Impact of low-dose or under-dose direct oral anticoagulant on coagulation and fibrinolytic markers in patients with atrial fibrillation

Background

Atrial fibrillation (AF) is known to increase the risks of cerebral and systemic embolism. Apart from vitamin K antagonists, edoxaban, a direct oral anticoagulant (DOAC), has been approved for oral anticoagulation in patients with non-valvular AF. On the other hand, DOACs are sometimes prescribed at off-label under-doses for patients who have undergone ablation for AF. Prothrombin fragment F1+2 is an activation peptide released from prothrombin during thrombin formation. The purpose of this study is to compare the effects of DOAC doses on coagulation and fibrinolytic markers.

Methods and results

A total of 88 patients with AF (age: 68±11 years, male:45%, paroxysmal AF n=49, persistent AF n=39) were recruited. All patients were received edoxaban (60mg or 30mg) once a day. For the purpose of the study, patients were divided into three groups according to whether they had been treated before the ablation procedure under an appropriate standard dose group (n=30 [34.1%]), appropriate low-dose group (n=35 [39.8%]), or off-label under-dose group (n=23 [26.1%]). We examined the coagulation and fibrinolytic markers, and echocardiographic parameters before ablation. All patients were followed up for 12 months after AF ablation. Creatinine clearance was significantly higher in appropriate standard-dose group than in appropriate low-dose or off-label under-dose group (101.1±38.4, 57.1±15.9 and 73.2±14.6 mL/min, respectively; P<0.001). There were no significant baseline differences in AF type, history of stroke/transient ischemic attack (TIA), plasma B-type natriuretic peptide, protein C, fibrinogen, D-dimer level, left ventricular ejection fraction or left atrium dimension among the three groups. Prothrombin fragment F1+2 level was significantly lower in the appropriate standard-dose group than the appropriate low-dose and off-label under-dose groups (105.9±29.4, 142.6±41.3 and 142.8±84.9 pmol/L, respectively; P=0.011, Figure). One patient in the appropriate low-dose group had a TIA and 1 patient in the off-label under-dose group had a bleeding event during the follow up period after ablation.

Conclusion

Our results suggest that an appropriate standard dose of edoxaban is needed to suppress hypercoagulability in patients with AF.

Funding Acknowledgement

Type of funding sources: None. Prothrombin fragment F1+2 level

Risk factors for thrombocytopenia and analysis of time to platelet transfusion after azacitidine treatment

The use of azacitidine (AZA) has been known to lead to a high incidence of hematotoxic adverse events. The aims of this study were to identify the risk factors for thrombocytopenia after the administration of AZA and to analyze time to the initial platelet transfusion. Sixty-two patients with myelodysplastic syndrome (MDS), who were treated with AZA in Gifu Municipal Hospital between March 2012 and June 2020, were included in this study. The risk factors for thrombocytopenia were identified using univariate analysis of patient characteristics, disease type, and laboratory values immediately before the start of treatment. Variables with p<0.2 identified in the univariate analysis were used as independent variables in the multivariate analysis. This analysis identified "creatinine clearance (CCr) <60 mL/min" as a significant factor (odds ratio, 4.790; 95% confidence interval [CI], 1.380-16.70; p=0.014). Subsequently, time in days to the initial platelet transfusion after the initial administration of AZA was analyzed using the log-rank test. The overall median time in days to platelet transfusion was 370 days. The log-rank test was used to determine the influence of patient characteristics, disease type, and laboratory values immediately before the start of treatment. The subsequent Cox proportional hazard regression analysis using variables with p<0.2 as independent variables identified "hemoglobin (Hb) <8.0 g/dL" as a significant factor (hazard ratio, 2.143; 95% CI, 1.001-4.573; p=0.048). The results of this study led to the following clinical implications: first, patients with CCr of <60 mL/min at the start of treatment should be treated with caution due to the risk of thrombocytopenia. Second, patients with Hb of <8.0 g/dL at the start of treatment may require platelet transfusion in the early stage of treatment.

Impact of stress myocardial blood flow as an important predictor for major adverse cardiac and cerebrovascular event in hemodialysis patients, even in patients without myocardial perfusion abnormality

Background

In the clinical setting, ischemic heart disease (IHD) is a major problem not only in general patients but also in regular hemodialysis (HD) patients. Positron emission tomography (PET) is becoming a reliable modality for detecting coronary artery disease. Of course, PET illustrates myocardial perfusion (MP), PET also measures myocardial blood flow (MBF) directly. We have reported stress MBF is an independent predictor in HD population. Although some prior studies show CFR is an independent predictor for their prognosis in patients without MP abnormality, there is limited data about the predictability of stress MBF in HD patients without MP abnormality.

Methods

A total 438 of HD patients who undergone 13NH3PET for suspected IHD were enrolled. All patients were undergone13NH3PET at Nagoya Radiological Diagnosis Foundation. After we excluded patients whose summed stress score (SSS) &lt;4, we identified 182 eligible patients. Patients were divided into two group according to the median value of CFR levels; low stress MBF group (≤2.56) and high stress MBF group (&gt;2.56). We followed up them up to 4.2 years (median 2.4 years) and collected their data. We evaluated their major adverse cardiac cerebrovascular event. We performed Kaplan-Meyer analysis and multivariable cox regression models. Furthermore, we evaluated the incremental value with C-index, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) when CFR added into a model with established risk factors.

Result

There were intergroup difference in baseline characteristics: age, gender, prior CVD and diabetes. Kaplan-Meyer analysis shows statistically intergroup difference [log rank p=0.013, hazard ratio (HR) 0.413, 95% confidential interval (CI) 0.220–0.775]. Multivariable cox regression model for MACCE shows CFR is an independent risk factor (p=0.004, HR 0.311, 95% CI 0.137–0.684). As regarding model discrimination, all of C-index (0.832 vs 0.796, p=0.15), NRI (0.513, p=0.008) and IDI (0.032, p=0.033) were greatest in a predicting model with established risk factors plus stress MBF.

