A Rescue Use of ECPELLA for Sepsis-Induced Cardiogenic Shock Followed by Mitral Valve Replacement.

The use of veno-arterial extracorporeal membrane oxygenation (ECMO) in patients with sepsis-induced cardiogenic shock has been reported, but the clinical implication of the Impella percutaneous axial-flow left ventricular assist device for such patients remains unknown. We had a 37-year-old man with septic shock and severely reduced cardiac function. Veno-arterial ECMO and concomitant Impella CP support ameliorated his end-organ dysfunction and achieved cardiac recovery, whereas severe mitral valve regurgitation due to chordal rupture developed later. Mitral valve replacement concomitant with ECMO removal as well as an Impella upgrade successfully treated the patient. ECMO and Impella support might be an effective therapeutic strategy for the bridge to recovery in patients with sepsis-induced cardiogenic shock; however, paying attention to mitral chordal rupture is highly encouraged.

Trans-Apical Transcatheter Aortic Valve Replacement in a Dialysis Patient with Systolic Heart Failure.

Mortality and morbidity remain high following transcatheter aortic valve replacement (TAVR) in dialysis patients or those with low left ventricular ejection fraction. Therapeutic strategy for those with these comorbidities remains unestablished. We had a dialysis patient with peripheral artery disease and low left ventricular ejection fraction, who received successfully scheduled trans-apical TAVR following sufficient reverse remodeling by 3-month optimal medical therapy. Our strategy should be validated in a larger robust cohort.

Effects of Trained Health Professionals' Behavioral Counseling Skills on Smoking Cessation Outcomes.

Background: There is evidence that training health professionals in behavioral counseling skills can lead to greater success in helping their smokers to quit. However, it is still unknown how counseling skills relate to counseling effects. Purpose: We established a method of skills evaluation of health professionals for smoking cessation counseling based on videotaped counseling sessions with a standardized smoker, and examined the relationship between skill levels and smoking cessation outcomes. Methods: Twenty-three health professionals at Japanese workplaces underwent a training program. Their counseling skills were evaluated before and after the program using a structured evaluation form-based analysis of videotaped interactions between participants and a standardized smoker. A total of 858 smokers then received individual smoking cessation counseling by the trained health professionals at an annual health checkup. These patients were followed-up through surveys after 1 year. Results: On a scale from 0 to 24, Total skill scores, which ranged from 0 to 24, were significantly higher after the training than before the training (p < .001). Multiple two-level logistic regression analysis adjusted for smokers' characteristics showed that the odds ratios of skill scores after the training for point prevalence and sustained abstinence rates among smokers who received counseling were 1.21 (95% confidence interval: 1.03-1.42) and 1.26 (1.05-1.50), respectively. Conclusions: This study demonstrates that higher behavioral counseling skills were associated with better smoking cessation outcomes. This research is of clinical importance in that it provides a tool for assessing counselling skills in a way that is demonstrably relevant to outcomes.

Determinants of participation in prostate cancer screening: a simple analytical framework to account for healthy-user bias.

In Japan at present, fecal occult blood testing (FOBT) is recommended for cancer screening while routine population-based prostate-specific antigen (PSA) screening is not. In future it may be necessary to increase participation in the former and decrease it in the latter. Our objectives were to explore determinants of PSA-screening participation while simultaneously taking into account factors associated with FOBT. Data were gathered from a cross-sectional study conducted with random sampling of 6191 adults in Osaka city in 2011. Of 3244 subjects (return rate 52.4%), 936 men aged 40-64 years were analyzed using log-binomial regression to explore factors related to PSA-screening participation within 1 year. Only responders for cancer screening, defined as men who participated in either FOBT or PSA-testing, were used as main study subjects. Men who were older (prevalence ratio [PR] [95% confidence interval (CI)] = 2.17 [1.43, 3.28] for 60-64 years compared with 40-49 years), had technical or junior college education (PR [95% CI] = 1.76 [1.19, 2.59] compared with men with high school or less) and followed doctors' recommendations (PR [95% CI] = 1.50 [1.00, 2.26]) were significantly more likely to have PSA-screening after multiple variable adjustment among cancer-screening responders. Attenuation in PR of hypothesized common factors was observed among cancer-screening responders compared with the usual approach (among total subjects). Using the analytical framework to account for healthy-user bias, we found three factors related to participation in PSA-screening with attenuated association of common factors. This approach may provide a more sophisticated interpretation of participation in various screenings with different levels of recommendation.

