Two-dimensional echocardiographic scoring system of the left ventricular filling pressure and clinical outcomes in heart failure with preserved ejection fraction

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Japan Society for the Promotion of Science (JSPS)

Introduction

Elevated left ventricular (LV) filling pressure in non-decompensated state is a powerful indicator of worse clinical outcomes in heart failure regardless of LV ejection fraction. However, its detection is often challenging in heart failure with preserved ejection fraction (HFpEF).

Purpose

This study aimed to elucidate the predictive value of recently proposed echocardiographic parameter of LV filling pressure, Visually assessed time difference between the Mitral valve and Tricuspid valve opening (VMT) score in HFpEF.

Methods

We retrospectively analyzed 310 well-differentiated HFpEF patients in stable conditions. Using two-dimensional echocardiographic images, time sequence of opening of mitral valve and tricuspid valve was visually assessed in the apical four-chamber view and scored to 0 to 2 (0: tricuspid valve first, 1: simultaneous, 2: mitral valve first). When the inferior vena cava diameter was dilated, 1 point was added and VMT score was calculated as four grades from 0 to 3. Based on the previous study, VMT≥2 was regarded as a sign of elevated LV filling pressure (Figure 1). LV diastolic function was graded according to the guidelines. The primary endpoint was defined as a composite of cardiac death and heart failure hospitalisation during the two years after echocardiographic examination.

Results

During the follow-up period, 55 events (18%) occurred, including four cardiac deaths and 51 heart failure hospitalisations. Kaplan-Meier curves demonstrated that VMT≥2 (n = 54) was associated with worse outcomes compared to patients showing VMT ≤ 1 (n = 256) (log-rank test P <0.001). Furthermore, VMT≥2 was associated with worse outcomes when tested in 100 HFpEF patients with atrial fibrillation (log-rank test P = 0.026) (Figure 2). In the adjusted model including age, systolic blood pressure, serum albumin level, and the LV diastolic function grading, VMT≥2 was independently associated with the primary outcome (hazard ratio: 2.23; 95% confidence interval: 1.17 to 4.24, P = 0.014). Additionally, the nested regression model showed that VMT scoring provided an incremental prognostic value over clinically relevant variables (age, sex, the plasma brain natriuretic peptide level, atrial fibrillation) and LV diastolic function grading (chi-square 10.8 vs 16.3, P = 0.035).

Conclusions

In patients with HFpEF, the VMT score was independently and incrementally associated with adverse clinical outcomes. Moreover, it discriminated worse clinical outcome even in HFpEF patients with atrial fibrillation. Abstract Figure. VMT scoring  Abstract Figure. Kaplan-Meier analysis

Novel -75°C SEM cooling stage: application for martensitic transformation in steel

Microstructural changes during the martensitic transformation from face-centred cubic (FCC) to body-centred cubic (BCC) in an Fe-31Ni alloy were observed by scanning electron microscopy (SEM) with a newly developed Peltier stage available at temperatures to  −75°C. Electron channelling contrast imaging (ECCI) was utilized for the in situ observation during cooling. Electron backscatter diffraction analysis at ambient temperature (20°C) after the transformation was performed for the crystallographic characterization. A uniform dislocation slip in the FCC matrix associated with the transformation was detected at −57°C. Gradual growth of a BCC martensite was recognized upon cooling from −57°C to −63°C.

Simple echocardiographic scoring system to estimate left ventricular filling pressure based on visual assessment of time sequence of mitral and tricuspid valve opening

Introduction

In the presence of elevated left ventricular (LV) filling pressure, mitral valve (MV) becomes to open early and precedes tricuspid valve (TV) opening in early diastole. Accordingly, time-delay of right ventricular inflow relative to LV inflow assessed by dual Doppler system was recently reported as a parameter of LV filling pressure. We assumed that visually-assessed time-delay of TV relative to MV opening could be a simple and alternative marker of elevated LV filling pressure.

Purpose

This study aimed to elucidate the clinical usefulness of the 2-dimensional echocardiographic scoring system, Visual assessment of time-difference between Mitral and Tricuspid valve opening (VMT) score, in patients with heart failure (HF).

