Hereditary hemorrhagic telangiectasia with hepatic arteriovenous shunt diagnosed due to liver damage

A 53-year-old woman was diagnosed with liver dysfunction in August 20XX. Computed tomography (CT) revealed multiple hepatic AV shunts, and she was placed under observation. In March 20XX + 3, she developed back pain, and CT performed during an emergency hospital visit showed evidence of intrahepatic bile duct dilatation. She was referred to our gastroenterology department in May 20XX + 3. We conducted investigations on suspicion of hereditary hemorrhagic telangiectasia (HHT) with hepatic AV shunting based on contrast-enhanced CT performed at another hospital. HHT is generally discovered due to epistaxis, but there are also cases where it is diagnosed during examination of liver damage.

A Case of an Splenic Artery Aneurysm and Focal Nodular Hyperplasia Associated with an Abdominal Vascular Abnormality of Hereditary Hemorrhagic Telangiectasia

In October 2021, a 51-year-old woman developed a skin rash. Abdominal computed tomography revealed a large splenic artery aneurysm and an intrahepatic portovenous shunt. As her splenic artery aneurysm was at risk of rupture, she was referred to the Kindai University Hospital and underwent coiling surgery. In October 2023, approximately two years after she had been initially referred, contrast-enhanced ultrasound revealed findings suggestive of focal nodular hyperplasia. No reports have confirmed the occurrence of liver masses in patients with hereditary hemorrhagic telangiectasia, which is considered to be an interesting finding when investigating the mechanism of tumor development.

Hemophagocytic lymphohistiocytosis induced by nivolumab/ipilimumab combination therapy: A case of lung adenocarcinoma that responded to early steroid pulse therapy

BACKGROUND

Immune checkpoint inhibitors have been reported to have excellent therapeutic effects on various malignant tumors. However, immune-related adverse events can occur, targeting various organs.

CASE PRESENTATION

A 49-year-old male with lung carcinoma was started on carboplatin + pemetrexed + nivolumab (every 3 weeks) + ipilimumab (every 6 weeks), and nivolumab/ipilimumab was administered in the 3rd course. Subsequently, fever and fatigue developed, and grade 3 liver damage was also noted, so he was admitted to Kindai University Hospital. A bone marrow aspirate examination was performed on the third day of illness, and a definitive diagnosis of hemophagocytic lymphohistiocytosis (HLH) was made. It was determined that immediate therapeutic intervention was necessary, and pulse therapy with methylprednisolone was started on the third day of illness. After 3 days of pulse treatment, a rapid recovery of platelet values, a decrease in ferritin levels, and a decrease in lactate dehydrogenase were observed. Subjective symptoms such as fever and fatigue also quickly improved.

CONCLUSION

Early diagnosis and treatment for HLH resulted in a positive response. The number of HLH cases may increase in the future due to the expansion of immune checkpoint inhibitor indications.

Feasibility of transanal minimally invasive surgery for total pelvic exenteration for advanced primary and recurrent pelvic malignancies

BACKGROUND

The purpose of this study was to clarify the efficacy and safety of transanal minimally invasive surgery (TAMIS) for total pelvic exenteration (TPE) in advanced primary and recurrent pelvic malignancies.

METHODS

Using a prospectively collected database, we retrospectively analyzed the clinical, surgical, and pathological outcomes of TAMIS for TPE. Surgery was performed between September 2019 and April 2023. The median follow-up period was 22 months (2-45 months).

RESULTS

Fifteen consecutive patients were included in this analysis M:F = 14:1 and median (range) age was 63 (36-74). Their diagnoses were as follows: primary rectal cancer (n = 5; 33%), recurrent rectal cancer (n = 4; 27%), primary anorectal cancer (n = 5; 33%), and gastrointestinal stromal tumor (n = 1; 7%). Bladder-sparing TPE was selected for two patients (13%). In nine of 15 patients (60%) the anal sphincter could be successfully preserved, five patients (33%) required combined resection of the internal iliac vessels, and two (13%) required rectus muscle flap reconstruction. The median operative time was 723 min (561-1082), and the median intraoperative blood loss was 195 ml (30-1520). The Clavien-Dindo classifications of the postoperative complications were as follows: grade 0-2 (n = 11; 73%); 3a (n = 3; 20%); 3b (n = 1; 7%); and ≥ 4 (n = 0; 0%). No cases of conversion to laparotomy or mortality were observed. The pathological results demonstrated that R0 was achieved in 14 patients (93%).

CONCLUSIONS

The short-term outcomes of this initial experience proved that this novel approach is feasible for TPE, with low blood loss, acceptable postoperative complications, and a satisfactory R0 resection rate.

Erratum: Search for Cosmic-Ray Boosted Sub-GeV Dark Matter Using Recoil Protons at Super-Kamiokande [Phys. Rev. Lett. 130, 031802 (2023)]

This corrects the article DOI: 10.1103/PhysRevLett.130.031802.

Measurements of neutrino oscillation parameters from the T2K experiment using 3.6×1021 protons on target

The T2K experiment presents new measurements of neutrino oscillation parameters using 19.7 ( 16.3 ) × 10 20 protons on target (POT) in (anti-)neutrino mode at the far detector (FD). Compared to the previous analysis, an additional 4.7 × 10 20 POT neutrino data was collected at the FD. Significant improvements were made to the analysis methodology, with the near-detector analysis introducing new selections and using more than double the data. Additionally, this is the first T2K oscillation analysis to use NA61/SHINE data on a replica of the T2K target to tune the neutrino flux model, and the neutrino interaction model was improved to include new nuclear effects and calculations. Frequentist and Bayesian analyses are presented, including results on sin 2 θ 13 and the impact of priors on the δ CP measurement. Both analyses prefer the normal mass ordering and upper octant of sin 2 θ 23 with a nearly maximally CP-violating phase. Assuming the normal ordering and using the constraint on sin 2 θ 13 from reactors, sin 2 θ 23 = 0 . 561 - 0.032 + 0.021 using Feldman-Cousins corrected intervals, and Δ m 32 2 = 2 . 494 - 0.058 + 0.041 × 10 - 3 eV 2 using constant Δ χ 2 intervals. The CP-violating phase is constrained to δ CP = - 1 . 97 - 0.70 + 0.97 using Feldman-Cousins corrected intervals, and δ CP = 0 , π is excluded at more than 90% confidence level. A Jarlskog invariant of zero is excluded at more than 2 σ credible level using a flat prior in δ CP , and just below 2 σ using a flat prior in sin δ CP . When the external constraint on sin 2 θ 13 is removed, sin 2 θ 13 = 28 . 0 - 6.5 + 2.8 × 10 - 3 , in agreement with measurements from reactor experiments. These results are consistent with previous T2K analyses.

