Clinical practice guidelines for molecular tumor marker, 2nd edition review part 2

In recent years, rapid advancement in gene/protein analysis technology has resulted in target molecule identification that may be useful in cancer treatment. Therefore, "Clinical Practice Guidelines for Molecular Tumor Marker, Second Edition" was published in Japan in September 2021. These guidelines were established to align the clinical usefulness of external diagnostic products with the evaluation criteria of the Pharmaceuticals and Medical Devices Agency. The guidelines were scoped for each tumor, and a clinical questionnaire was developed based on a serious clinical problem. This guideline was based on a careful review of the evidence obtained through a literature search, and recommendations were identified following the recommended grades of the Medical Information Network Distribution Services (Minds). Therefore, this guideline can be a tool for cancer treatment in clinical practice. We have already reported the review portion of "Clinical Practice Guidelines for Molecular Tumor Marker, Second Edition" as Part 1. Here, we present the English version of each part of the Clinical Practice Guidelines for Molecular Tumor Marker, Second Edition.

Removal of a Giant Parapharyngeal Space Oncocytoma Without Osteotomy

Oncocytoma arising from the parotid gland and extending into the parapharyngeal space (PPS) has not been previously reported. A 64-year-old woman presented with a large slowly growing mass extending from the parotid to the submandibular area, expanding medially to displace the pharynx across the midline. Core-needle biopsy revealed an oncocytoma in the PPS measuring 120 × 88 × 60 mm in size. Although the tumor was of an unprecedentedly large size and extended into multiple spaces, it could be removed via a cervical-parotid approach without osteotomy. The resected tumor was again diagnosed as oncocytoma. A postoperative complication was weakness of the ipsilateral facial nerve, which almost completely resolved in 6 months. No recurrence has been noted on 1 y follow-up. We were able to resect an extremely large oncocytoma arising from the parotid gland without osteotomy.

Trastuzumab deruxtecan in previously treated patients with HER2-positive metastatic breast cancer: updated survival results from a phase II trial (DESTINY-Breast01)

BACKGROUND

Primary analysis of the multicenter, open-label, single-arm, phase II DESTINY-Breast01 trial (median follow-up 11.1 months) demonstrated durable antitumor activity with trastuzumab deruxtecan (T-DXd) in patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer (mBC) previously treated with trastuzumab emtansine (T-DM1). We report updated cumulative survival outcomes with a median follow-up of 26.5 months (data cut-off 26 March 2021).

PATIENTS AND METHODS

Patients with HER2-positive mBC resistant or refractory to T-DM1 received T-DXd 5.4 mg/kg intravenously every 3 weeks until disease progression, unacceptable adverse events, or withdrawal of consent. The primary endpoint was confirmed objective response rate (ORR) by independent central review (ICR). Secondary endpoints included overall survival (OS), duration of response (DoR), progression-free survival (PFS), and safety.

RESULTS

The ORR by ICR was 62.0% [95% confidence interval (CI) 54.5% to 69.0%] in patients who received T-DXd 5.4 mg/kg every 3 weeks (n = 184). Median OS was 29.1 months (95% CI 24.6-36.1 months). Median PFS and DoR were 19.4 months (95% CI 14.1-25.0 months) and 18.2 months (95% CI 15.0 months-not evaluable), respectively. Drug-related treatment-emergent adverse events (TEAEs) were observed in 183 patients (99.5%), and 99 patients (53.8%) had one or more grade ≥3 TEAEs. Adjudicated drug-related interstitial lung disease/pneumonitis occurred in 15.8% of patients (n = 29), of which 2.7% (n = 5) were grade 5.

CONCLUSIONS

These updated results provide further evidence of sustained antitumor activity of T-DXd with a consistent safety profile in heavily pretreated patients with HER2-positive mBC.

Brain-Specific Angiogenesis Inhibitor 3 Is Expressed in the Cochlea and Is Necessary for Hearing Function in Mice

Mammalian auditory hair cells transduce sound-evoked traveling waves in the cochlea into nerve stimuli, which are essential for hearing function. Pillar cells located between the inner and outer hair cells are involved in the formation of the tunnel of Corti, which incorporates outer-hair-cell-driven fluid oscillation and basilar membrane movement, leading to the fine-tuned frequency-specific perception of sounds by the inner hair cells. However, the detailed molecular mechanism underlying the development and maintenance of pillar cells remains to be elucidated. In this study, we examined the expression and function of brain-specific angiogenesis inhibitor 3 (Bai3), an adhesion G-protein-coupled receptor, in the cochlea. We found that Bai3 was expressed in hair cells in neonatal mice and pillar cells in adult mice, and, interestingly, Bai3 knockout mice revealed the abnormal formation of pillar cells, with the elevation of the hearing threshold in a frequency-dependent manner. Furthermore, old Bai3 knockout mice showed the degeneration of hair cells and spiral ganglion neurons in the basal turn. The results suggest that Bai3 plays a crucial role in the development and/or maintenance of pillar cells, which, in turn, are necessary for normal hearing function. Our results may contribute to understanding the mechanisms of hearing loss in human patients.

Effect of statins on hearing outcome in patients with idiopathic sudden sensorineural hearing loss

Objective

Statins have been reported to improve vascular endothelial function and microcirculation, reduce oxidative stress, and exert anti-inflammatory and protective effects against inner ear damage. Therefore, this study aimed to investigate the effect of statins on hearing prognosis in patients with idiopathic sudden sensorineural hearing loss (ISSNHL).

Methods

We reviewed the medical records of 149 patients diagnosed with ISSNHL. Clinical characteristics, hearing thresholds, statin medications, and hematological findings were investigated. First, patients with ISSNHL were assigned to the good and poor outcome groups, and factors influencing their prognosis were analyzed. Furthermore, patients with dyslipidemia were investigated to determine whether statins have therapeutic effects on ISSNHL.

Results

Significant differences in age (p = .011), days from the onset of ISSNHL to the initiation of treatment (p = .04), and hematological total cholesterol (TC; p = .015) between the good and poor outcome groups were observed. Furthermore, when hearing outcomes were investigated in patients with dyslipidemia, TC was significantly lower in the good outcome group (p = .03). Although no significant therapeutic effects of statins were observed in participants with dyslipidemia, patients in the statin-treated group were significantly older and experienced more diabetic complications than those in the non-statin-treated group.

Conclusion

Although our study showed that dyslipidemia is a poor prognostic factor for ISSNHL, statins had no significant therapeutic effects on hearing recovery in ISSNHL patients with dyslipidemia. The patients that received statin medications were significantly older and experienced more diabetic complications, which may have affected their hearing prognosis.

Level of Evidence

Level 4.

Simple lip reconstruction technique for middle-sized defects in lower lip cancer - Bilateral oblique mucosal V-Y advancement flap

There is no standardized technique for lip reconstruction because the structure and functions of the lip are diverse. We developed a new lip reconstructive approach using a bilateral oblique mucosal V-Y advancement flap. We present the case of a 76-year-old woman with severe dementia, referred to our institute for a tumor on her lower lip. She was diagnosed with lip squamous cell carcinoma (cT2N0M0). The tumor measured 25 × 20 mm. It was resected with a surgical safety margin of 6 mm. Bilateral triangular flaps were fashioned obliquely on the rear lateral side of the defect extending from the labial to the buccal mucosa and used to repair the defect. The operation time was 66 min. She was discharged on the fourth postoperative day without any complications. Speech and food intake functions have been preserved and she has been followed up for 26 months with no recurrence. The lip closing and color match has been adequate despite a slight thinning of the lip. This technique offered a major benefit of short operation and hospitalization time because it was a simple, less-invasive, one-step procedure. This is a practical procedure, suitable for vulnerable patients of advanced age or with comorbidities.

Effects of Pembrolizumab in Recurrent/Metastatic Squamous Cell Head and Neck Carcinoma: A Multicenter Retrospective Study

BACKGROUND/AIM

Pembrolizumab exhibits anticancer efficacy in platinum-sensitive or platinum-unfit patients with recurrent/metastatic squamous cell carcinoma of the head and neck (R/M SCCHN). However, no large-scale retrospective real-world data are available. This retrospective study aimed to examine the efficacy and safety of pembrolizumab in multiple facilities.

PATIENTS AND METHODS

Data of 167 patients with R/M SCCHN treated with pembrolizumab between December 2019 and February 2022 were analyzed. The endpoint was overall survival (OS), progression-free survival (PFS), and immune-related adverse events (irAEs). OS and PFS were analyzed comparatively with and without irAEs, and complete response (CR) or partial response (PR), and stable disease (SD) or progressive disease (PD) were compared.

RESULTS

One hundred thirty-five patients received pembrolizumab alone, whereas the others received pembrolizumab with chemotherapy. For the pembrolizumab only group, the median OS and PFS were 22.7 and 5.1 months, respectively. There were significant differences in OS and PFS between CR or PR and SD or PD (p<0.01, p<0.01, respectively). For pembrolizumab with chemotherapy, the OS was not reached and median PFS was 7.0 months. There was a significant difference in PFS between CR or PR and SD or PD (p<0.01). There was a significant difference in PFS between patients with and without irAEs (p=0.02).

CONCLUSION

The real-world therapeutic effect of pembrolizumab for R/M SCCHN was comparable to that observed in the KEYNOTE048 trial. In addition, irAEs and best overall response were considered as prognostic factors.

Investigation of hearing aid fitting according to the national acoustic laboratories' prescription for non-linear hearing aids and the desired sensation level methods in Japanese speakers: a crossover-controlled trial

OBJECTIVE

Some studies have directly compared the National Acoustic Laboratories' prescription for non-linear hearing aids (HAs) version 2 (NAL-NL2) and Desired Sensation Level for non-linear HAs version 5 (DSLv5), although none were performed in Japan. As the Japanese language is a tonal language that has different linguistic characteristics than those of the studied languages, we compared the outcomes of the NAL-NL2 and DSLv5 in hearing-impaired Japanese participants.

