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The ‘Hoshizaki’ Electric Co., Ltd., established in 1947, has developed fully-automated ice-making machines in Japan, and has been manufacturing and selling major refrigerators for business use as well as ice-making machines. The ice-making machines have the top share in the world. Annual sale in 2009 reached JPY160 B. Formerly, there were four issues concerning SCM promotion that aimed at reducing lead-time. The company has been continuing Kaizen that has resulted in a reduction of products inventory, a shortening of lead time, an increase in product variation, a change in production systems, and other events. This paper discusses how the manufacturing company tried to tackle these issues, and presents the establishment of an effective SCM in the treatment of increased product variation and quantity, inventory and operators resulted because of Kaizen, and management efforts in the use of information system.

Abstract. A general emulsion copolymerization of styrene and methacrylic acid was carried out with polyoxyethylene nonyl phenyl ether nonionic emulsifier. Surprisingly, about 75% of the nonionic emulsifier was included inside forming particles.

Introduction:Predicting heart rate (HR) after restoration of sinus rhythm (SR) remains one of the challenges when performing catheter ablation (CA) of persistent atrial fibrillation (AF).Objectives:To evaluate the association between pre-ablation HR during AF and post-ablation HR during SR, and whether the HR reduction is associated with AF recurrence.Methods:The analysis was performed from the EARNEST-PVI trial, a randomized controlled trial designed to assess a CA strategy for persistent AF, which was conducted in the Osaka region of Japan. After excluding patients with beta-blocker prescription, a total of 216 patients (median age, 67 years; 20% female; 23% long-standing persistent AF) with AF rhythm at baseline and SR at discharge were enrolled in this study. Baseline HR during AF and post-ablation HR during SR was measured on admission and at discharge using the 12-lead electrocardiograms, respectively.Results:There was a mild correlation between baseline HR (median 82 [interquartile range 72-95] bpm) and post-ablation HR (78 [48-117] bpm) (r = 0.27, p <0.001). Reduction in HR was positively associated with baseline HR (r = 0.79, p <0.001) and was negatively associated with post-ablation HR (r = - 0.37, p <0.001). During the follow-up of 1 year, 56 patients (25.9%) experienced AF recurrence. HR reduction had the higher diagnostic accuracy in predicting AF recurrence than HR at baseline and HR after CA (area under the curve, 0.625; 95% confidence interval, 0.557-0.690; p = 0.003). AF recurrence rate was significantly higher in 141 patients with smaller HR reduction (cut-off, <14bpm) than those with larger HR reduction (31.9% vs. 14.7%, p = 0.009). After adjustment of age, gender, long-standing persistent AF, and CA strategy, HR reduction of &lt;14 bpm was a significant predictor of AF recurrence (hazard ratio, 2.32; 95% confidence interval, 1.20-4.51; p = 0.013).Conclusions:There was a mild correlation between HR during AF and HR after restoration of SR in patients underwent CA of persistent AF. HR reduction after restoration of SR predicted AF recurrence.

Macrothrombocytopenia with leukocyte inclusions is a rare autosomal dominant platelet disorder characterized by a triad of giant platelets, thrombocytopenia, and characteristic Döhle body-like leukocyte inclusions. A previous study mapped a locus for the disease on chromosome 22q12.3-q13.2 by genome-wide linkage analysis. In addition, the complete DNA sequence of human chromosome 22 allowed a positional candidate approach, and results here indicate that the gene encoding nonmuscle myosin heavy chain-A, NMMHC-A, is mutated in this disorder. Mutations were found in 6 of 7 Japanese families studied: 3 missense mutations, a nonsense mutation, and a one-base deletion resulting in a premature termination. Immunofluorescence studies revealed that NMMHC-A distribution in neutrophils appeared to mimic the inclusion bodies. These results provide evidence for the involvement of abnormal NMMHC-A in the formation of leukocyte inclusions and also in platelet morphogenesis.