Conclusion

The low stress MBF group has poor prognosis in MACCE comparing to the high stress MBF group. Stress MBF is an independent risk factor for MACCE. Adding stress MBF on conventional risk factors could more accurately predict MACCE in HD patients, even in patients without MP abnormality.

Funding Acknowledgement

Type of funding source: None

Diabetes and hemodialysis are important factor for decrease coronary flow reserve even in the patients with normal myocardial perfusion

Background

In clinical setting, patients with traditional coronary risk factors are at high risk for coronary artery disease (CAD). Such patients who complain chest discomfort are usually performed nuclear myocardial perfusion (MP) test. We sometimes find patients whose PET result shows normal MP and abnormal coronary flow reserve (CFR). However, there are limited data about the predictors for decreased CFR. In the view of describe above, we have investigated the parameters for decreased CFR in the patients without MP abnormality.

Methods and results

From 20th April 2013 to 21st December 2018, we performed 2,930 13N- ammonia PET for suspected CAD. After excluding the follows; 966 patients with repeated test, 54 patients with incomplete data, one patient missed, we investigated 1,909 eligible patients' data. We performed least square to identify the factors decreased CFR. Hemodialysis (HD), age, prior revascularization, diabetes (DM) and body mass index (BMI) were independent risk factor for decreased CFR in all population. On the other hand, HD, age, DM, hypertension and BMI were independent risk factor for decreasing CFR in patients without MP abnormality. According to the result of least square methods, we classified all patients into four groups; without DM/ without HD group, with DM/ without HD group, without DM/ with HD group and with DM/ with HD group. The value of CFR in each group were as follows: without DM/ without HD group (median, 1st quartile-3rd quartile; 2.88, 2.21–3.52), with DM/ without HD group (2.65, 2.00–3.38), without DM/ with HD group (2.29, 1.67–2.95) and with DM/ with HD group (1.97, 1.43–2.68). There were statistically significant intergroup differences. The value of CFR in the patients without MP abnormality were as follows: without DM/ without HD group (3.04, 2.47–3.65), with DM/ without HD group (2.98, 2.40–3.61), without DM/ with HD group (2.52, 2.10–3.08) and with DM/ with HD group (2.38, 1.86–2.97). Even in the patients without MP abnormality, there were also statistically significant intergroup differences.

Conclusion

According to our 13N-ammonia PET data analysis, DM and HD were important and independent factors for decreased CFR. Even in the patients without MP abnormality, DM and HD were important factor for decreased CFR.

Funding Acknowledgement

Type of funding source: None

Microsecretory adenocarcinoma of the hard palate: A case report of a recently described entity

We report a case of microsecretory adenocarcinoma of the hard palate. The patient is a 37-year-old woman with a 15 mm submucosal tumor, which was incidentally found by her primary care dentist, in her hard palate. Preoperative magnetic resonance imaging revealed a tumor exhibiting high signal on T2-weighted image, which was gradually enhanced on dynamic study. Histologically, the tumor border was ill-defined without fibrous capsule and adjoined minor salivary gland with permeative infiltration at the tumor periphery. The tumor comprised intercalated duct-like cells with polygonal narrow eosinophilic to clear cytoplasm and small, uniform oval nuclei. These cells formed small infiltrative microcysts, tubules and fascicular cords collecting pale basophilic secretions and small vacuoles setting in an abundant fibromyxoid stroma. The tumor cells were positive for CK AE1+AE3, S-100 protein, and p63, while are completely negative for p40, alpha-SMA, and calponin. The MEF2C-SS18 fusion was identified by reverse transcriptase-polymerase chain reaction followed by Sanger sequencing. The combination of characteristic histology, immunophenotype, and presence of MEF2C-SS18 fusion indicated the diagnosis of microsecretory adenocarcinoma of the hard palate, an entity described only recently. Post-operative course was uneventful and there was no evidence of disease at 4 months after surgery.

Bounds on Lorentz Invariance Violation from MAGIC Observation of GRB 190114C

On January 14, 2019, the Major Atmospheric Gamma Imaging Cherenkov telescopes detected GRB 190114C above 0.2 TeV, recording the most energetic photons ever observed from a gamma-ray burst. We use this unique observation to probe an energy dependence of the speed of light in vacuo for photons as predicted by several quantum gravity models. Based on a set of assumptions on the possible intrinsic spectral and temporal evolution, we obtain competitive lower limits on the quadratic leading order of speed of light modification.

Anti-allergic effect of the Src family kinase inhibitor saracatinib

The aim of this study was to evaluate the anti-anaphylactic and anti-allergic potentials of saracatinib, a Src family kinase inhibitor that was already shown to be safe in clinical trials when it was used as an anti-cancer drug. Using in vitro mast cell models, we found that saracatinib inhibited the degranulation response and cytokine production in RBL2H3 cells that were stimulated with IgE and antigen without affecting cell viability. Phosphorylation of Lyn, Akt, a PI3K substrate, and MAPKs including ERK, JNK, and p38, as well as the intracellular Ca²⁺ increase induced by this stimulation were also suppressed by saracatinib. This drug also inhibited symptoms in our established anaphylaxis mouse model, anaphylaxis-dependent spotted distribution of immune complex in skin (ASDIS). The intravenous injection of the mixture of IgE and antigen induced acute spotted distribution of immune complex in skin in hairless HR-1 mice, and its inhibition by intradermal injection of saracatinib was observed. Moreover, toluidine blue-stained skin sections indicated that the degranulation ratio of dermal mast cells was reduced in saracatinib-treated skin compared with vehicle-treated skin. Because only a few signaling inhibitors are used as anti-anaphylaxis and anti-allergic drugs, these results indicated the valuable suggestion that saracatinib and the Src family kinase inhibitors are good candidates for anti-anaphylaxis and anti-allergic drugs.