METHODS

A crossover-controlled trial was conducted on 18 first-time HA users with bilateral moderate sensorineural hearing loss. Participants wore HAs adjusted with each prescriptive method for four weeks. The prescriptions were assessed using speech discrimination testing and the abbreviated profile of hearing aid benefit (APHAB). Consequently, participants were asked to select their preferred prescription and determine which was better for "listening to a conversation" and when "noisy."

RESULTS

The mean DSLv5 real ear insertion gain for an input level of 65 dB sound pressure level (SPL) was higher than that of the NAL-NL2 at 250 and 500 Hz. The average speech discrimination score was 78 ± 14% at a 65-dB SPL and 75 ± 17% at an 80-dB SPL for the NAL-NL2, and 79 ± 11% at a 65-dB SPL and 77 ± 17% at an 80-dB SPL for the DSLv5. These differences were not significant. No significant differences were observed in APHAB subscale scores between the two prescription methods. Ultimately, 11 (61%) and 7 (39%) participants preferred the NAL-NL2 and DSLv5, respectively, with no significant differences.

CONCLUSION

Although the gain of the NAL-NL2 is smaller than that of the DSLv5, both had the same hearing effect. Therefore, the NAL-NL2 may be more useful than the DSLv5 in Japanese.

[Effects of Coarse and Fine Atmospheric Particulate Matter on a Mast Cell Line]

We investigated the cytotoxicity on a mast cell line (C57 cells) of water-soluble extracts of coarse (>3 µm, PM_>3) and fine (0.05-3 µm, PM_0.05-3) atmospheric particulates collected from April 2016 to March 2019 in Fukuoka, Japan. We examined the direct cytotoxicity with punched-out membrane filter fragments of PM_>3 and PM_0.05-3 collected from April 2019 to March 2021, without extraction of the components. Also, cell proliferation and degranulation assays were conducted under conditions which caused no cytotoxicity with water-soluble extracts of PM_>3 from FY2016 and PM_>3 direct samples from FY2019. The findings revealed the significant direct cytotoxicity of many PM_>3 and all PM_0.05-3 samples, with higher cytotoxicity for PM_0.05-3 (FY2019-2020). These results were different from the cytotoxicity effects of water-soluble extracts of PM_>3 and PM_0.05-3 samples (FY2016) in previous studies. In addition, inhibition of cell proliferation and induction of degranulation were significantly induced in a few PM_>3 samples, showing a correlation with the suspended particulate matter (SPM) concentrations. This method using punched-out membrane filters is convenient and useful for assessing the direct effects of atmospheric particles on a small scale.

Novel color fluorescence imaging for sentinel lymph node detection in oral and oropharyngeal cancer

AIM

Fluorescence imaging (FI) using indocyanine green (ICG) is a noteworthy alternative technique for sentinel lymph node (SLN) detection without radiation exposure in oral cavity and oropharynx cancer. However, conventional FI is monochrome, so the visibility is limited. This study assessed whether color FI using the HyperEye Medical System (HEMS) is feasible as an alternative for SLN detection.

METHODS

Patients with previously untreated cT1-2N0 oral or oropharyngeal cancer who were to undergo primary tumor resection and elective neck dissection (END) in our hospital were enrolled from November 2012 to March 2016. The patients underwent SLN detection for biopsy via the HEMS following the injection of ICG solution around the primary lesion before neck dissection. The visibility and the diagnostic accuracy of the imaging were evaluated.

RESULTS

SLNs were visualized in all eight cases; however, transcutaneous fluorescence detection was not observed in all cases. Utilizing color mode imaging simplified harvest by clearly discriminating SLNs from surrounding structures, while the monochrome mode proved to be more sensitive for detection. Two cases showed occult metastases on both sentinel and regional nodes. The identification and false negative rates were 100% and 0%, respectively. There were no complications incurred due to this method.

CONCLUSION

Our results suggest that color FI with the HEMS allows for the accurate and safe harvest of SLNs with a preparatory skin incision. Although there is room for improvement of sensitivity, this easy-to-handle procedure might provide the potential to expand the role of the ICG method for SLN detection in head and neck cancer.

The value of serum p53 antibody as a biomarker in oral and pharyngeal squamous cell carcinoma

BACKGROUND

The development of more sensitive biomarkers for the detection of early-stage head and neck squamous cell carcinoma is needed.

AIMS/OBJECTIVES

This study was performed to assess the value of serum p53 antibody (s-p53-Ab) as a biomarker for oral and pharyngeal carcinoma.

MATERIAL AND METHODS

Pre-treatment serum was collected for 71 patients with oral and pharyngeal carcinoma and 117 healthy volunteers as controls and analyzed s-p53-Ab using enzyme-linked immunosorbent assay (ELISA).

RESULTS

Using 1.3 U/mL as the cut-off value, 14 of 71 patients (sensitivity 19.7%), and 12 of 117 control cases were positive for s-p53-Ab (specificity 89.7%). Excluding 12 cases of p16-positive oropharyngeal and nasopharyngeal cancer which were all negative for s-p53-Ab, the sensitivity in early-stage 1-2 cases was 30.0%, which was higher than conventional tumor markers.

CONCLUSIONS AND SIGNIFICANCE

The s-p53-Ab was not detected in any cases of virus-related cancer in which p53 gene mutations were not involved in carcinogenesis. Since the s-p53-Ab sensitivity was high even in early-stage disease, s-p53-Ab measurement may be useful as an early diagnostic biomarker in patients with oral, p16- oropharyngeal, and hypopharyngeal cancer.

Is repetitive systemic corticosteroid therapy effective for idiopathic sudden sensorineural hearing loss? a retrospective study

Introduction

Some idiopathic sudden sensorineural hearing loss (ISSHL) cases experience repetitive systemic corticosteroid treatment, but studies focusing on repetitive systemic corticosteroid administration have not been reported. Thus, we investigated the clinical characteristics and usefulness of repetitive systemic corticosteroid treatment in ISSHL cases.

Methods

We reviewed the medical records of 103 patients who received corticosteroids only in our hospital (single-treatment group), and 46 patients who presented at our hospital after receiving corticosteroids in a nearby clinic and were subsequently treated with corticosteroids again in our hospital (repetitive-treatment group). Clinical backgrounds, hearing thresholds, and hearing prognosis were assessed.

Results

The final hearing outcomes were not different between the two groups. Further, in the repetitive-treatment group, statistical differences were found between the good and poor prognosis groups in the number of days to start corticosteroid administration (p = 0.03), the dose of corticosteroid (p = 0.02), and the duration of corticosteroid administration (p = 0.02) at the previous facility. Multivariate analysis revealed a significant difference in the dose of corticosteroids administered by the previous clinic (p = 0.004).

Conclusion

The repetitive systemic corticosteroid administration might play a supplementary role in hearing improvement, and initial sufficient corticosteroid administration would lead to good hearing outcomes in an early phase of ISSHL.

Clinical Characteristics and Corticosteroid Responses of Acoustic Neuroma Treated as Idiopathic Sudden Sensorineural Hearing Loss

BACKGROUND

Few investigations have been conducted on the clinical characteristics of the differential diagnosis of acoustic neuroma with acute sensorineural hearing loss and idiopathic sudden sensorineural hearing loss. The aim of the study was to investigate the clinical characteristics of the differential diagnoses between acoustic neuroma and idiopathic sudden sensorineural hearing loss.

METHODS

The medical records of patients with acute sensorineural hearing loss (142 ears), including acoustic neuroma (19 ears) and idiopathic sudden sensorineural hearing loss (123 ears), who underwent audiometric and hematologic examinations and received systemic corticosteroid treatment, were retrospectively reviewed.

RESULTS

Hematological examination revealed that the erythrocyte sedimentation rate and fibrinogen values were significantly higher in the idiopathic sudden sensorineural hearing loss group compared to the acoustic neuroma group. Although all patients received corticosteroid treatment, hearing thresholds at the initial examination and 3 months after corticosteroid treatment were significantly higher in the idiopathic sudden sensorineural hearing loss group compared to the acoustic neuroma group at all frequencies. However, hearing recovery was worse in the acoustic neuroma group compared to the idiopathic sudden sensorineural hearing loss group. Furthermore, speech discrimination and short increment sensitivity index tests were not significantly different between the acoustic neuroma and idiopathic sudden sensorineural hearing loss groups.

CONCLUSION

This is the first study to reveal that speech discrimination and short increment sensitivity index tests are not useful for the differential diagnoses between acoustic neuroma and idiopathic sudden sensorineural hearing loss, whereas erythrocyte sedimentation rate and fibrinogen, blood biomarkers of inflammation and blood viscosity, would be considered valuable. Furthermore, acoustic neuroma should be considered in cases where acute sensorineural hearing loss did not recover after corticosteroid treatment, although the initial hearing loss was mild.

Total laryngectomy increases the risk of chronic constipation: a cross-sectional study of 50 patients

PURPOSE

Due to difficulties in breath holding, patients who undergo total laryngectomy may be prone to the development of chronic constipation. However, few reports have described chronic constipation in laryngectomized patients, and no report has described prevalence in patients who have undergone total pharyngolaryngectomy.

METHODS

We conducted a cross-sectional study to investigate the prevalence of chronic constipation after laryngectomy and evaluated the relationship between patient characteristics and chronic constipation. Information on patient characteristics and the details of surgery were obtained from medical records and an original questionnaire survey in 50 patients.

