Co-infection with Neisseria mucosa in a patient with tuberculous otitis media

Tuberculous otitis media (TOM) is a rare manifestation caused by Mycobacterium tuberculosis with low incidence rates among extrapulmonary tuberculosis cases. Diagnosis is often delayed because of the presence of several clinical manifestations and the high prevalence of secondary bacterial infections. Few reports have attributed secondary bacterial infections in patients with TOM to commensal Neisseria. Thus, understanding the pathogenic mechanisms and clinical features of commensal Neisseria is important, considering its recent presentation as an infection-causing pathogen. Neisseria mucosa is a commensal inhabitant in humans and is generally considered non-pathogenic but can cause infection in rare cases. Here, we report an atypical secondary infection caused by Neisseria mucosa in an 81-year-old woman with TOM being treated for pulmonary tuberculosis. Direct purulent otorrhea smear microscopy revealed no acid-fast bacilli using Ziehl-Neelsen staining, whereas the phagocytosis of gram-negative cocci by white blood cells was confirmed using Gram staining. Otorrhea culture revealed the growth of N. mucosa. Subsequently, M. tuberculosis infection in the otorrhea was identified using a culture-based method. Vigilance is critical for the early detection of TOM to prevent further complications. This report raises awareness regarding TOM and provides insight into the pathogenicity of N. mucosa in otitis media.

Real-World Experience of the Comparative Effectiveness and Safety of Molnupiravir and Nirmatrelvir/Ritonavir in High-Risk Patients with COVID-19 in a Community Setting

Molnupiravir (MOV) and nirmatrelvir/ritonavir (NMV/r) are efficacious oral antiviral agents for patients with the 2019 coronavirus (COVID-19). However, little is known about their effectiveness in older adults and those at high risk of disease progression. This retrospective single-center observational study assessed and compared the outcomes of COVID-19 treated with MOV and NMV/r in a real-world community setting. We included patients with confirmed COVID-19 combined with one or more risk factors for disease progression from June to October 2022. Of 283 patients, 79.9% received MOV and 20.1% NMV/r. The mean patient age was 71.7 years, 56.5% were men, and 71.7% had received ≥3 doses of vaccine. COVID-19-related hospitalization (2.8% and 3.5%, respectively; p = 0.978) or death (0.4% and 3.5%, respectively; p = 0.104) did not differ significantly between the MOV and NMV/r groups. The incidence of adverse events was 2.7% and 5.3%, and the incidence of treatment discontinuation was 2.7% and 5.3% in the MOV and NMV/r groups, respectively. The real-world effectiveness of MOV and NMV/r was similar among older adults and those at high risk of disease progression. The incidence of hospitalization or death was low.

Prevalence and implications of exercise pulmonary hypertension in chronic thromboembolic pulmonary disease

Introduction

Recent international statement on chronic thromboembolic pulmonary hypertension proposed the definition of chronic thromboembolic pulmonary disease (CTEPD) and advocated further research regarding its clinical characteristic, natural history, and therapeutic strategy. Exercise pulmonary hypertension (Ex-PH) has been considered a mild degree of pulmonary hypertension (PH) among patients with normal pulmonary hemodynamics at rest. However, the clinical significance of Ex-PH in CTEPD remains unknown.

Purpose

In the patients with CTEPD, we aimed to verify 1) the prevalence and clinical profiles of Ex-PH, 2) effect of BPA on pulmonary vascular response after exercise in Ex-PH, 3) long-term clinical outcomes of conservative management in non-Ex-PH.

Methods

We retrospectively reviewed 26 patients with CTEPD (median age 65 years, 38% male), who underwent cardiopulmonary exercise test with right heart catheterization (CPET-RHC). The definitions of CTEPD are the following 1) pulmonary artery occlusion due to organic thrombus confirmed by imaging studies after ≥3 months of anticoagulation, 2) mPAP<25 mmHg and PAWP≤15 mmHg at rest. PQslope was plotted using multipoint plots. Ex-PH was defined by PQ slope>3.0, and the patients were divided into Ex-PH and non-Ex PH groups. Clinical profiles and long-term outcomes were compared between two groups. The patients in Ex-PH groupunderwent CPET-RHC 6–12 months after balloon pulmonary angioplasty (BPA). In Non-Ex-PH group, serial measurements of echocardiography were performed.

Results

Overall, 5 and 21 patients were categorized as CTEPD with PH (mPAP 21–24mmHg) and without PH (mPAP≤20mmHg), and 14 and 12 were categorized Ex-PH and non-Ex-PH groups, respectively. Although all 5 patients with CTEPD with PH were classified as Ex-PH group (Figure 1), there was no significant difference in baseline hemodynamics at rest between Ex-PH and non-Ex-PH groups (mPAP: 19.5 [18.4–20.6] vs. 17.7 [16.6–18.9] mmHg, PVR: 2.2 [1.7–2.7] vs. 2.3 [1.9–2.8] wood units, P>0.05, respectively). PQ slope was significantly higher in Ex-PH group (4.6 [3.2–6.0] vs. 1.31 [0.2–2.8], p=0.002). There were no differences in respiratory function test, blood gas analysis, and 6-minute walk distance between two groups. There were no major adverse events such as all-cause mortality and hospitalization for PH in overall cohort. Among Ex-PH group, BPA decreased PQslope (4.8 [3.6–6.4] to 2.3 [1.9–3.0], p<0.05). Among no-Ex-PH group, there was no significant change in tricuspid regurgitation pressure gradient (28 [17–33] to 27 [21–36] mmHg, p>0.05) over the 997 [651–1451] days.

Conclusion

Ex-PH was common in patients with CTEPD, and there were no clinical profiles differentiating Ex-PH from non-Ex-PH, except parameters of CPET-RHC. BPA improved an abnormal pulmonary vascular response to exercise in Ex-PH. The conservative management in non-Ex-PH was feasible. Randomized clinical trials will be needed to further investigate this treatment strategy.

Funding Acknowledgement

Type of funding sources: None.

The outcome spectrum for Dilated Cardiomyopathy and Ventricular Tachycardia: results from the prospective, multicenter, DCM-VT ablation study

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): The study was partially supported by an investigator initiated grant from Biosense Webster (a Johnson & Johnson company)

Background

Recurrent sustained ventricular tachycardia (VT) due to nonischemic dilated cardiomyopathy (DCM) is difficult to treat and long-term outcome data are limited.