Search for Cosmic-Ray Boosted Sub-GeV Dark Matter Using Recoil Protons at Super-Kamiokande

We report a search for cosmic-ray boosted dark matter with protons using the 0.37  megaton×years data collected at Super-Kamiokande experiment during the 1996-2018 period (SKI-IV phase). We searched for an excess of proton recoils above the atmospheric neutrino background from the vicinity of the Galactic Center. No such excess is observed, and limits are calculated for two reference models of dark matter with either a constant interaction cross section or through a scalar mediator. This is the first experimental search for boosted dark matter with hadrons using directional information. The results present the most stringent limits on cosmic-ray boosted dark matter and exclude the dark matter-nucleon elastic scattering cross section between 10^{-33}cm^{2} and 10^{-27}cm^{2} for dark matter mass from 1  MeV/c^{2} to 300  MeV/c^{2}.

Tongue Muscle for the Analysis of Head Muscle Regeneration Dynamics

Tongue muscle damage impairs speaking and eating, thereby degrading overall health and quality of life. Skeletal muscles of the body are diverse in embryonic origin, anatomic location, and gene expression profiles. Responses to disease, atrophy, aging, or drugs vary among different muscles. Currently, most muscle studies are focused on limb muscles and the tongue is neglected. The regenerative ability of tongue muscle remains unknown, and thus there is need for tongue muscle research models. Here, we present a comprehensive characterization of the spatiotemporal dynamics in a mouse model of tongue muscle regeneration and establish a method for the isolation of primary tongue-derived satellite cells. We compare and contrast our observations with the tibialis anterior (TA) limb muscle. Acute injury was induced by intramuscular injection of cardiotoxin, a cytolytic agent, and examined at multiple timepoints. Initially, necrotic myofibers with fragmented sarcoplasm became infiltrated with inflammatory cells. Concomitantly, satellite cells expanded rapidly. Seven days postinjury, regenerated myofibers with centralized nuclei appeared. Full regeneration, as well as an absence of fibrosis, was evident 21 d postinjury. Primary tongue-derived satellite cells were isolated by enzymatic separation of tongue epithelium from mesenchyme followed by magnetic-activated cell sorting. We observed that tongue displays an efficient regenerative response similar to TA but with slightly faster kinetics. In vitro, tongue-derived satellite cells differentiated robustly into mature myotubes with spontaneous contractile behavior and myogenic marker expression. Comparison of gene expression signatures between tongue and TA-derived satellite cells revealed differences in the expression of positional-identity genes, including the HOX family. In conclusion, we have established a model for tongue regeneration useful for investigations of orofacial muscle biology. Furthermore, we showed that tongue is a viable source of satellite cells with unique properties and inherited positional memory.

Case Report: Regulatory T Cell-Independent Induction of Remission in a Patient With Collagenous Colitis

Collagenous colitis (CC), a prototypical microscopic colitis, is a chronic inflammatory disorder of the colon. The diagnosis of CC depends on the pathological examination. The colonic mucosa of patients with CC is characterized by the presence of a substantially thickened collagen band (>10μm) under the surface epithelium. In addition, intraepithelial and lamina propria lymphocytes are markedly increased in patients with CC. However, the roles played by the lymphocytes accumulating in the colonic mucosa of patients with CC are poorly defined. Recent studies indicate that T cells infiltrating the colonic mucosa of patients with CC are mainly represented by CD4⁺ T cells, CD8⁺ T cells, and forkhead box P3 (FOXP3)⁺ regulatory T cells (Tregs). Given that activation of CD4⁺/CD8⁺ T cells and FOXP3⁺ Tregs usually mediates pro-inflammatory and anti-inflammatory responses, respectively, alterations in the colonic numbers of these adaptive T cells might be related to the resolution of colitis in patients with CC. We determined alterations in the composition of colonic T cells by extensive immunohistochemical (IHC) analyses in a case of CC successfully treated with budesonide and metronidazole. Colonic lamina propria immune cells mainly comprised CD3⁺ T cells, CD4⁺ T cells, CD8⁺ T cells, CD68⁺ macrophages, and FOXP3⁺ Tregs, but not CD20⁺ B cells or myeloperoxidase (MPO)⁺ granulocytes in the active phase. During remission, the numbers of CD3⁺ T cells, CD4⁺ T cells, CD8⁺ T cells, and CD68⁺ macrophages did not change significantly in the colonic lamina propria, whereas FOXP3⁺ Tregs were markedly decreased, suggesting that induction of remission was achieved in a Treg-independent manner. Thus, our study indicates that accumulation of FOXP3⁺ Tregs in the colonic mucosa of patients with CC might be a counter-regulatory mechanism reflecting persistent inflammation and that induction of remission might be achieved without activation of Tregs.

POS0657 GEOGRAPHIC VARIATION OF SAFETY IN THE FILGOTINIB RHEUMATOID ARTHRITIS PROGRAM

Background:

The Janus kinase-1 preferential inhibitor filgotinib (FIL) improved signs and symptoms of rheumatoid arthritis (RA) in the FIL clinical program.1–3

Objectives:

To assess FIL safety across regions.

Methods:

This was an analysis of patients (pts) meeting 2010 ACR/EULAR RA criteria in pooled phase (P)2 DARWIN 1–2 (D1–2), P3 FINCH 1–3 (F1–3), and long-term extension studies (DARWIN 3, FINCH 4). Data were analyzed by region: North America, South and Central America, Western Europe, Eastern Europe, Asia, South East (SE) Asia, and Other. Week (W)12 placebo (PBO)-controlled analysis included data from pts receiving once-daily FIL 100 mg (FIL100), FIL 200 mg (FIL200), or PBO for ≤12W (D1–2, F1–2); long-term as-treated data included pts from all 7 studies receiving FIL100 or FIL200; data after rerandomization were included and contributed to treatment received. Data presented as exposure-adjusted incidence rates (EAIRs)/100 patient-years of exposure (PYE) of treatment-emergent (TE) adverse events (TEAEs).

