A latent bleeding complication in ipsilateral common femoral puncture involving delayed diagnosis: a case report.

BACKGROUND: The trans femoral ipsilateral approach is often adopted for endovascular treatment (EVT) for better steerability of guidewires or better device deliverability. However, contrary to the trans femoral contralateral approach, ipsilateral antegrade puncture sometimes causes peculiar bleeding complications. CASE PRESENTATION: A 76-year-old female underwent EVT for chronic occlusion of the left superficial femoral artery (SFA) via the ipsilateral antegrade approach. After guidewire passage, we inflated the drug-coated balloons, but angiography showed blood flow stasis at the mid segment of the SFA. We also ensured prolonged balloon inflation, which resulted in favorable blood flow. While trying to ensure hemostasis, the blood pressure remained decreased, but neither bleeding nor superficial hematoma were observed at the puncture site. After hemostasis was achieved, we removed the surgical drape and noticed a swelling in the mid-portion of the thigh, distant from the puncture point. We then approached the left common femoral artery (CFA) contralaterally. Angiography showed continuous bleeding from a little bit distally to the sheath insertion point that was spreading through an intramuscular space. We stopped the bleeding with balloon tamponade inside the CFA. Angiography after hemostasis demonstrated blood flow stasis at the mid-segment of the SFA, similarly as that seen before. We confirmed compression of the SFA by a large hematoma using both intra- and extra- vascular ultrasound. Therefore, we deployed a self-expandable stent at the compressed SFA position. Finally, we achieved favorable blood flow on angiography. CONCLUSION: We encountered a case that latent bleeding unrecognized in the surgical field persisted while prolonged inflation of DCB was conducted at just proximal SFA. We could have avoided bailout stenting by noticing the bleeding incident in a timely manner. Prediction and prevention are essential for all kinds of procedural complications in EVT.

Percutaneous Closure Based on Physiological Assessment of an Arteriovenous Fistula in a Patient With Chronic Limb Threatening Ischaemia.

Introduction: An arteriovenous fistula (AVF) is a potential complication of endovascular therapy (EVT). Arteriovenous fistula steal syndrome sometimes leads to severe limb ischaemia; however, assessment of peripheral perfusion in AVF has not yet been established. Report: A 90 year old woman diagnosed with chronic limb threatening ischaemia underwent EVT. However, subintimal angioplasty of infrapopliteal lesions resulted in AVF formation in the posterior tibial artery (PTA). Revascularisation of the anterior tibial artery and PTA was performed, but severe AVF steal syndrome persisted and wound healing was delayed. An attempt to physiologically assess the effects of AVF closure and perform an AVF closing manoeuvre, if necessary, was performed. The physiological assessment was performed by laser Doppler flowmetry (LDF) and blood flow was temporarily blocked via the AVF at the distal PTA using a 6 F guiding extension catheter. A significant increase in blood flow was observed in the perfused area of the plantar artery. Coil embolisation and covered stent implantation in the PTA completely closed the AVF. During the procedure, peripheral perfusion with LDF gradually increased in the heel and fifth toe. After AVF closure, the skin perfusion pressure values increased significantly, wound healing was accelerated, and complete healing was achieved. Discussion: Laser Doppler flowmetry measurements under simulated AVF closure using a guiding extension catheter may be useful for the physiological assessment of peripheral perfusion before percutaneous AVF closure.

Impact of Controlling Nutritional Status Score on Comprehensive Clinical Outcomes in Patients With Chronic Limb-Threatening Ischemia in a Local Area of Super-Aged Society.

