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• Predictors of pulmonary edema in acute heart failure according to blood pressure. • Relation between right ventricular systolic function and pulmonary edema. • Interventricular functional mismatch assessed by speckle tracking echocardiography. Parameters of cardiac function related to the development of pulmonary edema (PE) in acute heart failure (AHF), including right ventricular (RV) function and a mismatch of interventricular function, are not fully elucidated. The aim of this study was to verify the hypothesis that a relatively preserved RV function compared with left ventricular function may be associated with the development of PE by using two-dimensional speckle tracking echocardiography (2DSTE). Hospitalized patients with AHF at 11 institutions were enrolled. PE was defined as lung congestion on chest X-ray with hypoxemia. Patients with systolic blood pressure ≥140 mmHg on admission were defined to have hypertensive AHF. Echocardiographic analyses, including 2DSTE, were performed prior to discharge. The index of mismatch between RV and left ventricular systolic function was assessed by interventricular longitudinal strain difference (IVLSD) which was defined as RV free wall longitudinal strain and left ventricular global longitudinal strain. Of 610 patients with AHF, 422 (69.2%) had PE. In patients with PE, IVLSD (p = 0.007) and RV fractional area change ratio (p <0.001) was significantly higher than those in patients without PE. In patients with non-hypertensive AHF, RV fractional area change ratio, age, ischemic etiology, and serum brain natriuretic peptide (BNP) levels were independent predictors of PE. In patients with hypertensive AHF, IVLSD, age, and serum BNP levels were independent predictors of PE. Preserved RV function might be one of the underlying mechanisms of the development of PE in AHF. Furthermore, interventricular functional mismatch might be related to the development of PE in hypertensive AHF. [Display omitted] [ABSTRACT FROM AUTHOR]

Worldwide spread of Enterobacteriaceae resistant to colistin, a polypeptide antibacterial drug for last-resort treatment of carbapenemase-producing Enterobacteriaceae (CPE) infections, is concerning. This study aimed to elucidate colistin MICs and molecular characteristics of mcr-1 to mcr-9 of ESBL-producing Escherichia coli (ESBL-Ec) and CPE in Japan and clarify the genomic structure of strains harboring mcr genes (especially mcr-9). This study included 168 ESBL-Ec and 126 CPE strains isolated at Japanese medical facilities. Colistin susceptibility testing and multiplex PCR targeting mcr-1 to mcr-9 were performed for all strains with S1-nuclease pulsed-field gel electrophoresis, Southern blot hybridization, and whole-genome sequencing (WGS) with hybrid assembly performed for mcr gene-carrying strains. Two CPE strains showed a MIC ≥ 4 μg/ml in colistin susceptibility testing, with no known resistance mechanism detected. However, PCR conducted on all target strains detected three mcr-9 -carrying strains showing colistin susceptibility. The bla CTX–M–62 -positive E. coli THUN648 strain simultaneously carried bla CTX–M–62 and mcr-9 on a 275-kbp plasmid. Besides, bla IMP–6 + bla CTX–M–2 -positive Klebsiella pneumoniae THUN262 and bla GES–24 -positive Enterobacter kobei THUN627 had mcr-9 encoded on the chromosome. Only THUN627 encoded qseB/C , which is suggested to be a regulatory gene for mcr-9 , downstream of mcr-9. However, this strain showed no increased expression of these genes in mRNA quantitative analysis under colistin exposure. Colistin MICs of ESBL-Ec and CPE in Japan were all below 2 μg/ml, which is below the epidemiological cutoff (ECOFF) value (https://eucast.org/) or clinical breakpoint (CB) (CLSI M100-S30) reported for colistin, indicating neither "microbiological" nor "clinical" resistance. Several colistin-susceptible Enterobacteriaceae carrying silent mcr-9 encoded on plasmids and chromosomes have already spread worldwide along with other antimicrobial resistance genes. However, the mechanism of colistin resistance by mcr-9 remains unclear. [ABSTRACT FROM AUTHOR]