Methods

We analyzed 119 consecutive HF patients who underwent echocardiography and cardiac catheterization within a day. Elevated LV filling pressure was defined as mean pulmonary arterial wedge pressure (PAWP) ≥15 mmHg. LV diastolic function was graded according to the ASE/EACVI recommendations. Time sequence of opening of MV and TV was visually assessed in the apical 4-chamber view and scored to 3 grades (0: TV opening first, 1: simultaneous, 2: MV opening first). When the inferior vena cava diameter was >21 mm and collapsed <20% during normal respiration, 1 point was added and VMT score was calculated as 4 grades from 0 to 3. We also investigated 113 patients without worsening HF at VMT scoring for cardiac events defined as worsening HF, LV assist device implantation, or cardiac death for 1 year after the echocardiography.

Results

VMT was scored as 0 in 20 patients, 1 in 50 patients, 2 in 37 patients, and 3 in 12 patients. PAWP was elevated in patients with VMT score of 2 and 3 (0: 10±5, 1: 12±4, 2: 22±8, 3: 28±4 mmHg, ANOVA P<0.001) (Figure). In overall patients, VMT≥2 predicted elevated PAWP with accuracy of 86%. When the accuracy was tested in patients with reduced (<40%, HFrEF) and preserved LV ejection fraction (≥40%) respectively, the accuracy was excellent in HFrEF (96% and 77%, respectively). Importantly, VMT≥2 also had good accuracy of 82% for elevated PAWP in 33 patients in whom recommendations usually cannot grade diastolic function due to monophasic LV inflow. In the sequential Cox models, the addition of VMT score to the model including the plasma brain natriuretic peptide (BNP) level and LV diastolic grading improved the predictive power for elevated PAWP (P<0.001). During the follow-up, 20 cardiac events were observed (6 worsening HF, 9 LV assist device implantation and 5 cardiac death). Kaplan-Meier analysis showed that the patients with VMT≥2 were at higher risk of cardiac events than those with VMT≤1 (log-rank test P<0.001) (Figure).

Conclusions

The VMT score was a simple and accurate marker of elevated LV filling pressure and has an incremental benefit over BNP and LV diastolic function grading. Moreover, it could be a novel prognostic marker in patients with HF.

Figure 1

Funding Acknowledgement

Type of funding source: None

Association between accessibility to elementary school and depression in older Adults: JAGES Study

Background

The connection in a local community has diluted in an aging society, and the importance of intergenerational exchange has increased for older adults' health. Some positive effects of intergenerational exchange have reported. For example, a reciprocal intergenerational exchange contributes to better mental health in later life. However, there is little evidence of the relationship between neighborhood environments causing intergenerational exchange and the health status of older adults. This study investigated the association between geographical accessibility to elementary school, enhancing intergenerational exchange, and depression in older adults.

Methods

The data were retrieved from the Japan Gerontological Evaluation Study (JAGES) 2016, a population-based study of independently living people ≥65 years old. The dependent variable is depression evaluated by the Geriatric Depression Scale (GDS≥5). The geographical accessibility to elementary School is the distance between the representative points of their residences and the nearest elementary school. Logistic regression analysis calculates the odds ratio to determine the association between depression and accessibility to elementary school and compare models to examine the effect of intermediate factors.

Results

Overall, 20.4% of the participants had depression. Compared with the longest distance from elementary school (≥950m), the odds ratio was 0.91 (95% CI = 0.86, 0.96) for the nearest category (<330m), 0.91 (95% CI = 0.87, 0.96) for the second-nearest (330-490m) and 0.94 (95% CI = 0.89, 0.99) for the third (490-670m) in model 1. After adjusting for intermediate factors, the odds ratio was 0.94 for the first and second-nearest groups.

Conclusions

Geographical accessibility to elementary school was associated with decreased depression for older adults. The result indicates that older adults' daily meetings with children around elementary schools can result in a positive effect on their mental health.

Key messages

Geographical accessibility to elementary school was associated with decreased depression for older adults. The neighborhood design enhancing intergenerational exchange might be useful for age-friendly cities.