Objective

We aimed to identify predictors for mortality or heart transplantation (MHT) and VT recurrence.

Methods

Consecutive DCM patients accepted for VT catheter ablation (RFCA) in 9 centers were prospectively enrolled and followed.

Results

Of 281 consecutive patients (age 60±13yrs, 85% men, LVEF 36±12%) 35% had VT storm, 20% incessant VT, and 68% failed amiodarone. During a median follow-up of 21 (IQR 6-30) months after RFCA (epicardial in 58%, no RFCA due to inaccessible target in 6.4%), 67(24%) patients died/underwent HT and 138(49%) had VT recurrence (45 within 30 days defined as early); the cumulative 4-year rate of VT or MHT was 70% and of MHT 38%.

In multivariable analysis predictors of MHT were early VT recurrence (HR 2.92 (CI1.37-6.21), p<0.01), amiodarone at discharge (HR 3.23 (CI1.43-7.33, p<0.01), renal dysfunction (HR 1.92 (CI1.01-3.64), p=0.046), and LVEF (HR 1.36 (CI 1.0-1.84), p=0.052). A LVEF ≤32% was the optimal threshold to identify patients at risk for MHT (AUC 0.75).

MHT per 100 person-years was 40.4 after early VT recurrence and significantly higher, compared to 14.2 after later VT recurrence and to 8.5 after RFCA with no VT recurrence (both p<0.01). Mortality rates for patients with VT recurrence after 30 days were not significantly higher than for patients with no VT recurrences

Patients with early recurrence and LVEF≤32% had a 1-year MHT rate of 55% (figure). VT recurrence was predicted by prior ICD shocks, basal antero-septal VT origin, and procedural failure but not LVEF.

Conclusion

DCM patients needing RFCA for VT are a high-risk group. Following RFCA half remain free of VT recurrences. Early VT recurrence with LVEF<0.32 identifies those with a very high risk and screening for mechanical support/ HT should be considered. Late VT recurrence after RFCA does not predict worse outcome.

Leg raise can detect exercise-induced pulmonary arterial wedge pressure elevation

Background

Exercise-induced elevation of pulmonary arterial wedge pressure (PAWP) may show preclinical or exercise-induced left ventricular diastolic dysfunction. Invasive hemodynamic assessment during provocative maneuvers, like exercise and volume challenge, in these patients allows greater sensitivity to diagnose or exclude HFpEF. The aim of this study was to examine how the leg raise, which is a simple way to increase preload, can detect exercise-induced PAWP elevation.

Methods

Four hundred seventy-nine patients (60±14y.o, mean pulmonary arterial pressure (PAP) 19mmHg, PAWP 8mmHg, CTEPH /IPAH/CTD-PH/SOB unknown reason: 357/56/38/28pts) with near-normal PAP and normal PAWP at rest underwent symptom-limited exercise test using supine cycle ergometer with right heart catheter. Exercise-induced elevation in PAWP of over 20mmHg was defined as exercise-induced elevation group.

Results

ΔPAWP (after leg raise - rest) in the exercise-induced elevation group was significantly higher (6.0±4.1 vs. 2.7±3.9mmHg, p<0.001, in the older (age≥60y.o) group (n=276); 3.4±3.5 vs. 1.9±3.4mmHg, p<0.001, in the younger (age<60y.o) group (n=203)) than that in the non-elevation group after legs raise for cycle ergometer exercise. The area under the ROC curve for ΔPAWP was 0.72 (95% CI: 0.65–0.78) in the older and 0.64 (95% CI: 0.53–0.75) in the younger. In the older, the cut-off value for detect exercise-induced PAWP elevation of ΔPAWP was 4mmHg, with 72% sensitivity and 58% specificity. On the other hand, in the younger, the cut-off value was 3mmHg, with 69% sensitivity and 59% specificity.

Conclusion

Leg raise can easily detect occult left ventricular diastolic dysfunction.

Funding Acknowledgement

Type of funding source: None

Leadless pacemaker implant in patients with a history of open heart surgery: experience with the Micra transcatheter pacemaker

Background

The Micra transcatheter pacemaker has demonstrated a favorable safety and efficacy profile relative to transvenous pacing. Patients with a history of open heart surgery have a higher risk of complications with transvenous pacemakers during follow-up. The experience with leadless pacemakers among a large cohort of patients with a history of open heart surgery has not been reported.

Objective

To report outcomes in patients with a history of open heart surgery undergoing Micra implant.

Methods

Patients undergoing Micra implant from the Micra Transcatheter Pacing Post-Approval Registry (PAR) were included in the analysis. Baseline and procedural characteristics, major complications, and electrical performance were compared among patients with vs. without history of cardiac surgery.

Results

A total of 331 out of 1815 (18.2%) patients had a history of open heart surgery, underwent Micra implant, and were followed for 19.4±10.4 months. The mean age was 74.6±13.5 years, 40% were female. The most common cardiac surgery was aortic valve surgery (71%) followed by mitral valve surgery (39%). Patients with prior open-heart surgery were more likely to have contraindications to transvenous pacing, were more likely to be on oral anticoagulants, and had more co-morbidities including atrial fibrillation, heart failure, and coronary artery disease (all p<0.005). Implantation was successful in 327 of 331 patients (98.8%) with a median procedure time of 29 minutes. Mean pacing capture thresholds (PCTs) at implant were 0.66±0.51V and remained stable through follow-up. There were 11 major complications in 10 cardiac surgery patients, with no device or procedure-related infections reported. The major complication rate was 3.1% (Figure) and was not significantly different than that of patients without a history of open heart surgery (HR: 0.85, P=0.640). There was 1 cardiac perforation (with no intervention required) in the open heart surgery group (0.3%) and there were 14 cardiac perforations (0.94%, P=0.332) in the non-open heart surgery group of which 10 required intervention.

Conclusion

The Micra transcatheter pacemaker can be safely implanted in patients with a history of open heart surgery, with a similar long-term safety profile to patients without a history of open heart surgery. Importantly, there were no device-related infections reported in either group.

Risk of Major Complication

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Medtronic, Inc.

