DASC-21 score and the risk of in-hospital death in elderly patients with heart failure

AIM

We investigated whether the Dementia Assessment Sheet for Community-based Integrated Care System-21 Items (DASC-21), a questionnaire that assesses cognitive function, including activities of daily living (ADL), was predictive of in-hospital death and prolonged hospital stay in elderly patients hospitalized for heart failure.

METHODS

We retrospectively assessed the DASC-21 score at the time of admission, in-hospital death, length of hospital stay, and change in the Barthel index in 399 patients hospitalized for heart failure between 2016 and 2019.

RESULTS

The mean patient age was 85.8 ± 7.7 years (61.3% women). The median DASC-21 score was 38 (64.7% higher than 31). On multivariate logistic regression analysis, a higher DASC-21 score was associated with an increased risk of in-hospital death (odds ratio [OR] = 1.045 per 1 point increase, 95% confidence interval [CI]: 1.010-1.081, P = 0.012), even after adjusting for confounding factors, including atrial fibrillation, ejection fraction, and B-type natriuretic peptide. Difficulties (3 or 4) with the self-management of medication in instrumental ADL inside the home (OR = 3.28, 95% CI: 1.05-10.28, P = 0.042), toileting (OR = 3.66, 95% CI: 1.19-11.29, P = 0.024), grooming (OR = 6.47, 95% CI: 2.00-20.96, P = 0.002), eating (OR = 7.96, 95% CI: 2.49-25.45, P < 0.001), and mobility in physical ADL (OR = 5.99, 95% CI: 1.85-19.35, P = 0.003) were identified as risk factors for in-hospital death. Patients in the highest tertile of the DASC-21 score had a significantly longer hospital stay (P = 0.006) and a greater reduction in the Barthel index (P < 0.001).

CONCLUSIONS

In elderly patients hospitalized for heart failure, higher DASC-21 scores were associated with an increased risk of in-hospital death, prolonged hospital stay, and impaired ADL. Geriatr Gerontol Int 2024; ••: ••-••.

Prevalence and clinical characteristics of diabetic cardiomyopathy in patients with acute heart failure

BACKGROUND AND AIMS

Diabetic cardiomyopathy refers to cases of diabetes mellitus (DM) complicated by cardiac dysfunction in the absence of cardiovascular disease and hypertension. Its epidemiology remains unclear due to the high rate of coexistence between DM and hypertension. Therefore, this study aimed to examine the prevalence and clinical characteristics of diabetic cardiomyopathy among patients with acute heart failure (HF).

METHODS AND RESULTS

This multicenter, retrospective study included 17,614 consecutive patients with acute HF. DM-related HF was defined as HF complicating DM without known manifestations of coronary artery disease, significant valvular heart disease, or congenital heart disease, while diabetic cardiomyopathy was defined as DM-related HF without hypertension. Univariable and multivariable logistic regression analyses were performed to identify factors associated with in-hospital mortality. Diabetic cardiomyopathy prevalence was 1.6 % in the entire cohort, 5.2 % in patients with acute HF complicating DM, and 10 % in patients with DM-related HF. Clinical characteristics, including the presence of comorbidities, laboratory data on admission, and factors associated with in-hospital mortality, significantly differed between the diabetic cardiomyopathy group and the DM-related HF with hypertension group. The in-hospital mortality rate was significantly higher in patients with diabetic cardiomyopathy than in patients with DM-related HF with hypertension (7.7 % vs. 2.8 %, respectively; P < 0.001).

CONCLUSION

The prevalence of diabetic cardiomyopathy was 1.6 % in patients with acute HF, and patients with diabetic cardiomyopathy were at high risk for in-hospital mortality. The clinical characteristics of patients with diabetic cardiomyopathy were significantly different than those of patients with DM-related HF with hypertension.

Association of pulse pressure and mean blood pressure to frailty, sarcopenia, and cognitive dysfunction in elderly outpatients with history of hypertension

This study aimed to evaluate the relationship between pulse pressure (PP) and sarcopenia, frailty, and cognitive function in elderly patients with hypertension. We evaluated 435 elderly patients with a history of hypertension who visited the frail outpatient clinic between July 2015 and October 2021. Data at the 1-, 2-, and 3-year follow-ups were available for 222, 177, and 164 patients, respectively. Sarcopenia, frailty, and cognitive function, including Mini-Mental State Examination (MMSE) scores, were evaluated. The patients' mean age was 79.2 ± 6.3 years (male, 34.9%). PP and mean blood pressure (BP) were 60.1 ± 13.6 mmHg and 94.1 ± 13.0 mmHg, respectively. At baseline, lower PP was associated with probable dementia (MMSE score ≤23 points) (OR = 0.960 per 1 mmHg increase; 95% CI, 0.933-0.989; P = 0.006) in the model adjusted for conventional confounding factors and comorbidities, whereas higher PP was associated with low handgrip strength (OR = 1.018 per 1 mmHg increase; 95% CI, 1.001-1.036; P = 0.041). In multivariate-adjusted logistic regression analysis of patients with preserved handgrip strength at baseline, reductions in PP (OR = 0.844; 95% CI, 0.731-0.974; P = 0.020) and mean BP (OR = 0.861; 95% CI, 0.758-0.979; P = 0.022) were significantly associated with the incidence of low handgrip strength at 3 years. In conclusion, a higher PP induced by increased arterial stiffness was associated with lower handgrip strength, whereas a lower PP was associated with probable dementia. Reduced PP was associated with decreased handgrip strength after three years.

Automated office blood pressure measurement with the assistance of an instructional video in patients with hypertension

OBJECTIVES

Automated office blood pressure (AOBP) measurement often requires assistance. Accompanied by an instructional video, AOBP measurement could be performed independently by patients.

DESIGN AND METHODS

Seventy-five patients with hypertension were enrolled. AOBP was measured three times at 1-min intervals after 5 min of rest by an automated BP measurement device with the assistance of an animated instructional video. The video was designed originally to instruct patients on the way to measure BP appropriately. Perceived stress was evaluated using a questionnaire after the AOBP measurement. Office BP was measured three times using the same device. Home BP measurement was performed on 5 consecutive days.

RESULTS

The mean age of the patients was 74.5 ± 10.6 years, and 96% were taking antihypertensive drugs. Mean AOBP, office BP and home BP measurements were 135.2 ± 17.2/81.3 ± 11.1, 139.3 ± 16.3/78.6 ± 10.9 and 129.2 ± 16.7/72.7 ± 8.9 mmHg, respectively. Regarding SBP, the mean AOBP was significantly lower than office BP ( P  = 0.005) and higher than home BP ( P  = 0.004). The differences in SBP and DBP between AOBP and home BP measurements were significantly related to patients' perceived stress when performing AOBP measurements ( r  = 0.289; P  = 0.013 and r  = 0.328; P  = 0.004). In a multivariate analysis, patients' perceived stress was a significant predictor of the difference between AOBP and home BP ( P  = 0.013), even after adjusting for age, sex, BMI and mean of AOBP and home BP.

CONCLUSION

AOBP values measured with the assistance of an instructional video were between conventional office and home BP measurements. Perceived stress during AOBP measurement was related to the difference in AOBP from home BP.

Relationship between blood pressure and cognitive impairment in elderly outpatients with cardiometabolic diseases

AIM

The aim of this study was to clarify the relationship between high or low blood pressure (BP) and cognitive function in elderly outpatients with cardiometabolic diseases.

METHODS

We evaluated the association between BP and the Dementia Assessment Sheet for Community-based Integrated Care System-21 items (DASC-21), Mini Mental State Examination (MMSE), and Montreal Cognitive Assessment Tool (MoCA) (N = 677).