PURPOSE: This study aimed to evaluate the relationship between nutritional status and hospital outcomes in patients with chronic limb-threatening ischemia (CLTI) in a local area of contemporary super-aged society of Japan. MATERIALS AND METHODS: We analyzed 131 consecutive patients with 179 lower limb diseases admitted to our hospital for the treatment of CLTI between April 2018 and March 2023. These 131 patients were divided into 3 groups according to hospital outcomes: home discharge (HD), out-of-home discharge (OD), and in-hospital death (ID). Patient and lesion backgrounds were compared among the 3 groups, and a multivariable regression analysis was used to analyze the interaction between malnutrition and composite hard endpoints. RESULTS: The median age was 82.8 years, and non-ambulatory patients comprised 61.8% of the study population. The HD group included more ambulatory and fewer patients with higher CONUT score or inflammation than OD or ID group. The Rutherford classification and Wound, Ischemia, and foot Infection stage were significantly more severe in the ID group than in the HD group. Endovascular treatment (EVT) was more often implemented in the HD (94.9%) and OD (81.7%) groups than in the ID group (60.0%). However, all EVT procedures in the ID group were performed until as distally as possible to achieve the target arterial path success contrary to some EVT procedures in the HD or ID group that targeted lesions only above the knee. Multivariate analysis showed that a non-ambulatory state (hazard ratio [HR]=3.65, 95% confidence interval [CI]=1.48-9.02) and a higher controlling nutritional status (CONUT) score (≥5) (HR=7.46, 95% CI=1.66-33.6) were significant predictors for composite endpoints (major amputation or ID). Patients with lower CONUT scores (≤4) showed better outcomes in all indices including overall survival, major amputation-free survival, and wound healing. CONCLUSION: Condition of the CLTI patients represented by higher CONUT score emerged as the most influential predictor of major amputation or ID. Furthermore, non-ambulatory status or condition of higher CONUT score affects the destination after discharge. Implementing multidisciplinary approaches to address patients' nutritional state and physical disability, in addition to revascularization, may enhance comprehensive prognoses in patients with CLTI. CLINICAL IMPACT: In this single-center retrospective study, we analyzed prognoses of 131 consecutive patients with 179 lower limb diseases admitted for the treatment of chronic limb-threatening ischemia (CLTI) between April 2018 and March 2023. Our main finding was that condition of the CLTI patients represented by higher controlling nutritional status (CONUT) score was the most significant predictor of either major amputation or in-hospital death. Furthermore, condition of higher CONUT score or non-ambulatory status affects the destination after discharge. This suggests that multidisciplinary approaches to address patients' nutritional state and physical disability, in addition to revascularization, may enhance the prognosis in patients with CLTI. This is the first report to evaluate nutritional status associated with comprehensive hospital outcomes in addition to previously reported hard endpoints, such as major amputation or overall survival, and will be of great help in future clinical practice.

The dual role of Spn-E in supporting heterotypic ping-pong piRNA amplification in silkworms.

The PIWI-interacting RNA (piRNA) pathway plays a crucial role in silencing transposons in the germline. piRNA-guided target cleavage by PIWI proteins triggers the biogenesis of new piRNAs from the cleaved RNA fragments. This process, known as the ping-pong cycle, is mediated by the two PIWI proteins, Siwi and BmAgo3, in silkworms. However, the detailed molecular mechanism of the ping-pong cycle remains largely unclear. Here, we show that Spindle-E (Spn-E), a putative ATP-dependent RNA helicase, is essential for BmAgo3-dependent production of Siwi-bound piRNAs in the ping-pong cycle and that this function of Spn-E requires its ATPase activity. Moreover, Spn-E acts to suppress homotypic Siwi-Siwi ping-pong, but this function of Spn-E is independent of its ATPase activity. These results highlight the dual role of Spn-E in facilitating proper heterotypic ping-pong in silkworms.

Emphysematous changes as red flag signs preceding rapidly progressive infectious aortic disease: two case reports.

