Skeletal Muscle Electrical Stimulation Prevents Progression of Disuse Muscle Atrophy via Forkhead Box O Dynamics Mediated by Phosphorylated Protein Kinase B and Peroxisome Proliferator-Activated Receptor gamma Coactivator-1alpha

Although electrical muscle stimulation (EMS) of skeletal muscle effectively prevents muscle atrophy, its effect on the breakdown of muscle component proteins is unknown. In this study, we investigated the biological mechanisms by which EMS-induced muscle contraction inhibits disuse muscle atrophy progression. Experimental animals were divided into a control group and three experimental groups: immobilized (Im; immobilization treatment), low-frequency (LF; immobilization treatment and low-frequency muscle contraction exercise), and high-frequency (HF; immobilization treatment and high-frequency muscle contraction exercise). Following the experimental period, bilateral soleus muscles were collected and analyzed. Atrogin-1 and Muscle RING finger 1 (MuRF-1) mRNA expression levels were significantly higher for the experimental groups than for the control group but were significantly lower for the HF group than for the Im group. Peroxisome proliferator-activated receptor gamma coactivator-1alpha (PGC-1alpha) mRNA and protein expression levels in the HF group were significantly higher than those in the Im group, with no significant differences compared to the Con group. Both the Forkhead box O (FoxO)/phosphorylated FoxO and protein kinase B (AKT)/phosphorylated AKT ratios were significantly lower for the Im group than for the control group and significantly higher for the HF group than for the Im group. These results, the suppression of atrogin-1 and MuRF-1 expression for the HF group may be due to decreased nuclear expression of FoxO by AKT phosphorylation and suppression of FoxO transcriptional activity by PGC-1alpha. Furthermore, the number of muscle contractions might be important for effective EMS.

Study of the electron-doping mechanism in single-walled carbon nanotubes using dimethylbenzimidazole

Single-walled carbon nanotubes (SWCNTs) exhibit p-type properties in air, necessitating electron doping using n-dopants (e.g., reducing agents) for the development of SWCNT-based electronic devices. Dimethylbenzimidazole (DMBI-H) derivatives serve as effective electron dopants, not only for SWCNTs, but also for various organic semiconducting materials. However, the doping reaction is still a subject of debate. In this study, the electron-doping reactions of ortho-methoxy-substituted DMBI-H for SWCNTs were analyzed in protic and aprotic solvents in the presence and absence of dioxygen (O2). The presence of O2 was found to cause the reduction of O2 on the SWCNT surface in the protic solvent, resulting in the production of DMBI cations and water through proton-coupled electron transfer (PCET) from the n-doped SWCNT and ethanol. This work elucidates the mechanism behind the air-stability of n-type SWCNTs.

Extensive-Disease Small-Cell Lung Cancer With Severe Immune-Related Adverse Events Due to Atezolizumab Maintaining a Complete Response for Two Years: A Case Report

A 75-year-old male with diabetes mellitus was referred to our hospital with an abnormal shadow on chest radiography, based on which he was diagnosed with extensive-disease small-cell lung cancer (ED-SCLC; cT2bN2M1a). The first-line therapy comprised atezolizumab, carboplatin, and etoposide. After four cycles, the patient achieved complete response (CR), and maintenance therapy was initiated with atezolizumab. However, even though CR was maintained, maintenance therapy was discontinued after 16 cycles due to persistent grade 2 anorexia and fatigue. Simultaneously, the HbA1c decreased to 5.5%, and antidiabetic therapy was discontinued. Six months after the last dose of atezolizumab, the patient visited the emergency room because of anorexia, dry mouth, and fatigue. Laboratory findings were as follows: blood glucose was 668 mg/dL, glycated hemoglobin (HbA1c) was 8.8%, urine ketone was 2+, sodium (Na) was 127 mmol/L, potassium (K) was 6.5 mmol/L, creatinine (Cre) was 1.43 mg/dL, and arterial pH was 7.29. Based on these findings, his presentation was consistent with fulminant type 1 diabetes mellitus (T1DM) complicated by diabetic ketoacidosis (DKA). Regular continuous insulin and saline administration was initiated in the intensive care unit, and acidosis and electrolyte abnormalities were corrected. His C-peptide was <0.03 ng/mL. His insulin secretory capacity was considered to be depleted, and he required continuous subcutaneous insulin injections. Glutamic acid decarboxylase and insulin autoantibodies were absent. The complete response persisted without further therapy until two years since the event.

GWAS for systemic sclerosis identifies six novel susceptibility loci including one in the Fcγ receptor region

Here we report the largest Asian genome-wide association study (GWAS) for systemic sclerosis performed to date, based on data from Japanese subjects and comprising of 1428 cases and 112,599 controls. The lead SNP is in the FCGR/FCRL region, which shows a penetrating association in the Asian population, while a complete linkage disequilibrium SNP, rs10917688, is found in a cis-regulatory element for IRF8. IRF8 is also a significant locus in European GWAS for systemic sclerosis, but rs10917688 only shows an association in the presence of the risk allele of IRF8 in the Japanese population. Further analysis shows that rs10917688 is marked with H3K4me1 in primary B cells. A meta-analysis with a European GWAS detects 30 additional significant loci. Polygenic risk scores constructed with the effect sizes of the meta-analysis suggest the potential portability of genetic associations beyond populations. Prioritizing the top 5% of SNPs of IRF8 binding sites in B cells improves the fitting of the polygenic risk scores, underscoring the roles of B cells and IRF8 in the development of systemic sclerosis. The results also suggest that systemic sclerosis shares a common genetic architecture across populations.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Cooperative Carbene Photocatalysis for β-Amino Ester Synthesis

β-Amino acids are useful building blocks of bioactive molecules, including peptidomimetics and pharmaceutical compounds. The current limited accessibility to β2,2-type amino acids which bear an α-quaternary center has limited their use in chemical synthesis and biological investigations. Disclosed herein is the development of a new N-heterocyclic carbene/photocatalyzed aminocarboxylation of olefins, affording β2,2-amino esters with high regioselectivity. The generation of nitrogen-centered radicals derived from simple imides via a sequence of deprotonation and single-electron oxidation allows for the subsequent addition to geminal-disubstituted olefins regioselectively. The intermediate tertiary radicals then cross-couple with a stabilized azolium-based radical generated in situ to efficiently construct the quaternary centers. Mechanistic studies, including Stern-Volmer fluorescence quenching experiments, support the proposed catalytic cycle.

European and multi-ancestry genome-wide association meta-analysis of atopic dermatitis highlights importance of systemic immune regulation

Atopic dermatitis (AD) is a common inflammatory skin condition and prior genome-wide association studies (GWAS) have identified 71 associated loci. In the current study we conducted the largest AD GWAS to date (discovery N = 1,086,394, replication N = 3,604,027), combining previously reported cohorts with additional available data. We identified 81 loci (29 novel) in the European-only analysis (which all replicated in a separate European analysis) and 10 additional loci in the multi-ancestry analysis (3 novel). Eight variants from the multi-ancestry analysis replicated in at least one of the populations tested (European, Latino or African), while two may be specific to individuals of Japanese ancestry. AD loci showed enrichment for DNAse I hypersensitivity and eQTL associations in blood. At each locus we prioritised candidate genes by integrating multi-omic data. The implicated genes are predominantly in immune pathways of relevance to atopic inflammation and some offer drug repurposing opportunities.