Background:Both the periatrial epicardial adipose tissue (EAT) and thyroid dysfunction (TD) are known to play an important role in progression of atrial fibrillation (AF). However, there is little information available on prognostic value of periatrial EAT and thyroid stimulating hormone (TSH) for the prediction of AF recurrence after catheter ablation (CA).Methods and Results:We enrolled 64 consecutive paroxysmal AF patients (pts) without both heart failure and thyroid dysfunction, who were scheduled for CA (cryoablation, n=36; radiofrequency ablation, n=28). The volume of the total and periatrial EAT surrounding the left atrium were measured by multiple detector computed tomography before CA, and periatrial to total EAT ratio (P/T) was obtained. TSH was measured before CA. During a 12?4 month follow-up after CA, AF recurrence (AR) was observed in 14 (22%) pts without any antiarrhythmic drugs. P/T and TSH were significantly greater in pts with than without AR (19.1?4.3% vs 16.1?4.1%, p=0.010, 2.63?1.51?U/mL vs 1.95?1.58?U/mL, p=0.028, respectively). P/T (?17.1% [AUC 0.727]) and TSH (?1.85?U/mL [AUC 0.694] by ROC curve analysis) were independently associated with AR. AR was significantly more frequent in patients with higher P/T (?17.1%) and higher TSH (?1.85?U/mL) than those with either and none of them (60% vs 15% vs 4%, p<0.0001).Conclusions:The combination of periatrial EAT and TSH might provide more prognostic information about AF recurrence in paroxysmal AF pts without heart failure.

Introduction:Cardiac iodine-123 metaiodobenzylguanidine (MIBG) imaging has been shown to provide prognostic information in patients with chronic heart failure. Patients with diabetes mellitus (DM) often have impaired cardiac sympathetic innervation. However, little is known about the influence of DM on the prognostic value of cardiac MIBG imaging in patients who are admitted for acute decompensated heart failure (ADHF).Hypothesis:We assessed the hypothesis that the prognostic value of cardiac MIBG imaging is different between the ADHF patients with and without DM.Methods:We prospectively studied 374 consecutive patients who were admitted for ADHF and survived to discharge. Cardiac MIBG imaging was performed just before discharge. The cardiac MIBG heart-to-mediastinum ratio (HMR) and washout rate (WR) were calculated from the chest anterior view images obtained at 20 and 200 min after isotope injection. The endpoint was a composite of all-cause mortality and unplanned hospitalization for worsening heart failure.Results:There were 166 patients with DM and 208 patients without DM. During a median follow-up period of 2.2 years, 165 patients reached the endpoint. In the multivariate Cox analysis, HMR on delayed image (late HMR) was significantly independently associated with the endpoint (p=0.0001) in patients with DM but not in those without DM, although late HMR showed a significant association with the endpoint in patients without DM in the univariate analysis. Kaplan-Meier analysis showed that the difference in the risk of the endpoint was more pronounced in DM patients compared to patients without DM when patients were stratified into 2 groups based on the median value of late HMR (Figure).Conclusions:Cardiac sympathetic nerve dysfunction had higher prognostic impact in ADHF patients with DM than in those without DM.

Backgrounds:In heart failure, comorbidities are reported as robust prognostic marker. AHEAD (A: atrial fibrillation; H: hemoglobin; E: elderly; A: abnormal renal parameters; D: diabetes mellitus) risk score based on age and comorbidities has been reported as a useful long-term risk stratification score in acute decompensated heart failure (ADHF) patients. The aim of this study is to clarify the incremental prognostic value of cognitive function over AHEAD risk score in patients with ADHF.Methods and Results:We studied 273 patients admitted for ADHF with survival discharge in our prospective cohort study. We evaluated AHEAD risk score (range 0-5, atrial fibrillation, hemoglobin <13 mg/dL for men and 12 mg/dL for women, age >70 years, creatinine >130 ?mol/L, and diabetes mellitus). Cognitive function was assessed by Mini Mental Status Examination (MMSE). The endpoint of this study was all-cause mortality. During a follow up period of 2.7?1.5 years, 94 patients died. At multivariable Cox analysis, MMSE (p=0.0001) and AHEAD risk score (p=0.0001) were significantly associated with all-cause mortality after adjustment for major confounding factors. Kaplan-Meier analysis showed that patients with high AHEAD score (defined as 3-5 point) had significantly greater risk of all-cause mortality than those with low AHEAD score (0-2 point) (46% vs 22%, p<0.0001). Furthermore, in the subgroup of both high and low AHEAD risk score, all-cause mortality was significantly higher in patients with low MMSE (<24 determined median value) than those with high MMSE (?24) (57% vs 31% p=0.0003, low AHEAD risk score 37% vs 13% p=0.0038). C-statistics of AHEAD score for the prediction of all-cause mortality was 0.693 (95%CI 0.634-0.747) and significantly increased to 0.746 (0.690-0.796) by adding MMSE to AHEAD score (p=0.0137).Conclusion:Cognitive function provides the additional long-time prognostic information to AHEAD risk score in patients with acute decompensated heart failure.