P5410Combination assessment of renal and hepatic dysfunction improves the predictability of prognosis in patients with acute decompensated heart failure

Background

Renal dysfunction is associated with poor mortality in patients with heart failure (HF). Hepatic dysfunction, assessed by Fibrosis-4 (FIB4) index, has also prediction ability in acute decompensated HF (ADHF) patients. We investigated whether the assessment of the combination of FIB4 index and renal dysfunction improves predictability in patients with ADHF.

Methods

We retrospectively enrolled consecutive 758 patients who admitted due to ADHF from January 2011 to February 2018 and followed up for one year. FIB4 index on admission was calculated by the formula: age (yrs) × AST[U/L] / (platelets [103/μL] × (ALT[U/L])1/2). Study subjects were divided into high FIB4 index (>3.25) and low FIB4 index (≤3.25), furthermore each group were classified by the presence/absence of CKD (estimated glomerular filtration rate <60 ml/min/1.73m). We have generated four groups; low FIB4/without CKD (n=154), low FIB4/with CKD (n=294), high FIB4/without CKD (n=56), and high FIB4/with CKD (n=254). The primary outcome was defined as all-cause mortality in one year. We performed Kaplan-Meyer analysis and multivariable Cox regression models. Furthermore, we evaluated the incremental value with C-index, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) when FIB4 index and renal dysfunction added to a baseline model.

Results

In total, 106 patients died in one year. High FIB4 index and CKD showed significantly higher 1-year mortality (high FIB4 index: 19.7% vs 10.3%, p<0.001, CKD: 17.0% vs 6.7%, p<0.001, respectively). Kaplan-Meyer analysis shows that high FIB4 index with CKD showed statistically higher mortality than the others (vs low FIB4/without CKD, p<0.001, vs high FIB4/without CKD, p=0.031, vs low FIB4/with CKD, p<0.001, respectively).

Multivariate Cox regression model revealed that both high FIB4 index and CKD were an independent risk predictor of 1-year mortality (FIB4 index: p<0.001, HR 1.06, 95% CI 1.035–1.087, CKD: p=0.004, HR 1.834, 95% CI 1.213–2.773, respectively) in patients with ADHF.

A baseline model for prediction of 1-year mortality was determined by multivariable logistic regression including age, body mass index, systolic blood pressure, and serum albumin (C-index: 0.688). Adding high FIB4 index and CKD to the baseline model, all of C-index (0.738, p=0.04), NRI (0.122, p=0.067), and IDI (0.024, p=0.004) were improved.

Receiver operating characteristic curves

Conclusions

Combination assessment of renal and hepatic dysfunction could improve the predictability of prognosis in patients with ADHF.

Acknowledgement/Funding

None

P4551Prognostic utility of Palliative Prognostic Index for prediction of 30-day and 1-year outcome in patients with acute decompensated heart failure

Background

The prognosis of heart failure remains poor similar to the terminal cancer patients, although recent progress in medical treatment. Palliative Prognostic Index (PPI) is a widely used prognostic index for terminal cancer patients (PPI includes: Palliative Performance Scale, oral intake, oedema, dyspnea at rest and delirium), suggesting the short-term prognostic marker of terminal cancer patients.

Purpose

The purpose of this study was to evaluate the impact of PPI on 30-day mortality, 1-year mortality and 1-year events (including all-cause mortality, readmission due to heart failure and new onset of cerebral infarction after hospital discharge) among acute decompensated heart failure (ADHF) patients.

Method

Study subjects comprised of consecutive 764 patients who admitted due to ADHF and followed up for 1-year. PPI were calculated at the time of hospital admission. Study subjects were divided into two groups based on the PPI: L-PPI (PPI<6) and H-PPI (6≤PPI). We calculated the C-index, net reclassification improvement (NRI) and the integrated discrimination improvement (IDI) to evaluate the improvement of prediction ability on 30-day mortality.

Result

H-PPI showed significantly higher 30-day mortality than L-PPI [7.9% vs 2.0%, log rank p<0.001, Hazard retio (HR): 1.26, 95% confidential interval(CI): 1.14–1.37, p<0.001], 1-year mortality [20.0% vs 12.7%, log rank p=0.022, HR 1.15, 95% CI 1.09–1.21, p<0.001]and 1-year events [45.5% vs 31.1%, log rank p<0.001, HR 1.13, 95% CI 1.09–1.17, p<0.001]. Multivariate cox proportional hazard models adjusted with several covariates revealed that PPI was an independent predictor of 30-day mortality (HR: 1.23, 95% CI: 1.10–1.36, p<0.001), 1-year mortality (HR: 1.10, 95% CI: 1.04–1.16, p<0.001) and 1-year events (HR: 1.11, 95% CI: 1.07–1.15, p<0.001), respectively.

A reference model for prediction of 30-day mortality was determined including left ventricular ejection fraction and serum albumin concentration by multivariable logistic regression analysis. (P<0.05) (C-index: 0.720) Adding PPI to the reference model (C-index: 0.773) significantly improved both NRI (0.458, p=0.038) and IDI (0.046, p=0.007), respectively.

Conclusion

We suggest that assessment of PPI showed good prognostic ability for 30-day and 1-year outcome, while PPI provided additional prognostic information in patients with ADHF.

P6240The impact of stress myocardial blood flow as a very strong predictor for all-cause mortality, cardiovascular mortality and adverse cardiac and cerebrovascular event in hemodialysis population

Background

In the clinical setting, ischemic heart disease (IHD) is a major problem not only in general patients but also in regular hemodialysis (HD) patients. 13ammonia positron emission tomography (13NH3PET) is an established and excellent diagnostic device for IHD. Although coronary flow reserve is the most important index in IHD diagnosis, there are limited data about stress myocardial blood flow (MBF). We investigated the prognosis predictability of stress MBF in all-cause mortality, cardiovascular (CV) mortality and adverse cardiac and cerebrovascular event (MACCE).