Various Organ Damages in Rats with Fetal Growth Restriction and Their Slight Attenuation by Bifidobacterium breve Supplementation

Children with fetal growth restriction (FGR) and its resultant low birthweight (LBW) are at a higher risk of developing various health problems later in life, including renal diseases, metabolic syndrome, and sarcopenia. The mechanism through which LBW caused by intrauterine hypoperfusion leads to these health problems has not been properly investigated. Oral supplementation with probiotics is expected to reduce these risks in children. In the present study, rat pups born with FGR-LBW after mild intrauterine hypoperfusion were supplemented with either Bifidobacterium breve (B. breve) or a vehicle from postnatal day 1 (P1) to P21. Splanchnic organs and skeletal muscles were evaluated at six weeks of age. Compared with the sham group, the LBW-vehicle group presented significant changes as follows: overgrowth from infancy to childhood; lighter weight of the liver, kidneys, and gastrocnemius and plantaris muscles; reduced height of villi in the ileum; and increased depth of crypts in the jejunum. Some of these changes were milder in the LBW-B.breve group. In conclusion, this rat model could be useful for investigating the mechanisms of how FGR-LBW leads to future health problems and for developing interventions for these problems. Supplementation with B. breve in early life may modestly attenuate these problems.

Health-Related Quality of Life at Five Years for a Randomized Trial of Tri-Modality Therapy with I-125 Brachytherapy, External Beam Radiation Therapy, and Short- vs. Long-Term Androgen Deprivation Therapy for High-Risk Localized Prostate Cancer (TRIP)

PURPOSE/OBJECTIVE(S)

To describe the patient-reported health-related quality of life (HR-QoL) outcomes at five years for a multicenter randomized trial of tri-modality therapy with iodine-125 brachytherapy, external beam radiation therapy (EBRT), and short- versus long-term androgen deprivation therapy (ADT) for high-risk localized prostate cancer (TRIP/TRIGU0907).

MATERIALS/METHODS

A total of 332 men with high-risk prostate cancer were randomized to either 6 months of ADT (n = 165) or 30 months of ADT (n = 167) in conjunction with combined modality radiation therapy. For the HR-QoL assessment, general HR-QoL and disease-specific HR-QoL were measured using the Japanese version of the Medical Outcomes Study 8-items Short-Form Health Survey (SF-8) and the Expanded Prostate Cancer Index Composite (EPIC). Patient-reported outcome questionnaires were filled out before ADT initiation, and five years after. Scores were reported as mean with the standard deviation. QoL end points were assessed as the change between pre and post treatment using paired student t-test. Changes in the International Prostate Symptom Scores (IPSS) score, including total score and subscores, were also evaluated. The study was powered according to the primary endpoint of biochemical progression free survival with HR-QoL as a secondary endpoint. In addition, recovery of testosterone level (300ng/dL or higher) was calculated as the cumulative incidence curve and compared between arms by log-rank test.

RESULTS

The cumulative incidence of biochemical progression, and salvage ADT treatment were not different between the arms. Mean domain scores at baseline were well balanced between the two arms in all HR-QoL. There were no differences in the SF-8 assessment and the total and subscore EPIC assessments between the arms. The average sexual function score was lower in short arm versus long arm; 16.24 versus 20.24 at baseline, but not different at five years, 9.96 versus 7.78 (p = 0.164). There were no significant differences between the arms for the total and subscore IPSS. Significantly higher percentage of patients, 71.7% in the short arm recovered to a normal testosterone level at 6 years after the initiation of ADT compared to 43.2% in long arm (p<0.0001).

CONCLUSION

At five years after ADT initiation, there were no significant differences in all score changes between the two arms with general HR-QoL and disease-specific HR-QoL. Most of HR-QoL returned to baseline level, and sexual function scores were low from baseline in this population. Two-years' adjuvant ADT did not affect HR-QoL at five years, although it significantly retarded testosterone recovery compared to 6 months of hormone therapy.

Interlaboratory comparison of electron paramagnetic resonance tooth enamel dosimetry with investigations of the dose responses of the standard samples

A total of seven Japanese laboratories participated in an intercomparison study to estimate the dose given to tooth enamel samples, using the electron spin resonance method. Each of four of the participating laboratories prepared a set of tooth enamel samples, using the electron spin resonance method. Four of the participating laboratories each prepared a set of tooth enamel samples, consisting of seven standard aliquots irradiated from 100 to 2000 mGy and three samples with an 'unknown' dose between 140 and 960 mGy, were intended to eliminate bias from sample preparation. Although not all seven laboratories measured all four sets of samples, the major finding was that systematic biases in estimating doses may be caused by differences in laboratory measurements rather than by the enamel extracting procedures. When doses were averaged by measurements made by multiple laboratories, the averaged values were close to the actual values. Scattering in the intercepts in the standard dose response would be a serious problem in actual dosimetry where no background sample is available.

A comprehensive microbial analysis of pediatric patients with acute appendicitis

BACKGROUND

Pathogenesis of pediatric acute appendicitis (AA) is yet to be elucidated. Therefore, we performed a comprehensive microbial analysis of saliva, feces, and appendiceal lumen of AA patients using 16S ribosomal RNA (rRNA) gene amplicon sequencing to elucidate the pathogenesis of pediatric AA.

METHODS

This study included 33 AA patients and 17 healthy controls (HCs) aged <15 y. Among the AA patients, 18 had simple appendicitis, and 15 had complicated appendicitis. Salivary and fecal samples were obtained from both groups. The contents of the appendiceal lumen were collected from the AA group. All samples were analyzed using 16S rRNA gene amplicon sequencing.

RESULTS

The relative abundance of Fusobacterium was significantly higher in the saliva of AA patients as compared to that in HCs (P = 0.011). Bacteroides, Escherichia, Fusobacterium, Coprobacillus, and Flavonifractor were significantly increased in the feces of AA patients, as compared to that in HCs (P = 0.020, 0.010, 0.029, 0.031, and 0.002, respectively). In the appendiceal lumen, Bacteroides, Parvimonas, Fusobacterium, and Alloprevotella were the top bacterial genera with an average relative abundance >5% (16.0%, 9.1%, 7.9%, and 6.0%, respectively).

CONCLUSIONS

The relative abundance of Fusobacterium was high in the appendiceal lumen of pediatric AA patients. Moreover, the relative abundance of Fusobacterium was significantly higher in the saliva and feces of pediatric AA patients than in those of healthy children. These results suggest that ectopic colonization of oral Fusobacterium in the appendix might play an important role in the pathogenesis of pediatric AA.

Clinical application of endoscopic soft palate augmentation in the treatment of velopharyngeal insufficiency

Velopharyngeal structure augmentation with the injection of autologous fat tissue into the nasal mucosa of the soft palate has been reported previously. However, as the injection points in the velopharyngeal space cannot be observed directly, these injections may be difficult to perform accurately. This report describes a new endoscope-assisted approach in which the materials for velopharyngeal structure augmentation are administered while observing the injection points directly, also enabling adjustment of the amount of material injected. A case series of five patients aged 8-16 years who underwent endoscopic soft palate augmentation under general anaesthesia is reported. Autologous fat tissue was injected into the nasal mucosa of the soft palate using a needle-type device of an endoscope, and the effects of the treatment were evaluated. The injections were performed successfully, and the velopharyngeal function was improved. This new technique of endoscopy-assisted augmentation was useful for the treatment of velopharyngeal insufficiency.

Anesthetic management using costoclavicular brachial plexus block with patient-controlled analgesia in Pediatrics: A case report

The costoclavicular brachial plexus block (CBPB) has been receiving increasing attention as an effective technique for upper arm surgery conducted without phrenic paralysis. However, studies in children are lacking. CBPB was applied to a 10 year-old girl undergoing scheduled radial and ulnar osteotomy due to multiple cartilaginous exostoses and ulnar lengthening. CBPB was performed with a bolus administration of 10 mL of 0.25% levobupivacaine, and the catheter was sequentially replaced in the right costoclavicular space. After surgery, a continuous infusion of 0.17% levobupivacaine through a catheter was initiated at 2 mL/h, along with patient-controlled analgesia (PCA) of 3 mL 0.17% levobupivacaine with a 60-min lock out. The patient complained of 5/10 pain on the numerical rating scale (NRS) 2 h after surgery, which improved immediately after bolus administration. The analgesia induced by CBPB was otherwise effective (NRS ≤ 2). CBPB with PCA may provide adequate analgesia in paediatric cases.

