Sex differences in lower urinary tract function in mice with or without spinal cord injury

OBJECTIVES

We examined sex differences of lower urinary tract function and molecular mechanisms in mice with and without spinal cord injury (SCI).

METHODS

SCI was induced by Th8-9 spinal cord transection in male and female mice. We evaluated cystometrograms (CMG) and electromyography (EMG) of external urethral sphincter (EUS) at 6 weeks after SCI in spinal intact (SI) and SCI mice. The mRNA levels of Piezo2 and TRPV1 were measured in L6-S1 dorsal root ganglia (DRG). Protein levels of nerve growth factor (NGF) in the bladder mucosa was evaluated using an enzyme-linked immunosorbent assay.

RESULTS

Sex differences were found in the EUS behavior during voiding as voiding events in female mice with or without SCI occurred during EUS relaxation periods without EUS bursting activity whereas male mice with or without SCI urinated during EUS bursting activity in EMG recordings. In both sexes, SCI decreased voiding efficiency along with increased tonic EUS activities evident as reduced EUS relaxation time in females and longer active periods of EUS bursting activity in males. mRNA levels of Piezo2 and TRPV1 of DRG in male and female SCI mice were significantly upregulated compared with SI mice. NGF in the bladder mucosa showed a significant increase in male and female SCI mice compared with SI mice. However, there were no significant differences in Piezo2 or TRPV1 levels in DRG or NGF protein levels in the bladder mucosa between male and female SCI mice.

CONCLUSIONS

We demonstrated that female and male mice voided during EUS relaxation and EUS bursting activity, respectively. Also, upregulation of TRPV1 and Piezo2 in L6-S1 DRG and NGF in the bladder could be involved in SCI-induced lower urinary tract dysfunction in both sexes of mice.

Prognostic Factors of Platinum-Refractory Advanced Urothelial Carcinoma Treated with Pembrolizumab

INTRODUCTION

Immune checkpoint inhibitor (ICI) therapy has significantly improved the prognosis of some patients with advanced urothelial carcinoma (UC), but it does not provide high therapeutic efficacy in all patients. Therefore, identifying predictive biomarkers is crucial in determining which patients are candidates for ICI treatment. This study aimed to identify the predictors of ICI treatment response in patients with platinum-refractory advanced UC treated with pembrolizumab.

METHODS

Patients with platinum-refractory advanced UC who had received pembrolizumab at two hospitals in Japan were included. Univariate and multivariate analyses were performed to identify biomarkers for progression-free survival (PFS) and overall survival (OS).

RESULTS

Forty-one patients were evaluable for this analysis. Their median age was 75 years, and the vast majority of the patients were male (85.4%). The objective response rate was 29.3%, with a median overall survival (OS) of 17.8 months. On multivariate analysis, an Eastern Cooperative Oncology Group performance status (ECOG-PS) ≥ 2 (HR = 6.33, p = 0.03) and a baseline neutrophil-to-lymphocyte ratio (NLR) > 3 (HR = 2.79, p = 0.04) were significantly associated with poor OS. Antibiotic exposure did not have a significant impact on either PFS or OS.

CONCLUSIONS

ECOG-PS ≥ 2 and baseline NLR > 3 were independent risk factors for OS in patients with platinum-refractory advanced UC treated with pembrolizumab. Antibiotic exposure was not a predictor of ICI treatment response.

First observation of 28O

Subjecting a physical system to extreme conditions is one of the means often used to obtain a better understanding and deeper insight into its organization and structure. In the case of the atomic nucleus, one such approach is to investigate isotopes that have very different neutron-to-proton (N/Z) ratios than in stable nuclei. Light, neutron-rich isotopes exhibit the most asymmetric N/Z ratios and those lying beyond the limits of binding, which undergo spontaneous neutron emission and exist only as very short-lived resonances (about 10-21 s), provide the most stringent tests of modern nuclear-structure theories. Here we report on the first observation of 28O and 27O through their decay into 24O and four and three neutrons, respectively. The 28O nucleus is of particular interest as, with the Z = 8 and N = 20 magic numbers1,2, it is expected in the standard shell-model picture of nuclear structure to be one of a relatively small number of so-called 'doubly magic' nuclei. Both 27O and 28O were found to exist as narrow, low-lying resonances and their decay energies are compared here to the results of sophisticated theoretical modelling, including a large-scale shell-model calculation and a newly developed statistical approach. In both cases, the underlying nuclear interactions were derived from effective field theories of quantum chromodynamics. Finally, it is shown that the cross-section for the production of 28O from a 29F beam is consistent with it not exhibiting a closed N = 20 shell structure.

Prognosis of Patients Receiving Chemotherapy for Metastatic Upper Tract Urothelial Carcinoma Compared With Metastatic Urinary Bladder Cancer

BACKGROUND/AIM

The treatment strategy for metastatic upper tract urothelial carcinoma (mUTUC) is currently based on the evidence from metastatic urinary bladder cancer (mUBC). However, some reports have shown that the outcomes of UTUC differ from those of UBC. Therefore, we retrospectively analyzed the prognosis of patients with mUBC and mUTUC treated with first-line platinum-based chemotherapy.

PATIENTS AND METHODS

Patients who underwent platinum-based chemotherapy at the Kindai University Hospital and affiliated hospitals between January 2010 and December 2021 were included in the study. There were 56 patients with mUBC and 73 with mUTUC. Kaplan-Meier curves were used to estimate progression-free (PFS) and overall (OS) survival. Multivariate analyses were performed using Cox proportional hazards model to predict prognostic factors.

RESULTS

The median PFS was 4.5 and 4.0 months for the mUBC and mUTUC groups, respectively (p=0.094). The median OS was 17.0 months for both groups (p=0.821). The multivariate analysis showed no prognostic factor for PFS. The multivariate analysis for OS showed that younger age at the initiation of chemotherapy and immune checkpoint inhibitor use after first-line therapy were significantly associated with better OS.

CONCLUSION

Platinum-based chemotherapy had a similar effect on patients with mUTUC and mUBC.

Antithrombotic monotherapy for stable coronary artery disease and atrial fibrillation patients with and without prior coronary artery revascularization: Insights from the AFIRE trial

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): The Japan Cardiovascular Research Foundation under a contract with Bayer Yakuhin

Background

The AFIRE (Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease) trial demonstrated that rivaroxaban monotherapy was noninferior to combination therapy with rivaroxaban plus a single antiplatelet therapy regarding efficacy and superior for safety endpoints in patients with atrial fibrillation and stable coronary artery disease including patients not requiring revascularization [prior percutaneous coronary intervention (PCI) or bypass grafting (CABG)].

Purpose

The aim of this post-hoc subgroup analysis was to investigate the efficacy and safety of rivaroxaban monotherapy compared to combination therapy in patients with and without prior revascularization.

Methods

Among 2,215 patients included in the modified intention-to-treat analysis in the AFIRE trial, 1445 patients (65.2%) had undergone previous PCI alone, and 252 (11.4%) had undergone previous CABG. The remaining 518 patients (23.4%) was categorized as a group without prior revascularization and then compared with a group with prior revascularization (PCI or CABG). The primary efficacy end point was a composite of stroke, systemic embolism, myocardial infarction, unstable angina requiring revascularization, or death from any cause. The primary safety end point was major bleeding, according to the criteria of the International Society on Thrombosis and Hemostasis.

Results

In 1697 patients with prior revascularization, efficacy and safety endpoints of rivaroxaban monotherapy were superior to combination therapy (efficacy: HR 0.62, 95%CI 0.45-0.85, p=0.003; safety: HR 0.62, 95%CI 0.39-0.98, p=0.040), whereas there were no significant differences in efficacy and safety endpoints among 518 patients without prior revascularization (efficacy: HR 1.19, 95%CI 0.67-2.11, p=0.553; safety: HR 0.47, 95%CI 0.18-1.26, p=0.125). There was a borderline interaction of efficacy endpoint (P for interaction=0.055) by randomized treatment assignment (Figure 1 and Figure 2). Compared with combination therapy, the safety benefit of rivaroxaban monotherapy on any bleeding was significant in patients without prior revascularization (HR 0.59, 95%CI 0.38-0.93, p=0.022).