Comparison of pulmonary vascular resistance and pulmonary artery compliance during exercise between IPAH and CTEPH with normal pulmonary artery pressure

Background

Pulmonary vascular resistance (PVR) and pulmonary artery compliance (PAC) are inversely related. However, the little is known about dynamics during exercise by disease difference. The aim of this study was to reveal the relationships of PVR and PAC during exercise between idiopathic pulmonary arterial hypertension (IPAH) and chronic thromboembolic pulmonary hypertension (CTEPH) patients.

Methods

Sixty-two IPAH patients (45±9 y.o) and 359 CTEPH patients (63±13 y.o) with normal mean PAP and PAWP at rest underwent symptom-limited exercise test using supine cycle ergometer with right heart catheter.

Results

There were no differences between baseline mean PAP and PAWP in 2 groups, however, cardiac output, SaO2 and SvO2 were lower in CTEPH group. Lower PAC (2.9±1.1 vs. 3.7±1.7 ml/mmHg, p<0.001) and higher PVR (2.3±1.0 vs. 1.9±1.0 wood.unit, p=0.016) were observed in CTEPH group. These trends were also seen at peak exercise. PVR-PAC relationship in CTEPH group was leftward shift compared with IPAH group (Figure 1).

Conclusion

Resting and exercise PVR and PAC in CTEPH patients were worse than those in IPAH patients who had normal PAP and PAWP at rest.

Figure 1

Funding Acknowledgement

Type of funding source: None

Usefulness of peripheral-pressure-directed balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension

Background

Balloon pulmonary angioplasty (BPA) in expert center may be considered in patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are technically non-operable for pulmonary endarterectomy. BPA based on objective quantitative methods has not been established. The endpoint at BPA sessions has not been clarified yet.

Objectives

The purpose of this study was to investigate the usefulness of BPA according to peripheral pressure measured by pressure wire or catheter.

Methods

This study included consecutive 143 CTEPH who underwent cardiopulmonary exercise test with right heart catheterization after BPA. All patients were divided into 2 groups such as angio-guided (n=47) group or pressure-guidedgroup (n=96). In pressure-guided group, the pulmonary arterial pressure (PAP) proximal and distal to the target lesion and the ratio of the 2 pressures were measured by the pressure wire or catheter. the endpoint was determined to when the pressure ratio of distal to proximal pressures was >0.7 to 0.8 finally. The dilation was stopped when the distal mean PAP after each dilation reached 35 mm Hg and when the baseline mean PAP was >35 mm Hg. Changes of hemodynamic parameters such as PAP and pulmonary vascular resistance (PVR) from baseline, and mean PAP and PVR at peak oxygen consumption, and pulmonary arterial pressure – cardiac output (PA-CO) slope were compared between two groups. All data except changes of hemodynamics from baseline were expressed by median [25th percentile-75th percentile]. Changes of hemodynamics from baseline were expressed by average [95% confidence interval]

Results

The median age and male were 66 [56–72] years old and 35. There were no significant differences in number of sessions and dilated vessels between two groups (Angio-guided group vs. Pressure-guided group: 4 [3–6] vs. 4 [3–5], P>0.05; 19 [12–22] vs. 17 [13–22], P>0.05). Changes of PAP and PVR from baseline in pressure-guided group was significantly higher than in angio-guided groups (Angio-guided group vs. Pressure-guided group; ΔPAP: −19 [−20 to −17] vs. −20 [−21 to −20], P>0.05; ΔPVR: −6.0 [−6.3 to −5.7] vs. −6.6 [−6.8 to −6.3], P<0.01). Mean PAP and PVR at peak oxygen consumption (VO2) and PA-CO slope in pressure-guided group were significantly lower than in angio-guided group (Angio-guided group vs. Pressure-guided group; PAP at VO2: 43 [36–50] vs. 39 [34–43], P<0.05; PVR at VO2: 2.7 [1.9–4.5] vs. 2.2 [1.6–2.9], P<0.01; PA-CO slope: 3.8 [2.1–5.2] vs. 2.9 [1.9–4.0], P<0.05).

Conclusions

Peripheral-pressure-directed BPA can improve hemodynamics at rest and exercise more effectively.

Funding Acknowledgement

Type of funding source: None

P1298SEASONAL VRIABILITIES OF HOME AND CLINIC BLOOD PRESSURE IN HEMODIALYSIS PATIENTS ARE DPEND ON VOLUME STATUS AND TEMPERATURE CHANGE IN MULTICENTER OF VARIOUS DISTRICTS IN JAPAN

Background and Aims

In general population, there are weekly and seasonal variabilities of blood pressure (BP) which are supposed to be the risk of cardiovascular disease. Home BP is well correlated to the cardiovascular risk compared to clinic BP. We already reported home and clinic BP of hemodialysis (HD) patients fluctuate seasonally partly due to temperature. The aim of this study is to determine in large number of HD patients whether the seasonal BP variability correlates to the volume status and temperature.

Method

One hundred sixty nine dialysis patients (93 male, 76 female) in ten Saiseikai hospitals in various districts in Japan were recruited. All patients were asked to measure BP at least four times a day in a sitting position, twice consecutively in the morning after urination before breakfast and medication and twice consecutively in the evening just before going to bed. The mean of twice measurements was defined as the data of measurement time. Data from Oct. 2015 to Oct. 2017 were analyzed. If the dialysis were performed 3 times a week (Mon, Wed, Fri), Monday was defined as 1st day. If the dialysis were performed on Tue. Thurs. and Sat., Tuesday was defined as 1st day. Seasonal variabilities in morning home BP and night home BP were evaluated. Seasonal changes in clinic BP just before and after HD were also evaluated in 61 patients.

Results

Weekly home BP variability in the morning, 1st day 153±16 / 78±13 mmHg, 2nd day 144±28 / 76±12, 3rd day 150±14 / 77±13, 4th day 142±26 / 75±13, 5th day 149±14 / 77±12, 6th day 144±24 / 76±13, 7th day 149±16 / 78±13. Systolic home BPs in 1st, 3rd and 5th days were significantly elevated compared with 2nd, 4th and 6th days. Morning home BP significantly elevated gradually from 6th, 7th and to 1st day. Lowest SBP in the morning was 4th day but not 6th day which was the same as the previous result (CJASN 3: 416-422, 2008). Seasonal variability of morning home BP in 1st day was evident with the rise in autumn and winter (spring 153±19 / 78±12, summer 146±17 / 77±12, autumn 158±16* / 80±12, winter 156±19* / 80±13, * p<0.05 vs summer) (figure). There was almost same seasonal morning home BP variability in 4th day which had the lowest value of morning home BP in a week. Seasonal changes of night home BP in 5th day were not significant through four seasons, which night was supposed to be the driest volume status in a week. Seasonal changes in clinic BP just before and after HD, in 1st day before HD: spring 147±19 / 74±13 mmHg, summer 144±20 / 71±11, autumn 150±19 / 74±13, winter 147±21 / 74±12. Systolic BP in autumn was significantly elevated compared to summer. In the other clinic BPs before and after HD in 3rd and 5th days, there were no significant seasonal changes observed. Seasonal changes of highest temperature were significant (spring 19.9±3.1*°C, summer 30.9±2.6, autumn 23.3±2.7*, winter 8.5±2.8*, *p<0.05 vs summer). Morning BP of 1st day in a randomly selected patient was correlated with highest temperature (r=-0.397 p<0.0001).

