Derivation of clinical predictive factors (CHIEF) for first recurrent Clostridioides difficile infection

BACKGROUND

Current models for predicting Clostridioides difficile infection (CDI) recurrence rates have a limited capacity to account for important risk factors. This study developed a clinical prediction rule for CDI recurrence.

METHODS

This retrospective cohort study evaluated 209 patients with CDI at a university hospital in Japan. Logistic regression and receiver operating characteristic curve analyses were performed to identify potential predictors (age, sex, underlying diseases, antibiotic use, acid suppressants, immunosuppressants, CDI history) of CDI recurrence.

RESULTS

Forty-five patients developed recurrent CDI. Univariate analyses identified several significant recurrence predictors (enteral feeding, inflammatory bowel diseases [IBD], community-onset CDI, severe CDI). Enteral feeding (odds ratio: 3.87, 95% confidence interval: 1.75-8.56) and IBD (odds ratio: 7.08, 95% confidence interval: 1.28-39.06) were significant factors in the multivariate analysis. The CHIEF predictive scoring system was developed using 5 relevant variables (carbapenem use, hematologic malignancy, IBD, enteral feeding, fluoroquinolone use); the area under the receiver operating characteristic curve for the CHIEF score was 0.70.

DISCUSSION

The CHIEF score incorporates useful, clinically available factors and could help identify patients at risk of recurrent CDI.

CONCLUSIONS

These findings contribute to the understanding of risk factors associated with CDI recurrence and provide support for the development of prevention strategies.

Clinical characteristics and antimicrobial susceptibility of Fusobacterium species isolated over 10 years at a Japanese university hospital

PURPOSE

Anaerobic bacteria, existing on human skin and mucous membranes, can cause severe infections with complications or mortality. We examined the clinical characteristics of patients infected with Fusobacterium spp. and assessed their antibiotic susceptibility.

METHODS

Clinical data were collated from patients diagnosed with Fusobacterium infections in a Japanese university hospital between 2014 and 2023. Antibiotic susceptibility tests were conducted following the Clinical and Laboratory Standards Institute guidelines.

RESULTS

We identified 299 Fusobacterium isolates. The median age was 61 years (range, 14-95 years), with females constituting 43.1% of the patients. Most infections were community-acquired (84.6%, 253/299). Multiple bacterial strains were isolated simultaneously in 74.6% of cases. One-fourth of the patients had solid organ malignancies (25.4%, 76/299), and 14.5% (11/76) of those had colorectal cancer. The 30-day mortality rate was 1.3%. Fusobacterium species were isolated from blood cultures in 6% (18/299) of the patients. Patients, aged 75 years or older, with cerebrovascular disease or hematologic malignancy exhibited significantly higher prevalence of blood culture isolates in univariate analysis. Each Fusobacterium species had its characteristic infection site. Approximately 5% F. nucleatum and F. necrophorum isolates showed penicillin G resistance. Moxifloxacin resistance was observed in varying degrees across strains, ranging from 4.6 to 100% of isolates. All isolates were sensitive to β-lactam/β-lactamase inhibitors, carbapenems, and metronidazole.

CONCLUSION

We show a link between Fusobacterium species and solid organ malignancies. We observed resistance to penicillin, cefmetazole, clindamycin, and moxifloxacin, warranting caution in their clinical use. This study offers valuable insights for managing Fusobacterium infections and guiding empirical treatments.

Oral Clostridium butyricum on mice endometritis through uterine microbiome and metabolic alternations

Endometritis occurs frequently in humans and animals, which can negatively affect fertility and cause preterm parturition syndrome. Orally administered Clostridium butyricum, a butyrate-producing gram-positive anaerobe, exhibits anti-inflammatory effects. However, the precise mechanism by which Clostridium butyricum attenuates endometritis remains unclear. This in vivo study evaluated the anti-inflammatory effects of orally administered Clostridium butyricum on uterine tissues. In addition, we conducted uterine microbiome and lipid metabolome analyses to determine the underlying mechanisms. Female Balb/c mice were divided into the following four groups (n = 5-20): (1) mock group, (2) only operation group (mice only underwent operation to exposed uterine horns from the side), (3) control group (mice underwent the same operation with the operation group + perfusion of lipopolysaccharide solution from uterine horns), and (4) Clostridium butyricum administration group (mice underwent the same operation with the control group + oral Clostridium butyricum administration from days 0 to 9). Clostridium butyricum was administered via oral gavage. On day 10, we investigated protein expression, uterine microbiome, and lipid metabolism in uterine tissues. Consequently, orally administered Clostridium butyricum altered the uterine microbiome and induced proliferation of Lactobacillus and Limosilactobacillus species. The effects can contribute to show the anti-inflammatory effect through the interferon-β upregulation in uterine tissues. Additionally, oral Clostridium butyricum administration resulted in the upregulations of some lipid metabolites, such as ω-3 polyunsaturated fatty acid resolvin D5, in uterine tissues, and resolvin D5 showed anti-inflammatory effects. However, the orally administered Clostridium butyricum induced anti-inflammatory effect was attenuated with the deletion of G protein-coupled receptor 120 and 15-lipooxgenase inhibition. In conclusion, Clostridium butyricum in the gut has anti-inflammatory effects on uterine tissues through alterations in the uterine microbiome and lipid metabolism. This study revealed a gut-uterus axis mechanism and provided insights into the treatment and prophylaxis of endometritis.

Lung cancer progression alters lung and gut microbiomes and lipid metabolism

Despite advances in medical technology, lung cancer still has one of the highest mortality rates among all malignancies. Therefore, efforts must be made to understand the precise mechanisms underlying lung cancer development. In this study, we conducted lung and gut microbiome analyses and a comprehensive lipid metabolome analysis of host tissues to assess their correlation. Alternations in the lung microbiome due to lung cancer, such as a significantly decreased abundance of Firmicutes and Deferribacterota, were observed compared to a mock group. However, mice with lung cancer had significantly lower relative abundances of Actinobacteria and Proteobacteria and higher relative abundances of Cyanobacteria and Patescibacteria in the gut microbiome. The activations of retinol, fatty acid metabolism, and linoleic acid metabolism metabolic pathways in the lung and gut microbiomes was inversely correlated. Additionally, changes occurred in lipid metabolites not only in the lungs but also in the blood, small intestine, and colon. Compared to the mock group, mice with lung cancer showed that the levels of adrenic, palmitic, stearic, and oleic (a ω-9 polyunsaturated fatty acid) acids increased in the lungs. Conversely, these metabolites consistently decreased in the blood (serum) and colon. Leukotriene B4 and prostaglandin E2 exacerbate lung cancer, and were upregulated in the lungs of the mice with lung cancer. However, isohumulone, a peroxisome proliferator-activated receptor gamma activator, and resolvin (an ω-3 polyunsaturated fatty acid) both have anti-cancer effects, and were upregulated in the small intestine and colon. Our multi-omics data revealed that shifts in the microbiome and metabolome occur during the development of lung cancer and are of possible clinical importance. These results reveal one of the gut-lung axis mechanisms related to lung cancer and provide insights into potential new targets for lung cancer treatment and prophylaxis.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