RESULTS

The prevalence of chronic constipation after laryngectomy was high, at 36%, with 18 cases. Patients who received total laryngectomy were significantly more likely to have chronic constipation than those who received total pharyngolaryngectomy (47.1% vs 12.5%, P = 0.026), who had a similar prevalence to the general public. Furthermore, the period from surgery to survey was significantly shorter in the constipation group than in the no constipation group (P = 0.043).

CONCLUSIONS

The prevalence of chronic constipation in patients who had undergone laryngectomy for head and neck cancer was high, particularly in patients who received total laryngectomy and in those with only a short period since surgery.

Reduction of Severe Hypoglycemic Events Among Outpatients with Type 2 Diabetes Following Sodium-Glucose Cotransporter 2 Inhibitor Marketing in Japan

Recently, oral hypoglycemic agents with newer glucose lowering mechanisms have been on release. This is mostly to meet the diabetic patient's need to avoid hypoglycemia, which is profoundly important for better long-term outcome of the treatment. In this study, we quantified the annual number of patients with type 2 diabetes who experienced hypoglycemia needing the third-party assistance who had random sample plasma glucose<59.4 mg/dl (3.3 mmol/l) on the one hand and analyzed the prescription trend of hypoglycemic agents all over Japan on the other. Analysis of the annual number of hypoglycemic patients visited ER was performed at Aizawa Hospital, a medical center located in the midst of a city. The study duration was over 10 years from 2008 to 2019. We found a clear-cut decreasing trend of hypoglycemia over the 10 years, ca. 61/year to 39/year. Immediately after the release of sodium-glucose co-transporter-2 inhibitors, since 2013 to 2017, the decrease was rather sharp as 81/year to 31/year, and the change of the national number of its prescription inversely correlated with the change of the number of the patients with hypoglycemia. This was not the case immediately after the introduction of dipeptidyl peptidase-4 inhibitors in the Japanese market since 2008 to 2012. There was no significant correlation between its prescription and the number of patients with hypoglycemia. The data strongly suggested that there was a causal relationship exclusively between the introduction of sodium-glucose cotransporter-2 inhibitor, and the reduction of hypoglycemic events among patients with type 2 diabetes.

Usefulness of echocardiographic parameters in predicting the incidence of ischemic stroke in Japanese patients with non-valvular atrial fibrillation

Background

Atrial fibrillation (AF) is a risk factor for ischemic stroke (IS). We developed a novel risk score of IS (HELT-E2S2 score) in non-valvular atrial fibrillation (NVAF) patients from the combined database of 5 major AF registries in Japan. However, this score does not include echocardiographic (Echo) parameters that have been reported to be risk factors of IS, such as left atrial diameter (LAD) enlargement or increased relative wall thickness (RWT) of left ventricle (LV).

Purpose

To investigate the predictive value of Echo parameters in Japanese patients with NVAF.

Methods

After excluding patients without the Echo data, 6,032 NVAF patients were analyzed in the present study. LAD was measured in the parasternal long axis view at the end-ventricular systole. RWT was calculated as (2x posterior wall thickness)/ LV end-diastolic dimension. We compared clinical characteristics and the incidence of IS between NVAF patients divided by LAD level (High/Low LAD group) and RWT level (High/Low RWT group). To balance the follow-up period among the registries, event data from individuals whose follow-up period exceeded 730 days were excluded from the analysis.

Results

The optimal cut-off value of LAD and RWT to predict the incidence of IS with the receiver operating characteristic analysis was 43.3 mm and 0.4167, respectively. Between the High/Low LAD groups (High LAD: n=2,640 vs. Low LAD: n=3,392), age (70.3±12.1 vs. 68.3±12.5 years; p&lt;0.001), CHA2DS2-VASc score (3.02±1.84 vs. 2.57±1.78; p&lt;0.001), HELT-E2S2 score (2.20±1.31 vs. 1.55±1.33; p&lt;0.001), the prescription of oral anticoagulants (OACs) (69.5 vs. 51.5%; p&lt;0.001), LV ejection fraction (60.4±13.4 vs. 64.4±10.7%; p&lt;0.001) and RWT (0.401±0.091 vs. 0.396±0.082; p=0.02) were significantly different. Between the High/Low RWT groups (High RWT: n=2,293 vs. Low RWT: n=3,739), percentage of female (35.6 vs. 27.8%; p&lt;0.001), age (71.2±12.1 vs. 68.0±12.4 years; p&lt;0.001), CHA2DS2-VASc score (3.08±1.82 vs. 2.58±1.79; p&lt;0.001), HELT-E2S2 score (2.10±1.39 vs. 1.67±1.31; p&lt;0.001), the prescription of OACs (62.6 vs. 57.4%; p&lt;0.001), LV ejection fraction (65.5±9.9 vs. 60.9±13.0%; p&lt;0.001) and LAD (43.0±8.1 vs. 42.4±8.3; p=0.004) were significantly different. In Kaplan-Meier analysis, the incidence of IS was different between the groups during the median follow-up period of 730 days (High LAD vs. Low LAD; 1.82 vs. 1.00 per 100 person-years; p&lt;0.001, by log-rank test, High RWT vs. Low RWT; 1.86 vs. 1.06; p&lt;0.001) (Figure). Both High LAD (hazard ratio: 1.65, 95% CI: 1.12–2.46; p=0.01) and High RWT (hazard ratio: 1.43, 95% CI: 1.01–2.04; p=0.045) were independent predictors of the incidence of IS after adjustment by the components of the HELT-E2S2 score and other clinically relevant variables including co-existing diseases, gender, and the prescription of OACs (Table).

Conclusion

Echo parameters, LAD and RWT, were independently associated with the incidence of IS among Japanese patients with NVAF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Japan Agency for Medical Research and Development

Prediction of recurrence after catheter ablation for atrial fibrillation using left atrial morphology on preprocedural computed tomography: application of radiomics

Background

Radiomics is a comprehensive analysis methodology of medical image and involves the extraction of numerous features from standard imaging. Its usefulness has been reported mainly in the field of cancer for diagnosis and prediction of prognosis. In the territory of cardiac imaging, several reports have investigated the utility of radiomics for classifying the risk of prognosis in coronary artery disease, and few practical applications have been reported for patients with atrial fibrillation (AF) who underwent pulmonary vein isolation (PVI). Although the left atrial morphology can affect the clinical course after the PVI procedure, it is unclear whether the radiomics feature values of the left atrial morphology on cardiac computed tomography (CT) is useful for predicting the AF recurrence after PVI.

Purpose

To predict the recurrence of AF after PVI using the radiomics feature values of the left atrial morphology on cardiac computed tomography (CT).

Methods

We analyzed 525 consecutive three-dimensional cardiac CT in patients with atrial fibrillation who underwent PVI from 2018 to 2019 in our institute. After marking the region of interest on left atrium (including the root of pulmonary veins) semiautomatically, 107 radiomics feature values were obtained by Python program. After excluding the parameters having collinearity or with low predictive capability for the recurrence of AF after PVI, 42 parameters were applied to the final prediction model. Two prediction models were constructed by multivariate Cox regression analysis and machine learning model by support vector machine algorithm.

Results

The area under the curve (AUC) for predicting the recurrence of AF was 0.815 for the multivariate Cox regression model and 0.826 for the machine learning model by support vector machine.

Conclusion

The radiomics feature values on preprocedural cardiac CT could be helpful for predicting the recurrence of AF after PVI. Since radiomics feature analysis yields a huge number of numerical values representing the left atrial morphology in a reproducible manner, it would provide a new direction to construct a good prediction model using machine learning including artificial intelligence out of a routine cardiac CT scan.

Funding Acknowledgement

Type of funding sources: None.

Advantage of POLARx over ARCTIC FRONT ADVANCE PRO during pulmonary vein isolation for paroxysmal atrial fibrillation

Introduction

The electrical pulmonary vein (PV) isolation has been established as a curative therapy for paroxysmal atrial fibrillation (AF). Arctic Front™cryoballoon has been used worldwide for AF cryoablation. Recently, a new cryoballoon, POLARxTM CRYOABLATION system have been introduced, of which material of the balloon is softer and the N2O gas flow rate is higher.

Purpose

The aim was to investigate the procedural parameter and efficacy of POLARx comparing with Arctic Front.

Methods

This retrospective single center study included 101 consecutive patients who underwent paroxysmal AF ablation using cryoballoon at Keio University hospital from April 2021 to March 2022. The procedural data including the cryoballoon temperature and the number and duration of cryoablation were compared between POLARx (POLARx group) and ARCTIC FRONT ADVANCE PRO (AFA group). After the cryoablation, we added the radiofrequency application in order to maximize the isolated area when the voltage was remained inside PV (Figure 1). The necessities of the additional radiofrequency applications were also compared.

Results

In the present study, 64 patients in AFA group and 37 patients in POLARx group were analyzed. POLARx group included younger population and less females (62.8±9.9 vs 67.5±9.4 year of age, P=0.02; 13.5 vs 32.8%, P=0.04). There was no significant difference in comorbidities and examination data such as left atrium diameter or brain natriuretic peptide level. The minimal cryoballoon temperatures reached in POLARx group were lower than AFA group (−59.3±6.2 vs −47.7±7.5°C, P&lt;0.01). No difference was found in the total number and duration of cryoablation and the time to isolate PV (6.1±2.1 vs 5.9±1.6, P=0.69; 790.2±256.1 vs 776.1±235.0 sec, P=0.69; 41.8±21.3 vs 47.1±29.6 sec, P=0.44, respectively). With regard to individual PVs, the total number and duration were tended to be larger at right superior PV in POLARx group (1.9±1.1 vs 1.4±0.7, P=0.01; 231.8±123.8 vs 193.2±83.0 sec, P=0.07), while there was no significant difference at the other PVs. The rate of successful PV isolation by a single cryo-application was not different between AFA and POLARx group (54.3 vs 61.4%, P=0.17). The additional radiofrequency applications were more frequent in AFA group (14.8 vs. 4.9%, P=0.003). There was a significant difference at right inferior PV (32.8 vs 8.1%, P=0.01), while not at left superior PV, left inferior PV and right superior PV (9.4 vs 2.9%, P=0.42; 9.4 vs 5.7%, P=0.71; 7.8 vs 2.7%, P=0.41). Phrenic nerve injury was occurred 1 case in both group and esophageal ulcer was occurred in 1 case in AFA group. No other complication including cardiac tamponade was occurred.