Basic evaluation of a novel 4D target and human body phantom

Stereotactic body radiation therapy (SBRT) is usually verified with a dynamic phantom or solid phantom, but there is a demand for phantoms that can accurately simulate tumor dynamics within an individual that would allow customized validation in every patient. We developed a new 4D dynamic target phantom (multi-cell 4D phantom) that allows simulation of tumor movement in patients. The basic quality and dynamic reproducibility of this new phantom was verified in this investigation. The newly developed multi-cell 4D phantom comprises four main components: soft tissue, bones, lungs, and tumor (target). The phantom structure was based on computed tomography (CT) data of a male. In this study, we investigated the basic performance of a multi-cell 4D phantom. All the CT numbers of the phantom were very close to those of human data. The geometric maximum amplitudes were 4.57 mm in the lateral direction, 4.59 mm in the ventrodorsal direction, and 3.68 mm in the cranio-caudal direction. Geometric errors were 0.84, 0.58, and 0.40 mm, respectively. Movements of the abdominal surface were stable for 60 s. Repeated measurements show no actual differences in target movements between multiple measurements and indicated high reproducibility (r  >  0.97). End-to-end tests using Gafchromic film revealed a gamma pass rate of 98% or above (2 mm/3%). Although our phantom performed limited reproducibility in the movement of the patient tumor at present, a satisfactory level of precision was confirmed in general. This is a very promising device for use in the verification of radiation therapy for moving targets.

X-ray photoelectron spectroscopy and transmission electron microscopy analysis of silver-coated gold nanorods designed for bionanotechnology applications

Multicomponent nano-agents were designed and built via a core-shell approach to enhance their surface enhanced Raman scattering (SERS) signals. These nano-agents had 36 nm × 12 nm gold nanorod cores coated by 4 nm thick silver shell films and a subsequent thin bifunctional thiolated polyethylene glycol (HS-PEG-COOH) layer. Ambient time-lapsed SERS signal measurements of these functionalized nanorods taken over a two-week period indicated no signal degradation, suggesting that large portions of the silver shells remained in pure metallic form. The morphology of the nanorods was characterized by transmission electron microscopy (TEM) and ultra-high resolution scanning TEM. X-ray photoelectron spectroscopy (XPS) and Auger electron spectroscopy (AES) were utilized to assess the oxidation states of the silver shells covered by HS-PEG-COOH. The binding energies of Ag 3d XPS spectra yielded very small chemical shifts with oxidation; however, the AES peak shapes gave meaningful information about the extent of oxidation undergone by the nano-agent. While the silver shells without HS-PEG-COOH coatings oxidized significantly, the silver shells with HS-PEG-COOH remained predominantly metallic. In fact, six month-old samples still retained mostly metallic silver shells. These findings further demonstrate the stability and longevity of the nanostructures, indicating their significant potential as plasmonically active agents for highly sensitive detection in various biological systems, including cancer cells, tissues, or even organisms.

Polymorphisms in PTCH1 Affect the Risk of Ameloblastoma

Ameloblastoma is the most common odontogenic tumor, but the genetic nature of the changes in the tumor cells has been unclear. Mutations of CTNNB1 or PTCH1 are observed in many human tumors. Both CTNNB1 and PTCH1 are important in tooth development and are expressed in ameloblastoma. The aim of this study was to investigate whether genetic alterations of CTNNB1 and PTCH1 are present in ameloblastoma. We investigated 14 cases of ameloblastoma. The polymorphisms found in the ameloblastoma patients were further examined in a subsequent case-control study. We found a CTNNB1 mutation in one case of plexiform-type ameloblastoma. CGG triplet repeat-number polymorphism (CGG7/CGG8) in the 5′-untranslated region of PTCH1 was observed. The proportion of CGG8 alleles was significantly higher in the ameloblastoma group. The results of this study indicate a possible relationship between the CGG8 allele in PTCH1 and the risk for ameloblastoma.