BACKGROUND: Infectious aortic disease is a rare and fatal disease, that requires the appropriate intervention. An accurate diagnosis should be promptly established. However, this is difficult because the clinical manifestations of this disease vary and are non-specific. CASE PRESENTATION: (CASE 1) An 87-year-old male, presenting with generalized malaise and weight loss, was admitted for further examination. A chest computed tomography (CT) showed mediastinal emphysema. Empirical intravenous antibiotics were administered to address the non-specific infectious findings in the laboratory data. The treatment was effective, and the patient fully recovered. However, he was in shock due to aortic rupture and marked pseudo aneurysmal formation around the aortic arch day 25 of hospitalization. An emergency total aortic arch replacement was performed, and the patient was discharged. (CASE 2) An 82-year-old male who had undergone Y-graft replacement in the abdominal aorta 15 years previously was admitted due to general malaise and anorexia. Abdominal CT revealed emphysematous changes adjacent to the abdominal aorta. The patient responded favorably to empirical treatment with intravenous antibiotics and was discharged 19 days after admission. Four days after discharge, the patient went into cardiac arrest after an episode of hematemesis. Abdominal CT revealed an enlarged stomach and duodenum, filled with massive high-density contents proximal to the abdominal aorta. He died of hemorrhagic shock despite cardiopulmonary resuscitation. CONCLUSIONS: Although emphysematous changes are rare, they are red flag signs during the early stage of infectious aortic disease. Thus, physicians should remain vigilant for this kind of critical sign.

Non-gonadal somatic piRNA pathways ensure sexual differentiation, larval growth, and wing development in silkworms.

PIWI-interacting RNAs (piRNAs) guide PIWI proteins to target transposons in germline cells, thereby suppressing transposon activity to preserve genome integrity in metazoans' gonadal tissues. Piwi, one of three Drosophila PIWI proteins, is expressed in the nucleus and suppresses transposon activity by forming heterochromatin in an RNA cleavage-independent manner. Recently, Piwi was reported to control cell metabolism in Drosophila fat body, providing an example of piRNAs acting in non-gonadal somatic tissues. However, mutant flies of the other two PIWI proteins, Aubergine (Aub) and Argonaute3 (Ago3), show no apparent phenotype except for infertility, blurring the importance of the piRNA pathway in non-gonadal somatic tissues. The silkworm, Bombyx mori, possesses two PIWI proteins, Siwi (Aub homolog) and BmAgo3 (Ago3 homolog), whereas B. mori does not have a Piwi homolog. Siwi and BmAgo3 are mainly expressed in gonadal tissues and play a role in repressing transposon activity by cleaving transposon RNA in the cytoplasm. Here, we generated Siwi and BmAgo3 loss-of-function mutants of B. mori and found that they both showed delayed larval growth and failed to become adult moths. They also exhibited defects in wing development and sexual differentiation. Transcriptome analysis revealed that loss of somatic piRNA biogenesis pathways results in abnormal expression of not only transposons but also host genes, presumably causing severe growth defects. Our results highlight the roles of non-gonadal somatic piRNAs in B. mori development.

Utility of the New Early Warning Score (NEWS) in combination with the neutrophil-lymphocyte ratio for the prediction of prognosis in older patients with pneumonia.