Methods and results

A total 438 of HD patients who undergone 13NH3PET for suspected IHD were enrolled. 29 cases were excluded due to revascularization therapy in 60 days. In total we collected 409 eligible cases. All patients were undergone13NH3PET at Nagoya Radiological Diagnosis Foundation. Patients were divided into two group according to the median value of stress MBF levels; low stress MBF group (<2.12) and high stress MBF group (≥2.12). We followed up them up to 4.2 years (median 2.4 years) and collected their data. We evaluated their all-cause mortality, CV mortality and MACCE. Kaplan-Meyer analysis shows that intergroup difference in all-cause mortality (log rank p=0.001, hazard ratio [HR] 0.411, 95% confident interval [CI] 0.261–0.632), CV mortality (log rank p=0.002, HR 0.324, 95% CI 0.157–0.625) and MACCE (log rank p<0.001, HR 0.465, 95% CI 0.324–0.657). Multiple cox analysis that include established risk factors shows CFR is an independent risk factor for all-cause mortality (HR 0.261, 95% CI 0.154–0.442), CV mortality (HR 0.172, 95% CI 0.079–0.374) and MACCE (HR 0.329, 95% CI 0.213–0.503). As a result of the incremental value with C-index, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) when CFR added into a model with established risk factors, each indicator shows adding stress MBF on established risk factors improve the predictability in all-cause mortality, CV mortality and MACCE (all-cause mortality; NRI 0.642, p<0.001, IDI 0.091, p<0.001, CV mortality NRI 0.809, p<0.001, IDI 0.116, p<0.001, MACCE; NRI 0.646, p<0.001, IDI 0.072, p<0.001).

Conclusion

Considering prognosis of HD population, stress MBF is an important and independent predictor for all-cause mortality, CV mortality and MACCE. As a result of our investigation, stress MBF is one of most strong predictors in HD population.

P3764Morphological mechanisms of atrial functional mitral regurgitation in patients with atrial fibrillation

Background

Atrial functional mitral regurgitation (AFMR) occurs in patients with atrial fibrillation. However, morphological mechanisms of AFMR are poorly understood.

Purpose

The purpose of this study was to examine the morphological characteristics in patients with AFMR.

Methods

Among consecutive 795 patients undergoing initial radiofrequency catheter ablation (RFCA) at our hospital, twenty-five patients with persistent AF accompanied by AFMR (≥ moderate) before RFCA (AFMR group) were studied. Age-matched 25 patients with persistent AF without MR were defined as a control group.

Results

Left ventricular ejection fraction (LVEF) was lower and left atrium volume index was larger in the AFMR group (Table). Mitral valve annulus diameter and length of anterior mitral leaflet (AML) were similar between groups, whereas length of posterior mitral leaflet (PML) was significantly shorter in the AFMR group. Smaller tethering angle of AML (γ in the figure) and shorter tethering height were significantly associated with the occurrence of AFMR, which were different from morphology of functional mitral regurgitation in patients with dilated LV. Multiple regression analysis revealed that less tenting height (p<0.05) and LA dilatation toward the posterior (p<0.01) were significantly related to AFMR.

Echocardiographic parameters AFMR (n=25) Control (n=25) P value Age, y 69±8 66±10 NS Male, n (%) 9 (36) 20 (80) P=0.001 LVEF,% 60±9 67±6 P=0.004 LAD, mm 44±5 41±7 NS LAVI, ml/m2 56±17 41±13 P<0.001 MV diameter, mm 3.9±0.4 3.8±0.5 NS α angle, ° 34±9 35±7 NS β angle, ° 48±9 50±8 NS γ angle, ° 32±5 37±5 P=0.0005 AML length, mm 3.0±0.5 3.0±0.5 NS PML length, mm 2.1±0.1 2.4±0.1 P=0.03 Tenting height, mm 1.5±0.1 1.8±0.1 P=0.02 D, mm 0.8±0.3 0.5±0.3 P=0.001 LVEF: left ventricular ejection fraction; LAD: left atrial diameter; LAVI: left atrial volume index; AML: anterior mitral leaflet; PML: posterior mitral leaftlet.

Conclusions

AFMR occurs in patients with unique morphological features, such as less tethering height and LA dilatation toward the posterior.

REDUCTION IN AMBIENT GAMMA DOSE RATE FROM RADIOCESIUM DUE TO SNOW COVER

In the present study, variations in ambient gamma dose rate associated with snow cover were examined in a radioactive-contaminated site in Fukushima Prefecture, Japan. The ambient gamma dose rates decreased with increasing snow depth. The reduction trends were different between fresh snow (0.1-0.2 g/cm3) and granular snow (0.3-0.4 g/cm3) depending on snow density. Snow cover water content (snow water equivalent) calculated from snow depth and density was a key parameter governing the reduction in the ambient gamma dose rate. The ambient gamma dose rates reduced to 0.6 and 0.5 at 4 g/cm2 and 8 g/cm2 of snow water equivalent, respectively. Based on gamma-ray flux density distributions, the ambient gamma dose rates from the primary gamma rays decreased more compared to those from scattered gamma rays due to snow cover.

P1025Clinical predictors for the improvement of left ventricular ejection fraction and prognosis after catheter ablation of atrial fibrillation in patients with systolic dysfunction

Background

Catheter ablation (CA) of atrial fibrillation (AF) improves left ventricular ejection fraction (LVEF) and clinical outcomes in patients with left ventricular systolic dysfunction (LVSD). However, predictors of the improvement of LV function and clinical outcomes by CA were poorly understood.

Purpose

We examined the efficacy of CA in AF patients with LVSD and predictive factors associated with clinical outcomes.