Background: Carbapenemase-producing Enterobacterales (CPE) are spreading in hospitals, environment and retail foods in Yangon, Myanmar.Objectives: To investigate whether CPE colonize healthy individuals living in Yangon and whether clinical-related strains are spreading in the community.Methods: CPE was isolated from faecal samples obtained from healthy Japanese residents of Yangon with no history of hospitalization. Isolates were subjected to WGS using short- and long-read sequencers and compared with those previously isolated in Yangon.Results: Six Escherichia coli strains harbouring blaNDM-1 or blaNDM-5 belonging to five different STs-ST10, ST38, ST48, ST410 and ST8453-were isolated from 69 volunteers. The ST38 isolates were related to those previously isolated from retail food in Yangon. The ST410 and ST8453 isolates were highly related to previous Yangon isolates including those of clinical and food origins.Conclusions: The analysis suggested the acquisition of blaNDM-positive E. coli, which are disseminating in a clinical setting and through retail foods, by healthy residents in Yangon. [ABSTRACT FROM AUTHOR]

Aims Left ventricular diastolic dysfunction (LVDD) has prognostic significance in heart failure (HF). We aimed to assess the impact of LVDD grade stratified by the updated 2016 echocardiographic algorithm (DD2016) on post-discharge outcomes in patients admitted for acute HF and compare with the previous 2009 algorithm (DD2009). Methods and results The study included 481 patients hospitalized for acute decompensated HF. Comprehensive echocardiography and LVDD evaluation were performed just before hospital discharge. The primary endpoint was a composite of cardiovascular death and readmission for HF. The concordance between DD2016 and DD2009 was moderate (κ = 0.44, P  <   0.001); the reclassification rate was 39%. During the follow-up (median: 15 months), 127 (26%) patients experienced the primary endpoint. In the Kaplan–Meier analysis, Grade III in DD2016 showed a lower event-free survival rate than Grades I and II (log rank, P  <   0.001 and P  =   0.048, respectively) and was independently associated with a higher incidence of the primary endpoint than Grade I [hazard ratio 1.89; 95% confidence interval (CI) 1.17–3.04; P  =   0.009]. Grade II or III in DD2016, reflecting elevation of left ventricular (LV) filling pressure, added an incremental predictive value of the primary endpoint to clinical variables irrespective of LV ejection fraction. DD2016 was comparable to DD2009 in predicting the endpoint (net reclassification improvement = 11%; 95% CI −7% to 30%, P  =   0.23). Conclusion Despite simplification of the algorithm for LVDD evaluation, the prognostic value of DD2016 for post-discharge cardiovascular events in HF patients was maintained and not compromised in comparison with DD2009. [ABSTRACT FROM AUTHOR]

Highlights • Elevated level of soluble ST2 may be associated with malnutrition and inflammation. • Soluble ST2 was significantly associated with non-cardiovascular death. • Soluble ST2 may reflect different pathophysiology from brain natriuretic peptide. Abstract Background Soluble ST2 (sST2) is a marker of inflammation and fibrosis, which is a significant predictor of prognosis of heart failure (HF), independent of brain natriuretic peptide (BNP). This study aimed to clarify how sST2 associates with clinical outcome through investigations of clinical correlates and mode of death in patients with heart failure with preserved ejection fraction (HFpEF). Methods A total 191 patients with acute decompensated HF and EF ≥50% were prospectively enrolled. Echocardiographic and laboratory data including sST2 were obtained in pre-discharge stable condition. Results Serum sST2 level showed significant positive correlations with C-reactive protein and pentraxin3 levels, and negative correlations with body mass index, albumin, and hemoglobin. Serum sST2 level was significantly higher in patients with all-cause death and non-cardiovascular (CV) death compared to those without events, whereas there was no significant difference in sST2 level between patients with and without CV death. On the other hand, BNP level was significantly higher in patients with all-cause death and CV death compared to those without events. Cox regression analyses adjusted for age and sex revealed that sST2 was a significant predictor of non-CV death, whereas BNP was a significant predictor of CV death. Conclusions Serum sST2 level was associated with non-CV death showing significant correlations with systemic factors including malnutrition and inflammation, while BNP was associated with CV death. [ABSTRACT FROM AUTHOR]