OBJECTIVE: Predictors of prognosis are necessary for use in routine clinical practice for older patients with pneumonia, given the ageing of the population. Recently, the National Early Warning Score (NEWS), a comprehensive predictor of severity that consists solely of physiological indicators, has been proposed to predict the prognosis of pneumonia. The neutrophil/lymphocyte ratio (NLR) is a simple index of inflammation that may also be predictive of pneumonia. In the present study, we aimed to determine whether NEWS or a combination of NEWS and NLR predicts mortality in older patients with pneumonia. DESIGN: A retrospective cohort study. SETTING: A general hospital in Japan. PARTICIPANTS: We collected data from patients aged ≥65 years with pneumonia who were admitted between 2018 and 2020 (n=282; age=85.3 (7.9)). Data regarding vital signs, demographics and the length of hospital stay, in addition to the NEWS and NLR, were extracted from the participants' electronic medical records. INTERVENTION: The utility of the combination of NEWS and NLR was assessed using NEWS×NLR and NEWS+NLR. MAIN OUTCOME MEASURES: Their predictive ability for 30-day mortality as the primary outcome was assessed using receiver operating characteristic (ROC) curve analysis. RESULTS: According to the NEWS classification, 80 (28.3%), 64 (22.7%) and 138 (48.9%) of the participants were at low, medium and high risk of mortality, respectively. The 30-day mortality for the entire cohort was 9.2% (n=26), and the mortality rate increased with the NEWS classification: low, 1.3%; medium, 7.8%; and high, 14.5%. The NLRs were 6.0 (4.2-9.8), 6.8 (4.8-10.4) and 14.6 (9.4-22.2), respectively (p<0.001). The areas under the ROC curves for 30-day mortality were 0.73 for the NEWS score, 0.84 for NEWS×NLR and 0.83 for NEWS+NLR, indicating that the combinations represent superior predictors of mortality to the NEWS alone. NEWS×NLR and NEWS+NLR tended to have better sensitivity, accuracy, positive predictive value and negative predictive value than NEWS alone (p=0.06). CONCLUSIONS: A combination of the NEWS and NLR (NEWS×NLR or NEWS+NLR) may be superior to the NEWS alone for the prediction of 30-day mortality in older patients with pneumonia. However, further validation of these combinations for use in the prediction of prognosis is required.

Tako-Tsubo Syndrome Following Pulmonary Vein Isolation for Atrial Fibrillation in a Patient with Primary Aldosteronism.

Tako-tsubo syndrome (TTS) can be triggered by emotional or physical stress and is characterized by transient left ventricular dysfunction with apical ballooning. Some neurologic disorders and pheochromocytoma serve as triggers for TTS, however, its association with primary aldosteronism (PA) is not well known. Pulmonary vein isolation (PVI) with catheter ablation for atrial fibrillation (AF) has been performed worldwide, and TTS following PVI has been reported as a rare complication. Sympathetic stimulation can play an important role in TTS development, however, its mechanism and risk factors are not yet understood.We describe a 72-year-old woman with PA who developed TTS after PVI with radiofrequency catheter ablation (RFCA) for symptomatic paroxysmal AF. Complete isolation of the pulmonary vein was carried out without any complications, however, she complained of epigastric discomfort 7 hours after the procedure. An electrocardiogram showed recurrent AF with a new negative-T wave and prolonged QT interval. Transthoracic echocardiography revealed apical ballooning and basal hypercontraction, characteristic of TTS, and coronary angiography showed no significant stenosis. She was diagnosed with TTS following RFCA for AF and managed well with conservative therapy.The present case suggests that TTS should be recognized as a complication associated with AF ablation. Moreover, PA may be involved in TTS development by increasing sympathetic activity. Further studies on the mechanism and characteristics of TTS are required.

Masculinizer is not post-transcriptionally regulated by female-specific piRNAs during sex determination in the Asian corn borer, Ostrinia furnacalis.

Lepidopteran insects are heterogametic in females, although most insect species are heterogametic in males. In a lepidopteran model species, the silkworm Bombyx mori (Bombycoidea), the uppermost sex determinant Feminizer (Fem) has been identified on the female-specific W chromosome. Fem is a precursor of PIWI-interacting small RNA (piRNA). Fem piRNA forms a complex with Siwi, one of the two B. mori PIWI-clade Argonaute proteins. In female embryos, Fem piRNA-Siwi complex cleaves the mRNA of the male-determining gene Masculinizer (Masc), directing the female-determining pathway. In male embryos, Masc activates the male-determining pathway in the absence of Fem piRNA. Recently, W chromosome-derived piRNAs complementary to Masc mRNA have also been identified in the diamondback moth Plutella xylostella (Yponomeutoidea), indicating the convergent evolution of piRNA-dependent sex determination in Lepidoptera. Here, we show that this is not the case in the Asian corn borer, Ostrinia furnacalis (Pyraloidea). Although our previous studies demonstrated that O. furnacalis Masc (OfMasc) has a masculinizing function in the embryonic stage, the expression level of OfMasc was indistinguishable between the sexes at the timing of sex determination. Deep sequencing analysis identified no female-specific small RNAs mapped onto OfMasc mRNA. Embryonic knockdown of two PIWI genes did not affect the expression level of OfMasc in either sex. These results demonstrated that piRNA-dependent reduction of Masc mRNA in female embryos is not a common strategy of sex determination, which suggests the possibility of divergent evolution of sex determinants across the order Lepidoptera.

