the high risk group. Among patients in the high risk group, but not in the normal risk group, baseline LDL-C &lt;70 mg/dL was paradoxically associated with higher risk of MACE (P&lt;0.0001 by Log-rank test) (Figure). The Cox proportional hazard model confirmed that the high risk group (risk ratio 1.54, 95% CI [1.31–1.81]), baseline LDL-C &lt;70mg/dL (risk ratio 1.44, 95% CI [1.18–1.75]), baseline age (risk ratio 1.36, 95% CI [1.28–1.45] per 10 year), and prescription of statins (risk ratio 0.80, 95% CI [0.66–0.96]) were significantly associated with the risk of MACE in this population.

Conclusion

The CLIDAS real-world database revealed that baseline low LDL-C paradoxically associated with an increased risk of MACE among guideline-defined high risk patients after PCI.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Jichi Medical University, Tochigi, Japan, and Kowa

Effect of Oil-Droplet Diameter on Lipid Oxidation in O/W Emulsions

The effect of oil-droplet diameter on lipid oxidation in O/W emulsions is unclear, and conflicting results have been reported. These conflictions may be due to different experimental conditions being used, such as the type of oil, the type of emulsifier, temperature, and the range of oil-droplet diameters tested. The method used to evaluate the oxidation could also have varied among studies. In O/W emulsions, oxygen dissolved in the aqueous phase is transferred to the oil phase through the oil-water interface and is consumed in the oil phase by oxidation. Therefore, the effect of the oil-droplet diameter on the lipid oxidation rate was evaluated by simultaneously solving the mass balance equations of oxygen and oil in the oil phase. The simulation showed that the oil-droplet diameter does not affect the lipid oxidation rate in O/W emulsions with oil-droplet diameters on the order of micrometers or less because the oxidation reaction itself is rate-limiting.

Doubly labelled water-calibration approach attenuates the underestimation of energy intake calculated from self-reported dietary assessment data in Japanese older adults

OBJECTIVE

Self-reported energy intake (EI) estimation may incur systematic errors that could be attenuated through biomarker calibration. We aimed to confirm whether calibrated EI was comparable to total energy expenditure (TEE) measured using the doubly labelled water (DLW) technique.

DESIGN

Cross-sectional study.

SETTING

General older population from the Kyoto-Kameoka Study, Japan.

PARTICIPANTS

This study included sub- and main cohorts of 72 and 8058 participants aged≥ 65 years, respectively. EI was evaluated using a validated FFQ, and calibrated EI was obtained using a previously developed equation based on the DLW method. TEE was considered representative of true EI and also measured using the DLW method. We used a Wilcoxon signed-rank test and correlation analysis to compare the uncalibrated and calibrated EI with TEE.

RESULTS

In the sub-cohort, the median TEE, uncalibrated EI and calibrated EI were 8559 kJ, 7088 kJ and 9269 kJ, respectively. The uncalibrated EI was significantly lower than the TEE (median difference = -1847 kJ; interquartile range (IQR): -2785 to -1096), although the calibrated EI was not (median difference = 463 kJ; IQR: -330 to 1541). The uncalibrated (r = 0·275) and calibrated EI (r = 0·517) significantly correlated with TEE. The reproducibility was higher for calibrated EI (interclass correlation coefficient (ICC) = 0·982) than for uncalibrated EI (ICC = 0·637). Similar findings were observed when stratifying the sample by sex. For medians, uncalibrated EI was lower (about 17 %) than calibrated EI in the main cohort.

CONCLUSIONS

Biomarker calibration may improve the accuracy of self-reported dietary intake estimation.

Diagnostic Accuracy of Diastolic Fractional Flow Reserve for Functional Evaluation of Coronary Stenosis

Background

In the resting conditions, narrowing the window of coronary pressure measurements from the whole cardiac cycle to diastole improves diagnostic performance of coronary pressure–derived physiological index. However, whether this also applies to the hyperemic conditions has not yet been thoroughly evaluated.

Objectives

The purpose of this study was to assess whether diastolic fractional flow reserve (diastolic FFR) has better diagnostic performance in identifying ischemia-causing coronary lesions than conventional FFR in a prospective, multicenter, and independent core laboratory–based environment.

Methods

In this prospective multicenter registry at 29 Japanese centers, we compared the diagnostic performance of FFR, diastolic FFR, resting distal to aortic coronary pressure (Pd/Pa), and diastolic pressure ratio (dPR) using myocardial perfusion scintigraphy (MPS) as the reference standard in 378 patients with single-vessel coronary disease.