The present state and perception of young women with breast cancer towards breast reconstructive surgery.

PURPOSE: This study was conducted to identify factors influencing patients' decisions to undergo breast reconstruction, and to identify the influences of breast reconstruction on patient behavior and psychological well-being. METHODS: Data were collected from January to June 2011, using a questionnaire distributed to women ≤45 years old with breast cancer, at five medical institutes across Japan. RESULTS: Completed questionnaires were collected from 316 women (mean age: 39.46 ± 4.4 years, range: 27-45 years). Overall, 174 patients received breast-conserving surgery, 101 received mastectomy, 31 received subcutaneous mastectomy, 3 patients received none, and 49 were unreported). The data indicated a reconstruction rate of 36.7 % in women who underwent mastectomy. The most prevalent reason for not undergoing breast reconstruction was the fear of cancer relapse. Other factors mentioned were to avoid additional distress on the body from surgery, financial reasons, and a belief that breast reconstruction is unnecessary. The main factor that influenced the decision not to undergo delayed breast reconstruction, specifically, was the expense. Women who had completed breast reconstruction showed higher self-evaluations of physical attractiveness and were more active in comparison to those who did not. However, regardless of having undergone breast reconstruction or not, women who reported higher levels of self-consciousness over the treated areas showed more restrictions on activity and higher chances of a decline in psychological well-being. CONCLUSION: Regardless of deciding to undergo breast reconstruction or not, the results of this study suggested the need for cognitive interventions to avoid patients fixating on self-consciousness over treated areas.

Prognostic impact of elevated erythropoietin levels in patients with severe aortic stenosis receiving trans-catheter aortic valve implantation.

BACKGROUND: Elevated endogenous erythropoietin (EPO) levels are associated with worse clinical outcomes in patients with heart failure (HF). The clinical implication of endogenous EPO levels in patients undergoing trans-catheter aortic valve implantation (TAVI) beyond other conventional risk factors remains unknown. METHODS: Consecutive patients with EPO measurements who underwent TAVI for the treatment of their severe aortic stenosis at our institute between May 2015 and December 2020 were included. The association between the endogenous EPO levels and the primary outcome consisting of all-cause mortality and HF hospitalization was evaluated. RESULTS: A total of 263 patients (85.1 ±â€¯5.1 years old, 74 men) were included and tertiled according to the baseline EPO levels. The high EPO group had more advanced anemia, renal impairment, and hypoalbuminemia than the other two tertiled groups (p < 0.05 for both). Patients with high EPO had a significantly higher cumulative incidence of the primary outcomes compared to the other two groups (p = 0.002) with an adjusted hazard ratio of 6.0 (95 % confidence interval 1.9-18.1) in its logarithmic value (p < 0.001). CONCLUSIONS: Elevated baseline EPO levels were independently associated with mortality and morbidity following TAVI. The clinical implication of aggressive intervention on the elevated EPO levels in this cohort remains the next concern.

Paradoxical prognostic impact of severe aortic stenosis following trans-catheter aortic valve implantation.

