Abstract 4436: A novel antibody-enabled dual precision targeted protein stabilization (TPS2) that augments anti-tumor immune response by targeting CBL-B inhibitor to exhausted T cells while blocking checkpoint molecule, PD-1

It is well-established that T cells play a key role in the success of cancer immunotherapies. The goals of T cell-targeting therapies have been to restore the effector function of tumor-specific T cells that are either dysfunctional due to the immunosuppressive mechanisms in the tumor microenvironment, the lack of co-stimulatory signals, or negative regulation by expression of checkpoint molecules such as PD-1. E3 ligase Casitas B-Lineage Lymphoma Proto-Oncogene B (CBL-B) has recently gained attention as a master regulator of multiple immune-activation mechanisms. Inhibition of CBL-B enables the activation of antigen-specific T cells, and has been shown in syngeneic mouse tumor models to be efficacious as a cancer immunotherapy agent. CBL-B inhibition has also been shown to enhance and prolong the effects of anti-PD-1 antibody (Ab) therapy. However, genetic knockout of CBL-B in mice led to spontaneous autoimmunity characterized by auto-antibody production and infiltration of activated T cells and B cells into multiple organs that could result in tissue damage. In order to mitigate safety issues that could result from systemic CBL-B inhibition, we developed novel antibody-drug conjugates (ADCs) that target CBL-B inhibitors (CBL-Bi) to T cells via binding to PD-1. Using PD-1-expressing Jurkat NFAT reporter cells and mixed lymphocyte reaction assay, we demonstrated that our TPS2 approach enhanced the activation of T cells in vitro compared to treatment with anti-PD-1 Ab alone. Evaluation of pathways downstream of TCR activation in primary exhausted T cells showed increased Notch1, phospho-PLCγ2, and ZAP-70 accumulation following anti-PD-1/CBL-Bi treatment and is correlated with IFNγ induction. When autologous mature dendritic cells were co-cultured with dissociated tumor cells from melanoma patients, the highest magnitude of tumor-infiltrating lymphocyte activation was observed using delivery of CBL-Bi by anti-PD-1 ADC, compared to CBL-Bi alone, anti-PD-1 Ab alone, or combination treatment. The potential of anti-PD-1/CBL-Bi ADC for activation effector T cell function is also evident by increased intratumoral transcript levels of Granzyme B and Perforin following treatment in a humanized mouse model. In conclusion, we validated that the biological activity of CBL-Bi is retained after conjugation with an anti-PD-1 antibody. The use of anti-PD-1 Ab for developing the ADC not only targets the CBL-Bi payload to exhausted T cells but also blocks negative regulation of T cells via PD-1. Together, anti-PD-1/CBL-Bi ADC enhanced T cell activation in vitro as well as in vivo. Evaluation of safety and efficacy in animal tumor models is ongoing, to support further development of the TPS2 approach.

Citation Format: Joanne Lim, Anna Skaletskaya, Uttapol Permpoon, Yeonjoon Kim, Shikha Saini, Khuloud Takrouri, Zinaida Ribkovskaia, Palash Bhar, Nathan Fishkin, Dong-Ki Choi, Ji Hyun Park, James Palacino, Peter U. Park. A novel antibody-enabled dual precision targeted protein stabilization (TPS2) that augments anti-tumor immune response by targeting CBL-B inhibitor to exhausted T cells while blocking checkpoint molecule, PD-1. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4436.

Effective dose of remimazolam co-administered with remifentanil to facilitate I-gel insertion without neuromuscular blocking agents: an up-and-down sequential allocation trial

BACKGROUND

Remimazolam is a new anesthetic drug developed and is an ultra-short-acting agent with rapid onset and offset. The pharmacology of this drug seems to be ideal for short surgeries eligible for I-gel insertion. Therefore, this study aimed to determine the optimal bolus dose of remimazolam for I-gel insertion when co-administered with remifentanil without neuromuscular blocking agents (NMBAs).

METHODS

Patients aged 19-65 years with American Society of Anesthesiologists physical status I or II scheduled for general anesthesia were enrolled. The first dose of remimazolam was 0.15 mg/kg and remifentanil was co-administered at an effect-site concentration (Ce) of 3.0 ng/mL. The dose of remimazolam for the following patient was decreased or increased by 0.05 mg/kg depending on the success or failure of I-gel insertion in the previous patient.

RESULTS

The remimazolam bolus dose required for successful I-gel insertion in 50% of adult patients using modified Dixon's up-and-down method with remifentanil Ce 3.0 ng/mL and no NMBAs was 0.280 ± 0.048 mg/kg. Isotonic regression analysis showed that the 50% and 95% effective doses were 0.244 (83% confidence interval [CI] 0.213-0.313) mg/kg and 0.444 (95% CI 0.436-0.448) mg/kg, respectively. The mean time to loss of consciousness (Modified Observer's Assessment of Alertness/Sedation score < 2) was 52.2 s. Three patients (12.0%) showed a reduction in systolic blood pressure of more than 30% from baseline.