Results:

Table 1 shows EAIRs of TEAEs in PBO-controlled analysis. EAIRs/100 PYE of all TEAEs in Western Europe, Asia, and Other were higher than in remaining regions and for PBO vs FIL arms; EAIRs for FIL200/FIL100 in North America and SE Asia were higher vs PBO. EAIRs/100 PYE of TE serious AEs were higher in SE Asia for FIL100 and for FIL200/FIL100 in Other, with high PBO EAIRs in Western Europe. EAIRs/100 PYE of TEAEs leading to study discontinuation were higher in FIL arms vs PBO in Western Europe and Other (FIL200); in Asia and SE Asia, EAIRs were higher for PBO vs FIL200/FIL100.

Table 1.

EAIR of TEAEs (placebo-controlled)

North AmericaN = 481South and Central AmericaN = 350Western EuropeN = 141Eastern EuropeN = 933AsiaN = 236South East AsiaN= 135OtherN = 70TEAEFIL200a216.9 (162.5, 289.5)205.6 (155.1, 272.6)285.0 (188.6, 430.8)150.3 (119.3, 189.4)248.9 (180.6, 343.1)165.1 (104.0, 262.1)298.4 (150.3, 592.5)FIL100b182.2 (136.8, 242.7)159.2 (117.3, 216.1)285.7 (183.7, 444.3)146.4 (115.9, 185.0)246.9 (180.3, 338.1)153.7 (94.2, 251.0)263.5 (113.9, 609.2)PBOC174.5 (130.3, 233.7)162.1 (118.8, 221.2)314.9 (200.7, 493.9)148.4 (117.6, 187.4)259.0 (188.0, 356.8)81.6 (40.8, 163.3)306.0 (142.8, 655.7)TE serious AEFIL200a14.3 (6.0, 34.4)11.4 (3.7, 35.5)8.3 (1.2, 59.0)12.2 (5.2, 28.7)5.5 (0.8, 38.9)0.0 (0.0, ∞)49.6 (10.2, 144.9)FIL100b10.6 (4.0, 28.3)7.2 (1.8, 28.7)19.9 (5.0, 79.7)15.1 (6.8, 33.7)16.2 (5.2, 50.2)28.8 (9.3, 89.4)20.5 (0.5, 114.0)PBOC16.1 (7.2, 35.9)7.5 (1.9, 30.0)29.6 (9.5, 91.7)4.6 (1.3, 15.8)11.4 (2.8, 45.5)10.2 (1.4, 72.4)0.0 (0.0, 69.2)TEAE leading to discontinuationFIL200a8.6 (2.8, 26.6)3.8 (0.1, 21.2)16.6 (4.2, 66.5)12.9 (5.5, 30.5)0.0 (0.0, 20.2)9.2 (1.3, 65.1)16.5 (0.4, 92.1)FIL100b10.6 (4.0, 28.3)7.2 (0.9, 26.0)19.9 (5.0, 79.7)1.9 (0.2, 13.8)5.4 (0.1, 30.1)9.6 (1.4, 68.2)0.0 (0.0, 75.5)PBOC5.4 (1.3, 21.5)0.0 (0.0, 13.8)9.9 (1.4, 70.0)12.9 (5.4, 30.7)17.1 (3.5, 49.9)20.4 (5.1, 81.6)0.0 (0.0, 69.2)

Data presented as EAIR (95% CI)/100 patient-years

aN = 777, 179.8 PYE bN = 788, 181.6 PYE cN = 781, 178.4 PYE

A subject may contribute to more than one treatment group if they received more than one treatment of interest.

EAIR and corresponding 95% CI were estimated using Poisson regression model by treatment, including study and treatment with an offset of natural log of exposure time, except when 0 events occurred; Poisson model was not adjusted by study.

AE, adverse event; CI, confidence interval; EAIR, exposure-adjusted incidence rate; FIL, filgotinib; PBO, placebo; PYE, patient-years of exposure; TE, treatment-emergent

Figure shows serious infections (SI), venous thromboembolism (VTE) and herpes zoster (HZ) EAIRs.

EAIRs for SI were highest in Other for FIL200 and SE Asia for FIL100. While VTE EAIRs were low, pts in 5/7 regions had VTE. HZ EAIRs were highest in Asia.

Conclusion:

Although EAIR of TEAEs varied between regions, no consistent trend was reflected in any particular region.

References:

[1]Genovese et al. JAMA. 2019;322:315–25.

[2]Westhovens et al. Ann Rheum Dis. 2021; online first.

[3]Combe et al. Ann Rheum Dis. 2021; online first.

Disclosure of Interests:

Bernard Combe Speakers bureau: BMS; Eli Lilly & Co.; Gilead Sciences, Inc.; MSD; Pfizer; Roche-Chugai; and UCB, Consultant of: AbbVie; Eli Lilly & Co.; Gilead Sciences, Inc.; Janssen; Pfizer; Roche-Chugai; and Sanofi, Grant/research support from: Novartis, Pfizer, and Roche-Chugai, Tsukasa Matsubara Speakers bureau: Pfizer Japan, Nichi-Iko, Astellas, Meiji Seika, Bristol-Myers Squibb, AbbVie GK, Janssen, Chugai, Eisai, AYUMI, Alena Pechonkina Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., YingMeei Tan Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Zhaoyu Yin Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Jaehyung Hong Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Robin Besuyen Shareholder of: Galapagos, BV, Employee of: Galapagos, BV, Antonio Gomez-Centeno Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly & Co., Gebro, Janssen, Menarini, Merck Sharp & Dohme, Pfizer, Roche, Rubio, Sanofi, and UC, Consultant of: AbbVie, Biogen, Bristol-Myers Squibb, Celgene, Eli Lilly & Co., Gebro, Gilead Sciences, Inc., Hospira, Merck Sharp & Dohme, Pfizer, Roche, Rubio, Sandoz, Sanofi, Grant/research support from: Boehringer Ingelheim, Celltrion, Eli Lilly & Co., Galapagos NV, Gilead Sciences, Inc., Novartis, Pfizer, Roche, Sanofi, UCB, YL Biologics, Maya H Buch Speakers bureau: AbbVie; Eli Lilly and Company; Gilead Sciences, Inc.; Merck-Serono; Pfizer; Roche; Sandoz; Sanofi; and UCB, Consultant of: AbbVie; Eli Lilly and Company; Gilead Sciences, Inc.; Merck-Serono; Pfizer; Roche; Sandoz; Sanofi; and UCB, Grant/research support from: AbbVie; Eli Lilly and Company; Gilead Sciences, Inc.; Merck-Serono; Pfizer; Roche; Sandoz; Sanofi; and UCB

POS0658 GEOGRAPHIC VARIATION OF EFFICACY IN THE FILGOTINIB RHEUMATOID ARTHRITIS PROGRAM

Background:

The Janus kinase-1 preferential inhibitor filgotinib (FIL) improved signs and symptoms of rheumatoid arthritis (RA) across the FIL clinical program.1–3

Objectives:

To assess FIL efficacy across geographic regions.