Conclusion

The total number and duration of cryoablation were not significantly different between AFA and POLARx group, except for right superior PV. There was an advantage in largely isolating right inferior PV in POLARx group comparing with AFA group.

Funding Acknowledgement

Type of funding sources: None.

Real-world effectiveness and safety of edoxaban in patients with and without a history of ischaemic stroke: results from the ETNA-AF programme

Background

Atrial fibrillation (AF) patients with a history of ischaemic stroke (IS) have a higher risk for recurrent IS events and were largely excluded from the pivotal, randomised, controlled phase 3 trials on oral anticoagulants. Thus, the effectiveness and safety of edoxaban in these patients need to be studied in a real-world setting.

Purpose

To compare edoxaban real-world effectiveness and safety in AF patients with or without an IS history.

Methods

The Global ETNA-AF programme (EU: NCT02944019, Japan: UMIN000017011, South Korea/Taiwan: NCT02951039) integrates data from multiple prospective, observational, noninterventional regional studies of AF patients receiving edoxaban for stroke prevention. This snapshot analysis summarises baseline characteristics with medical history and 2-year annualised rates of all-cause death, cardiovascular (CV) death, stroke (haemorrhagic, ischaemic, any), and bleeding (including major bleeding [MB], major gastrointestinal [GI] bleeding, intracranial haemorrhage [ICH], clinically relevant nonmajor bleeding [CRNMB], and any bleeding) in patients with or without IS history.

Results

Data from 27,333 patients (3215 with prior IS and 24,118 without) from Europe, Japan, South Korea, and Taiwan were analysed. Patients with IS history were significantly older, more likely ≥75 years of age, and had a lower mean body weight and creatinine clearance (P&lt;0.0001 for all; Table). Patients with IS history also had significantly higher baseline stroke (CHA2DS2-VASc) and bleeding (HAS-BLED) risk scores (P&lt;0.0001 for both; Table). A significantly higher percentage of patients with IS history had previous transient ischaemic attacks (TIA), MB, and ICH (P&lt;0.0001 for all; Table). Patients with IS history more likely received edoxaban 30 mg vs 60 mg at baseline (P&lt;0.0001). Effectiveness and safety outcomes hazard ratios are shown in the Figure. Patients with IS history had significantly higher rates of all-cause death (4.5% vs 3.0%; P&lt;0.0001), CV death (1.9% vs 1.4%; P=0.004), IS (2.5% vs 0.5%; P&lt;0.0001), any stroke (3.1% vs 0.7%; P&lt;0.0001), and TIA (0.5% vs 0.2%; P=0.0002). Patients with IS history had significantly higher annualised rates of MB (1.6% vs 1.0%; P&lt;0.0001), major GI bleeding (0.8% vs 0.5%; P=0.003), ICH (0.6% vs 0.3%; P&lt;0.0001), haemorrhagic stroke (0.5% vs 0.2%; P&lt;0.0001), CRNMB (2.3% vs 1.3%; P&lt;0.0001), and any bleeding (6.1% vs 4.1%; P&lt;0.0001).

Conclusions

Patients with AF who have a history of IS are more likely elderly; have histories of MB, ICH, and TIA; and have high baseline stroke and bleeding risk scores. Patients with IS history receiving edoxaban have a considerably higher likelihood of experiencing IS or TIA, whereas the risk of experiencing any bleeding event (with the exception of ICH) is only modestly higher than in those without IS history.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo

Clinical phenotypes of older adults with non-valvular atrial fibrillation not treated with oral anticoagulants by hierarchical cluster analysis in the ANAFIE registry

Background and purpose

The All Nippon AF In the Elderly (ANAFIE) registry evaluated the current status of anticoagulant therapy in older adult patients (aged ≥75 years) with non-valvular atrial fibrillation (NVAF) in Japan. Although older adult NVAF patients requires anticoagulation therapy, some of them do not receive it and the reasons would be diverse. Therefore, we aimed to identify the phenotypes of older adult NVAF patients not treated with oral anticoagulants using data from the ANAFIE registry.

Methods

In this sub-analysis of the ANAFIE registry, the phenotypes of patients who were not receiving anticoagulants at baseline were evaluated by cluster analysis using Ward's linkage hierarchical algorithm. We used 20 categorical variables and 6 continuous variables for the cluster analysis which were used as the risk factors in the main analysis of the ANAFIE registry [1].

Results

Of 33,275 enrolled patients, 2445 (7.3%) were not receiving anticoagulants. Two clusters were identified: (1) elderly paroxysmal AF (PAF) patients with a low prevalence of comorbidities (58%) and (2) very elderly patients with a high previous major bleeding prevalence (42%). For each cluster, mean ages were 79.9 and 85.7 years, mean CHADS2 scores were 2.3 and 3.1, PAF prevalences were 83% and 54%, heart failure prevalences were 18% and 48%, the proportions of patients with a history of major bleeding were 0% and 25%, the proportions of patients with a history of catheter ablation were 21% and 8%, respectively. Annual incidence rates of each cluster were 2.62% and 9.08% for all-cause death, 1.72% and 5.83% for major adverse cardiovascular or neurological events, 1.22% and 3.14% for stroke or systemic embolism, and 0.53% and 1.43% for major bleeding.

Conclusions

In this cohort of elderly NVAF patients not receiving anticoagulants, more than half (∼60%) were PAF patients and had a low incidence of adverse outcomes. The remaining ∼40% were characterized as very elderly patients with a high prevalence of previous major bleeding and a high incidence of adverse outcomes.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Co., Ltd.

Prediction of persistent form of atrial fibrillation using left atrial morphology on preprocedural computed tomography: application of radiomics

Background

Radiomics is a comprehensive analysis methodology of medical image and involves the extraction of numerous features from standard imaging. Its usefulness has been reported mainly in the field of cancer for diagnosis and prediction of prognosis. In the territory of cardiac imaging, several reports have investigated the utility of radiomics for classifying the risk of prognosis in coronary artery disease, and few practical applications have been reported for patients with atrial fibrillation (AF) who underwent catheter ablation (CA).

Purpose

The objective of this study was to evaluate the utility of radiomics analysis applying to the preprocedural cardiac computerized tomography (CT) in AF patients.

Methods

We analyzed 525 consecutive three-dimensional CT in patients with AF who underwent CA. After marking the region of interest on left atrium (LA) (including the root of pulmonary veins) semiautomatically, 107 radiomics feature values were obtained by Python program. We calculated the amount of representative statistics for each radiomics feature for prediction of persistent AF (PeAF) (Wald statistic in logistic regression analysis) and LA diameter (LAD) (coefficient correlation), respectively. To compare the distribution of the two statistics, the relative importance (calculated as the ratio of statistic to the maximum statistics among 107 radiomics features [%]) was calculated for each statistic. Further, we compared the area under the curve (AUC) in receiver operation characteristic (ROC) curve analysis for predicting PeAF between radiomics features (multivariate model) and LAD (single parameter).

Results

In 525 study patients (age 63±10 years old and male 80%), 253 (48%) were PeAF and remaining were paroxysmal AF (PAF). LAD was 43±6 mm and 38±6 mm in patients with PeAF and PAF, respectively. The relative importance of the two statistics (Wald statistic for PeAF and coefficient correlation for LAD) of 107 radiomics features are displayed in Figure 1, which shows similar distribution of two statistics. It means the close relationship between LA morphology and the form of PeAF in AF patients and the radiomics features possibly well explain the relationship. In Figure 2, the predictive capability for PeAF was compared between radiomics feature values and LAD, where the AUC was 0.85 (95% confidence interval [CI], 0.82–0.88) and 0.73 (95% CI, 0.69–0.78) for radiomics feature values and LAD, respectively (Delong test, P&lt;0.001).

Conclusion

We applied the radiomics features for the evaluation of LA morphology. The predictive capability for PeAF in the prediction model with the radiomics feature values was much better than that with LAD alone. Since radiomics feature analysis yields a huge number of numerical values representing the LA morphology in a reproducible manner, it would provide a new direction to construct a good prediction model using machine learning including artificial intelligence out of a routine cardiac CT scan.

Funding Acknowledgement

Type of funding sources: None.

Two-year effectiveness and safety outcomes in 27,333 edoxaban-treated patients with and without a history of major bleeding from the Global ETNA-AF programme

Background

Atrial fibrillation patients with a history of major bleeding (MB) are at high risk of future bleeding events; this history was an exclusion criterion in pivotal phase 3 trials of anticoagulation for stroke prevention. Real-world edoxaban effectiveness and safety in patients with a history of MB were analysed from the global ETNA programme.

Purpose

To compare edoxaban effectiveness and safety in AF patients with or without an MB history.