Boehringer Ingelheim and Eli Lilly.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

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

Intra-Abdominal Abscess and Bacteremia Due to Stenotrophomonas maltophilia After Total Gastrectomy: A Case Report and Literature Review

Stenotrophomonas maltophilia (S. maltophilia) is increasingly recognized as a pathogen responsible for nosocomial infections, particularly in immunocompromised patients. The most common types of S. maltophilia infections are pneumonia and catheter-related bloodstream infection, and clinical cases of intra-abdominal abscesses due to S. maltophilia are rare. We present a rare case of intra-abdominal abscess and bacteremia as a surgical site infection (SSI) caused by S. maltophilia in a patient following total gastrectomy. We also reviewed previous literature to elucidate the clinical characteristics of intra-abdominal abscess due to S. maltophilia. The patient, a 75-year-old man with diabetes and polymyositis (treated with prednisolone), developed a fever 17 days after undergoing a total gastrectomy for gastric cancer. Abdominal computed tomography revealed a hypodense solid mass at the esophagojejunostomy site, which appeared to be an intra-abdominal abscess. The culture of both blood and drained abscess pus confirmed only S. maltophilia. Treatment with intravenous trimethoprim-sulfamethoxazole and abscess drainage led to complete resolution. The patient recovered and was discharged and did not experience a recurrence. We reviewed the English literature and found only two additional case reports of intra-abdominal abscesses caused by S. maltophilia. As in our case, the intra-abdominal abscess occurred after abdominal surgery and the source was suspected to be deep SSI. This case highlights the importance of considering S. maltophilia as a potential pathogen in patients with atypical post-surgical abdominal infections. Physicians should be aware that S. maltophilia has the potential to cause intra-abdominal abscesses secondary to SSI, in addition to Enterobacteriaceae, a major causative pathogen of SSI. Further studies are required to elucidate the etiology, epidemiology, and risk factors for SSI caused by S. maltophilia.

Real-World Experience of the Comparative Effectiveness and Safety of Combination Therapy with Remdesivir and Monoclonal Antibodies versus Remdesivir Alone for Patients with Mild-to-Moderate COVID-19 and Immunosuppression: A Retrospective Single-Center Study in Aichi, Japan

The coronavirus disease (COVID-19) pandemic continues to threaten global public health. Remdesivir and monoclonal antibodies have shown promise for COVID-19 treatment of patients who are immunocompromised, including those with cancer, transplant recipients, and those with autoimmune disorder. However, the effectiveness and safety of this combination therapy for patients who are immunosuppressed remain unclear. We compared the efficacy and safety of combination therapy and remdesivir monotherapy for patients with mild-to-moderate COVID-19 who were immunosuppressed. Eighty-six patients treated in July 2021-March 2023 were analyzed. The combination therapy group (CTG) showed a statistically significant reduction in viral load compared with the monotherapy group (MTG) (p < 0.01). Patients in the CTG also experienced earlier resolution of fever than those in the MTG (p = 0.02), although this difference was not significant in the multivariate analysis (p = 0.21). Additionally, the CTG had significantly higher discharge rates on days 7, 14, and 28 than the MTG (p < 0.01, p < 0.01, and p = 0.04, respectively). No serious adverse events were observed with combination therapy. These findings suggest that combination therapy may improve the clinical outcomes of immunosuppressed COVID-19 patients by reducing the viral load and hastening recovery. Further studies are required to fully understand the benefits of this combination therapy for immunocompromised COVID-19 patients.

Clinical Efficacy of Fidaxomicin and Oral Metronidazole for Treating Clostridioides difficile Infection and the Associated Recurrence Rate: A Retrospective Cohort Study

Clostridioides difficile infection (CDI) has significant implications for healthcare economics. Although clinical trials have compared fidaxomicin (FDX) and vancomycin, comparisons of FDX and oral metronidazole (MNZ) are limited. Therefore, we compared the therapeutic effects of FDX and oral MNZ. Patients diagnosed with CDI between January 2015 and March 2023 were enrolled. Those treated with oral MNZ or FDX were selected and retrospectively analyzed. The primary outcome was the global cure rate. Secondary outcomes included factors contributing to the CDI global cure rate; the rate of medication change owing to initial treatment failure; and incidence rates of clinical cure, recurrence, and all-cause mortality within 30 days. Of the 264 enrolled patients, 75 and 30 received initial oral MNZ and FDX treatments, respectively. The corresponding CDI global cure rates were 53.3% and 70% (p = 0.12). In multivariate analysis, FDX was not associated with the global cure rate. In the MNZ group, 18.7% of the patients had to change medications owing to initial treatment failure. The FDX group had a higher clinical cure rate and lower recurrence rate than the MNZ group, although not significant. However, caution is necessary owing to necessary treatment changes due to MNZ failure.

Three Successfully Treated Cases of Lodderomyces elongisporus Fungemia: Case Reports and a Review of the Literature

Fungemia is a fatal systemic infection that can occur in immunocompromised patients. Despite that, antifungal stewardship is spreading widely, but the mortality rate is extremely high, showing 40-60%. Loderomyces elongiporus is a newly morphologically detected pathogen, first described in 1994, followed by isolation in humans in 2008. It has been misrecognized as Candida parapsilosis. Recently, fever attributable to L. elongisporus fungemia cases has been reported, and the etiology and clinical features are still unknown. Here, we present three successfully treated L. elongisporus fungemia cases by echinocandin. In total, 11 cases were reviewed, including ours. Six of the eleven cases (55%) had external devices. All cases had some immunocompromised conditions or underlying diseases, such as diabetes mellitus, lung cancer, etc. Six patients survived, and the remaining five died. Seven patients who had received echinocandin initially survived. Risk factors for L. elongiporus fungemia overlap with those of candidemia. Even though there is no breakpoint for L. elongiporus, echinocandin can be a helpful treatment regimen for L. elongiporus fungemia.

