Disease-specific variant interpretation highlighted the genetic findings in 2325 Japanese patients with retinitis pigmentosa and allied diseases

BACKGROUND

As gene-specific therapy for inherited retinal dystrophy (IRD) advances, unified variant interpretation across institutes is becoming increasingly important. This study aims to update the genetic findings of 86 retinitis pigmentosa (RP)-related genes in a large number of Japanese patients with RP by applying the standardised variant interpretation guidelines for Japanese patients with IRD (J-IRD-VI guidelines) built upon the American College of Medical Genetics and Genomics and the Association for Molecular Pathology rules, and assess the contribution of these genes in RP-allied diseases.

METHODS

We assessed 2325 probands with RP (n=2155, including n=1204 sequenced previously with the same sequencing panel) and allied diseases (n=170, newly analysed), including Usher syndrome, Leber congenital amaurosis and cone-rod dystrophy (CRD). Target sequencing using a panel of 86 genes was performed. The variants were interpreted according to the J-IRD-VI guidelines.

RESULTS

A total of 3564 variants were detected, of which 524 variants were interpreted as pathogenic or likely pathogenic. Among these 524 variants, 280 (53.4%) had been either undetected or interpreted as variants of unknown significance or benign variants in our earlier study of 1204 patients with RP. This led to a genetic diagnostic rate in 38.6% of patients with RP, with EYS accounting for 46.7% of the genetically solved patients, showing a 9% increase in diagnostic rate from our earlier study. The genetic diagnostic rate for patients with CRD was 28.2%, with RP-related genes significantly contributing over other allied diseases.

CONCLUSION

A large-scale genetic analysis using the J-IRD-VI guidelines highlighted the population-specific genetic findings for Japanese patients with IRD; these findings serve as a foundation for the clinical application of gene-specific therapies.

Baseline characteristics associated with the incidence of intraocular inflammation after the intravitreous injection of brolucizumab

PURPOSE

To investigate baseline characteristics associated with the incidence of intraocular inflammation (IOI) after the intravitreal injection of brolucizumab (IVBr) for the treatment of neovascular age-related macular degeneration (nAMD).

METHODS

This retrospective study included 66 eyes of 62 consecutive patients with nAMD who received IVBr (18 eyes were treatment naïve and 48 eyes had switched from other anti-vascular endothelial growth factor [VEGF] therapy). Baseline clinical characteristics were compared in non-IOI and IOI groups.

RESULTS

Although a dry macula was achieved at a high rate even 6 months after IVBr, IOI occurred in 8 of 66 eyes (12.1%; all had switched therapy) during the study period. Baseline characteristics including age, sex, nAMD type, lens status, visual acuity, central macular thickness, and a history of diabetes did not differ between the groups. The number of previous anti-VEGF injections before IVBr was greater in the IOI group (P = 0.004), and the ratio of patients with a laser flare-cell photometry (LFCP) value over 15 photon count per millisecond (pc/ms) was higher in the IOI group (P = 0.017). Multivariate logistic regression analysis showed that a greater number of previous anti-VEGF injections (odds ratio [OR]: 1.12, P = 0.006; area under the curve: 0.82, cut-off score: 14.0) and an LFCP value over 15 pc/ms (OR: 81.6, P = 0.031) were significantly associated with the incidence of IOI after IVBr.

CONCLUSION

A number of previous anti-VEGF injections greater than 14 and an LFCP value more than 15 pc/ms might be useful predictors of the incidence of IOI after IVBr in eyes with nAMD.

A comparative study between a transscleral sustained-release device and eyedrops on intraocular distribution of carteolol hydrochloride

The objectives of this study were to develop a sustained-release device for carteolol hydrochloride (CH) and investigate any potential difference in the intraocular distribution of this agent between the transscleral administration of the device and treatment with eyedrops. The device was formulated with photocurable resin, poly (ethyleneglycol) dimethacrylate, to fit within the curve of the rabbit eyeball. In vitro study showed that CH was released in a sustained-release manner for 2 weeks. The concentration of CH in the retina, choroid/retinal pigment epithelium, sclera, iris, and aqueous humor was determined by high-performance liquid chromatography. Transscleral administration was able to deliver CH to the posterior segment (i.e., retina and choroid/retinal pigment epithelium) rather than the anterior segment (i.e., aqueous humor), while eyedrops delivered CH only to the anterior segment. Transscleral administration could deliver CH to aqueous humor at half the concentration versus treatment with eyedrops and reduced intraocular pressure (IOP) at 1 day after implantation; however, the IOP-lowering effect was not sustained thereafter. In conclusion, transscleral drug delivery may be a useful method for the reduction of IOP. Notably, the aqueous concentration must be equal to that delivered by the eyedrops, and this approach might be preferable for drug delivery to the posterior segment of the eye.

Preoperative assessment of dominant occipital sinus in patients with Chiari malformation type I: anatomical variations and implications for preventing potentially life-threatening surgical complications

OBJECTIVE

The surgical treatment of Chiari malformation type I (CM-I) frequently involves dural incision at the posterior cranial fossa. In cases of persistent patent occipital sinus (OS), the sinus is usually obliterated and divided. However, there are some patients whose OS is prominent and requires crucial modification of the operative planning to avoid potentially life-threatening massive hemorrhage and disturbance of cerebral venous circulation. In the present study, the anatomical variations of the dominant OS in patients with CM-I were analyzed and the authors attempted to develop treatment recommendations for patients with CM-I with dominant OS.

METHODS

The study included 213 patients with CM-I who underwent MR venography (MRV) prior to surgical treatment. OS dominance was assessed using 2D time-of-flight MRV or 3D phase-contrast MRV. Particular attention was paid to the pattern of venous outflow channels. The characteristics of the patients with dominant OS and the surgical outcomes were retrospectively reviewed.

RESULTS

Dominant OS was identified in 7 patients (3.3%). The age in those with dominant OS was significantly younger than in those without (p = 0.0202). The incidence of concurrent scoliosis in the patients with dominant OS was significantly higher than in those without (p = 0.0366). All the dominant OSs were found to be of the oblique type. Unilateral oblique OS (OOS) with normal ipsilateral transverse sinus (TS) and hypoplastic contralateral TS was found in 2 patients (0.9%). The authors found 1 patient each (0.5%) who had unilateral OOS with hypoplastic ipsilateral TS and normal contralateral TS, unilateral OOS with bilateral hypoplastic TSs, and bilateral OOSs with bilateral normal TSs. Bilateral OOSs with bilateral hypoplastic TSs were found in 2 patients (0.9%). All these patients had syringomyelia. Instead of performing Y-shaped dural incision and duraplasty, surgical procedures were modified depending on the types of the OOSs to preserve their venous drainage routes. Although massive bleeding from the dominant OS during dural incision occurred in 1 patient, none suffered neurological deterioration. The syrinx volume decreased in all but 1 of the patients postoperatively.

CONCLUSIONS

Assessment of the venous drainage pattern using MRV is indispensable for safe surgical treatment in patients with CM-I. The surgical procedure should be modified based on the type of dominant OS to minimize the surgical risks.

Cross-Sectional and Longitudinal Associations of Creatinine-to-Cystatin C Ratio with Sarcopenia Parameters in Older Adults

OBJECTIVES

Accumulating evidence from cross-sectional studies suggests that the serum creatinine-to-cystatin C ratio (CCR) may be a useful biomarker for sarcopenia. This study aimed to assess the cross-sectional and longitudinal associations of CCR with sarcopenia and its parameters in community-dwelling older adults.

DESIGN

Cross-sectional and longitudinal study.

SETTING AND PARTICIPANTS

This 6-year prospective cohort study included the repeated measurement data from 1,253 Japanese residents (662 males and 591 females) aged ≥65 years who underwent medical checkups in Kusatsu and Hatoyama, Japan. A total of 4,421 observations were collected.

MEASUREMENTS

The CCR was grouped into quartiles by sex (Q1-Q4) using Q4 as the reference category. Sarcopenia was defined according to the Asian Working Group for Sarcopenia 2019 algorithm. Skeletal muscle mass index (SMI) measured using segmental multifrequency bioelectrical impedance analysis, handgrip strength (HGS), usual gait speed (UGS), and maximal gait speed (MGS) were measured repeatedly as sarcopenia parameters. The association of the CCR with changes in sarcopenia, SMI, HGS, UGS, and MGS during the 6-year period were analyzed using a generalized linear mixed-effects model.