Methods:

Pooled data from patients (pts) meeting 2010 ACR/EULAR RA criteria randomised to once-daily FIL 200 mg (FIL200), FIL100 mg (FIL100), or placebo (PBO) with background conventional synthetic disease-modifying antirheumatic drugs in DARWIN 1 (P2; up to week [W]12) and FINCH 1–2 (P3; up to W24) studies were evaluated. Data were analysed by region: North America, South and Central America, Western Europe, Eastern Europe, Asia, South East (SE) Asia, and Other. W12 American College of Rheumatology 20% improvement (ACR20) and W24 Disease Activity Score in 28 joints (C-reactive protein) (DAS28[CRP]) <2.6 and ≤3.2 response rates were analysed by a logistic regression model. Change from baseline (CFB) in Health Assessment Questionnaire-Disability Index (HAQ-DI) at W12 was analysed by a mixed-effects model for repeated measures. Analyses were exploratory and not adjusted for multiplicity.

Results:

Despite high PBO response rates in Eastern Europe and South and Central America, greater proportions of pts receiving FIL200 or FIL100 vs PBO achieved ACR20 at W12 (P <0.05) in all regions, except Other (with lowest sample size, n = 69), where both FIL doses were numerically greater than PBO (Table 1). At W12, least-squares mean CFB in HAQ-DI improved for pts receiving FIL200 or FIL100. vs PBO (P <0.05) in all regions, except SE Asia, where improvement was numeric (Table 1).

Table 1.

Proportion of pts achieving ACR20 and LSM change from baseline HAQ-DI at week 1

ACR20HAQ-DIFIL200FIL100FIL200FIL100FIL200FIL100North America64.8*58.3*33.8−0.63*−0.58*−0.34n = 455(56.7, 72.9)(50.3, 66.4)(26.0, 41.6)(−0.70, −0.56)(−0.65, −0.51)(−0.41, −0.27)South and Central America77.277.357.4−0.77*−0.67*−0.43n = 283(68.1, 86.3)†(65.8, 86.2)†(46.9, 68.0)(−0.85, −0.68)(−0.75, −0.59)(−0.52, −0.35)Western Europe69.4*68.3*24.4−0.69*−0.61*−0.28n = 135(55.5, 83.3)(52.8, 83.8)(10.8. 38.1)(−0.80, −0.58)(−0.73, −0.49)(−0.40, −0.17)Eastern Europe77.1*69.1*54.6−0.62*−0.51*−0.34n = 822(71.9, 82.3)(63.5, 74.7)(48.5, 60.7)(−0.68, −0.56)(−0.57, −0.45)(−0.40, −0.28)Asia81.0*60.0†37.7−0.83*−0.61†−0.42n = 236(71.7, 90.3)(48.6, 71.4)(26.2, 49.1)(−0.92, −0.73)(−0.70, −0.52)(−0.52, −0.33)South East Asia70.2†71.1†39.5−0.61−0.57−0.45n = 135(56.1, 84.4)(56.8, 85.5)(23.8, 55.3)(−0.73, −0.49)(−0.69, −0.45)(−0.58, −0.33)Other60.052.439.1−0.56‡−0.60‡−0.33n = 69(38.8, 81.2)(28.6, 76.1)(17.0, 61.2)(−0.72, −41)(−0.76, −0.43)(−0.49, −0.17)Overall73.4*66.4*45.3−0.71*−0.61*−0.40N = 2135(70.1, 76.8)(62.9, 70.0)(41.5, 49.0)(−0.76, −0.66)(−0.66, −0.56)(−0.45, −0.35)

Includes only patients initially randomised to the treatment groups in each study for the comparison of interest. ACR20 presented as percentage (95% CI); 95% CI was based on normal approximation method with a continuity correction; P values calculated from the logistic regression.HAQ-DI presented as LSM (95% CI); LSM, 95% CI, and P value calculated from a mixed-effects model for repeated measures.*P <0.001, †P <0.01, ‡P <0.05; not adjusted for multiplicity.

ACR20, American College of Rheumatology 20% improvement; CI, confidence interval; FIL, filgotinib; HAQ-DI, Health Assessment Questionnaire-Disability Index; LSM, least square mean; PBO, placebo.

At W24, DAS28(CRP) <2.6 and ≤3.2 response rates were higher for both doses of FIL vs PBO (P <0.05) in all regions, with the exception of Other, where PBO was higher than FIL100 for DAS28(CRP) <2.6 (Figure 1).

Conclusion:

In exploratory analyses, ACR20, DAS28(CRP) <2.6 and ≤3.2 response rates and HAQ-DI scores varied between regions; however, no stable trend was shown in any particular region. Small pt numbers in some subgroups may confound statistical analysis.

References:

[1]Genovese et al. JAMA. 2019;322:315–25.

[2]Westhovens et al. Ann Rheum Dis. 2021; online first.

[3]Combe et al. Ann Rheum Dis. 2021; online first.