BACKGROUND: Aortic valve replacement is recommended for patients with "very severe" aortic stenosis (AS), irrespective of symptomatic manifestation. Nonetheless, the prognostic ramifications of "very severe" AS, as opposed to "severe" AS, subsequent to trans-catheter aortic valve implantation (TAVI) remain enigmatic. METHODS: We enrolled consecutive patients who received TAVI at our institute between May 2015 and April 2021. We scrutinized the impact of baseline "very severe" AS upon 3-year all-cause death or heart failure hospitalization following TAVI, in comparison to "severe" AS. RESULTS: A total of 239 patients (84.8 ±â€¯5.4 years old, 58 men) were included. Baseline "very severe" AS was observed in 65 (27 %) patients, who exhibited more advanced hypertrophy and higher B-type natriuretic peptide levels compared to those with "severe" AS (p < 0.05 for both). Baseline "very severe" AS was paradoxically associated with higher freedom from the primary endpoint following TAVI compared to those with "severe" AS (p = 0.01). CONCLUSIONS: The presence of baseline "very severe" AS was paradoxically associated with improved clinical outcomes subsequent to TAVI, in contrast to the cases of "severe" AS.

A Case of Liver Cancer with Overlapping Myasthenia Gravis, Myocarditis, Seronegative Autoimmune Autonomic Ganglionopathy, and Myositis Symptoms Induced by Atezolizumab: A Case Report.

An 83-year-old man with hepatocellular carcinoma developed muscle weakness, ptosis, and dyspnea 3 weeks after receiving atezolizumab. Soon after, mechanical ventilation was initiated, which was followed by marked blood pressure spikes. The levels of creatine kinase and troponin-I were significantly elevated, and acetylcholine receptor antibodies were positive. The patient was diagnosed with immune checkpoint inhibitor (ICI)-induced myositis, myasthenia gravis (MG), myocarditis, and suspected autoimmune autonomic ganglionopathy (AAG). After immunotherapy, the serum markers and blood pressure normalized, and he was weaned from the ventilator after five months. To our knowledge, this is the first reported case of AAG secondary to ICI-induced myositis, MG, and myocarditis.

LOXL2 expression is associated with invasiveness and negatively influences survival in breast cancer patients.

Lysyl oxidase-like 2 (LOXL2) is associated with invasiveness and metastasis in breast cancer. We analyzed the prognostic impact of LOXL2 for breast cancer patients and investigated the role of LOXL2 in breast cancer cell lines. Immunohistochemical study of LOXL2 expression was done in samples from 309 patients. Survival analysis was performed using log-rank test and Cox regression hazard model. After identification of LOXL2 expression in breast cancer cell lines, we performed matrigel invasion and wound-healing assays with LOXL2-silenced cell lines. In the human study, LOXL2 was expressed in 16.2 % of patients. Comparing the LOXL2-positive versus negative groups, there was a significantly higher proportion of estrogen receptor-negative patients (54.0 vs. 37.0 %, respectively; p = 0.029) and triple-negative patients (34.0 vs. 18.0 %; p = 0.022) in the positive group. In multivariate analysis for overall survival and metastasis-free survival, positive LOXL2 was demonstrated as a poor prognostic factor (HR 2.27 and 2.10, respectively). In vitro study indicated that LOXL2 silencing induces a mesenchymal-epithelial transition-like process in basal cell lines (MDA-MB-231 and BT549) associated with decreased invasive and migratory properties. These clinical and preclinical data confirm that higher LOXL2 expression is associated with invasiveness of basal-like breast cancer cells and lower survival of breast cancer patients. Our results suggest the clinical value of LOXL2 as a therapeutic target in breast cancer.

Modeling the effect of disseminating brief intervention for smoking cessation at medical facilities in Japan: a simulation study.

PURPOSE: The Japanese male smoking prevalence is still high. Underlying causes are the low quit attempt rate (QAR) and lack of pharmacotherapy (PT) use. Though health checkups are widely and systematically performed in Japan, this setting has not been utilized for intervention to smokers. We aimed to estimate the population effect of disseminating brief intervention (BI) at health checkup facilities combined with encouraging PT utilization. METHODS: The annual population quit rate (PQR) was modeled as a product of three components: the QAR, utilization of PT, and effectiveness of PT. A policy to disseminate effective BI at health checkup facilities was then incorporated into the PQR model as means to increase the QAR and/or PT utilization. Japanese male smokers aged 40-74 years were the target population, and the baseline year was set at 2005. The PQR and the number of smokers who successfully quit were compared with the baseline to evaluate the BI policy. RESULTS: The BI policy was estimated to increase the PQR from 4.3 to 5.7 % (rate ratio: 1.34) in a scenario where 75 % of smokers having an annual health checkup received BI and 60 % of BI-induced quit attempts were supported by PT, resulting in 177,000 new successful quitters on an annual basis and 3,000 avoidable cancer deaths in 10 years. Comparisons of different scenarios revealed that increasing QAR and encouraging PT were both essential to maximize the effect of BI policy. CONCLUSION: The dissemination of BI at health checkup facilities encouraging PT utilization is an effective tobacco control policy in Japan.