A Gap of Patients with Infective Endocarditis between Clinical Trials and the Real World

Introduction: A randomized control trial (RCT) is considered to be the highest level in the Evidence-Based Medicine (EBM) pyramid. While EBM is essential to make a practical tool such as a prognostic guideline, it has been unclear how many patients in the real world can be eligible for a randomized control trial (RCT). Patients and method: This study was performed to clarify if there is a difference in patients' profiles and clinical outcomes between the patients eligible and not eligible for any RCT. We reviewed all IE patients at our institute between 2007 and 2019. The patients were divided into two groups: those eligible for RCTs (RCT appropriate group) and those who were not (RCT inappropriate group). Exclusion criteria for clinical trials were set based on previous clinical trials. Results: A total of 66 patients were enrolled in the study. The median age was 70 years (range 18 to 87 years), and 46 (70%) were male. Seventeen (26%) of the patients were eligible for RCTs. Comparing the two groups, patients in the RCT appropriate group were younger and had fewer comorbidities. The disease severity was milder in the RCT appropriate groups than in the RCT inappropriate groups. Patients in the RCT appropriate group showed significantly longer overall survival times than those in the RCT inappropriate group (Log-Rank test, p < 0.001). Conclusions: We found a significant gap in patients' characteristics and clinical outcomes between the groups. Physicians should be aware that RCT can never reflect the real-world population.

Mycobiome and Mycobiome-Associated Diseases

The human body is host to a large number of commensal microbial species such as bacteria, fungi, and viruses. Among these, the human mycobiome is often neglected as a potential cause of disease, as it is thought to be comparatively much less abundant and less diverse than the human bacteriome. Additionally, most fungi are not easily cultured, even in specific media. Hence, their study has been limited to date, mainly because of the unavailability of methods used for their detection. However, the utilization of a novel metagenomic methodology will enable the identification of well-characterized mycobiomes in several parts of the human body and broaden our knowledge of their contribution to human health and disease. In this article, we review the role of the human mycobiome in the gut, respiratory organs, skin, genital tract, and carcinogenesis, highlighting the correlations between the human mycobiome and mycobiome-associated diseases.

Clostridium butyricum-induced ω-3 fatty acid 18-HEPE elicits anti-influenza virus pneumonia effects through interferon-λ upregulation

The precise mechanism by which butyrate-producing bacteria in the gut contribute to resistance to respiratory viral infections remains to be elucidated. Here, we describe a gut-lung axis mechanism and report that orally administered Clostridium butyricum (CB) enhances influenza virus infection resistance through upregulation of interferon (IFN)-λ in lung epithelial cells. Gut microbiome-induced ω-3 fatty acid 18-hydroxy eicosapentaenoic acid (18-HEPE) promotes IFN-λ production through the G protein-coupled receptor (GPR)120 and IFN regulatory factor (IRF)-1/-7 activations. CB promotes 18-HEPE production in the gut and enhances ω-3 fatty acid sensitivity in the lungs by promoting GPR120 expression. This study finds a gut-lung axis mechanism and provides insights into the treatments and prophylaxis for viral respiratory infections.

Efficacy and validity of guideline-concordant treatment according to the JRS guidelines for the managements of pneumonia in adults updated in 2017 for nursing and healthcare-associated pneumonia. A propensity-matching score analysis

INTRODUCTION

Patients with nursing and healthcare-associated pneumonia (NHCAP) commonly receive empiric antibiotic therapy according to the guideline's recommendation corresponding to the patient's deteriorated conditions. However, it is unclear whether guideline-concordant treatment (GCT) could be effective or not.

PATIENTS AND METHODS

To evaluate the efficacy and validity of GCT according to the current guideline for pneumonia, we conducted this retrospective study. NHCAP patients who were admitted to our institute between 2014 and 2017 were enrolled. Based on the initial antibiotic treatment, these patients were divided into two groups, the GCT group (n = 83) and the non-GCT group (n = 146). Propensity score matching (PSM) was used to balance the baseline characteristics and potential confounders between the two groups. After PSM, patients' characteristics, microbial profiles, and clinical outcomes were evaluated.

RESULTS

Both groups were well-balanced after PSM, and 78 patients were selected from each group. There were no differences in patients' characteristics or microbial profiles between the two groups. As for outcomes, there were no differences in 30-day, in-hospital mortality rate, duration of antibiotic treatment, or admission. The severity of pneumonia was more severe in patients with the GCT group than those with the non-GCT group. Anti-pseudomonal agents as initial treatment were more frequently seen in patients with the GCT group than those in the non-GCT group.

CONCLUSION

Unlike previous studies, GCT's recommendation for management of pneumonia by the JRS in 2017 would appear to be valid and does not increase the mortality rate.

In Vivo Pharmacodynamics of β-Lactams/Nacubactam against Carbapenem-Resistant and/or Carbapenemase-Producing Enterobacter cloacae and Klebsiella pneumoniae in Murine Pneumonia Model

Carbapenem-resistant Enterobacterales (CRE) and carbapenemase-producing Enterobacterales (CPE) have become global threats. CRE− and CPE− derived infections have been associated with high mortality due to limited treatment options. Nacubactam is a β-lactamase inhibitor and belongs to the new class of diazabicyclooctane. The agent has an in vitro antimicrobial activity against several classes of β-lactamase-producing Enterobacterales. This study evaluated antimicrobial activity of combination therapies including β-lactams (aztreonam, cefepime, and meropenem) and nacubactam against four Enterobacter cloacae and six Klebsiella pneumoniae isolates with murine pneumonia model. Based on changes in bacterial quantity, antimicrobial activities of some regimens were assessed. Combination therapies including β-lactams (aztreonam, cefepime, and meropenem) with nacubactam showed enhanced antimicrobial activity against CRE E. cloacae (−3.70 to −2.08 Δlog₁₀ CFU/lungs) and K. pneumoniae (−4.24 to 1.47 Δlog₁₀ CFU/lungs) with IMP-1, IMP-6, or KPC genes, compared with aztreonam, cefepime, meropenem, and nacubactam monotherapies. Most combination therapies showed bacteriostatic (−3.0 to 0 Δlog₁₀ CFU/lungs) to bactericidal (<−3.0 Δlog₁₀ CFU/lungs) activities against CRE isolates. This study revealed that combination regimens with β-lactams (aztreonam, cefepime, and meropenem) and nacubactam are preferable candidates to treat pneumonia due to CRE and CPE.

Comparison of mortality between echinocandins and polyenes for an initial treatment of candidemia: A systematic review and meta-analysis

BACKGROUND

Current guidelines recommend echinocandins for the initial treatment of candidemia. However, polyenes are often chosen in clinical settings because of their fungicidal and anti-biofilm effects. Therefore, we performed a systematic review and meta-analysis to evaluate whether echinocandins are superior to polyenes in terms of mortality for the initial treatment of candidemia.

METHODS

We systematically searched the Scopus, EMBASE, Cochrane Central Register of Controlled Trials, PubMed, and CINAHL databases until July 1, 2020. We compared the mortality rates of patients who received echinocandins and polyenes. As a subgroup analysis, we compared the mortality rates following the use of echinocandins versus liposomal amphotericin B.