Imaging of surface spin textures on bulk crystals by scanning electron microscopy

Direct observation of magnetic microstructures is vital for advancing spintronics and other technologies. Here we report a method for imaging surface domain structures on bulk samples by scanning electron microscopy (SEM). Complex magnetic domains, referred to as the maze state in CoPt/FePt alloys, were observed at a spatial resolution of less than 100 nm by using an in-lens annular detector. The method allows for imaging almost all the domain walls in the mazy structure, whereas the visualisation of the domain walls with the classical SEM method was limited. Our method provides a simple way to analyse surface domain structures in the bulk state that can be used in combination with SEM functions such as orientation or composition analysis. Thus, the method extends applications of SEM-based magnetic imaging, and is promising for resolving various problems at the forefront of fields including physics, magnetics, materials science, engineering, and chemistry.

Short-term outcomes of robotic radical esophagectomy for esophageal cancer by a nontransthoracic approach compared with conventional transthoracic surgery

Transthoracic esophagectomy (TTE) is believed to have advantages for mediastinal lymphadenectomy in the treatment of resectable esophageal cancer despite its association with a greater incidence of pulmonary complications and postoperative mortality. Transhiatal esophagectomy is regarded as less invasive, though insufficient in terms of lymph node dissection. With the aim of achieving lymph dissection equivalent to that of TTE, we have developed a nontransthoracic esophagectomy (NTTE) procedure combining a video-assisted cervical approach for the upper mediastinum and a robot-assisted transhiatal approach for the middle and lower mediastinum. We prospectively studied 22 accumulated cases of NTTE and verified feasibility by analyzing perioperative and histopathological outcomes. We compared this group's short-term outcomes with outcomes of 139 equivalent esophageal cancer cases operated on at our institution by conventional TTE (TTE group). In the NTTE group, there were no procedure-related events and no midway conversions to the conventional surgery; the mean operation time was longer (median, 524 vs. 428 minutes); estimated blood loss did not differ significantly between the two groups (median, 385 mL vs. 490 mL); in the NTTE group, the postoperative hospital stay was shorter (median, 18 days vs. 24 days). No postoperative pneumonia occurred in the NTTE group. The frequencies of other major postoperative complications did not differ significantly, nor were there differences in the numbers of harvested mediastinal lymph nodes (median, 30 vs. 29) or in other histopathology findings. NTTE offers a new radical procedure for resection of esophageal cancer combining a cervical video-assisted approach and a transhiatal robotic approach. Although further accumulation of surgical cases is needed to corroborate these results, NTTE promises better prevention of pulmonary complications in the management of esophageal cancer.

Morphological and chemical analysis of bainite in Cu-17Al-11Mn (at.%) alloys by using orthogonal FIB-SEM and double-EDS STEM

In this study, new microscopy techniques were developed for understanding the mechanism for the bainitic transformation in a Cu-17Al-11Mn (at%) alloy. An orthogonally arranged focused ion beam and a scanning electron microscope were employed to observe three-dimensional (3D) morphology of the bainite phase, in addition to compositional analysis by using a scanning transmission electron microscope equipped with a double-detector energy-dispersive X-ray spectrometer system. The 3D morphology of these samples was observed at different aging times and aging temperatures; the results obtained indicated that with increasing aging time and/or aging temperature, the bainite phase at the initial stage of formation exhibits a plate-like shape, which changes to a lenticular form. A habit plane was uniquely determined as ∼{9 3 2} by the combination of 3D image reconstruction and an electron back-scattered diffraction technique. The compositional analysis revealed the spatial distribution of the compositional variation between the bainite and matrix phases in the initial stages of the transformation. In the bainite phase, the Cu concentration was higher, while the concentrations of Al and Mn were lower than those in the surrounding matrix, indicative of the diffusion of the constituent elements with the growth of the bainite phase.

Biodegradable shape memory polymers functionalized with anti-biofouling interpenetrating polymer networks

A novel type of shape memory polyurethane (SMPU) with high mechanical properties and biodegradability was constructed using a lactone copolymer (poly(ε-caprolactone-co-γ-butyrolactone), PCLBL), a diol- or triol-based chain extender (1,5-pentanediol, glycerol and 2-amino-2-hydroxymethyl-1,3-propanediol) and a diisocyanate cross-linker (1,6-hexamethylene diisocyanate).