Results

Inducible myocardial ischemia was found on MPS in the relevant myocardial territory of the target vessel in 85 patients (22%). In the receiver-operating curve analyses, diastolic FFR had comparable area under the curve (AUC) compared with FFR (AUC_{diastolic FFR}: 0.66; 95% confidence interval [CI]: 0.58-0.73, vs AUC_FFR: 0.66; 95% CI: 0.58-0.74, P = 0.624). FFR and diastolic FFR showed significantly larger AUCs than resting Pd/Pa (0.62; 95% CI: 0.54-0.70; P = 0.033 and P = 0.046) but did not show significantly larger AUCs than dPR (0.62; 95% CI: 0.55-0.70; P = 0.102 and P = 0.113).

Conclusions

Diastolic FFR showed a similar diagnostic performance to FFR as compared with MPS. This result reaffirms the use of FFR as the most accurate invasive physiological lesion assessment. (Diagnostic accuracy of diastolic fractional flow reserve (d-FFR) for functional evaluation of coronary stenosis; UMIN000015906)

Efficient Generation of Microdroplets Using Tail Breakup Induced with Multi-Branch Channels

In recent years, research on the application of microdroplets in the fields of biotechnology and chemistry has made remarkable progress, but the technology for the stable generation of single-micrometer-scale microdroplets has not yet been established. In this paper, we developed an efficient and stable single-micrometer-scale droplet generation device based on the fragmentation of droplet tails, called "tail thread mode", that appears under moderate flow conditions. This method can efficiently encapsulate microbeads that mimic cells and chemical products in passively generated single-micrometer-scale microdroplets. The device has a simple 2D structure; a T-junction is used for droplet generation; and in the downstream, multi-branch channels are designed for droplet deformation into the tail. Several 1-2 µm droplets were successfully produced by the tail's fragmentation; this continuous splitting was induced by the branch channels. We examined a wide range of experimental conditions and found the optimal flow rate condition can be reduced to one-tenth compared to the conventional tip-streaming method. A mold was fabricated by simple soft lithography, and a polydimethylsiloxane (PDMS) device was fabricated using the mold. Based on the 15 patterns of experimental conditions and the results, the key factors for the generation of microdroplets in this device were examined. In the most efficient condition, 61.1% of the total droplets generated were smaller than 2 μm.

Myofascial Release of the Hamstrings Improves Physical Performance-A Study of Young Adults

Physical performance is mainly assessed in terms of gait speed, chair rise capacity, and balance skills, and assessments are often carried out on the lower limbs. Such physical performance is largely influenced by the strength of the quadriceps and hamstrings muscles. Flexibility of the hamstrings is important because quadriceps muscle activity influences the hip flexion angle. Therefore, hamstring flexibility is essential to improve physical performance. In this study, Myofascial Release (MFR) was applied to the hamstrings to evaluate its effects. MFR on the hamstrings was performed on 17 young adults. Physical function and physical performance were measured before, immediately after, and 5 days after the MFR intervention: finger floor distance (FFD), range of motion (ROM) of the straight leg raising test (SLR), standing long jump (SLJ), squat jump (SJ), functional reach test (FRT), comfortable walking speeds (C-walking speed), and maximum walking speeds (M-walking speed). The results of the analysis show a significant increase in FFD (−2.6 ± 8.9 vs. 0.4 ± 9.4 vs. 2.4 ± 8.9, p < 0.01), SLJ (185.6 ± 44.5 vs. 185.0 ± 41.8 vs. 196.6 ± 40.1, p < 0.01), and M-walking speed (2.9 ± 0.6 vs. 3.0 ± 0.6 vs. 3.3 ± 0.6, p < 0.01). This study has shown that MFR for hamstrings not only improves flexibility but also increases M-walking speed and physical performance of the SLJ. As MFR is safe and does not involve joint movement, it may be useful for maintaining and improving performance and flexibility during inactivity and for stretching before exercise.