Backgrounds:Liver abnormalities have been reported as an important prognostic factor in patients with heart failure. ALBI (Albumin-Bilirubin) score was newly developed as a simple model to assess liver function. Furthermore, serum cholinesterase (CHE), one of the biomarkers of hepatic function and malnutrition, was reported to be a prognostic factor in patients with chronic heart failure. The aim of this study is to compare the prognostic values of CHE and ALBI in patients with acute decompensated heart failure (ADHF).Methods and Results:We studied 415 patients admitted for ADHF with survival discharge in our prospective cohort study. Laboratory data including CHE, bilirubin and albumin were obtained at discharge. We calculated ALBI score in the formula as follows: (log10 bilirubin?0.66) + (albumin?-0.085), where bilirubin is in ?mol/L and albumin in g/L. The cut points were defined as follows: ALBI grade1?-2.60, -2.60< ALBI grade2?-1.39, -1.39< ALBI grade3. The endpoint of this study was all-cause mortality. During a follow up period of 2.5?1.4 years, 122 patients died. At multivariable Cox analysis, CHE (p=0.0001), not ALBI score, was significantly associated with all-cause mortality, independently of age, NYHA class, diabetes mellitus, ACEI or ARB use and LVEF after adjustment for sex, BMI, ?-blocker use, prior history of heart failure hospitalization, serum sodium, hemoglobin level and plasma BNP level. Kaplan-Meier analysis showed that patients with low CHE (<215U/L defined as median) had significantly greater risk of all-cause mortality than those with high CHE (?215U/L) (42% vs 16% p<0.0001). ROC curve analysis showed that AUC of CHE for the prediction of all-cause mortality was significantly higher than that of ALBI score (CHE: 0.741 [0.696-0.783] vs ALBI score: 0.632 [0.584-0.679], p=0.0008).Conclusion:CHE was more powerful prognostic indicator than ALBI score in patients with acute decompensated heart failure.

Background:CHADS2 score, HAS-BLED score, ATRIA score and ORBIT score are novel risk scores that combine clinical characteristics to predict thromboembolic and hemorrhagic events in atrial fibrillation (AF) patients (pts) receiving oral anticoagulants. Several reports have shown that HE in AF patients are associated with all-cause death (ACD). The aim of this study was to develop a simple score for the prediction of ACD in AF pts with direct oral anticoagulants (DOAC) and to compare with those scores.Methods and Results:We retrospectively studied 924 consecutive AF pts with DOAC (age: 72?11 years, male: 63%, dabigatoran; n=389, rivaroxaban; n=273, apixaban; n=239, edoxaban, n=23). During a mean follow-up period of 1.9?1.4 years, 50 pts had ACD. At multivariate Cox analysis, age (?75 years old), BMI (?22.8) and cancer were significantly independently associated with ACD. ABC score was derived from the sum of the point values of the following parameters; age (>75 years old; 1 point), BMI (?22.8; 1 point) and cancer (1 point). C-index of ABC score (0.740, 95%CI [0.668-0.800]) for prediction of ACD was significantly (p<0.05) greater than those of other indices (CHADS2 score; 0.642, 95%CI [0.577-0.702], HAB-BLED score; 0.631, 95%CI [0.557-0.700], ATRIA score; 0.654, 95%CI [0.570-0.730]) and ORBIT score; 0.623, 95% CI [0.535-0.703]). Kaplan-Meier curve showed that the risk of ACD increased with higher ABC score (0 point; 1.0%, 1 point; 4.4%, 2 point; 8.5%, 3 point; 37%, p<0.0001).Conclusions:ABC score might be a novel simple risk score to predict all-cause death in atrial fibrillation pts with DOAC.