RESULTS

Fifteen studies involving 854 patients were included. Various Candida species were detected, and the rates of resistance of echinocandins and polyenes against the overall detected isolates were 1.0% and 0%, respectively. The overall mortality recorded in 15 studies was 41.0%, and the mortality was significantly higher for polyenes than echinocandins (odd ratios [OR] 1.68, 95% confidential interval [CI] 1.17-2.42). Furthermore, liposomal amphotericin B showed higher mortality in the initial treatment than echinocandins (OR 1.42; 95% CI 0.84-2.39).

CONCLUSIONS

We revealed an association between echinocandin treatment and reduced mortality in the initial treatment of candidemia when causative fungi were not considered. Our findings partially support current guidelines recommending echinocandins for the treatment of candidemia.

Ceftriaxone versus tazobactam/piperacillin and carbapenems in the treatment of aspiration pneumonia: A propensity score matching analysis

INTRODUCTION

Aspiration pneumonia (AP) accounts for 5.0-53.2% of hospitalized pneumonia and the treatment commonly used is by broad-spectrum antibiotics to cover anaerobes. Since ceftriaxone (CTRX) could generally cover oral streptococcus and anaerobes implicated in AP, it could be a useful option in the treatment of AP, instead of piperacillin-tazobactam/(PIPC/TAZ) or Carbapenems.

PATIENTS AND METHODS

For the purpose of examining whether CTRX is as effective as broad-spectrum antibiotics for the treatment of AP, this retrospective study included consecutive community-onset patients who were admitted to our institute between 2014 and 2017. These patients were divided into two groups, a CTRX group (n = 25) and a PIPC/TAZ or carbapenems group (n = 97) based on the initial antibiotic treatment. Propensity score matching (PSM) was used to balance the potential confounders, and 23 patients were selected from each group. Patients among CTXR group received CTRX, while those among PIPC/TAZ or carbapenems group received PIPC/TAZ, or carbapenems and/or other agents.

RESULTS

Both groups were well-balanced after PSM. There were no differences in 30-day mortality, duration of hospital stay or antibiotic treatments in the between them. The medical costs were much more expensive in the PIPC/TAZ or carbapenems group than in the CTR group (35,582 v. s. 8678 Japanese yen, p < 0.001).

CONCLUSION

CTRX is one of the most useful antibiotic treatment for AP, which is not inferior to broad-spectrum antibiotic treatment. In addition, usage of CTRX in the treatment of AP is more economical than broad-spectrum antibiotic treatment, and could contribute to reduction of medical costs.

Efficacy and validity of automated quantitative chemiluminescent enzyme immunoassay for SARS-CoV-2 antigen test from saliva specimen in the diagnosis of COVID-19

INTRODUCTION

The pandemic of a novel coronavirus disease 2019 (COVID-19) caused by a severe acute respiratory coronavirus 2 (SARS-CoV-2) infection has been problematic worldwide. A new SARS-CoV-2 antigen test (LUMIPULSE^Ⓡ) was licensed and widely used in Japan since May 2020. We conducted this study intending to whether the automated quantitative CLEIA antigen test using a saliva sample is effective and valid for the diagnosis of COVID-19.

PATIENTS AND METHODS

We analyzed and compared the diagnostic accuracy of both the automated quantitative CLEIA antigen test and real-time RT-PCR (rRT-PCR) using a saliva sample from individuals suspected as having COVID-19.

RESULTS

A total of 305 samples were collected and tested in Aichi Medical University Hospital and affiliated facilities from December 2020 until January 2021 at our institute. Using reverse-transcription PCR as a reference, the AUROC of the automated quantitative CLEIA antigen test was 0.903 (95% confidential interval 0.845-0.962, p < 0.001). The appropriate cut-off antigen level was 4.0 pg/mL and had a sensitivity of 77.8%, a specificity of 99.6%, a positive predictive value of 98%, and a negative predictive value of 94.5%. On the other hand, the diagnostic accuracy of the antigen test decreased among patients among patients with COVID-19 with threshold cycle (Ct-value)≥27, which shows the AUROC was 0.795 (95%CI 0.687-0.907, p < 0.001).

CONCLUSION

While the automated quantitative CLEIA antigen test from saliva specimen could be one of the most useful diagnostic tests for the diagnosis of COVID-19 in general practice, clinicians should know the limitations of the antigen test.

Pharmacodynamic evaluation of meropenem, cefepime, or aztreonam combined with a novel β-lactamase inhibitor, nacubactam, against carbapenem-resistant and/or carbapenemase-producing Klebsiella pneumoniae and Escherichia coli using a murine thigh-infection model

BACKGROUND

Carbapenem-resistant Enterobacterales (CRE) and carbapenemase-producing Enterobacterales (CPE) are difficult to treat and are a serious public health threat. Nacubactam (NAC) is a novel non-β-lactam diazabicyclooctane β-lactamase inhibitor with in vitro activity against some Enterobacterales expressing classes of β-lactamases.

METHODS

The antimicrobial efficacy of meropenem (MEM), cefepime (FEP), and aztreonam (ATM), each in combination with NAC, were assessed in vitro and in vivo against Klebsiella pneumoniae and Escherichia coli. Ten isolates, including CRE and/or CPE with β-lactamase genes, were used in this study. The relationship between phenotype and in vivo efficacy was assessed in a murine neutropenic thigh-infection model. Efficacy was determined by the change in bacterial quantity.

RESULTS

The results of the in vitro study showed the minimum inhibitory concentrations of the combination of NAC with either MEM, FEP, or ATM in a 1:1 ratio were 2 to >128-fold lower than those of MEM, FEP, or ATM alone against CRE+ isolates. In addition, combinations of β-lactams and NAC administered in the murine thigh-infection model showed greater efficacy against CRE+/CPE+, CRE+/CPE-, and CRE-/CPE+ isolates harboring various β-lactamase genes (IMP-1, IMP-6, KPC, DHA-1, or OXA-48) compared with MEM, FEP, ATM, and NAC alone.

CONCLUSION

MEM, FEP, or ATM in combination with NAC showed potent in vivo antimicrobial activity in a murine thigh-infection model caused by K. pneumoniae and E. coli, including CRE and/or CPE isolates. These findings indicate that these combinations of β-lactams and NAC are potential candidates for the treatment of CRE and/or CPE infections.