A high-dynamic-range digital RF-over-fiber link for MRI receive coils using delta-sigma modulation

Coaxial cables commonly used to connect radio-frequency (RF) coil arrays with the control console of an MRI scanner are susceptible to electromagnetic coupling. As the number of RF channels increases, such coupling could result in severe heating and pose a safety concern. Non-conductive transmission solutions based on fiber-optic cables are considered to be one of the alternatives but are limited by the high dynamic range (>80 dB) of typical MRI signals. A new digital fiber-optic transmission system based on delta-sigma modulation (DSM) is developed to address this problem. A DSM-based optical link is prototyped using off-the-shelf components and bench-tested at different signal oversampling rates (OSRs). An end-to-end dynamic range (DR) of 81 dB, which is sufficient for typical MRI signals, is obtained over a bandwidth of 200 kHz, which corresponds to OSR = 50. A fully integrated custom fourth-order continuous-time DSM is designed in 180 nm CMOS technology to enable transmission of full-bandwidth MRI signals (up to 1 MHz) with an adequate DR. Initial electrical test results from this custom chip are also presented.

Kinetic analysis of thermal degradation of betanin at various pH values using deconvolution method

Although betanin is commonly used as a water-soluble red colorant in foods, it is unstable when heated. In this study, the discoloration of betanin in a buffer solution was kinetically studied in the pH range of 2.6 to 7.6 at 40 °C to 80 °C. The absorption spectrum of betanin was deconvoluted into the spectra of betanin and its degradation product, betalamic acid. Subsequently, a reversible consecutive reaction, in which betanin was reversibly degraded to betalamic acid, and betalamic acid was further degraded, was assumed to calculate the first-order rate constant of each step. The apparent reaction mechanism varied depending on the pH values. Based on these rate constants, the activation energy of each process, as well as the equilibrium constant and enthalpy change for the reversible reaction between betanin and betalamic acid were evaluated.

Juzentaihoto extract suppresses adipocyte hypertrophy and improves hyperglycemia in KKAy mice

Juzentaihoto is a herbal medicine with reported anti-inflammatory effects, and it is predicted to improve inflammation and insulin sensitivity within obesity. In the present study, juzentaihoto hot water extract (JTT) was administered to obese type 2 diabetic model mice (KKAy) for 56 days. In addition, the effects of JTT on the adipose tissue, glucose metabolism, and blood lipids were evaluated for examining its impact on insulin sensitivity and obesity. As a result of JTT administration, KKAy mice exhibited suppressed adipocyte hypertrophy, decreased the mRNA levels of tumor necrosis factor α, and increased the mRNA levels of adiponectin in epididymal fat tissue. In addition, fasting blood glucose levels, blood triglyceride, and total cholesterol decreased. In summary, these data indicated that JTT administration suppressed the production of inflammatory cytokines and increased adiponectin levels in the adipose tissue. Therefore, with improved insulin sensitivity, blood glucose, and lipid decreased.

Association of bioelectrical phase angle with aerobic capacity, complex gait ability and total fitness score in older adults

PURPOSE

This study aimed to examine the association between whole-body or segmental phase angle (PhA) based on bioelectrical impedance analysis (BIA) and aerobic capacity (endurance), complex gait ability, and total fitness age score (FAS).

METHODS

A total of 426 community-dwelling older adults (332 women and 94 men) aged 60 to 93 years participated in this study. PhA and appendicular skeletal mass index (ASMI) were obtained by an eight-electrode standing BIA. Aerobic capacity was assessed using the shuttle stamina walk test (SSTw); complex gait ability, using the timed-up-and-go test (TUG). FAS was obtained using the previously validated multi-dimensional equations based on 7-year longitudinal data. SSTw, TUG, and FAS were compared between the low PhA (<4.4° for women and <5.2° for men) and normal PhA groups. Pearson's correlation between PhA and SSTw, TUG, and FAS was determined. Multiple linear regression analysis was conducted using SSTw, TUG, and FAS as dependent variables. Age, sex, height, body mass index (BMI), ASMI, and PhA were entered into the linear model.

RESULTS

SSTw and TUG results and FAS were significantly lower in the low PhA group (P < 0.05). PhA was significantly correlated with SSTw, TUG, and FAS (P < 0.001), and leg PhA showed a stronger correlation than whole-body or arm PhA. PhA at 50 kHz had higher correlation coefficients with SSTw, TUG, or FAS compared with PhA at 5 or 250 kHz. Multiple regression analyses indicated that leg PhA at 50 kHz was a significant predictor of SSTw, TUG, and FAS, independent of age, sex, height, BMI, and ASMI.

CONCLUSION

Our results indicate that leg PhA is associated with multi-dimensional physical fitness in community-dwelling older adults. PhA is a highly informative biomarker of skeletal muscle and exercise physiology in clinical settings.