Methods

The Global ETNA-AF programme (EU: NCT02944019, Japan: UMIN000017011, South Korea/Taiwan: NCT02951039) integrates data from multiple prospective, observational, noninterventional regional studies of AF patients treated with edoxaban for stroke prevention. This snapshot analysis summarises global baseline characteristics and 2-year annualised rates of all-cause death, cardiovascular death, stroke (haemorrhagic, ischaemic, any), and bleeding (including MB, major gastrointestinal bleeding [MGIB], intracranial haemorrhage [ICH], clinically relevant nonmajor bleeding, and any bleeding) in patients with or without MB history.

Results

Data from 27,333 patients (479 with MB history and 26,854 without) from Europe, Japan, South Korea, and Taiwan were analysed. Patients with MB history were significantly older (P&lt;0.0001) and more likely to be ≥75 years of age (P=0.0003), to be male (P=0.024), and to have a lower body weight and creatinine clearance (P&lt;0.0001 for both) (Table). Globally, antiplatelet use was significantly higher in patients with MB history compared with patients without (P=0.005). Patients with MB history were more likely to have previously diagnosed heart failure (HF, P=0.001) and to receive 30 mg vs 60 mg edoxaban at baseline (P&lt;0.0001). Hazard ratios for effectiveness and safety outcomes are shown in the Figure. Patients with MB history had significantly higher annualised rates of all-cause death (5.7% vs 3.1%; P&lt;0.0001), ischaemic stroke (1.8% vs 0.7%; P=0.002), and any stroke (3.1% vs 0.9%; P&lt;0.0001) than patients without MB history. Patients with MB history also had significantly higher annualised rates of MB (3.6% vs 1.0%; P&lt;0.0001), MGIB (1.5% vs 0.5%; P=0.001), ICH (1.5% vs 0.3%; P&lt;0.0001), fatal bleeding (0.9% vs 0.2%; P&lt;0.0001), and fatal ICH (0.5% vs 0.1%; P=0.0002). Among patients with MB history, the annualised rate of ICH did not differ between patients with ICH history (1.42%/yr) vs without (1.65%/yr); whereas the annualised rate of MGIB was significantly higher in patients with MGIB history vs without (4.14%/yr vs 1.08%/yr; P=0.0337).

Conclusions

Patients with AF receiving edoxaban and who have a history of MB are more likely elderly, male, and have comorbidities, including HF. These patients are also more susceptible to any adverse cardiovascular event. ICH event rates were not higher in patients with prior ICH than those with non-ICH major bleedings, whereas history of MGIB was associated with a high risk of MGIB recurrence.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo

Prognosis of low-flow low-gradient aortic valve stenosis with atrial fibrillation

Background

Patients with Low-flow low-gradient (LFLG) aortic valve stenosis (AS) have possibly poor prognosis. Recently, it was reported that the LFLG AS patients have similar outcomes compared to high-gradient (HG) patients but worse outcomes compared to the normal-flow low-gradient [NFLG: SVi≥35 ml/m2, mPG &lt;40mmHg] subgroup. The main determinant of LF state in severe AS patients with preserved LVEF are male gender, heart rate, LV volume and atrial fibrillation (AF). However, the relationship between the comorbidity with AF in LFLG AS and the risk of heart failure (HF) remains unclear.

Purpose

We elucidated about the prognosis of LFLG AS with AF.

Methods

We included 225 consecutive patients with severe AS (SAS, iAVA&lt;0.6 cm2/m2) from 2013 to 2020. Among these patients, high-gradient SAS [HG-SAS; mean pressure gradient (mPG) ≥40 mmHg, n=88] and LFLG AS [stroke volume index (SVi) ≤35 ml/m2, mPG &lt;40 mmHg, n=82] patients was extracted and the baseline characteristics including the presence or absence of AF were evaluated. The primary endpoint was worsening HF that required unplanned hospitalization or readjustment of HF drug therapy.

Results

Among patients with HG SAS and LFLG AS, worsening HF was observed in 65 patients. LFLG AS patients exhibited a higher oral rate of renin-angiotensin-system inhibitors (p=0.02). In addition, SVi and E/e' was lower in LFLG AS patients compared with HG SAS [SVi; 29.4 (24.4–34.0) versus 37.7 (28.2–45.3), p&lt;0.0001, E/E'; 16.0 (13.1–21.5) vs 20.9 (16.0–27.4), p=0.002]. There is no differences between 2 groups in AF prevalence. Furthermore, 2 groups were subdivided as follow; HG SAS with AF (n=25), HG SAS without AF (n=63), LFLG AS with AF (n=24), LFLG AS without AF (n=58). The Kaplan Meier curves demonstrated LFLG SAS with AF experienced higher rate of worsening HF compared with HG SAS without AF and equivalent rate of worsening HF compared with HG SAS with AF (log rank, p&lt;0.001). In the Cox hazard analysis among the LFLG AS patients, LFLG AS with paroxysmal AF (pAF, n=12) instead of chronic AF (cAF, n=12) showed a higher risk for worsening HF compared with those without AF (HR 5.0; 95% CI, 1.8–14; p=0.0028, HR 1.9; 95% CI, 0.62–5.8; p=0.26, respectively).

Conclusion

LFLG AS with AF exhibited a poor prognosis for HF compared with HG SAS without AF and equivalent rate of worsening HF compared with HG SAS with AF. Furthermore, the presence of pAf was associated with an increased risk of HF in patients with LFLF AS. Thus, intervention including drugs and catheter ablation for pAF in LFLG AS patients could lead to prevent worsening clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.

Long-term outcomes of stapes surgery

OBJECTIVE

Hearing improvement following stapes surgery is generally good; however, we sometimes encounter patients where hearing loss gradually progresses over the long term. In this study, we investigated the causes of hearing loss in these cases.

METHODS

A total of 30 ears from 23 patients, who underwent stapes surgery at Kitasato University Hospital from 2001 to 2021 and were followed up for ≥5 years, were included in the study. Changes in air conduction (AC) and bone conduction (BC) thresholds were measured, and hearing evaluation was performed by calculating the air-bone gap (ABG) at the mean of 4 frequencies. Cases with a postoperative ABG of ≤10 dB at 6 months after surgery were classified into the following groups according to their hearing changes at 5 years after surgery: Group A (no ABG increase of ≥10 dB and no AC threshold increase of ≥10 dB) and Group B (an ABG increase of ≥10 dB and an AC threshold increase of ≥10 dB). In groups A and B, we examined factors affecting long-term postoperative results. In addition, the patients who underwent reoperation were examined.

RESULTS

The AC thresholds 6 months and 5 years after surgery decreased significantly compared with those before surgery (p  <  0.01); however, the BC thresholds 6 months and 5 years after surgery did not vary significantly from those before surgery (p  >  0.05). Group A included 16 ears from 13 patients (53.3%), and Group B included 3 ears from 3 patients (10.0%). There were no significant differences in age, sex, surgical method, piston type, piston length, presence of incudostapedial joint subluxation, computed tomography findings, and preoperative ABGs between groups A and B (p  >  0.05). A total of 6 reoperations were performed in 3 ears from 3 patients, and there were 5 operations with the platinotomy hole to be closed by bone regrowth and 3 operations with the narrowed long process of the incus.

CONCLUSION

In 10.0% of the patients who underwent stapes surgery, the ABG improved 6 months after surgery; however, the AC threshold and ABG increased 5 years after surgery. Our findings suggested that piston displacement and the platinotomy hole to be closed by bone regrowth are possible causes of hearing loss in cases where hearing loss progresses in the long term after stapes surgery.

Different changes in the biomarker C-terminal telopeptides of type II collagen (CTX-II) following intra-articular injection of high molecular weight hyaluronic acid and oral non-steroidal anti-inflammatory drugs in patients with knee osteoarthritis: a multi-center randomized controlled study

OBJECTIVES

We previously reported, based on a multicenter randomized-control study, that the efficacy of intra-articular injections of hyaluronic acid (IA-HA) was not inferior to that of oral non-steroidal anti-inflammatory drugs (NSAIDs) in patients with knee osteoarthritis (OA). However, the molecular effects on the pathophysiology of knee OA remain unclear. C-terminal telopeptides of type II collagen (CTX-II) is reported to primarily originate from the interface between articular cartilage and subchondral bone, which is a site of potential remodeling in OA. We performed a predefined sub-analysis of the previous study to compare the changes of urinary CTX-II (uCTX-II) in response to IA-HA to those in response to NSAID for knee OA.

DESIGN

A total of 200 knee OA patients were registered from 20 hospitals and randomized to receive IA-HA (2,700 kDa HA, 5 times at 1-week intervals) or NSAID (loxoprofen sodium, 180 mg/day) for 5 weeks. The uCTX-II levels were measured before and after treatment.

RESULTS

The uCTX-II levels were significantly increased by IA-HA treatment (337.7 ± 193.8 to 370.7 ± 234.8 ng/μmol Cr) and were significantly reduced by NSAID treatment (423.2 ± 257.6 to 370.3 ± 250.9 ng/μmol Cr). The %changes of uCTX-II induced by IA-HA (11.6 ± 29.5%) and NSAID (-9.0 ± 26.7%) was significantly different (between-group difference: 20.6, 95% confidence intervals: 10.6 to 30.6).

CONCLUSIONS

While both IA-HA and NSAID improved symptoms of knee OA, uCTX-II levels were increased by IA-HA and reduced by NSAIDs treatment, suggesting these treatments may improve symptoms of knee OA through different modes of action.

Preoperative S-1 Therapy for Head and Neck Carcinoma During the Waiting Period Before Surgery

BACKGROUND/AIM

In patients with squamous cell carcinoma of the head and neck (SCCHN), delayed surgery can result in poorer postoperative function and prognosis due to the growth of the tumor and extended surgery. Further, delay may even make the tumor unresectable. To prevent tumor growth during the waiting period before surgery, S-1 has been administrated preoperatively at several facilities in Japan. To date, however, the safety and efficacy of preoperative S-1 remain unclear.