In vivo pharmacodynamics of lascufloxacin and levofloxacin against Streptococcus pneumoniae and Prevotella intermedia in a pneumonia mixed-infection mouse model

This study aimed to evaluate the antimicrobial activity of a new quinolone, lascufloxacin, for the treatment of complicated pneumonia caused by Streptococcus pneumoniae and Prevotella intermedia using a neutropenic mice pneumonia mixed-infection model. In this study, one S. pneumoniae and four P. intermedia isolates were utilized. Antimicrobial efficacy was calculated for each isolate as the reduction of the bacterial count comparatively to the non-treated mice (log₁₀ colony forming units (cfu)/mL) obtained in the lungs of the treated mice after 24 h. Consequently, the bacterial densities of S. pneumoniae (KY-9) and P. intermedia (335) in the lungs of control animals were 8.20 ± 0.19 log₁₀ cfu/mL and 5.26 ± 1.50 log₁₀ cfu/mL, respectively. At human-simulated doses, lascufloxacin and levofloxacin showed high antimicrobial activities against not only S. pneumoniae (lascufloxacin: 1.88 ± 0.43 log₁₀ cfu/mL, p < 0.001; levofloxacin 4.30 ± 0.75 log₁₀ cfu/mL, p < 0.001), but also P. intermedia (lascufloxacin: 1.54 ± 0.57 log₁₀ cfu/mL, p < 0.001; levofloxacin: 2.79 ± 0.55 log₁₀ cfu/mL, p = 0.0102). Additionally, levofloxacin demonstrated attenuated antimicrobial efficacies against S. pneumoniae in the mixed-infection model compared with that in the single infection model. In contrast, lascufloxacin showed enhanced antimicrobial activities against S. pneumoniae and P. intermedia in the mixed-infection model. In conclusion, lascufloxacin resulted in enhanced efficacies against S. pneumoniae and P. intermedia, in both the single and mixed-infection models used. These data support the clinical utility of lascufloxacin for use against S. pneumoniae and P. intermedia in the treatment of pneumonia.

Meta-analysis of vancomycin versus linezolid in pneumonia with proven methicillin-resistant Staphylococcus aureus

OBJECTIVE

American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines suggest that linezolid (LZD) is preferred over vancomycin (VCM) for treating methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. We conducted a systematic review and comparative meta-analysis to compare VCM and LZD efficacy against proven MRSA pneumonia.

METHODS

We searched EMBASE, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), and PubMed up to November 2019. The outcomes of the meta-analysis were mortality, clinical cure, microbiological evaluation, and adverse events.

RESULTS

Seven randomized controlled trials (RCTs) with a total of 1239 patients and eight retrospective cohort or case-control studies (CSs) with a total 6125 patients were identified. Clinical cure and microbiological eradication rates were significantly increased in patients treated with LZD in RCTs (clinical cure: risk ratio (RR) = 0.81, 95% confidential interval (CI) = 0.71-0.92; microbiological eradication: RR = 0.71, 95% CI = 0.62-0.81) and CSs (clinical cure: odds ratio (OR) = 0.35, 95% CI = 0.18-0.69). However, mortality was comparable between patients treated with VCM and LZD in RCTs (RR = 1.08, 95% CI = 0.88-1.32) and CSs (OR = 1.20, 95% CI = 0.94-1.53). Likewise, there was no significant difference in adverse events between VCM and LZD in CSs (thrombocytopenia: OR = 0.95, 95% CI = 0.50-1.82; nephrotoxicity: OR = 1.72, 95% CI = 0.85-3.45).

CONCLUSIONS

According to our meta-analysis of RCTs and CSs conducted worldwide, we found robust evidence to corroborate the IDSA guidelines for the treatment of proven MRSA pneumonia.

Primary solitary fibrous tumour of the prostate: A case report and literature review

INTRODUCTION

Solitary fibrous tumour (SFT) is a rare mesenchymal tumour with intermediate malignant potential. Although this tumour arises in several sites, prostatic SFT is an extremely rare neoplasm and may prove confusing owing to the lack of clinical experience because of tumour rarity. The diagnosis may be further difficult because SFTs can manifest positive immunoreactivity for CD34 and progesterone receptor, which are known markers of prostatic stromal tumours. Herein, we describe a case of prostatic SFT that was difficult to differentiate from a prostatic stromal tumour of uncertain malignant potential because of positive immunoreactivity to CD34 and progesterone receptor.

CASE REPORT

A 40-year-old Japanese man presented with lower abdominal pain. Computed tomography revealed a prostatic mass; furthermore, prostate core needle biopsy revealed proliferating bland spindle cells, without necrosis or prominent mitoses. Tumour cells were positive for CD34 and progesterone receptor on immunohistochemical analysis; thus, a prostatic stromal tumour of uncertain malignant potential was initially suspected. However, as the tumour cells showed positive immunoreactivity for STAT6, the final diagnosis was an SFT of the prostate. The patient underwent tumour resection, and at the 6-month postoperative follow-up, neither local recurrence nor distant metastasis occurred.

CONCLUSION

For an accurate diagnosis of an SFT of the prostate, STAT6 immunohistochemistry should be conducted for all mesenchymal tumours of the prostate. When STAT6 immunohistochemical analysis is unfeasible, pathologists should be aware that the morphological and immunohistochemical characteristics of SFT variable from case to case and diagnose with combined analysis of several immunohistochemical markers.

Long-year follow-up of acute myocardial infarction with preserved initial LVEF: prognostic impact of progressively reduced LVEF

Background

Severely reduced left ventricular ejection fraction (LVEF ≤35%) is commonly seen in approximately 5% of the myocardial infarction (MI) survivors in its acute-phase, which is recognized as a risk factor of post-MI cardiac death. However, clinical incidence and risk factor of the progressively reduced LVEF in the chronic-phase after MI has not been clarified.

Purpose

To evaluate clinical incidence and risk factor of the progressively reduced LVEF in the chronic-phase after MI by serial echocardiography.

Method

We evaluated 1144 consecutive patients with acute MI with preserved LVEF (≥50%) in acute-phase. Primary outcome was severely reduced LVEF (&lt;35%) in the chronic-pahse. We analyzed the predictive factor using multivariate analysis.

Result

During follow-up (median:1097 days), severely reduced LVEF newly developed in 8.6% of AMI survivors. Kaplan-meier curve is shown in the Figure. Multivariate analysis showed that men, eGFR &lt;30, AMI of LAD and absence of renin-angiotensin system blocking drugs was an independent predictor of severely reduced LVEF.

Conclusions

Progressively reduced LVEF during chronic-phase occurred 8.6% in acute MI survivors with preserved initial LVEF. Especially patients with these risk factors, careful long-term follow-up after MI should be needed to identify possible candidate for the implantable cardioverter-defibrillator.

Figure 1

Funding Acknowledgement

Type of funding source: None

Prognostic impact of initial serum albumin for newly developing heart failure after acute myocardial infarction

Background/Introduction

Previous studies have shown that poor nutritional status relate to the clinical outcomes in patients with heart failure (HF). However, relationships between initial serum albumin and newly developing HF after acute myocardial infarction (AMI) remain unclear.

Methods

We evaluated 2289 consecutive patients with AMI in our hospital. Primary outcome was HF hospitalization after AMI. We analyzed the predictive impact of initial serum albumin using multivariate analysis, both in all AMI patients and subgroup of AMI patient without known risk factors of HF (LMT, peak CK &gt;8000, eGFR &lt;30, and LVEF &lt;35%).

