Survey of in vitro fertilization add-ons in Japan (Izanami project)

Objective

To identify any correlations between evidence levels, adoption rates, and additional costs of in vitro fertilization (IVF) add-ons.

Design

Online survey.

Subjects

The survey was conducted in 621 assisted reproductive technology-registered facilities that are members of the Japanese Society of Obstetrics and Gynecology from December 22, 2021, to February 13, 2022.

Exposure

The survey included details regarding the specific add-on modalities employed and their associated costs; inquiries pertained to the fertility healthcare infrastructure in Japan before the implementation of the National Health Insurance scheme.

Main outcome measures

The correlation between the adoption rate and cost of IVF add-ons and their evidence levels were analyzed. The evidence level of the add-on treatments was classified into Green, Amber, and Red categories based on the United Kingdom's Human Fertilisation and Embryology Authority and Cochrane systematic reviews.

Results

A total of 438 eligible responses were analyzed, with clinics constituting 70.9% of the respondents' facilities. A total of 18 add-ons were assessed, and 96.5% (423/438) of facilities used at least one add-on. A positive correlation of the adoption rate and an inverse correlation of the cost with the evidence level of the IVF add-on treatment were observed (not significant). Outpatient clinics, defined as medical facilities with no beds, had a significantly higher adoption rate (Amber, 65.7%; Red, 52.0%) of add-ons than other facilities, regardless of the evidence rating, although the costs were similar across all site attributes.

Conclusion

Accumulating evidence on the efficacy and safety of add-ons will lead to the development of medical care with a high-cost benefit, as an increase in the adoption rate and a decrease in cost are expected when limiting to medical care with a high level of evidence.

Targeted Pubic Neoantigen Immunotherapy Using Encapsulated Nanoparticles, Directed by Radiation

PURPOSE/OBJECTIVE(S)

We tested a treatment combining radiotherapy with pubic neoantigen nanoparticles of CAND1 and ADGRF5-II (120 ± 56 nm) in nanocapsules detectable by computed tomography (CT) (545± 24 nm) with IFN γ or PD-L1 antibody (Ab), which released their contents upon radiation exposure. We performed two radiotherapy sessions: 1) induction of MHC-I and II in tumor cells and dendritic cells (DC) by the first round of radiation with concurrently released IFN γ from nanoparticles; 2) targeted neoantigen immunotherapy with PD-L1 blockade by the second round of radiation, elicited by CAND1-specific CD8+T-cell and ADGRF5-II-specific CD4+T-cell, related to induced MHC-I and MHC-II in session 1, respectively.

MATERIALS/METHODS

For session one, nanocapsules were generated by mixing iopamiron and 15 mg IFN γ with a 1.0 mL solution containing 4.0% alginate, 3.0% hyaluronate, and 1 μg/mL P-selectin. This mixture was sprayed into 0.5 mmol/l FeCl2 supplemented with 1 µg/mL anti-VEGFR-1/2 Ab. For session two, Mixture of 110 fmol CAND1 and fmol ADGRF5-II, were encapsulated into poly lactic-co-Glycolic acid (PLGA) particle, using nanoprecitation method. Those particles were encapsulated by mixing into above alginate-hyaluronate cocktail with 400 mg PD-L1 antibody (Ab), then sprayed into 0.5 mmol/l FeCl2 supplemented with P-selectin Ab. In session one, 1 × 1010 nanocapsules were intravenously injected into BALB/c mice exhibiting primary 4TI mammary carcinoma in the left hind leg and lung metastases. Tumor accumulation was monitored by CT. Subsequently, 10 or 20 Gy 60Co γ-radiation was administered to primary tumors and lung metastasis. In session two, 1 × 1010 nanocapsules were injected i.v. and allowed to interact with P-selectin for 24 h; a further 10 or 20 Gy 60Co γ-radiation was administered to tumors and lung metastasis.

RESULTS

In session one, CT imaged the accumulation of anti-VEGFR-1/2 nanocapsules around primary and metastatic tumors, which helped determine the timing of the first radiation. The nanocapsules released P-selectin and IFN γ in response to first radiation. P-selectin was deposited on tumor vessels. Radiation and released IFN γ elicited MHC-I and II on tumor cells and DCs. In session two, released CAND1 and ADGRF5-II from PLGA particle, which were emitted from nanocapsules upon second radiation, were loaded onto MHC-I and II. Subsequently, two kinds of tertiary complex were formed on tumor cells and DC: 1) MHC-I-CAND1-CD8+T-cell receptor (TCR); and 2) MHC-II- ADGRF5-II-CD4+TCR, which destroyed tumor cells, in collaboration with released PD-L1 Ab. Those T-cell mediated cell killing was magnified via enhanced DC-mediated T-cell priming by the two kinds of tertiary complex on DC. Those treatments resulted in EF 1.5 and 86% reduction of new metastasis formation.