RESULTS

The patients' mean age was 79.2 ± 6.3 years (male 35.3%), and BP was 132.1 ± 18.1/73.5 ± 12.2 mmHg. Systolic BP (SBP) was linearly related to the DASC-21 score (r = -0.122, P = 0.004), but not to the MMSE score (P = 0.101) or MoCA score (P = 0.802). Multiple linear regression analysis showed that lower SBP was significantly related to the DASC-21 score, even after controlling for confounding factors (B = -0.411 per 10 mmHg; 95% confidence interval [CI], -0.673 to -0.149; P = 0.002). Moreover, logistic regression analysis showed that lower SBP was associated with DASC-21 ≥ 31 (odds ratio = 0.838 per 10 mmHg, P = 0.048). An MMSE score ≤23 was significantly associated with higher SBP in patients without a history of hypertension but with lower SBP in those with hypertension, those on hypertensive medication, and those with dyslipidemia.

CONCLUSION

Higher BP was associated with a higher prevalence of probable dementia in those without a history of hypertension, even in late life. In those with hypertension and those taking antihypertensives with comorbidities of stroke or heart failure, lower BP was associated with probable dementia, which was largely dependent on reduced activities of daily living, as measured by the DASC-21 score. Geriatr Gerontol Int 2024; 24: 110-117.

Forecasting the Acute Heart Failure Admissions: Development of Deep Learning Prediction Model Incorporating the Climate Information

BACKGROUND

Climate is known to influence the incidence of cardiovascular events. However, their prediction with traditional statistical models remains imprecise.

METHODS AND RESULTS

We analyzed 27,799 acute heart failure (AHF) admissions within the Tokyo CCU Network Database from January 2014 to December 2019. High-risk AHF (HR-AHF) day was defined as a day with the upper 10th percentile of AHF admission volume. Deep neural network (DNN) and traditional regression models were developed using the admissions in 2014-2018 and tested in 2019. Explanatory variables included 17 meteorological parameters. Shapley additive explanations were used to evaluate their importance. The median number of incidences of AHF was 12 (9-16) per day in 2014-2018 and 11 (9-15) per day in 2019. The predicted AHF admissions correlated well with the observed numbers (DNN: R2 = 0.413, linear regression: R2 = 0.387). The DNN model was superior in predicting HR-AHF days compared with the logistic regression model [c-statistics: 0.888 (95% CI: 0.818-0.958) vs 0.827 (95% CI: 0.745-0.910): P = .0013]. Notably, the strongest predictive variable was the 7-day moving average of the lowest ambient temperatures.

CONCLUSIONS

The DNN model had good prediction ability for incident AHF using climate information. Forecasting AHF admissions could be useful for the effective management of AHF.

Presence of ectopic germinal center structures in autoimmune hepatitis

Autoimmune tissues may contain ectopic germinal centers (EGCs). However, these structures have never been described in the liver of patients suffering from autoimmune hepatitis (AIH). We retrospectively reviewed histological features of 120 definite AIH cases, and found 10 cases harboring markers of EGCs. In these cases, CD21+ follicular dendritic cells were intermixed with CD3+ T and CD20+ B lymphocytes. The latter expressed the GC-specific marker bcl6, and some were proliferative as assessed by Ki67 expression. Antibody-secreting cells (ASCs) defined by expression of the mum-1 transcription factor and presence of cytoplasmic IgMs were usually present in the periphery of these structures, but some were also present within the EGCs. Notably, some ASCs were IgG-switched. Common treatment applied to AIH patients achieved biochemical normalization as efficiently as in patients without EGCs. In the present study, we provide the proof for the occurrence of functional EGCs enabling differentiation of B cells into ASCs and occurrence of immunoglobulin switch in AIH livers.

Impact of the COVID-19 pandemic on incidence and mortality of emergency cardiovascular diseases in Tokyo

BACKGROUND

The impact of the coronavirus disease 2019 (COVID-19) pandemic on the incidence and in-hospital mortality of emergency cardiovascular disease (CVD) has not been clarified in Japan.

METHODS

We compared the number of admissions and in-hospital mortality for emergency CVD during the pandemic (from January to December 2020) with those of pre-pandemic periods (from January 2018 to December 2019), using quarterly data from the Tokyo Cardiovascular Care Unit Network. The incidence rate in 2020 is compared with the average incidence rate observed in the same quarter of 2018 and 2019 and is presented as an incidence rate ratio (IRR) with 95 % confidence interval (CI).

RESULTS

The number of admissions for acute myocardial infarction during the pandemic was significantly lower than before the pandemic, with an IRR of 0.93 (95 % CI; 0.88-0.98). Similarly, the IRR for unstable angina was 0.78 (95 % CI; 0.72-0.83), for acute heart failure was 0.84 (95 % CI; 0.76-0.91), for acute aortic dissection was 0.88 (95 % CI; 0.78-0.98), and for ruptured aortic aneurysm was 0.75 (95 % CI; 0.62-0.88). In quarterly comparisons, the numbers of acute aortic diseases and emergency arrhythmia significantly decreased from July to September 2020, while those of other emergency CVDs significantly declined in the 2020 April-June period, which includes the first wave period in Japan. In-hospital mortality of emergency CVDs was unchanged from the pre-pandemic period, except for acute aortic dissection, which increased in odds ratio of 1.31 (95 % CI 1.10-1.57).

CONCLUSIONS

The COVID-19 pandemic significantly reduced the number of admissions for all emergency CVDs in all or part of the year. In-hospital mortality was unchanged from the pre-pandemic period, except for acute aortic dissection, which increased.

Association between physical performance during sit-to-stand motion and frailty in older adults with cardiometabolic diseases: a cross-sectional, longitudinal study

BACKGROUND

Although physical performance tests of the lower extremities are used to assess sarcopenia and frailty, little is known about the mechanisms by which the parameters of ground reaction force (GRF) measured during sit-to-stand motion affect the frailty status in older adults. We aimed to examine the association between GRF parameters during sit-to-stand motion and the incidence of frailty in older adults.

METHODS

This longitudinal study evaluated 319 outpatients aged ≥ 65 years with cardiometabolic diseases. The GRF parameters were measured using a motor function analyzer, in which the power, speed, and balance scores were calculated. Frailty was diagnosed using the modified version of the Cardiovascular Health Study (mCHS) and the Kihon Checklist (KCL). The independent associations between scores and frailty indices were assessed using multivariate binomial logistic regression analyses. Cox regression analysis was used to examine whether power and speed scores were associated with the incidence of frailty after adjusting for covariates.

RESULTS

Logistic regression analyses adjusted for covariates showed that the power and speed scores were associated with frailty according to the mCHS criteria (power: OR = 0.37, 95% CI = 0.22-0.63; speed: OR = 0.64, 95% CI = 0.52-0.79) and KCL criteria (power: OR = 0.40, 95% CI = 0.26-0.62; speed: OR = 0.81, 95% CI = 0.69-0.96) at baseline. Receiver operating characteristic analyses revealed that the area under the curve values of power and speed scores for discriminating mCHS-defined frailty were 0.72 and 0.73. The Cox regression analysis showed that the speed score predicted the incidence of mCHS-defined (HR = 0.45, 95% CI = 0.22-0.92, P = 0.029) and KCL-defined (HR = 0.77, 95% CI = 0.60-0.99, P = 0.039) frailty, whereas the power score was associated with the incidence of KCL-defined frailty (HR = 0.72, 95% CI = 0.55-0.95, P = 0.02) after adjusting for covariates.

CONCLUSIONS

The speed and power scores measured during sit-to-stand motion are predictive of frailty in older adults with cardiometabolic disease. Therefore, the GRF parameters measured during sit-to-stand motion could be an important indicator of frailty. Further studies are necessary to examine whether the GRF parameters can be improved by exercise or whether the changes in these parameters are associated with the improvement of frailty status.