Discussion

There is seasonal home BP variability probably due to temperature change because BP was correlated well with temperature. Seasonal morning BP variability was evident in the 1st day of the HD week, but this seasonal home BP variability was disappeared measuring BP in the night without volume overload. We assumed that vasoconstriction due to change in temperature was enhanced by volume overload and sympathetic activation in the morning.

Conclusion

In the large number of HD patients in multicenter of various districts in Japan, seasonal BP variabilities were affected by the volume status and temperature.

P942 Outcome prediction by exercise stress echocardiography and cardiopulmonary exercise testing assessment in patients with heart failure

Background

Cardiopulmonary exercise testing (CPX) is essential to the assessment of functional impairment and prognosis in patients with heart failure (HF). Peak oxygen consumption (peak VO2) continues to be considered the gold standard for assessing prognosis in HF. The minute ventilation-carbon dioxide production (VE-VCO2) slope has recently demonstrated prognostic significance in patients with HF. Ergometer stress echocardiography (Erg-Echo) is useful to evaluate the exercise-induced pulmonary hypertension and the potential cardiac dysfunction that are difficult to evaluate in the resting state.

Objective

The aim of this study is to evaluate the relationship between CPX and Erg-echo indices, and the usefulness of Erg-echo to determine the severity of cardiac dysfunction and the prognosis in patients with HF.

Methods

We studied 58 patients with HF (age 65.2 ± 11.9 years) and performed CPX and Erg-Echo. The peak VO2 and the VE-VCO2 slope were measured by CPX. Cardiac output (CO) and estimated mean pulmonary artery pressure (mPAP) were measured by Erg-Echo at rest and peak exercise load, and the change ratio (ΔmPAP / ΔCO) were calculated. We evaluated the clinical outcome during a1 year period.

Results

The ΔmPAP / ΔCO was significantly correlated with the peak VO2 (R = -0.6767, P <0.0001) and the VE-VCO2 slope (R = 0.6809, P <0.0001). Cardiovascular events (1 patient of cardiovascular death, 8 patients of re-hospitalization due to HF, 4 patients of myocardial ischemia, 2 patients of Cardiac Resynchronization Therapy (CRT) devices implantation, 1 patient of ventricular tachycardia) developed in 16 of the 58 patients (27.5%: Group CE) during the 1 year. The peak VO2 was significantly lower (12.1 ± 2.5 vs. 16.1 ± 3.1ml/min/kg, P <0.0001) and the VE-VCO2 slope was significantly higher (41.1 ±. 12.3 vs. 31.8 ± 6.1ml/ml, P <0.0001) in Group CE compared to the other 42 patients (Group N). The ΔmPAP was significantly higher (19.1 ± 4.4 vs. 14.9 ± 6.4, P = 0.0408) and the ΔCO was significantly lower (2.4 ± 1.2 vs. 4.1 ± 2.0, P = 0.0078), and the ΔmPAP / ΔCO was significantly higher (9.7 ± 4.6 vs. 4.4 ± 2.4, P <0.0001) in Group CE compared to Group N.

Conclusions

The ΔmPAP/ ΔCO by Erg-Echo is useful to evaluate the severity of cardiac dysfunction and the prognosis of HF patients.

P1802 Prevalence and prognostic significance of pulmonary artery aneurysms in patients with pulmonary artery hypertension

Background

Pulmonary artery aneurysm (PAA) occurs in some patients with pulmonary arterial hypertension (PAH) and can be accompanied by various complications.

Objective

The aim of the this study is to evaluate the characteristics of cardiac dysfunction and the prognostic impact of PAA by analysing the outcome of patients with PAH complicated by PAA.

Methods

We performed echocardiography and right-heart catheterization in 130 PAH patients. We measured the maximum dimensions of the main pulmonary artery (MPA) trunk. We evaluated the right ventricular (RV) function and the five-year prognosis of patients with PAA.

Results

The maximum MPA trunk diameter of >40 mm by echocardiography was defined as PAA. PAA appeared in 32 of the 130 PAH patients (24.6%: Group PAA), other 98 patients were defined as Group non-PAA. Systolic pulmonary artery pressure (76 ±18 vs. 61 ± 21 mmHg, P = 0.0008) and mean right atrial pressure (10.0 ± 8.1 vs. 5.4 ± 3.8 mmHg, P < 0.0001) were significantly higher in Group PAA than in Group non-PAA. RV end-diastolic area index was significantly larger (37.3 ± 8.8 vs. 32.3 ± 7.8 mmHg, P = 0.0048), and RV fractional area change (32 ± 8 vs. 36 ± 9 %, P = 0.0176) and RV longitudinal strain amplitude (-16 ±5 vs. -20 ± 6, P = 0.0017) were significantly lower in Group PAA than those in Group non-PAA. During the five-year follow-up period, 20 patients (15%) died. The five-year mortality rate was significantly higher in Group PAA compared to Group non-PAA (30% vs. 10%, P = 0.007).

Conclusion

In PAH patients with PAA, RV dysfunction was more severe and the prognosis was poor. Assessment of PAA can be a useful index for the extraction of high-risk PAH patients.

P1825The characteristics of type A acute aortic dissection in patients with out-of-hospital cardiopulmonary arrest analyzed by computed tomography

Background/Introduction

Acute aortic dissection (AAD) is a life-threatening condition associated with high morbidity and mortality rates, and is reported to have a 1–2% fatality rate per hour after onset. Therefore, many cases with AAD are considered to be included in patients with out-of-hospital cardiopulmonary arrest (OHCPA). However at this time, there is a lack of documentation of these cases.