RESULTS

The prevalence of sarcopenia at baseline was 13.1% (11.9% in males and 14.5% in females). In a cross-sectional analysis, the CCR quartile was inversely associated with sarcopenia and was positively associated with SMI, HGS, and MGS (P for trend < 0.001). In a longitudinal analysis during the 6 years, a significant increase in sarcopenia in Q2 (B = 1.1% point/year; P = 0.026 for group-by-time interaction) and significant declines in SMI (B = -0.01 kg/m2/year; P = 0.044 for group-by-time interaction) and MGS (B = -0.008 m/sec/year; P = 0.041 for group-by-time interaction) in Q1 were observed compared with Q4. However, the dose-response relationship was significant only for MGS (P = 0.033 for trend). No significant group-by-time interaction was observed for HGS. CCR was not significantly associated with UGS either cross-sectionally or longitudinally.

CONCLUSIONS

CCR is a useful biomarker regarding the status of sarcopenia. It may be used for sarcopenia screening even in older adults whose physical function is difficult to assess. However, further longitudinal studies are needed to determine whether CCR can be a predictor of future sarcopenia.

Minimally Invasive Sub-Retinal Transplantation of RPE-J Cells on a Biodegradable Composite PCL/Collagen Nanosheet

Retinal cells are irreparably damaged by diseases such as age-related macular degeneration (AMD). A promising method to restore partial or whole vision is through cell-based transplantation to the damaged location. However, cell transplantation using conventional vitreous surgery is an invasive procedure that may induce infections and has a high failure rate of cell engraftment. In this study, we describe the fabrication of a biodegradable composite nanosheet used as a substrate to support retinal pigment epithelial (RPE-J) cells, which can be grafted to the sub-retinal space using a minimally invasive approach. The nanosheet was fabricated using polycaprolactone (PCL) and collagen in 80:20 weight ratio, and had size of 200 µm in diameter and 300 nm in thickness. These PCL/collagen nanosheets showed excellent biocompatibility and mechanical strength in vitro. Using a custom designed 27-gauge glass needle, we successfully transplanted an RPE-J cell loaded nanosheet into the sub-retinal space of a rat model with damaged photoreceptors. The cell loaded nanosheet did not trigger immunological reaction within 2 weeks of implantation and restored the retinal environment. Thus, this composite PCL/collagen nanosheet holds great promise for organized cell transplantation, and the treatment of retinal diseases.

Release of ranibizumab using a porous poly(dimethylsiloxane) capsule suppressed laser-induced choroidal neovascularization via the transscleral route

The administration of anti-vascular endothelial growth factor drugs in the posterior eye segment with sustained release through less invasive methods is a challenge in the treatment of age-related macular disease. We developed a flexible capsule device using porous poly(dimethylsiloxane) (PDMS) that was able to release ranibizumab. The porous PDMS sheet was fabricated by salt-leaching of a micro-sectioned PDMS sheet containing salt microparticles. Observation with scanning electron microscopy revealed that the pore densities could be adjusted by the concentration of salt. The in vitro release study showed that the release rate of fluorescein isothiocyanate-tagged albumin could be adjusted based on the pore density of the porous PDMS sheet. Ranibizumab could be released in a sustained-release manner for 16 weeks. The device was implanted on the sclera; its efficacy in terms of the suppression of laser-induced choroidal neovascularization (CNV) in rats was compared with that of monthly intravitreal injections of ranibizumab. At 8 and 18 weeks after implantation, the CNV area was significantly reduced in rats that received the ranibizumab-releasing device compared with those that received the placebo device. However, although monthly intravitreal injections of ranibizumab reduced CNV for 8 weeks, this reduction was not sustained for 18 weeks. In conclusion, we demonstrated a novel controlled-release device using a porous PDMS sheet that could suppress CNV via a less invasive transscleral route versus intravitreal injections. This device may also reduce the occurrence of side effects associated with frequent intravitreal injections.

Oleic acid‐bound FABP7 drives glioma cell proliferation through regulation of nuclear lipid droplet formation

Fatty acid-binding protein 7 (FABP7), one of the fatty acid (FA) chaperones involved in the modulation of intracellular FA metabolism, is highly expressed in glioblastoma, and its expression is associated with decreased patients' prognosis. Previously, we demonstrated that FABP7 requires its binding partner to exert its function and that a mutation in the FA-binding site of FABP7 affects tumour biology. Here, we explored the role of FA ligand binding for FABP7 function in tumour proliferation and examined the mechanism of FABP7 and ligand interaction in tumour biology. We discovered that among several FA treatment, oleic acid (OA) boosted cell proliferation of FABP7-expressing cells. In turn, OA increased FABP7 nuclear localization, and the accumulation of FABP7-OA complex in the nucleus induced the formation of nuclear lipid droplet (nLD), as well as an increase in colocalization of nLD with promyelocytic leukaemia (PML) nuclear bodies. Furthermore, OA increased mRNA levels of proliferation-related genes in FABP7-expressing cells through histone acetylation. Interestingly, these OA-boosted functions were abrogated in FABP7-knockout cells and mutant FABP7-overexpressing cells. Thus, our findings suggest that FABP7-OA intracellular interaction may modulate nLD formation and the epigenetic status thereby enhancing transcription of proliferation-regulating genes, ultimately driving tumour cell proliferation.

POS1471-HPR PAIN CATASTROPHIZING AND ITS ASSOCIATION WITH PAIN OF PATIENTS WITH RHEUMATOID ARTHRITIS IN A NON-INFLAMMATORY CONDITION

Background

Pain in rheumatoid arthritis (RA) is considered to be linked with non-inflammatory factors, including physical disabilities, psychiatric disorders, and pain catastrophizing (PC) (1.

Objectives

We investigated the role of PC in the possible link between physical disabilities and psychiatric disorders in RA patients in a non-inflammatory condition.

Methods

In this cross-sectional study, a total of 81 RA patients in a non-inflammatory condition were included; all patients had serum C-reactive protein levels <0.5 mg/dL, without any inflammatory joints. We examined the demographic and clinical data and administered the pain visual analog scale (VAS), the pain catastrophizing scale (PCS), the Health Assessment Questionnaire Disability Index (HAQ-DI), and the patient version of the Brief Scale for Psychiatric Problems in Orthopedic Patients (pBS-POP). A series of multivariate-adjusted multiple regression analyses were performed to examine the associations between PC and pain intensity, physical disabilities, and psychiatric disorders.

Results

We found associations between all the above-mentioned variables in separate models associated with HAQ-DI, pBS-POP, and PCS scores. However, in the model associated with pain VAS, the PCS score (β=0.34, p=0.0073) emerged as the only variable showing statistically significant association.

Conclusion

PC is associated with pain in RA patients in a non-inflammatory condition, and this association may be mediated through pathways involving physical disabilities and psychiatric disorders.

References

[1]Edwards RR, Giles J, Bingham CO, Campbell C, Haythornthwaite JA, Bathon J (2010) Moderators of the negative effects of catastrophizing in arthritis. Pain Med 11:591–599.

Table 1.

Multiple linear regression analysis of factors associated with each outcome

OutcomeVariablesß95% CIP valuePain VASAge0.044-0.32 to 0.510.66Sex (female)0.0089-4.65 to 5.090.93Stage0.0092-4.34 to 4.700.94Disease duration0.19-0.13 to 0.880.14HAQ-DI0.23-0.23 to 1.760.13pBS-POP0.038-1.06 to 1.450.76PCS0.340.13 to 0.810.0073pBS-POPAge-0.18-0.15 to 0.000.046Sex (female)-0.0081-0.95 to 0.860.93Stage-0.033-0.97 to 0.710.77Disease duration0.10-0.053 to 0.140.40Pain VAS0.033-0.037 to 0.0500.76HAQ-DI0.410.10 to 0.450.0026PCS0.310.02 to 0.160.0088HAQ-DIAge0.160.01 to 0.200.029Sex (female)0.14-0.10 to 2.100.93Stage0.17-0.06 to 2.000.77Disease duration0.220.017 to 0.250.025Pain VAS0.14-0.01 to 0.090.76pBS-POP0.290.15 to 0.700.0026PCS0.260.03 to 0.190.0088PCSAge-0.10-0.42 to 0.120.27Sex (female)-0.21-6.77 to -0.600.02Stage-0.082-4.10 to 1.830.45Disease duration-0.13-0.53 to 0.140.25Pain VAS0.280.06 to 0.350.0073pBS-POP0.300.28 to 1.850.0087HAQ-DI0.360.23 to 1.500.0080

ß: standardized regression coefficient; CI: confidence interval; HAQ-DI: Health Assessment Questionnaire Disability Index; pBS-POP: the patient version of the Brief Scale for Psychiatric Problems in Orthopedic Patients; PCS: Pain Catastrophizing Scale; VAS: visual analog scale

Disclosure of Interests

None declared

A Combined Assessment Method of Phase Angle and Skeletal Muscle Index to Better Predict Functional Recovery after Acute Stroke

OBJECTIVES

We aimed to investigate whether combination assessment of phase angle (PhA) and skeletal muscle index (SMI), was a possible predictor of physical function at discharge from the hospital in patients with acute stroke.