Background:In heart failure (HF), the use of multiple drugs based on the therapeutic regimen is common and recommended by international guidelines. Furthermore, HF is common disease in the elderly who have the multiple comorbidities that increase the burden of polypharmacy and it is known to lead to negative influence such as drug-drug interaction. On the other hand, comorbidities are reported as robust prognostic marker in HF patients (pts). However, there is no information available on the prognostic value of combining polypharmacy and comorbidities in pts admitted for acute decompensated heart failure (ADHF).Methods:We prospectively studied 414 ADHF pts with survival discharge. Laboratory data and echocardiography were obtained at discharge. We used the number of drugs at discharge (ND) as an index of polypharmacy. Comorbidity was assessed by the Age-adjusted Charlson comorbidity index (ACCI) which is weighted and scored with additional points for age. The endpoint was cardiac event (CE) defined as a composite of cardiac death and unplanned hospitalization for worsening HF.Results:During a follow-up period of 2.2?1.4 years, 141 pts had CE. At multivariate Cox analysis, ND (p=0.0053) and ACCI (p=0.0199) were significantly associated with CE, independently of NYHA class, history of worsening HF hospitalization and plasma BNP level. Patients with both higher ND (?11 by ROC analysis, AUC 0.611[0.562-0.658]) and higher ACCI (?5 by ROC analysis, AUC 0.653[0.604-0.700]) had a significantly increased risk of CE than those with either or none of them (46% vs 36% vs 15%, respectively). Net reclassification improvement afforded by addition of ND to ACCI score was also statistically significant (0.215 [95% CI: 0.015-0.415])Conclusions:Polypharmacy might provide the incremental prognostic value of the comorbidity in ADHF patients.

Background:The objective nutritional indices such as the Controlling Nutritional Status (CONUT) score, Geriatric Nutritional Risk Index (GNRI) and Prognostic Nutritional Index (PNI) are useful for the prediction of prognosis in patients (pts) with heart failure. However, there is no information available on the prognostic value of the combination of these objective nutritional indices in pts with heart failure with preserved LVEF (HFpEF) who are admitted with acute decompensated heart failure (ADHF).Purpose:We sought to assess the usefulness of the combined objective nutritional score (CONS) for the prediction of post-discharge clinical outcome in ADHF pts with HFpEF.Methods:Data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT HFpEF) study. PURSUIT-HFpEF study is a prospective multicenter observational study in which collaborating hospitals in Osaka recorded clinical, echocardiographic, and outcome data of ADHF pts with HFpEF. We analyzed 296 pts with survival discharge. Venous blood sampling, echocardiography, and measurement of body weight were performed just before discharge. CONUT score, GNRI and PNI were calculated as previously reported. We determined CONS by assigning 1 point each for high CONUT score (5-12), low GNRI (<92) or low PNI (?38). The study endpoint was all-cause death.Results:During a follow-up period of 1.2?0.5years, 41 pts had all-cause death. Multivariate Cox analysis showed that CONS was independently associated with all-cause death (p=0.0065). When the pts were stratified into the three groups based on CONS (normal nutritional status: 0 point, mild-to-moderate malnutrition: 1-2 points, severe malnutrition: 3 points), the incidence of all-cause death appeared to increase in relation to the score (normal: 7%, mild-to moderate: 16%, severe: 26%, p=0.0003).Conclusion:CONS is a useful tool to risk stratify ADHF pts with HFpEF.

Background:The Get with The Guidelines (GWTG) heart failure (HF) risk score was developed in the GWTG inpatient HF registry to predict in-hospital mortality and has been recently reported to be associated with post-discharge long-term outcomes. On the other hand, systemic inflammation plays a critical role in the outcomes of heart failure. Malnutrition is also associated with poor outcome in heart failure patients. It has been recently reported that advanced lung cancer inflammation index (ALI), which is calculated as body mass index ? serum albumin / neutrophil to lymphocyte ratio, is an independent prognostic marker in several types of cancer. We sought to investigate the prognostic value of the combination of GWTG-HF risk score and ALI in patients with acute decompensated heart failure (ADHF).Methods and Results:We studied 259 patients admitted for ADHF and discharged with survival. At the discharge, we obtained ALI and GWTG-HF risk score. Variables required for the GWTG-HF risk score were race, age, systolic blood pressure, heart rate, serum levels of blood urea nitrogen and sodium, and the presence of chronic obstructive pulmonary disease. During a follow-up period of 5.0?4.2 yrs, 65 patients had cardiovascular death (CVD). At multivariate Cox analysis, GWTG-HF risk score and ALI were significantly associated with CVD, independently of prior heart failure hospitalization, after the adjustment with eGFR and anemia. The patients with both greater GTWG-HF score (?median value: 39) and lower ALI (?median value: 42.518) had a significantly increased risk of CVD than those with either and none of them (48% vs 18% vs 8%, p<0.0001, respectively).Conclusion:ALI would provide the additional long-term prognostic information to GWTG-HF score in patients with ADHF.