Purpose

In this study, we investigated the characteristics of Stanford type A AAD (TAAD) cases between OHCPA cases and survival cases using acute phase CT.

Methods

An acute phase CT scanning was performed on consecutive patients with OHCPA transported to our hospital in order to estimate the causes of cardiopulmonary arrest (CPA). Based on our emergency outpatient databases, we retrospectively reviewed the acute phase CT findings of OHCPA TAAD cases and survival TAAD cases diagnosed at our hospital during the same period.

Results

Of 1,011 consecutive patients with OHCPA, except for exogenous death from 1 January 2015 to 31 December 2017, 934 patients underwent CT examination in the acute phase. Based on the clinical course and CT findings, 71 of the 934 patients (7.6%) were diagnosed with AAD. Out of 71 AAD patients, 66 were TAAD patients, and all of these patients were enrolled in the OHCPA group. On the other hand, 41 patients were registered as the survival group during the same period. These patients were diagnosed as TAAD and were admitted to our hospital without falling into CPA. Increased Age (78±8 years old vs 69±13 years old, P<0.01), visible intimal flap (63.6% vs 41.5%, P=0.043), bloody pericardial effusion (72.7% vs 26.8%, P<0.01), hemothorax (24.2% vs 0%, P<0.01) were significant in patients with the OHCPA group compared with the survival group. In addition, 56 patients with OHCPA (84.8%) had at least one of massive bloody pericardial effusion or massive hemothorax. Using multivariate logistic regression analysis, increased age and bloody pericardial effusion were both found to be independent factors related to OHCPA.

Conclusion

In this study, it is thought that the main characteristics of the CT findings with OHCPA due to TAAD are a rupture of the aorta into the pericardial cavity or thoracic cavity.

5970Morbidity and mortality in patients precluded for transvenous pacemaker implantation: experience with the Micra transcatheter pacemaker

Background

The Micra transcatheter pacemaker has proven to be a safe and effective alternative to transvenous pacemakers (TVPs). However, the safety profile after Micra implantation in patients deemed poor candidates for TVPs is poorly understood.

Purpose

To evaluate the safety and all-cause mortality outcomes in Micra recipients stratified by whether or not they were precluded for therapy with TVP.

Methods

Micra patients from the Micra Transcatheter Pacing (IDE) Study, Continued Access (CA) study, and Post-Approval Registry (PAR) were divided into groups based upon whether or not the implanting physician considered the patient to be precluded from receiving a transvenous pacing system. All-cause mortality was compared between the Micra patient groups and patients receiving a single-chamber transvenous pacing system (SC-TVP) since 2010 from the Medtronic product surveillance registry using univariate and multivariate Cox models.

Results

Among 2,819 patients who underwent a Micra implant attempt, the overall major complication rate through 24 months was 3.5%. In these patients, 548 were deemed precluded from TVP implantation. Prior device infection or bacteremia (38.9%), venous access issues (36.1%) and thrombosis (10.2%) were amongst the most common causes of preclusion for TVP implantation. These patients were younger (71.7 vs. 76.7 years), more frequently on hemodialysis (26.3% vs. 2.5%), and more often had a prior CIED implanted (38.4% vs. 4.4%) than non-precluded patients. Over an average follow-up of 13.5±11.1 months, all-cause mortality was significantly higher in precluded Micra patients compared with SC-TVP patients (HR: 2.16, 95% CI: 1.54–3.2, P<0.001) (Figure 1). However, there was no significant difference in all-cause mortality when comparing non-precluded Micra patients and SC-TVP patients (HR: 1.12, 95% CI: 0.86–1.44, P=0.401). Acute all-cause death (within 1 month) among Micra patients was 2.74% and 1.32% in the precluded and non-precluded TVP groups, respectively. The procedure-related death rate was 0.55% for the TVP precluded group and 0.13% for the not precluded group (P=0.092). The major complication rate through 24-months was similar between the two Micra groups (4.0% vs 3.4%, P=0.630).

All-cause mortality for Micra and SC-TVP

Conclusion

The overall safety profile of Micra remains is in line with previously reported data. All-cause mortality risk (both acute and long term) appears to be higher in patients who were precluded from receiving TVP.

Acknowledgement/Funding

Supported by Medtronic

Observation of Granulocyte Adsorption in Adacolumn Cellulose Acetate Beads after Granulocytapheresis

Adacolumn is a therapeutic mode for ulcerative colitis that achieves therapeutic efficacy through the adhesion of leukocytes to cellulose acetate beads. We used scanning electron microscopy and observed leukocyte adsorption on Adacolumn beads after granulocytapheresis/granulocyte and monocyte adsorption apheresis. We then compared results between two patients with a low and high C-reactive protein (CRP) levels to determine whether adhesion is affected by a difference in leukocyte activity depending on the level of inflammation. We found that the surface layers of the beads from both patients were covered by a clay-like layer, and spherical granulocytes were adsorbed here and there on top of it. In cross-section the adsorbed granulocytes were visible in the clay-like layer and the surface layer alike. The clay-like layer had a maximum thickness of approximately 12 μm in the low CRP patient and approximately 50 μm in the high CRP patient, so in the high CRP patient the clay-like adsorption layer was thicker. Taken together, adsorption onto beads is considered to involve an immunological mechanism. Our findings suggest that granulocytes contact and adhere to each other at the surface layer after adsorption, and that granulocyte-granulocyte adhesion is enhanced by a higher inflammatory response.

Force-induced IL-8 from Periodontal Ligament Cells Requires IL-1β

During orthodontic tooth movement, mechanical stresses induce inflammatory reactions in the periodontal ligament (PDL). We hypothesized that chemokines released from PDL cells under mechanical stress regulate osteoclastogenesis, and investigated the profiles and mechanisms of chemokine expression by human PDL cells in response to mechanical stress. In vitro, shear stress and pressure force rapidly increased the gene and protein expressions of IL-8/CXCL8 by PDL cells. Consistently, amounts of IL-8 in the gingival crevicular fluid of healthy individuals increased within 2 to 4 days of orthodontic force application. The PDL cells constitutively expressed low levels of IL-1β, which were not further increased by mechanical stress. Interestingly, neutralization of IL-1β abolished IL-8 induction by mechanical stresses, indicating that IL-1β is essential for IL-8 induction, presumably though autocrine or paracrine mechanisms. Finally, experiments with signal-specific inhibitors indicated that MAP kinase activation is essential for IL-8 induction.