RESEARCH METHODS AND PROCEDURES

In this retrospective cohort study that was conducted from May 2020 and July 2021, we determined PhA and SMI using bioimpedance analysis (BIA) in patients with acute stroke. Patients were classified as normal, low PhA + SMI group, pre-sarcopenia (low SMI only), and dynapenia (low PhA only) using cut-off points (men: SMI < 7.0 kg/m2, PhA < 4.05 degrees; women: SMI < 5.7 kg/m2, PhA < 3.55 degrees). The main outcome was physical function based on functional independence measure motor (FIM-motor) score at discharge. Multiple regression analysis was used to determine the association between low PhA + SMI and FIM-motor score.

RESULTS

We included 244 patients (161 men; mean age, 73.9 years). low PhA + SMI was found in 21 (8.6%) patients. Multiple regression analysis showed that low PhA + SMI was independently associated with the FIM-motor score at discharge (β= -0.099, 95%CI: -0.193,-0.005, p = 0.039). The PhA cutoff values for determining good functional results using receiver operating characteristic (ROC) curves were 5.36 for men (sensitivity = 0.769, specificity = 0.586, area under the curve [AUC] = 0.682), and 3.85 for women (sensitivity = It was 0.881, specificity = 0.481, AUC). Further, pearson correlation coefficient showed that PhA was significantly related to FIM-motor score in patients with mild or moderately severe stroke (mild: r = 0.472, p < 0.001; moderate: r = 0.524, p < 0.001).

CONCLUSIONS

Combination of low PhA and SMI values at baseline, was an independent predictor of physical function at discharge in patients with acute stroke. The findings highlighted the importance of measuring PhA and SMI using BIA in patients with acute stroke.

Non-driving older adults living in a rural hilly area are at high risk for poor physical function

Background

While some studies have found an association between built environments and physical function, it is unclear whether living in a hilly area is associated with poor physical function among older adults, and whether this association varies by car driving status. This cross-sectional study investigated the association between hilliness and physical function in community-dwelling older adults and whether it varied according to their car driving status.

Methods

Data were collected from 633 participants aged 60 years and older living in Okinoshima Town, Shimane prefecture, Japan, in 2018. Physical function was objectively assessed; &lt; 1.0 m/s was defined as poor walking speed, and hilliness was measured by mean land slope within a 1000-meter network buffer zone around each participant's home using geographic information system. Logistic regression examined whether hilliness was associated with poor walking speed adjusted for sex, age, body mass index, current smoking, current alcohol consumption, exercise habits, current chronic disease, and living arrangements. A stratified analysis by car driving status was also conducted.

Results

A total of 159 (25.1%) participants had poor walking speed. After adjusting for all confounders, hilliness was positively associated with poor walking speed (OR = 1.07, 95% CI, 1.02-1.12). The stratified analysis by car driving status showed that living in a hilly area was positively associated with poor walking speed among non-drivers (OR = 1.10, 95% CI, 1.03-1.17), though there were no associations among drivers (OR = 1.00, 95% CI 0.92-1.08).

Conclusions

Our study found that a hilly environment was associated with poor walking speed in community-dwelling older adults in Japan. Moreover, car driving status potentially modified the relationship between living in a hilly environment and poor walking speed.

Key messages

Older adults living in a hilly environment were more likely to have poor walking speed, compared to those living in less hilly area. The stratified analysis by car driving status showed that non-driving older adults living in a rural hilly environment may be at high risk for poor physical function.

Environmental Factors Affecting Cognitive Function Among Community-dwelling Older Adults

Background

Although neighborhood environmental factors have been found to be associated with cognitive decline, few longitudinal studies have focused on their effect among older adults living in rural areas. This longitudinal study aimed to investigate the effect of neighborhood environmental factors on cognitive decline among rural older adults.

Methods

The data of 503 older adults aged &gt; 60 years who were living in Unnan City in Japan and had participated in two surveys conducted between 2014 and 2018 were analyzed. Cognitive function was assessed using the Cognitive Assessment for Dementia, iPad version 2. Elevation, hilliness, residential density, and proximity to a community center were measured using geographic information system. Logistic regression examined the effect of each neighborhood environmental factor (in quartiles: Q1-Q4) on cognitive decline.

Results

A total of 57 (11.3%) participants demonstrated a decrease in cognitive function at follow up. Elevation (Odds ratio (OR): 3.37, 95% Confidence Interval (CI): 1.11-10.20 for Q3 vs. Q1; OR: 5.43, 95% CI: 1.89-15.56 for Q4 vs. Q1) and hilliness (OR: 3.45, 95% CI: 1.46-8.11 for Q4 vs. Q1) were associated with a higher likelihood of cognitive decline. Residential density and distance to a community center were not associated with cognitive decline.

Conclusions

Elevated and hilly environments may increase risk of cognitive decline among rural older adults.

Key messages

Residents in mountainous regions tend to have limited accessibility to various living centers. Those who live in elevated and hilly areas within the mountainous regions may have further limited accessibility and availability of locations where they can interact with others.

Use of a Simulation Model to Investigate the Mechanisms of Sports-related Head Injuries

A simulation model was developed to better understand the mechanisms of brain injuries in sports. A three-dimensional model comprising approximately 1.22 million elements was constructed from cranial computed tomography images of adult male volunteers by the voxel method. To simulate contact sports that permit actions such as tackling, a sinusoidal wave with duration of 10 ms and maximum acceleration of 2000 m/s² was applied to the lowest point of the model to apply rotational acceleration to the head from different directions. The von Mises stress was then observed at five points in the coronal plane of the brain: cingulate gyrus (CG), corpus callosum (CC), brain stem (BS), lateral temporal lobe (LT), and medial temporal lobe (MT). LS-DYNA universal finite element analysis software with explicit time integration was used for the analysis. Concentrations of stress started to appear in the CC and BS at 10 ms post-impact, after which they also became evident in the CG and MT. The maximum changes in stress at each location occurred 10–15 ms post-impact. The von Mises stress was 9–14 kPa in the CG, 8–24 kPa in the CC, 12–24 kPa in the BS, 7–12 kPa in the LT, and 12–18 kPa in the MT. The highest stress in every part of the brain occurred after lateral impact, followed by oblique impact and sagittal impact. Such simulations may help elucidate the mechanisms of brain injuries in sports and help develop measures to prevent chronic traumatic encephalopathy.

Low serum chloride level gives renin-angiotensin system inhibitor a prognostic impact in heart failure patients with preserved ejection fraction

Background

Hypochloremia is associated with a poor prognosis of heart failure (HF) patients. This phenomenon is sustained even in HF with preserved ejection fraction (HFpEF). Serum chloride level is known to be affected by serum renin secretion; however, this relationship is one of the least investigated field in HF patients. Renin-angiotensin system (RAS) inhibitor is recommended as a first-line medication for HF patients with reduced left ventricular ejection fraction, but no prior studies of RAS inhibitors have achieved to improve the prognosis of HFpEF patients.

Purpose

We investigated the relationship between baseline serum chloride level and the prognostic impact of RAS inhibitor in HFpEF patients.

Methods

This is an observational study including 1,913 consecutive patients who admitted to hospital due to worsening of HF and discharged alive in a single university hospital. After excluding patients who received regular hemodialysis and whose left ventricular ejection fraction were under 50%, 506 HFpEF patients were ultimately analyzed. They were categorized into tertiles by serum chloride levels at discharge (T1: −100 mEq/L, T2: 101–104 mEq/L, T3: 105- mEq/L), and patients in each category were further divided into subgroups depending on the prescription of RAS inhibitor at discharge (RAS inhibitor group and Non-RAS inhibitor group). The primary endpoint of this study was death from any cause.

Results

During the observation period with 479 days of median follow-up, 77 (15.2%) died. Patients in the RAS inhibitor group had significantly better prognosis than those in the Non-RAS inhibitor group in T1 category (Log-rank: p=0.003, Figure). In contrast, there was no statistical difference in the mortality between the RAS inhibitor group and Non-RAS inhibitor group in T2 and T3 categories (Log-rank: p=0.15, p=0.81, respectively, Figure). Multivariate Cox regression analysis in T1 category revealed that taking RAS inhibitor at discharge was independently associated with a lower mortality rate, even after the adjustment of diverse covariates (hazard ratio: 0.40, 95% confidence interval: 0.20–0.80).

Conclusion

In this observational study, the administration of RAS inhibitor was associated with an improved prognosis of HFpEF patients only in low serum chloride level at discharge. Therapeutic strategy focusing on the chloride level may be one of the promising options to find the light on a unintervenable prognosis of HFpEF.