Conclusions

In patients with prior PCI or CABG, rivaroxaban monotherapy resulted in more favorable safety and efficacy outcomes than combination therapy. There was a borderline interaction for primary efficacy outcome between prior revascularization and anti-thrombotic therapy.

The pressure flow study investigation of pathophysiology of post-micturition dribble in male patients

PURPOSE

In this study, we aimed to elucidate the pathophysiology of post-micturition dribble (PMD) through analyzing several variables including pressure flow study (PFS) findings and symptoms questionnaire.

METHODS

We retrospectively analyzed male patients who visited our department between 2010 and 2020. We used modified international prostate symptom score (m-IPSS), which consists of eight sub-score related to lower urinary tract symptoms (Incomplete Emptying, Frequency, Intermittency, Urgency, Weak Stream, Straining, Nocturia, and PMD) and one question related to quality of life (QOL). Multivariate regression analysis was conducted to evaluate the relationship between PMD and the variables, including age, prostate volume (PV), body mass index, bladder outlet obstruction index (BOOI), bladder contractility index, and bladder voiding efficiency, which were obtained by PFS.

RESULTS

A total of 143 male patients were analyzed. The patients with PMD showed significantly larger PV and higher BOOI, and worse IPSS total and QOL score than those without PMD. Multivariate regression analysis showed that large PV and BOOI were significantly associated with PMD. In Spearman's correlation analysis, PMD and each m-IPSS sub-score except nocturia had significant positive correlation. Furthermore, Spearman's correlation analysis showed that PMD and QOL had significant strong positive correlation.

CONCLUSION

PMD was significantly associated with large PV and BOO evaluated by PFS. Furthermore, PMD significantly exacerbated QOL. The severity of PMD and the other m-IPSS sub-score except nocturia could have intercorrelation with each other.

Effect of rivaroxaban monotherapy vs. combination with anti-platelet therapy in patients with atrial fibrillation and stable coronary artery disease across different body mass index categories

Background

The AFIRE (Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease) trial showed both noninferiority for efficacy and superiority for safety endpoints of rivaroxaban monotherapy compared to rivaroxaban plus antiplatelet therapy (combination therapy) in patients with atrial fibrillation (AF) and stable coronary artery disease (CAD). However, no accumulating evidence regarding efficacy and safety of these fixed-dose direct oral anticoagulant therapy was available in underweight and obese patients.

Purpose

The aim of this post-hoc analysis of the AFIRE trial was to evaluate outcomes of rivaroxaban monotherapy (vs. combination therapy) in patients with AF and stable CAD across body mass index (BMI) categories.

Methods

Patients were categorized into groups 1 (underweight: BMI of <18.5 kg/m2), 2 (normal: BMI of 18.5 to <25 kg/m2), 3 (overweight: BMI of 25 to <30 kg/m2), and 4 (obesity: BMI of ≥30 kg/m2). Efficacy (a composite of all-cause death, myocardial infarction, unstable angina requiring revascularization, stroke, or systemic embolism) and safety (major bleeding defined according to International Society on Thrombosis and Haemostasis criteria) were compared between rivaroxaban monotherapy and combination therapy across BMI categories.

Results

We analyzed 2,054 patients with a median age of 75.0 (interquartile range [IQR], 69 to 80)) years old and CHA2DS2-VASc of 4 (IQR, 3 to 5). Group 1 through 4 included 72 (3.5%), 1,158 (56.4%), 680 (33.1%), 144 (7.0%) patients and 62.3%, 52.3%, 36.2%, and 30.3% were received reduced dose of rivaroxaban, respectively. Although the sample sizes for group 1 and 4 were limited, monotherapy was superior to combination therapy for efficacy in group 2 (hazard ratio [HR], 0.64; 95% CI, 0.44 to 0.95) and safety in group 3 (HR, 0.25; 95% CI, 0.10 to 0.62), whereas a significant difference in the endpoints was not observed in the other BMI categories. Impact of monotherapy on endpoints did not have a significant interaction in BMI.

Conclusions

Rivaroxaban monotherapy had similar effect on prognosis across all BMI categories in patients with AF and stable CAD.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Japan Cardiovascular Research Foundation based on a contract with Bayer Yakuhin, Ltd

A new nomogram of urinary flow rate and volume based on multiple measurements per healthy adult Japanese men using a portable uroflowmeter (P-Flowdiary®)

BACKGROUND

To develop a nomogram of urinary volume and flow based on the data of Japanese men without lower urinary tract symptoms and multiple flows per participant whose characteristics were clear.

METHODS

Overall, 101 Japanese male volunteers without lower urinary tract symptoms aged between 20 and 59 years were enrolled. A portable uroflowmeter (P-Flowdiary®) was used to record urinary information (flow rate and volume) for 2 successive days. The model (quadratic, linear, or logarithmic regression) most fit for the relationship between maximum flow rate and voided volume was determined. The maximum flow rate at > 150 mL was compared among the 20-29-, 30-39-, 40-49-, and 50-59-year age groups. Nomograms appropriate for the age groups were created.

RESULTS

The mean age, International Prostate Symptom Score, and Overactive Bladder Symptom Score were 38.5 years, 0.42, and 0.24, respectively. The quadratic regression model was the most fit because its mean coefficient determination was 0.93 ± 0.06. The mean maximum flow rate was significantly lower in the 50-59-year age group (21.8 ± 5.05 mL/s, P < 0.01) than in the younger groups (24.14 ± 4.94, 24.05 ± 6.99, and 24.64 ± 5.72 mL/s). The 2 nomograms are Y = 28.99 {1 - exp(- 0.01 × X)} and Y = 25.67 {1 - exp(- 0.01 × X)} for the 20-49- and 50-59-year age groups, respectively.

CONCLUSIONS

The nomogram can predict maximum flow rate based on voided volume in Japanese men aged 20-59 years without lower urinary tract symptoms.

Prognostic factors in Japanese men with high-Gleason metastatic castration-resistant prostate cancer

Background

Several therapeutic agents are available for metastatic castration-resistant prostate cancer (CRPC). However, prognosis is still not well developed. The Gleason score (GS) is a prognostic factor available for patients with metastatic CRPC. GSs ranging from 6 to 10 and GSs ≥8 are usually categorized as single prognostic factors. In this study, we evaluated the prognosis of high-GS metastatic CRPC in Japanese men.

Methods

Overall, 105 patients with metastatic CRPC with a GS ≥8 were retrospectively analyzed. Multivariate analyses of patient age, GS, and Eastern Cooperative Oncology Group performance status (ECOG-PS) were performed using Cox proportional hazards analysis to predict overall survival (OS).

Results

GS 8 had all Gleason patterns of 4+4. Thirty patients (28.6%) had GS of 8, and 75 (71.4%) had GS of 9 or 10. As a first-line treatment for metastatic CRPC, 42 patients (40%) received abiraterone, 35 (33.3%) received enzalutamide, and 26 (24.8%) received docetaxel. The 5-year OS in patients with GS of 8 was 65.0% [95% confidence interval (CI): 43.07–86.82%], while the 5-year OS in patients with GS of 9 or 10 was 37.0% (95% CI: 24.41–56.11%). There was a significant difference in OS between the GS 8 and GS 9–10 groups (log-rank test, P=0.038). Multivariate analysis showed that GS and ECOG-PS were significant prognostic factors for OS.

Conclusions

Patients with metastatic CRPC with GS 9–10 had poor prognoses, suggesting the need for additional treatment options.

Clinical features of detrusor underactivity in elderly men without neurological disorders

OBJECTIVES

To investigate the clinical features of detrusor underactivity (DU) in elderly men without neurological disorders.

METHODS

A total of 336 men aged ≥50 years without neurogenic disorders who underwent pressure flow studies and who had DU or bladder outlet obstruction (BOO) were reviewed retrospectively. According to the bladder contractility index (BCI) and the BOO index (BOOI), the subjects were classified into the following three groups: (a) pure DU group, BCI < 100 and BOOI < 40; (b) DU + BOO group, BCI < 100 and BOOI ≥ 40; and (c) pure BOO group, BCI ≥ 100 and BOOI ≥ 40. Subjective and objective parameters were compared among the three groups, and the predictors for pure DU were evaluated by multivariate analysis.