Changes in blood pressure associated with frailty and sarcopenia in elderly outpatients with cardiometabolic diseases

AIM

We aimed to examine the relationship between changes in clinic blood pressure (BP) and frailty and sarcopenia in elderly outpatients with cardiometabolic disease.

METHODS

In 691 elderly outpatients with cardiometabolic diseases, the associations of frailty according to the modified Japanese Cardiovascular Health Study score (J-CHS) and Kihon Checklist (KCL) criteria with clinic BP were evaluated at baseline and followed up for 3 years.

RESULTS

Among the patients (79.2 ± 6.3 years, male 35.6%), 30.4% had frailty by the J-CHS criteria and 38.0% by the KCL criteria. A J-curve relationship was observed between BP and frailty; the prevalence of frailty was the lowest in patients with systolic BP (SBP) 119.5-130.5 mmHg and in those with diastolic BP (DBP) 72.0-80.5 mmHg. Frailty by the J-CHS criteria correlated with lower DBP (OR = 0.892 per 5 mmHg increase, 95% confidence interval [CI] 0.819-0.972, P = 0.009), whereas that by the KCL criteria correlated with lower SBP (OR = 0.872 per 10 mmHg increase, 95% CI 0.785-0.969, P = 0.011) in multivariate-adjusted models. In patients with frailty by the J-CHS criteria at baseline, changes in DBP (OR = 0.921 per 1 mmHg change, 95% CI 0.851-0.996, P = 0.038) were associated with sustained frailty 1 year later. Changes in DBP were associated with progression to a slow walking speed 1 year later (OR = 0.939, 95% CI 0.883-0.999, P = 0.047). Changes in SBP (OR = 0.928, 95% CI 0.878-0.981, P = 0.008) and DBP (OR = 0.926, 95% CI 0.859-0.997, P = 0.042) were associated with progression to a weak hand grip strength 3 years later.

CONCLUSION

A J-curve relationship was observed between frailty and BP, and a decline in BP was associated with progression to a slow walking speed and weak hand grip strength in elderly outpatients with cardiometabolic diseases. Geriatr Gerontol Int 2023; ••: ••-••.

Short-term effects of transcatheter aortic valve replacement on blood pressure and cardiac function in elderly patients with severe aortic stenosis

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is a standard treatment for elderly and high-risk patients with aortic valve stenosis (AS); however, its short-term effects on blood pressure (BP) and cardiac function are not clear. Therefore, we aimed to determine the short-term effects of TAVR in elderly patients (>75 years), who reflect the clinical situation in Japan.

METHOD AND RESULTS

Twenty-eight consecutive elderly patients with severe AS and hypertension who underwent TAVR under general anesthesia were retrospectively investigated. All patients had hypertension that was well controlled with antihypertensive drugs. Serum brain natriuretic peptide level and peak velocity in the aortic valve were significantly reduced. TAVR induces an increase in BP that requires additional antihypertensive agents. There was no correlation between the change rate of SBP and stroke volume index (SVI), but there was a positive correlation between the rate of change in pulse pressure (PP) and SVI. This tendency was particularly observed in patients with low brachial-ankle pulse wave velocity (baPWV).

CONCLUSION

We observed post-TAVR hypertension and required additional antihypertensive drugs. The increases in SVI and PP after TAVR resulted in post-TAVR hypertension. Moreover, post-TAVR hypertension is less likely to occur in elderly patients with a high baPWV, which indicates advanced arteriosclerosis.

Utility of 5-aminolaevulinic acid fluorescence-guided endoscopic biopsy for malignant mesothelioma in a cat and dog

Malignant mesothelioma (MM) is uncommon in cats and dogs and can be challenging to diagnose. Adequate tissue sampling is required for superior diagnostic accuracy. Protoporphyrin IX, a metabolite of 5-aminolaevulinic acid (5-ALA), is a photosensitiser for photodynamic diagnosis (PDD). To the best of our knowledge, no study has reported the use of 5-ALA-PDD to detect MM in veterinary medicine. The present study describes the use of 5-ALA-PDD for MM diagnosis in a cat and dog, as well as the effectiveness of intracavitary chemotherapy. We evaluated the use of PDD with 5-ALA hydrochloride (5-ALA-PDD) in two cases of MM. A 12-year-old cat presented with a 1-month history of respiratory distress, and a 9-year-old dog presented with a 3-month history of mild abdominal distention. We endoscopically biopsied lesions in both the cases using 5-ALA-PDD. Histopathological examination revealed mesothelioma, and immunohistochemical staining was positive for calretinin. Both patients were treated with carboplatin. The cat died of respiratory failure. Although, the dog's condition improved 21 days after the first chemotherapeutic drug administration, the dog died on day 684 owing to cardiac-related issues. 5-ALA-PDD is thus, safe and feasible for the diagnosis of MM in veterinary medicine.

Determinants of depressive symptoms in older outpatients with cardiometabolic diseases in a Japanese frailty clinic: Importance of bidirectional association between depression and frailty

INTRODUCTION

Frailty and depression may play important roles in the management of older patients with cardiometabolic diseases. We explored the determinants of depressive symptoms and their association with frailty among patients with cardiometabolic diseases (hypertension, diabetes, and atrial fibrillation) in a cross-sectional study.

METHODS

A total of 633 outpatients aged 65 years or older with cardiometabolic disease and suspected symptoms of frailty participated in this study. Depressive symptoms, physical activity, and social network were assessed using the Geriatric Depression Scale (GDS)-15, International Physical Activity Questionnaire, and Lubben Social Network Scale-6 (LSNS-6), respectively. Frailty was evaluated using the Kihon Checklist (KCL) based on the Comprehensive Geriatric Assessment (CGA), the modified Cardiovascular Health Study (mCHS), and the Clinical Frailty Scale (CFS). Binomial logistic regression analysis was used to examine the determinants of depressive symptoms and their association with frailty.

RESULTS

Depressive symptoms with GDS-15 scores ≥ 5 were present in 43.6% of the patients. In logistic regression, after adjusting for covariates, the determinants of depressive symptoms in all patients were lack of social network, low years of education, and frailty. In contrast, in logistic regression with frailty as the dependent variable, depressive symptoms were independently associated KCL-defined frailty (OR = 6.28, 95% CI: 4.13-9.55) and mCHS-defined frailty (OR = 2.66, 95% CI: 1.70-4.17), but not with CFS. Similarly, significant associations between depression and frailty were observed in patients with hypertension, diabetes, or atrial fibrillation.

CONCLUSIONS

Lack of social networks, low education, and frailty based on the KCL and mCHS were important determinants of depressive symptoms in all patients. The relatively strong associations between depressive symptoms and frailty based on CGA in patients with hypertension, diabetes, or atrial fibrillation suggest that the assessment of depressive symptoms is of great importance in clinical practice in those patients at high risk of frailty.