CONCLUSION

Our encapsulated pubic neoantigen particle will lead to quick and effective neoantigen immunotherapy.

A Systemically Administered Unconjugated Antisense Oligonucleotide Targeting DUX4 Improves Muscular Injury and Motor Function in FSHD Model Mice

Facioscapulohumeral muscular dystrophy (FSHD), one of the most common muscular dystrophies, is caused by an abnormal expression of the DUX4 gene in skeletal muscles, resulting in muscle weakness. In this study, we investigated MT-DUX4-ASO, a novel gapmer antisense oligonucleotide (ASO). MT-DUX4-ASO decreased the expression of DUX4 and its target genes in FSHD patient-derived myoblasts. For the first time, we demonstrated that a systemically administered ASO, even without a ligand for drug delivery, could significantly improve muscle injury and motor function in the ACTA1-MCM/FLExDUX4 (DUX4-TG) mouse model of FSHD. Tamoxifen (TMX) injection transiently induces skeletal-muscle-specific DUX4 expression in DUX4-TG mice, while the skeletal muscles of TMX-untreated DUX4-TG mice have leaky DUX4 expression in a small subset of myofibers similar to those of FSHD patients. Subcutaneous 10 mg/kg of MT-DUX4-ASO at two-week intervals significantly suppressed muscular DUX4 target gene expression, histological muscle injury, and blood muscle injury marker elevation in TMX-untreated DUX4-TG mice. Notably, MT-DUX4-ASO at 10 mg/kg every other week significantly prevented the TMX-induced declines in treadmill test running speed and muscle force in DUX4-TG mice. Thus, the systemically administered unconjugated MT-DUX4-ASO suppressed disease progression in DUX4-TG mice, extending the potential of unconjugated ASOs as a promising FSHD treatment strategy.

Sustainable chromatographic purification of milbemectin: Application of high-speed countercurrent chromatography coupled with off-line atmospheric pressure solid analysis probe-high resolution mass spectrometry

Isolation of valuable chemicals is an important process in reagent manufacturing for the pharmaceutical and food science industries. This process is traditionally time-consuming, expensive, and consumes vast amounts of organic solvents. Considering green chemistry and sustainability concerns, we sought to develop a sustainable chromatographic purification methodology for obtaining antibiotics by focusing on the reduction of organic solvent waste generation. Milbemectin (mixture of milbemycin A3 and milbemycin A4) was successfully purified using high-speed countercurrent chromatography (HSCCC) and pure fractions (>98% purity, HPLC) could be identified using the organic solvent fee atmospheric pressure solid analysis probe mass spectrometry (ASAP-MS). The organic solvents required for HSCCC could be redistilled and recycled for continued HSCCC purification, thus reducing the consumption of organic solvent (n-hexane/ethyl acetate) by 80+%. Optimization of the two-phase solvent system (n-hexane/ethyl acetate/methanol/water, 9/1/7/3, v/v/v/v) for HSCCC was assisted computationally, thereby reducing solvent waste from an experimental determination. Our proposal application of HSCCC and offline ASAP-MS provides proof of concept for a sustainable, preparative scale, chromatographic purification methodology for obtaining antibiotics in high purity.

Validation of pencil beam scanning proton therapy with multi-leaf collimator calculated by a commercial Monte Carlo dose engine

This study aimed to evaluate the clinical beam commissioning results and lateral penumbra characteristics of our new pencil beam scanning (PBS) proton therapy using a multi-leaf collimator (MLC) calculated by use of a commercial Monte Carlo dose engine. Eighteen collimated uniform dose plans for cubic targets were optimized by the RayStation 9A treatment planning system (TPS), varying scan area, modulation widths, measurement depths, and collimator angles. To test the patient-specific measurements, we also created and verified five clinically realistic PBS plans with the MLC, such as the liver, prostate, base-of-skull, C-shape, and head-and-neck. The verification measurements consist of the depth dose (DD), lateral profile (LP), and absolute dose (AD). We compared the LPs and ADs between the calculation and measurements. For the cubic plans, the gamma index pass rates (γ-passing) were on average 96.5% ± 4.0% at 3%/3 mm for the DD and 95.2% ± 7.6% at 2%/2 mm for the LP. In several LP measurements less than 75 mm depths, the γ-passing deteriorated (increased the measured doses) by less than 90% with the scattering such as the MLC edge and range shifter. The deteriorated γ-passing was satisfied by more than 90% at 2%/2 mm using uncollimated beams instead of collimated beams except for three planes. The AD differences and the lateral penumbra width (80%-20% distance) were within ±1.9% and ± 1.1 mm, respectively. For the clinical plan measurements, the γ-passing of LP at 2%/2 mm and the AD differences were 97.7% ± 4.2% on average and within ±1.8%, respectively. The measurements were in good agreement with the calculations of both the cubic and clinical plans inserted in the MLC except for LPs less than 75 mm regions of some cubic and clinical plans. The calculation errors in collimated beams can be mitigated by substituting uncollimated beams.