Background:In heart failure (HF), the use of multiple drugs based on the therapeutic regimen is common and recommended by international guidelines. Furthermore, HF is common disease in the elderly who have the multiple comorbidities that increase the burden of polypharmacy, and polypharmacy is known to lead to negative influence such as drug-drug interaction. On the other hand, cognitive function is one of the most important comorbidities among the elderly with HF. However, there is no information available on the prognostic value of polypharmacy in patients (pts) admitted with acute decompensated heart failure (ADHF), relating to cognitive function.Methods:We studied 273 pts admitted for ADHF with survival discharge in our prospective cohort study. Echocardiography and venous blood sampling were performed just before discharge. Trained clinical research assistants evaluated cognitive function using the Mini Mental Status Examination (MMSE) and cognitive dysfunction was defined as MMSE<25. We used the number of drugs on discharge (ND) as an index of polypharmacy. The endpoint of this study was all-cause death (ACD).Results:During a follow up period of 2.7?1.5 years, 94 pts had ACD. At multivariate Cox analysis, MMSE (p<0.0001) and ND (p=0.0004) were significantly and independently associated with ACD. Pts with higher ND (?13: determined by ROC analysis, AUC 0.667 [0.607-0.723]) had a significantly greater risk of ACD (46.4% vs 20.6%, p=0.0001, HR 2.43 [1.55-3.81]). In the group of higher MMSE score?25 , pts with higher ND had a significantly greater risk of ACD (32.3% vs 7.0%, p=0.0018, adjusted HR 4.66[1.61-13.50]). However, in the group of lower MMSE score<25, there was no significantly difference in ACD risk between pts with and without higher ND (52.9% vs 33.9%, p=0.10).Conclusions:Polypharmacy could provide the additional prognostic value in ADHF pts without cognitive dysfunction, but not with that.

Backgrounds:Systemic inflammation plays a critical role in the outcomes of heart failure. Malnutrition is also associated with poor outcome in heart failure patients It has been recently reported that advanced lung cancer inflammation index (ALI), which is calculated as body mass index ? serum albumin / neutrophil to lymphocyte ratio, is an independent prognostic marker in several types of cancer. Recently, a new group of heart failure patients with mid-range ejection fraction (HFmrEF) has been defined, separated from reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). However, there is no information available on the prognostic impact of ALI in patients admitted with acute decompensated heart failure (ADHF), relating to HFrEF, HFmrEF and HFpEF.Methods and Results:We studied 263 ADHF patients (HFrEF:n=103, HFmrEF:n=59, HFpEF:n=101) discharged with survival. At the discharge, we calculated ALI. During a follow up period of 5.1?4.3 yrs, 67 patients had cardiovascular death (CVD). At multivariate Cox analysis, ALI (hazard ratio 0.975[0.961-0.990], p=0.001) was significantly associated with CVD, independently of systolic blood pressure, serum sodium and creatinine levels. Patients with lower ALI (

Background:Both cardiac sympathetic nerve activity (CSNA) and thyroid dysfunction (TD) are known to play an important role in progression of atrial fibrillation (AF). However, there is little information available on prognostic value of CSNA and thyroid stimulating hormone (TSH) for the prediction of AF recurrence after catheter ablation (CA).Methods and Results:We enrolled 100 consecutive paroxysmal AF patients (pts) without both heart failure and thyroid dysfunction, who were scheduled for CA (cryoablation, n=68; radiofrequency ablation, n=66). Cardiac MIBG scintigraphy was performed at baseline and 3 months post-ablation. The heart-to-mediastinum ratio of 123I-mIBG uptake at 20 min (H/Me) and 200 min (H/Md), as well as the washout rate (WR) were measured. TSH was measured before CA. During a 11?4 month follow-up after CA, AF recurrence (AR) was observed in 23 (23%) pts without any antiarrhythmic drugs. WR change from the baseline to 3 months after (dWR) and TSH were significantly greater in pts with than without AR (9.3[2.5, 14.3]% vs 1.0[-3.8, 7.5]%, p=0.0016, 2.06[1.53, 4.02]?U/mL vs 1.51[1.05, 2.09]?U/mL, p=0.0032, respectively). dWR(?6.9% [AUC 0.717]) and TSH (?1.85?U/mL [AUC 0.703] by ROC curve analysis) were independently associated with AR. AF was significantly more frequent in patients with higher dWR (?6.9%) and higher TSH (?1.85?U/mL) than those with either and none of them (57% vs 24% vs 5%, p<0.0001).Conclusions:The combination of dWR and TSH might provide more prognostic information about AF recurrence after CA in paroxysmal AF pts without heart failure.