Inframalleolar thrice distal puncture in a single endovascular treatment session for successful revascularization.

BACKGROUND: Most patients with chronic limb-threatening ischemia (CLTI) have infrapopliteal arterial disease, which are often challenging to treat. In endovascular treatment (EVT) for these complex lesions, establishing retrograde access is an essential option not only for guidewire crossing but also for device delivery. However, no EVT case has yet been reported requiring inframalleolar thrice distal puncture in a single EVT session so far. CASE PRESENTATION: A 60-year-old CLTI patient with grade 3 Wound, Ischemia and foot Infection (WIfI) classification underwent EVT for occluded dorsal artery and posterior tibial artery. First, we conducted successful balloon angioplasty of the posterior tibial artery by establishing a retrograde approach via the lateral plantar artery. To treat the occlusion of the dorsal artery, we punctured the first dorsal metatarsal artery, and retrogradely advanced a guidewire to the dorsal artery occlusion; however, the microcatheter could not follow the guidewire. Therefore, we punctured the occluded distal anterior tibial artery and introduced the retrograde guidewire into the puncture needle. After guidewire externalization, we pulled up the retrograde microcatheter into the occlusion of dorsal artery using the "balloon deployment using forcible manner" technique. Thereafter, we were able to advance the antegrade guidewire into the retrograde microcatheter. After guidewire externalization, an antegrade balloon catheter was delivered and inflated for the purpose of dorsal artery dilation and hemostasis at the "needle rendezvous" point. Consecutively, balloon dilation was performed for puncture site hemostasis of the first dorsal metatarsal artery and complete hemostasis was achieved. Finally, we confirmed good vascular patency and favorable blood flow. After revascularization, transmetatarsal amputation was performed and the wound healed favorably. CONCLUSIONS: We can markedly increase the success rate of revascularization by effectively utilizing the retrograde approach in EVT for complex chronic total occlusions in infrapopliteal arterial diseases.

A Multicenter Prospective Interventional Trial of Therapeutic Angiogenesis Using Bone Marrow-Derived Mononuclear Cell Implantation for Patients With Critical Limb-Threatening Ischemia Caused by Thromboangiitis Obliterans.

BACKGROUND: Thromboangiitis obliterans (TAO) can lead to the development of critical limb-threatening ischemia (CLTI). Despite conventional treatments, such as smoking cessation or revascularization, young patients (<50 years) still require limb amputation. Therapeutic angiogenesis using bone marrow-derived mononuclear cell (BM-MNC) implantation has been tested and shown to have reasonable efficacy in CLTI. In this multicenter prospective clinical trial, we evaluated the safety and efficacy of BM-MNC implantation in CLTI patients with TAO.Methods and Results: We enrolled 22 CLTI patients with skin perfusion pressure (SPP) <30 mmHg. The primary endpoint of this trial is the recovery of SPP in the treated limb after a 180-day follow-up period. Secondary endpoints include the pain scale score and transcutaneous oxygen pressure (TcPO2). One patient dropped out during follow-up, leaving 21 patients (mean age 48 years, 90.5% male, Fontaine Class IV) for analysis. BM-MNC implantation caused no serious adverse events and increased SPP by 1.5-fold compared with baseline. Surprisingly, this effect was sustained over the longer term at 180 days. Secondary endpoints also supported the efficacy of this novel therapy in relieving pain and increasing TcPO2. Major amputation-free and overall survival probabilities at 3 years among all enrolled patients were high (95.5% and 89.5%, respectively). CONCLUSIONS: BM-MNC implantation showed safety and significant efficacy in CLTI patients with TAO.