A novel therapeutic strategy: remote dielectric sensing-guided management of pulmonary congestion.

Management of pulmonary congestion is a key to improve mortality and morbidity in patients with congestive heart failure, but it is often challenging due to a lack of gold standard to accurately assess the lung fluid level. We had an 86-year-old man who was admitted to our institute due to worsening congestive heart failure. His pulmonary congestion was quantified repeatedly by the novel noninvasive device, remote dielectric sensing, and was optimally managed by the medication adjustment. Remote dielectric sensing might be a promising device to quantify pulmonary congestion and guide clinicians to optimize medications in addition to the conventional multi-modalities. .

Novel Ramp Test to Optimize Pressure Setting of Adaptive Servo-Ventilation Using Non-Invasive Lung Fluid Level Quantification.

BACKGROUND Optimal patient selection and device pressure settings are key to successful adaptive servo-ventilation therapy, but there is no established strategy thus far. Adaptive servo-ventilation therapy at an inappropriately high pressure setting for those without pulmonary congestion decreases cardiac output and worsens clinical outcomes. The remote dielectric sensing system (ReDS) is a novel noninvasive tool to estimate the lung fluid amount. The ReDS might be a promising tool for successful adaptive servo-ventilation therapy if appropriately utilized for optimal patient selection and device pressure setting. CASE REPORT An 83-year-old woman was admitted to our hospital to treat acute decompensated heart failure with preserved ejection fraction that was refractory to conventional medical therapy. Following the confirmation that she had significant pulmonary congestion with 47% of the ReDS value (normal range, 20-35%), we performed a "ramp test" to optimize device pressure, by measuring ReDS values and noninvasively estimating the cardiac output and stroke volume at each pressure setting. The device pressure setting was finally determined to minimize pulmonary congestion and maximize cardiac output. Following the continuous adaptive servo-ventilation therapy with the optimized pressure setting, the patient's hospitalization was uneventful and she was discharged. CONCLUSIONS We propose performing a ramp test to optimize the pressure setting of adaptive servo-ventilation by utilizing ReDS technology for each patient, instead of using a default or inappropriately higher pressure setting. However, further studies including large patient populations are warranted to validate the prognostic implication of this customized ramp test protocol.

A case of chronic myocarditis remitted by immunosuppressive and central extracorporeal membrane oxygenation therapy.

The concept and therapeutic strategy for chronic lymphocytic myocarditis remain unestablished. We had a 57-year-old man with advanced biventricular (predominantly right ventricular) failure due to chronic lymphocytic myocarditis. He received central extracorporeal membrane oxygenation therapy that was explanted on day 129 following the aggressive steroid pulse and plasma exchange therapy. Infiltration of inflammatory cells persisted even after the device removal, which required long-term oral steroid administration after the index discharge on day 200. High-sensitivity cardiac troponin T level was normalized and inflammatory cell infiltration was remitted following post-discharge 4-month 10 mg/day prednisolone therapy. Aggressive immunosuppressive therapy under mechanical circulatory support might be a promising strategy for those with chronic lymphocytic myocarditis. .

Successful Management of Pheochromocytoma Crisis with Cardiogenic Shock by Percutaneous Left Ventricular Assist Device.