Disclosure of Interests:

Maya H Buch Speakers bureau: AbbVie; Eli Lilly and Company; Gilead Sciences, Inc.; Merck-Serono; Pfizer; Roche; Sandoz; Sanofi; and UCB, Consultant of: AbbVie; Eli Lilly and Company; Gilead Sciences, Inc.; Merck-Serono; Pfizer; Roche; Sandoz; Sanofi; and UCB., Grant/research support from: AbbVie; Eli Lilly and Company; Gilead Sciences, Inc.; Merck-Serono; Pfizer; Roche; Sandoz; Sanofi; and UCB., Tsukasa Matsubara Speakers bureau: Pfizer Japan, Nichi-Iko, Astellas, Meiji Seika, Bristol-Myers Squibb, AbbVie GK, Janssen, Chugai, Eisai, AYUMI, Bernard Combe Speakers bureau: BMS; Eli Lilly & Co.; Gilead Sciences, Inc.; MSD; Pfizer; Roche-Chugai; and UCB, Consultant of: AbbVie; Eli Lilly & Co.; Gilead Sciences, Inc.; Janssen; Pfizer; Roche-Chugai; and Sanofi, Grant/research support from: Novartis, Pfizer, and Roche-Chugai, Alena Pechonkina Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., YingMeei Tan Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Zhaoyu Yin Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Jaehyung Hong Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Robin Besuyen Shareholder of: Galapagos, BV, Employee of: Galapagos, BV, Antonio Gomez-Centeno Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly & Co., Gebro, Janssen, Menarini, Merck Sharp & Dohme, Pfizer, Roche, Rubio, Sanofi, and UCB, Consultant of: AbbVie, Biogen, Bristol-Myers Squibb, Celgene, Eli Lilly & Co., Gebro, Gilead Sciences, Inc., Hospira, Merck Sharp & Dohme, Pfizer, Roche, Rubio, Sandoz, Sanofi, Grant/research support from: Boehringer Ingelheim, Celltrion, Eli Lilly & Co., Galapagos NV, Gilead Sciences, Inc., Novartis, Pfizer, Roche, Sanofi, UCB, YL Biologics

Impact of body mass index on the clinical outcomes in heart failure patients undergoing cardiac rehabilitation

Background

Increased body mass index (BMI) has recently shown to have a favorable effect on the prognosis in heart failure (HF) patients. However, the impact of BMI on clinical events and mortality in HF patients who underwent cardiac rehabilitation (CR) remains unclear.

Purpose

This study aimed to investigate whether the obesity paradox is present in HF patients who have undergone CR.

Methods

This study enrolled 238 consecutive HF patients who had undergone CR at our university hospital between November 2015 and October 2017. The clinical characteristics and anthropometric data of these patients, including BMI, were collected at the beginning of the CR. The major adverse cardiovascular event (MACE) was defined as a composite of all-cause mortality and unplanned hospitalization for HF. Follow-up data regarding the primary endpoints were collected until November 2018.

Results

Patients (mean age 68.7 years, male 61%) were divided into four groups as per BMI quartiles. More patients in the highest BMI group were women, were significantly younger, and had a higher prevalence of hypertension, dyslipidemia, and diabetes mellitus; however, no significant differences were observed in the prevalence of chronic kidney disease, left ventricular ejection fraction, and brain natriuretic peptide levels of the four groups. During a median follow-up duration of 583 days, 28 patients experienced all-cause mortality, and 42 were hospitalized for HF. Kaplan–Meier analysis showed that patients in the highest BMI quartiles had lower rates of MACE (Log-rank P&lt;0.05) (Figure 1). After adjusting for confounding factors, Cox regression multivariate analysis revealed that BMI was negatively and independently associated with the incidence of MACE (hazard ratio: 0.89, 95% confidence interval: 0.83–0.96, P&lt;0.05).

Conclusion

Increased BMI was associated with better clinical prognosis even in HF patients who have undergone CR Therefore, BMI assessment may be useful for risk stratification in HF patients who have undergone CR.

Figure 1. Kaplan-Meier survival curve

Funding Acknowledgement

Type of funding source: None

Uninterrupted twice-daily direct oral anticoagulants are safer than once-daily ones for atrial fibrillation catheter ablation

Background

In patients undergoing AF catheter ablation (CA), uninterpreted DOACs reduced bleeding events without increasing ischemic events compared with vitamin K antagonist, and the continuation of anticoagulants is recommended for AF ablation. However, in the past studies, patients received once-daily DOACs in the evening, not in the morning of the procedure day. Moreover, there has been no study comparing uninterrupted 4 DOACs; therefore, the safety and effect of uninterpreted DOACs taken just in the morning of AF ablation is unknown.

Objective

The purpose of this study was to compare bleeding complications and thromboembolism events between 4 DOACs in patients undergoing AF ablation.

Method

This study was the retrospective single-center cohort study of consecutive patients who underwent AF ablation between April 2014 to July 2019. All patients continued DOAC uninterruptedly including just in the morning of the procedure. The primary endpoint included major bleeding events within the first 30 days after CA. The secondary endpoints included the composite events of ischemic stroke, systemic embolism, myocardial infarction, and vascular death.

Result

A total of 713 patients (mean age 64±12 years, 72% male) were included in this analysis; enrolled patients were 88, 238, 218, and 169 respectively in dabigatran, rivaroxaban, apixaban and edoxaban group. At the baseline, the ratio of age ≥75 years and CHADS2 score was higher in apixaban group, though all other baseline variables were similar between them.

The primary endpoint was observed 0%, 2.1%, 0.45%, and 4.7% respectively in dabigatran, rivaroxaban, apixaban, and edoxaban group (P=0.013) without significant difference about secondary endpoint between them (P=0.3).

Comparing twice-daily vs once-daily DOACs, the primary endpoint was observed significantly lower in the twice-daily group than in once-daily group (0.32% and 3.2% respectively, P=0.0054), without any significant difference about secondary endpoint (0% and 0.73% respectively, P=0.26).

Conclusion

Taking DOACs also in the morning of AF ablation, uninterrupted twice-daily DOACs are safer than once-daily DOACs without increasing ischemic event, although twice-daily DOACs, especially apixaban, were used in higher aged patients.

Figure 1

Funding Acknowledgement

Type of funding source: None

Effect of Oxygen Free Radicals on Cardiac Contractile Activity and Sarcolemmal Na+–Ca2+Exchange

Background

Although oxygen free radicals have been shown to induce myocardial cell damage and cardiac dysfunction, the exact mechanism by which these radicals affect the heart function is not clear. Since the occurrence of intracellular Ca2+overload is critical in the genesis of cellular damage and cardiac dysfunction, and since the sarcolemmal Na+–Ca2+exchange is intimately involved in Ca2+movements in myocardium, this study was undertaken to examine the effects of oxygen free radicals on the relationship between changes in cardiac contractile force development and sarcolemmal Na+–Ca2+exchange activity.