The piRNA cluster torimochi is an expanding transposon in cultured silkworm cells.

PIWI proteins and PIWI-interacting RNAs (piRNAs) play a central role in repressing transposable elements in animal germ cells. It is thought that piRNAs are mainly produced from discrete genomic loci named piRNA clusters, which often contain many "dead" transposon remnants from past invasions and have heterochromatic features. In the genome of silkworm ovary-derived cultured cells called BmN4, a well-established model for piRNA research, torimochi was previously annotated as a unique and specialized genomic region that can capture transgenes and produce new piRNAs bearing a trans-silencing activity. However, the sequence identity of torimochi has remained elusive. Here, we carefully characterized torimochi by utilizing the updated silkworm genome sequence and the long-read sequencer MinION. We found that torimochi is in fact a full-length gypsy-like LTR retrotransposon, which is exceptionally active and has massively expanded its copy number in BmN4 cells. Many copies of torimochi in BmN4 cells have features of open chromatin and the ability to produce piRNAs. Therefore, torimochi may represent a young, growing piRNA cluster, which is still "alive" and active in transposition yet capable of trapping other transposable elements to produce de novo piRNAs.

Early experience with coronary debulking devices in a newcomer facility after introducing revised facility criteria in Japan.

Coronary debulking devices are essential in obtaining optimal results in percutaneous coronary intervention (PCI) for severely calcified lesions. However, since the introduction of these devices in Japan, the presence of full-time cardiovascular surgeons in their own facilities has been an essential condition (on-site surgical back-up) as the facility criteria for their use. The criteria were revised in April 2020, making their implementation possible at our hospital. Between May 2020 and January 2022, we administered PCIs using rotational atherectomy (RA) for 33 lesions in 28 patients and orbital atherectomy system (OAS) for 36 lesions in 27 patients. The most preferred strategy in our hospital is OAS via the distal radial approach using a 6Fr Glide sheath or RA via the femoral approach using a 7Fr sheath. The percentages of usable imaging modality as an initial device without lesion modification were 57.1 and 66.7% in the RA and OAS groups, respectively. In the RA procedure, 1.5- and 2.0-mm Rota burrs were more frequently adopted for the initial and second sessions, respectively. In the OAS procedure, the debulking was always initiated at a low speed. Nineteen of the 27 patients underwent additional high-speed debulking. Pre-procedural quantitative coronary angiographic analysis revealed that the minimal lumen diameter was significantly smaller in the RA than in the OAS group. Debulking procedures were successful in all patients excluding two instances of procedure-related complications in the RA group, one of which was coronary perforation safely treated via covered stent deployment without any resulting hemodynamic instability. Our early experience with coronary debulking devices with off-site surgical back-up clearly reveals the safety and feasibility of this procedure in a newcomer facility.

The mechanisms of siRNA selection by plant Argonaute proteins triggering DNA methylation.

The model plant Arabidopsis thaliana encodes as many as ten Argonaute proteins (AGO1-10) with different functions. Each AGO selectively loads a set of small RNAs by recognizing their length and 5' nucleotide identity to properly regulate target genes. Previous studies showed that AGO4 and AGO6, key factors in DNA methylation, incorporate 24-nt small-interfering RNAs with 5' adenine (24A siRNAs). However, it has been unclear how these AGOs specifically load 24A siRNAs. Here, we biochemically investigated the siRNA preference of AGO4, AGO6 and their chimeric mutants. We found that AGO4 and AGO6 use distinct mechanisms to preferentially load 24A siRNAs. Moreover, we showed that the 5' A specificity of AGO4 and AGO6 is not determined by the previously known nucleotide specificity loop in the MID domain but rather by the coordination of the MID and PIWI domains. These findings advance our mechanistic understanding of how small RNAs are accurately sorted into different AGO proteins in plants.