Untreated sleep apnea and left atrial dilatation in patients with atrial fibrillation prior to catheter ablation

Background

Sleep apnea and left atrial dilatation are both risk factors for an arrhythmia recurrence after catheter ablation (CA) of atrial fibrillation (AF). Negative intrathoracic pressure fluctuations during an obstructive apnea episode may cause the left atrium to distend and stretch its wall. Whether sleep apnea is associated with left atrial dilatation in patients receiving CA of AF remains unknown.

Purpose

We sought to elucidate whether moderate or severe untreated sleep apnea was associated with left atrial dilatation in patients with AF before CA.

Methods

This study was conducted under a retrospective, single-center, observational design. The data were derived from screening tests for sleep apnea, which were routinely performed in patients scheduled to receive CA of AF in our institution. After excluding patients who were already diagnosed with sleep apnea, we enrolled 1265 consecutive patients (age 65±11 years, 27.8% females, and 46.2% of non-paroxysmal AF) who underwent both home sleep apnea testing and multidetector computed tomography (MDCT) before the CA of AF. The severity of the sleep apnea was evaluated by the apnea-hypopnea index (AHI) using a watch-type peripheral arterial tonometry. Left atrial dilatation was evaluated by the left atrial maximum volume (LA max V) using 256-slice MDCT.

Results

The age was 65±11 years, 27.8% were females, and 46.2% had non-paroxysmal AF. The mean AHI was 20.3±15.3 and LA max V 105±34 ml (R2=0.075, p<0.0001). LA dilatation was defined by larger than mean LA max V (LA max V≥105 ml). We examined an LA max V≥105 ml as a predictor. After an adjustment by an advanced age (≥65 years), non-paroxysmal AF, male sex, obesity, hypertension, and congestive heart failure, all of which were significant predictors of an LA max V≥105ml in the univariate analysis, moderate or severe sleep apnea (AHI≥15) was a significant predictor of an LA max V≥105 ml (odds ratio 1.63, 95% confidence interval 1.24–2.14, p=0.0005).

Conclusion

Among the patients scheduled to receive catheter ablation of AF, moderate or severe sleep apnea was independently associated with left atrial dilatation.

Funding Acknowledgement

Type of funding sources: None.

Interobserver Reliability on Intravoxel Incoherent Motion Imaging in Patients with Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Noninvasive perfusion-weighted imaging with short scanning time could be advantageous in order to determine presumed penumbral regions and subsequent treatment strategy for acute ischemic stroke (AIS). Our aim was to evaluate interobserver agreement and the clinical utility of intravoxel incoherent motion MR imaging in patients with acute ischemic stroke.

MATERIALS AND METHODS

We retrospectively studied 29 patients with AIS (17 men, 12 women; mean age, 75.2 [SD, 12.0 ] years; median, 77 years). Each patient underwent intravoxel incoherent motion MR imaging using a 1.5T MR imaging scanner. Diffusion-sensitizing gradients were applied sequentially in the x, y, and z directions with 6 different b-values (0, 50, 100, 150, 200, and 1000 seconds/mm²). From the intravoxel incoherent motion MR imaging data, diffusion coefficient, perfusion fraction, and pseudodiffusion coefficient maps were obtained using a 2-step fitting algorithm based on the Levenberg-Marquardt method. The presence of decreases in the intravoxel incoherent motion perfusion fraction and pseudodiffusion coefficient values compared with the contralateral normal-appearing brain was graded on a 2-point scale by 2 independent neuroradiologists. Interobserver agreement on the rating scale was evaluated using the κ statistic. Clinical characteristics of patients with a nondecreased intravoxel incoherent motion perfusion fraction and/or pseudodiffusion coefficient rated by the 2 observers were also assessed.

RESULTS

Interobserver agreement was shown for the intravoxel incoherent motion perfusion fraction (κ = 0.854) and pseudodiffusion coefficient (κ = 0.789) maps, which indicated almost perfect and substantial agreement, respectively. Patients with a nondecreased intravoxel incoherent motion perfusion fraction tended to show recanalization of the occluded intracranial arteries more frequently than patients with a decreased intravoxel incoherent motion perfusion fraction.