Methods and Results

Isolated rat hearts were perfused with a medium containing xanthine plus xanthine oxidase for different times, and changes in contractile force as well as sarcolemmal Na+–Ca2+exchange activity were monitored. Perfusion of the heart with xanthine plus xanthine oxidase resulted in a transient increase followed by a marked decrease in contractile activity; the resting tension was markedly increased. The xanthine plus xanthine oxidase-induced depression in developed tension, rate of contraction, and rate of relaxation, except the transient increase in contractile activity, was prevented by the addition of catalase, but not by superoxide dismutase, in the perfusion medium. A time-dependent depression in sarcolemmal Na+–Ca2+was also evident upon perfusing the heart with xanthine plus xanthine oxidase. This depression in Na+-dependent Ca2+uptake was associated with a decrease in the maximal velocity of reaction without any changes in the affinity of Na+–Ca2+exchanger for Ca2+. The presence of catalase, unlike superoxide dismutase, prevented the decrease in sarcolemmal Na+–Ca2+exchange activity in hearts perfused with xanthine plus xanthine oxidase.

Conclusion

The results support the view that a depression in the sarcolemmal Na+–Ca2+exchange activity may contribute to the occurrence of intracellular Ca2+overload and subsequent decrease in contractile activity. Furthermore, these actions of xanthine plus xanthine oxidase in the whole heart appear to be a consequence of H2O2production rather than the ‘ generation of superoxide radicals.

AB0089 THE ANALYSIS FOR THE INHIBITION OF ANGIOGENESIS BY JAK INHIBITOR

Background:

Many blood vessels are generated in the hyperplastic synovial tissue of patients with rheumatoid arthritis (RA), and lead to chronic tissue inflammation and joint destruction [1]. Janus kinase (JAK) family consisting of JAK1, JAK2, JAK3 and tyrosine kinase 2 (TYK2) are chain receptors which phosphorylate signal transducers and activators of transcription (STAT) and mediate inflammatory diseases including RA [2]. Nowadays, several JAK inhibitors such as Tofacitinib (TOF), Baricitinib (BAR) and Peficitinib (PEF) have been developed and demonstrated to have the inhibitory effects on inflammatory arthritis [3-5]. However, there were few reports concerning their effects on angiogenesis in vitro.

Objectives:

The purpose of the present study is to investigate the influence of JAK inhibitors on angiogenesis of human umbilical vein endothelial cell (HUVEC) activated by vascular endothelial growth factor (VEGF).

Methods:

The cell line of HUVECs were used for this study. The activity of proliferation and tube formation were analyzed by counting assay and tube formation assay, respectively.

In counting assay, HUVECs (5 × 104cells/ml) were seeded onto 96-well cell culture plate with 20 ng/ml VEGF including various doses (0.1µM, 1µM, 5µM) of TOF, BAR or PEF. After 48 hours incubation at 37°C in a humidified atmosphere containing 5% CO2, cell proliferation of each groups was assessed using cell counting kit. In tube formation assay, HUVECs (5 × 104cells/ml) were treated with 20ng/ml VEGF including various dose (0.1µM, 1µM, 5µM) of TOF, BAR or PEF for 00 hours, then seeded onto 48-well plate applied with Matrigel. After 24 hours incubation on Matrigel, the capillary-like tube formation of each well was photographed using phase contrast microscopy. Tube formation were quantitated by measurement of the length of branch.

Results:

HUVECs were activated in proliferation and tube formation by VEGF treatment. And, the proliferation and tube formation of HUVECs activated by VEGF were suppressed by All of TOF, BAR and PEF. In particular, TOF and PEF could suppress them highly.

Conclusion:

This study showed the inhibitory effect of JAK inhibitors on proliferation and tube formation of HUVECs activated by VEGF. In particular, the angiogenesis of HUVECs activated by VEGF was highly suppressed by TOF and PEF. VEGF is reported to regulate the angiogenesis through multi JAK-STAT signaling pathways [6]. The inhibitory effects on angiogenesis of TOF, BAR and PEF might depend on the differences in their affinity for JAKs. VEGF has been shown to a have a central involvement in the angiogenic process in RA [7]. JAK inhibitors might suppress the angiogenesis in RA synovial tissues by inhibiting VEGF signaling.

References:

[1]Scott DL, et al. Rheumatoid arthritis. Lancet. 2010.

[2]Banerjee S, et al. JAK-STAT signaling as a target for inflammatory and autoimmune diseases: current and future prospects. Drugs. 2017.

[3]William D, et al. JAK inhibitors in dermatology: the promise of a new drug class. Journal of the American Academy of Dermatology. 2017.

[4]Dhillon S. Tofacitinib: A Review in Rheumatoid Arthritis. Drugs. 2017.

[5]Markham A, et al. Peficitinib: First Global Approval. Drugs. 2019.

[6]Zhang HY, et al. Three important components in the regeneration of the cavernous nerve: brain-derived neurotrophic factor, vascular endothelial growth factor and the JAK/STAT signaling pathway. Asian journal of andrology. 2011.

[7]Paleolog EM. Angiogenesis in rheumatoid arthritis. Arthritis research. 2002.

Acknowledgments:

none

Disclosure of Interests:

None declared

SAT0019 HISTOPATHOLOGICAL CHANGES OF SYNOVIAL TISSUE IN RHEUMATOID ARTHRITIS PATIENTS TREATED WITH TNF INHIBITORS

Background:

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by hyperplasia of synovial tissues [1]. Tumor necrosis factor (TNF)-α is one of the pro-inflammatory cytokines that play a crucial role in the pathogenesis of RA synovitis, and TNF inhibitors (TNFi) were reported to force the RA to go into remission or low disease activity and have brought revolutionary impacts on RA treatment [2]. TNFi have been shown to act on inflammatory cells and form the discoid fibrosis in the sublining layers [3,4]. However, the changes of synovial tissue and the cause of discoid fibrosis in RA patients treated with TNFi has not been determined in detail.

Objectives:

The purpose of this study is to demonstrate the histological changes and the types of cells around discoid fibrosis in RA synovium treated with TNFi.