RESULTS

Of the 336 patients, 205 who met the study criteria were included in the analysis: 63 (30.7%) with pure DU, 48 (23.4%) with DU + BOO, and 94 (45.9%) with pure BOO. The proportion of the pure DU group increased with increasing age. Prostate volume was the lowest in the pure DU group. Frequency, urgency on the International Prostate Symptom Score (IPSS), and the IPSS storage subscore were the lowest in the pure DU group. Multivariate analysis showed that age (odds ratio [OR] 1.114 [95% CI, 1.032-1.203], P = .005), prostate volume (OR 0.968 [95% CI, 0.949-0.987], P = .001), and urgency (OR 0.623 [95% CI, 0.431-0.900], P = .012) were predictors of pure DU.

CONCLUSION

Older age, smaller prostate volume, and less urgency may be clinical features of pure DU.

Identification of diagnostic serum biomarkers for Hunner-type interstitial cystitis

OBJECTIVES

Diagnosis of Hunner-type interstitial cystitis (HIC) relies on the ability to identify Hunner lesions endoscopically, which can lead to storage symptom misdiagnosis. Here, we examined serum biomarkers for HIC and verified their utility.

METHODS

Based on the previous definition of the Japanese guidelines, which did not distinguish HIC and non-HIC diseases, we searched for serum biomarkers in 25 patients with interstitial cystitis (IC) and 25 control participants using metabolomics during 2013-2014. In 2019, we conducted a validation study in HIC and control groups. Serum samples were analyzed using liquid chromatography-tandem mass spectrometry, and candidate biomarker concentrations were compared between the groups using Mann-Whitney test.

RESULTS

Metabolomics targeted 678 metabolites and revealed that the levels of 14 lysolipids, seven γ-glutamyl amino acids, and two monoacylglycerols were significantly different between the IC and control groups. The following metabolites were selected from each metabolite category as candidates: 1-linoleoylglycerophosphocholine (1-linoleloyl-GPC [18:2]), γ-glutamylisoleucine (γ-Glu-Ile), and 1-arachidonylglycerol (1-AG). The serum concentrations of 1-linoleoyl-GPC (18:2) in the HIC and control groups were 27 920 ± 6261 and 40 360 ± 1514 ng/mL (P = 0.0003), respectively. The serum concentrations of γ-Glu-Ile and 1-AG were not significantly different between the groups. When the cut-off value of 1-linoleoyl-GPC (18:2) was set at 28 400 ng/mL, the sensitivity and specificity were 68% and 84%, respectively.

CONCLUSIONS

Serum 1-linoleoyl-GPC (18:2) is a candidate diagnostic biomarker for HIC. Additional studies on whether this biomarker can distinguish HIC from other diseases with high urination frequency are required for its clinical use.

Comparison of Abiraterone and Combined Androgen Blockade Therapy for High-Risk Metastatic Hormone-Sensitive Prostate Cancer: A Propensity Score-Matched Analysis

This study aimed to compare the effects of abiraterone acetate plus prednisone (AAP) with androgen deprivation therapy (ADT) with those of combined androgen blockade (CAB) therapy in patients with high-risk metastatic hormone-sensitive prostate cancer (mHSPC). This study retrospectively identified 163 patients with high-risk mHSPC at Kindai University and affiliated hospitals between January 2014 and December 2020. Kaplan-Meier analysis was used to summarize progression-free survival (PFS) and overall survival (OS). Multivariate Cox proportional hazard modeling was used to identify the prognostic factors in the overall cohort. Propensity score matching was used to adjust the clinical characteristics, and log-rank test was applied to these propensity score–matched cohorts. Seventy-four patients who received AAP with ADT and 89 patients who received CAB were included in this study. The median follow-up duration was 27 months (range, 2–89 months). The median PFS and OS were not reached by the AAP+ADT group and 15 and 79 months, respectively, in the CAB group. The Eastern Cooperative Oncology Group (ECOG) performance status (PS) score and AAP+ADT were significant prognostic factors for PFS, whereas ECOG PS score, visceral metastasis, and AAP+ADT were significant prognostic factors for OS. The 2-year PFS was 76.1% in the AAP+ADT group and 38.6% in the CAB group (P < 0.0001), and the 2-year OS was 90.2% in the AAP+ADT group and 84.8% in the CAB group (P = 0.015). In conclusion, AAP+ADT had better PFS and OS than CAB in patients with high-risk mHSPC.

Aspirin vs. P2Y12 inhibitors with anticoagulation therapy for atrial fibrillation: insights from the AFIRE trial

Background

Patients with coronary artery disease (CAD) and atrial fibrillation (AF) can be treated with multiple antithrombotic therapies including antiplatelets and oral anticoagulants; however, this has the potential to increase bleeding risk.

Purpose

This sub-analysis aimed to evaluate the efficacy and safety of P2Y12 inhibitors and aspirin in patients also receiving oral anticoagulant therapy.

Methods

We evaluated patients from the Atrial Fibrillation and Ischemic Events with Rivaroxaban in Patients with Stable Coronary Artery Disease (AFIRE) trial who received combination therapy (rivaroxaban plus a single antiplatelet agent). The choice of antiplatelets was left to the physician's discretion. The primary efficacy endpoint was a composite of stroke, systemic embolism, myocardial infarction, unstable angina requiring revascularization, and death from any cause. The primary safety endpoint was major bleeding according to the International Society on Thrombosis and Haemostasis criteria.

Results

A total of 1,075 patients were included (P2Y12 inhibitor group, n=297; aspirin group, n=778). Approximately 60% of patients were administered proton pump inhibitors (PPIs), and there was no significant difference in PPI use in the P2Y12 inhibitor and aspirin groups. Regarding the primary efficacy endpoint, there was no significant difference between the P2Y12 inhibitor and aspirin groups (hazard ratio, 1.31; 95% confidence interval, 0.88–1.94; p=0.178). Likewise, the primary safety endpoint was not different between the groups (hazard ratio, 0.79; 95% confidence interval, 0.43–1.47; p=0.456). In the detailed subgroup analysis, there were no differences in the efficacy and safety endpoints.

Conclusions

There were no significant differences between P2Y12 inhibitors and aspirin in cardiovascular events in patients with AF and stable CAD taking rivaroxaban in the chronic phase.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Japan Cardiovascular Research Foundation based on a contract with Bayer Yakuhin, Ltd. Summary of this study

Sarcopenia and Visceral Obesity are Significantly Related to Severe Storage Symptoms in Geriatric Female Patients

Purpose

This study aimed to elucidate the relationship of psoas muscle atrophy and visceral obesity with lower urinary tract symptoms in geriatric female patients.

Patients and Methods

We retrospectively reviewed the medical records of female patients aged ≥65 years. The psoas muscle index was defined, using computed tomography, as the cross-sectional area of the psoas muscle at the third lumbar vertebral level divided by the body surface area. We also measured visceral fat area at the umbilical level using computed tomography. We used logistic regression analysis to examine the relationships between the International Prostate Symptom Score (total score, voiding subscore, and storage subscore) and variables, such as age, body mass index, psoas muscle index, and visceral fat area. The International Prostate Symptom Score was categorized as mild, moderate, or severe.

Results

One hundred thirty-nine patients were included in our study. In the logistic regression analysis, we found statistically significant relationships between severe (versus mild-to-moderate) International Prostate Symptom Score storage subscore and variables, including low and high levels of psoas muscle index and visceral fat area, respectively. We could not find any significant relationships between the International Prostate Symptom Score total score and voiding subscore and the variables.

Conclusion

Psoas muscle atrophy and visceral fat accumulation are potential risk factors for severe storage symptoms in female patients aged ≥65 years.

Efficacy of vibegron, a novel β3-adrenoreceptor agonist, for lower urinary tract dysfunction in mice with spinal cord injury

OBJECTIVES

To investigate the effect of vibegron, a new clinically approved β3-adrenoceptor agonist in lower urinary tract dysfunction in mice with spinal cord injury.

METHODS

Investigators performed cystometry under awake conditions in 4-week spinal cord injury female mice. Two weeks after spinal cord injury, saline or vibegron (30 mg/kg) was orally administered for 2 weeks prior to the urodynamic study. Investigators removed L6-S1 dorsal root ganglia from the saline- or vibegron-treated spinal cord injury mice as well as from saline-treated normal (spinal intact) mice to evaluate the levels of transient receptor potential cation channel subfamily V member 1, transient receptor potential cation channel subfamily A member 1, activating transcription factor 3, and inducible nitric oxide synthase transcripts using real-time polymerase chain reaction.