Method

Among consecutive 795 patients undergone initial RFCA at our hospital, we studied 51 patients with LVSD (LVEF ≤50%). Improved LVEF more then 5% at 1-year after CA was classified as “responder” to CA. We analyzed clinical variables and echocardiographic parameters before and after the CAs.

Results

In the responder group, LVEF was significantly improved 1-year after catheter ablation compared with the non-responder group. (ΔLVEF 22±12% vs. −1±4%, p<0.001). The responder group was significantly younger, had more non-paroxysmal AF, smaller LV systolic diameter and lower plasma BNP level before CA (Table). Late gadolinium enhancement (LGE)-positive rate in cardiovascular magnetic resonance imaging (CMR) before CA was higher in the non-responder group than in the responder group (100% [6/6] vs. 38% [5/13], p<0.005). After CAs of AF, event-free survival from hospitalization for heart failure was significantly higher in the responder group (Figure) with less AF recurrence (27% vs. 47%, p=0.04) than in the non-responder group.

Baseline characteristics Responder (N=35) Non-Responder (N=16) P value Age, y 62±11 69±8 p<0.01 Male, n (%) 26 (74) 13 (76) NS Non-pAF 26 (74) 4 (24) p<0.01 LAD, mm 48±7 48±8 NS LAVI, ml/m2 54±17 58±20 NS LVDd, mm 54±7 58±10 NS LVDs, mm 43±7 48±10 p=0.05 EF, % 37±8 38±8 NS BNP (pg/ml) 278±225 684±848 p<0.05

Conclusion

Younger age, absence of LV dilatation, lower plasma BNP, or absence of LGE may well predict favorable clinical outcomes after CA in patients with LVSD.

Impact of a systematic education model for palliative care in cancer

In clinical practice, pharmacists are continually required to improve their knowledge and expertise; however, the postgraduate education system for professional development cannot be confidently stated to be well established. The establishment of a systematic and multifaceted educational curriculum should be useful to improve home care and pharmacists' contribution; therefore, we developed a curriculum in collaboration with the university faculty of pharmaceutical sciences, department of pharmacy in hospital, and the Fukuoka Pharmaceutical Association. Class topics were extracted from the "Kanwa-Iryou-Yakugaku", edited by the Japanese Society for Pharmaceutical Palliative Care and Sciences. The items are necessary to perform palliative care as a pharmacist. A class schedule of 6 days (24 classes in total) was formulated. Questionnaires on comprehension degree before and after each class were provided to the participants. Comprehension was assessed on a scale of 1 to 10, where "I do not understand at all" was 1 and "I understand enough" was 10. The average recovery rates of questionnaires from each class were 92.6 % and 88.9 % before and after class, respectively. The average number of participants who completely answered the questionnaire before and after class was 45.6; therefore, these data were analyzed. Comprehension degree on each topic had significantly increased after attendance of all classes (p < 0.01). The comprehension degree of participants of the medical science of palliative care did greatly improve. Consequently, it is clear that the standard education model constructed was meaningful for the professional development of pharmacists in palliative care medicine.

Cost utility analysis of pharmacist counseling care for breast cancer chemotherapy outpatients

Chemotherapy for cancer is increasingly implemented in the outpatient setting. Pharmacists contribute to cancer treatment by conducting counseling during outpatient chemotherapy visits. They provide guidance on drug treatment, side effects, and side effect countermeasures on every visit. However, there have been few economic evaluations of pharmacist involvement in outpatient chemotherapy. Therefore, we performed a cost utility analysis. We assigned usual care (control) and pharmacist counseling to two groups of 19 patients receiving outpatient chemotherapy for breast cancer at Gifu Municipal hospital. Quality of life was measured at three timepoints before and during chemotherapy treatment using the EuroQol 5 dimension instrument (EQ-5D). EQ-5D values across the timepoints were 0.831, 0.757, and 0.791 for the control group, and 0.882, 0.883, and 0.921 for the pharmacist counseling group. The additional cost in the pharmacist counseling group was 2,227 yen per counseling session. The change in quality-adjusted life years (QALY) was a maximum of -0.021±0.186 in the control group and 0.007±0.199 in the pharmacist counseling group. The maximum cost for one QALY was 1,360,558 yen (≈12,460 US dollars). Pharmacists' counseling in outpatient cancer chemotherapy for breast cancer patients had an acceptable incremental cost-effect ratio, contributing to improved patient quality of life without significant additional expenditure to healthcare.

Performance verification of a precise vibrating-wire magnet alignment technique for next-generation light sources

The high-accuracy alignment of magnets is a key issue in the development of next-generation light-source rings. To obtain adequate dynamic apertures, the magnets must be aligned to an accuracy of 10 µm or better. Recently, a new technique that utilizes a vibrating wire has attracted attention for this purpose as it can directly determine with high resolution the magnetic centers in a series of multipole magnets on a straight section between bending magnets. In conventional vibrating-wire alignment techniques, wire sag, which causes alignment errors, is determined from the theoretical catenary curve. By contrast, in the present study, we have measured the sag profiles of various wires in the longitudinal direction to micrometer-order accuracy. We concluded that we can reduce deviations of the actual wire sag from the theoretical curve by choosing a suitable wire. By setting up a test bench of a vibrating-wire alignment system for a series of multipole magnet on a straight section, we have achieved the total error of the magnetic-center measurements of micrometer-order in the standard deviation. Moreover, two systematic error factors, the drift of the magnetic centers due to thermal deformations of the magnets after they are excited and the change in the magnetic centers due to reassembly of the magnets after installing the vacuum chamber, are included in practical magnet alignments. We have experimentally investigated these error factors using the test bench.