PATIENTS AND METHODS

We conducted a retrospective cohort study of 118 patients with SCCHN treated with S-1 before radical surgery at 2 institutions in Japan. We evaluated the safety of S-1 therapy, which was evaluated by the incidence of grade 3 or greater adverse events (AEs). The rate of achievement of non-growth of tumors was also calculated.

RESULTS

Regarding safety, 125 AEs of all grades were recorded in 71 patients (60%). Of these, grade 3 AEs were detected in 3 patients (3%), and no grade 4 or 5 AEs occurred. The nongrowth rate of primary lesions and lymph node metastases was 89% and 85%, respectively.

CONCLUSION

Preoperative S-1 therapy might be useful, with acceptable toxicity, on an outpatient basis in patients with SCCHN.

Effectiveness and safety of edoxaban in 27,333 patients from ETNA-AF with and without a history of intracranial haemorrhage after 2 years of treatment

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): This study was sponsored by Daiichi Sankyo, Inc. Medical writing and editorial support were provided by Atreju Lackey, PhD of AlphaBioCom, LLC, and funded by Daiichi Sankyo, Inc.

Background/Introduction

Once-daily edoxaban significantly reduced the risk of intracranial haemorrhage (ICH) compared with well-managed warfarin in atrial fibrillation (AF) patients in the ENGAGE AF-TIMI 48 trial. The effectiveness and safety of edoxaban in patients with prior ICH is unknown.

Purpose

To compare the effectiveness and safety of edoxaban in AF patients with or without a history of ICH.

Methods

The Global ETNA-AF programme is composed of and, thus, integrates data from multiple prospective, observational, and noninterventional regional studies collecting data of AF patients treated with edoxaban for stroke prevention. This snapshot analysis presents global and regional baseline characteristics with medical history and 2-year annualised rates of all-cause mortality, stroke (haemorrhagic, ischaemic, any), and bleeding (major bleeding [MB] including ICH, clinically relevant nonmajor bleeding [CRNMB], any bleeding), in patients with or without ICH history.

Results

Overall, 27,333 patients from Europe, Japan, South Korea, and Taiwan were analysed, including 367 with prior ICH and 26,966 without prior ICH. There were proportionally fewer patients with a history of ICH in the European population. Patients with a history of ICH were older (P=0.006), had a lower body mass index (P&lt;0.0001), had a lower creatinine clearance (P=0.0001), and had more comorbidities, with a higher percentage of patients with a history of stroke, transient ischaemic attack (TIA), or MB (Table 1); the higher level of comorbidities noted in patients with a history of ICH was also reflected by higher baseline CHA2DS2-VASc and HAS-BLED scores (Table 1). Patients with a history of ICH were more likely receiving 30 mg edoxaban at baseline, whereas patients without ICH history were more often on 60 mg edoxaban (each P&lt;0.0001). In patients with vs without ICH history, all-cause mortality (5.10% vs 3.14%; P=0.01), ischaemic stroke (1.79% vs 0.73%; P=0.006), and any stroke rates (3.25% vs 0.95%; P&lt;0.0001) were higher (Table 2). Patients with vs without ICH history had higher annualised rates of MB (2.50% vs 1.00%; P=0.001), ICH (1.42% vs 0.27%; P&lt;0.0001), haemorrhagic stroke (1.42% vs 0.20%; P&lt;0.0001), CRNMB (2.49% vs 1.40%; P=0.04), and any bleeding (7.57% vs 4.27%; P=0.001), but these rates were low compared to other high-risk populations. ICH was not selected as a predictor of cardiovascular outcomes on multivariate prediction modelling. ICH had non-significant effects in predicting all-cause death (HR 1.22), ischemic stroke (HR 1.14), and major bleeding (HF 1.37) and repeat ICH (HR 1.94).

Conclusions

Patients with a history of ICH are a small, elderly, multimorbid subgroup of patients with AF. Treatment with the non-vitamin K antagonist oral anticoagulant edoxaban resulted in relatively low rates of major events.

Immune-Nutritional Status as a Novel Prognostic Predictor of Bell's Palsy

INTRODUCTION

The prognosis of Bell's palsy, idiopathic facial nerve palsy (FNP), is usually predicted by electroneuronography in subacute phase. However, it would be ideal to establish a reliable and objective examination applicable in acute phase to predict the prognosis of FNP. Immune-nutritional status (INS) calculated from peripheral blood examination is recently reported as the prognostic factor in various disease. However, the validity of INS as the prognostic factor in Bell's palsy is not well known. Thus, we conducted a retrospective study to investigate the usefulness of INS as prognostic predictors of Bell's palsy.

METHODS

We reviewed the medical records of 79 patients with Bell's palsy and divided into two groups as "complete recovery" and "incomplete recovery" groups. Clinical features such as severity of FNP and INS, including neutrophil-lymphocyte ratio (NLR), lymphocyte-monocyte ratio (LMR), prognostic nutritional index (PNI), and controlling nutrition status (CONUT) score, were assessed.

RESULTS

In univariate analysis, statistically significant differences were observed in clinical score of facial movement, NLR, LMR, PNI, and CONUT score at the initial examination between the two groups (p < 0.05). Furthermore, in multivariate analysis, statistically significant differences were also observed in facial movement score and PNI at the initial examination (p < 0.05).

CONCLUSION

Immune and nutritional condition play important roles in the pathogenesis of Bell's palsy, suggesting that INS would be one of the useful prognostic factors in Bell's palsy.

Adjuvant Abemaciclib Combined with Endocrine Therapy for High Risk Early Breast Cancer: Safety and Patient-Reported Outcomes From the monarchE Study

BACKGROUND

In monarchE, abemaciclib plus endocrine therapy (ET) as adjuvant treatment of hormone receptor-positive, human epidermal growth factor 2-negative, high risk, early breast cancer demonstrated a clinically meaningful improvement in invasive disease-free survival versus ET alone. Detailed safety analyses conducted at a median follow-up of 27 months and key patient-reported outcomes (PRO) are presented.

PATIENTS AND METHODS

The safety population included all patients who received at least one dose of study treatment (n=5591). Safety analyses included incidence, management, and outcomes of common and clinically relevant adverse events (AEs). Patient-reported health-related quality-of-life, ET symptoms, fatigue, and side effect burden were assessed.

RESULTS

The addition of abemaciclib to ET resulted in higher incidence of Grade≥3 AEs (49.7% vs 16.3% with ET alone), predominantly laboratory cytopenias (e.g., neutropenia [19.6%]) without clinical complications. Abemaciclib-treated patients experienced more serious adverse events (SAEs; 13.3% vs 7.8%). Discontinuation of abemaciclib and/or ET due to AEs occurred in 18.5% of patients, mainly due to Grade1/2 AEs (66.8%). AEs were managed with comedications (e.g., antidiarrheals), abemaciclib dose holds (61.7%), and/or dose reductions (43.4%). Diarrhea was generally low grade (Grade1/2: 77%); Grade2/3 events were highest in the first month (20.5%), most short-lived (≤7 days) and did not recur. Venous thromboembolic events (VTE) were higher with abemaciclib+ET (2.5%) vs ET (0.6%); in the abemaciclib arm, increased VTE risk was observed with tamoxifen vs AIs (4.3% vs 1.8%). PROs were similar between arms, including being 'bothered by side effects of treatment', except for diarrhea. At ≥3 months, most patients reporting diarrhea reported "a little bit" or "somewhat".

CONCLUSION

In patients with high risk EBC, adjuvant abemaciclib+ET has an acceptable safety profile and tolerability is supported by PRO findings. Most AEs were reversible and manageable with comedications and/or dose modifications, consistent with the known abemaciclib toxicity profile.

Postoperative Complications and Swallowing Function after Jejunal and Skin Flap Reconstruction for Hypopharyngeal Carcinoma-A Multicenter Retrospective Study

This study compared the incidence of perioperative complications and swallowing function between free jejunal flap reconstruction and cutaneous free tissue flap construction. We included 223 patients who underwent hypopharyngeal reconstruction using free flap. At discharge, +the free jejunal flap was associated with a Functional Oral Intake Scale (FOIS) score of 1-6 in 132 cases (70%) and a score of 7 in 56 cases (30%). Regarding the cutaneous free tissue flaps, FOIS scores of 1-6 were observed in 18 cases (51%), and a score of 7 was noted in 17 cases (49%). Donor site complications occurred in 12% of the patients who underwent free jejunal flap procedures and in none of the patients who underwent cutaneous free tissue flap procedures. We found that the free jejunal flap had a regular dietary intake rate in 56 patients (30%), whereas cutaneous free tissue flaps had a regular dietary intake rate in 17 patients (49%). Cutaneous free tissue flaps had a significantly higher regular dietary intake rate at discharge and a significantly lower incidence of donor site complications than free jejunal flaps. In conclusion, free-flap reconstruction may be a better method than free jejunal flap reconstruction for the treatment of hypopharyngeal cancer.

Effects of Exercise-Diet Therapy on Cognitive Function in Healthy Elderly People Evaluated by Deep Learning Based on Basic Blood Test Data

BACKGROUND

Recent studies reported that vascular cognitive impairment in the elderly caused by arteriosclerosis plays an important role in cognitive disorders in both vascular dementia and Alzheimer's disease. In addition, systemic metabolic disorders such as oxygen metabolism dysfunction could be risk of dementia. Based on these findings, we have developed a deep neural network-based screening test (DNN-based test) of cognitive function using basic blood test data, which allowed prediction of cognitive function expressed by Mini Mental State Examination (MMSE) scores.

AIM

Here, we investigated whether the DNN-based test could be applicable to assessment of the effects of exercise-diet on cognitive function.