Organic J-Aggregate Nanodots with Enhanced Light Absorption and Near-Unity Fluorescence Quantum Yield

Development of biocompatible fluorophores with small size, bright fluorescence, and narrow spectrum translate directly into major advances in fluorescence imaging and related techniques. Here, we discover that a small donor-acceptor-donor-type organic molecule consisting of a carbazole (Cz) donor and benzothiazole (BT) acceptor (CzBTCz) assembles into quasi-crystalline J-aggregates upon a formation of ultrasmall nanoparticles. The 3.5 nm CzBTCz Jdots show a narrow absorption spectrum (fwhm = 27 nm), near-unity fluorescence quantum yield (ϕ_fl = 0.95), and enhanced peak molar extinction coefficient. The superior spectroscopic characteristics of the CzBTCz Jdots result in two orders of magnitude brighter photoluminescence of the Jdots compared with semiconductor quantum dots, which enables continuous single-Jdots imaging over a 1 h period. Comparison with structurally similar CzBT nanoparticles demonstrates a critical role played by the shape of CzBTCz on the formation of the Jdots. Our findings open an avenue for the development of a new class of fluorescent nanoparticles based on J-aggregates.

Evolution of Sex Chromosome Heteromorphy in Geographic Populations of the Japanese Tago's Brown Frog Complex

The sex chromosomes of most anuran amphibians are characterized by homomorphy in both sexes, and evolution to heteromorphy rarely occurs at the species or geographic population level. Here, we report sex chromosome heteromorphy in geographic populations of the Japanese Tago's brown frog complex (2n = 26), comprising Rana sakuraii and R. tagoi. The sex chromosomes of R. sakuraii from the populations in western Japan were homomorphic in both sexes, whereas chromosome 7 from the populations in eastern Japan were heteromorphic in males. Chromosome 7 of R. tagoi, which is distributed close to R. sakuraii in eastern Japan, was highly similar in morphology to the Y chromosome of R. sakuraii. Based on this and on mitochondrial gene sequence analysis, we hypothesize that in the R. sakuraii populations from eastern Japan the XY heteromorphic sex chromosome system was established by the introduction of chromosome 7 from R. tagoi via interspecies hybridization. In contrast, chromosome 13 of R. tagoi from the 2 large islands in western Japan, Shikoku and Kyushu, showed a heteromorphic pattern of constitutive heterochromatin distribution in males, while this pattern was homomorphic in females. Our study reveals that sex chromosome heteromorphy evolved independently at the geographic lineage level in this species complex.

Comparison of Clinical Features Between Primary and Secondary Breast Diffuse Large B Cell Lymphoma: A Yokohama Cooperative Study Group for Hematology Multicenter Retrospective Study

We performed a retrospective analysis of DLBCL with breast involvement to compare the prognosis of primary breast lymphoma (PBL) to secondary breast lymphoma (SBL; especially in limited stage cases). We retrospectively reviewed records of 25 diffuse large B-cell lymphoma (DLBCL) patients with breast involvement who received chemotherapy between January 2000 and August 2012. We compared clinical features and prognosis among patients with PBL (n = 11), limited stage SBL (LSBL; n = 6), and advanced stage SBL (ASBL, n = 8). The PBL group had significantly lesser patients with breast tumours (BTs) > 5 cm than the SBL group (P = 0.02). After a median follow-up of 71.3 months, we observed significantly better 5-year overall survival (OS) in the PBL group (90.0%) than in the LSBL (33.3%, P = 0.01) group, but not for progression-free survival (PFS). Patients with BT > 5 cm had worse OS (P = 0.01) and PFS (P = 0.04) than those with BT ≤ 5 cm. PBL had a better prognosis than SBL among limited stage DLBCL.

[SURVEY OF PATIENTS' PERSPECTIVE ON SURGERY FOR CHRONIC RHINOSINUSITIS WITH NASAL POLYPS]

OBJECTIVE

To ensure that the best possible information is available for selecting treatment options in patients who have chronic rhinosinusitis with nasal polyps (CRSwNP), it is necessary to assess experiences with surgical procedures in real-world clinical practice.

METHODS

We used an internet questionnaire to survey 300 patients who had a history of CRSwNP surgery or had been recommended for such surgery.