Backgrounds:The Acute Decompensated Heart Failure National Registry (AHDERE) risk levels are a validated tool to assess the risk of in-hospital mortality in patients (pts) with acute decompensated heart failure (ADHF). Cardiac power is the rate of hydraulic work done by the heart. It has recently been shown that cardiac power index (CPI) provided prognostic independent and incremental prediction in adverse outcomes beyond traditional hemodynamic parameters in ambulatory patients with advanced heart failure. However, there is no information available on the long-term prognostic value of the combination of CPI and ADHRE risk level in pts admitted for ADHF.Methods and Results:We studied 208 patients admitted for ADHF, who underwent right heart catheterization at the admission and were discharged with survival. At admission, ADHERE risk levels were assigned by BUN (?43 vs <43 mg/dl), systolic blood pressure (?115 vs <115 mmHg), and creatinine (?2.75 vs <2.75 mg/dl). CPI (W/m2) was calculated by the following formula:([mean arterial pressure] - [right arterial pressure(mmHg)]) x cardiac index (L/min/m2) x 0.0022. During a follow up period of 5.4?4.5 yrs, 52 patients had cardiovascular death (CVD). At multivariate Cox analysis, ADHERE high/intermediate risk levels and CPI were significantly associated with CVD, independently of serum sodium level, after the adjustment with age, gender, BMI and serum albumin level. CVD was significantly frequently observed in patients with both ADHERE high/intermediate levels and lower CPI (?0.416 by ROC analysis: AUC 0.641[0.554-0.727]) than those with either or none of them (60% vs 27% vs 17%, p<0.0001, respectively). Hazard ratio for CVD in patients with both ADHERE high/intermediate levels and lower CPI was 4.9[2.4-10.2], which was about triple of that in patients with either of them (1.7[0.9-3.3]).Conclusion:CPI would provide the additional long-term prognostic information to ADHERE risk levels in ADHF patients.

Backgrounds:Meta-Analysis Global Group in Chronic Heart Failure Risk Score (MAGGIC risk score) is well-validated risk stratification score in patients with heart failure. On the other hand, we previously reported the prognostic value of serum cholinesterase (CHE) level in patients with acute decompensated heart failure (ADHF). The aim of this study was to investigate the incremental prognostic value of CHE over MAGGIC risk score in patients with ADHF.Methods and Results:We studied 415 patients admitted for ADHF with survival discharge in our prospective cohort study. Clinical data, echocardiography and laboratory data including CHE were obtained just before discharge. MAGGIC risk score was calculated from 13 variables as previously reported. The endpoint of this study was all-cause mortality. During a follow up period of 2.5?1.4 years, 119 patients died. At multivariate Cox analysis, CHE (p=0.0001), MAGGIC risk score (p<0.0001) were significantly independently associated with all-cause mortality after adjustment for plasma BNP, serum albumin, sodium and hemoglobin levels. In the subgroup with high MAGGIC risk score (?25 defined by median), Kaplan-Meier analysis showed that patients with low CHE (<188 defined by median in this subgroup) had significantly greater risk of mortality than those with high CHE (?188) (62% vs 34% p<0.0001). Furthermore, in the subgroup with low MAGGIC risk score (<25), patients with low CHE (<239 defined by median in this subgroup) had significantly greater risk of mortality than those with high CHE (?239) (16% vs 6% p=0.0051). C-statistics of MAGGIC score for the prediction of all-cause mortality was 0.794 (95%CI 0.751-0.832) and the improvement of C-statistics by adding CHE to MAGGIC score was statistically significant (0.815 (95% CI 0.774-0.852), p=0.0438).Conclusion:Serum CHE level provides the additional long-term prognostic information over MAGGIC risk score in patients with acute decompensated heart failure.