A Wolbachia factor for male killing in lepidopteran insects.

Bacterial symbionts, such as Wolbachia species, can manipulate the sexual development and reproduction of their insect hosts. For example, Wolbachia infection induces male-specific death in the Asian corn borer Ostrinia furnacalis by targeting the host factor Masculinizer (Masc), an essential protein for masculinization and dosage compensation in lepidopteran insects. Here we identify a Wolbachia protein, designated Oscar, which interacts with Masc via its ankyrin repeats. Embryonic expression of Oscar inhibits Masc-induced masculinization and leads to male killing in two lepidopteran insects, O. furnacalis and the silkworm Bombyx mori. Our study identifies a mechanism by which Wolbachia induce male killing of host progeny.

The two Gtsf paralogs in silkworms orthogonally activate their partner PIWI proteins for target cleavage.

The PIWI-interacting RNA (piRNA) pathway is a protection mechanism against transposons in animal germ cells. Most PIWI proteins possess piRNA-guided endonuclease activity, which is critical for silencing transposons and producing new piRNAs. Gametocyte-specific factor 1 (Gtsf1), an evolutionarily conserved zinc finger protein, promotes catalysis by PIWI proteins. Many animals have multiple Gtsf1 paralogs; however, their respective roles in the piRNA pathway are not fully understood. Here, we dissected the roles of Gtsf1 and its paralog Gtsf1-like (Gtsf1L) in the silkworm piRNA pathway. We found that Gtsf1 and Gtsf1L preferentially bind the two silkworm PIWI paralogs, Siwi and BmAgo3, respectively, and facilitate the endonuclease activity of each PIWI protein. This orthogonal activation effect was further supported by specific reduction of BmAgo3-bound Masculinizer piRNA and Siwi-bound Feminizer piRNA, the unique piRNA pair required for silkworm feminization, upon depletion of Gtsf1 and Gtsf1L, respectively. Our results indicate that the two Gtsf paralogs in silkworms activate their respective PIWI partners, thereby facilitating the amplification of piRNAs.

Screening for untreated atrial fibrillation in the elderly population: A community-based study.

BACKGROUND: Strokes are common in people with atrial fibrillation (AF), and can have devastating consequences, especially in the elderly and if AF is untreated. However, community-based studies on screening for untreated AF have not been conducted in Japan, and there has been no evaluation of the effectiveness of early screening for AF in the elderly (≥65 years). METHODS: The Kyoto Prefectural University of Medicine (KPUM) Education Initiative has conducted an AF awareness campaign consisted of screening tests using a blood pressure (BP) monitor with electrocardiogram (ECG) (the Complete, Omron Healthcare Co., Ltd., Kyoto, Japan) and educational lectures for the elderly (≥65 years) from 2019 to 2020. A modeled effectiveness analysis was performed comparing the life-years and QALYs (quality-adjusted life-years) between direct-acting oral anticoagulation (DOAC)-treated AF and untreated AF in a Japanese setting. The basic description of the Markov model was used for the analysis. RESULTS: A total of 1648 participants were screened, and after excluding those with missing information or data (n = 41), 1607 were finally enrolled. The mean (± standard deviation) age of participants was 72.4±5.8 years, 827 (51.5%) were female, 628 (39.1%) had hypertension, and 1368 (85.1%) had CHA2DS2-VASc score ≥2. After cardiologists' evaluation of all ECG recordings of the Complete, 15 (0.93%) AF were newly detected. For each AF treated with DOAC, 0.859 QALYs gained over the lifetime for 65 years-old men, and 0.856 QALYs for 65 years-old women compared to non-treatment. CONCLUSION: A moderate number of untreated AF were identified in the community-based study. Identification of an increased number of patients with AF, if properly treated with DOAC, ultimately leads to a reduction in the number of strokes occurred over subjects' lifetime.