Funding Acknowledgement

Type of funding sources: None.

Prognostic advantage of optimal medical therapy is not cancelled in hospitalized heart failure patients receiving regular hemodialysis

Background

As the first-line medications, renin-angiotensin-aldosterone system inhibitor (RAASi) and β-blocker provide prognostic benefits in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF). However, the negative inotropic effect of these drugs may destabilize the hemodynamics during hemodialysis (HD) and become prognostically controversial in patients receiving regular HD. Indeed, prior studies have reported the cancellation of the favorable prognostic effects of RAASi and β-blocker in patients with HD. However, it is totally unknown whether the guideline-directed medical therapy affects the prognosis in HF patients receiving regular HD.

Purpose

We aimed to evaluate the prognostic impact of RAASi and β-blocker on the cardiovascular (CV) events in HF patients on regular HD.

Methods

This observational study initially included 1,930 consecutive patients who were hospitalized due to HF and discharged alive. Of these, 151 patients who received regular HD were ultimately analyzed. They were classified into 3 groups depending on the prescribing medications at discharge; patients who received none of RAASi or β-blocker (None group: N=19), either RAASi or β-blocker (Either group: N=56), and both RAASi and β-blocker (Both group: N=76). The primary endpoint was a composite of CV death and readmission due to HF.

Results

During the observation period of median 501 (interquartile range: 197–954) days, the primary endpoint occurred in 61 patients (40%). Kaplan-Meier analysis showed the highest rate of composite endpoint in the None group (log-rank for trend: p&lt;0.001, Figure). After adjusting for covariates of age, sex, LVEF, and systolic blood pressure and heart rate at discharge, the hazard ratio (HR) for a composite endpoint was significantly lower in the Either group or Both group than that in the None group [HR: 0.19, 95% confidence interval (CI): 0.08–0.45; HR: 0.16, 95% CI: 0.06–0.42, respectively].

Conclusions

The prescription of RAASi or β-blocker at discharge was associated with lower adverse CV event rates in patients on regular HD who were hospitalized for HF. In order to improve long-term prognosis of HF patients on HD, we should consider the prescription of RAASi or β-blocker for them if hemodynamics during HD is affordable.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Heart failure re-hospitalization differently affects the following mortality in patients with reduced, mid-range and preserved LVEF

Introduction

The recent advances in the treatment for heart failure with reduced ejection fraction (HFrEF) have been remarkable, while no therapy has convincingly improved the prognosis in HF patients with preserved (HFpEF) and mid-range (HFmrEF) ejection fraction. Frequent decompensations of HF lead to progressive deterioration of cardiac and renal function, and quality of life. Hence, prior studies have reported that the mortality of HFrEF patients increases as hospitalization for HF repeats. However, it is still unclear whether this trend applies for HFpEF and HFmrEF patients.

Purpose

We aimed to compare the prognostic impact of re-hospitalization due to HF on cardiovascular death (CVD) among HFrEF, HFmrEF and HFpEF patients.

Methods

This observational study included 1,930 consecutive patients who were hospitalized for worsening of HF and discharged alive. Of them, patients who have never or have not been hospitalized for HF at least last 2 years, were finally analyzed. Patients were consisted of the population with HFrEF (EF&lt;40%, n=421), HFmrEF (EF 40–49%, n=202) and HFpEF (EF&gt;50%, n=291). Patients in each EF-classified population were divide into 2 subgroups based on whether patients were re-hospitalized for HF during the observational period, respectively. The primary endpoint of this study was CVD.

Results

During the observation period, Kaplan-Meier analysis showed that patients who were re-hospitalized for HF had higher event rate of CVD in HFrEF group (Log-rank p=0.008, Figure). Even after adjusting with multivariate covariates including age, sex, EF, brain natriuretic peptide and estimated glomerular filtration rate, re-hospitalization for HF was an independent predictor for CVD in HFrEF group (HR: 1.95, 95% CI: 1.11–2.86, p=0.029). However, in HFmrEF group and HFpEF group, there was no significant difference in the rates of CVD between 2 subgroups divided whether patients were re-hospitalized for HF or not (p=0.91, p=0.34, respectively).

Conclusion

Re-hospitalization for HF affected the CVD rate in HFrEF group, but not in HFmrEF and HFpEF groups. The prevention of re-hospitalization for HF is important particularly in HFrEF patients in order to improve cardiovascular mortality.

Funding Acknowledgement

Type of funding sources: None.

P–192 Efficacy of postponement of intracytoplasmic sperm injection timing after spindle visualization for Metaphase I oocytes

Study question

Does postponement of intracytoplasmic sperm injection (ICSI) timing after spindle visualization for Metaphase I (MI) oocytes improve developmental outcomes of embryos?

Summary answer

Postponement of ICSI timing after spindle visualization for MI oocytes improves blastocyst utility rates.

What is known already

Immature oocytes are generally considered poor developmental outcomes. Meanwhile, the timing of ICSI adjusted by using spindle visualization can improve clinically utilized embryos and live birth rates, but these outcomes remain inferior to those of mature oocytes. In in vitro maturation culture, nuclear maturation is thought to occur before the completion of cytoplasmic maturation, and in immature oocytes, synchronization of nuclear and cytoplasmic maturation may be insufficient for ICSI immediately after spindle visualization.

Study design, size, duration

Data for this retrospective cohort study were obtained 672 oocytes retrieved under mild stimulation cycles using letrozole, in patients aged younger than 39 years between April 2017 and October 2020.Written informed consent was obtained from all patients. This study was approved by the institutional review board.

Participants/materials, setting, methods

As a control group, 464 MetaphaseIIoocytes that underwent ICSI immediately after visualization of the spindle were used. In group A, 103 MI oocytes underwent ICSI immediately after the first polar body release and spindle visualization, and in group B, 105 oocytes underwent ICSI 2–3 hours after spindle visualization. The primary outcomes were fertilization rates, degeneration, cleavage, embryo blastocyst formation, and utility rates. Outcomes were compared among the three groups.

Main results and the role of chance

The baseline fertilization rates of each group (control, A, B) were 82.3% (382/464), 73.8% (76/103), and 83.8% (88/105), respectively. The rate was significantly lower in group A than in the control group (P &lt; 0.05), and also tended to be lower in group A than in group B, although the difference was not significant. There was no significant difference in abnormal fertilization rates, oocyte degeneration rates, cleavage rates, and blastocyst formation rates among the three groups. [control, A, B: abnormal fertilization rate: 4.3% (20/464), 8.7% (9/103), 4.8% (5/105); oocyte degeneration rates: 3.0% (14/464), 1.9% (2/103), 3.8% (4/105); cleavage rates: 95.6% (307/321), 93.8% (61/65), 98.7% (74/75); blastocyst formation rates: 58.6% (177/302), 51.7% (31/60), 55.4% (41/74), respectively]. The blastocyst utility rates of control group and group B were significantly higher than in group A [41.7% (126/302), 45.9% (34/74), 26.7% (16/60), respectively] (P &lt; 0.05). There were no significantly different outcomes between the control group and group B.

Limitations, reasons for caution

The optimal timing of ICSI for MI oocyte cannot be determined by the presence or absence of spindles. In addition, the postponement duration we set was based on reports which reported on final oocyte maturation, and further investigation is needed to establish the optimal ICSI timing for MI oocytes.

Wider implications of the findings: In MI oocytes, postponement of ICSI timing after spindle visualization is essential for synchronization of the nucleus and cytoplasmic maturation.

Trial registration number

none

P–609 The chances of one live birth rates after first ART cycle in minimal stimulation cycle IVF with letrozole only and natural cycle IVF

Study question

Are one live birth rates (LBRs) similar in minimal stimulation cycle IVF with letrozole only and natural cycle IVF for the first ART cycle?

Summary answer

LBRs after first ART cycle in minimal stimulation cycle IVF with letrozole only are superior to natural cycle IVF.

What is known already

The addition of letrozole to gonadotropins in ovarian stimulation (OS) may reduce the risk of OHSS, but there is no significant difference were reported in ongoing pregnancy rate or number of oocytes retrieved in the letrozole + FSH group compared to the FSH only. No differences were also reported in clinical pregnancy rates or number of mature oocytes in the additional of letrozole in an GnRH antagonist protocol group compared to the GnRH antagonist group. There are no previous study comparing LBRs after first ART cycle in minimal stimulation cycle IVF with letrozole and natural cycle IVF.

Study design, size, duration

Data for this retrospective cohort study were obtained 643 women, 30–39 years of age started their first ART cycle at one private fertility clinic between January 2016- December 2019.