Backgrounds:Liver dysfunction in patients with heart failure is caused by liver congestion, which is related to liver stiffness. It has been recently reported that liver stiffness assessed by non-invasive fibrosis marker such as Fibrosis-4 (Fib-4) index (based on age, aspartate aminotransferase [AST] and alanine aminotransferase [ALT] levels, and platelet counts) predicts mortality in patients with heart failure. Plasma volume (PV) expansion plays an essential role in heart failure. PV is estimated by a simple formula based on hematocrit and body weight, not using radioisotope assays, and PV status provides prognostic information in patients with acute decompensated heart failure (ADHF). However, there is no information available on the long-term prognostic significance of the combination of Fib-4 index and PV status in ADHF patients.Methods and Results:We studied 299 ADHF patients with survival discharge. Fib-4 index was calculated by the formula: age(yrs) ? AST[U/L]/(platelets [103/?L] ? (ALT[U/L])1/2). PV status was calculated as the following: Actual PV=(1-hematocrit) x [a+(b ? body weight)] (a=1530 in males and a=864 in females, b=41 in males and b=47.9 in females), Ideal PV=c ? body weight (c=39 in males and c=40 in females), and PV status=[(actual PV-ideal PV)/ideal PV]?100(%). During a follow-up period of 4.3?3.3 yrs, 94 patients died. At multivariate Cox analysis, Fib-4 index and PV status were significantly associated with total mortality, independently of systolic blood pressure, prior HF hospitalization and serum creatinine level after adjustment with hemoglobin and albumin levels. Patients with both greater Fib-4 index (>2.674: median) and PV status (>4.8%: median) had a significantly higher risk of total mortality than those with either or none of them (41% vs 31% vs 23%, respectively).Conclusion:The combination of Fib-4 index and PV status might identify higher risk subset for total mortality in ADHF patients.

Backgrounds:Concomitant presence of pulmonary hypertension in heart failure is associated with increased adverse events and may be related to interventricular uncoupling and impaired cardiac efficiency. It has recently been shown that an increased mean pulmonary artery pressure to mean systemic arterial pressure ratio (MPS ratio), a marker of interventricular coupling and efficiency, is associated with worse clinical outcomes in patients (pts) with advanced heart failure. On the other hand, cardiohepatic interactions have been a focus of attention in heart failure, and the model of end-stage liver disease excluding INR (MELD-XI), a robust scoring system of liver dysfunction, has been shown to be useful for prediction of poor outcome in pts with acute decompensated heart failure (ADHF). However, there is no information available on the prognostic value of the combination of MPS ratio and MELD-XI score in ADHF patients.Methods and Results:We studied 240 pts admitted for ADHF, who underwent right heart catheterization at the admission and were discharged with survival. MPS ratio was obtained at the admission. MELD-XI score was calculated by the formula: 5.11?ln(bilirubin)+11.79?ln(creatinine)+9.44. During a follow up period of 5.2?4.4 yrs, 59 pts had cardiovascular death (CVD). At multivariate Cox analysis, MPS ratio (p=0.0005) and MELD-XI score (p=0.0078) were significantly associated with CVD, independently of age, serum sodium level, prior heart failure hospitalization and body mass index. The pts with both MPS ratio ?0.374 (AUC 0.669[0.587-0.751]) and MELD-XI score ?12 (AUC 0.689[0.612-0.765]) had a significantly increased risk of CVD than those with either greater MPS or MELD-XI score and none of them (48% vs 25% vs 8%, p<0.0001, respectively).Conclusion:The combination of MPS ratio and MELD-XI score might be useful for stratifying ADHF pts at higher risk for CVD.

Background:Comorbidities are associated with poor clinical outcome in patients (pts) with heart failure (HF). Recently, a new group of HF pts with mid-range ejection fraction (HFmrEF) has been defined, separated from reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). However, there is no information available on the prognostic role of comorbidities in the pts admitted for acute decompensated heart failure (ADHF), relating to HFrEF, HFmrEF and HFpEF.Methods:We prospectively studied 409 ADHF pts with survival discharge (HFrEF[n=142], HFmrEF[n=99] and HFpEF[n=168]). Comorbidity was measured with the Age-adjusted Charlson comorbidity index (ACCI) which is commonly used for the evaluation of the comorbid condition. ACCI contains 19 issues which was weighted according to their potential influence on mortality with additional points added for age. The endpoint of this study was cardiac events (CE) defined as the composite of readmission for worsening heart failure and cardiac death.Results:During a follow-up period of 2.2?1.4 years, 145 pts had CE (49 pts in HFrEF, 34 pts in HFmrEF and 64 pts in HFpEF). At multivariate Cox analysis in HFrEF, HFmrEF and HFpEF pts, ACCI was significantly and independently associated with CEs. (HFrEF: p=0.0004, HFmrEF:p=0.0168, HFpEF:p=0.0156) In subgroup of HFrEF, pts with high ACCI (?5 by ROC curve analysis, AUC 0.645)had a significantly greater risk of CEs (48% vs 26%, p=0.0004, adjusted HR 2.65 [1.49-4.70]). HFmrEF pts with high ACCI (?6, AUC 0.610)had also a significantly greater risk of CEs (45% vs 28%, p=0.0343, adjusted HR 2.07 [1.04-4.12]). Furthermore, in subgroup of HFpEF, high ACCI (?5, AUC 0.610) were significantly associated with CEs (48% vs 26%, p=0.0048, adjusted HR 2.65 [1.49-4.70]).Conclusions:Comorbidities were associated with poor outcome in ADHF patients, irrespective of HFrEF, HFmrEF and HFpEF.