[A case of deep vein thrombosis in an elderly patient whose symptoms were exacerbated after applying catheter-based thrombolytic therapy]

We herein report a 99-year-old woman with hypertension and dyslipidemia. From the beginning of August 20XX, significant edema from the left thigh to the toes had been observed, so she had consulted her previous doctor. She had been suspected of having cellulitis and was given antibiotics, but no improvement in her symptoms was noted, so she was transferred to our hospital. The edema of the lower leg was localized to the left lower leg only, and the D-dimer level was as high as 16.6 μg/mL at her visit to the emergency room, so deep vein thrombosis (DVT) was suspected, and the patient received immediate hospitalization. Continuous administration of undifferentiated heparin was started, and lower extremity venous ultrasound was performed. As a result, central-type DVT extending from the left iliac vein to the common iliac vein bifurcation was observed. However, despite administering inferior vena cava (IVC) filter into under the renal vein, and changing heparin to edoxaban 30 mg, no improvement in the lower limb edema was observed. Therefore, catheter-based thrombolysis (CDT) was started on day 11 of illness, and continuous administration of urokinase was started via the catheter. Heparin and edoxaban were not used in combination in order to reduce the risk of bleeding. The edema gradually improved, and after confirming that the thrombus had completely disappeared on lower extremity venous ultrasound, the catheter was removed on day 14 (day 24 of illness) after starting CDT. The IVC filter was also removed, and prescription of edoxaban 30 mg was restarted. Since the patient had used a walking frame at home, she started rehabilitation from the initiation of CDT therapy and was discharged once she was able to use a self-sustaining portable toilet. The basic treatment for DVT is anticoagulant therapy; however, a large amount of thrombosis was observed in the present case, and no marked improvement was observed with conventional anticoagulant therapy. As the patient was particularly elderly, and considering that it was important to improve the edema promptly in order to maintain her activities of daily living, we performed CDT treatment and concluded that it was very effective in this case. However, the CDT procedure for DVT has yet to be standardized, and there are few cases of CDT treatment, especially for such super-elderly patients. In the current aging society, the incidence of DVT diseases is increasing, and in cases such as the present case, anticoagulation therapy alone and CDT therapy should be considered and implemented after careful consideration of the bleeding risk.

Predictive Validity of Different Walking Measures to Identify the Incident Long-Term Care Needs in Older Adults

OBJECTIVES

A comfortable walking speed is a suitable measurement of functional status in older adults. In addition to assessing their comfortable walking speed, two complex walking tests were administered to a cohort of older people, assuming that these tests would be a more sensitive predictor of the incident long-term care needs than comfortable walking speed.

DESIGN

A prospective observational study was conducted to collect data.

SETTING AND PARTICIPANTS

Among the initial 5,563 community-dwelling independent older adults (aged ≥ 65 years), 935 were excluded and the data of 4,628 (mean age, 73.9 ± 5.5 years, 65-94 years; 2,052 men, 2,576 women) older adults were finally analyzed.

METHODS

Three walking tasks were administered: comfortable, complicated balance, and Go-stop walking. Complicated balance walking was measured under comfortable walking conditions, with participants having to walk with their hands crossed at the shoulder joint at 90°. For the Go-stop walking test, the time taken to walk 2 meters was measured using a stopwatch. For two years following baseline assessments, participants received monthly follow-ups for incident certification of the need for care under the long-term care insurance (LTCI) system.

RESULTS

Low performance in comfortable, complicated balance, and Go-stop walking were 29.8%, 37.7%, and 35.1%, respectively. During the 24-month follow-up period, 246 participants (5.3%) required LTCI certification. The Youden Index was used to determine the cut-points of the incident long-term care needs in the comfortable, complicated balance, and Go-stop walking conditions, which were 1.055 m/s, 0.936 m/s, and 3.205 seconds, respectively. Participants classified as exhibiting low performance included 1,381 (29.8%) under comfortable walking, 1,746 (37.7%) under complicated balance walking, and 1,623 (35.1%) under the Go-stop walking tests. The C-indices of the comfortable, complicated balance, and Go-stop walking tests were 0.72 (95% confidence interval (CI) 0.69-0.76), 0.71 (95% CI 0.67-0.74), and 0.65 (95% CI 0.61-0.69), respectively. Cox proportional hazards regression model revealed significant relationships between the incident long-term care needs and the comfortable (hazard ratio (HR) 2.14, 95% CI 1.62-2.84), complicated balance (1.81, 1.36-2.41), and Go-stop (1.46, 1.12-1.91) walking conditions.

CONCLUSIONS AND IMPLICATIONS

The findings suggest that slow walking speed has a considerably greater impact on the incident long-term care needs in older adults. However, the complex walking task did not improve the predictive performance. Comfortable walking speed tests, which can easily be measured to predict the future incident long-term care needs, are effective tools in community health promotion and primary care.

Seasonal influenza, its complications and related healthcare resource utilization among people 60 years and older: A descriptive retrospective study in Japan

Evidence suggests that older people aged ≥65 years and those aged 60–64 years with chronic medical conditions are at higher risk of developing severe complications due to influenza virus infection when compared with young, healthy adults. Although seasonal influenza is monitored through a nationwide passive surveillance in Japan, influenza related outcomes and medical resource consumption have not been fully documented. This retrospective database study aimed to describe the epidemiological and clinical characteristics of medically attended influenza cases aged ≥60 years and the associated medical resource consumption in Japan. We used clinically diagnosed influenza (CDI) based on the international classification of disease codes, and laboratory-confirmed influenza (LCI) based on influenza test results, to identify the patient population during a total of nine seasons (2010/2011 to 2018/2019). A total of 372,356 CDI and 31,122 LCI cases were identified from 77 medical institutions. The highest numbers of medically-attended influenza episodes were in patients aged 65–74 years and 75–84 years. On average, across seasons, 5.9% of all-cause hospitalizations were attributable to CDI and 0.4% were LCI. Influenza viruses type A and B co-circulated annually in varying degree of intensity and were associated with similar level of complications, including cardiovascular-related. Oxygen therapy increased with age; by contrast, mechanical ventilation, dialysis, blood transfusion, and intensive care unit admission were higher in the younger groups. In-hospital mortality for inpatients aged ≥ 85 years with CDI and LCI were 18.6% and 15.5%, respectively. Considering the burden associated with medically-attended influenza in this population, influenza prevention, laboratory confirmation and clinical management should be emphasized by general practicians and specialists like cardiologists to protect this aging population.

Association of ambient temperature and acute heart failure with preserved and reduced ejection fraction

AIMS

Evidence on the association between ambient temperature and the onset of acute heart failure (AHF) is scarce and mixed. We sought to investigate the incidence of AHF admissions based on ambient temperature change, with particular interest in detecting the difference between AHF with preserved (HFpEF), mildly reduced (HFmrEF), and reduced ejection fraction (HFrEF).

METHODS AND RESULTS

Individualized AHF admission data from January 2015 to December 2016 were obtained from a multicentre registry (Tokyo CCU Network Database). The primary event was the daily number of admissions. A linear regression model, using the lowest ambient temperature as the explanatory variable, was selected for the best-estimate model. We also applied the cubic spline model using five knots according to the percentiles of the distribution of the lowest ambient temperature. We divided the entire population into HFpEF + HFmrEF and HFrEF for comparison. In addition, the in-hospital treatment and mortality rates were obtained according to the interquartile ranges (IQRs) of the lowest ambient temperature (IQR1 <5.5°C; IQR25.5-13.3°C; IQR3 13.3-19.7°C; and IQR4 >19.7°C). The number of admissions for HFpEF, HFmrEF and HFrEF were 2736 (36%), 1539 (20%), and 3354 (44%), respectively. The lowest ambient temperature on the admission day was inversely correlated with the admission frequency for both HFpEF + HFmrEF and HFrEF patients, with a stronger correlation in patients with HFpEF + HFmrEF (R²  = 0.25 vs. 0.05, P < 0.001). In the sensitivity analysis, the decrease in the ambient temperature was associated with the greatest incremental increases in HFpEF, followed by HFmrEF and HFrEF patients (3.5% vs. 2.8% vs. 1.5% per -1°C, P < 0.001), with marked increase in admissions of hypertensive patients (systolic blood pressure >140 mmHg vs. 140-100 mmHg vs. <100 mmHg, 3.0% vs. 2.0% vs. 0.8% per -1°C, P for interaction <0.001). A mediator analysis indicated the presence of the mediator effect of systolic blood pressure. The in-hospital mortality rate (7.5%) did not significantly change according to ambient temperature (P = 0.62).

CONCLUSIONS

Lower ambient temperature was associated with higher frequency of AHF admissions, and the effect was more pronounced in HFpEF and HFmrEF patients than in those with HFrEF.