Result

In the remote-phase(median follow-up: 754 days), 5.4% of all AMI patients were hospitalized due to HF. Multivariate analysis showed that low albumin (&lt;4.0g/dl) was an independent predictor of HF hospitalization after AMI in all patients, as well as other known risk factors. Interestingly, low albumin still showed the predictive value even in the no-HF risk subgroup. Kaplan-meier curve of no-HF risk group is shown in the Figure.

Conclusions

Low initial albumin level would be an useful predictor of newly developing HF in the remote-phase after AMI.

Figure 1

Funding Acknowledgement

Type of funding source: None

Meta-analysis of fluoroquinolones versus macrolides for treatment of legionella pneumonia

BACKGROUND

Only a single meta-analysis has reported the clinical benefit of fluoroquinolones (FQs) for Legionella pneumonia; however, there is no robust data available to confirm this result, based on current guidelines.

METHODS

We performed a systematic review and meta-analysis comparing FQs with macrolides (MCs) on their efficacy and safety in Legionella pneumonia, using studies published until January 2020. The outcomes included mortality (overall; 30-day), clinical cure, time to apyrexia, length of hospital stay, and adverse events.

RESULTS

Five RCTs and twelve retrospective studies were identified. Clinical cure was comparable between the treatment groups (risk rate (RR) 1.07, 95% confidential interval (CI) 0.86-1.31). Mortality was significantly higher for MCs than for FQs (overall, odd rate (OR) 0.59, 95% CI 0.35-0.98; 30-day, OR 0.41, 95% CI 0.20-0.85). FQs significantly reduced the length of hospital stay, compared to MCs (mean difference -3.58, 95% CI -5.48-1.69). Other outcomes were not significantly different between the treatment groups (time to apyrexia; mean difference -1.83, 95% CI -5.15-1.5, adverse events; OR 0.61, 95% CI 0.33-1.15). In subgroup analyses, levofloxacin significantly reduced the length of hospital stay over two specific MCs (azithromycin and clarithromycin) (mean difference -3.03, 95% CI -5.33-0.72), whereas mortality was not significantly different between the treatment groups (overall, OR 0.49, 95% CI 0.19-1.24; 30-day, OR 0.38, 95% CI 0.13-1.13).

CONCLUSIONS

FQs exhibited superior effects in terms of mortality and length of hospital stay in Legionella pneumonia. These results support current guidelines recommending FQs for the treatment of Legionella pneumonia.

Preoperative MRI for predicting pathological changes associated with surgical difficulty during laparoscopic cholecystectomy for acute cholecystitis

BACKGROUND

Severe inflammation with necrosis and fibrosis of the gallbladder in acute cholecystitis increases operative difficulty during laparoscopic cholecystectomy. This study aimed to assess the use of preoperative MRI in predicting pathological changes of the gallbladder associated with surgical difficulty.

METHODS

Patients who underwent both preoperative MRI and early cholecystectomy for acute cholecystitis between 2012 and 2018 were identified retrospectively. On the basis of the layered pattern of the gallbladder wall on MRI, patients were classified into three groups: high signal intensity (HSI), intermediate signal intensity (ISI), and low signal intensity (LSI). The endpoint was the presence of pathological changes of the gallbladder associated with surgical difficulty, such as necrosis, abscess formation and fibrosis.

RESULTS

Of 229 eligible patients, pathological changes associated with surgical difficulty were found in 17 (27 per cent) of 62 patients in the HSI group, 84 (85 per cent) of 99 patients in the ISI group, and 66 (97 per cent) of 68 patients in the LSI group (P < 0·001). For detecting these changes, intermediate to low signal intensity of the gallbladder wall had a sensitivity of 90 (95 per cent c.i. 84 to 94) per cent, specificity of 73 (60 to 83) per cent and accuracy of 85 (80 to 90) per cent.

CONCLUSION

Preoperative MRI predicted pathological changes associated with surgical difficulty during laparoscopic cholecystectomy for acute cholecystitis.

Plasma procalcitonin levels remain low at the onset of gram-positive bacteremia regardless of severity or the presence of shock: A retrospective analysis of patients with detailed clinical characteristics

OBJECTIVES

Procalcitonin (PCT) is an early diagnosis marker of sepsis/bacteremia. However, some reports refer to its lower responsiveness to gram-positive bacteremia. We retrospectively evaluated the PCT values at the onset of bacteremia in relation to severity index.

METHODS

Patients with bacteremia caused by two gram-negative bacteria (46 E. coli and 50 Klebsiella pneumoniae) and three gram-positive bacteria (45 S. aureus, 56 S. epidermidis, and 10 S. mitis) were studied. The plasma PCT and C-reactive protein (CRP) levels were compared between species and different Sequential Organ Failure Assessment (SOFA) score groups.

RESULTS

The median PCT level was higher in gram-negative than in gram-positive bacteremia in overall (13.09 vs. 0.50 ng/mL, p < 0.0001), in SOFA score≥4 group (28.85 vs.1.72 ng/mL, p < 0.0001) and in SOFA<4 group (2.64 vs. 0.42 ng/mL, p < 0.0001). Only 46%, and 11% of patients showed PCT ≥0.5 ng/mL in S. epidermidis, and S. mitis bacteremia, respectively. PCT was significantly better than CRP in discriminating gram-negative from gram-positive bacteremia (AUCROC; 0.828 and 0.634, p < 0.001), but it was low in Staphylococcus epidermidis bacteremia regardless of SOFA scores.

CONCLUSIONS

PCT levels are lower in gram-positive bacteremia regardless of SOFA scores or the presence of shock. The conventional sepsis cutoff of 0.5 ng/mL may overlook certain proportions of gram-positive bacteremia.

Sequentially addressable dielectrophoretic array for high-throughput sorting of large-volume biological compartments

Droplet microfluidics has become a powerful tool in precision medicine, green biotechnology, and cell therapy for single-cell analysis and selection by virtue of its ability to effectively confine cells. However, there remains a fundamental trade-off between droplet volume and sorting throughput, limiting the advantages of droplet microfluidics to small droplets (<10 pl) that are incompatible with long-term maintenance and growth of most cells. We present a sequentially addressable dielectrophoretic array (SADA) sorter to overcome this problem. The SADA sorter uses an on-chip array of electrodes activated and deactivated in a sequence synchronized to the speed and position of a passing target droplet to deliver an accumulated dielectrophoretic force and gently pull it in the direction of sorting in a high-speed flow. We use it to demonstrate large-droplet sorting with ~20-fold higher throughputs than conventional techniques and apply it to long-term single-cell analysis of Saccharomyces cerevisiae based on their growth rate.

P762 Preserved mitral apparatus dynamics predict the improvement of acute ischemic mitral regurgitation: four-dimensional quantitative echocardiographic study

Background

We sought to evaluate the predictive value of acute stage mitral apparatus geometry and dynamics for the reduction of ischemic mitral regurgitation (IMR) in the remote phase after successful primary percutaneous coronary intervention (pPCI) by using real-time 3D-transthoracic echocardiography (3D-TTE).