Quantification of venous reflux parameters using duplex scanning and air plethysmography

Objective: To compare different duplex-and air plethysmography (APG)-derived parameters between patients with relatively early and those with advanced chronic venous insufficiency (CVI), and to investigate the indicative parameters reflecting the progression of CVI.

Methods: Design: Prospective study at the University Hospital. Patients: In total 686 limbs in 574 patients at various clinical stages of CVI were included. The clinical manifestations were categorized according to the CEAP (clinical, aetiologic, anatomic and pathophysiologic) classification, and the patients were divided into two groups: group I (C1-3EP,SAS,D,PPR,O, relatively early stage of CVI) and group II (C4-6EP,SAS,D,PPR,O, advanced CVI). The distribution of venous insufficiency including the sapheno-femoral junction (SFJ), great saphenous vein (GSV), sapheno–popliteal junction (SPJ), common femoral vein (CFV), femoral vein (FV), popliteal vein (POPV), thigh perforators (TPV) and calf perforators (CPV) was determined by duplex ultrasound. The main duplex-derived parameters assessed were the reflux time (RT; s), peak reflux velocity (PRV; cm/s) and peak reflux flow (PRF; mL/s). The venous reflux was assumed to be present if the duration of reflux was ≥0.5 s. The data obtained by APG were on VV (mL), VFI (mL/s), EF (%) and RVF (%).

Results: There was no significant difference in overall superficial venous reflux between the groups ( P=0.331). The frequency of deep and perforating vein incompetence differed only when superficial reflux was included in group II. The VFI and RVF were significantly higher in secondary CVI than in primary CVI ( P=0.0001, 0.003, respectively). In the secondary CVI, patients with reflux and obstruction showed significantly higher RVF than those with reflux alone ( P=0.003). The RT did not improve the discrimination power between the groups. In contrast, the PRV had significant discrimination power at the SFJ ( P<0.0001) and SPJ ( P=0.022), and in the GSV ( P<0.0001), the FV ( P=0.017), and the POPV ( P=0.0003). The PRF was significantly higher in group II at the SFJ ( P<0.0001), in the GSV ( P=0.002), in the CFV ( P=0.011), in the FV ( P=0.027), and the POPV ( P=0.016).

Conclusions: This present study has suggested the importance of superficial venous insufficiency in the development of advanced CVI. In the secondary CVI, obstruction affects the RVF alone. The PRV and PRF are better parameters than the RT for discrimination of clinical severity in both superficial and deep venous insufficiency, and should be used to quantify venous valvular insufficiency.

Harvesting epithelial keratinocyte sheets from temperature-responsive dishes preserves basement membrane proteins and improves cell survival in a skin defect model

Cultured epithelial autograft (CEA) therapy has been used in clinical applications since the 1980s. However, there are some issues related to this treatment that still remain unsolved. Enzymatic treatment is typically used in the collection of epithelial keratinocyte sheets, but it tends to break the adhesion and basement membrane proteins. It is thought that the loss of proteins after enzymatic treatment is responsible for the poor survival of transplanted cell sheets. Our laboratory has developed a temperature-responsive culture dish that does not require enzymatic treatment to harvest the cells. In this study, we compare morphological and survival results from rat epithelial keratinocyte cell sheets harvested by temperature-reducing treatment (TT sheets) against cell sheets harvested by enzymatic (dispase) treatment (DT sheets). TT sheets preserve keratin structure in better conditions and express higher levels of collagen IV and laminin 5 than DT sheets. In order to evaluate cell sheet survival after transplantation, we created an in vivo transplant model. Keratinocyte sheets obtained from GFP-positive animals were transplanted into athymic rats. The survival rate 7 days after transplantation of TT sheet was higher than that of DT sheets. Collagen IV and Laminin 5 expression was observed in the TT sheet transplantation group. These results indicate that the remaining basement membrane proteins are important for initial attachment and cell survival. We believe that the cell sheet harvesting method using temperature-responsive culture dishes provides superior cell survival and can solve one of the roadblocks in CEA therapy. Copyright © 2016 John Wiley & Sons, Ltd.

Linker regions and flexibility around the metalloprotease domain account for conformational activation of ADAMTS-13

BACKGROUND

Recently, conformational activation of ADAMTS-13 was identified. This mechanism showed the evolution from a condensed conformation, in which the proximal MDTCS and distal T2-CUB2 domains are in close contact with each other, to an activated, open structure due to binding with von Willebrand factor (VWF).

OBJECTIVES

Identification of cryptic epitope/exosite exposure after conformational activation and of sites of flexibility in ADAMTS-13.

METHODS

The activating effect of 25 anti-T2-CUB2 antibodies was studied in the FRETS-VWF73 and the vortex assay. Cryptic epitope/exosite exposure was determined with ELISA and VWF binding assay. The molecular basis for flexibility was hypothesized through rapid automatic detection and alignment of repeats (RADAR) analysis, tested with ELISA using deletion variants and visualized using electron microscopy.

RESULTS

Eleven activating anti-ADAMTS-13 antibodies, directed against the T5-CUB2 domains, were identified in the FRETS-VWF73 assay. RADAR analysis identified three linker regions in the distal domains. Interestingly, identification of an antibody recognizing a cryptic epitope in the metalloprotease domain confirmed the contribution of these linker regions to conformational activation of the enzyme. The proof of flexibility around both the T2 and metalloprotease domains, as shown by by electron microscopy, further supported this contribution. In addition, cryptic epitope exposure was identified in the distal domains, because activating anti-T2-CUB2 antibodies increased the binding to folded VWF up to ~3-fold.

CONCLUSION

Conformational activation of ADAMTS-13 leads to cryptic epitope/exosite exposure in both proximal and distal domains, subsequently inducing increased activity. Furthermore, three linker regions in the distal domains are responsible for flexibility and enable the interaction between the proximal and the T8-CUB2 domains.

Electron reemission processes following photoelectron recapture due to post-collision interaction in inner-shell photoionization of water molecules

Electron reemission following photoelectron recapture due to post-collision interaction has been studied at 0.7 eV the inner-shell photoionization threshold of water molecules, using a multi-electron coincidence method. Electron reemissions after single Auger decay occur from O and OH fragments which are produced by the dissociations of high-n Rydberg H2O(+) states populated through photoelectron recapture. In addition, electron reemissions after double Auger decay are identified in triple coincidence events, where autoionization lines from O and O(+) fragments are observed.