CONCLUSIONS

Intravoxel incoherent motion MR imaging could be performed in < 1 minute in addition to routine DWI. Intravoxel incoherent motion parameters noninvasively provide feasible, qualitative perfusion-related information for assessing patients with acute ischemic stroke.

Association between myocardial wall thickness and left ventricular functional recovery after catheter ablation of atrial fibrillation in patients with reduced ejection fraction

Background

Catheter ablation of atrial fibrillation (AFCA) is an effective treatment to develop left ventricular (LV) functional recovery. However, the degree of recovery differs between individuals due to the different extent of myocardial fibrosis and scarring.

Purpose

To examine whether pre-ablation LV wall thickness (WT) and its regional heterogeneity predict LV functional recovery after AFCA in patients with LV systolic dysfunction.

Methods

Of 3682 consecutive patients who underwent first-time AFCA between January 2012 and September 2020 in our institution, 174 (age, 63±10 years; male, 83%; ischemic cardiomyopathy, 14%) with a baseline LV ejection fraction (LVEF) of &lt;40% were retrospectively evaluated. They were subjected to 256-slice MDCT scanning at baseline and 3 months after AFCA. Baseline WT was evaluated by 16-segment model. Mean and standard deviation (SD) of 16 regional WT were calculated in both end-systolic and end-diastolic phase.

Results

LVEF significantly improved from 30±7% to 57±17% (p&lt;0.001) after AFCA. Increase in LVEF (delta-LVEF) was positively correlated with baseline end-diastolic WT (r=0.31, p&lt;0.001) and negatively correlated with SD of end-systolic WT (r=−0.21, p=0.007). Independent of WT measurements, delta-LVEF was negatively correlated with LV end-diastolic volume (r=−0.42, p&lt;0.001). We created a scoring system to predict the degree of wall motion recovery using the median value of the 3 variables; assigned 1 point each for end-diastolic WT &gt;7.4mm, SD of end-systolic WT &lt;1.61mm, and LV end-diastolic volume &lt;125ml. The model successfully predicted improvement in LVEF after AFCA (0 point (N=13) vs. 1 point (N=72) vs. 2–3 point (N=89), 11±16% vs. 20±17% vs. 33±12%, p&lt;0.001).

Conclusion

Myocardial WT and its regional heterogeneity as well as LV end-diastolic volume predicted functional recovery after AFCA in patients with reduced LVEF.

Funding Acknowledgement

Type of funding sources: None.

External validation of H2ARDD score for the prediction of heart failure events in patients with atrial fibrillation

Background

Heart failure is an important consequence in patients with atrial fibrillation (AF) which is associated with worse prognosis. The H2ARDD score, calculated from 5 clinical risk factors, was reported as a predictor of heart failure events in patients with AF. However, this score has not been externally validated.

Purpose

The purpose of this study was to evaluate and validate the usefulness of the H2ARDD score for the prediction of heart failure events in AF patients.

Methods

We used prospective data of patients with AF followed up from 2007 to 2017 in our institute. Patients with active cancer were excluded according to the previous report. H2ARDD score was calculated as follows; history of heart disease=2 points, anemia=1 point, renal dysfunction=1 point, diabetes =1 point, diuretic use=1 point (range from 0 to 6 points). Outcome of interest was defined as heart failure events including new-onset heart failure and death with heart failure. Heart failure was ascertained based on the Framingham criteria. Univariable and multivariable Cox-proportional hazards model were used to assess the risk of heart failure events. Heart failure events-free survival was estimated with Kaplan-Meier methods, and the predictive accuracy of the H2ARDD score for the prediction of heart failure events was measured by the area under the receiver operating characteristic (ROC) curve.

Results

Of 562 AF patients, 522 (age 69±10 year–old, 64.9%men) met study criteria. Patients who had a history of heart disease was 185 (35%), diabetes mellitus was 135 (26%), anemia was 54 (10%), renal dysfunction was 221 (43%), and diuretic use was 193 (37%). The mean H2ARDD score was 1.88±1.57. Of all study patients, 84 (16.2%) developed heart failure events during a mean follow–up of 54±42 months. Patients who developed heart failure events in 1 year was 24 (4.6%). In multivariable Cox–proportional hazards model, H2ARDD score was shown as an significant predictor for heart failure events (hazard ratio: 1.56, 95% confidence interval: 1.36 - 1.79, P&lt;0.0001), independently of age (per 10 years, hazard ratio: 1.35, 95% confidence interval: 1.03 – 1.78, P&lt;0.05). In the Kaplan–Meier analyses stratified by H2ARDD score (0–1, 2–3, 4–6), patients who had a higher H2ARDD sore had significantly worse heart failure event-free survival (log-rank P&lt;0.0001) (Figure 1). The area under the ROC curve for the prediction of heart failure events in 1-year was 0.812 (95% confidence interval: 0.737 – 0.887, P&lt;0.0001), and the best cut-off value was ≥4 points (sensitivity: 67%, specificity: 83%) (Figure 2).