Methods

We performed 2D and 3D-TTE in consecutive 44 first acute MI patients with more than mild IMR within 3 days after successful pPCI. 3DTTE of left ventricle (LV) volumes and mitral apparatus dynamics through the cardiac cycle were quantified offline. We compared the 3D geometric and dynamic parameters in the acute phase between 1)20 remained MR group and 2)24 improved MR group in 6-to-12 months after MI onset.

Results

Ejection fraction (EF) was preserved in the improved MR group compared to the remained MR group (49.0 ± 11.2 vs. 56.5 ± 7.0%, p = 0.013). Mitral valve annulus area, leaflet tenting length and papillary muscles spatial position had no significant difference between the two groups (all p &gt; 0.05) throughout cardiac cycle. In contrast, mitral annulus saddle shape was preserved in the improved MR group than the remained MR group (p = 0.010) and annular area changed dynamically through early- to late-systole in the improved MR group (phasic p = 0.017) despite it was adynamic in remained MR group (phasic p = 0.201). Conclusions: IMR improvement in the remote phase after AMI associated with preserved EF, mitral annulus saddle shape and dynamics during systole in the acute phase of MI. 4D dynamics of the mitral apparatus can be clinically useful predictor of the improvement in acute IMR and may contribute to the clinical decision making including surgical or percutaneous intervention for IMR.

P292 The risk of adverse outcome with ischemic mitral regurgitation at 6-month after myocardial infarction: possible benefit of early intervention by transcatheter mitral-valve repair

Background

The latest study has demonstrated the better outcomes of transcatheter mitral-valve repair in patients with decompensated heart failure (HF) and left ventricular (LV) dysfunction. However, it is unknown whether earlier intervention for mitral regurgitation (MR) can improve the outcome of myocardial infarction (MI).

Purpose

The aim of this study was to investigate the prognostic value of ischemic MR (IMR) at 6-month after MI for the later incidence of HF and death.

Methods

We retrospectively examined 723 MI patients who were admitted to our hospital. 95.5% of the patients were treated by primary coronary intervention. Patients were clinically followed-up at 6-month after the onset of MI, and divided into 3 groups according to the degree of IMR, i.e. No/Trivial IMR group (n = 528), Mild IMR group (n= 154) and ≥Moderate IMR group (n= 41). We compared the later incidence of hospitalization for HF and all-cause death at 3-year for each group.

Results

The studied population had preserved ejection fraction (EF) (56.9 ± 10.7%, average) and mostly asymptomatic at 6-month after MI. All-cause mortality within 3-year was higher in patients with ≥Moderate IMR (p &lt; 0.001), and the incidence of hospitalization for HF was significantly higher depends on the degree of IMR at 6-month (p &lt; 0.001). Multivariate analysis showed EF and the degree of IMR were the independent predictor for the hospitalization for HF.

Conclusions

IMR at 6-month after MI was associated with the later adverse events despite relatively preserved LV contraction without heart failure symptoms at the index examination. Early intervention for IMR potentially benefit for the better outcome.

Abstract P292 Figure. Caplan-Meier estimates on adverse events

1182 Clinical evidence of the mitral valve leaflet remodeling after st-elevation acute myocardial infarction: longitudinal observation using real-time 3D echocardiography

Background

Mitral valve (MV) leaflet remodeling after acute myocardial infarction (AMI) has been proposed as biological and physiological reaction under the ischemic environment mainly by animal experiments. Clinical evidence of leaflet growth after AMI is lacking.

Purpose

We aimed to assess the clinical evidence of the mitral valve leaflet remodeling after acute myocardial infarction by serial 2D/3D transthoracic echocardiography.

Methods

Sixty-six patients with first-onset ST-elevation MI (33 anterior and 33 inferior) were serially examined by 2D/3D-transthoracic echocardiography. MV complex geometry including leaflet surface area and leaflet thickness was quantitatively analyzed in acute phase and 6-month follow-up.

Results

3D-leaflet surface area was significantly increased in 6-month follow-up (anterior MI; 5.58 [4.93-6.00] versus 5.98 [5.68-6.40] cm²/m²; P &lt; 0.001, inferior MI; 5.48 [4.69-6.07] versus 5.79 [4.74-6.37] cm²/m²; P &lt; 0.001). In anterior MI, both anterior and posterior leaflet lengths significantly increased (anterior leaflet; 12.78 [11.55-13.55] versus 13.63 [12.52-14.15] mm/m²; P = 0.001, posterior leaflet; 9.61 [8.73-10.77] versus 9.84 [8.94-10.96] mm/m²; P = 0.037). In inferior MI, posterior leaflet length significantly increased (9.18 [8.50-10.38] versus 10.00 [8.56-10.85] mm/m²; P = 0.029), while there was no significant change in anterior leaflet length (12.54 [11.61-13.56] versus 12.56 [12.08-14.06] mm/m²; P = 0.214). Leaflet thickness was found to become greater in both groups in 6-month follow-up (anterior MI; 1.08 [0.92-1.21] versus 1.32 [1.25-1.45] mm; P &lt; 0.001, inferior MI; 1.14 [0.98-1.25] versus 1.32 [1.21-1.49] mm; P &lt; 0.001) (Figure).

Conclusions

In six months from the onset of AMI, MV enlarged in area and increased in thickness. Anterior leaflet mainly enlarged in anterior MI, while posterior leaflet enlarged in inferior MI. This is the first clinical evidence of the MV remodeling after AMI, and long-year follow-up should contribute to assess the course of valve growth with relation to ischemic mitral regurgitation.

Abstract 1182 Figure. 3D analysis of the mitral valve

Childhood leukemia in Ukraine after the Chornobyl accident

This population-based ecological study analyzes the prevalence of childhood leukemia in Ukraine before and after the Chornobyl nuclear power plant accident, based on the contamination status of the territory, time period, gender, and age. Three regions-Zhytomyr, Kyiv (except Kyiv city), and Chernihiv were included as areas contaminated by radioactive ¹³⁷Cs from 1 to 15 Ci/km² with annual effective doses exceeding 1.0 mSv, and Sumy region as the control (non-contaminated) area with ¹³⁷Cs contamination less than 1 Ci/km² and effective doses less than 0.5 mSv per year. The integrated database of the National Research Centre for Radiation Medicine used in the present study included 1085 childhood leukemia cases. Two aggregated periods were used for analysis: 1980-1986 (pre-accident) and 1987-2000 (post-accident). ICD-9 codes for leukemia (204-208.9) were used to perform analyses according to the extent of leukemic cells maturity (acute, chronic, and maturity unspecified leukemia), leukemic cell lineage (lymphoid, myeloid and lineage unspecified leukemia) and all leukemia cases in different age subgroups (1-4, 5-9, 10-14, and 15-19 years). Standard methods of descriptive epidemiology were used to calculate the prevalence of disease and frequency ratio in regression models. A statistically significant increase in frequency ratio for acute leukemia (1.44; 95% confidence interval (CI), 1.22-1.71), myeloid leukemia (2.93; 95% CI, 1.71-5.40), cell lineage unspecified leukemia (II) (1.48; 95% CI, 1.18-1.87) and all forms of leukemia (1.59; 95% CI, 1.36-1.86) was found for the post-accident period in highly contaminated areas. The results indicate that the frequency of childhood leukemia (and of some of its types) increased in contaminated areas during the post-accident period, suggesting that radiation exposure after the Chornobyl accident might be the cause of the increase. However, further analytical studies, with individual or at least group dose estimates, are needed to confirm a link between childhood leukemia and the Chornobyl accident.