Single photon K(-2) and K(-1)K(-1) double core ionization in C(2)H(2n) (n=1-3), CO, and N(2) as a potential new tool for chemical analysis

We have observed single photon double K-shell photoionization in the C(2)H(2n) (n=1-3) hydrocarbon sequence and in N(2) and CO, using synchrotron radiation and electron coincidence spectroscopy. Our previous observations of the K(-2) process in these molecules are extended by the observations of a single photon double photoionization with one core hole created at each of the two neighboring atoms in the molecule (K(-1)K(-1) process). In the C(2)H(2n) sequence, the spectroscopy of K(-1)K(-1) states is much more sensitive to the bond length than conventional electron spectroscopy for chemical analysis spectroscopy based on single K-shell ionization. The cross section variation for single photon K(-1)K(-1) double core ionization in the C(2)H(2n) sequence and in the isoelectronic C(2)H(2n), N(2) and CO molecules validates a knock-out mechanism in which a primary ionized 1s photoelectron ejects another 1s electron of the neighbor atom. The specific Auger decay from such states is clearly observed in the CO case.

Prospective randomised comparative study of visual foam sclerotherapy alone or in combination with ultrasound-guided foam sclerotherapy for treatment of superficial venous insufficiency: preliminary report

OBJECTIVE

The aim of the study is to compare ultrasound-guided foam sclerotherapy (UGFS: injection of foam sclerosant under ultrasound guidance) of the great saphenous vein (GSV) combined with visual foam sclerotherapy (VFS: injection of foam sclerosant under visual control) for varicose tributary veins and VFS alone in the treatment of GSV reflux.

DESIGN AND METHODS

A total of 133 limbs in 97 patients with GSV reflux were randomised to receive either VFS alone or VFS combined with UGFS. In both groups, 1% polidocanol foam was used. Assessments included duplex ultrasonography, evaluation of Venous Clinical Severity Scores (VCSS) and CEAP (clinical, etiologic, anatomic, and pathophysiologic) scores. Ultrasonographic inspection of the foam in the GSV was carried out during 5 min before compression was applied. The primary 'end' point of the study was obliteration of the GSV at 6 months.

RESULTS

A total of 51 limbs in 48 patients were treated with UGFS + VFS and the remaining 52 limbs in 49 patients were treated with VFS alone. There were no significant inter-group differences in patient age, male: female ratio, height, weight, body mass index, CEAP clinical scores or VCSS. The GSV diameter was 6.0 ± 1.7 mm (median ± interquartile range) in the UGFS + VFS group and 5.7 ± 1.6 mm in the VFS group (p = 0.419). The mean injected volume of foam for varicose tributary veins was 4 ± 2 ml in the UGFS + VFS group and 6 ± 2 ml in the VFS group, a significantly higher amount of foam being used in the latter (p < 0.001). However, the mean total amount of foam was greater in limbs treated with UFGS + VFS than in those treated with VFS alone (p = 0.017). Ultrasonographic inspection revealed complete vasospasm of the GSV in 37 (72.5%) limbs in the UGFS + VFS group and 29 (55.8%) in the VFS group during sclerotherapy (p = 0.097). At 6-month follow-up, complete occlusion was found in 23 limbs (45.1%) treated with UGFS + VFS and in 22 limbs (42.3%) treated with VFS. The difference between the two groups was not significant (p = 0.775). Reflux was absent in 30 limbs (58.8%) treated with UGFS + VFS and in 37 (71.2%) treated with VFS (p = 0.190). There was no inter-group difference in post-treatment VCSS (p = 0.223).

CONCLUSIONS

These results show that UGFS + VFS and VFS are equally effective for the treatment of GSV reflux, despite the lower volume of foam used for VFS alone.

P4-20-05: Inflammatory Breast Cancer: Comparison of Epidemiology, Biology, and Prognosis between Japan and the United States, a Hospital-Based Study

Background: Inflammatory breast cancer (IBC) is a challenging disease characterized by low incidence, rapid progression, and poor survival. The epidemiology of IBC has been slow to emerge, given that the rarity of IBC makes large prospective clinical trials difficult. Compared to non-IBC, well-established features of IBC include a younger age of onset and lower frequency of hormone receptor positivity. Higher body mass index (BMI) is a purported risk factor. Previous reports also suggest that IBC is associated with more racial disparities, including incidence and age at diagnosis. The epidemiology of IBC in East Asia, however, has not been investigated. We performed a comparative study of IBC in Japan versus the United States to determine its epidemiologic and clinical features and to evaluate the differences in epidemiological factors between the two countries.

Patients and Method: Patients who visited St. Luke's International hospital (SLIH) in Tokyo, Japan and The University of Texas MD Anderson Cancer Center (MDA) in Texas, USA between 2003 and 2009 were identified. Epidemiological and biological data were collected from electronic medical records. Patient and tumor characteristics were tabulated and stratified by hospital. Kaplan-Meier curves were created for survival estimates and log-rank test was used for cross-group comparisons. Cox proportional-hazard analysis was used to identify a subset of significant prognostic variables that related to overall survival.

Result: 34 patients at SLIH and 531 patients at MDA were identified. Mean age at diagnosis was 52 years old (range, 32–81, SD, 10.8) and 50 years old (range, 22–87, SD, 11.6), respectively (P=0.476). Mean BMI was 22.9 kg/m2 (range, 17.3−30.5, SD 3.3 ) and 31.0 kg/m2 (range, 13.6−88.9, SD, 7.8) respectively (P&lt;0.01). Clinical Staging was not significantly different; Stage IIIB 38.2%, Stage IIIC 26.5%, and Stage IV 32.4% at SLIH versus 48.6%, 23.7%, and 27.3% at MDA (P= 0.167). Estrogen receptor (ER) and progesterone receptor (PR) negative cases were, respectively, 50.0% and 64.7% at SLIH and 50.5% and 64.2% at MDA (ER, P= 0.935; PR, P=0.908). Her-2 over-expression cases were 38.2% at SLIH and 28.6% at MDA (P=0.174). A significant difference in nuclear grade was seen between SLIH and MDA: 20.6% at SLIH were Grade 3 versus 68.7% at MDA (P&lt;0.01). Median overall survival at SLIH was 3.6 years versus 2.3 years at MDA (P=0.570). No prognostic factors were associated with overall survival.