Conclusion

H2ARDD score was demonstrated as a significant independent predictor for the prediction of heart failure events, with high predictive accuracy. H2ARDD score may be useful for heart failure risk stratification of AF patients.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Stable Isotope Labeling by Carbon-13 in Bacteria Culture for the Analysis of Residual Avermectin Using Stable Isotope Dilution Liquid Chromatography Tandem Mass Spectrometry

This study describes the development of a new stable isotope labeling method by carbon-13 in bacteria culture (SILCB) for the analysis of residual antibiotics via liquid chromatography with tandem mass spectrometry (LC-MS/MS). Stable isotope dilution (SID) LC-MS/MS with QuEChERS was employed to determine avermectin, particularly avermectin B1a (AV-a) and B1b (AV-b), based on completely ¹³C-labeled internal standards (¹³C-ISs) obtained from the SILCB. Our SILCB was developed from an optimal inorganic medium using ¹³C₆-glucose for Streptomyces avermitilis (14893 strain). A rough extract containing ¹³C-ISs was purified via high-speed countercurrent chromatography with a volatile two-phase solvent system composed of n-hexane/ethyl acetate/methanol/0.5% formic acid in water (7/3/5/5/, V/V). The purified ¹³C-ISs were evaluated to confirm the presence of completely ¹³C-labeled ions with m/z 938 > 326 and m/z 923 > 309 for AV-a and AV-b, respectively. The QuEChERS approach with the ¹³C-ISs procedure achieved acceptable recovery rates in beef meat samples of 99.5 - 100.0% (RSD < 2.0%, n = 6). For the analysis of residual antibiotics in foodstuffs by SID-LC-MS/MS and QuEChERS, the SILCB represents a significant improvement over previous methods suffering from cumbersome sample preparation and matrix effects.

Usefulness of H2FPEF score as an independent predictor of heart failure development in patients with atrial fibrillation

Background

The H2 FPEF score, which based on simple clinical characteristics and echocardiography, enables discrimination of HFpEF from noncardiac causes of dyspnea.

Purpose

We sought to evaluate whether H2 FPEF score predicts congestive heart failure (CHF) development in patients with atrial fibrillation (AF).

Methods

Among adult AF patients who underwent transthoracic echocardiography between July 2007 and December 2008, those with preserved left ventricular ejection fraction (LVEF) (≥50%) were included and followed up to new-onset CHF events. Patients with a history of CHF, cardiac surgery, or significant left-sided valvular heart disease were excluded. The H2 FPEF score was calculated from 6 variables (obesity = 2 points, treatment with ≥2 antihypertensive drugs = 1 point, AF = 3 points, echocardiographic pulmonary artery systolic pressure &gt;35 mmHg = 1 point, age &gt;60 years = 1 point, and echocardiographic E/e'ratio &gt;9 = 1 point). CHF was ascertained using Framingham criteria. Cox-proportional hazards modeling was used to assess risk of CHF development.

Results

Of 562 AF patients, 367 (69±10 year old, 66% men) met all study criteria. Of whom, 37 (10%) developed CHF events during a mean follow–up of 56±43 months. The mean H2 FPEF score was 5.50±1.14, and the number of patients with H2 FPEF score ≥7 was 64 (17%). After adjusting for comorbidities in a multivariate model, H2 FPEF score was significant predictor of new-onset CHF events both as continuous (HR=1.43, 95% CI: 1.05–1.96, P&lt;0.05) or categorical (H2 FPEF score ≥7) (HR=2.32, 95% CI: 1.17–4.63, P&lt;0.05) variables. The Kaplan-Meier estimates of CHF-free survival stratified by H2 FPEF status (≥7 or &lt;7) were shown in Figure.

Conclusion

H2 FPEF score provides prognostic information for new-onset CHF development in patients with AF.

Figure 1

Funding Acknowledgement

Type of funding source: None

Serum modified HDL was associated with cardiovascular disease in a Japanese community-based cohort

Background

Previous studies have shown that high density lipoprotein (HDL) is protective against cardiovascular disease (CVD). However, recent studies suggested that function of HDL was more important than HDL cholesterol levels. The present study aimed to clarify the relationship between modified HDL levels and CVD incidence.