Background:Controlled heart rate (HR) and increased pulse pressure (PP) are related to better outcomes in stable heart failure (HF). Hemodynamic response to stress evaluated by an acute hemodynamics index (AHI), the product of HR and PP, has been reported to be associated with in-hospital mortality in patients admitted for acute decompensated heart failure (ADHF). However, there is no information available on the long-term prognostic value of AHI in patients admitted for acute decompensated heart failure (ADHF), relating to left ventricular ejection fraction (LVEF).Methods and Results:We studied 302 ADHF patients (LVEF<40%:n=118, LVEF?40%:n=184) discharged with survival. AHI (HR x PP/1000) was calculated at the admission. During a follow-up period of 5.1?4.3 years, 121 patients died. At multivariate Cox analysis, AHI was significantly associated with the total mortality, independently of prior heart failure hospitalization, eGFR and serum sodium level after the adjustment with age, gender, BMI, anemia, and serum albumin level, in both groups with and without reduced LVEF. Patients with low AHI (lowest tertile) had a significantly increased risk of the total mortality than those with high AHI in groups with (57% vs 29%, p=0.0091) and without reduced LVEF (51% vs 35%, p=0.0094).Conclusion:AHI could provide long-term prognostic information in ADHF patients, irrespective of reduced LVEF.

Backgrounds:Malnutrition is associated with increased mortality risk in patients with heart failure. Decreased muscle mass and sarcopenia are also associated with the prognosis of heart failure patients. Although muscle mass distribution varies by gender, the prognostic impact of the coexistence of sarcopenia and malnutrition has not been fully elucidated in patients admitted with acute decompensated heart failure (ADHF), relating to gender.Methods and Results:We studied 262 patients admitted with ADHF (male: 158 patients and female: 104 patients) and discharged with survival. At the discharge, sarcopenia was assessed by estimated creatinine excretion rate index (eCERi[mg/day/m2]) calculated as follows:{879.89+12.51?body weight[kg]-6.19?age+(34.51 if black)-(379.42 if female)}/(height[m])2}. Nutritional status was also evaluated by prognostic nutritional index (PNI: 10?serum albumin[g/dl]+0.005?total lymphocyte count[/ml]). During a follow-up period of 4.2?3.2 yrs, 87 patients died. At multivariate Cox analysis, eCERi and PNI were significantly associated with the mortality independently of systolic blood pressure, estimated glomerular filtration rate and hemoglobin level in not only men but also women. Patients with both lower eCERi and PNI (below the median value) had a higher risk of mortality than those with either lower eCERi or PNI and those with both higher eCERi and PNI in men (eCERi<424 / PNI<45.8: 59% vs 38% vs 14%, respectively, p<0.0001) and women (eCERi<281 / PNI<44.9: 51% vs 24% vs 13%, respectively, p=0.0002).Conclusion:The combination of malnutrition and sarcopenia might be useful for stratifying ADHF patients at risk for the total mortality in both genders.

The etiologies of secondary idiopathic thrombocytopenic purpura (ITP) include infection, autoimmune disease, and immunodeficiency. We report the cases of three elderly patients who developed ITP after receiving influenza vaccinations. The platelet count of an 81-year-old woman fell to 27,000/μL after she received an influenza vaccination. A 75-year-old woman developed thrombocytopenia (5,000 platelets/μL) after receiving an influenza vaccination. An 87-year-old woman whose laboratory test values included a platelet count of 2,000/μL experienced genital bleeding after receiving an influenza vaccination. After Helicobacter pylori (HP) eradication or corticosteroid treatment, all of the patients’ platelet counts increased. Influenza vaccination is an underlying etiology of ITP in elderly patients. HP eradication or corticosteroid treatment is effective for these patients. Clinicians should be aware of the association between ITP and influenza vaccinations.