Adverse Drug Reactions for Medicines Newly Approved in Japan from 1999 to 2013: Hypertension and Hypotension

In this survey, the correlation between adverse drug reactions (ADRs) in human and animal toxicities was investigated for 393 medicines which were approved in Japan from September 1999 to March 2013. ADRs were collected from each Japanese package insert. Comparable animal toxicities with ADRs were collected by thorough investigation of common technical documents. The results of this survey show that hypertension and/or hypotension were mainly observed in medicines affecting the central nervous system. Hypertension was also observed in antipyretics, analgesics, anti-inflammatory agents, vasoconstrictors and agents using antibody. Concordance between human ADRs and animal toxicities was analysed. True-positive rate for hypertension and hypotension is 0.29 and 0.52, respectively. Positive likelihood ratio and inverse negative likelihood ratio are 1.98 and 1.21, respectively, in hypertension and 1.67 and 1.44, respectively, in hypotension. Concordance between human ADRs and animal toxicities is not so high in hypertension and hypotension. Identified mechanisms as on-target for hypertension and hypotension are 29.8% and 30.5%, respectively. More than half of the causative factors of hypertension and hypotension were unable to be elucidated. Our results show that the intake of medicines is often linked to blood pressure variations that are not predicted in animal toxicity studies. Improvement of drug development processes may be necessary to provide safer medicines because current animal toxicity studies are insufficient to predict all ADRs in human beings.

Does surgery improve live birth rates in patients with recurrent miscarriage caused by uterine anomalies?

We found that congenital uterine anomalies have a negative impact on reproductive outcome in recurrent-miscarriage couples, being associated with further miscarriage with a normal embryonic karyotype. There has been no study comparing live birth rates between patients with and without surgery. We conducted a prospective study to prove that surgery for a bicornuate or septate uterus might improve the live birth rate. A total of 170 patients with congenital uterine anomalies suffering two or more miscarriages were examined. The live birth rate after ascertainment of anomalies, cumulative live birth rate and infertility rate, were compared between patients with and without surgery. In patients with a septate uterus, the live birth rate (81.3%) at the first pregnancy after ascertainment of anomalies with surgery tended to be higher than that (61.5%) in those without surgery. The infertility rates were similar in both groups, while the cumulative live birth rate (76.1%) tended to be higher than without surgery (60.0%). Surgery showed no benefit in patients with a bicornuate uterus for having a baby, but tended to decrease the preterm birth rate and the low birth weight. The possibility that surgery has benefits for having a baby in patients with a septate uterus suffering recurrent miscarriage could not be excluded.

PERMANENT GENETIC RESOURCES: Isolation and characterization of microsatellite loci in the cichlid fish in Lake Victoria, Haplochromis chilotes

Twelve short tandem repeat markers were successfully isolated from a cichlid, Haplochromis chilotes, in Lake Victoria, and characterized in Haplochromis pyrrhocephalus. The microsatellite regions of these markers were found to have between two and 48 alleles with heterozygosity ranging from 0.07 to 0.97. No loci showed significant departures from the Hardy-Weinberg or linkage equilibrium after the Bonferroni correction (P > 0.05). Cross-species amplification in other cichlids of Lake Victoria, Haplochromis laparogramma, Lithochromis rubripinnis, L. rufus and Haplochromis sp. 'rockkribensis', was successful.

Genetic Divergence among Southeast and East Asian Populations of Rana limnocharis (Amphibia: Anura), with Special Reference to Sympatric Cryptic Species in Java

An electrophoretic survey was conducted for the Southeast and East Asian populations of Rana limnocharis. Results indicated that specimens from a single locality in Java derived from two genodemes showing complete allelic displacement at eight out of 25 presumptive loci examined. Within each of these genodemes, genotype frequencies at all polymorphic loci were well concordant with the Hardy-Weinberg expectation. These results strongly suggest that those specimens actually represent two biological species. Comprehensive distance analyses suggested that one of the two species from Java is genetically most divergent among all samples examined, whereas the other is most similar to the Laos sample and then to a group consisting of samples from Hongkong, western China, and the southern Ryukyus. Large values of genetic distances obtained for each combination of allopatric samples imply the presence of additional cryptic species in this nominal species.