Methods

LOX-1 (lectin-like oxidized LDL receptor) is the receptor that mediates modified LDL (low density lipoprotein) activity; however, some lipoproteins with apolipoprotein A1 (Apo A-1) are also bonded to LOX-1. In this study, serum LOX-1 ligand containing Apo A-1 was defined as modified HDL, which were measured by our new development method. We conducted a nested case-control study in a Japanese cohort study, involving 11,002 community dwellers. During 4.0 years follow-up, we observed 127 new CVD onsets. For each CVD case, age and sex matched three controls were randomly selected (N = 381). Serum samples collected at baseline survey stored at − 80 °C were used for the measurement of modified HDL. We estimated multivariable-adjusted odds ratio (OR) and 95% confidence interval (CI) for the association between modified HDL levels and CVD by conditional logistic regression.

Results

Modified HDL levels were associated with increased risk of CVD (OR for one unit increase of log transformed modified HDL, 2.05: 95% CI, 1.16-3.62) after adjustment for body mass index, hypertension, diabetes, LDL cholesterol, HDL cholesterol, lipid lowering agents, chronic kidney disease, smoking and alcohol drinking. The magnitude of OR was almost equivalent to those of hypertension and diabetes, which were 2.33 (95% CI, 1.37-3.98) and 2.61 (95% CI, 1.48-4.59), respectively. On the other hands, other lipids markers showed relatively weak associations with CVD.

Conclusions

Serum modified HDL, i.e., LOX-1 ligand containing Apo A-1, might be a novel predictive marker for CVD in apparently healthy individuals.

Key messages

Recent epidemiologic studies suggested that function of high-density lipoprotein (HDL) was more important than HDL cholesterol level itself to predict cardiovascular disease. Modified HDL measured by a novel cell-free, non-fluorescent method as LOX-1 ligand containing Apo A-1, was a predictive marker for CVD after adjusting for other traditional risk factors.

P303Prognostic value of diastolic wall strain in patients with asymptomatic severe aortic stenosis

Background

Diastolic wall strain (DWS) has been reported to be associated with left ventricular (LV) stiffness and worse clinical outcomes. We sought to assess the utility of this new index for prediction of prognosis in asymptomatic patients with severe aortic stenosis (AS).

Methods

Asymptomatic severe AS patients [peak flow velocity (PFV) ≥4.0m/s, mean pressure gradient (mPG) ≥40mmHg, aortic valve area (AVA) ≤1.0cm2, or indexed AVA ≤0.6cm2/m2)] diagnosed between July 2007 and April 2016 were included in this study. Patients with significant mitral valve disease, posterior wall motion abnormality, prior cardiac surgery, hypertrophic cardiomyopathy, and LV ejection fraction <50% were excluded. DWS was calculated with a validated formula [DWS = (posterior wall thickness at end-systole − posterior wall thickness at end-diastole)/posterior wall thickness at end-systole]. All study patients were prospectively followed up to last visit or death until November 2017, and predictive value of all-cause death was assessed using Cox-proportional hazards modeling. Patients who underwent aortic valve replacement (AVR) during the study period were censored on the date of surgery.

Results

A total of 184 asymptomatic severe AS, 138 (age 76±9year-old, men 41%, PFV 3.9±1.0m/s, mPG 38±19mmHg, AVA 0.83±0.18cm2, indexed AVA 0.56±0.13cm2/m2) met all study criteria. Of whom, 43 (31%) underwent AVR and 28 (20%) died during a mean follow-up of 25±28months. In a multivariable model after adjusting for clinical and echocardiographic variables, advancing age (per10yrs; HR=2.19, 95% CI=1.19–4.03, P<0.05), history of hemodialysis (HR=4.31, 95% CI=1.30–14.35, P<0.05), and low-DWS (DWS <0.30) (HR=2.83, 95% CI=1.25–6.40, P<0.05) were independent predictors of all-cause death. In the Kaplan-Meier estimates of cumulative survival stratified by DWS status were shown (Figure).

The Kaplan-Meier estimates of survival

Conclusion

Low-DWS provides prognostic information in patients with asymptomatic severe AS.

Isolated Superior Mesenteric Artery Dissection Following Liver Transplant: Report of 3 Cases

BACKGROUND

Isolated superior mesenteric artery (SMA) dissection (SMAD) is considered a relatively rare disease. Especially, isolated SMAD following liver transplant has been rarely reported.