Extensive ablation strategy for persistent atrial fibrillation impairs left atrial function but reduces recurrence rate

Background

In catheter ablation for persistent atrial fibrillation (AF), extensive ablation strategy, such as linear ablation and/or complex fractionated atrial electrogram (CFAE) ablation in addition to pulmonary vein isolation (PVI-plus), might impair left atrial function more severely than PVI-alone strategy.

Purpose

The aim of this study is to investigate the impact of extensive ablation strategy on LA function and assess the relationship between post-ablation LA function and recurrence.

Methods

This study is a post-hoc subanalysis of the EARNEST-PVI randomized controlled trial, which investigated the efficacy of the PVI-alone strategy in comparison with PVI-plus strategy for persistent AF. From the 497 participants of EARNEST-PVI trial, we enrolled 191 patients with full datasets of pre- and post-ablation cardiac computed tomography (CT) at our Hospital. Patients were divided into PVI-alone and PVI-plus groups. Within one month before and 3 months after ablation, LA volume index (LAVI) and LA emptying fraction (LAEF) were calculated by using the Comprehensive Cardiac Analysis software on the Extended Brilliance Workspace. We assessed i) post-ablation LA function, ii) AF/atrial tachycardia (AT) -free rate after single and final session, and iii) relationship between post-ablation LAEF and ablation success in each group.

Results

The indices of baseline LA remodeling were not different between PVI-alone (N=96) and PVI-plus groups (N=95) [LAVI: 71.4 (57.8, 82.0) vs. 68.7 (61.0, 78.1), P=0.92, LAEF: 13.7 (10.0, 17.4) vs. 13.0 (10.0, 16.9), PVI-alone vs. PVI-plus, P=0.78]. In overall patients, post-ablation LAEF did not differ among them [34.4 (26.1, 40.7) vs. 31.6 (26.0, 37.4), P=0.13]. In the analysis of patients showing sinus rhythm during the CT study, LAEF was significantly higher in PVI-alone (N=87) than in PVI-plus group (N=93) [35.7 (29.0, 41.0) vs. 31.7 (26.1, 37.5), P=0.011] (Figure 1A). AF/AT-free survival rate during median follow-up of 44 months was not different after first session (63.5% vs. 68.4%, P=0.33), while PVI-plus had a tendency towards higher success rate after final session (72.9% vs. 84.2%, P=0.053) (Figure 2). In receiver operating characteristics analysis for recurrence after first session, post-ablation decreased LAEF had significantly related to recurrence after PVI-alone (AUC: 0.733, P&lt;0.0001), but not after PVI-plus (AUC: 0.567, P=0.31) (Figure 1B, C).

Conclusion

Compared with PVI-alone strategy, PVI-plus strategy damaged LA function more severely, but tended to be related to higher success rate. Post-ablation LA function was related to recurrence in PVI-alone, but not in PVI-plus. Extensive ablation might have additional anti-arrhythmic effect regardless of iatrogenic myocardial damage. Myocardial injury by extensive ablation may less attribute to recurrence than intrinsic damage of LA.

Funding Acknowledgement

Type of funding sources: None.

Development of the new risk score to predict occurrence of atrial fibrillation early after acute myocardial infarction

Background/Introduction

New onset of atrial fibrillation (AF) is associated with adverse short- and long-term outcomes after acute myocardial infarction (AMI), and its prediction is relevant for the risk stratification in patients with AMI. Although several risk scores were developed for AF in the general population, there is no established risk score for AF occurrence after AMI.

Purpose

To develop a risk score to predict occurrence of AF early after AMI.

Methods

We enrolled consecutive 751 patients with AMI who admitted to our hospital between April 2006 and September 2012 for the present study. New occurrence of AF was defined as AF detected during hospital stay in a patient showing normal regular sinus rhythm at admission. Parameters relevant to the occurrence of AF was selected from the clinical characteristics, physical status and blood test data at admission, and peak CK/CK-MB, by stepwise logistic regression analysis. We constructed a risk score model to predict the new occurrence of AF, using selected parameters and their logistic regression coefficients. C-statistics was determined by constructing a receiver operating characteristic curve to evaluate the accuracy of the risk score for prediction of AF occurrence.

Results

We excluded 48 patients (6.4%) who had AF at admission, and 208 patients without sufficient data at admission, and thus, the study group consisted of 459 patients (age; 65±13 years, male gender; 79.6%). New AF occurrence was observed in 72 patients (14.5%). The following 7 parameters was selected as parameters related with AF (as p&lt;0.1); Inferior/posterior AMI, use of β blockers, use of diuretics, single vessel disease, absence of reperfusion therapy, systolic blood pressure (sBP) at admission, and smoking. One point was given to sBP&gt;128mmHg, 2 points to absence of reperfusion, and one point to other parameters. Sum of these points was calculated as the AF risk score (Table 1). AF occurred in 27.1% of patients with ≥5 points whereas it was observed 5.2% of those with &lt;5 points. C-statistics of the risk score was 0.75 (95% CI 0.68–0.83).

Conclusion

We developed a novel risk score to estimate the risk of AF occurrence early after AMI, which can be a useful tool for the risk stratification after AMI.

Funding Acknowledgement

Type of funding sources: None.

Untreated sleep apnea and left atrial dilatation in patients with atrial fibrillation prior to catheter ablation

Background

Sleep apnea and left atrial dilatation are both risk factors for an arrhythmia recurrence after catheter ablation (CA) of atrial fibrillation (AF). Negative intrathoracic pressure fluctuations during an obstructive apnea episode may cause the left atrium to distend and stretch its wall. Whether sleep apnea is associated with left atrial dilatation in patients receiving CA of AF remains unknown.

Purpose

We sought to elucidate whether moderate or severe untreated sleep apnea was associated with left atrial dilatation in patients with AF before CA.

Methods

This study was conducted under a retrospective, single-center, observational design. The data were derived from screening tests for sleep apnea, which were routinely performed in patients scheduled to receive CA of AF in our institution. After excluding patients who were already diagnosed with sleep apnea, we enrolled 1265 consecutive patients (age 65±11 years, 27.8% females, and 46.2% of non-paroxysmal AF) who underwent both home sleep apnea testing and multidetector computed tomography (MDCT) before the CA of AF. The severity of the sleep apnea was evaluated by the apnea-hypopnea index (AHI) using a watch-type peripheral arterial tonometry. Left atrial dilatation was evaluated by the left atrial maximum volume (LA max V) using 256-slice MDCT.

Results

The age was 65±11 years, 27.8% were females, and 46.2% had non-paroxysmal AF. The mean AHI was 20.3±15.3 and LA max V 105±34 ml (R2=0.075, p&lt;0.0001). LA dilatation was defined by larger than mean LA max V (LA max V≥105 ml). We examined an LA max V≥105 ml as a predictor. After an adjustment by an advanced age (≥65 years), non-paroxysmal AF, male sex, obesity, hypertension, and congestive heart failure, all of which were significant predictors of an LA max V≥105ml in the univariate analysis, moderate or severe sleep apnea (AHI≥15) was a significant predictor of an LA max V≥105 ml (odds ratio 1.63, 95% confidence interval 1.24–2.14, p=0.0005).

Conclusion

Among the patients scheduled to receive catheter ablation of AF, moderate or severe sleep apnea was independently associated with left atrial dilatation.

Funding Acknowledgement

Type of funding sources: None.