RESULTS

In vibegron-treated spinal cord injury mice, nonvoiding contractions during bladder filling, which were increased in spinal cord injury compared to spinal intact mice, were significantly decreased. Micturition pressure or voiding efficiency was not significantly increased in comparison to measurements in saline-treated spinal cord injury mice. The expression of transient receptor potential cation channel subfamily V member 1, transient receptor potential cation channel subfamily A member 1, activating transcription factor 3, and inducible nitric oxide synthase messenger RNA was increased in spinal cord injury mice compared to spinal intact mice, but significantly decreased after vibegron treatment.

CONCLUSIONS

Vibegron improves spinal cord injury-induced detrusor overactivity in addition to significantly reducing C-fiber afferent receptors such as transient receptor potential cation channel subfamily V member 1, transient receptor potential cation channel subfamily A member 1, and inflammatory cytokines/markers, such as activating transcription factor 3 and inducible nitric oxide synthase, in spinal cord injury mice. Thus, vibegron might be effective in the treatment of storage lower urinary tract dysfunction induced by C-fiber afferent activation after spinal cord injury.

Comparison of the Safety and Efficacy of Photoselective Vaporization of the Prostate (PVP) and Transurethral Enucleation with a Bipolar System (TUEB): A Single-Center Retrospective Study

Purpose

The aim of this study was to compare the safety and efficacy of photoselective vaporization of the prostate (PVP) and transurethral enucleation with a bipolar system (TUEB).

Patients and Methods

Patients who underwent PVP or TUEB surgery for lower urinary tract symptoms due to bladder outlet obstruction at our institution from September 2015 to May 2019 were retrospectively reviewed. A total of 83 patients (PVP: n=45, TUEB: n=38) who were available for follow-up at least 12 months after surgery were included. Preoperative characteristics, perioperative parameters, and postoperative outcomes-such as International Prostate Symptom Score (IPSS), quality of life (QoL), maximum urinary flow rate (Qmax), post-void residual urine volume (PVR), and complications-at 3, 6, and 12 months after surgery were compared between the two groups.

Results

Although differences in age, IPSS, and QoL were not significant, a significantly greater prostate volume, lower Qmax, and greater PVR were noted in the TUEB group. In perioperative parameters, a significantly shorter operation time, less change in serum hemoglobin, fewer days of catheterization, and shorter length of stay were observed in the PVP group. As for postoperative outcomes, the IPSS storage subscore and PVR were significantly improved in the TUEB group. As complications, stress urinary incontinence was more frequently observed in the TUEB group, and urethral stricture was more common in the PVP group.

Conclusion

The present data suggest that PVP and TUEB are efficient and safe surgical treatment options. Management of patients undergoing PVP in the perioperative period appears easy. Improvements of subjective and objective parameters were superior after TUEB than after PVP.

Daily salt intake is associated with leg edema and nocturnal urinary volume in elderly men

AIMS

There is accumulating evidence that excessive salt intake contributes to nocturnal polyuria. We aimed to investigate the relationship between salt intake, leg edema, and nocturnal urine volume (NUV) to assess the etiology of nocturnal polyuria.

METHODS

A total of 56 men aged ≥60 years who were hospitalized for benign prostatic hyperplasia or with suspected prostatic cancer were enrolled. Urine frequency-volume charts of the patients were maintained, and they underwent bioelectrical impedance analysis twice daily (at 5:00 pm and 6:00 am) and examination of blood (brain natriuretic peptide levels) and urine (sodium and creatinine levels and osmotic pressure) samples once daily (at 6:00 am). Free-water clearance, solute clearance, and sodium clearance at night were measured, and daily salt intake was estimated.

RESULTS

The data of 52 patients were analyzed. Daily salt intake positively correlated with leg edema at 5:00 pm, differences in leg extracellular fluid levels between 5:00 pm and 6:00 am, and NUV, but not with diurnal urine volume. Partial correlation coefficients showed that salt intake was a factor of the correlation between NUV and change in extracellular volume in the legs between 5:00 pm and 6:00 am. A multivariate logistic model showed that sleep duration and sodium clearance were independent predictive factors for nocturnal polyuria.

CONCLUSIONS

Sodium intake correlates with diurnal leg edema and NUV in elderly men. These results provide evidence supporting sodium restriction as an effective treatment for nocturnal polyuria.

Sodium plays an important role in the absorption of intravesical fluid

OBJECTIVES

To investigate the role of sodium in intravesical absorption of water in the bladder and the sodium pathway in the urothelium.

METHODS

Adult female Sprague-Dawley rats received either saline or a 5% glucose solution injection into their bladders. The changes in intravesical fluid volume; concentrations of sodium and chlorine and osmolality; and expression of aquaporin-2, epithelial sodium channel, and claudins were compared after 3 hours.

RESULTS

Intravesical volume decreased significantly in the saline group compared to that in the 5% glucose solution group. The expression of claudin-3 and -6 was higher in the saline group than in the glucose group. There was a significant correlation between changes in the intravesical saline volume and the concentration of sodium and chlorine. Intravesical administration of amiloride did not affect changes in the fluid volume and concentration of sodium.

CONCLUSIONS

The presence of sodium is important for the absorption of intravesical fluid through aquaporin-2 in the urinary bladders of rats. Claudin-3 and -6 may be associated with the transport of sodium through the bladder urothelium.

Extending the Southern Shore of the Island of Inversion to ^{28}F

Detailed spectroscopy of the neutron-unbound nucleus ^{28}F has been performed for the first time following proton/neutron removal from ^{29}Ne/^{29}F beams at energies around 230  MeV/nucleon. The invariant-mass spectra were reconstructed for both the ^{27}F^{(*)}+n and ^{26}F^{(*)}+2n coincidences and revealed a series of well-defined resonances. A near-threshold state was observed in both reactions and is identified as the ^{28}F ground state, with S_{n}(^{28}F)=-199(6)  keV, while analysis of the 2n decay channel allowed a considerably improved S_{n}(^{27}F)=1620(60)  keV to be deduced. Comparison with shell-model predictions and eikonal-model reaction calculations have allowed spin-parity assignments to be proposed for some of the lower-lying levels of ^{28}F. Importantly, in the case of the ground state, the reconstructed ^{27}F+n momentum distribution following neutron removal from ^{29}F indicates that it arises mainly from the 1p_{3/2} neutron intruder configuration. This demonstrates that the island of inversion around N=20 includes ^{28}F, and most probably ^{29}F, and suggests that ^{28}O is not doubly magic.

Role of p38 MAP kinase signaling pathways in storage and voiding dysfunction in mice with spinal cord injury

AIM

To investigate the role of p38 MAP kinase in lower urinary tract dysfunction in mice with spinal cord injury (SCI).

METHODS

Cystometry and external urethral sphincter-electromyography were performed under an awake condition in 4-week SCI female mice. Two weeks after SCI, a catheter connected to an osmotic pump filled with a p38 mitogen-activated protein kinase (MAPK) inhibitor or artificial cerebrospinal fluid (CSF) was implanted into the intrathecal space of L6-S1 spinal cord for continuous intrathecal instillation at infusion rate of 0.51 μL/h for 2 weeks before the urodynamic study. L6 dorsal root ganglia were then removed from CSF and p38 MAPK inhibitor-treated SCI mice as well as from CSF-treated normal (spinal intact) mice to evaluate the levels of transient receptor potential cation channel subfamily V member 1 (TRPV1), tumor necrosis factor-α (TNF-α), and inducible nitric oxide synthase (iNOS) transcripts by real-time polymerase chain reaction.

RESULTS

In p38 MAPK inhibitor-treated SCI mice, nonvoiding contractions during bladder filling, bladder capacity, and post-void residual volume were significantly reduced while micturition pressure and voiding efficiency were significantly increased in comparison to these measurements in CSF-treated SCI mice. The expression of TRPV1, TNF-α, and iNOS messenger RNA was increased in SCI mice compared with expression in spinal intact mice and significantly decreased after p38 MAPK inhibitor treatment.

CONCLUSIONS

The p38 MAPK signaling pathway in bladder sensory neurons or in the spinal cord plays an important role in storage and voiding problems such as detrusor overactivity and inefficient voiding after SCI.