Therapeutic strategy utilizing mechanical circulatory supports in patients with pheochromocytoma-related cardiogenic shock remains unestablished. We had a 51-year-old man with acute decompensated heart failure due to pheochromocytoma crisis. He received a percutaneous left ventricular assist device-supported alpha-blocker and intensive fluid infusion therapy, which ameliorated impaired end-organ dysfunction, maintaining hemodynamics and achieving cardiac recovery, followed by the successfully scheduled adrenalectomy. Early suspicion of pheochromocytoma and Impella-supported disease-specific medical management might be a promising bridge to surgery strategy.

Prognostic implication of pulmonary artery pulsatility index before transcatheter aortic valve replacement.

Background: Pulmonary artery pulsatility index (PAPI) is a recently proposed hemodynamic index that is associated with right ventricular function independently on volume status. However, its clinical implication in patients receiving transcatheter aortic valve replacement (TAVR) remains uninvestigated. Baseline PAPI might be a promising index that stratify patients' clinical outcomes following TAVR. Methods: In this retrospective cohort study, patients with severe aortic stenosis who received TAVR and completed baseline invasive hemodynamic assessments using right heart catheterization were included. The impact of baseline PAPI on the 2-year incidence of heart failure re-hospitalizations following TAVR was investigated. Results: A total of 227 patients (median 86 years old, 29% men) were included. Median baseline PAPI was 3.6 (2.6, 5.5). PAPI was an independent predictor of the primary endpoint with adjusted hazard ratio of 7.01 (95% confidence interval: 2.08-23.2, P=0.008) with a cutoff of 2.1, which significantly stratified the 2-year cumulative incidence of primary endpoint (lower PAPI 21% versus high PAPI 5%, P=0.003). Conclusions: Baseline impaired right ventricular function, indicated by lower PAPI below 2.1, was associated with the occurrence of heart failure following TAVR. Further studies are warranted to clarify the mechanism underlying on our findings and the prognostic implication of aggressive intervention to improve PAPI.

Clinical Implications of Changes in Respiratory Instability Following Transcatheter Aortic Valve Replacement.

BACKGROUND: Respiratory instability, which can be quantified using respiratory stability time (RST), is associated with the severity and prognostic impact of the disease in patients with chronic heart failure. However, its clinical implications in patients with severe aortic stenosis receiving transcatheter aortic valve replacement (TAVR) remain unknown. METHODS: Patients who received TAVR and had paired measurements of RST at a baseline and one week following TAVR were prospectively included. Changes in RST following TAVR and its impact on post-TAVR heart failure readmissions were investigated. RESULTS: Seventy-one patients (median age, 86 years old; 35% men) were included. The baseline RST was correlated with the severity of heart failure including elevated levels of plasma B-type natriuretic peptide (p < 0.05 for all). RST improved significantly following TAVR from 34 (26, 37) s to 36 (33, 38) s (p < 0.001). Post-TAVR lower RST (<33 s, n = 18) was associated with a higher 2-year cumulative incidence of heart failure readmission (21% vs. 8%, p = 0.039) with a hazard ratio of 5.47 (95% confidence interval 0.90-33.2). CONCLUSION: Overall, respiratory instability improved following TAVR. Persistent respiratory instability following TAVR was associated with heart failure recurrence.

Clinical implications of troponin-T elevations following TAVR: Troponin Increase Following TAVR.

BACKGROUND: Baseline and post-procedural elevations in serum troponin-T levels are associated with increased morbidity and mortality following transcatheter aortic valve replacement (TAVR). However, the prognostic impact of change in serum troponin-T level following TAVR remains unknown. METHODS: Among the patients with severe aortic stenosis who underwent TAVR, those with baseline serum troponin-T level ≥51.5 ng/L were excluded. The impact of increases in serum troponin-T level to an abnormally high range (≥51.5 ng/L) following TAVR on 2-year cardiovascular death or heart failure readmissions was investigated. RESULTS: Among 189 included patients (median 86 years old, 28% men), serum troponin-T level increased in 79 patients following TAVR. An increase in serum troponin-T was associated with a higher rate of 30-day adverse events, predominantly due to pacemaker implantation for complete atrio-ventricular block, and a higher 2-year cumulative incidence of the primary endpoint (hazard ratio 5.24, 95% confidence interval 1.64-16.8, p = 0.005) adjusted for the potential confounders. CONCLUSION: Post-procedural increase in serum troponin-T level was associated with adverse clinical outcomes following TAVR.