Participants/materials, setting, methods

A total of 643 women were scheduled their first oocyte retrieval cycle. 118 women started with letrozole (LE) and 525 women started natural cycle (NC). The main strategy for OS in our center is minimal stimulation and natural cycle IVF. Patients consulted with gynecologists to determine their treatment plan based on patients’ preference or their menstrual cycle. All pregnancies generated from oocyte retrieval during the first IVF cycle including fresh and frozen-thaw cycles were registered.

Main results and the role of chance

The number of retrieved oocytes and the normal fertilization rates were significantly higher in the LE than NC (4.4 vs 3.4, 77.6% vs 71.1%), p &lt; 0.05 respectively). There was no significant difference in the clinical pregnancy rates (CPRs) per embryo transfer (ET) (fresh cleavage stage ET: 32.9% vs 28.0%, frozen-thaw blastocyst ET: 39.4% vs 44.9% ns). However, the CPRs and LBRs per oocyte retrieval (OR) were significantly higher in the LE group (39.0% vs 28.6, 33.9% vs 21.9%, p &lt; 0.05 respectively). In a subsequent regression analyses, LBRs per OR of LE was significantly higher than NC as well. (adjusted OR = 1.63 (95% CI: 1.02–2.58, p = 0.041).

Limitations, reasons for caution

The strength of the present study was the use of a large cohort of women who underwent minimal stimulation IVF with letrozole only. Although our results are promising, limited by retrospective cohort study. These interpretations prompted the need for a perspective cohort study to evaluate the efficacy of letrozole.

Wider implications of the findings: When comparing minimal stimulation IVF with letrozole only and natural cycle IVF, we found significantly higher LBRs per OR in minimal stimulation IVF with letrozole only, despite similar CPRs per ET.

Trial registration number

none

MRI characteristics of syringomyelia associated with foramen magnum arachnoiditis: differentiation from Chiari malformation

BACKGROUND

It is important to distinguish foramen magnum arachnoiditis (FMA) from Chiari malformation (CM) before surgery because the operative strategies for these diseases differ. In the current study, we compared pretreatment magnetic resonance imaging (MRI) of FMA with CM and investigated the MRI findings useful to differentiate between these diseases.

METHODS

We retrospectively reviewed patients with FMA or CM aged ≥ 18 years who underwent surgeries at our institution between 2007 and 2019. The morphologies of the syrinx, neural elements, and posterior cranial fossa were preoperatively evaluated with MRI. We used the receiver operating characteristic (ROC) curve for the fourth ventricle-to-syrinx distance (FVSD).

RESULTS

Ten patients with FMAs and 179 with CMs were included. FVSD in the FMA group was significantly shorter than that in the CM group (7.5 mm [IQR, 2.8-10 mm] in FMA vs. 29.9 mm [IQR, 16.3-52.9 mm] in CM, p < 0.0001). The other MRI findings that showed the height, size, and length of the syrinx; size of the foramen magnum; degree of cerebellar tonsillar descent; shape of the cerebellar tonsil; and dorsal subarachnoid space at the foramen magnum differed significantly between the two groups. The ROC curve analysis showed that patients whose FVSD was less than 11 mm could be diagnosed with FMA with a specificity of 90% and sensitivity of 96%.

CONCLUSIONS

A more cranial syrinx development (FVSD < 11 mm) appears to be the characteristic MRI finding in FMA.

A multicenter cohort study of osimertinib compared with afatinib as first-line treatment for EGFR-mutated non-small-cell lung cancer from practical dataset: CJLSG1903

Background

FLAURA, the prospective trial of osimertinib as a first-line therapy compared with first-generation epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs), did not show superior survival benefit for osimertinib in either the subgroup of Asians or the subgroup with the L858R mutation. In addition, the superiority of osimertinib compared with second-generation EGFR-TKI is thus far unclear.

Patients and methods

We reviewed the clinical data of all consecutive patients who were treated with osimertinib or afatinib as first-line therapy between May 2016 and October 2019 from 15 institutions in Japan. We defined the groups based on first-line EGFR-TKI as the afatinib group and the osimertinib group. Outcomes included time to discontinuation of any EGFR-TKI (TD-TKI), overall survival (OS), and time to treatment failure, with propensity score analysis carried out as an exploratory analysis in the survival and subgroup analyses.

Results

A total of 554 patients were enrolled. Data on 326 patients in the osimertinib group, and 224 patients in the afatinib group were analyzed. TD-TKI adjusted by propensity score in the afatinib and osimertinib groups was 18.6 months (95% confidence interval 15.8 to 22.0) and 20.5 months (95% confidence interval 13.8 to not reached), respectively, without significant difference (P = 0.204). OS adjusted by propensity score favored the afatinib group with a significant difference (P = 0.018). Subgroup analysis with propensity score showed that patients with L858R and without brain metastasis had superior survival benefit with afatinib compared with osimertinib (P < 0.001).

Conclusions

TD-TKI in the afatinib group was not significantly prolonged compared with the osimertinib group in the practical data. In the exploratory analysis of patients with L858R-mutated non-small-cell lung cancer without brain metastasis, afatinib showed more benefit in OS over osimertinib.

•

The large-scale practical data of 550 patients who were treated with osimertinib or afatinib as first-line therapy were analyzed.

•

The superiority of osimertinib compared with afatinib could not be demonstrated in all populations.

•

Osimertinib therapy showed effectiveness in patients with brain metastasis.

•

Afatinib therapy showed potential benefit in patients with L858R mutation and without brain metastasis.

Clinical Characteristics of Fragile X Syndrome Patients in Japan

Background

Fragile X syndrome (FXS) is a well-known X-linked disorder clinically characterized by intellectual disability and autistic features. However, diagnosed Japanese FXS cases have been fewer than expected, and clinical features of Japanese FXS patients remain unknown.

Methods

We evaluated the clinical features of Japanese FXS patients using the results of a questionnaire-based survey.

Results

We presented the characteristics of seven patients aged 6 to 20 years. Long face and large ears were observed in five of seven patients. Macrocephaly was observed in four of five patients. The meaningful word was first seen at a certain time point between 18 and 72 months (median = 60 months). Developmental quotient or intellectual quotient ranged between 20 and 48 (median = 29). Behavioral disorders were seen in all patients (autistic spectrum disorder in six patients, hyperactivity in five patients). Five patients were diagnosed by polymerase chain reaction analysis, and two patients were diagnosed by the cytogenetic study. All physicians ordered FXS genetic testing for suspicious cases because of clinical manifestations.

Conclusion

In the present study, a long face, large ears, macrocephaly, autistic spectrum disorder, and hyperactivity were observed in almost cases, and these characteristics might be common features in Japanese FXS patients. Our finding indicated the importance of clinical manifestations to diagnosis FXS. However, the sample size of the present study is small, and these features are also seen to patients with other disorders. We consider that genetic testing for FXS should be performed on a wider range of intellectually disabled cases.

Clinical significance of late diastolic tissue doppler parameters after onset of STEMI: from the view point of the timing of the echocardipography

Background

The early transmitral flow velocity (E) divided by the early diastolic velocity of the mitral valve annulus (e') is referred to as the “E/e' ratio,” is useful even for ST elevation acute myocardial infarction (STEMI). However, the role of late diastolic velocity (a') which reveals the atrial function for STEMI is still unclear.

Objectives

We evaluated the clinical usefulness of tissue Doppler including atrial function for a first-time STEMI by long time follow up. Furthermore, we evaluated the meaning of each parameters by performing immediately after PCI or 2 weeks later.

Methods

We treated consecutive 571 first-time STEMI patients by immediate PCI within 12 hours after onset, and we examined 270 patients at immediately after PCI (GroupA, 65 years, 250 male) and 301 patients at 2 weeks after onset (GroupB, 64 years, 243 male). We examined trans mitral flow and TDI, then defined E/e' as LV filling pressure and A/a' as left atrial function. We followed them for a long time (&gt;5 years). The primary end point (PE) was cardiac death or re-admission for heart failure (HF).

Results

We followed the patients in Group A for 10 years, Group B for 5 years. PE occurred in 64 patients in GroupA during 10 years, and 45 patients in GroupB during 5 years. We analyzed the univariate and multivariate Cox hazard analyses and we compared e' and a', E/e' and A/a' (Table). In GroupA, a' and A/a' were the independent predictors, on the other hand neither a' nor A/a' were the predictors in GroupB. E/e' was an independent predictor both in GroupA and B.

Conclusion

TDI parameters have different meanings by the timing of echocardiography after onset of a first-time STEMI. These results demonstrated that atrial dysfunction immediately after onset of STEMI suggests the poor prognosis after STEMI.