REPORT OF CASES

Among 96 consecutive adult recipients who underwent liver transplant at our institution, 3 recipients (3.1%) demonstrated isolated noncommunicating SMAD, type IV according to Sakamoto's classification. Patient characteristics are the following: mean age, 53 years (range, 49-60 years); male to female ratio, 2:1, right lobe graft to left lobe graft ratio, 2:1; operating time, 760 minutes (range, 614-880 minutes); and blood loss, 6570 mL (range, 2435-13,329 mL). New onset of abdominal pain was noted in 33.3% (1/3). The diagnosis was made by the first follow-up computed tomography scan after liver transplant. The mean distance between the proximal end of SMAD and the root of SMA was 21.3 mm (range, 9-40 mm). There were no signs of ischemic changes in the small intestine in any of the 3 patients. Thus, conservative managements such as anticoagulation therapy were performed without other aggressive interventions. One patient died because of subarachnoid hemorrhage. In the other 2 patients, SMAD disappeared at 6 months following the diagnosis.

DISCUSSION

The morbidity of isolated SMAD is around less than 0.1% at the autopsy. Compared with this result, we found significantly higher morbidity rate in liver transplant recipients. It is true that mechanical stress from retraction of the stomach to the caudal end including the root of SMA may play an important role in the onset of SMA dissection.

CONCLUSION

Isolated SMA dissection following living donor liver transplant is a rare but potentially life-threatening condition. It is required to ascertain whether emergency revascularization should be considered.

Graft Immunocomplex Capture Fluorescence Analysis Can Detect Intragraft Anti-Major Histocompatibility Complex Antibodies in Mice Cardiac Transplant

BACKGROUND

Immunocomplex capture fluorescence analysis has recently been applied as a method for detection of intragraft donor-specific anti-major histocompatibility complex (MHC) antibodies (DSA) in humans. Although intragraft DSA in humans is an intense topic of investigation, there is no report to assess intragraft DSA in murine organ transplantation.

METHODS

A model of presensitized mouse cardiac transplantation by donor splenocytes was used. To capture mouse MHC, anti-MHC class I/II antibodies were immobilized on Luminex beads. The MHC/DSA complexes were captured by the Luminex beads followed by detection of phycoerythrin-conjugated antimouse IgG antibodies where DSA had already reacted with the allograft in vivo.

RESULTS

Luminex beads were capable of detecting class I DSA in the cardiac allograft, though results for class II DSA were negative. Immunohistochemical investigation revealed that cardiac allografts had abundant MHC class I expression but only minor expression of MHC class II. Furthermore, MHC/class II DSA complexes were successfully detected in splenocytes and serum from a presensitized recipient.

CONCLUSIONS

These data suggested that graft immunocomplex capture fluorescence analysis can be also applied in murine cardiac transplantation. This novel application in mice would accelerate our comprehension of DSA through mechanistic studies.

Abstract P2-07-03: Refining neoadjuvant predictors of three year distant metastasis free survival: Integrating volume change as measured by MRI with residual cancer burden

Background: Patients achieving a pathologic complete response (pCR) following neoadjuvant therapy have significantly improved event-free survival relative to those who do not; and pCR is an FDA-accepted endpoint to support accelerated approval of novel agents/combinations in the neoadjuvant treatment of high risk early stage breast cancer. Previous studies have shown that recurrence risk increased with increasing burden of residual disease (as assessed by the RCB index). As well, these studies suggest that patients with minimum residual disease (RCB-I class) also have favorable outcomes (comparable to those achieving a pCR) within high risk tumor subtypes. In this study, we assess whether integrating RCB with MRI functional tumor volume (FTV), which in itself is prognostic, can improve prediction of distant recurrence free survival (DRFS); and identify a subset of patients with minimal residual disease with comparable DRFS as those who achieved a pCR. Imaging tools can then be used to identify the subset that will do well early and guide the timing of surgical therapy.

Method: We performed a pooled analysis of 596 patients from the I-SPY2 TRIAL with RCB, pre-surgical MRI FTV data and known follow-up (median 2.5 years). We first assessed whether FTV predicts residual disease (pCR or pCR/RCB-I) using ROC analysis. We applied a power transformation to normalize the pre-surgical FTV distribution; and assessed its association with DRFS using a bi-variate Cox proportional hazard model adjusting for HR/HER2 subtype. We also fitted a bivariate Cox model of RCB index adjusting for subtype; and assessed whether adding pre-surgical FTV to this model further improves association with DRFS using a likelihood ratio (LR) test. For the Cox modeling, penalized splines approximation of the transformed FTV and RCB index with 2 degrees of freedom was used to allow for non-linear effects of FTV and RCB on DRFS.