Expressions of PD-L1 and Nectin-4 in urothelial cancer patients treated with pembrolizumab

OBJECTIVES

Recently, the standard of care for advanced urothelial cancer (UC) has been changed by developing immune-checkpoint inhibitors (ICIs). However, its response rate is limited to 20-30%. The identification of biomarkers to predict the therapeutic effects of ICIs is urgently needed. The present study explored the association between immunohistochemical biomarkers and clinical outcomes in UC patients treated with pembrolizumab.

PATIENTS AND METHODS

A total of 85 patients with UC who received pembrolizumab after chemotherapy from January 2018 to May 2020 were retrospectively reviewed. Tumor tissues were obtained for immunohistochemical study from 47 out of 85 patients. The protein expressions of PD-L1, WT1, Nectin-4, CD4, CD8, Foxp3, and CD68 in tumor cells and/or tumor infiltrating lymphocytes were immunohistochemically examined. The associations between protein expressions and overall survival (OS), progression-free survival (PFS), and disease control rate (DCR) were statistically analyzed.

RESULTS

Patients with positive PD-L1 in tumor cells showed significantly worse OS (Log-rank test: HR 5.146, p = 0.001, Cox regression analysis: HR 4.331, p = 0.014) and PFS (Log-rank test: HR 3.31. p = 0.022), along with significantly lower DCR (14.3%) compared to the PD-L1 negative patients (67.5%). In addition, patients with strong expression of Nectin-4 in tumor cells showed significantly higher DCR (100%) than the other patients (50%).

CONCLUSION

PD-L1 expression in tumor cells was associated with poor prognosis (OS and PFS) and low DCR. Interestingly, the strong expression of Nectin-4 was correlated with high DCR. PD-L1 and Nectin-4 expression in tumor cells could be prognostic biomarkers useful for pembrolizumab in patients with advanced UC.

Hypoxemia found after hospitalization with right hemiplegia due to cerebral infarction: platypnea-orthodeoxia syndrome in the older people

An 89-year-old woman was admitted to our hospital for subacute onset of right upper and lower limb weakness and was diagnosed with acute cerebral infarction. During rehabilitation, close observation revealed that her oxygen saturation decreased in the sitting position and improved in the recumbent position without any subjective symptoms of dyspnea. Transthoracic and transesophageal echocardiography and cardiac catheterization revealed a large patent foramen ovale with an atrial septal aneurysm with right-to-left shunting through the defect, and she was diagnosed with platypnea-orthodeoxia syndrome. Her right hemiplegia caused the trunk to collapse, so the patient slumped when in sitting position, and the trunk tilted to the right forward, resulting in an increased right-to-left shunt. Her peripheral capillary oxygen saturation improved in the upright sitting position supported by therapists. This case suggests that right hemiplegia may exacerbate the symptoms of platypnea-orthodeoxia syndrome. <Learning objective: Platypnea-orthodoxia syndrome (POS) is a rare disease and often not clearly diagnosed. Previous studies have reported POS due to patent foramen ovale (PFO) after the onset of subclinical cerebral infarction. To our knowledge, this is the first case to suggest that trunk collapse during sitting due to right hemiplegia exacerbated the hypoxemia caused by POS. Moreover, 20-30% of adults may have asymptomatic PFO. POS may be detected by examining changes in oxygen saturation in different postures.>.

[Posture-dependent left ventricular outflow tract obstruction in a case of Lewy body dementia that presented with transient loss of consciousness]

An 80-year-old woman with a history of hypertrophic obstructive cardiomyopathy and Lewy body dementia was admitted to our hospital with a first episode of syncope while walking. The pressure gradient of left ventricular outflow tract (LVOT) had been stable at nearly 10 mmHg for 3 years before the admission. We evaluated the cause of syncope. Echocardiography showed that the pressure gradient of LVOT was unchanged, even in the supine position ergometer exercise test. Although the head-up tilt test revealed a drop in blood pressure of 44 mmHg systolic and 23 mmHg diastolic, she was asymptomatic during the test. The orthostatic hypotension was considered to be a manifestation of autonomic failure due to Lewy body dementia; however, it was insufficient to explain the syncope on exertion. Echocardiography in a sitting-up position showed that the pressure gradient of LVOT was exacerbated to 41 mmHg, which might be the cause of syncope while walking. Orthostatic hypotension, especially in patients with Lewy body dementia, is a common cause of syncope in the elderly. However, we should keep in mind that the exacerbation of LVOT obstruction due to posture-dependent fluid shift can be a cause of syncope in patients with hypertrophic cardiomyopathy or sigmoid-shaped interventricular septum. In such patients, echocardiography in a sitting-up position can be an effective tool to diagnose the cause of syncope.

Study Protocol of a Comprehensive Activity Promotion Program for the Prevention of Dementia: A Randomized Controlled Trial Protocol

BACKGROUND

Several technical devices are available to monitor and promote changes in behavior toward higher activity. In particular, smartphones are becoming the primary platform for recognizing human activity. However, the effects of behavior change techniques that promote physical, cognitive, and social activities on incident dementia in older adults remain unknown.

OBJECTIVES

This randomized controlled trial aims to examine the effects of behavior change techniques on the prevention of dementia among community-dwelling older adults using a smartphone as a behavior change tool.

DESIGN

A randomized controlled trial.

SETTING

Community in Japan.

PARTICIPANTS

The study cohort comprises 3,498 individuals, aged ≥60 years, randomized into two groups: the smartphone group (n = 1,749) and the control group (n = 1,749).

INTERVENTION

The smartphone group will be asked to use smartphone applications for at least 30 minutes daily to self-manage and improve their physical, cognitive, and social activities. The smartphone group will perform 60-minute group walking sessions using application-linked Nordic walking poles with cognitive stimulation twice a week during the intervention period. The walking poles are a dual-task exercise tool that works with a smartphone to perform cognitive tasks while walking, and the poles are equipped with switches to answer questions for simple calculation and memory tasks. The smartphone and control groups will receive lectures about general health that will be provided during the baseline and follow-up assessments.

MEASUREMENTS

Incident dementia will be detected using cognitive tests (at baseline, after 15 months, and after 30 months) and by preparing diagnostic monthly reports based on data from the Japanese Health Insurance System. Participants without dementia at baseline who will be diagnosed with dementia over the 30-month follow-up period will be considered to have incident dementia.

CONCLUSIONS

This study has the potential to provide the first evidence of the effectiveness of information communication technology and Internet of Things in incident dementia. If our trial results show a delayed dementia onset for self-determination interventions, the study protocol will provide a cost-effective and safe method for maintaining healthy cognitive aging.

Association of Daily Physical Activity with Disability in Community-Dwelling Older Adults With/Without Chronic Kidney Disease

OBJECTIVES

Physical activity is recommended for disability prevention in the older adult population; however, the level of physical activity required for older adults with chronic kidney disease (CKD) remains unknown. This study aimed to examine the associations between daily physical activity and disability incidence in older adults with and without CKD to determine relevant daily physical activity levels.

DESIGN

Prospective observational study.

SETTING AND PARTICIPANTS

3,786 community-dwelling older adults aged ≥65 years.

MEASUREMENTS

Mean daily times spent in light- (LPA) and moderate-to-vigorous physical activity (MVPA) were measured using triaxial accelerometers. CKD was defined by a creatinine estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2. Disability incidence was identified as long-term care insurance certification during a 60-month follow-up period. Associations between physical activity and disability incidence were examined using Cox proportional hazard models stratified by the CKD status. Non-linear and linear associations were tested using the restricted cubic spline.

RESULTS

A total of 1,054 individuals were identified to have CKD. Disability incidence was higher in the CKD group than in the non-CKD group. The adjusted cox proportional hazard models indicated that a 10-minute increase in MVPA time was associated with lower disability incidence in the non-CKD group (hazard ratio [HR], 0.838; 95% confidence interval [CI]: 0.764-0.918) and the CKD group (HR, 0.859; 95% CI: 0.766-0.960). Linear associations were observed in MVPA for the non-CKD and CKD groups.