Cox Hazard Proportional Analysis

Funding Acknowledgement

Type of funding source: None

The prognostic impact of catheter ablation for atrial fibrillation after heart failure hospitalization on long-term mortality – Propensity-score matching analysis

Background

In the last two decades, catheter ablation (CA) for atrial fibrillation (AF) including pulmonary vein isolation (PVI) has been developed as a standard and effective treatment for atrial fibrillation (AF). In patients with chronic heart failure with reduced left ventricular ejection fraction (LVEF) (HFrEF), PVI CA for AF dramatically improves LVEF, resulting in better clinical prognoses. On the contrary, there still has been no data that PVI CA for AF improves the prognosis in heart failure patients with preserved LVEF (HFpEF).

Purpose

The aim of this study was to evaluate the prognostic impact of PVI CA for AF after the hospitalization due to decompensation of heart failureHF, focusing on LVEF.

Methods

From the database including 1,793 consecutive patients who were hospitalized due to congestive HF, we ultimately analyzed 624 AF patients who were discharged alive. They were assigned into two groups due that PVI CA for AF procedure done after the index hospitalization for HF; the PVI CA group (n=62) and Non-PVI CA group (n=562). For the two groups, we performed propensity-score (PS) matching using variables as follows: age, sex, LVEF, brain natriuretic peptide (BNP), blood urea nitrogen (BUN) and estimated glomerular filtration rate (eGFR) at discharge. Further analysis was performed separately in HFrEF (LVEF &lt;50%) and HFpEF (LVEF &gt;50%). The primary endpoint of this study was death from any cause.

Results

In unmatched patients, Kaplan-Meier analysis showed that patients in the PVI CA group had a significantly lower all-cause mortality than those in the Non-PVI CA group during 678 median follow-up period (Log-rank test: P=0.003, Figure A). In 96 PS-matched patients, patients in the PVI CA group still had lower mortality rate than those in the Non-PVI CA group (hazard ratio 0.28, 95% confidence interval 0.09–0.86, p=0.018, Figure B). When the whole study population was classified into HFrEF and HFpEF, HFrEF patients who received PVI showed a significantly lower mortality than those who did not (p=0.007); whereas, in HFpEF patients, PVI CA for AF did not make statistical difference in all-cause mortality (p=0.061).

Conclusions

In this observational study, PVI CA for AF may improve the mortality in HF patients with reduced LVEF. However, the prognostic impact of PVI CA for AF was not observed in HF patients with preserved LVEF.

Funding Acknowledgement

Type of funding source: None

Insufficient lipid lowering therapy could not bring favorable prognostic effect in high risk patients who were functionally deferred percutaneous coronary intervention

Introduction

Deferral of percutaneous coronary intervention (PCI) of a functionally insignificant stenosis is associated with favorable long-term prognoses. However, previous reports revealed that patients with fractional flow reserve (FFR) 0.81–0.85 had higher cardiovascular adverse event rates than those with FFR &gt;0.85. Numbers of large clinical trials established the lower, the better strategy for low-density lipoprotein cholesterol (LDL-C) management for patients after PCI. However, in the real clinical practice, the achievement rate of target LDL-C is often insufficient in patients with atherosclerotic risk factors who were functionally deferred PCI.

Purpose

We aimed to examine optimal LDL-C management for patients with intermediate coronary stenosis deferred PCI by FFR measurement.

Methods

This observational study included 293 consecutive patients with coronary stenosis deferred PCI due to greater FFR than 0.80. We separately analyzed 90 patients with 0.81–0.85 of FFR and 203 patients with &gt;0.85. Patients in each group were further classified into 2 groups based on LDL-C level at one year after FFR measurement; the Lower LDL-C group (&lt;100 mg/dL) and the Higher LDL-C group (&gt;100 mg/dL). The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE) including death, non-fatal myocardial infarction, ischemic stroke, heart failure hospitalization and unplanned revascularization.

Results

Patients with FFR 0.81–0.85 had a significantly higher MACCE rate than those with FFR &gt;0.85 (hazard ratio (HR): 1.77, 95% confidence interval (CI): 1.02–3.07, p=0.043). In patients with FFR 0.81–0.85, the Lower LDL-C group (n-=53) had a significantly lower rate of the primary endpoint than the Higher LDL-C group (HR: 0.41, 95% CI: 0.18–0.97, Log-rank p=0.036, Figure A). Whereas, there was no significant difference in the event rate between 2 groups in patients with FFR &gt;0.85 (Log-rank p=0.42, Figure B).

Conclusion

Uncontrolled LDL-C level was associated with higher MACCE rate in patients who were deferred PCI due to FFR 0.81–0.85. These results suggested that even in patients who were deferred PCI, those with coronary artery stenosis of lower FFR value should receive strict LDL-C lowering therapy with close monitoring.

Figure 1

Funding Acknowledgement

Type of funding source: None

Serial echocardiographical assessment for urgent control of rapid atrial fibrillation in acute heart failure

Objectives

Doppler echocardiography is a well-recognized technique for noninvasive evaluation; however, little is known about its efficacy in patients with rapid atrial fibrillation (AF) accompanied by acute decompensated heart failure (ADHF). The aim of this study was to explore the usefulness of serial echocardiographical assessment for rapid AF patients with ADHF.

Patients

A total of 110 ADHF patients with reduced ejection fraction (HFrEF) and rapid AF who were admitted to the CCU unit and received landiolol treatmentto decrease the heart rate (HR) to &lt;110 bpm and change HR (ΔHR) of &gt;20% within 24 hours were enrolled.

Interventions

Immediately after admission, the patients (n=110) received landiolol, and its dose was increased to the maximum; then, we repeatedly performed echocardiography. Among them, 39 patients were monitored using invasive right heart catheterization (RHC) simultaneously with echocardiography.

Measurements and main results

There were significant relationships between Doppler and RHC parameters through the landiolol treatment (Figure, baseline–max HR treatment). We observed for the major adverse events (MAE) during initial hospitalization, which included cardiac death, HF prolongation (required intravenous treatment at 30 days), and worsening renal function (WRF). MAE occurred in 44 patients, and logistic regression analyses showed that the mean left atrial pressure (mLAP)-Doppler (odds ratio = 1.132, 95% confidence interval [CI]: 1.05–1.23, p=0.0004) and stroke volume (SV)-Doppler (odds ratio = 0.93, 95% confidence interval [CI]: 0.89–0.97, p=0.001) at 24 hours were the significant predictors for MAE, and multivariate analysis showed that mLAP-Doppler was the strongest predictor (odds ratio = 1.16, 95% CI: 0.107–1.27, p=0.0005) (Table).

Conclusions

During the control of the rapid AF in HFrEF patients withADHF, echocardiography was useful to assess their hemodynamic condition, even at bedside.

Doppler for rapid AF of ADHF

Funding Acknowledgement

Type of funding source: None

Ocular microcirculation changes, measured with laser speckle flowgraphy and optical coherence tomography angiography, in branch retinal vein occlusion with macular edema treated by ranibizumab

PURPOSE

This study searched for early predictive vascular biomarkers for visual outcomes in eyes with macular edema caused by branch retinal vein occlusion (BRVOME).

METHODS

Twenty-four eyes of 24 subjects with BRVOME were treated with the intravitreal injection of ranibizumab (IVR) for at least 6 months. We measured mean blur rate (MBR) in the optic nerve head (ONH) and vessel density (VD) in the macula with laser speckle flowgraphy and optical coherence tomography angiography, respectively.

RESULTS

Six-month post-IVR best-corrected visual acuity (BCVA) was correlated positively with age, pre-IVR BCVA, 1-month post-IVR BCVA, 3-month post-IVR BCVA and pre-IVR systolic blood pressure (P < 0.001, P < 0.001, P < 0.001, P < 0.001 and P = 0.02, respectively) and negatively with pre-IVR overall MBR, 1-month post-IVR overall MBR, 6-month post-IVR overall MBR, 3-month post-IVR deep retinal capillary plexus (DCP) VD and 6-month post-IVR DCP VD (P = 0.03, P = 0.03, P = 0.02, P = 0.01 and P = 0.005, respectively). Furthermore, a multiple regression analysis showed that pre-IVR overall MBR (β =  - 0.67, P = 0.009) was among independent prognostic factors predicting 6-month post-IVR BCVA. Six-month post-IVR DCP VD was also correlated with overall MBR at all time points.

CONCLUSION

ONH blood flow may be a pre-IVR biomarker of both visual outcomes and post-IVR deep macular microcirculation in eyes with BRVOME.

Environmental factors and physical activity among youth in rural Japan: a 1-year prospective study

Background

Although moderate-to-vigorous physical activity (MVPA) has multiple health benefits, current global activity levels among children are quite low. Environmental influences on MVPA levels among children and adolescents in rural areas are unclear. The present study examined if environmental factors were associated with MVPA in children and adolescents in rural Japan.