RESULTS

The patients who underwent surgery showed high satisfaction with the effectiveness of the surgery. However between 20% and 30% were notably dissatisfied with the safety of the procedure, its effects on quality of life (QOL), its economic impact, and its influence on societal activities, such as attendance at work or school. This dissatisfaction tended to be particularly pronounced among older patients and those who had multiple surgeries. The primary reasons given for avoiding surgery were "afraid of surgery," "no time for hospitalization and treatment," and "surgery is too expensive."

CONCLUSION

Our research indicates that, although recipient patients are highly satisfied with the effectiveness of surgery for CRSwNP, a number of patients hesitate because of concerns about safety, cost, and societal activities such as work and school attendance. These findings suggest that treatment in a clinical setting should consider not only therapeutic effects but also the patient's attitude and situation.

The Effect of Dupilumab on Intractable Chronic Rhinosinusitis with Nasal Polyps in Japan

Objectives/Hypothesis

Dupilumab, which blocks the shared receptor component for interleukin‐4 and interleukin‐13, reduced polyp size, sinus opacification, and symptom severity, and was well tolerated in patients with chronic rhinosinusitis with nasal polyps (CRSwNP) in the SINUS‐52 study (NCT02898454). We assessed dupilumab in patients enrolled at Japanese centers.

Methods

Patients on a background of mometasone furoate nasal spray, received dupilumab 300 mg every 2 weeks (q2w) for 52 weeks (Arm A); dupilumab 300 mg q2w for 24 weeks, followed by every 4 weeks (q4w) for 28 weeks (Arm B); or placebo (Arm C). Co‐primary endpoints were week 24 nasal polyp score (NPS), nasal congestion (NC) score, and sinus Lund–Mackay CT (LMK‐CT) scores. Symptoms, sense of smell, health‐related quality of life, and safety were assessed during the 52‐week treatment period.

Results

Of 49 patients enrolled in Japan, 45 completed the study. Week 24 least squares (LS) mean improvement versus placebo were as follows: NPS (Arm A: −3.1, P < .0001; Arm B: −2.1, P = .0011); NC score (Arm A: −1.2, P < .0001; Arm B: −0.9, P < .0001); and LMK‐CT (Arm A: −5.1, P = .0005; Arm B: −2.8, P = .0425). The most common treatment‐emergent adverse event in dupilumab and placebo‐treated patients was nasopharyngitis.

Conclusion

Dupilumab provided rapid, significant, and clinically meaningful improvements for patients with CRSwNP in Japan. Dupilumab was well tolerated, and safety and efficacy were consistent with the overall study population.

Level of Evidence

2 Laryngoscope, 131:E1770–E1777, 2021

Combined pre- and post-capillary pulmonary hypertension defined by new criteria is worse prognosis group in patients with heart failure

Background

The 6th World Symposium on Pulmonary Hypertension suggested major revision about definition of pulmonary hypertension (PH) as mean pulmonary artery pressure (mPAP) &gt;20 mmHg. The definitions of two subsets of PH due to left heart disease (PH-LHD) also revised. The aim of this study was to investigate clinical characteristics and outcomes of subsets of PH-LHD defined by new criteria.

Methods

We analyzed 701 patients admitted for symptomatic heart failure (NYHA ≥2) and underwent right heart catheterization at compensated stage between 2007 and 2016. These patients were divided into 4 groups as follows: (i) Isolated post-capillary PH (Ipc-PH); mPAP &gt;20 mmHg and pulmonary artery wedge pressure (PAWP) &gt;15 mmHg and pulmonary vascular resistance (PVR) &lt;3 WU, (ii) Combined pre- and post-capillary PH (Cpc-PH); mPAP &gt;20 mmHg and PAWP &gt;15 mmHg and PVR ≥3 WU, (iii) pre-capillary PH; mPAP &gt;20 mmHg and PAWP ≤15 mmHg, (iv) no PH; mPAP ≤20 mmHg. Kaplan-Meier curves were applied to investigate whether each groups predict heart failure (HF) death or HF readmission.

Results

The study patients were divided into Ipc-PH (n=268), Cpc-PH (n=54), Pre-capillary PH (n=112), and no PH (n=267). Cpc-PH was significantly associated with HF death or HF readmission as compared to other groups (Figure).

Conclusions

Cpc-PH defined by new criteria was significantly associated with poor long-term clinical outcomes, which suggests new criteria of two subsets of PH-LHD could be strict risk stratification for symptomatic heart failure.

Figure1. Kaplan-Meier curves.

Funding Acknowledgement

Type of funding source: None