CONCLUSION

Increasing MVPA was associated with lower disability incidence in older adults with and without CKD. These findings can help devise disability prevention strategies for older CKD patients.

Association between Non-Face-to-Face Interactions and Incident Disability in Older Adults

OBJECTIVES

This observational prospective cohort study, conducted between September 2015 and February 2019, aimed to investigate the association between the incidence of disability and non-face-to-face interactions among community-dwelling older adults in Japan.

DESIGN

Participants reported their interaction status using a self-report questionnaire. Face-to-face interactions comprised in-person meetings, while virtual interactions (e.g., via phone calls or emails) were defined as non-face-to-face interactions. We examined the relationship between their interaction status at baseline and the risk of disability incidence at follow-up. We also considered several potential confounding variables, such as demographic characteristics.

SETTING

The National Center for Geriatrics and Gerontology-Study of Geriatric Syndromes.

PARTICIPANTS

We included 1159 adults from Takahama City aged ≥75 years (mean age ± standard deviation = 79.5 ± 3.6 years).

MEASUREMENTS

Interaction status was assessed using a self-reported questionnaire consisting of two sections (face-to-face and non-face-to-face interactions), and four questionnaire items. Based on the responses we categorized study participants into four groups: "both interactions," "face-to-face only," "non-face-to-face only," and "no interactions."

RESULTS

Individuals with both kinds of interactions (49.3/1000 person-years) or only one kind of interaction (face-to-face = 57.7/1000 person-years; non-face-to-face = 41.2 person-years) had lower incidence of disability than those with no interactions (88.9/1000 person-years). Moreover, the hazard ratios adjusted for potential confounding factors for the incidence of disability in the both interaction, face-to-face-only, and non-face-to-face only groups were 0.57 (confidence interval = 0.39-0.82; p = 0.003), 0.66 (confidence interval = 0.44-0.98; p = 0.038), and 0.47 (confidence interval = 0.22-0.99; p = 0.048), respectively.

CONCLUSION

Considering the interaction status of older adults in their day-to-day practice, clinicians may be able to achieve better outcomes in the primary prevention of disease by encouraging older adults to engage in any form of interaction, including non-face-to-face interactions.

Unconventional supercurrent phase in Ising superconductor Josephson junction with atomically thin magnetic insulator

In two-dimensional (2D) NbSe₂ crystal, which lacks inversion symmetry, strong spin-orbit coupling aligns the spins of Cooper pairs to the orbital valleys, forming Ising Cooper pairs (ICPs). The unusual spin texture of ICPs can be further modulated by introducing magnetic exchange. Here, we report unconventional supercurrent phase in van der Waals heterostructure Josephson junctions (JJs) that couples NbSe₂ ICPs across an atomically thin magnetic insulator (MI) Cr₂Ge₂Te₆. By constructing a superconducting quantum interference device (SQUID), we measure the phase of the transferred Cooper pairs in the MI JJ. We demonstrate a doubly degenerate nontrivial JJ phase (ϕ), formed by momentum-conserving tunneling of ICPs across magnetic domains in the barrier. The doubly degenerate ground states in MI JJs provide a two-level quantum system that can be utilized as a new dissipationless component for superconducting quantum devices. Our work boosts the study of various superconducting states with spin-orbit coupling, opening up an avenue to designing new superconducting phase-controlled quantum electronic devices.

Van der Waals structures provide a new platform to explore novel physics of superconductor/ferromagnet interfaces. Here, NbSe₂ Josephson junction with Cr₂Ge₂Te₆ enables non-trivial Josephson phase by spin-dependent interaction, boosting the study of superconducting states with spin-orbit coupling and phase-controlled quantum electronic device.

Abstract P190: Antihypertensive Treatment Improves Left Ventricular Geometry After 10 Years Even In Elderly Hypertensive Patients

Introduction: Both ageing and high blood pressure (BP) is associated with a risk of left ventricular hypertrophy; therefore, it is unclear whether antihypertensive treatment for 10 years period reduce cardiac hypertrophy and concentricity beyond the impact of ageing. We assessed the hypothesis that even in elderly patients, BP reduction is effective for left ventricular remodeling.

Methods: Among 558 hypertensive patients without concurrent heart disease referred to a cardiology clinic who underwent echocardiography and ambulatory blood pressure monitoring, 151 patients’ data of echocardiography was available after 10 years of follow up period. We evaluated the relation among BP at baseline, antihypertensive medications, and change in echocardiographic parameters of left ventricular geometry.

Results: Mean age was 70.8±8.2 years at baseline. 24-hour BP was 127.4±16.4/71.4±9.6mmHg, awake BP was 129.9±17.1/72.4±10.2mmHg, and asleep BP was 122.5±16.9/67.1±9.1 mmHg. After 10 years (mean age 81.0±9.0 years), number of antihypertensive increased from 1.3±1.2 to 2.0±1.1. Left ventricular mass index (LVMI) insignificantly decreased from 115.7 to 98.7mg/m 2 (p=0.167)and relative wall thickness (RWT) significantly decreased from 0.51 to 0.47(p<0.001). There were 12% of patients with normal left ventricular geometry (N), 52% with concentric remodeling (CR), 9% with eccentric hypertrophy (EH), and 27% with concentric hypertrophy (CH) at baseline. Among patients with N or CR at baseline, those who developed to CH or EH had higher night time systolic BP (126.5±17.0 vs 118.9 ±15.4, p=0.037) than those who did not. Neither number nor type of antihypertensive was related to this geometry change. In logistic regression analysis, night time systolic BP was significantly related to the progression of hypertrophy adjusting for age, sex, BMI, LVMI, RWT, and clinic systolic BP at baseline (p=0.04).

Conclusions: Even in elderly hypertensive patients, antihypertensive treatment for 10 years improved LV geometry in spite of ageing. Nighttime BP at baseline predicted worsening of LV geometry after 10 years beyond clinic BP.

The relationship between blood pressure and cognitive function

Background

Although an elevated systolic blood pressure (SBP) is associated with cognitive dysfunction, BP may decrease with advanced cognitive dysfunction; therefore, we attempted to identify the turning point in the relationship between cognitive function and SBP in elderly subjects.

Methods

In pooled datasets of general populations and outpatient clinics (age>65 years), in which the risk of frailty or cognitive dysfunction was assessed (N = 4076), the relationship between SBP and the Mini Mental State Examination (MMSE) score was examined.

Results

Mean age was 72.5 ± 6.2 years (male 45.1%), and SBP was 133.0 ± 19.5 mmHg. In an analysis of locally weighted scatter plot smoothing, the relationship between SBP and MMSE scores changed at an MMSE score of 24 points. In subjects with preserved cognitive function (MMSE ≥24 points), MMSE scores decreased with increases in SBP (B = −0.047 per 10 mmHg increase, P = 0.002) after adjustments for age, sex, body mass index, alcohol habit, smoking status, diabetes, a history of stroke, and the geriatric nutritional index; however, in subjects with reduced cognitive function (MMSE<24 points), decreases in the MMSE score were associated with reductions in SBP (B = 1.178 per 1 point decrease in the MMSE score, P = 0.002).

Conclusion

The relationship between SBP and cognitive function changed at a MMSE score of approximately 24 points (mild to moderate cognitive dysfunction). In patients with preserved MMSE, higher BP values were associated with a reduction of cognitive function, but this was not a case for those with impaired MMSE.

Abstract P137: Nonspecific ST-T Change In Electrocardiogram Was Associated With A Reduced Constructive Myocardial Work In Hypertensive Patients With Preserved Ejection Fraction

Background: Nonspecific ST-T change in electrocardiogram can be observed in hypertensive heart disease with preserved left ventricular ejection fraction (LVEF); however, the relationship between nonspecific ST-T change and global myocardial work in echocardiography was unclear.