Methods

Two school-based serial surveys were conducted in 2017 and 2018 for 1,461 children and adolescents (10-14 years old) in Unnan City, Japan. If meeting the WHO recommended MVPA levels: at least 60 minutes/day was assessed via the Japanese translation of the WHO Health Behaviour in School-aged Children survey questionnaire. Environmental factors, namely habitable land area, population size, and population density were calculated for each individuals' residential town, and categorized into three levels (small, medium, and large). Logistic regression was used to determine odds ratios (OR) and 95% confidence intervals (CI) of engaging in the recommended level of MVPA after 1 year by each environmental factor, adjusting for sex, school grades, body mass index, screen time, preference for PA, and MVPA level at baseline.

Results

Only 22.4% of children and adolescents were engaging in the recommended MVPA levels in 2018. Engaging in the recommended level of MVPA after 1 year was significantly associated with medium (OR = 1.63; 95%CI, 1.08-2.46) and large (OR = 1.69; 95%CI, 1.15-2.47) compared to small habitable areas, and with medium (OR = 1.01; 95%CI, 0.61-1.67) and large (OR = 1.75; 95%CI, 1.09-2.81) compared to small population size. Population density was not associated with MVPA.

Conclusions

This prospective study found that habitable area and population size were positively associated with MVPA at 1-year follow-up in rural Japan. In rural areas, habitable land areas and population size itself may be a better predictor for MVPA among children than population density.

Key messages

Habitable area and population size was positively associated with physical activity among children and adolescents in rural Japan. Population density as an environmental factor was not associated with physical activity.

Daytime Dynamo Electrodynamics With Spiral Currents Driven by Strong Winds Revealed by Vapor Trails and Sounding Rocket Probes

We investigate the forces and atmosphere-ionosphere coupling that create atmospheric dynamo currents using two rockets launched nearly simultaneously on 4 July 2013 from Wallops Island (USA), during daytime Sq conditions with ΔH of -30 nT. One rocket released a vapor trail observed from an airplane which showed peak velocities of >160 m/s near 108 km and turbulence coincident with strong unstable shear. Electric and magnetic fields and plasma density were measured on a second rocket. The current density peaked near 110 km exhibiting a spiral pattern with altitude that mirrored that of the winds, suggesting the dynamo is driven by tidal forcing. Such stratified currents are obscured in integrated ground measurements. Large electric fields produced a current opposite to that driven by the wind, believed created to minimize the current divergence. Using the observations, we solve the dynamo equation versus altitude, providing a new perspective on the complex nature of the atmospheric dynamo.

Influence of an SGLT2 inhibitor, tofogliflozin, on the resting heart rate in relation to adipose tissue insulin resistance

AIMS

To examine the effects of a sodium-glucose co-transporter 2 (SGLT2) inhibitor, tofogliflozin, on resting heart rate by exploring baseline factors that independently influenced changes in the resting heart rate.

METHODS

Data on 419 participants in tofogliflozin phase 2/3 trials were analysed. Changes in resting heart rate from baseline to week 24 were analysed using an analysis of covariance (ANCOVA) model with groups (tofogliflozin/placebo) as a fixed effect and baseline values as covariates. The antilipolytic effect was evaluated as adipose tissue insulin resistance (Adipo-IR) and was calculated as the product of fasting insulin and free fatty acid. Multivariate analysis evaluated independent factors for changes in resting heart rate from baseline to week 24.

RESULTS

Of the participants, 58% were men, and mean age, HbA_1c , BMI and resting heart rate were 57.6 years, 65 mmol/mol (8.1%), 25.5 kg/m² and 66 bpm, respectively. At week 24, adjusted mean difference vs. placebo in the change from baseline was -2.3 bpm [95% confidence interval (CI) -4.6, -0.1] with tofogliflozin. Changes in resting heart rate were positively correlated with changes in Adipo-IR, whereas reductions in HbA_1c , body weight and blood pressure were similar independent of changes in resting heart among quartiles of resting heart rate change. On multivariate analysis, higher baseline resting heart rates and Adipo-IR values were significantly associated with greater reductions in resting heart rate.

CONCLUSIONS

Tofogliflozin corrected resting heart rate levels in accordance with baseline levels. Correction of high resting heart rates may be attributed to improved adipose tissue insulin resistance, leading to correction of hyperinsulinaemia.

Successful surgical outcomes after 23-, 25- and 27-gauge vitrectomy without scleral encircling for giant retinal tear

PURPOSE

Retinal detachment due to giant retinal tears (GRTs), tears larger than 90°, is rare and difficult to treat. Here, we show and compare surgical results of 23-, 25- and 27-gauge (G) micro-incision vitrectomy surgery (MIVS) for GRT.

STUDY DESIGN

Retrospective and interventional case series.

METHODS

Retrospective review of 41 eyes of 38 patients with GRT who underwent MIVS. Surgical outcomes after MIVS, including reattachment rates and postoperative complications, were compared between instrument gauges. All patients were followed for at least 6 months postoperatively.

RESULTS

MIVS with 23G, 25G and 27G instruments was performed in 7, 19 and 15 eyes, respectively. Silicone oil (SO) was used in 34 of 41 eyes (83%) with a mean removal time of 43.8 days after first surgery. Best-corrected visual acuity (BCVA) was recovered or maintained in 39 eyes (95%). Reattachment was attained after initial surgery in 38 of 41 eyes (93%) (23G: 6/7 [86%]; 25G: 17/19 [89%]; 27G: 15/15 [100%]). Final reattachment was eventually achieved in all eyes (two eyes needed support from scleral encircling). Postoperative complications occurred in 16 eyes (39%) (23G: 3/7 [43%]; 25G: 8/19 [42%]; 27G: 5/15 [33%]), including macular pucker, cystoid macular edema, macular hole, subretinal perfluorocarbon liquid, retinal folds, vitreous hemorrhage and redetachment. There were no significant differences between the three groups in rate of high myopia, GRT size, operation time, phacovitrectomy rate, SO usage rate, initial reattachment rate, final reattachment rate, preoperative BCVA, final BCVA or rate of postoperative complications.

CONCLUSION

Despite occasional postoperative complications, primary MIVS, regardless of gauge size, appears to be a safe and feasible option for GRT surgery.

Accelerometer-Determined Intensity and Duration of Habitual Physical Activity and Walking Performance in Well-Functioning Middle-Aged and Older Women: A Cross-Sectional Study

BACKGROUND

The association of physical activity (PA) intensities and duration spent in those activities with different walking tasks remains unclear.

OBJECTIVES

To examine the association between the duration of PA intensities and three walking speeds (usual walking speed, maximal walking speed and zig-zag walking speed).

DESIGN

Multiple linear regression analysis was used to estimate the association of age, BMI, maximum knee extension strength, light PA, moderate PA and vigorous PA with walking speeds.

SETTING

University lab.

PARTICIPANTS

Eighty-six older women (67 ± 7 years).

MEASUREMENTS

PA was measured for 30 consecutive days using the Lifecorder-EX accelerometer. Exercise intensity was categorized as light (levels 1-3), moderate (levels 4-6) and vigorous (levels 7-9) based on the manufacturer algorithms. Usual straight walking speed (20 m), maximal straight walking speed (20 m) and zig-zag walking speed tests (10 m) were performed by each participant.

RESULTS

For the usual straight walking speed model (R2 = 0.296, SEE = 0.15 m/s), the significant predictors were BMI, knee extension strength, light PA and vigorous PA. For the maximal straight walking speed model (R2 = 0.326, SEE = 0.20 m/s), only age was a significant predictor. For the zig-zag walking speed model (R2=0.417, SEE = 0.14 m/s), age and maximum knee strength were significant predictors in the model.

CONCLUSIONS

Overall, the results of this study suggest that vigorous PA and maximal knee extension strength are two important factors that are associated with different walking speeds in older women.

Effect of sustained insulin-releasing device made of poly(ethylene glycol) dimethacrylates on retinal function in streptozotocin-induced diabetic rats

In this study, we developed a subcutaneous insulin-releasing device consisting of a disk-shaped capsule and drug formulation comprised of poly(ethylene glycol) dimethacrylates, then evaluated its efficacy on retinal function in streptozotocin (STZ)-induced diabetic rats. In vitro release studies showed that recombinant human insulin was released with a constant rate for more than 30 days. The device was able to maintain a basal level of blood glucose in diabetic rats for a prolonged period of more than 30 days, simultaneously preventing a decrease in body weight. For assessing the pharmacological effect of the device on retinal function in diabetic rats, electroretinograms were conducted for 12 weeks. The reduction in amplitude and delay in implicit time were attenuated by the device during the initial 4 weeks of application. The increase in gene expression of protein kinase C (PKC)-γ and caspase-3 in the diabetic retina was also attenuated by the device. Immunohistochemistry showed that the increase in glial fibrillary acidic protein expression in the diabetic retina was attenuated by the device. Histological evaluation of subcutaneous tissue around the device showed the biocompatibility of the device. In conclusion, the insulin-releasing device attenuated the reduction of retinal function in STZ-induced diabetic conditions for 4 weeks and the efficacy of the device might be partially related to PKC signaling in the retina. The long-term ability to control the blood glucose level might help to reduce the daily frequency of insulin injections.