Sex differences in terms of recurrent atrial fibrillation after catheter ablation according to the history of heart failure: insights from the Kansai Plus Atrial Fibrillation (KPAF) registry

Background

There are significant differences in the prevalence and prognosis of cardiovascular diseases between male and female. We previously reported that catheter ablation (CA) of atrial fibrillation (AF) was less effective in female than male, but whether their history of heart failure influence the recurrence after CA of AF remains still unknown.

Purpose

We sought to clarify sex differences in terms of AF recurrence after RFCA of AF according to the history of heart failure.

Methods

We conducted a large-scale, prospective, multicenter, observational study (Kansai Plus Atrial Fibrillation Registry). We enrolled 5010 consecutive patients who underwent an initial RFCA of AF at 26 centers (64±10 years; 1369 [27.3%] females; non-paroxysmal AF, 35.7%). The median follow-up duration was 2.9 years.

Results

Fourteen % of female had a history of heart failure prior to CA, while 12.8% of male had a history of heart failure at baseline (p=0.29). The 3-year cumulative incidence of AF recurrence after a single procedure was 43.3% in female and 39.0% in male (log rank P=0.0046). In patients with the history of heart failure, AF recurrence rates were 42.2% in female and 45.8% in male (log rank P=0.51). On the other hand, in patients without history of heart failure, more females experienced AF recurrence (female vs. male, 43.5% vs. 38.0%, log rank P=0.001).

The rate of AF recurrence after multiple procedures was higher in female (24.2% vs. 19.6%, log rank P&lt;0.0001). AF recurrence rates were similar between sexes in patients with history of heart failure (female vs. male, 26.0% vs. 26.7%, log rank P=0.86), while AF recurrence rates were higher in female without history of heart failure than those in male (females vs. males, 23.9% vs. 18.5%, log rank P&lt;0.0001).

Conclusion

The Kansai Plus Atrial Fibrillation Registry revealed a distinct sex difference in terms of the AF recurrence after CA of AF. Females had higher recurrence rates compared with males in patients without history of heart failure, while recurrence rates were similar between sexes in patients with history of heart failure.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Research Institute for Production Development in Kyoto, Japan.

Premature atrial contraction on Holter electrocardiogram predicts the recurrence of atrial fibrillation after catheter ablation

Introduction

It is important to detect the recurrence of atrial fibrillation (AF) after catheter ablation (CA) early, but the method of detection has not been established. The purpose of this study is to determine whether 24-h Holter electrocardiogram (ECG) can predict the recurrence of AF after CA.

Methods

We studied 336 patients of 497 patients enrolled in EARNEST-PVI trial to investigate whether the total number of premature atrial contraction (PAC) and the maximum number of PAC run by 24-h Holter ECG at 6 months after CA predicted AF recurrence after 6 months. We excluded 86 patients with recurrence by 6 months after CA and 75 patients without Holter ECG at 6 months after CA.

Results

Median age was 66 years, male were 77% and median follow-up period was 1138 days. Receiver operating characteristic curve analysis identified the total number of PAC ≥270 beats and the maximum number of PAC run ≥8 beats as the optimal cutoff for prediction of AF recurrence. Kaplan-Meier analysis showed patients with the total number of PAC ≥270 beats had more frequent AF recurrence than those without (Kaplan-Meier estimated 3-year AF recurrence rate 34% vs. 17%, Log-rank P=0.001) and patients with the maximum number of PAC run ≥8 beats had more frequent AF recurrence than those without (Kaplan-Meier estimated 3-year AF recurrence rate 33% vs. 20%, Log-rank P=0.006). Multivariate analysis revealed that the total number of PAC ≥270 beats and the maximum number of PAC run were significantly associated with AF recurrence (hazard ratio [95% confidence interval] 1.83 [1.16–2.91], P=0.01 and 1.01 [1.01–1.02], P=0.001, respectively)

Conclusion

The total number of PAC and the maximum number of PAC run on the Holter ECG may be useful in predicting AF recurrence after CA.

Funding Acknowledgement

Type of funding sources: None.

OP0112 THE EVER-LARGEST ASIAN GWAS FOR SYSTEMIC SCLEROSIS AND TRANS-POPULATION META-ANALYSIS IDENTIFIED SEVEN NOVEL LOCI AND A CANDIDATE CAUSAL SNP IN A CIS-REGULATORY ELEMENT OF THE FCGR REGION

Background

Genome-wide association studies (GWASs) have identified 29 disease-associated single nucleotide polymorphisms (SNPs) for systemic sclerosis (SSc) in non-human leukocyte antigen (HLA) regions (1-7). While these GWASs have clarified genetic architectures of SSc, study subjects were mainly Caucasians limiting application of the findings to Asians.

Objectives

The study was conducted to identify novel causal variants for SSc specific to Japanese subjects as well as those shared with European population. We also aimed to clarify mechanistic effects of the variants on pathogenesis of SSc.

Methods

A total of 114,108 subjects comprising 1,499 cases and 112,609 controls were enrolled in the two-staged study leading to the ever-largest Asian GWAS for SSc. After applying a strict quality control both for genotype and samples, imputation was conducted using the reference panel of the phase 3v5 1,000 genome project data combined with a high-depth whole-genome sequence data of 3,256 Japanese subjects. We conducted logistic regression analyses and also combined the Japanese GWAS results with those of Europeans (6) by an inverse-variance fixed-effect model. Polygenicity and enrichment of functional annotations were evaluated by linkage disequilibrium score regression (LDSC), Haploreg and IMPACT programs. We also constructed polygenic risk score (PRS) to predict SSc development.

Results

We identified three (FCRLA-FCGR, TNFAIP3, PLD4) and four (EOMES, ESR1, SLC12A5, TPI1P2) novel loci in Japanese GWAS and a trans-population meta-analysis, respectively. One of Japanese novel risk SNPs, rs6697139, located within FCGR gene clusters had a strong effect size (OR 2.05, P=4.9×10-11). We also found the complete LD variant, rs10917688, was positioned in cis-regulatory element and binding motif for an immunomodulatory transcription factor IRF8 in B cells, another genome-wide significant locus in our trans-ethnic meta-analysis and the previous European GWAS. Notably, the association of risk allele of rs10917688 was significant only in the presence of the risk allele of the IRF8. Intriguingly, rs10917688 was annotated as one enhancer-related histone marks, H3K4me1, in B cells, implying that FCGR gene(s) in B cells may play an important role in the pathogenesis of SSc. Furhtermore, significant heritability enrichment of active histone marks and a transcription factor C-Myc were found in B cells both in European and Japanese populations by LDSC and IMPACT, highlighting a possibility of a shared disease mechanism where abnormal B-cell activation may be one of the key drivers for the disease development. Finally, PRS using effects sizes of European GWAS moderately fit in the development of Japanese SSc (AUC 0.593), paving a path to personalized medicine for SSc.

Conclusion

Our study identified seven novel susceptibility loci in SSc. Downstream analyses highlighted a novel disease mechanism of SSc where an interactive role of FCGR gene(s) and IRF8 may accelerate the disease development and B cells may play a key role on the pathogenesis of SSc.

References

[1]F. C. Arnett et al. Ann Rheum Dis, 2010.

[2]T. R. Radstake et al. Nat Genet, 2010.

[3]Y. Allanore et al. PLoS Genet, 2011.

[4]O. Gorlova et al. PLoS Genet, 2011.

[5]C. Terao et al. Ann Rheum Dis, 2017.

[6]E. López-Isac et al. Nat Commun, 2019.

[7]W. Pu et al. J Invest Dermatol, 2021.