P5635Predictive ability of lipdic burden for FFR-derived physiological measures: insights from near-infrared spectroscopy imaging analysis

Background

Fractional flow reserve (FFR) has enabled to physiologically assess the myocardial ischemia of coronary artery with intermediate stenosis. Mechanistically, not only the severity of coronary stenosis but also the extent of maximal vasodilatation within the entire coronary artery potentially affects this physiological measure. Since the accumulation of lipidic materials within vessel wall increases vascular stiffness via inducing endothelial dysfunction, the presence of lipidic atheroma burden may affect physiological measures.

Purpose

To investigate the association of FFR with lipidic coronary atheroma by near-infrared spectroscopy/intravascular ultrasound (NIRS/IVUS) imaging, which quantitatively visualize lipidic burden in vivo.

Methods

We analyzed 61 coronary arteries (LAD/RCA/LCX=52/5/4) with FFR≤0.80 in 59 stable coronary artery disease subjects receiving PCI. Following FFR measurement, NIRS/IVUS imaging was conducted to evaluate the extent of atheroma burden (maximum percent plaque area=max%PA) and lipidic materials (lipid core burden index within the entire vessel=LCBIvessel). The analyzed vessels were stratified according to FFR: definite FFR group (FFR≤0.74, n=34) and gray-zone FFR group (0.75≤FFR≤0.80, n=27).

Results

NIRS/IVUS imaging analysis (analyzed longitudinal length=77±7mm) was more likely to exhibit a significantly higher LCBIvessel and a larger max%PA in the definite FFR group (Table). Of note, FFR was significantly correlated to LCBIvessel (ρ=-0.299, p=0.02), but not max%PA (ρ=-0.255, p=0.07). Multivariate analysis demonstrated that an independent determinant of FFR≤0.74 was LCBIvessel [odds ratio (OR)=1.016, 95% confidential interval (CI)=1.002–1.031, p=0.02], but not max%PA [OR=1.084, 95% CI=0.994–1.182, p=0.07]. Area under the receiver-operating characteristic curve analysis elucidated that the addition of LCBIvessel to angiography- and IVUS-derived measures resulted in a significant improvement for detecting FFR≤0.74 (picture).

Definite FFR Group (FFR≤0.74, n=34) Gray-zone FFR Group (0.75≤FFR≤0.80, n=27) p value Fractional flow reserve (FFR) 0.68±0.05 0.78±0.02 <0.01 Percent diameter stenosis (%) 56.2±13.1 51.9±7.8 0.16 Maximum percent plaque area (max%PA, %) 84.3±6.9 79.9±7.2 0.01 Lipid core burden index within the entire vessel (LCBIvessel) 102.0±60.2 65.6±51.6 0.01

ROC analysis for detecting FFR≦0.74

Conclusion

The propagation of lipidic burden associates with the physiological measures. The present findings indicate the possibility that vessel characteristics or instability may have influence for causing ischemia on the coronary artery.

P4512Impact of pulmonary artery catheter on all-cause death of patients with acute heart failure with preserved ejection fraction: Short-term results from the PURSUIT-HFpEF registry

Background

Appropriate pulmonary artery catheter (PAC) use may effectively decrease mortality in acute heart failure patients. The concept that the pulmonary artery catheter (PAC) is a valuable tool for hemodynamic monitoring when used in appropriately selected patients and by physicians trained well to interpret and apply the data correctly provided has not been evaluated adequately yet in acute heart failure patients with preserved ejection fraction (HFpEF).

Methods

The PERSUIT-HFpEF Registry is a prospective, observational, multicenter cohort study on prognosis of HFpEF in Japan. Patients hospitalized for heart failure (diagnosed by using Framingham criteria) who met both of the following criteria were enrolled: 1) a left ventricular ejection fraction of 50% or more as measured at the local site by echocardiography; 2) an elevated level of N terminal pro brain natriuretic peptide (NT proBNP) (400 pg per milliliter or more) or brain natriuretic peptide (BNP) (100 pg per milliliter or more). In the present study, we evaluated the impact of PAC on all-cause death of the patients with HFpEF. PAC use was left at the discretion of attending physicians.

Results

The PERSUIT-HFpEF Registry enrolled 486 patients (81±9 years, 259 females, mean follow-up duration 198±195 days). Of these, data of PAC usage was available in 434 patients. Patients were further stratified according to use of a PAC: PAC 153 patients vs. non-PAC 281 patients. Length of hospitalization was numerically shorter in the PAC group than in the non-PAC group [20.3±14.7 vs. 22.5±17.4 days, p=0.182]. Kaplan-Meier estimated 1-year all-cause death rate was significantly lower in the PAC group than in the non-PAC group (9.5% vs. 19.1%, p=0.019). PAC use was associated with significant risk reduction of all-cause death [hazard ratio (HR) 0.425, 95% confidence interval (CI), 0.203–0.890, p=0.023] in the crude analysis. The significant risk reduction still existed after multivariate adjustment including potential confounders [HR 0.427, 95% CI, 0.185–0.984, p=0.046]

Kaplan Meier analysis

Conclusions

In the real-world Asian registry data, PAC use was associated with the improved all-cause death rate, suggesting that the PAC might be a useful guidance tool for treatment of the patients with HFpEF.

Acknowledgement/Funding

Roche diagnostics FUJIFILM Toyama Chemical

P938Extensive formation of atherosclerotic cardiovascular disease in subjects with severe familial hypercholesterolemia defined by the international atherosclerosis society criteria

Introduction

The International Atherosclerosis Society (IAS) has proposed “severe familial hypercholesterolemia (FH)” as a FH phenotype with the highest cardiovascular risk. Coronary artery disease (CAD) represents a major atherosclerotic change in FH patients. Given their higher LDL-C level and atherogenic clinical features, more extensive formation of atherosclerosis cardiovascular disease including not only CAD but stroke/peripheral artery disease (PAD) may more frequently occur in severe FH.

Methods

481 clinically-diagnosed heterozygous FH subjects were analyzed. Severe FH was defined as untreated LDL-C>10.3 mmol/l, LDL-C>8.0 mmol/l+ 1 high-risk feature, LDL-C>4.9 mmol/l + 2 high-risk features or presence of clinical ASCVD according to IAS proposed statement. Cardiac (cardiac death and ACS) and non-cardiac (stroke and peripheral artery disease) events were compared in severe and non-severe FH subjects.

Results

Severe FH was identified in 50.1% of study subjects. They exhibit increased levels of LDL-C and Lipoprotein (a) with a higher frequency of LDLR mutation. Furthermore, a proportion of %LDL-C reduction>50% was greater in severe FH under more lipid-lowering therapy (Table). However, during the observational period (median=6.3 years), severe FH was associated with a 5.9-fold (95% CI, 2.05–25.2; p=0.004) and 5.8-fold (95% CI, 2.02–24.7; p=0.004) greater likelihood of experiencing cardiac-death/ACS and stroke/PAD, respectively (picture). Multivariate analysis demonstrated severe FH as an independent predictor of both cardiac-death/ACS (hazard ratio=3.39, 95% CI=1.12–14.7, p=0.02) and stroke/PAD (hazard ratio=3.38, 95% CI=1.16–14.3, p=0.02) events.

Clinical characteristics of severe FH Non-severe FH Severe FH P-value Baseline LDL-C (mmol/l) 5.3±1.5 6.6±2.0 <0.0001 Lp(a) (mg/dl) 15 [8–28] 21 [10–49] <0.0001 LDLR mutation (%) 49.6% 58.9% 0.00398 On-treatment LDL-C (mmol) 133 [106–165] 135 [103–169] 0.9856 %LDL-C reduction>50% 21.3% 49.8% <0.0001 High-intensity statin (%) 13.3% 42.3% <0.0001 PCSK9 inhibitor (%) 6.3% 21.2% <0.0001

Clinical outcome

Conclusions

Severe FH subjects exhibit substantial atherosclerotic risks for coronary, carotid and peripheral arteries despite lipid lowering therapy. Our finding underscore the screening of systemic arteries and the adoption of further stringent lipid management in severe FH patients.