Methods:

Synovial tissues were obtained from 30 patients with RA during joint surgeries. 6 patients were treated with TNFi (1 patient with golimumab, 3 patients with etanercept, 2 patients with infliximab). As a control, synovial tissues were obtained from 6 patients who were treated only with csDMARDs (6 patients with MTX). The frozen sections were stained by hematoxylin and eosin (HE). To detect the apoptosis, TdT-mediated dUTP nick end labeling (TUNEL) was performed. The immunohistochemical characterization of the synovial cells was performed by using following antibodies: CD20 and CD3 for detecting B and T lymphocytes respectively, CD163 and CD86 for detecting M1 and M2 macrophage respectively.

Results:

In the sections stained with HE, the formation of discoid fibrosis and the other characteristic changes including hydropic degeneration, vacuolation, sclerosis of small vasculature, and the number of multilayered synovial cells was decreased in synovium from RA patients treated with TNFi. In the sections with TUNEL stain, apoptosis of lining cells around the discoid fibrosis was detected in RA synovium treated with TNFi (Figure 1a, 1b). In the sections with immunohistochemistry stain, CD86 expression increased in lining layer of RA synovium treated with TNFi. CD163 positive cells showed diffuse expression in RA synovium treated with TNFi. In contrast, CD20 and CD3 positive cells decreased around discoid fibrosis compared to control sections. These results showed indicated that the types of cells in lining and sublining layers were mainly macrophages and that the apoptosis of macrophages might form the discoid fibrosis in lining layers.

Conclusion:

This study showed the apoptosis of lining cells derived from macrophages resulted in the formation of the discoid fibrosis. These findings indicated TNFi might induce apoptosis of macrophage leading to the suppression of RA synovitis.

References:

[1] Scott Dl, et al. Progression of radiological changes in rheumatoid arthritis. Ann Rheum Dis. 1984.

[2]van der Heijde D,et al. Comparison of etanercept and methotrexate, alone and combined, in the treatment of rheumatoid arthritis: two-year clinical and radiographic results from the TEMPO study, a double-blind, randomized trial. Arthritis Rheum. 2006.

[3] Hirohata S,et al. TNF inhibitors induce discoid fibrosis in the sublining layers of the synovium with degeneration of synoviocytes in rheumatoid arthritis. Rheumatol Int. 2013.

[4] Yamanaka H,et al. Scoring evaluation for histopathological features of synovium in patients with rheumatoid arthritis during anti-tumor necrosis factor therapy. Rheumatol Int. 2010.

Acknowledgments :

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Disclosure of Interests:

None declared

Search for Electron Antineutrino Appearance in a Long-Baseline Muon Antineutrino Beam

Electron antineutrino appearance is measured by the T2K experiment in an accelerator-produced antineutrino beam, using additional neutrino beam operation to constrain parameters of the Pontecorvo-Maki-Nakagawa-Sakata (PMNS) mixing matrix. T2K observes 15 candidate electron antineutrino events with a background expectation of 9.3 events. Including information from the kinematic distribution of observed events, the hypothesis of no electron antineutrino appearance is disfavored with a significance of 2.40σ and no discrepancy between data and PMNS predictions is found. A complementary analysis that introduces an additional free parameter which allows non-PMNS values of electron neutrino and antineutrino appearance also finds no discrepancy between data and PMNS predictions.

P974Efficacy of plaque debulking for bifurcated or ostial lesion by directional coronary atherectomy before 2nd generation drug eluting stent (PERFECT2)

Objectives

We sought to evaluate the efficacy of plaque debulking by directional coronary atherectomy (DCA) before 2nd generation drug-eluting stent (DES) implantation for bifurcated coronary lesions.

Background

Percutaneous coronary intervention (PCI) for bifurcated lesions still remains complex and challenging in terms of restenosis or stent thrombosis regardless of whether simple or complex stenting used.

Methods

Patients with bifurcated lesions were enrolled in this prospective multicenter registry. Pre-2nd generation DES plaque debulking with a novel DCA was conducted. All patients were scheduled to perform a follow up (9–12 months) angiography (coronary angiography or coronary computed tomography). The primary end point was the target vessel failure (TVF) at follow-up. Secondary end points were procedure-related events and major adverse cardiac events at 1 year.

Results

A total of 77 patients with bifurcated lesions were enrolled. PCI with DCA was performed successfully in all without any major procedure-related event and only 1 case needed complex stenting. TVF rate at 9–12 months follow up was 3.9% (3 of 77) and those were all associated with revascularization of the target vessel. Restenosis was only observed at ostial of main-branch in 3cases. No death, no coronary artery bypass grafting, and no myocardial infarction were reported in the patients within the first year.

Figure1

Conclusion

DCA before 2nd generation DES implantation can possibly avoid complex stenting and provide a good mid-term outcome in patients with bifurcated lesions.

Acknowledgement/Funding

None

P6209Relationship between skin autofluorescence levels and clinical outcomes in heart failure patients undergoing cardiac rehabilitation

Background

Advanced glycation end-products, indicated by skin autofluorescence (SAF) levels, could be prognostic predictors of all-cause and cardiovascular mortality in patients with diabetes mellitus (DM) and renal disease. However, the clinical usefulness of SAF levels in patients with heart failure (HF) who underwent cardiac rehabilitation (CR) remains unclear.

Purpose

The purpose of this study was to investigate the prognostic value of SAF levels in patients with HF who underwent CR.

Methods

This study enrolled 204 consecutive patients with HF who had undergone CR at our university hospital between November 2015 and October 2017. Clinical characteristics and anthropometric data were collected at the beginning of CR. SAF levels were noninvasively measured with an autofluorescence reader. The major adverse cardiovascular event (MACE) was a composite of all-cause mortality and unplanned hospitalization for HF. Follow-up data concerning primary endpoints were collected until November 2018.

Results

Patients' mean age was 68.1 years, and 61% were males. Patients were divided into two groups according to the median SAF levels (high and low SAF groups). Patients in the high SAF group were significantly older, had a higher prevalence of chronic kidney disease, and histories of coronary artery bypass surgery; however, there were no significant between-group differences in sex, prevalence of DM, left ventricular ejection fraction, and physical function. During a median follow-up period of 623 days, 25 patients experienced all-cause mortality and 34 were hospitalized for HF. Kaplan–Meier analysis showed that patients in the high SAF group had a higher incidence of MACE (log-rank P<0.05), whereas when patients were divided into two groups according to the median hemoglobin A1c level, no significant between-group difference was observed for the incidence of MACE (Figure). After adjusting for confounding factors, Cox regression multivariate analysis revealed that SAF levels were independently associated with the incidence of MACE (hazard ratio: 1.74, 95% confidence interval: 1.12–2.65, P<0.05).