METHODS

We studied the following two groups: (1) seven subjects of the local fitness gym (68.6 ± 3.2 years old). We evaluated cognitive function by the DNN-based test using blood data before and after the intervention (for 3 months). These results were compared with the measured MMSE score. (2) we studied a total of 230 subjects (67.9 ± 7.4 years old) who were members of the Tsuminory health class (Apple classroom). We assessed cognitive function by the DNN-based test before and after the intervention (for 2 months). We compared the predicted MMSE scores by the DNN-based test before and after the 2-month intervention.

RESULTS

In the first group, the MMSE score predicted by the DNN-based test increased from 27.1 ± 0.8 to 27.6 ± 0.7 after the intervention period (p = 0.024). The measured MMSE score also increased after exercise, but not significant (P = 0.28). In the second group, the exercise-diet therapy increased the predicted MMSE scores in 189 cases (p < 0.001). In contrast, the therapy significantly reduced the mean MMSE score (p < 0.001).

DISCUSSION

The MMSE score predicted by the DNN-based test were increased by exercise-diet therapy in most subjects. The DNN-based test may be useful to monitor the effect of exercise-diet therapy on cognitive function aged people.

Descending necrotizing mediastinitis and the proposal of a new classification

Objective

Methods

Results

Conclusions

Characteristics that predict penetration - aspiration in elderly patients following supracricoid laryngectomy with cricohyoidoepiglottopexy - a videofluoroscopic study

Objective

This study aimed to determine the incidence of laryngeal penetration and aspiration in elderly patients who underwent supracricoid laryngectomy with cricohyoidoepiglottopexy for laryngeal cancer.

Method

A retrospective analysis of dynamic videofluoroscopic swallowing studies was performed in patients who had received supracricoid laryngectomy with cricohyoidoepiglottopexy as a treatment for laryngeal cancers. Digital analysis of videofluoroscopic swallowing studies included measurements of displacement and timing related to swallowing safety.

Results

Videofluoroscopic swallowing studies from 52 patients were analysed. All participants were male and over 65 years old. Studies were performed five years after surgery. Among 52 videofluoroscopic swallowing studies, analysis showed that elevated pharyngeal constriction ratio (pharyngeal constriction ratio more than 0.0875, odds ratio = 5.2, p = 0.016), reduced pharyngoesophageal sphincter opening time (pharyngoesophageal sphincter open less than 0.6 seconds, odds ratio = 11.6, p = 0.00018) and reduced airway closure time (airway close less than 0.6 seconds, odds ratio = 10.6, p = 0.00057) were significantly associated with aspiration.

Conclusion

Deteriorated pharyngeal constriction, shortened airway closure and reduced pharyngoesophageal sphincter opening time are key factors for predicting laryngeal penetration or aspiration after supracricoid laryngectomy with cricohyoidoepiglottopexy.

Clinical usefulness of a novel fluorescence technique for the intraoperative diagnosis of surgical margins in patients with breast cancer

In both 5- and 15-min data, FI was significantly higher in malignant tissues than in benign tissues. The diagnostic accuracy was similar at 5 and 15 min. Therefore, the 5-min FI was enough applying in the further analyses.

Effect of Fascia Implantation and Controlled Release of Basic Fibroblast Growth Factor for Muscle Atrophy in Rat Laryngeal Paralysis

OBJECTIVE

To improve lateral thyroarytenoid (TA) muscle atrophy after laryngeal paralysis, reconstruction of the vascular network of the atrophied muscle is necessary. We therefore evaluated whether the controlled release of basic fibroblast growth factor (bFGF) with autologous fascia implantation could affect vascular reconstruction in the lateral TA muscle.

STUDY DESIGN

Animal experiment.

SETTING

Laboratory.

METHODS

Unilateral laryngeal paralysis was induced in 20 rats. The rats were implanted with autologous fascia and a gelatin hydrogel sheet with or without 1 µg of bFGF (fascia and bFGF + fascia groups; n = 5 each) and with only a gelatin hydrogel sheet with bFGF (bFGF group: n = 5). Another group remained untreated (n = 5) at 4 months after paralysis. At 3 months since transplantation, intra- and intergroup comparisons of the muscle volumes and total area of blood vessels in the lateral TA muscle were performed.

RESULTS

When compared with the untreated group, the bFGF + fascia group showed a significant increase in muscle volume (P =.0008) and vascular area (P =.0002) in the lateral TA muscle, whereas the other 2 treated groups demonstrated an insufficient effect.

CONCLUSION

bFGF + fascia implantation showed histologic improvement in severe laryngeal paralysis. We demonstrated that the decrease in lateral TA muscle mass after paralysis might be countered by the reconstruction of the vascular network. Our findings indicate that hypovascular and denervated areas of the laryngeal muscle can be regenerated by the implantation of growth factors and scaffolds with surgical stress.

LEVEL OF EVIDENCE

5.

Edoxaban treatment in real-world practice is highly concordant with ESC atrial fibrillation guidelines: results from the non-interventional global ETNA-AF program

Background

The ESC atrial fibrillation management guidelines recommend a risk-based approach to oral anticoagulant (OAC) therapy. How clinical practice aligns with these recommendations is of interest.

Purpose

To analyse real world data from Global ETNA-AF program in patient groups stratified by stroke and bleeding risk scores according to ESC guidelines.

Methods

Global ETNA-AF is a multicentre, prospective, noninterventional program evaluating the safety and effectiveness of edoxaban in patients from European and Asian countries. Baseline characteristics and clinical event data at 2-year follow-up were analysed in 4 subgroups defined by CHA2DS2-VASc score (≥3 for female / ≥2 for male [OAC recommended] vs 2 for female / 1 for male [OAC should be considered]) and HAS-BLED score (≥3 [Bleeding risk high] vs &lt;3 [Bleeding risk low]) (Table 1).

Results

Of 27,616 patients included in this analysis, 23,152 (83.8%) were in the “OAC recommended” category and 3,539 (12.8%) were in the “OAC should be considered” category. Only 3.3% of patients did not meet ESC guideline criteria for OAC initiation. Among patients with high bleeding risk, 98% were in the “OAC recommended” category. A similar distribution was observed across regions (Table 2). The recommended edoxaban dose was used in the vast majority (&gt;80%) of patients across all risk stratification subgroups. In the “OAC recommended” category, patients with high bleeding risk had higher rates of thromboembolic, bleeding, and death events than those with low bleeding risk.

Conclusion

Data from routine clinical practice in Global ETNA-AF demonstrate high concordance of edoxaban treatment with ESC guidelines. Edoxaban dose is consistent with label recommendation in the vast majority (&gt;80%) of patients. Clinical event rates were generally low across all risk groups, including acceptable bleeding rates in anticoagulated patients with high bleeding risk.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Table 1. Subgroups as per ESC guidelinesTable 2. Patient characteristics & events

Temporal trend of clinical events in patients with atrial fibrillation on edoxaban therapy: results from the non-interventional global ETNA-AF program

Background

Patients with atrial fibrillation (AF) who initiated vitamin K antagonist (VKA) were at highest risk of stroke and bleeding in the first few months of therapy. Understanding of the temporal trend of clinical events in AF patients on non-VKA oral anticoagulant (NOAC) therapy should aid therapeutic decisions.

Purpose

To evaluate the temporal trend of clinical events in AF patients receiving edoxaban in routine clinical practice in the Global ETNA-AF program.

Methods

Global ETNA-AF is a multicentre, prospective, noninterventional program evaluating the safety and effectiveness of edoxaban in patients from European and Asian countries. Thromboembolic, bleeding and death events were analysed separately for the 1st and 2nd year of the follow-up period, using a time-to-first-event estimation of cumulative incidence and annual rate via Kaplan-Meier method.

Results

A total of 27,617 patients were included in this analysis, 48.6% from Europe and 51.4% from Japan, Korea, and Taiwan. Baseline characteristics were consistent with typical AF population in real world studies (Table 1). Approximately 83% of patients received the recommended edoxaban dose. Annualized rates of ischaemic stroke and major bleeding (ISTH) were lower in the 2nd year than in the 1st year: ischaemic stroke 0.59% (95% CI, 0.50–0.70) vs 0.86% (95% CI, 0.75–0.98), p=0.015; major bleeding 0.87% (95% CI, 0.75–1.00) vs 1.15% (95% CI, 1.02–1.29), p=0.036. The trend toward lower rates of ischaemic stroke and major bleeding in the 2nd year was consistent across regions. All-cause mortality increased slightly from the 1st year to the 2nd year, which was not statistically significant and was not driven by cardiovascular (CV) mortality (Table 2).

Conclusion

In routine clinical practice in the Global ETNA-AF program, major bleeding and ischaemic stroke rates in &gt;27,000 patients on edoxaban therapy declined from 1st year to 2nd year. Further analyses will investigate whether such trend is influenced by selection for healthier patients over time. Longer follow-up is needed to better understand long-term trends.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Table 1. Baseline characteristicsTable 2. Annualised clinical event rates

Impact of polypharmacy on clinical outcomes in elderly patients with nonvalvular atrial fibrillation: sub-analysis of the ANAFIE Registry

Background

Elderly patients with AF often have multimorbidities leading to treated by polypharmacy, which has been reported to be associated with worse prognosis. Although stroke prevention is a cornerstone of optimal anticoagulation management, data on elderly NVAF patients aged ≥75 years with polypharmacy are lacking.

Purpose

The All Nippon Atrial Fibrillation In the Elderly (ANAFIE) Registry is a prospective, multicenter, observational study that seeks to elucidate real-world data on the clinical status and prognosis of more than 30,000 Japanese patients (aged ≥75 y) with NVAF. This sub-analysis of the ANAFIE Registry assessed 2-year outcomes and the status of anticoagulant management in elderly NVAF patients in view of polypharmacy.