Result: Pre-surgical MRI FTV is significantly associated with DRFS (Wald p&lt;0.00001), and more effective at predicting pCR/RCB-I than predicting pCR alone (AUC: 0.72 vs. 0.65). Larger pre-surgical FTV remains associated with worse DRFS adjusting for subtype (Wald p &lt;0.00001). The RCB index is also significantly associated with DRFS adjusting for subtype (Wald p&lt;0.00001). Adding FTV to a model containing RCB and subtype further improves association with DRFS (LR p=0.0007). RCB-I patients have excellent DRFS (94% at 3 years compared to 95% in the pCR group). Efforts are underway to identify an optimal threshold for dichotomizing pre-surgical FTV and FTV change measures for use in combination with pCR/RCB-I class to generate integrated RCB (iRCB) groups as a composite predictor of DRFS.

Conclusion: Pre-surgical MRI FTV is effective at predicting minimal residual disease (RCB0/I) in the I-SPY 2 TRIAL. Despite the association between FTV and RCB, FTV appears to provide independent added prognostic value (to RCB and subtype), suggesting that integrating MRI volume measures and RCB into a composite predictor may improve DRFS prediction.

Citation Format: Hylton NM, Symmans WF, Yau C, Li W, Hatzis C, Isaacs C, Albain KS, Chen Y-Y, Krings G, Wei S, Harada S, Datnow B, Fadare O, Klein M, Pambuccian S, Chen B, Adamson K, Sams S, Mhawech-Fauceglia P, Magliocco A, Feldman M, Rendi M, Sattar H, Zeck J, Ocal I, Tawfik O, Grasso LeBeau L, Sahoo S, Vinh T, Yang S, Adams A, Chien AJ, Ferero-Torres A, Stringer-Reasor E, Wallace A, Boughey JC, Ellis ED, Elias AD, Lang JE, Lu J, Han HS, Clark AS, Korde L, Nanda R, Northfelt DW, Khan QJ, Viscusi RK, Euhus DM, Edmiston KK, Chui SY, Kemmer K, Wood WC, Park JW, Liu MC, Olopade O, Tripathy D, Moulder SL, Rugo HS, Schwab R, Lo S, Helsten T, Beckwith H, Haugen PK, van't Veer LJ, Perlmutter J, Melisko ME, Wilson A, Peterson G, Asare AL, Buxton MB, Paoloni M, Clennell JL, Hirst GL, Singhrao R, Steeg K, Matthews JB, Sanil A, Berry SM, Abe H, Wolverton D, Crane EP, Ward KA, Nelson M, Niell BL, Oh K, Brandt KR, Bang DH, Ojeda-Fournier H, Eghtedari M, Sheth PA, Bernreuter WK, Umphrey H, Rosen MA, Dogan B, Yang W, Joe B, I-SPY 2 TRIAL Consortium, Yee D, Pusztai L, DeMichele A, Asare SM, Berry DA, Esserman LJ. Refining neoadjuvant predictors of three year distant metastasis free survival: Integrating volume change as measured by MRI with residual cancer burden [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-07-03.

Short- and Long-Term Outcomes of Live Donor Renal Allografts From Older and Younger Donors

BACKGROUND

The rising demand for living renal donors has led to the recruitment of older donors. Findings vary, but these grafts appear to survive as long as grafts from standard criteria deceased and expanded criteria deceased donors. We investigated the effects of donor age ≥65 years and the presence or absence of donor antihypertensive therapy on patient condition 1 year after transplantation, and retrospectively examined 1-year (273 patients), 3-year (217 patients), and 5-year (140 patients) patient and graft survival.

METHODS

We divided 273 donor-recipient pairs into Group Y (donor age <65 years, n = 224) and Group O (donor age ≥65 years, n = 49). Group O was subdivided into donors receiving treatment for hypertension (subgroup O-1, n = 16) and those not receiving treatment for hypertension (subgroup O-2, n = 33). We compared results of 1 hour post-transplant biopsies and looked at a small number of 1 year post-transplant biopsies.

RESULTS

Although a significantly larger percentage of recipients from younger donors were undergoing preemptive transplantation, and the incidence of arteriosclerosis was significantly higher in the Group O kidneys, there were no significant differences between the 2 groups in terms of patient or graft survival at 1, 3, or 5 years; serum creatinine levels; or number of episodes of acute rejection. The presence or absence of donor antihypertensive treatment had no effect.

CONCLUSIONS

We found that donor age ≥65, with or without antihypertensive treatment, had no effect on graft or patient survival.