Platelet count and mean platelet volume are associated with not only bone, soft tissue, and lymph node metastases but also with malignant pleural effusion in lung cancer patients

An increased platelet count is often observed in lung cancer patients. Whether and how the platelets affect cancer progression have yet to be established. The aim of the study was to investigate the involvement of the platelet count and mean platelet volume (MPV) in the prognosis and progression of lung cancer patients. This retrospective study included 146 patients with newly diagnosed primary lung cancer. The platelet count and MPV were measured before invasive diagnostic procedures and treatment. These platelet indices, overall survival of the patients, and tumor metastases for each organ were analyzed. On Kaplan-Meier survival analysis, the overall survivals of patients with platelet counts ≤ 244.0 × 109/L or MPV > 9.7 fL were longer than those of patients with platelet counts > 244.0 × 109/L or MPV ≤ 9.7 fL. Cox regression analysis showed that poor performance status, increased platelet count, and increased C-reactive protein were independent prognostic factors. The platelet indices were associated with metastases to bone, soft tissue, and lymph node, in addition to malignant pleural effusion. Increased platelet count and decreased MPV were unfavorable prognostic factors for patients with lung cancer, and they were involved in bone, soft tissue, and lymph node metastases and malignant pleural effusion.

Postoperative intensive care unit admission does not affect outcomes in elective surgical patients with severe comorbidity

OBJECTIVE

The impact of postoperative intensive care upon patient outcomes was evaluated by retrospectively investigating the rate of poor outcomes among miscellaneous elective surgical patients with severe comorbidities.

DESIGN

A retrospective cohort study was carried out.

SETTING

University hospital.

PATIENTS

Surgical patients with severe comorbidities.

INTERVENTION

The outcomes of 1218 surgical patients treated in intensive care units (ICUs) and postsurgical wards (ICU group vs. non-ICU group) were reviewed for poor outcomes (i.e., no discharge or death). A propensity score analysis was used to generate 248 matched pairs of ICU-admitted patients and controls.

VARIABLES OF INTEREST

Poor outcome rates on postoperative day 90 and mortality on postoperative days 30 and 90.

RESULTS

No significant between-group differences were observed in terms of poor outcomes on postoperative day 90 [ICU vs. non-ICU: 33/248 (13%) vs. 28/248 (11%), respectively; ICU odds ratio (OR): 1.19, 95% confidence interval (CI), 0.71-2.01, p=0.596] or in between-group differences in terms of mortality on postoperative days 30 and 90 [ICU vs. non-ICU: 4/248 (1.6%) vs. 2/248 (0.8%) on postoperative day 30 and 5/248 (2.0%) vs. 3/248 (1.2%) on day 90, respectively; ICU OR (95% CI), 2.00 (0.37-10.9) and 1.67 (0.40-6.97) for postoperative 30- and 90-day mortality, respectively (p=0.683 and 0.724)]. Low preoperative body weight was negatively correlated to patient outcomes [OR (95% CI): 0.82/10kg (0.70-0.97), p=0.019], whereas regional analgesia combined with general anesthesia was positively correlated to patient outcomes [OR (95% CI): 0.39 (0.69-0.96), p=0.006]. Extra ICU admission was correlated to poor patient outcomes [OR (95% CI): 4.18 (2.23-7.81), p < 0.0001].

CONCLUSIONS

Postoperative ICU admission failed to demonstrate any meaningful benefits in patients with severe comorbidities undergoing miscellaneous elective surgeries.

Amiodarone does not affect brain injury in a rat model of transient forebrain ischemia

OBJECTIVES

Although amiodarone may cause neurotoxicity that can affect patient outcomes when used during cardiopulmonary resuscitation (CPR), it has been commonly prescribed during CPR. This study investigated the possible neurotoxic effects of amiodarone in a rat model of transient forebrain ischemia.

DESIGN

A prospective laboratory animal study was carried out.

SETTING

Animal laboratory.

MATERIALS

Male Sprague-Dawley rats.

INTERVENTION

Eight minutes of forebrain ischemia was induced in rats by bilateral carotid occlusion and hypotension (mean arterial pressure=35mmHg) under isoflurane (1.5%) anesthesia. Amiodarone (0, 50, 100 and 150mg/kg) with saline was injected intraperitoneally 10min after ischemia. Rats given 0mg/kg of amiodarone were used as saline-treated controls. Sham operated rats received no treatment.

VARIABLES OF INTEREST

Animals were evaluated neurologically on postoperative days 4-7, and histologically after a one-week recovery period.

RESULTS

The greatest improvement in water maze test performance corresponded to the sham operated group (p=0.015 vs. saline-treated controls). No differences in performance were seen in amiodarone-treated rats compared with saline-treated controls. In the control group, 45% of the CA1 hippocampal neurons survived, compared with 78% in the sham operated group (p=0.009). Neuron survival after ischemia in the amiodarone treatment groups (50, 100 and 150mg/kg) (58%, 40% and 36%, respectively) and in the control rats did not differ significantly.

CONCLUSIONS

The administration of amiodarone immediately after transient forebrain ischemia did not worsen spatial cognitive function or neuronal survival in the hippocampal CA1 region in rats. The current results must be applied with caution in humans. However, they indicate that the potential neurotoxicity induced by amiodarone during resuscitation after cardiac arrest may be negligible.

Shunt-preserving disconnection of the portal to systemic circulation in patients with hepatic encephalopathy

Background Portosystemic shunt obliteration by surgical or interventional radiological techniques can be effective for patients with hepatic encephalopathy (HE) although this approach is often associated with accumulation of ascites and/or formation of esophageal varices. Purpose To evaluate the clinical efficacy and safety of shunt-preserving disconnection of the portosystemic circulation (SPDPS) in patients with HE. Material and Methods Nine patients with HE and a splenorenal shunt were treated by SPDPS: eight underwent selective coil embolization of the splenic vein and one underwent stent-graft closure of the shunt. The primary endpoint was change in HE severity based on the West-Haven criteria. The secondary endpoints were changes in serum ammonia levels, hepatic function, HE recurrence during the follow-up period, and post-treatment HE recurrence based on the West-Haven diagnostic criteria. Results The technical success rate was 100% with no severe complications. After the procedure, the mean portal blood pressure increased from 18 mmHg to 22 mmHg ( P = 0.02), the mean HE grades fell from 2.1 to 1.1 ( P < 0.01), and one month after the procedure, the mean serum ammonia level decreased from 177 µg/dL to 87 µg/dL ( P = 0.03) and the mean total Child-Pugh score from 8 to 7 ( P = 0.07). Conclusion SPDPS using selective coil embolization and stent-graft closure of the shunt can be an effective and safe treatment for patients with HE.