Disclosure of Interests

None declared

Heavily T2-weighted imaging findings of spinal cord swelling in dogs with intervertebral disc extrusion

This study investigated causes of attenuation of cerebrospinal fluid (CSF) signal on heavily T2-weighted (T2W) images in dogs with thoracolumbar disc extrusion. Medical records and magnetic resonance images were retrospectively reviewed. Dogs were classified into the following grades; grade 1, non-ambulatory paraparesis; grade 2, paraplegia with deep pain perception and grade 3, paraplegia without deep pain perception. The length of intramedullary T2W hyperintensity of the spinal cord, cranial/ caudal expansion of extradural compressive materials (ECM), and the CSF signal attenuation were measured. Ratios to the second lumbar vertebra (L2) were calculated for the length of intramedullary T2W hyperintensity (T2W:L2), cranial/caudal expansion of ECM (ECML:L2), and CSF signal attenuation (CSF:L2). The dogs were classified into focal or extended T2W hyperintensity groups according to the length [focal, shorter than length of L2; extended, longer than L2]. The area of EMC and the spinal canal were measured on transverse images at the lesion deriving occupancy ratio. The correlation between CSF:L2 and other data were analysed, and CSF:L2 was compared between the grades. In dogs with intramedullary T2W hyperintensity, the locations of CSF attenuation and the hyperintensity were compared if those locations were matched. Fifty-five dogs were included, 36 of which showed intramedullary T2W hyperintensity. Twenty-two of 36 dogs were considered as match of the location of the CSF attenuation and hyperintensity. CSF:L2 was significantly correlated with T2W:L2 in dogs with extended T2W hyperintensity (p = 0.0002), while CSF:L2 was significantly correlated with ECML:L2 in dogs with focal or no T2W hyperintensity (p = 0.0103 and p = 0.0364, respectively). CSF:L2 in grade 3 was significantly greater than those in patients who were grade 1 or 2 (both p < 0.001). In conclusion, higher CSF:L2, which was frequently seen in grade 3, would be most consistent with a higher T2W:L2 which might indicate spinal cord swelling.

Impact of heart rate reduction on recurrence after catheter ablation of persistent atrial fibrillation

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Johnson & Johnson KK

OnBehalf

OCVC Arrhythmia Investigators

Background

Predicting heart rate (HR) after restoration of sinus rhythm (SR) remains one of the challenges when performing catheter ablation (CA) of persistent atrial fibrillation (AF).

Purpose

To evaluate the association between pre-ablation HR during AF and post-ablation HR during SR, and whether the HR reduction is associated with AF recurrence.

Methods

The analysis was performed from the EARNEST-PVI trial, a randomized controlled trial designed to assess a CA strategy for persistent AF, which was conducted in the Osaka region of Japan. After excluding patients with beta-blocker prescription, a total of 216 patients (median age, 67 years; 20% female; 23% long-standing persistent AF) with AF rhythm at baseline and SR at discharge were enrolled in this study. Baseline HR during AF and post-ablation HR during SR was measured on admission and at discharge using the 12-lead electrocardiograms, respectively.

Results

There was a mild correlation between baseline HR (median 82 [interquartile range 72-95] bpm) and post-ablation HR (78 [48-117] bpm) (r = 0.27, p &lt;0.001). Reduction in HR was positively associated with baseline HR (r = 0.79, p &lt;0.001) and was negatively associated with post-ablation HR (r = - 0.37, p &lt;0.001). During the follow-up of 1 year, 56 patients (25.9%) experienced AF recurrence. HR reduction had the higher diagnostic accuracy in predicting AF recurrence than HR at baseline and HR after CA (area under the curve, 0.625; 95% confidence interval, 0.557–0.690; p = 0.003). AF recurrence rate was significantly higher in 141 patients with smaller HR reduction (cut-off, &lt;14bpm) than those with larger HR reduction (31.9% vs. 14.7%, p = 0.009). After adjustment of age, gender, long-standing persistent AF, and CA strategy, HR reduction of &lt;14 bpm was a significant predictor of AF recurrence (hazard ratio, 2.32; 95% confidence interval, 1.20–4.51; p = 0.013).

Conclusions

There was a mild correlation between HR during AF and HR after restoration of SR in patients underwent CA of persistent AF. HR reduction after restoration of SR predicted AF recurrence.

Evaluation of Antimicrobial Drug Use and Concurrent Infections During Hospitalization of Patients With COVID-19 in Japan

This cross-sectional study examines the prevalence and necessity of antimicrobial drug use among patients who are hospitalized with COVID-19 infection in Japan.

Bifidobacterium breve during infancy attenuates mobility in low birthweight rats

BACKGROUND

Children with low birthweight (LBW) have a higher risk for developing attention-deficit/hyperactivity disorder, for which no prophylactic measure exists. The gut microbiota in infants with LBW is different from that in infants with normal birthweight and is associated with attention-deficit/hyperactivity disorder. Oral supplementation with Bifidobacterium has several health benefits, such as suppressing inflammation.

METHODS

We examined the effect of gavage supplementation with Bifidobacterium breve M-16V from postnatal days 1-21 in a rat model of intrauterine hypoperfusion.

RESULTS

The open-field test at 5 weeks of age (equivalent to human pubertal age) showed that rats in the LBW-vehicle group were marginally hyperactive compared with rats in the sham group, while rats in the LBW-B.breve group were significantly hypoactive compared with rats in the LBW-vehicle group. The gut microbiota in the LBW-vehicle group exhibited a profile significantly different from that in the sham group, whereas the gut microbiota in the LBW-B.breve group did not exhibit a significant difference from that in the sham group. Anatomical/histological evaluation at 6 weeks of age demonstrated that the brain weight and the cerebral areas on coronal sections were reduced in the LBW groups compared with the sham group. Probiotic supplementation did not ameliorate these morphological brain anomalies in LBW animals. The percentage of Iba-1⁺ cells in the brain was not different among the LBW-B.breve, LBW-vehicle, and sham groups.

CONCLUSION

Bifidobacterium breve supplementation during early life is suggested to have the potential to help children with LBW attenuate hypermobility in adolescence.

The effect of casirivimab with imdevimab on disease progression in nonsevere COVID‐19 patients in a single hospital in Japan

Background

Recent randomized trials have revealed that neutralizing monoclonal antibodies can reduce disease progression in mild–moderate COVID‐19 patients. However, no studies have investigated the effect of neutralizing monoclonal antibodies on clinical outcomes in Japan.

Methods

A single‐center retrospective and prospective cohort study was conducted. All consecutive febrile nonsevere COVID‐19 patients with at least one risk factor were included. The primary outcome was progression to severe COVID‐19. Severe COVID‐19 cases were defined as patients requiring oxygen therapy and dexamethasone. The differences in the primary outcomes between the patients who were treated with casirivimab with imdevimab (treatment group) and those who were not (control group) were compared using the chi‐squared test.

Results

A total of 128 patients were included. Of those, the mean age was 53.6 years old (SD 9.9), and 52 (40.6%) were women. Fifty‐three patients were treated with casirivimab with imdevimab, and 75 patients were given the standard treatment only. The primary outcome occurred in eight (15.1%) of the 53 patients in the treatment group and 33 (44.0%) of the 75 patients in the control group (odd ratio [OR] 0.23, 95% CI 0.09 to 0.55). The multivariate analysis revealed that the use of casirivimab with imdevimab (OR 0.21, 95% CI 0.08 to 0.54) was the only independent risk factor associated with progression to severe COVID‐19. No patients died during hospitalization in either group.

Conclusion

Similar to other countries, casirivimab with imdevimab significantly reduced disease progression in early nonsevere COVID‐19 patients with fever and risk factors in Japan.

Chondroprotective effects of CDK4/6 inhibition via enhanced ubiquitin-dependent degradation of JUN in synovial fibroblasts

OBJECTIVE

Targeting synovial fibroblasts (SF) using a cyclin-dependent kinase (CDK) 4/6 inhibitor (CDKI) could be a potent therapy for rheumatoid arthritis (RA) via inhibition of proliferation and MMP-3 production. This study was designed to elucidate the mechanism of chondroprotective effects on SFs by CDK 4/6 inhibition.