Gastrectomy with or without omentectomy for cT3–4 gastric cancer: a multicentre cohort study

Background

Omentectomy is performed widely for locally advanced gastric cancer to prevent disease recurrence. However, its clinical benefit is unknown.

Methods

This retrospective cohort study compared the outcome of gastrectomy with preservation of the omentum (GPO) and gastrectomy with resection of the omentum (GRO) among patients with cT3–T4 gastric cancer who underwent gastrectomy between 2006 and 2012 in one of five participating institutions. A consensus conference identified 28 variables potentially associated with outcome after gastrectomy for the estimation of propensity scores, and propensity score matching (PSM) was undertaken to control for possible confounders. Postoperative surgical outcomes, overall survival and disease recurrence were compared between GPO and GRO.

Results

A total of 1758 patients were identified, of whom 526 remained after PSM, 263 in each group. Median follow-up was 4·9 (i.q.r. 3·1–5·9) years in the GRO group and 5·0 (2·5–6·8) years in the GPO group. The incidence of postoperative complications of Clavien–Dindo grade III or more was significantly higher in the GRO group (17·5 versus 10·3 per cent; P = 0·016). Five-year overall survival rates were 77·1 per cent in the GRO group and 79·4 per cent in the GPO group (P = 0·749). There were no significant differences in recurrence rate or pattern of recurrence between the groups.

Conclusion

Overall survival and disease recurrence were comparable in patients with cT3–4 gastric cancer who underwent GPO or GRO.

A 3D Printed Self-Sustainable Cell-Encapsulation Drug Delivery Device for Periocular Transplant-Based Treatment of Retinal Degenerative Diseases

Self-sustainable release of brain-derived neurotrophic factor (BDNF) to the retina using minimally invasive cell-encapsulation devices is a promising approach to treat retinal degenerative diseases (RDD). Herein, we describe such a self-sustainable drug delivery device with human retinal pigment epithelial (ARPE-19) cells (cultured on collagen coated polystyrene (PS) sheets) enclosed inside a 3D printed semi-porous capsule. The capsule was 3D printed with two photo curable polymers: triethylene glycol dimethacrylate (TEGDM) and polyethylene glycol dimethylacrylate (PEGDM). The capsule's semi-porous membrane (PEGDM) could serve three functions: protecting the cells from body's immune system by limiting diffusion (5.97 ± 0.11%) of large molecules like immunoglobin G (IgG)(150 kDa); helping the cells to survive inside the capsule by allowing diffusion (43.20 ± 2.16%) of small molecules (40 kDa) like oxygen and necessary nutrients; and helping in the treatment of RDD by allowing diffusion of cell-secreted BDNF to the outside environment. In vitro results showed a continuous BDNF secretion from the device for at least 16 days, demonstrating future potential of the cell-encapsulation device for the treatment of RDD in a minimally invasive and self-sustainable way through a periocular transplant.

Impact of Fat-Free Adipose Tissue on the Prevalence of Low Muscle Mass Estimated Using Calf Circumference in Middle-Aged and Older Adults

Previous studies proposed calf circumference cutoff values for predicting dual-energy X-ray absorptiometry (DXA)-derived low muscle mass. However, DXA-derived appendicular lean mass (aLM) includes non-skeletal muscle components such as the appendicular fat-free component of adipose tissue fat cells (aFFAT). The purpose of this study was to compare the calf circumference method of classification before (Model #1) and after (Model #2) eliminating the influence of FFAT in healthy Japanese adults (50 to 79 years; mean age 70 (SD 7) years). Model 1, and Model 2 for classifying low muscle mass had a sensitivity of 78% and 64%, specificity of 76% and 75%, positive predictive value of 31% and 28%, and negative predictive value of 96% and 93%, respectively. Appendicular fat-free component of adipose tissue has the potential to influence the ability of calf circumference to accurately classify individuals with low muscle mass. Consideration should be made when using this as a screening tool for low muscle mass.

A founder Alu insertion in RP1 gene in Japanese patients with retinitis pigmentosa

PURPOSE

To screen for the 328 bp Alu insertion (c.4052_4053ins328, p.Tyr1352Alafs) in RP1 in a group of retinitis pigmentosa (RP) patients who had been previously identified with a heterozygous deleterious mutation in the gene.

STUDY DESIGN

Prospective, clinical and experimental study.

METHODS

The Alu insertion in RP1 was screened with an optimized PCR-based method in 26 RP patients with a heterozygous deleterious mutation (nonsense or frameshift) in RP1 that had been identified in a preceding genetic study. The genetic location of the previously identified mutation and its inheritance pattern were assessed.

RESULTS

Out of 26 RP patients with a heterozygous deleterious mutation in RP1, 5 (19.2%) were found to carry an additional heterozygous Alu insertion, presumably resulting in a compound heterozygous state. This included 3 patients who had been previously diagnosed as autosomal dominant RP based on genetic findings. They were re-diagnosed as having an autosomal recessive disease following our new findings. In all patients identified with the Alu insertion, the other mutations found in the preceding study were outside the defined region in exon 4 (encoding amino acids 677 to 917) in which truncation mutations have been suggested to exert a dominant negative effect.

CONCLUSION

The founder Alu insertion in RP1 is an important cause of autosomal recessive RP in Japanese patients and can be missed in standard targeted resequencing. Screening optimized for this mutation is warranted, particularly in patients with a heterozygous deleterious mutation outside the defined region in exon 4 of RP1.

Outcome of maintenance systemic chemotherapy with drug-free interval for metastatic urothelial carcinoma

OBJECTIVE

Aiming to achieve long-term disease control, maintenance systemic chemotherapy (MSC) with a 1-3-month drug-free interval is continued in selected patients. We report our experience of MSC for metastatic urothelial carcinoma (UC).

METHODS

Of 228 metastatic UC patients treated with systemic chemotherapy, 40 (17.5%, 40/228) had continuously undergone MSC. Data on the regimen, cycle number, and reason for the discontinuation of MSC were also collected. We analyzed OS from the initiation of MSC until death or the last follow-up, using the log-rank test to assess the significance of differences.

RESULTS

The median number of cycles of chemotherapy was 6, and the responses were CR in 6, PR in 20, SD in 13, and PD in 1 before MSC. Gemcitabine plus CDDP or carboplatin was mainly performed as MSC (70%, 28/40). MSC was repeated quarterly in 30 (75%, 30/40), every two months in 8 (20%, 8/40), and with other intervals in 2 (5%, 2/40). Overall, a median of 3.5 cycles (range: 1-29) of MSC was performed. The reason for the discontinuation of MSC was PD in 24 (60%, 24/40), favorable disease control in 9 (22.5%, 9/40), and myelosuppression in 3 (7.5%, 3/40), and for other reasons in 2 (5%, 2/40). MSC was ongoing in 2 (5%, 2/40). The median OS was 27 months from the initiation of MSC. PS0 (P = 0.0169), the absence of lung metastasis (P = 0.0387), and resection of the primary site (P = 0.0495) were associated with long-term survival after MSC.

CONCLUSIONS

In selected patients, long-term systemic chemotherapy could be performed with a drug-free interval. Our maintenance strategy with cytotoxic drugs may become one of the treatment options for long-term disease control.

Prototyping a Versatile Two-Layer Multi-Channel Microfluidic Device for Direct-Contact Cell-Vessel Co-Culture

Microfluidic devices are gaining increasing popularity due to their wide applications in various research areas. Herein, we propose a two-layer multi-channel microfluidic device allowing for direct-contact cell-vessel co-culture. Using the device, we built a co-culture model of the outer blood-retina barrier (oBRB), mimicking the in vivo retinal pigment epithelial cells-Bruch membrane-fenestrated choroids. To demonstrate the versatility of the design, we further modified the device by inserting platinum electrodes for trans-epithelial electrical resistance (TEER) measurement, demonstrating the feasibility of on-chip assessment of the epithelial barrier integrity. Our proposed design allows for direct-contact co-culture of cell–cell or cell–vessel, modifiable for real-time evaluation of the state of the epithelial monolayers.