Methods

A total of 32,275 patients from the ANAFIE Registry were divided into 3 groups by the number of concomitant medicines other than oral anticoagulants (OAC) (0 to 4, 5 to 8, ≥9 medicines). The annualized incidence rates of clinical outcomes were determined by Kaplan-Meier analysis. Hazard ratios (HR) for clinical outcomes were determined using the Cox proportional-hazards model.

Results

In the overall population, the mean age was 81.5 y; men accounted for 57.3%; the mean CHA2DS2-VASc score was 4.5; the mean HAS-BLED score was 1.9; the prevalence of paroxysmal AF was 42.1%; the mean follow-up period was 1.88 y; oral anticoagulants (OAC) were used by 92.4% of patients (WF, 25.5%; DOAC, 66.9%); the major concomitant medicines were antihypertensive drugs (70.9%), antiarrhythmic drugs (56.2%), dyslipidemia drugs (37.1%), and proton pump inhibitors (36.6%). The numbers of patients using 0 to 4, 5 to 8, and ≥9 concomitant medicines were 12,186 (37.8%), 13,597 (42.1%), and 5,636 (17.5%), respectively. As the number of concomitant medicines increased, the prevalence of comorbidities and renal dysfunction of creatinine clearance &lt;50 mL/min increased. With an increase in concomitant medications, use of WF increased and that of DOAC decreased. Overall annualized incidence rates (% per patient-year) of clinical outcomes were 1.62 for stroke or systemic embolic events (SEE), 1.08 for major bleeding, 5.91 for cardiovascular (CV) events, 1.08 for CV death, and 3.71 for all-cause mortality. The annualized incidence rates and HR for each clinical outcome are shown in the table. As the number of concomitant medicines increased, the incidence for major bleeding, gastrointestinal bleeding, CV events, and all-cause death were significantly increased.

Conclusions

In elderly NVAF patients from the ANAFIE registry, polypharmacy was associated with increased risks of major bleeding, CV events, CV death, and all-cause mortality.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Co., Ltd.

Identifying patients with atrial fibrillation during sinus rhythm on ECG: confirming the utility of artificial intelligence algorithm in a small-scale cohort without structural heart diseases

Background

Detection of atrial fibrillation (AF) out of electrocardiograph (ECG) on sinus rhythm (SR) using artificial intelligence (AI) algorithm has been widely studied within recent couple of years. Generally, it is believed that a huge number of ECGs are necessary for developing an AI-enabled ECG to be adequate to correspond to a lot of minor variations of ECGs. For example, structural heart diseases have typical ECG characteristics, but they could be a noise for the purpose of detecting the small signs of electrocardiographic signature of AF. We hypothesized that when patients with structural heart diseases are excluded, AI-enabled ECG for identifying patients with AF can be developed with a small number of ECGs.

Methods

We developed an AI-enabled ECG using a convolutional neural network to detect the electrocardiographic signature of AF present during normal sinus rhythm (NSR) using a digital, standard 10-second, 12-lead ECGs. We included all patients who newly visited the Cardiovascular Institute with at least one NSR ECG between Feb 1, 2010, and March 31, 2018. We classified patients with at least one ECG with a rhythm of AF as positive for AF (AF label) and others as negative for AF (SR label). We allocated ECGs to the training, internal validation, and testing datasets in a 7:1:2 ratio. We calculated the area under the curve (AUC) of the receiver operating characteristic curve for the internal validation dataset to select a probability threshold, which we applied to the testing dataset. We evaluated model performance on the testing dataset by calculating the AUC and the sensitivity, specificity, F1 score, and accuracy with two-sided 95% confidence intervals (CIs).

Results

We totally included 19170 patients with 12-lead ECG. After excluding patients with structural heart diseases, 12825 patients with NSR ECGs at the initial visit were identified (1262 were clinically diagnosed as AF anytime during the time course and 11563 were never diagnosed as AF). Of 11563 non-AF patients, 1818 patients who were followed over 1095 days were selected for the analysis with the SR label, to secure the robustness for maintaining SR. Of 1262 AF patients, 251 patients were selected for the analysis with the AF label, of whom a NSR ECG within 31 days before or after the index AF ECG (the first AF ECG during the time course) could be obtained. In the patients with AF label, the NSR ECG of which the date was the nearest to the index AF ECG was selected for the analysis. The AI-enabled ECG showed an AUC of 0.88 (0.84–0.92) with sensitivity 81% (72–88), specificity 80% (77–83), F1 score 50% (43–57), and overall accuracy 80% (78–83).

Conclusion

An AI-enabled ECG acquired during NSR allowed identification of patients with AF in a small population without structural heart diseases.

Funding Acknowledgement

Type of funding sources: None.

Influence of renal dysfunction on clinical outcomes in elderly patients with atrial fibrillation: a subanalysis of the phase 3, randomized, placebo-controlled ELDERCARE-AF trial

Background

Renal dysfunction is common in elderly patients with atrial fibrillation (AF) and is thought to be associated with increased risk of thromboembolic and bleeding events. Once-daily low-dose (15 mg) edoxaban was superior to placebo in preventing stroke or systemic embolic events (S/SEE) without significantly increasing major bleeding events in very elderly (≥80 years) non-valvular AF (NVAF) patients in whom standard oral anticoagulant therapy at approved doses was inappropriate (ELDERCARE-AF trial). Little is known about how renal dysfunction affects the effects of low-dose edoxaban in these patients.

Purpose

We used prespecified subgroup analysis to investigate the relation between renal function (assessed by creatinine clearance, CrCl) and the efficacy and safety of edoxaban in elderly NVAF patients.

Methods

ELDERCARE-AF patients were divided into 3 subgroups according to baseline CrCl: normal renal function/mild dysfunction (CrCl &gt;50 mL/min), moderate renal dysfunction (CrCl ≥30 to ≤50 [“30–50”] mL/min) and severe renal dysfunction (CrCl ≥15 to &lt;30 [“15–30”] mL/min). Primary efficacy and safety endpoints were annualized incidence of S/SEE and ISTH-defined major bleeding, respectively.

Results

Of 984 patients randomized to edoxaban 15 mg or placebo (each group N=492), 681 completed the trial. The 303 discontinuations were due to withdrawal of consent (n=158), death (n=135), or other causes (n=10). Discontinuation rate was the same in the edoxaban and placebo groups. S/SEE incidence in patients with CrCl &gt;50, 30–50 and 15–30 mL/min was 2.0%, 1.3% and 3.5%, respectively, in edoxaban, and 4.4%, 4.6% and 9.7%, respectively, in placebo. In those with CrCl 30–50 and 15–30 mL/min, it was significantly lower in edoxaban than in placebo (adjusted hazard ratio [HR], 0.30 [95% CI, 0.10–0.91], p=0.03; and 0.33 [95% CI, 0.16–0.71], p&lt;0.01, respectively). Incidence of major bleeding in patients with CrCl &gt;50, 30–50 and 15–30 mL/min was 1.0%, 1.8% and 6.2%, respectively, in edoxaban, and 0.9%, 1.5% and 2.4%, respectively, in placebo. Incidence of major bleeding in those with CrCl 15–30 mL/min was higher in edoxaban but not significantly (adjusted HR, 2.53 [95% CI, 0.96–6.72], p=0.062). Incidence of gastrointestinal bleeding in patients with CrCl 15–30 mL/min was 4.3% in edoxaban and 1.6% in placebo (adjusted HR, 2.61 [95% CI, 0.79–8.68], p=0.12). Incidence of all-cause death in patients with CrCl &gt;50, 30–50 and 15–30 mL/min was 5.8%, 6.8% and 15.2%, respectively, in edoxaban, and 7.0%, 6.3% and 15.5%, respectively, in placebo (no significant intergroup differences).

Conclusions

Incidence of S/SEE, major bleeding and all-cause death increased with declining renal function in elderly NVAF patients. Edoxaban 15 mg remained superior to placebo in preventing S/SEE, even in those with moderate to severe renal dysfunction. Incidence of major bleeding in patients with severe renal dysfunction was higher (non-significantly) with edoxaban than with placebo.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi-Sankyo Co., Ltd.

Clinical features and hearing prognosis of idiopathic sudden sensorineural hearing loss in patients undergoing hemodialysis: A retrospective study

BACKGROUND

Patients undergoing hemodialysis (HD) tend to experience hearing loss, including idiopathic sudden sensorineural hearing loss (ISSHL). However, little is known about the relationship between HD and ISSHL.

OBJECTIVE

To investigate the effects of HD on the hearing level and the treatment prognosis of ISSHL.

METHODS

We reviewed the medical records of 23 patients with ISSHL receiving HD treatment (HD group) and 101 patients with ISSHL not receiving HD treatment (non-HD group), and assessed clinical features, results of audiometric tests and blood examination results.

RESULTS

Statistically significant differences were not observed in pretreatment hearing level and hearing recovery of the ear affected with ISSHL between the two groups (P > .05). Conversely, hearing thresholds in the unaffected ear were statistically different (P < .0001), and the hearing thresholds of the HD groups were significantly increased compared with those of the non-HD groups, especially at high frequency. In addition, patients with renal dysfunction not receiving HD treatment showed similar hearing thresholds in the unaffected ear when compared with patients receiving HD treatment.

CONCLUSION

HD itself did not influence the treatment prognosis of ISSHL. Renal dysfunction itself, and not HD treatment, worsened the hearing level. As similar treatment results are expected, standard treatment should be administered to patients undergoing HD.

LEVEL OF EVIDENCE

3b.