Typing of the Gut Microbiota Community in Japanese Subjects.

Gut microbiota are involved in both host health and disease and can be stratified based on bacteriological composition. However, gut microbiota clustering data are limited for Asians. In this study, fecal microbiota of 1803 Japanese subjects, including 283 healthy individuals, were analyzed by 16S rRNA sequencing and clustered using two models. The association of various diseases with each community type was also assessed. Five and fifteen communities were identified using partitioning around medoids (PAM) and the Dirichlet multinominal mixtures model, respectively. Bacteria exhibiting characteristically high abundance among the PAM-identified types were of the family Ruminococcaceae (Type A) and genera Bacteroides, Blautia, and Faecalibacterium (Type B); Bacteroides, Fusobacterium, and Proteus (Type C); and Bifidobacterium (Type D), and Prevotella (Type E). The most noteworthy community found in the Japanese subjects was the Bifidobacterium-rich community. The odds ratio based on type E, which had the largest population of healthy subjects, revealed that other types (especially types A, C, and D) were highly associated with various diseases, including inflammatory bowel disease, functional gastrointestinal disorder, and lifestyle-related diseases. Gut microbiota community typing reproducibly identified organisms that may represent enterotypes peculiar to Japanese individuals and that are partly different from those of indivuals from Western countries.

Relationship Between Body Posture and Lung Fluid Volume Assessed Using a Novel Noninvasive Remote Dielectric Sensing System.

Background: The relationship between body posture and lung fluid level has not been quantified thus far. Remote dielectric sensing (ReDSTM) is a recently introduced non-invasive electromagnetic-based technology to quantify lung fluid percentage. Methods and Results: ReDS values were measured at different body postures (i.e., sitting, supine, and supine with legs elevated) in a healthy volunteer cohort (n=16; median age 39 years, 69% men, median [interquartile range {IQR}] body mass index 23.3 kg/m2 [21.0-26.2 kg/m2]). In the sitting position, the median ReDS value was 27% (IQR 25-29%). The ReDS value increased significantly in the supine position (median 28%; IQR 27-30%; P=0.009), and increased further upon leg elevation (median 29%; IQR 28-32%; P=0.001). Conclusions: In this proof-of-concept study, the relationship between body posture and lung fluid level was quantitatively validated in a healthy cohort.

Burden on oncologists when communicating the discontinuation of anticancer treatment.

OBJECTIVE: Communicating the discontinuation of anticancer treatment to patients is a difficult task. The primary aim of this study was to clarify the level of oncologist-reported burden when communicating about discontinuation of an anticancer treatment. The secondary aims were (i) to identify the sources of burden contributing to their levels and (ii) to explore the useful strategies to alleviate their burden. METHODS: A multicenter nationwide questionnaire survey was conducted on 620 oncologists across Japan (response rate, 67%). RESULTS: High levels of perceived burden were reported by 47% of respondents, and 17% reported that they sometimes, often or always wanted to stop oncology work because of this burden. There was a significant association between high levels of burden and: a feeling that breaking bad news would deprive the patient of hope; concern that the patient's family would blame the oncologist; concern that the patient may lose self-control; and a feeling that there was not enough time to break the bad news. Strategies perceived to be useful by oncologists included training in how to effectively communicate to patients discontinuation of anticancer treatment, a reduction in total workload to allow sufficient time to break bad news, and development of a multidisciplinary model to facilitate cooperation with other professionals and facilities. CONCLUSIONS: Many oncologists reported high levels of burden relating to communication of discontinuation of anticancer treatment. A specific communication skills training program, sufficient time for communication and development of a multidisciplinary model could help alleviate the burden on oncologists.