METHODS

CDK4/6 activity was inhibited using CDKI treatment or enhanced by adenoviral gene transduction. Chondroprotective effects were evaluated using a collagen induced arthritis model (CIA). Gene and protein expression were evaluated with quantitative PCR, ELISA, and Western blotting. The binding of nuclear extracts to DNA was assessed with an electrophoresis mobility shift assay. RNA-Seq was performed to identify gene sets affected by CDKI treatment.

RESULTS

CDKI attenuated cartilage destruction and MMP-3 production in CIA. In RASFs, CDKI impaired the binding of AP-1 components to DNA and inhibited the production of MMP-1 and MMP-3, which contain the AP-1 binding sequence in their promoter. CDK4/6 protected JUN from proteasome-dependent degradation by inhibiting ubiquitination. The RNA-Seq analysis identified CDKI-sensitive inflammatory genes, which were associated with the pathway of RA-associated genes, cytokine-cytokine receptor interaction, and IL-17 signalling. Notably, the AP-1 motif was enriched in these genes.

CONCLUSION

The mechanism of chondroprotective effects by CDK4/6 inhibition was achieved by the attenuation of AP-1 transcriptional activity via the impaired stability of JUN. Since the pharmacologic inhibition of CDK4/6 has been established as tolerable in cancer treatment, it could also be beneficial in patients with RA due to its chondroprotective and anti-inflammatory effects.

Optimal First-Line Antibiotic Treatment for Pediatric Complicated Appendicitis Based on Peritoneal Fluid Culture

PURPOSE

Consensus is lacking regarding the optimal antibiotic treatment for pediatric complicated appendicitis. This study determined the optimal first-line antibiotic treatment for pediatric patients with complicated appendicitis based on peritoneal fluid cultures.

METHODS

This retrospective study examined the cases of pediatric patients who underwent appendectomy for complicated appendicitis at our institution between 2013 and 2019. Peritoneal fluid specimens obtained during appendectomy were cultured for the presence of bacteria.

RESULTS

Eighty-six pediatric patients were diagnosed with complicated appendicitis. Of them, bacteria were identified in 54 peritoneal fluid samples. The major identified bacteria were Escherichia coli (n=36 [66.7%]), Bacteroides fragilis (n=28 [51.9%]), α-Streptococcus (n=25 [46.3%]), Pseudomonas aeruginosa (n=10 [18.5%]), Enterococcus avium (n=9 [16.7%]), γ-Streptococcus (n=9 [16.7%]), and Klebsiella oxytoca (n=6 [11.1%]). An antibiotic susceptibility analysis showed E. coli was inhibited by sulbactam/ampicillin in 43.8% of cases versus cefmetazole in 100% of cases. Tazobactam/piperacillin and meropenem inhibited the growth of 96.9-100% of the major identified bacteria. E. coli (100% vs. 84.6%) and P. aeruginosa (100% vs. 80.0%) were more susceptible to amikacin than gentamicin.

CONCLUSION

Tazobactam/piperacillin or meropenem is a reasonable first-line antibiotic treatment for pediatric complicated appendicitis. In the case of aminoglycoside use, amikacin is recommended.

Association between myocardial wall thickness and left ventricular functional recovery after catheter ablation of atrial fibrillation in patients with reduced ejection fraction

Background

Catheter ablation of atrial fibrillation (AFCA) is an effective treatment to develop left ventricular (LV) functional recovery. However, the degree of recovery differs between individuals due to the different extent of myocardial fibrosis and scarring.

Purpose

To examine whether pre-ablation LV wall thickness (WT) and its regional heterogeneity predict LV functional recovery after AFCA in patients with LV systolic dysfunction.

Methods

Of 3682 consecutive patients who underwent first-time AFCA between January 2012 and September 2020 in our institution, 174 (age, 63±10 years; male, 83%; ischemic cardiomyopathy, 14%) with a baseline LV ejection fraction (LVEF) of &lt;40% were retrospectively evaluated. They were subjected to 256-slice MDCT scanning at baseline and 3 months after AFCA. Baseline WT was evaluated by 16-segment model. Mean and standard deviation (SD) of 16 regional WT were calculated in both end-systolic and end-diastolic phase.

Results

LVEF significantly improved from 30±7% to 57±17% (p&lt;0.001) after AFCA. Increase in LVEF (delta-LVEF) was positively correlated with baseline end-diastolic WT (r=0.31, p&lt;0.001) and negatively correlated with SD of end-systolic WT (r=−0.21, p=0.007). Independent of WT measurements, delta-LVEF was negatively correlated with LV end-diastolic volume (r=−0.42, p&lt;0.001). We created a scoring system to predict the degree of wall motion recovery using the median value of the 3 variables; assigned 1 point each for end-diastolic WT &gt;7.4mm, SD of end-systolic WT &lt;1.61mm, and LV end-diastolic volume &lt;125ml. The model successfully predicted improvement in LVEF after AFCA (0 point (N=13) vs. 1 point (N=72) vs. 2–3 point (N=89), 11±16% vs. 20±17% vs. 33±12%, p&lt;0.001).

Conclusion

Myocardial WT and its regional heterogeneity as well as LV end-diastolic volume predicted functional recovery after AFCA in patients with reduced LVEF.

Funding Acknowledgement

Type of funding sources: None.

Cardiac phenotypes in the acute-phase of microscopic polyangiitis involves dilatation of the left atrium caused by LV diastolic dysfunction

Background

Microscopic polyangiitis (MPA) is a type of primary systemic vasculitis that affects various organs, especially the lungs and kidneys. However, few reports regarding cardiac features of MPA patients were found.

Purpose

We aim to investigate the echocardiographic parameters of acute-phase MPA.

Methods and results

This single-center retrospective study included 15 patients with MPA (Mean age at 72.2±7.1 years, women 73.3%) who underwent echocardiography within two weeks of commencing steroid therapy for induction or reinduction. The echocardiography parameters of the patients were compared with those of 30 age and sex-matched controls. In the MPA group, the commonly affected organs were kidneys (93.3%) and lungs (46.7%); 5 patients (33.3%) had a history of hypertension, which had a similar frequency as the control group. No significant difference in left ventricular (LV) diameter, LV ejection fraction, e', or inferior vena cava diameter was observed between the two groups. However, the MPA group showed significantly higher left atrial (LA) diameter (p=0.033) and LA volume index (p=0.001), as well as higher early diastolic filling velocity (E-wave, p=0.015; E/A, p=0.043; E/e', p=0.041), diastolic pulmonary venous flow velocity (p=0.013), trans-tricuspid pressure gradient (p=0.019), and shorter deceleration time (p=0.038), associated with mildly thicker ventricular walls of left ventricle (LV) than the control group. Moreover, serum levels of C-reactive protein showed significant correlation between E wave (r=0.58, p=0.023), E/A (r=0.67, p=0.006), and deceleration time (r=−0.69, p=0.005) in the MPA group. These results may indicate that in MPA, increased LV stiffness, rather than impairment of LV relaxation was contributed to LV diastolic function, resulting in LA enlargement.

Conclusion

Patients with acute-phase MPA had LA dilatation associated with LV diastolic dysfunction. This finding indicates the importance of cardiac assessment in patients with MPA.

Funding Acknowledgement

Type of funding sources: None.

Reappraising the role of baseline plasma C-reactive protein levels on recurrence after catheter ablation of persistent atrial fibrillation: insight from EARNEST-PVI trial

Background

Subclinical inflammation is an important pathogenesis of developing and sustaining atrial fibrillation (AF). Because AF itself contribute to the inflammatory response, the role of baseline subclinical inflammation on AF recurrence after catheter ablation (CA) remains controversial in patients with persistent AF.