Conclusion: Though IBC at SLIH differed significantly from IBC at MDA by several epidemiologic and biologic factors, there was no significant difference in survival. To define the epidemiological, prognostic, and risk factors of IBC in Japan, as well as in the world, further studies are needed.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-20-05.

Evidence of single-photon two-site core double ionization of C2H2 molecules

We observe the formation in a single-photon transition of two core holes, each at a different carbon atom of the C2H2 molecule. At a photon energy of 770.5 eV, the probability of this 2-site core double ionization amounts to 1.6 ± 0.4% of the 1-site core double ionization. A simple theoretical model based on the knockout mechanism gives reasonable agreement with experiment. Spectroscopy and Auger decays of the associated double core hole states are also investigated.

Energy correlation among three photoelectrons emitted in core-valence-valence triple photoionization of Ne

The direct observation of triple photoionization involving one inner shell and two valence electrons is reported. The energy distribution of the three photoelectrons emitted from Ne is obtained using a very efficient multielectron coincidence method using the magnetic bottle electron spectroscopic technique. A predominance of the direct path to triple photoionization for the formation of Ne3+ in the 1s 2s2 2p4 configuration is observed. It is demonstrated that the energy distribution evolves with photon energy and indicates a significant difference with triple photoionization involving only valence electrons.

Natural history of Upshaw-Schulman syndrome based on ADAMTS13 gene analysis in Japan

Upshaw-Schulman syndrome (USS) is an extremely rare hereditary deficiency of ADAMTS13 activity, termed congenital TTP. The clinical signs are usually mild during childhood, often with isolated thrombocytopenia. But their symptoms become more evident when patients have infections or get pregnant. We identified 43 USS-patients in Japan, who ranged in age from early childhood to 79 years of age. Analysing the natural history of these USS patients based on ADAMTS13 gene mutations may help characterise their clinical phenotypes. Severe neonatal jaundice that requires exchange blood transfusion, a hallmark of USS, was found in 18 of 43 patients (42%). During childhood, 25 of 43 patients were correctly diagnosed with USS without gender disparity. These 25 patients were categorised as having 'the early-onset phenotype'. Between 15 and 45 years of age, 15 were correctly diagnosed, and, interestingly, they were all female. The remaining three patients were male and were diagnosed when they were older than 45 years of age, suggesting that they were 'the late-onset phenotype'. Two of these three males developed sudden overt TTP when they were 55 and 63 years old, respectively. These two men had two different homozygous ADAMTS13 gene mutations, p.R193W/p.R193W and p.C1024R/p.C1024R, respectively. Both of which were not discovered in the US or Western countries. In vitro expression studies showed that these two proteins were consistently secreted into the culture medium but to a lesser extent and with reduced activity compared to the wild-type protein. Our results indicate that 'the late-onset phenotype' of USS is formed with ethnic specificity.

Properties of hollow molecules probed by single-photon double ionization

The formation of hollow molecules (with a completely empty K shell in one constituent atom) through single-photon core double ionization has been demonstrated using a sensitive magnetic bottle experimental technique combined with synchrotron radiation. Detailed properties are presented such as the spectroscopy, formation, and decay dynamics of the N(2)(2+) K(-2) main and satellite states and the strong chemical shifts of double K holes on an oxygen atom in CO, CO2, and O2 molecules.

Prognostic impact of calf muscle near-infrared spectroscopy in patients with a first episode of deep vein thrombosis

BACKGROUND

The risk factors that affect the development of post-thrombotic syndrome (PTS) are not fully recognized, and it is difficult to reliably predict which patients are likely to develop PTS in acute phase of deep vein thrombosis (DVT).

AIMS

To investigate changes in calf muscle deoxygenated hemoglobin (HHb) levels after DVT, and to determine the indicative parameters reflecting the progression of PTS.

METHODS

Seventy-six consecutive patients with a first episode of unilateral DVT were prospectively enrolled. Clinical manifestations were categorized according to the CEAP (Clinical, Etiologic, Anatomical, and Pathophysiologic) classification, and the patients were divided into no-PTS (C(0-3)E(s),A(s,d,p),P(r,o)) and PTS (C(4-6)E(s),A(s,d,p),P(r,o)) groups. Near-infrared spectroscopy (NIRS) was used to measure calf muscle HHb levels at 6 months after diagnosis of DVT. The calf venous blood filling index (HHbFI) was calculated on standing, and the venous ejection index and the venous retention index (HHbRI) were then obtained after exercise. All patients were followed up for more than 24 months after the diagnosis of DVT.

RESULTS

Of 76 patients evaluated, 20 (26.3%) had PTS. The NIRS-derived HHbFI and HHbRI were significantly increased in patients who developed PTS in comparison with those who did not (P = 0.04 and P = 0.0001, respectively). HHbRI was significantly increased in patients with iliofemoral DVT in comparison with patients with calf DVT (P = 0.041). An optimal cut-off point of 2.9 for HHbRI showed the strongest ability to predict the development of PTS, with a sensitivity of 100% and a specificity of 82.1%.

CONCLUSIONS

HHbRI as measured by NIRS is significantly increased in patients with iliofemoral DVT as compared with those with calf DVT. Furthermore, HHbRI > 2.9 is a strong predictor of the development of PTS at 6 months.

Photosensitization reaction-induced electrical blockade in myocardial tissue

We proposed the application of photodynamic therapy (PDT) as a new type of atrial fibrillation treatment. PDT is well known as a practical cancer treatment using cytotoxicity of reactive oxygen species generated by the photochemical interaction. We predicted that the photocytotoxic effect induced by PDT might cause electrical blockade in myocardial tissue. We studied the electrical blockade induced by the PDT with talaporfin sodium in vitro, ex vivo, and in vivo. The cell lethality measurement using rat cardiac myocytes confirmed the PDT-induced photocytotoxic effect and its dependence on the loading time of the photosensitizer. In ex vivo experiment using rat right ventricle, the PDT caused a shutdown of the stimulated electrical signal propagation. The long-lasting atrioventricular block induced by the PDT was obtained in vivo experiment with rat heart. These results revealed the possibility of atrial fibrillation treatment with the PDT.