P1828Aortic calcification detected by computed tomography and aortic vulnerable plaques: aortic angioscopy study

Background

Aortic calcification is associated with atherosclerotic risk factors and an increased risk of death and cardiovascular disease. However, the relationships aortic calcification and aortic plaque instability are not yet elucidated. Recently, some reports showed non-obstructive aortic angioscopy seemed to visualize atherosclerotic changes of aortic wall more clearly compared with computed tomography (CT). The purpose of this study was to evaluate whether aortic calcification is associated with aortic vulnerable plaques in patients with cardiovascular disease.

Methods

We investigated 60 consecutive patients with confirmed or suspected coronary artery disease who underwent both aortic angioscopy and CT. The AC volume (ACV) was measured using the volume-rendering method by extracting the area >130 HU within the whole aorta. ACV index (ACVI) was defined as ACV divided by the body surface area. We evaluated the number of ruptured plaque (RP), ulceration and fissure by aortic angioscopy in the whole aorta. We excluded 4 hemodialysis patients. All patients were divided into the median value of ACVI.

Results

The mean age of patients was 68±10. The median of ACVI was 10.7 ml/m2 [3.9–22.7]. High ACVI patients had significantly greater number of RP, ulceration and atheromatous plaques detected by aortic angioscopy compared with those of low ACVI (2.2±2.7 vs 0.8±1.1, p=0.033, 1.6±1.2 vs 0.9±1.0, p=0.041, 4.0±3.1 vs 1.9±1.8, p=0.009, respectively). Furthermore, the patients without aortic calcification did not have RP at all. In a multivariate model, the number of the atheromatous plaques was independently associated with high ACVI (odds ratio 1.57, 95% confidence interval 1.07–2.69, p=0.018)

Conclusions

Aortic calcification detected by CT was related to aortic vulnerable plaques in patients with cardiovascular disease.

P3471Anti-inflammatory effects of direct oral anticoagulants in patients with non-valvular atrial fibrillation: insights from 2216 patients in the DIRECT registry

Background

Several previous studies reported anti-inflammatory effect of direct oral anticoagulant (DOAC). However, it was limited to basic pathological data with small sample size. Real-world large clinical data is still scarce.

Methods

We conducted a single-center prospective observational registry of NVAF patients treated with DOACs: the DIRECT registry (UMINehz745.034333283). All patients with nonvalvular atrial fibrillation (NVAF) (N=2216) who were users of dabigatran (N=648), rivaroxaban (N=538), apixaban (N=599), or edoxaban (N=431) from June 2011 to November 2017 were enrolled (71.6±10.8 years, 36.4% female, follow-up duration: 407.2±388.3 days). High sensitive C-reactive protein (hsCRP) test was performed before (within 3 months from the start) and after the start of DOAC prescription (6±3 months after the start). Patients with a hsCRP value >1.00 mg/dL were excluded from the analysis due to possibility of other systemic inflammatory conditions. The present post-hoc study of the DIRECT registry assessed anti-inflammatory effect of DOAC. Pre-hsCRP and post-hsCRP were compared by Wilcoxon Signed Ranks test.

Results

A total of 1,855 patients were analyzed in the present study (71.0±10.7 years, 677/1,855 (36%) females). In the overall cohort, hsCRP significantly decreased after the start of DOAC prescription (pre median 0.08 interquartile range [0.04–0.17] mg/dL vs. post 0.06 [0.03–0.12] mg/dL, p<0.001). The significant reduction of hsCRP was consistent across all DOACs (p=0.301) [dabigatran (N=562), pre 0.08 [0.04–0.1625] mg/dL vs. post 0.06 [0.03–0.12] mg/dL, p<0.001: rivaroxaban (N=457), pre 0.07 [0.04–0.16] mg/dL vs. post 0.07 [0.03–0.125] mg/dL, p<0.001: apixaban (N=494), pre 0.09 [0.04–0.19] mg/dL vs. post 0.06 [0.03–0.13] mg/dL, p<0.001: edoxaban (N=342), pre 0.08 [0.04–0.19] mg/dL vs. post 0.06 [0.03–0.13] mg/dL, p<0.001].

Conclusions

The present study of DIRECT registry suggested anti-inflammatory effect of DOAC presented as a significant reduction of hsCRP. Although further investigation would be warranted to evaluate the clinical significance of the suppressed systemic inflammation, the recent favorable clinical data of DOACs might be attributed to the present finding.

P1701Sex-related difference in receiving bystander cardiopulmonary resuscitation and clinical outcome among out-of-hospital cardiac arrest patients

Background

Early studies from US and Europe have reported that female out-of-hospital cardiac arrest (OHCA) patients were less likely to receive bystander cardiopulmonary resuscitation (CPR). However, little is known about sex-related difference in receiving CPR and clinical outcome among adult OHCA patients in Japan.

Methods

This study was a nation-wide, population-based observational study of OHCA in Japan from 2011 to 2015. We included all adult cardiogenic OHCA patients. We excluded patients witnessed by emergency medical services (EMS) from the present analysis. To account for the age-related difference, we stratified by age category: 18–39, 40–64, 65–79, and ≥80. To examine the association between patient sex and neurological outcome at 30-day, we fitted multivariable logistic regression model with adjustment for age, bystander CPR status, first document rhythm, dispatcher instruction and EMS response time.

Results

There were 339,317 adult cardiogenic, not EMS-witnessed OHCA patients (median age, 80; female, 43.5%) in Japan from 2011 to 2015. Overall, 171,122 (50.4%) received CPR by citizen, 34,283 (10.1%) had initial shockable rhythm, and 11,421 (3.4%) had favorable neurological status at 30-day. Female patients were more likely to receive bystander CPR (vs. male; 53.8% vs. 47.8%), and were less likely to have initial shockable rhythm (5.2% vs. 13.9%) and favorable neurological status at 30-day (1.8% vs. 4.6%) (all; p<0.001). With stratification by age category, elderly female patients (aged ≥65) were more likely to received bystander CPR (P<0.001), whereas male patients were more likely to received bystander CPR among patients aged <40. Multivariable logistic regression analysis showed that female patients had a lower rate of favorable neurological status at 30-day, compared to male patients in all age categories (all; P<0.05).

Sex difference in bystander CPR Overall Male (n=191,672) Female (n=147,645) p-value All (n=339,317) 50.4% 47.8% 53.8% <0.001 Aged 18–39 (n=6,216) 56.0% 56.9% 53.5% 0.02 Aged 40–64 (n=50,320) 48.5% 48.5% 48.3% 0.69 Aged 65–80 (n=105,141) 46.5% 45.5% 48.3% <0.001 Aged ≥80 (n=177,640) 53.2% 49.0% 56.7% <0.001

OR for neurological outcome at 30-day

Conclusion

Unlike the situation in Europe and US, female OHCA patients, especially elderly female, were more likely to receive bystander CPR in Japan. However, female patients had worse clinical outcome after OHCA. Further investigations including in-hospital treatment are needed to clarify the sex-difference in clinical outcome after OHCA.

Acknowledgement/Funding

None

P827EXPLORE-J: Lipid management and 2-year long-term clinical outcome in Japanese patients with acute coronary syndrome

Background

The cardiovascular event rate in Japan is much lower than that in Western countries. However, the incidence of atherosclerotic CV disease and its burden are expected to increase in the Japanese society with rapid aging, westernization of lifestyles and metabolic derangement. An increase in patients with CAD has been remarkable in spite of various preventive measures. The positive linear correlation of LDL-C level with CAD incidence along with LDL-C lowering and CAD event reduction is established by large-scale studies in Western countries, but data in Japan are limited. EXPLORE-J, observational study, was conducted to gain insights into the relationship between LDL-C management and CV events in the Japanese ACS patients.

Purpose

The primary objective was to evaluate the status of post-ACS lipid management and CV events in Japan.

Method

ACS patients aged ≥20 years were enrolled and followed up for 2 years. The primary endpoint was the incidence proportion of major adverse cardiovascular events (MACE), including CV death (death associated with MI/stroke and other CV deaths), non-fatal ACS/stroke requiring hospitalization during the observation period. Other endpoints were medications and metabolic parameters. Additional stratified analyses of MACE incidence proportions by median LDL-C reduction category (above/below absolute or % reduction) from the first measurement after ACS to V1 (Day 1 + 14 days) was also conducted.