Purpose

To evaluate whether baseline plasma C-reactive protein (CRP) levels, a sensitive marker of inflammation, are associated with AF recurrence following CA.

Methods

The analysis was performed from the EARNEST-PVI trial, a randomized controlled trial designed to assess a CA strategy for persistent AF, which was conducted in the Osaka region of Japan. A total of 441 patients (median age, 67 years; 26% female; 25% long-standing persistent AF) whose plasma CRP levels were measured at baseline were included in this study.

Results

At baseline, a median (interquartile range) of plasma CRP level was 0.10 [0.06–0.19] mg/dl. Plasma CRP levels significantly increased at discharge (0.83 [0.21–1.84] mg/dl, p&lt;0.001) and decreased 1 year after CA (0.10 [0.05–0.20] mg/dl, p=0.040) compared to the baseline value. During the follow-up of 1 year, 115 patients (26%) experienced AF recurrence, and the incidence was significantly higher in 124 patients with low CRP levels at baseline (cut-off ≤0.06 mg/dl) than the other 317 patients (33.9% vs. 23.0%, p=0.017). After adjustment of age, gender, body mass index, long-standing persistent AF, CA strategy, and plasma brain natriuretic peptide levels, low plasma CRP levels was a significant predictor of AF recurrence (hazard ratio, 1.51; 95% confidence interval, 1.02–2.24; p=0.042).

Conclusions

Low plasma CRP levels at baseline predicted AF recurrence in the EARNEST-PVI trial. Reappraising the role of CRP on AF recurrence may be needed in patients with persistent AF.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Johnson & Johnson KK

Renal function and arrhythmia outcomes in persistent atrial fibrillation patients after catheter ablation: subanalysis of the EARNEST-PVI trial

Background

Atrial fibrillation (AF) reduces the renal function. Renal dysfunction and AF often coexist. Catheter ablation (CA) of persistent AF can maintain a sinus rhythm and may improve the renal function.

Purpose

We sought to elucidate whether the estimated glomerular filtration rate (eGFR) in patients with persistent AF was increased after CA, especially with the presence of an AF recurrence.

Methods

We enrolled 487 persistent AF patients whose eGFR data were available both before and 1-year after the CA out of 512 patients in the EARNEST-PVI trial.

Results

The mean age was 65±9 year and 113 patients (24.8%) had long-standing persistent AF. We compared the eGFR at baseline with that 1-year after the CA. AF recurrences were recognized in 118 patients (25.8%). The eGFR was similar between the group without recurrence and that with recurrence at baseline (without AF recurrence vs. with AF recurrence; 63.8±14.3 vs. 62.7±13.6 mL/min/1.73m2, p=0.46). In patients without AF recurrence, the G1, G2, G3a, G3b, G4, and G5 were 13 (3.8%), 198 (58.4%), 98 (28.9%), 26 (7.7%), 3 (0.9%), and 1 (0.3%), respectively at baseline. In the patients with AF recurrence, the G1, G2, G3a, G3b, G4, and G5 were 3 (2.5%), 68 (57.8%), 38 (32.2%), 6 (5.1%), 3 (2.5%), and 0 (0%), respectively at baseline. The ΔeGFR was significantly higher in the patients without AF recurrence than in those with AF recurrence (without AF recurrence vs. with AF recurrence; 5.1 [−0.3, 10.8] vs. 3.0 [−3.0, 7.6], p=0.0033). In the patients without AF recurrence, a better eGFR class at 1-year after the CA than in those before the CA was recognized in 75 patients (22.1%), while it was recognized in 19 patients (16.1%) with AF recurrences.

Conclusion

Successful catheter ablation in patients with persistent AF led to a better renal outcome.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This study was funded by Medtronic, Johnson & Johnson, and Abbott.

Anesthetic management using costoclavicular brachial plexus block with patient-controlled analgesia in Pediatrics: A case report

Anesthetic management using costoclavicular brachial plexus block with patient-controlled analgesia in pediatrics: a case report Abstract The costoclavicular brachial plexus block (CBPB) has been receiving increasing attention as an effective technique for upper arm surgery conducted without phrenic paralysis. However, studies in children are lacking. CBPB was applied to a 10 year-old girl undergoing scheduled radial and ulnar osteotomy due to multiple cartilaginous exostoses and ulnar lengthening. CBPB was performed with a bolo administration of 10 mL of 0.25% levobupivacaine, and the catheter was sequentially replaced in the right costoclavicular space. After surgery, a continuous infusion of 0.17% levobupivacaine through a catheter was initiated at 2 mL/h, along with patient-controlled analgesia (PCA) of 3 mL 0.17% levobupivacaine with a 60-minute lock out. The patient complained of 5/10 pain on the numerical rating scale (NRS) 2 hours after surgery, which improved immediately after bolus administration. The analgesia induced by CBPB was otherwise effective (NRS ≤ 2). CBPB with PCA may provide adequate analgesia in pediatric cases.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Chichibabin/isoChichibabin pyridinium synthesis of ma'edamines C and D

Ma'edamines C and D were isolated from an Okinawan marine sponge and exhibited a unique tetrasubstituted pyridinium skeleton. The proposed biosynthetic pathway is similar to that of desmosine and isodesmosine, which are elastin-crosslinking amino acids. In this study, first total synthesis of ma'edamines C and D was achieved via Pr(OTf)₃-promoted Chichibabin/isoChichibabin pyridinium synthesis starting from the corresponding aldehydes and amine.

Floral and pollination characteristics of Eriocaulon heleocharioides, an extinct species in the wild, for evidence-based conservation management

Generally, floral characteristics and pollination are important factors enhancing the quality and quantity of reproductive output for regeneration in plant conservation. However, lack of evidence-based management could decrease fitness under ex-situ conservation. We investigated the capitulum and pollination characteristics of Eriocaulon heleocharioides Satake (Eriocaulaceae), which is extinct in the wild, to develop an evidence-based conservation management plan incorporating previously ignored reproductive characteristics. To evaluate the functional characteristics of capitula, pollen-ovule ratio, and reproductive status (maximum pollination success/florivory damage) were investigated along six flowering sequences of capitulum. To evaluate the effect of plant density on pollen transfer, high- and low-density plots were established. Total deposited pollen on stigma, insect visitation, and visit duration per capitulum were observed. A significantly lower pollen-ovule ratio was observed in the first of six capitula, reflecting higher female functionality. The highest pollination success was found in the second-fourth capitula, whereas florivory increased along the terminal capitula position. High plant density affected the pollen deposited on stigmas via insect visitation and low pollinator visit duration. Different capitula in E. heleocharioides could have different effects: different sexual functionality, enhancement of reproductive output both in quality and quantity through active pollen transfer, and escaping from florivores. High plant density could facilitate outcross-pollen transfer in E. heleocharioides. Multiple perspectives are important for determining potential reproductive success in ex-situ conservation. Thus, density management reflecting capitulum characteristics could improve the efficiency of conservation efforts for E. heleocharioides.

In vitro evidence of propagation of superoxide dismutase-1 protein aggregation in canine degenerative myelopathy

Canine degenerative myelopathy (DM) is a progressive and fatal neurodegenerative disorder that has been linked to mutations in the superoxide dismutase 1 (SOD1) gene. The accumulation of misfolded protein aggregates in spinal neurons and astrocytes is implicated as an important pathological process in DM; however, the mechanism of protein aggregate formation is largely unknown. In human neurodegenerative diseases, such as amyotrophic lateral sclerosis (ALS), cell-to-cell propagation of disease-relevant proteins has been demonstrated. Therefore, in this study, propagation of aggregation-forming property of mutant SOD1 protein in DM in vitro was investigated. This study demonstrated that aggregates composed of canine wild type SOD1 protein were increased by co-transfection with canine mutant SOD1 (E40K SOD1), indicating intracellular propagation of SOD1 aggregates. Further, aggregated recombinant SOD1 proteins were released from the cells, taken up by other cells, and induced further aggregate formation of normally folded SOD1 proteins. These results suggest intercellular propagation of SOD1 aggregates. The hypothesis of cell-to-cell propagation of SOD1 aggregates proposed in this study may underly the progressive nature of DM pathology.