Abstract P3-07-06: TRIM44 is a possible poor prognostic factor for breast cancer patients and positively regulates NF-κB signaling pathway

[Background]

Many of the tripartite motif (TRIM) proteins, like Efp/TRIM25 which was identified by our group previously (Nature 417, 871-875, 2002), function as E3 ubiquitin ligases, and are thought to be involved in various physiological and pathological processes such as immunity and oncogenesis. In regard to tripartite motif containing 44 (TRIM44), which is an atypical TRIM family protein lacking RING finger domain, some evidences suggest that it is implicated in the progression of several human malignancies. But its pathophysiological significance in breast cancer remains unknown.

[Methods]

In the present study, immunohistochemical analysis using anti-TRIM44 antibody was performed in clinical breast cancer tissues from 129 patients with the approval of institutional ethical committees (approval number: 845). We then explored the pathophysiological role of TRIM44 in breast cancer by modulating TRIM44 expression in MCF-7 and MDA-MB-231 breast cancer cells.

[Results]

TRIM44 strong immunoreactivity was significantly associated with nuclear grade, distant disease-free survival and overall survival of the breast cancer patients. With multivariate analysis it was shown that the TRIM44 status was an independent prognostic factor for distant disease-free survival and overall survival. The proliferation of MCF-7 and MDA-MB-231 cells was significantly decreased by siRNA-mediated TRIM44 knockdown. TRIM44 knockdown also suppressed migration of MDA-MB-231 cells. Microarray analysis and qRT-PCR revealed that TRIM44 knockdown upregulated CDK19 (Cyclin Dependent Kinase 19), which is reported to be a tumor suppressor gene, whereas downregulated MMP1 (Matrix Metallopeptidase 1) in MDA-MB-231 cells. Notably, TRIM44 knockdown impaired nuclear factor-kappa B (NF-κB)-mediated transcriptional activity stimulated by tumor necrosis factor α (TNFα). Moreover, TRIM44 knockdown substantially attenuated the TNFα-dependent phosphorylation of p65 subunit of NF-κB and IκBα in both MCF-7 and MDA-MB-231 cells.

[Discussion]

Our clinical study showed that prognosis of breast cancer patients is correlated with the immunoreactivity detected by anti-TRIM44 antibody. This result suggested that expression of TRIM44 protein could be used as a potential biomarker of breast cancer. We demonstrated that NF-κB signaling pathway is modulated by TRIM44. Since NF-κB augmentation is shown to be related to aggressive character of breast cancer, stimulation of NF-κB signaling with TRIM44 might be underlying mechanism of poor prognosis. Our in vitro study showed TRIM44 knockdown caused attenuated proliferation and migration of breast cancer cells, raising the possibility of TRIM44 as a potential therapeutic target for breast cancer. These findings provide new clues to develop alternative effective strategies for breast cancer management.

Citation Format: Kawabata H, Azuma K, Ikeda K, Sugitani I, Kinowaki K, Fujii T, Osaki A, Saeki T, Horie-Inoue K, Inoue S. TRIM44 is a possible poor prognostic factor for breast cancer patients and positively regulates NF-κB signaling pathway [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-07-06.

Effects of deep sedation under mechanical ventilation on cognitive outcome in patients undergoing surgery for oral and maxillofacial cancer and microvascular reconstruction

OBJECTIVE

Cognitive impairment after intensive care unit (ICU) admission is becoming increasingly recognized. High-dose deep sedation has been suggested to play an important role in the development of cognitive impairment. However, the impact of heavy sedation as a single cause in the development of cognitive impairment in ICU patients remains unclear. In this study we investigated whether a three-day deep sedation protocol could reduce cognitive function in mechanically ventilated non-critical patients.

DESIGN

A prospective observational study was carried out.

PATIENTS

A total of 17 surgical patients were studied.

INTERVENTION

None.

VARIABLES OF INTEREST

Cognitive function before and after ICU admission.

RESULTS

Thirty-one patients requiring three days of sedation after microvascular reconstruction were initially enrolled in the study. Sedation in the ICU was maintained with propofol and dexmedetomidine combined with fentanyl. Cognitive function was assessed using a battery of 6 neuropsychological tests two days before surgery and three weeks after surgery. Finally, a total of 17 patients were included in the analysis. Cognitive impairment (defined as a decline of >20% from the pre-admission cognitive evaluation scores in at least two of 6 tests) was observed in 5 of the 17 patients (29%). However, there were no significant differences between the pre- and post-admission cognitive evaluations in 6 tests.

CONCLUSIONS

Middle-term cognitive function can be impaired in some patients subjected to deep sedation during several days following maxillary-mandibular oral surgery with microvascular reconstruction.