P3619Incidence of progressively reduced LVEF during long-year follow-up after myocardial infarction: impact for mid-term outcomes

Background

Severely reduced left ventricular ejection fraction (LVEF≤35%) is commonly seen in approximately 5% of the myocardial infarction (MI) survivors in its acute-phase, which is recognized as a risk factor of post-MI cardiac death. However, clinical impact of the progressively reduced LVEF in the chronic-phase after MI has not been clarified.

Purpose

To evaluate clinical impact of the progressively reduced LVEF in the chronic-phase after MI.

Method

We evaluated 1659 consecutive patients with acute MI by serial echocardiography. Primary outcome was severely reduced LVEF. And secondary outcome was all cause death and cardiac death.

Result

During follow-up (median: 1097 days), severely reduced LVEF newly developed in 8.6% of AMI survivors. These patients had significantly higher incidence of all cause death (20.7% vs. 4.4%, p<0.01) and cardiac death (10.6% vs. 1.2%, p<0.01) than those with LVEF>35%. Severely reduced LVEF progressed in the chronic-phase associated with all cause death and cardiac death as well as those with severely reduced EF in the acute-phase.

Figure 1

Conclusions

Progressively reduced LVEF during chronic-phase occurred 8.6% per 10-year in MI survivors. Careful long-term follow-up after MI should be needed to identify possible candidate for the implantable cardioverter-defibrillator.

P3604Gender difference in Low-BMI patients with acute myocardial infarction makes an impact on mid-term outcomes

Background/Introduction

There are some reports about impact of low body-mass-index (BMI) on patients with acute myocardial infarction (MI), suggesting an obesity paradox. However, the differential impact of gender between low-BMI and mid-term outcome remains unclear.

Purpose

To evaluate the differential impact of gender between low-BMI patients with acute MI and mid-term outcome.

Methods

We evaluated 3038 consecutive patients with acute MI in Miyazaki medical association hospital. Patients were stratified low-BMI group (BMI≤20) from other-BMI group (BMI>20), and compared. BMI was measured at admission of acute MI. Primary outcome was cardiac death. We also analyzed each gender, using Kaplan-meier curve with long-rank test.

Result

Among all patients, low-BMI patient was 8.6%. Median follow-up was 1085 days, and cardiac death was significantly higher rate in low-BMI group (14.5% vs 7.7%, p<0.001). Male patient with low-BMI was significantly higher event rate, compared with other-BMI group (11.0% vs 5.5%, p<0.001). However, female patient group had no significant difference of outcomes between low-BMI and other-BMI (12.6% vs 10.3%, p=0.315). Event rate is shown in the Figure.

Gender

Conclusions

Low BMI was associated with mid-term outcomes in acute MI patients. Impact of low-BMI on mid-term outcome seems to be gender dependent in acute MI patients.

P45945-years clinical outcomes of patients underwent percutaneous coronary intervention for calcified lesions with rotational atherectomy and second-generation drug eluting stent

Background

Percutaneous coronary Intervention (PCI) with rotational atherectomy (RA) was useful for severe calcified lesions. However, the long-term clinical outcomes of PCI with second-generation drug eluting stent (DES) following RA has been still unclear.

Purpose

The purpose of this study was to investigate the long-term clinical outcomes of RA followed by second-generation DES.

Methods

We retrospectively enrolled 254 consecutive patients treated with second-generation DES following RA. The primary outcome was the cumulative 5-year incidence of MACE, defined as cardiac death, myocardial infarction, clinically-driven target lesion revascularization and definite stent thrombosis.

Results

The incidence of MACE was 22.8% at 5-years. Multivariate analysis showed 3 predictors of MACE, hemodialysis, diabetic mellitus and extremely angulated lesions (>90°).Significantly higher MACE was observed in the high-risk (≥2 risk factors) group, compared with the low-risk (2< risk factors) group (68.7% vs. 18.7%, P<0.001, Figure).

Multivariate analysis for MACE at 5 year Hazard ratio (95% Confidence Interval) P-value Diabetic Mellitus 2.58 (1.35–4.91) 0.004 Hemodialysis 4.57 (1.64–12.76) 0.004 extremely angulated (>90°) 3.08 (1.06–8.93) 0.04

Kaplan-Meier curves for 5-years MACE

Conclusions

The long-term clinical outcomes of PCI for severely calcified lesions was acceptable. However, the clinical outcomes of patients classified high risk cohort was unsatisfactory.

Retrospective study on clinical efficacy and safety for daptomycin intermittent doses with or without loading dose in renal failure patients

This retrospective study is to evaluate the efficacy and safety of daptomycin (DAP) intermittent doses and the effectiveness of DAP loading dose in renal failure patients received DAP intermittent doses. One hundred and ninety-seven patients received DAP for at least 3 days from 2014 to 2017. Clinical and microbiological outcomes and the safety were assessed. A total of 183 patients (93, 60 and 30 patients received DAP daily dose, every 48 h dose and thrice per week dose) were included. DAP intermittent doses, such as every 48 h dose (28.3%) and thrice per week dose (30.0%), showed significantly higher mortality rates than that of DAP daily dose (6.5%) (p = 0.0320). Especially for bacteremia patients, significantly higher mortality was admitted, compared with patients received DAP daily doses (p = 0.0160). Moreover, patients received DAP intermittent doses were admitted slower improvements of their inflammation after DAP therapy started, compared with patients received daily dose. Additionally, DAP loading dose for renal failure patients decreased their mortality and improved patients' inflammation early. Especially for patients received DAP thrice per week dose, they showed significantly lower mortality than patients received non-loading dose (p = 0.0306). Additionally, these clinical enhancements of DAP therapy with loading dose were admitted without any enhancements of its adverse effect risks, except alkaline phosphatase elevation, compared with non-loading dose. In conclusion, DAP intermittent doses showed poor clinical outcomes, compared with daily dose. Then, DAP loading dose would be better clinical option for patients received DAP intermittent doses.