Result

Of the 2016 registered patients, 1944 were analyzed. The mean age and BMI were 66.0 years and 24.2 kg/m2, respectively. At 2-year follow up, the cumulative incidence proportion of MACE was 6.8%. The cumulative incidence proportions of CV death, non-fatal ACS and stroke were 0.7%, 4.5% and 1.7%, respectively. Statin, intensive statin, and ezetimibe were prescribed, respectively, to 93.6%, 8.2%, and 3.9% at V1, and 92.3%, 10.5%, and 11.6% at V5 (Day 730±30 days).

The mean LDL-C levels were 121.2, 99.4, 80.9, and 79.8 mg/dL at the first measurement after ACS, V1, V2 (Day 30±7 days) and V5, respectively. The proportions of patients who achieved LDL-C <70 and <100 mg/dL at V1 and V5 were 14.4% to 34.6% and 56.5% to 82.8%, respectively. The incidence rate of MACE was lower among patients with larger than median absolute reduction in LDL-C level than among those with smaller reduction (median −17.0 mg/dL; 5.5% vs 8.3%, p=0.0435). The same trend was observed in patients with higher LDL-C reduction rate (median −15.36%; 6.3% vs 7.6%, p=0.4302).

Kaplan-Meier estimates of MACE incidence

Conclusion

The results show the status of medical management and CV event rates in post-ACS Japanese patients. It also shows that half of the ACS patients did not achieve the recommended LDL-C levels of <70 mg/dL per guidelines, indicating the need to intensify lipid lowering therapy. To further characterize and quantify the patient population and the benefit of lipid management, we plan to conduct additional analyses with risk stratification of the population.

Acknowledgement/Funding

This study was sponsored by Sanofi and Regeneron Pharmaceuticals, Inc.

P767Survey of palliative sedation at the end-of-life in terminally ill heart failure patients - a five year experience in national cardiovascular center

Background

Palliative sedation is a therapeutic option when symptom relief is difficult to achieve at the end-of-life. However, little is known regarding palliative sedation in terminally ill heart failure (HF) patients.

Purpose

To survey the practice of palliative sedation in terminally ill HF patients at a tertiary referral cardiovascular center, and to investigate the efficacy and safety of sedative agents in HF patients.

Methods

We retrospectively reviewed consecutive patients who were referred to palliative care team at our institution between September 2013 and August 2018. Patients who were hospitalized for HF and died during hospitalization despite optimal medical therapy were selected and defined as terminally ill HF. We investigated the practice of palliative sedation in terminally ill HF patients and analysed the vital signs and sedation scale before starting sedative agents and about 1 hour afterward.

Results

Among 95 terminally ill HF patients, 37 were prescribed palliative sedation at the end-of-life (Picture). Of 37 patients (mean age: 70 years, median B-type natriuretic peptide: 1018 pg/ml, median creatinine: 3.0 mg/dl, intravenous inotrope: 81%), 25 were prescribed dexmedetomidine, and 12 were prescribed midazolam as first agent for sedation. Patient's backgrounds were comparable between the two groups. Richmond Agitation-Sedation Scale was significantly reduced (P<0.01), whereas blood pressure and heart rate were not altered after treatments in both groups. In midazolam group, significant decreases were noted regarding respiratory rate (P=0.01) and oxygen saturation (P=0.02); however, these parameters were not changed in dexmedetomidine group (Table).

Table 1. Vital signs and sedation scale Dexmedetomidine group (n=25) Midazolam group (n=12) Baseline After P value Baseline After P value Richmond Agitation-Sedation Scale 1 (0, 1) −1 (−2, 0) <0.01 1 (0, 1) −2 (−3, −1) <0.01 Vital signs   Systolic blood pressure (mmHg) 90±15 89±16 0.51 89±21 84±23 0.33   Diastolic blood pressure (mmHg) 52±13 54±11 0.34 60±14 56±23 0.48   Heart rate (beats per minute) 95±20 91±22 0.17 90±21 90±19 0.70   Respiratory rate (breaths per minute) 22±5 20±5 0.24 21±5 17±2 0.01   Oxygen saturation (%) 97±3 96±6 0.59 96±5 94±5 0.02

Picture. Study flowchart

Conclusions

Dexmedetomidine and midazolam were commonly used in real-word practice for HF patients at the end-of-life. Although impact on respiratory system differed by treatments, both agents could be prescribed effectively and safely in terminally ill HF patients.

6125High wall shear stress predicts plaque rupture of the aortic arch: computational fluid dynamics model and non-obstructive general angioscopy study

Background

Wall shear stress (WSS) has been considered as a major determinant of aortic atherosclerosis. Recently, non-obstructive general angioscopy (NOGA) was developed to be able to visualize a variety of its atherosclerotic pathology, including in vivo ruptured plaque (RP) in the aorta. We, therefore, investigated the relationship between NOGA derived RP in the aortic arch and the stereographic distribution of WSS by using computational fluid dynamics modeling (CFD) on three-dimensional CT angiography (3D-CT).

Methods

We investigated 30 consecutive patients who underwent 3D-CT before and NOGA during coronary angiography. WSS in the aortic arch was measured with an application of CFD based on finite element method by using uniform inlet and outlet flow conditions. Aortic RP was detected by NOGA.

Results

The maximum and mean values of WSS were 67.2±29.2 Pa and 2.4±0.6 Pa. A total of 18 RPs was detected by NOGA. The patients with a distinct RP showed a significantly higher maximum WSS in the whole aortic arch, and the greater and lesser curvature of the aortic arch than those without it (73.3±29.0 Pa vs 50.4±15.2 Pa, p=0.035, 95.0±27.5 Pa vs 42.8±25.2 Pa, p=0.003, 70.8±29.3 Pa vs 46.1±11.9 Pa, p=0.013, respectively), whereas there was no significant difference in the mean WSS between those with and without it. In a multivariate analysis, the maximum value of WSS was an independent predictor of RP in the aortic arch (odds ratio 1.05, 95% confidence interval 1.01–1.13, p=0.019).

Representative picture of WSS and NOGA

Conclusions

Aortic RP detected by NOGA was strongly associated with the higher maximum WSS in the aortic arch derived by CFD using 3D-CT. Maximum WSS may explain the underlying mechanism of not only aortic atherosclerosis, but also aortic RP.

P1831Prediction of cardiovascular events by atheromatous plaques detected by non-obstructive general angioscopy: two-year results of EAST-NOGA Registry

Background

Non-obstructive general angioscopy (NOGA) has revealed the intimal damages or atheromatous plaques as well as its spontaneous rupture of the aorta. Recent study revealed that plaque debris or different size of cholesterol crystals were detected in the blood above the spontaneous ruptured aortic plaque observed by NOGA and these plaque materials might cause the peripheral organ damages as the embolic source. These various morphological changes may cause the acute aortic events or atheroembolic events on the peripheral organs, such as brain, kidney, peripheral artery and so on.

Purpose

EAST-NOGA (Evaluation of AtheroSclerotic and rupture events by Non-Obstructive General Angioscopy) is a multi-center prospective observational study to assess the relationship between the findings of NOGA and future cardiovascular events.

Methods

Five hundred and seventy-seven patients with atherosclerotic cardiovascular disease who underwent NOGA study. The major cerebrocardiovascular events including cardiovascular death, non-fatal myocardial infarction, non-fatal cerebral infarction, and acute aortic syndrome were accumulated during the 2-year follow-up after NOGA study.

Results

The median number of aortic atheromatous plaques was 6 [IQR: 3–12]. A total of 514 patients were followed up (89.1%). The mean follow-up duration was 757±120 days. Major adverse cardiovascular events developed in 23 (4.5%) during 2 years follow-up. Patients with MACE and cerebral infarction, had significantly greater number of aortic atheromatous plaques (11 [5–19] vs. 6 [3–11], p<0.001, 12 [4–20] vs. 6 [3–12], p=0.014, respectively). In a univariate analysis, the number of aortic atheromatous plaques and ruptured plaque were significant predictors of MACE (HR: 1.09 95% confidence interval 1.05–1.14, p<0.001) and (HR: 1.12, 95% confidence interval 1.02–1.23, p=0.02). In a multivariate logistic analysis, the number of aortic atheromatous plaques is one of the independent predictors of MACE (HR 1.05, 95% confidence interval 1.00–1.10, p=0.032).