Methods: We evaluated global longitudinal strain (GLS), GWI (global work index), GCW (global constructive work), GWW (global wasted work), GWE (global work efficiency), using offline analyzing system (View Pal, GE) in 196 hypertensive patients with preserved LVEF (>50%). Nonspecific ST-T change and major ST-T change (depression of ST in V5 lead >1mV) was also evaluated in electrocardiogram.

Results: Mean age was 79.3±8.2 years (men 37.8%). Compared with patients with no ST-T change, those with nonspecific and major ST-change had a smaller absolute value of GLS (-20±3, -18±4, -14±5%, P<0.001) and had smaller constructive work load [GWI (2140±488, 1915±472, 1523±776 mmHg%, P<0.001), GCW (2410±514, 2165±471, 1694±784 mmHg%, P<0.01)]. Additionally, those with nonspecific and major ST-T change had an increased wasted myocardial work [GWW (87±61, 109±58, 138±71 mmHg%, P<0.001)], and this resulted in reduction of myocardial work efficiency [GWE (95±4,93±3,87±12%,P<0.001)]. Even after adjustment for age, sex, diabetes, dyslipidemia, EF, LV mass index, relative wall thickness, parameters of diastolic function (E/A, E/e’, left atrial volume index, tricuspid valve regurgitant flow velocity), and electrocardiogram LVH of Cornell product and Sokolow-Lyon voltage, the patients with nonspecific ST-T change had a significantly smaller LV global constructive work. [GWI (2243±41 vs. 1998±96 mmHg%, P=0.025), GCW (2501±45 vs. 2210±105 mmHg%, P=0.015)].

Conclusion: In hypertensive patients with preserved LVEF, nonspecific ST-T change in electrocardiogram was associated with a reduced constructive work in LV.

Efficacy and Safety of Favipiravir in Moderate COVID-19 Pneumonia Patients without Oxygen Therapy: A Randomized, Phase III Clinical Trial

Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause of coronavirus disease 2019 (COVID-19), is an enveloped, single-stranded RNA virus. Favipiravir is an orally administrable antiviral drug whose mechanism of action is to selectively inhibit RNA-dependent RNA polymerase. A preliminary trial in COVID-19 patients reported significant improvements across a multitude of clinical parameters, but these findings have not been confirmed in an adequate well-controlled trial. We conducted a randomized, single-blind, placebo-controlled Phase III trial assessing the efficacy and safety of favipiravir in patients with moderate pneumonia not requiring oxygen therapy.

Methods

COVID-19 patients with moderate pneumonia (SpO₂ ≥ 94%) within 10 days of onset of fever (temperature ≥ 37.5 °C) were assigned to receive either placebo or favipiravir (1800 mg twice a day on Day 1, followed by 800 mg twice a day for up to 13 days) in a ratio of 1:2. An adaptive design was used to re-estimate the sample size. The primary endpoint was a composite outcome defined as the time to improvement in temperature, oxygen saturation levels (SpO₂), and findings on chest imaging, and recovery to SARS-CoV-2-negative. This endpoint was re-examined by the Central Committee under blinded conditions.

Results

A total of 156 patients were randomized. The median time of the primary endpoint was 11.9 days in the favipiravir group and 14.7 days in the placebo group, with a significant difference (p = 0.0136). Favipiravir-treated patients with known risk factors such as obesity or coexisting conditions provided better effects. Furthermore, patients with early-onset in the favipiravir group showed higher odds ratio. No deaths were documented. Although adverse events in the favipiravir group were predominantly transient, the incidence was significantly higher.

Conclusions

The results suggested favipiravir may be one of options for moderate COVID-19 pneumonia treatment. However, the risk of adverse events, including hyperuricemia, should be carefully considered.

Trial registration

Clinicaltrials.jp number: JapicCTI-205238.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-021-00517-4.

Primary cardiac B cell lymphoma in an immunocompetent patient

Primary cardiac lymphoma is a rare entity of extranodal lymphoma and is observed with increasing frequency in immunocompromised hosts. However, a considerable proportion of cardiac lymphomas still occur in immunocompetent patients. We report the case of a 55-year-old immunocompetent Japanese man with a large amount of pericardial fluid and the presentation of heart failure secondary to primary cardiac B cell lymphoma, which was diagnosed by cytological examination of pericardial fluid and imaging. The right atrium, right ventricle and pericardium were affected by the tumour, which encased the mid/distal portion of the right coronary artery (RCA). Pretreatment optical coherence tomography of the RCA demonstrated no tumour extension into the vascular structure but a focal mural thrombus. We initiated chemotherapy (steroid therapy then COP at half dose/R-CHOP/R-CHASE) [COP (C: Cyclophosphamide, O: Oncovin, P: Prednisolone) R-CHOP (R: Rituximab, C: Cyclophosphamide, H: Doxorubicin Hydrochloride, O: Oncovin, P: Prednisolone) R-CHASE (R: Rituximab, C: Cyclophosphamide, HA: high dose Cytarabine, S: Steroid, E: Etoposide)]with administration of low-dose aspirin to prevent possible ischaemic events. The patient had a good clinical course without adverse events except for transient pericarditis.

Impact of tumor growth rate during preceding treatment on tumor response to nivolumab or irinotecan in advanced gastric cancer

Background

Nivolumab (NIVO) and irinotecan (IRI) are standard treatments for refractory advanced gastric cancer (AGC); however, it is unclear which drug should be administered first or in which cases. The tumor growth rate (TGR) during preceding treatment is reported to be associated with tumor response in metastatic colorectal cancer patients treated with regorafenib or trifluridine/tipiracil, suggesting that TGR may be useful for drug selection. Therefore, we evaluated the association between TGR during preceding treatment and the tumor response to NIVO or IRI.

Patients and methods

We retrospectively evaluated consecutive AGC patients treated with NIVO or IRI and divided them into slow-growing (Slow) and rapid-growing (Rapid) groups according to TGR and the presence or absence of new lesions (NL+/NL−, respectively) during preceding treatment (Slow group: NL− with low TGR <0.30%/day; Rapid group: NL+ or high TGR ≥0.30%/day).

Results

A total of 117 patients (Rapid/Slow groups, 72/45; NIVO/IRI groups, 32/85) were eligible. All baseline characteristics except peritoneal metastases were similar between patients treated with NIVO and IRI in the Rapid and Slow groups. The response rate was significantly higher in patients treated with NIVO compared with IRI [31%/3%; odds ratio (OR), 13.8; P = 0.01; adjusted OR, 52; P = 0.002] in the Slow group, but there was no difference between patients treated with NIVO and IRI (5%/8%; OR, 0.68; P = 0.73; adjusted OR, 0.94; P = 0.96) in the Rapid group. Disease control rate, progression-free survival, and overall survival were consistent with these results.

Conclusions

Our findings suggest that NIVO treatment is a more favorable option for patients with slow-growing tumors, and NIVO and IRI are similarly recommended for patients with rapid-growing tumors in refractory AGC. TGR and NL emergence during preceding treatment may be helpful for drug selection and warrant further investigation.

•

NIVO and IRI are standard treatments for refractory AGC, although it is unclear which should be administered first.

•

TGR may be useful for drug selection, therefore we evaluated the association between TGR and the tumor response to NIVO or IRI.

•

In the Slow group, the response rate (RR) was significantly higher in patients treated with NIVO compared with IRI.

•

In the Rapid group, there was no significant difference in RR between the NIVO and IRI groups.

•

TGR and NL emergence during preceding treatment may be useful for drug selection.