Aims: The objective of the study was to evaluate whether the geriatric nutritional risk index (GNRI) at discharge may be helpful in predicting the long‐term prognosis of patients hospitalized with heart failure (HF) with preserved ejection fraction (HFpEF, left ventricular ejection fraction ≥50%), a common HF phenotype in the elderly. Methods and results: Overall, 110 elderly HFpEF patients (≥65 years) from the Ibaraki Cardiovascular Assessment Study‐HF (n = 838) were enrolled. The mean age was 78.5 ± 7.2 years, and male patients accounted for 53.6% (n = 59). All‐cause mortality was compared between the low GNRI (<92) with moderate or severe nutritional risk group and the high GNRI (≥92) with no or low nutritional risk group. Cox proportional hazard regression models were constructed to evaluate the influence of the GNRI on all‐cause death with the following covariates using forward stepwise selection: age, sex, nutritional status based on the GNRI as a categorical variable, history of HF hospitalization, haemoglobin level, estimated glomerular filtration rate, log brain natriuretic peptide levels (logBNP), history of hypertension, log C‐reactive protein levels, left ventricular ejection fraction, left ventricular mass index, and the New York Heart Association functional classification (I/II or III class). The prognostic value of the GNRI was compared with that of serum albumin using C‐statistics. The GNRI was added to the logBNP, serum albumin or the body mass index was added to the logBNP, and the C‐statistic was compared using DeLong's test. Cox regression analysis revealed that age and a low GNRI were independent predictors of all‐cause death (P < 0.05, n = 103; hazard ratio = 1.095, 95% confidence interval = 1.031–1.163, for age, and hazard ratio = 3.075, 95% confidence interval = 1.244–7.600, for the GNRI). DeLong's test for the two correlated receiver operating characteristic curves [area under the receiver operating characteristic curve (AUROC) of serum albumin, 0.71; AUROC of the GNRI, 0.75] demonstrated significant differences between the groups (P = 0.038). Adding the GNRI to the logBNP increased the AUROC for all‐cause death significantly (0.71 and 0.80, respectively; P = 0.040, n = 105). The addition of serum albumin or the body mass index to the logBNP did not significantly increase the AUROC for all‐cause death (P = 0.082 and P = 0.29, respectively). Conclusions: Nutritional screening using the GNRI at discharge is helpful to predict the long‐term prognosis of elderly HFpEF patients. [ABSTRACT FROM AUTHOR]

Background Overshoot phenomena of the gas exchange ratio ( R :VCO 2 /VO 2 ), ventilatory equivalent for O 2 (VE/VO 2 ), and end-tidal O 2 pressure (PETO 2 ) are commonly observed during recovery from maximal cardiopulmonary exercise testing (CPX). We investigated the clinical significance of the overshoots of these indices by comparing their magnitudes between healthy subjects and cardiac patients with left ventricular dysfunction. Methods In total, 121 subjects (73 healthy subjects and 48 cardiac patients with left ventricular ejection fraction < 40%) who underwent CPX and achieved peak R ≥ 1.10 were enrolled. We evaluated and calculated the presence and magnitude of the overshoot phenomena of R , VE/VO 2 , and PETO 2 . Results The overshoot phenomena of R , VE/VO 2 , and PETO 2 were observed in all the subjects. The magnitudes of the R (21.4 ± 12.4% vs. 29.3 ± 10.0%, p < 0.001), VE/VO 2 (45.5 ± 23.5% vs. 77.5 ± 28.5%, p < 0.001), and PETO 2 (5.3 ± 3.4% vs. 10.1 ± 4.2%, p < 0.001) overshoots were significantly lower in cardiac patients than in healthy subjects. In cardiac patients, the magnitude of the PETO 2 overshoot showed significant positive correlations with the peak O 2 uptake (VO 2 ) ( r = 0.52, p < 0.001), anaerobic threshold ( r = 0.43, p = 0.003), and ratio of the increase in VO 2 to the increase in the work rate ( r = 0.41, p = 0.005), and a negative correlation with the slope of the increase in ventilation versus the increase in CO 2 output ( r = −0.50, p < 0.001). The magnitudes of the R and VE/VO 2 overshoots showed the same patterns of significant correlation with the CPX indices. Conclusions We concluded that the overshoots of R , VE/VO 2 , and PETO 2 during recovery from maximal exercise reflect the natural cardiopulmonary adaptation after exercise and are more prominent in subjects with better cardiopulmonary function. [ABSTRACT FROM AUTHOR]