8-Nitro-cGMP is a promoter of osteoclast differentiation induced by RANKL

Osteoclasts are multinucleated giant cells differentiated from monocyte-macrophage-lineage cells under stimulation of receptor activator of nuclear factor κ-B (RANK) ligand (RANKL) produced by osteoblasts and osteocytes. Although it has been reported that nitric oxide (NO) and reactive oxygen species (ROS) are involved in this process, the mechanism by which these labile molecules promote osteoclast differentiation are not fully understood. In this study, we investigated the formation and function of 8-nitro-cGMP, a downstream molecule of NO and ROS, in the process of osteoclast differentiation in vitro. 8-Nitro-cGMP was detected in mouse bone marrow macrophages and osteoclasts differentiated from macrophages in the presence of RANKL. Inhibition of NO synthase suppressed the formation of 8-nitro-cGMP as well as RANKL-induced osteoclast differentiation from macrophages. On the other hand, RANKL-induced osteoclast differentiation was promoted by addition of 8-nitro-cGMP to the cultures. In addition, 8-nitro-cGMP enhanced the mRNA expression of RANK, the receptor for RANKL. However, 8-bromo-cGMP, a membrane-permeable derivative of cGMP, did not have an effect on either RANKL-induced osteoclast differentiation or expression of the RANK gene. These results suggest that 8-nitro-cGMP is a novel positive regulator of osteoclast differentiation, which might help to explain the roles of NO and ROS in osteoclast differentiation.

Analysis of treatment goal alignment between Japanese psoriasis patients and their paired treating physicians

Background

Appropriate goal‐oriented treatment strategies are important for optimal treatment outcomes and may prevent under‐treatment. As treatment goals vary by patient, a study to examine treatment goals is more meaningful when patients and their physicians are paired. There has not been any study that examines alignment between paired psoriasis patients and physicians in real‐world clinical practice using skin clearance as a treatment goal indicator.

Objectives

To evaluate treatment goal alignment between psoriasis patients and their paired physicians, and to quantitatively identify factors associated with goal misalignment.

Methods

The study was a nationwide multicenter cross‐sectional observational study. Subjects were physician‐reported moderate‐to‐severe psoriasis patients with a history of systemic treatments, directly paired with their treating physicians. Subjects completed surveys independently. Treatment goals included seven categories, and patient–physician pairs were grouped as ‘aligned’ or ‘misaligned’ when the answers were the same or different, respectively.

Results

A total of 425 pairs (mean response rate, 94.7%) of responses were collected from 54 sites (64.8% general practitioners or clinics; 35.2% university or large hospitals). Treatment goal misalignment was found in 67.9% of the patient–physician pairs. The misalignment was mainly ‘patient predominant’ (60.9%) indicating that patients had higher goals (‘complete clearance’) than physicians. In the multivariate logistic regression analyses, patients’ treatment expectation for ‘complete clearance’ [odds ratio (OR): 1.927; 95% confidential interval (CI): 1.232–3.016] and physician rating of ‘level of understanding on treatment options’ being low (OR: 1.552, 95% CI; 1.082–2.227) were significant factors for treatment goal misalignment.

Conclusions

The majority of treatment goal misalignment was found between paired psoriasis patients and their treating physicians in Japan. The most important contributing factors to misalignment were patients’ treatment expectation for ‘complete clearance’ and physicians’ rating of their patients’ ‘level of understanding on treatment options’ being low.

Fibroblast growth factor 13 regulates glioma cell invasion and is important for bevacizumab-induced glioma invasion

Glioblastoma has the poorest prognosis, and is characterized by excessive invasion and angiogenesis. To determine the invasive mechanisms, we previously used two glioma cell lines (J3T-1 and J3T-2) with different invasive phenotypes. The J3T-1 showed abundant angiogenesis and tumor cell invasion around neovasculature, while J3T-2 showed diffuse cell infiltration into surrounding healthy parenchyma. Microarray analyses were used to identify invasion-related genes in J3T-2 cells, and the expressed genes and their intracellular and intratumoral distribution patterns were evaluated in J3T-2 cell lines, human glioma cell lines, human glioblastoma stem cells and human glioblastoma specimens. To determine the role of the invasion-related genes, invasive activities were evaluated in vitro and in vivo. Fibroblast growth factor 13 (FGF13) was overexpressed in J3T-2 cells compared to J3T-1 cells, and in human glioma cell lines, human glioblastoma stem cells and human glioblastoma specimens, when compared to that of normal human astrocytes. Immunohistochemical staining and the RNA-seq (sequencing) data from the IVY Glioblastoma Atlas Project showed FGF13 expression in glioma cells in the invasive edges of tumor specimens. Also, the intracellular distribution was mainly in the cytoplasm of tumor cells and colocalized with tubulin. Overexpression of FGF13 stabilized tubulin dynamics in vitro and knockdown of FGF13 decreased glioma invasion both in vitro and in vivo and prolonged overall survival of several xenograft models. FGF13 was negatively regulated by hypoxic condition. Silencing of FGF13 also decreased in vivo bevacizumab-induced glioma invasion. In conclusion, FGF13 regulated glioma cell invasion and bevacizumab-induced glioma invasion, and could be a novel target for glioma treatment.

Intravenous immunoglobulin contributes to the control of antimelanoma differentiation-associated protein 5 antibody-associated dermatomyositis with palmar violaceous macules/papules

Autoantibodies to melanoma differentiation-associated protein 5 (MDA5) are associated with a subset of patients with dermatomyositis (DM) who have rapidly progressive interstitial lung disease (RP-ILD) with poor prognosis. Intensive immunosuppressive therapy is initiated before irreversible lung damage can occur; however, there are few lines of evidence for the treatment of RP-ILD. Here, we report three cases of anti-MDA5 antibody-associated DM with RP-ILD in which the patients were treated with combined-modality therapy, including high-dose prednisolone, tacrolimus, intravenous cyclophosphamide and intravenous immunoglobulin (IVIG). In all three cases, serum ferritin levels, which are known to represent the disease activity of RP-ILD, were decreased after IVIG administration. IVIG might contribute to the control of the disease activity of anti-MDA5 antibody-positive DM. Moreover, palmar violaceous macules/papules around the interphalangeal joints, which was observed in all three cases in the incipient stage, might be a useful sign in suggesting a diagnosis of anti-MDA5 antibody-associated DM.