Figure 1

Conclusion

SAF levels were significantly associated with the incidence of MACE in patients with HF and may be useful for risk stratification in patients with HF who undergo CR.

124Impact of intimal tracking for recanalization of CTO lesions on long-term clinical outcomes

Background

For recanalization of coronary chronic total occlusion (CTO) lesions, subintimal guidewire tracking in both antegrade and retrograde approaches are commonly used.

Purpose

This study aimed to assess the impact of subintimal tracking on long-term clinical outcomes after recanalization of CTO lesions.

Methods

Between January 2009 and December 2016, 474 CTO lesions (434patients) were successfully recanalized in our center. After guidewire crossing in a CTO lesion, those lesions were divided into intimal tracking group (84.6%, n=401) and subintimal tracking group (15.4%, n=73) according to intravascular ultrasound (IVUS) findings. Long-term clinical outcomes including death, target lesion revascularization (TLR), target vessel revascularization (TVR) were compared between the two groups. In addition, the rate of re-occlusion after successful revascularization was also evaluated.

Results

The median follow-up period was 4.7 years (interquartile range, 2.8–6.1). There was no significant difference of the rate of cardiac death between the two groups (intimal tracking vs. subintimal tracking: 7.0% vs. 4.1%; hazard ratio, 0.61; 95% confidence interval [CI], 0.19 to 2.00; p=0.41), TLR (14.3% vs. 16.2%; hazard ratio, 1.34; 95% CI, 0.71 to 2.53; p=0.37), and TVR (17.5% vs. 20.3%; hazard ratio, 1.27; 95% CI, 0.72 to 2.23; p=0.42). However, the rate of re-occlusion was significantly higher in the subintimal tracking group than intimal tracking group at 3-years re-occlusion (4.2% vs. 14.5%; log-rank test, p=0.002, Figure). In the multivariate COX regression, subintimal guidewire tracking was an independent predictor of re-occlusion after CTO recanalization (HR: 5.40; 95% CI: 2.11–13.80; p<0.001).

Figure 1

Conclusions

Subintimal guidewire tracking for recanalization of coronary CTO was associated with significantly higher incidence of target lesion re-occlusion during long-term follow-up period.

Search for CP Violation in Neutrino and Antineutrino Oscillations by the T2K Experiment with 2.2×10^{21} Protons on Target

The T2K experiment measures muon neutrino disappearance and electron neutrino appearance in accelerator-produced neutrino and antineutrino beams. With an exposure of 14.7(7.6)×10^{20} protons on target in the neutrino (antineutrino) mode, 89 ν_{e} candidates and seven anti-ν_{e} candidates are observed, while 67.5 and 9.0 are expected for δ_{CP}=0 and normal mass ordering. The obtained 2σ confidence interval for the CP-violating phase, δ_{CP}, does not include the CP-conserving cases (δ_{CP}=0, π). The best-fit values of other parameters are sin^{2}θ_{23}=0.526_{-0.036}^{+0.032} and Δm_{32}^{2}=2.463_{-0.070}^{+0.071}×10^{-3}  eV^{2}/c^{4}.

Cerebrospinal fluid orexin-A levels in systemic lupus erythematosus patients presenting with excessive daytime sleepiness

Objective Involvement of the hypothalamus is rare in patients with systemic lupus erythematosus (SLE). In this study, we measured cerebrospinal fluid (CSF) orexin-A levels in SLE patients with hypothalamic lesions to investigate whether the orexin system plays a role in SLE patients with hypothalamic lesions who present with excessive daytime sleepiness (EDS). Methods Orexin-A levels were measured in CSF from four patients with SLE who presented with hypothalamic lesions detected by MRI. Three patients underwent repeated CSF testing. All patients met the updated American College of Rheumatology revised criteria for SLE. Results Tests for serum anti-aquaporin-4 antibodies, CSF myelin basic protein and CSF oligoclonal bands were negative in all patients. All patients presented with EDS. Low to intermediate CSF orexin-A levels (92-180 pg/ml) were observed in three patients in the acute stage, two of whom (patients 1 and 2) underwent repeated testing and showed increased CSF orexin-A levels, reduced abnormal hypothalamic lesion intensities detected by MRI and EDS dissipation at follow-up. In contrast, CSF orexin-A levels were normal in one patient (patient 4) while in the acute stage and at follow-up, despite improvements in EDS and MRI findings. Patient 4 showed markedly increased CSF interleukin-6 levels (1130 pg/ml) and a slightly involved hypothalamus than the other patients. Conclusions Our findings suggest that the orexinergic system has a role in EDS in SLE patients with hypothalamic lesions. Furthermore, cytokine-mediated tissue damage might cause EDS without orexinergic involvement.

Changes regarding Age and Correlations between Serum Lipids and Body Mass Index in Humankind

Objectives: To improve insight into age and gender related distributions of serum lipids and their correlation with body mass index (BMI).

Methods: Serum lipids embracing atherogenic index (AI) and BMI were analyzed from the results obtained in 19,823 men and 14,788 women undergoing a health examination between 1986 and 1996.

Results: The changes in total cholesterol (TC), triglyceride (TG), AI and BMI differed regarding gender. Although high-density lipoprotein-cholesterol (HDL-C) showed a flat pattern for all ages in both genders, its level in women was higher than in men. The ratio of the number in the unsuitable range to those in the suitable range increased with age as to TC in both sexes, then more than half of the population have an unsuitable level in the sixth decade. As for the correlation between serum lipids and BMI: TC, TG and AI correlated positively, but HDL-C correlated negatively. There were significant gaps between both age and gender.

Conclusions: We suggest that the normal range of values of serum lipids needs to be revised according to gender and age to evaluate the risk status for a cardio-cerebrovascular disease more precisely in the field of preventive medicine. Simpler guidelines are preferable in specialized care as well as in general practice, particularly since computer technology is not yet universally adapted. In the near future, when computed information technology will be as common as the electricity and the telephone are current on the whole earth, all guidelines will have to be computed on the spot and personally.