Proteome analysis demonstrates involvement of endoplasmic reticulum stress response in human myocardium with subclinical left ventricular diastolic dysfunction

AIM

Heart failure is increasing in Japan, in particular that with preserved ejection fraction (HFpEF) prevalent in older-aged patients. The purpose of this study was to investigate the pathophysiology during the early stage of left ventricular (LV) diastolic dysfunction by the quantitative proteome analysis of human myocardium.

METHODS

Among 331 post-mortem autopsy patients, we selected 23 patients (aged 79 ± 9.6 years) with echocardiographic data and without major comorbidities, except hypertension. Cryopreserved autopsy tissue of the LV myocardium was subjected to proteome analysis. LV diastolic function was evaluated by echocardiographic data. Thirteen patients were classified into the impaired diastolic function (IDF) group, and 10 the normal cardiac function group. We performed comparative proteome analysis between the IDF and normal groups by isobaric tags for relative and absolute quantitation (iTRAQ) using nano-liquid chromatography-tandem mass spectrometry.

RESULTS

The iTRAQ-based proteome analysis revealed 57 differentially expressed proteins in the IDF group. Molecular network analysis of differentially expressed proteins indicated that endoplasmic reticulum (ER) stress was a potentially important event. Furthermore, the expressions of proteins associated with the ER stress response, such as glucose-regulated protein 78 kDa, inositol-requiring kinase 1α and spliced X-box binding protein 1, were significantly decreased in the IDF group.

CONCLUSIONS

This study suggested that reduced ER stress responses were involved during the early stage of LV diastolic dysfunction. Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2021; 21: 577-583.

Hospital performance in a large urban acute myocardial infarction emergency care system: Tokyo Cardiovascular Care Unit network

BACKGROUND

An ideal urban network system for improving regional acute myocardial infarction (AMI) outcomes should be geographically balanced and uniform according to regional population in performance of participating hospitals. The objective of our study is to evaluate whether there is a major difference in risk-adjusted in-hospital mortality between the Tokyo Cardiovascular Care Unit (CCU) network hospitals, which cover the whole population of large cities.

METHODS

The study subjects were all AMI patients without cardiac arrest on arrival admitted to the Tokyo CCU network hospitals from 2009 to 2017. Risk-adjusted in-hospital mortality rates (RAMRs) were compared between the categories of each hospital-level factor. A hospital-level multivariable linear regression was modeled to analyze the association between RAMRs and hospital-level factors. A funnel plot was constructed by plotting RAMRs against hospital volumes.

RESULTS

From 2009 to 2017, there were 42,123 hospitalizations for AMI in Tokyo CCU network hospitals (n=72, as of December, 2017). There were no significant differences in RAMRs in the comparison of hospital backgrounds. Each hospital background was not significantly associated with the RAMR. Considering the 99% CI in funnel plots, only five hospitals (7.2%) were located outside the control limits.

CONCLUSIONS

There was no major difference in the RAMRs between the participating hospitals within the Tokyo CCU network, despite the different hospital backgrounds.

Migration Stimulating Factor (MSF): Its Role in the Tumour Microenvironment

Migration Stimulating Factor (MSF) is a 70 kDa truncated isoform of fibronectin (FN); its mRNA is generated from the FN gene by an unusual two-stage processing. Unlike full-length FN, MSF is not a matrix molecule but a soluble protein which displays cytokine-like activities not displayed by any other FN isoform due to steric hindrance. There are two isoforms of MSF; these are referred to as MSF+aa and MSF-aa, while the term MSF is used to include both.MSF was first identified as a motogen secreted by foetal and cancer-associated fibroblasts in tissue culture. It is also produced by sprouting (angiogenic) endothelial cells, tumour cells and activated macrophages. Keratinocytes and resting endothelial cells secrete inhibitors of MSF that have been identified as NGAL and IGFBP-7, respectively. MSF+aa and MSF-aa show distinct functionality in that only MSF+aa is inhibited by NGAL.MSF is present in 70-80% of all tumours examined, expressed by the tumour cells as well as by fibroblasts, endothelial cells and macrophages in the tumour microenvironment (TME). High MSF expression is associated with tumour progression and poor prognosis in all tumours examined, including breast carcinomas, non-small cell lung cancer (NSCLC), salivary gland tumours (SGT) and oral squamous cell carcinomas (OSCC). Epithelial and stromal MSF carry independent prognostic value. MSF is also expressed systemically in cancer patients, being detected in serum and produced by fibroblast from distal uninvolved skin. MSF-aa is the main isoform associated with cancer, whereas MSF+aa may be expressed by both normal and malignant tissues.The expression of MSF is not invariant; it may be switched on and off in a reversible manner, which requires precise interactions between soluble factors present in the TME and the extracellular matrix in contact with the cells. MSF expression in fibroblasts may be switched on by a transient exposure to several molecules, including TGFβ1 and MSF itself, indicating an auto-inductive capacity.Acting by both paracrine and autocrine mechanisms, MSF stimulates cell migration/invasion, induces angiogenesis and cell differentiation and alters the matrix and cellular composition of the TME. MSF is also a survival factor for sprouting endothelial cells. IGD tri- and tetra-peptides mimic the motogenic and angiogenic activities of MSF, with both molecules inhibiting AKT activity and requiring αvβ3 functionality. MSF is active at unprecedently low concentrations in a manner which is target cell specific. Thus, different bioactive motifs and extracellular matrix requirements apply to fibroblasts, endothelial cells and tumour cells. Unlike other motogenic and angiogenic factors, MSF does not affect cell proliferation but it stimulates tumour growth through its angiogenic effect and downstream mechanisms.The epithelial-stromal pattern of expression and range of bioactivities displayed puts MSF in the unique position of potentially promoting tumour progression from both the "seed" and the "soil" perspectives.

Factors contributing to energy loss in left ventricle during diastolic and systolic phases in elderly patients

BACKGROUND

The change of left ventricular function deteriorated with age because of gradual increases of blood pressure may result in increased energy loss (EL) in left ventricle (LV). The present study investigated EL in LV among hypertensive elderly patients and examined factors contributing to EL.

METHODS

A single-center retrospective study was performed on elderly hypertensive outpatients (≥65 years) who underwent echocardiography (N = 105). EL in the LV was measured using a vector flow mapping system, and factors affecting peak EL during the early-diastolic phase (ED-EL), late-diastolic phase (LD-EL), and systolic phase (Sys-EL) were evaluated.

RESULT

Mean age was 79.9 ± 6.4 years (male 43%). Mean ED-EL, LD-EL, and Sys-EL were 42.1 ± 46.7, 75.6 ± 60.2, and 40.4 ± 40.2 mJ/N/s. In a stepwise regression analysis, the E/e'(lateral) (unstandardized B = 0.005, 95%CI -0.03 to 0.007, standardized β = 0.434, P < .001) was identified as factors affecting ED-EL. The factors affecting LD-EL were E/A ratio (B = -0.122, 95%CI -0.176 to -0.068, β = -0.470, P < .001) and time velocity integral (TVI) in LVOT (unstandardized B = 0.002, 95%CI 0.000 to 0.004, β = 0.247, P = .021). The factors influencing Sys-EL were TVI in LVOT (B = 0.002, 95%CI 0.001 to 0.004, β = 0.390, P < .001), E/A ratio (B = -0.054, 95%CI -0.093 to -0.015, β = -0.258, P = .008), left ventricular outflow tract (LVOT) diameter (B = -0.006, 95%CI -0.010 to -0.002, β = -0.307, P = .006), and left ventricular mass index (B = 0.000, 95%CI 0.000 to 0.001, β = 0.208, P = .039).

CONCLUSION

Peak EL in the LV was higher during diastolic phase than systolic phase among elderly hypertensive patients. Peak EL both during late-diastolic phase and systolic phase was affected by systolic blood flow in LVOT and LV transmitral flow pattern.

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

Introduction

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

Purpose

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

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

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

Results

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

Conclusions

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

Figure 1

Funding Acknowledgement

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