Eight novel susceptibility loci and putative causal variants in atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) is the most common allergic disease in the world. While genetic components play critical roles in its pathophysiology, a large proportion of its genetic background is still unexplored.

OBJECTIVES

This study sought to illuminate the genetic associations with AD using genome-wide association study (GWAS) and its downstream analyses.

METHODS

This study conducted a GWAS for AD comprising 2,639 cases and 115,648 controls in the Japanese population, followed by a trans-ethnic meta-analysis with UK Biobank data and downstream analyses including partitioning heritability analysis by linkage disequilibrium score regression.

RESULTS

This study identified 17 significant susceptibility loci, among which 4 loci-AFF1, ITGB8, EHMT1, and EGR2-were novel in the Japanese GWAS. The trans-ethnic meta-analysis revealed 4 additional novel loci, namely-ZBTB38,LOC105755953/LOC101928272, TRAF3, andIQGAP1. This study found a missense variant (R243W) with a deleterious functional effect in NLRP10 and a variant altering expression of CCDC80 via enhancer expression as highly likely causal variants. These 2 regions were Asian-specific, and these population-specific associations could be explained by the frequency of causal variants. The gene-based test showed SMAD4 as an additional novel significant locus. Downstream analyses revealed substantial overlap of GWAS significant signals in enhancers of skin cells and immune cells, especially CD4 T cells. A highly shared polygenic architecture of AD between Europeans and Asians was also found.

CONCLUSIONS

This study identified Japanese-specific loci and novel significant loci shared by different populations. Two putative causal variants were illuminated in Japanese-specific loci. Trans-ethnic analyses revealed strong heritability enrichment in immune-related pathways, and relevant cell types shared among populations.

POS0824 THE LONG-TERM CLINICAL COURSE OF MUSCULAR VASCULITIS DEPENDING ON THE ANTI-NEUTROPHIL CYTOPLASMIC ANTIBODY STATUS: A RETROSPECTIVE OBSERVATIONAL STUDY

Background:

Skeletal muscle is known as one of the organ involvements of primary systemic vasculitis.1,2 Muscle inflammation is detected by magnetic resonance imaging, and necrotizing vasculitis is proved by muscle biopsy.3 As with systemic vasculitis or single organ vasculitis, glucocorticoid (GC) and immunosuppressants are used in its treatment.4 There are not many reports about muscular vasculitis, and its long-term clinical course after initial treatment, including the rates of relapse and mortality, remains unclear.

Objectives:

To identify the predictors of relapse and mortality in patients with muscular vasculitis, especially focusing on the status of anti-neutrophil cytoplasmic antibody (ANCA).

Methods:

We retrospectively reviewed patients diagnosed with necrotizing vasculitis with muscle involvements in our hospital between 2004 and 2020. In all cases, muscular vasculitis was identified by muscle biopsy or magnetic resonance imaging. To focus on the clinical features of muscular vasculitis, we excluded patients with such severe organ involvements as cardiovascular, abdominal, cerebral, severe renal, and severe pulmonary involvements. We compared the 5-year cumulative incidence of relapse, the overall survival rate, and the dose of GC over 5 years between the ANCA-positive and ANCA-negative groups. A relapse was defined as any new or worsened state of disease activity requiring an escalation of GC dose. Gray’s method was used for assessing the cumulative incidence of relapse. The log-rank test was used for assessing overall survival. The Mann-Whitney U test was used for assessing the dose of GC. The possible factors for relapse in 5 years in a univariate analysis were selected for a multivariate analysis using the Cox proportional hazards model.

Results:

Forty-nine patients were enrolled. The median age of onset was 77 (69-82) years and 71.4% were women. There were 30 ANCA-positive patients (90.0% with anti-myeloperoxidase) and 19 ANCA-negative patients. The median age and the number of patients with renal involvements were higher in the ANCA-positive group than in the ANCA-negative group (73.0 ± 9.29 years vs. 79.5 ± 20.28 years, p=0.0062 and 7/30 [23.3%] vs. 0/19 [0.0%], p=0.034, respectively). The Birmingham Vasculitis Activity Score (ver. 3), the induction dose of GC, and the rate of immunosuppressants use were not significantly different between the two groups. During the observational period, 24 patients relapsed. The 5-year cumulative incidence of relapse was significantly higher in the ANCA-positive group than in the ANCA-negative group (p=0.026) (Figure 1). The Cox proportional hazards model revealed that the presence of ANCA was an independent risk factor for relapse (hazard ratio: 3.15; 95% confidence interval 1.06–9.38; p=0.040). During the observational period, 9 patients died (3 died from cancer, 1 from interstitial pneumonia, 1 from cerebral hemorrhage, 1 from infection, and 3 from unknown reasons). The ANCA-positive group exhibited a higher mortality rate than the ANCA-negative group without a statistical significance (p=0.12). The 5-year cumulative dose of GC was larger in the ANCA-positive group than in the ANCA-negative group without a statistical significance (14786 [11246–19138] mg vs. 10088 [7129–12634] mg, p=0.12).

Conclusion:

In muscular vasculitis, the presence of ANCA is an independent risk factor for long-term relapse. Stratified treatment depending on the ANCA status may reduce the relapse rate and the occurrence of side effects of GC in patients with muscular vasculitis.

References:

[1]Kitching AR et al. Nat Rev Dis Primers 2020; 6(1): 71.

[2]Hernández-Rodríguez J et al. J Autoimmun 2014; 48-49: 84-9.

[3]Ushiyama S et al. Rheumatol Int 2020; 40(10): 1667-74.

[4]Ganeshanandan LR et al. Semin Arthritis Rheum 2020; 50(3): 503-8.

Disclosure of Interests:

None declared

The utility of a novel approach to quantify dyssynchrony by multidetector computed tomography

Funding Acknowledgements

Type of funding sources: None.

Background

Quantification of left ventricular (LV) dyssynchrony is of great interest for resynchronization therapy (CRT). Recently, cardiac computed tomography (CCT) is feasible for evaluation of dyssynchrony. Our aim was to assess a novel simplified approach using CCT to quantify LV dyssynchrony.

Methods

We studied 346 consecutive patients with a wide range of QRS width and ejection fractions (EF). Electrocardiogram-gated contrast-enhanced 256-slice multidetector CT (Brilliance 256 iCT, Philips Medical Systems) was performed before CRT. After CCT scan, the LV endocardial boundaries from short-axis images reconstructed at 5% increments of cardiac cycle were automatically detected, and a time from R-wave to maximal wall motion was calculated for each of the 16 standardized segments for all slices using software "Myocardial Contraction Map" (Argus, Inc Ehime, Japan). The standard deviation of all segments modified by mean heart rate (%SD) was respectively calculated as the global parameter of dyssynchrony. LVEF was also measured using MDCT.

Results

%SD was feasible in all patients, respectably. %SD was significantly different between the different QRS duration groups; narrow QRS (&lt;120ms): 9 ± 5%, relatively wide QRS (120-150 ms): 11 ± 6%, and significantly wide QRS (&gt;150 ms): 14 ± 7% (p &lt;0.001). Moreover, there was significantly difference in %SD between the different morphology groups; normal: 9 ± 7%, Non-left bundle branch block (Non-LBBB): 10 ± 6%, LBBB: 17 ± 7% (p &lt;0.001).

Conclusion

This novel simplified approach by CCT can quantify dyssynchrony in different QRS duration and morphology groups. This method has promise for clinical applications to the evaluation of patients for CRT.

Abstract Figure.