Conclusion

The number of atheromatous plaques identified by NOGA has a significant relation to the onset of cerebral infarction, which suggest the atheromatous plaque were vulnerable and ruptured spontaneously, then cause the aortogenic cerebral infarction. The NOGA study would be useful for predicting the futured atheroembolic events.

Acknowledgement/Funding

None

Cognitive burden and polypharmacy in elderly Japanese patients treated with anticholinergics for an overactive bladder

This study aimed to investigate the cognitive burden and polypharmacy in elderly patients treated with anticholinergics for an overactive bladder. We conducted a retrospective study of patients with an overactive bladder receiving treatment at two hospitals in Japan (Nara Medical University Hospital and Saiseikai Nara Hospital). Prescription data were collected from the medical records of the patients registered between January 2013 and April 2014. The Anticholinergic Cognitive Burden Scale was used to estimate the severity of the anticholinergic effects on the cognition of each patient. We collected the prescription data of 584 and 246 patients from the Nara Medical University Hospital and Saiseikai Nara Hospital, respectively. The mean daily total Anticholinergic Cognitive Burden score ranged between 3 and 4 (3.59 ± 1.16 at Nara Medical University Hospital vs 3.32 ± 0.78 at Saiseikai Nara Hospital, P < 0.01). At both hospitals, the mean number of prescriptions was >5 in patients ≥75 years (5.95 ± 4.43 and 5.64 ± 3.90 at Nara Medical University Hospital and Saiseikai Nara Hospitals, respectively). Our findings suggest that 10%-20% of elderly patients (≥65 years) receiving treatment with anticholinergics for an overactive bladder are in a state of polypharmacy. The total anticholinergic cognitive burden of each patient mainly depends on the anticholinergics being used for treating the overactive bladder. Especially for elderly patients with a high risk of adverse effects, including cognitive impairment, careful attention needs to be paid during selection of drugs for treating patients with an overactive bladder.

Tadalafil, a phosphodiesterase type 5 inhibitor, restores urethra and detrusor function in the initial phase of diabetes in rats

OBJECTIVE

This study investigated the effects of tadalafil on the urethra and detrusor in the initial phase of diabetes in rats.

METHODS

Thirty-six female Sprague-Dawley rats were assigned to a non-diabetes (ND), diabetes (D), or tadalafil-treated diabetes (DT) group (n = 12 per group), with the DT group receiving oral tadalafil (2 mg/kg/d) for 7 days before the experiments. Seven weeks after diabetes induction (by a single intraperitoneal injection of streptozotocin), urethral and intravesical pressure were simultaneously recorded in vivo, whereas responses of detrusor strips to potassium chloride (30 mM), electrical field stimulation (EFS) and carbachol were measured in vitro.

RESULTS

The intravesical pressure at which the urethra started to relax was significantly lower in the DT than D group (mean [± s.d.] 18.9 ± 2.9 vs 29.1 ± 6.6 cm H₂ O; P < .05). In addition, the reduction in urethral pressure was significantly larger in the DT than D group (-10.9 ± 4.0 vs -4.0 ± 2.9 cm H₂ O; P < .05). Detrusor stimulation revealed that the mean contractile responses to EFS and carbachol were significantly lower in the ND and DT groups than in the D group (120.7 ± 26.5% and 130.8 ± 15.8% vs 200.1 ± 47.9% of the 30 mM KCl-induced contraction, respectively, in response to 50 Hz EFS [P < .05]; 211.1 ± 35.4% and 208.4 ± 25.3% vs 425.7 ± 125.0% of the 30 mM KCl-induced contraction, respectively, in response to 10^-3 M carbachol [P < .05]).

CONCLUSIONS

Tadalafil restored urethral relaxation function and detrusor responses to EFS and carbachol during the initial phase of diabetes.

Aquaporin-2 plays an important role in water transportation through the bladder wall in rats

AIM

We investigated the role of the bladder wall in permeating water, focusing on aquaporins.

METHODS

Female Sprague-Dawley rats weighing 300 g were used to investigate the role of the bladder wall in saline permeation. Changes in intravesical fluid volume and sodium concentration were measured in the desmopressin acetate hydrate-loaded and control groups 3 h after administration. Bladders were resected to measure aquaporin-1, 2, and 3 gene expression using qRT-PCR. Additionally, the change of aquaporin-2 expression was measured using Western blotting and immunohistochemistry in intravesical aquaporin-2 siRNA-treated and control groups.

RESULTS

Although the intravesical fluid volume and sodium concentration significantly decreased from 0 to 3 h (1.00 ± 0.00 vs 0.83 ± 0.08 mL, 157.80 ± 1.30 vs 146.8 ± 1.92 mEq/mL, P < 0.01, respectively in the control group), administration of desmopressin did not affect the extent of volume change. Aquaporin-2 expression was significantly higher in the 3-h distended bladders than in the empty bladder. Aquaporin-2 siRNA treatment suppressed aquaporin-2 expression and the change of intravesical fluid volume from 0 to 3 h (1.00 ± 0.00 and 0.99 ± 0.02 mL), which was related to the suppression of sodium concentration change in comparison with control siRNA treatment (149.6 ± 2.4 vs 143.6 ± 3.67 mEq/mL, P < 0.05).

CONCLUSIONS

The rat urinary bladder absorbs water and salts under the full-filled condition. Aquaporin-2 plays an important role in the transport of water, accompanied by sodium concentration change. We demonstrated a part of the bladder absorption mechanism, which may lead to development of a new method for regulating bladder storage function.

Overactive bladder induces transient hypertension

Objectives

Several studies have shown the relationship between lower urinary tract symptoms and autonomic imbalance. We investigated the relationship between detrusor overactivity (DO) or urgency, and transient increase in blood pressure as a type of hypertension related to sympathetic hyperactivity. Study 1: we enrolled 14 male patients with DO and 10 without DO. We measured the overactive bladder symptom score (OABSS) and blood pressure during cystometry. Study 2: we enrolled 14 men patients with overactive bladder (OAB) and 8 without OAB. We measured OABSS and blood pressure using a 24-h ambulatory device.

Results

Study 1: the mean systolic pressure was significantly higher at urgency or SDV than at the other measurement points in the DO group (161.3 ± 23.2 vs. 134.5 ± 16.3, 137.8 ± 15.3, or 139.5 ± 14.8 mmHg). Study 2: the mean systolic pressure was significantly higher at the measurement points before micturition than at the points unrelated to micturition in the OAB group (159.7 ± 24.9 vs. 124.9 ± 13.8 mmHg). In conclusion, DO or urgency induces a transient increase of blood pressure, suggesting that OAB induces a type of hypertension before micturition.

Morphological changes in different populations of bladder afferent neurons detected by herpes simplex virus (HSV) vectors with cell-type-specific promoters in mice with spinal cord injury

Functional and morphological changes in C-fiber bladder afferent pathways are reportedly involved in neurogenic detrusor overactivity (NDO) after spinal cord injury (SCI). This study examined the morphological changes in different populations of bladder afferent neurons after SCI using replication-defective herpes simplex virus (HSV) vectors encoding the mCherry reporter driven by neuronal cell-type-specific promoters. Spinal intact (SI) and SCI mice were injected into the bladder wall with HSV mCherry vectors driven by the cytomegalovirus (CMV) promoter, CGRP promoter, TRPV1 promoter or neurofilament 200 (NF200) promoter. Two weeks after vector inoculation into the bladder wall, L1 and L6 dorsal root ganglia (DRG) were removed bilaterally for immunofluorescent staining using anti-mCherry antibody. The number of CMV promoter vector-labeled neurons was not altered after SCI. The number of CGRP and TRPV1 promoter vector-labeled neurons was significantly increased whereas the number of NF200 vector-labeled neurons was decreased in L6 DRG after SCI. The median size of CGRP promoter-labeled C-fiber neurons was increased from 247.0 in SI mice to 271.3μm² in SCI mice whereas the median cell size of TRPV1 promoter vector-labeled neurons was decreased from 245.2 in SI mice to 216.5μm² in SCI mice. CGRP and TRPV1 mRNA levels of laser-captured bladder afferent neurons labeled with Fast Blue were significantly increased in SCI mice compared to SI mice. Thus, using a novel HSV vector-mediated neuronal labeling technique, we found that SCI induces expansion of the CGRP- and TRPV1-expressing C-fiber cell population, which could contribute to C-fiber afferent hyperexcitability and NDO after SCI.