CONCLUSIONS

Selecting the appropriate dose of remimazolam/remifentanil without NMBAs makes it feasible to insert the I-gel.

TRIAL REGISTRATION

This study protocol was registered at http://cris.nih.go.kr (KCT0007801, 12th, October, 2022).

Sudden Death Associated With Possible Flare-Ups of Multiple Sclerosis After COVID-19 Vaccination and Infection: A Case Report and Literature Review

We present an autopsy case of a 19-year-old man with a history of epilepsy whose unwitnessed sudden death occurred unexpectedly in the night. About 4 years before death, he was diagnosed with unilateral optic neuritis (ON). Demyelinating disease was suspected, but he was lost to follow up after the recovery. Six months before death, he received a second dose of mRNA coronavirus disease 2019 (COVID-19) vaccine. Three months before death, he experienced epileptic seizures for the first time. Seventeen days before death, he was infected with COVID-19, which showed self-limited course under home isolation. Several days before death, he complained of seizures again at night. Autopsy revealed multifocal gray-tan discoloration in the cerebrum. Histologically, the lesions consisted of active and inactive demyelinated plaques in the perivenous area of the white matter. Perivascular lymphocytic infiltration and microglial cell proliferation were observed in both white matter and cortex. The other major organs including heart and lung were unremarkable. Based on the antemortem history and postmortem findings, the cause of death was determined to be multiple sclerosis with suspected exacerbation. The direct or indirect involvement of cortex and deep gray matter by exacerbated multiple sclerosis may explain the occurrence of seizures. Considering the absence of other structural abnormalities except the inflammatory demyelination of the cerebrum, fatal arrhythmia or laryngospasm in the terminal epileptic seizure may explain his sudden unexpected death in the benign circumstances. In this case, the onset of seizure was preceded by COVID-19 vaccination, and the exacerbation of seizure was preceded by COVID-19 infection, respectively. Literature reporting first manifestation or relapse of multiple sclerosis temporally associated with COVID-19 vaccination or infection are reviewed.

A Phase 2 Study of Palbociclib for Recurrent or Refractory Advanced Thymic Epithelial Tumors (KCSG LU17-21)

INTRODUCTION

Thymic epithelial tumors (TETs) are rare but are the most common tumors of the anterior mediastinum. Platinum-based combination chemotherapy is the standard of care for such tumors and is associated with a 50% to 90% objective response rate (ORR) in metastatic disease. Nevertheless, there is no standard chemotherapeutic option after failure of platinum-based combination chemotherapy. Genetic alterations associated with the cell cycle, including pRB, p16^INK4A, and cyclin D1, are most often observed in TETs. On the basis of these results, we conducted a phase 2 trial to evaluate the efficacy and safety of palbociclib in patients with recurrent or refractory advanced TETs.

METHODS

This is a phase 2, multicenter, open-label, single-arm study of palbociclib monotherapy in patients with recurrent or metastatic advanced TETs who failed one or more cytotoxic chemotherapies. The patients received 125 mg of oral palbociclib daily for 21 days, followed by a 7-day break. The primary end point was progression-free survival (PFS). The secondary end points were ORR, duration of response, overall survival, and safety.

RESULTS

Between August 2017 and October 2019, a total of 48 patients were enrolled. The median number of previous chemotherapies was one (range: one to four), and 21 (43.7%) of 48 patients received thymectomy. By the WHO classification, the patients were type A (n = 1), type B1 (n = 2), type B2 (n = 8), type B3 (n = 13), thymic carcinoma (n = 23), and unknown (n = 1). With a median follow-up of 14.5 months (range: 0.8-38.2), the median number of cycles of palbociclib monotherapy was 10 (range: 1-40). The ORR was 12.5% (four partial responses in thymoma and two partial responses in thymic carcinoma). The PFS at 6 months was 60.2%, and the median PFS was 11.0 months (95% confidence interval: 4.6-17.4). The median overall survival was 26.4 months (95% confidence interval: 17.4-35.4). The most common treatment-related adverse events of any grade were neutropenia (62.5%), anemia (37.5%), and thrombocytopenia (29.1%), and the most common grade 3/4 treatment-related hematologic adverse event was neutropenia (41.7%). Neutropenia above grade 3 was reversible, and there were no cases with neutropenic fever.

CONCLUSIONS

Palbociclib monotherapy was well tolerated and had encouraging efficacy in patients with TETs who failed platinum-based combination chemotherapy.

The Glasgow Microenvironment Score and risk and site of recurrence in TNM I-III colorectal cancer

BACKGROUND

Glasgow Microenvironment Score (GMS) stratifies long-term survival into three groups based on tumour phenotype: peritumoural inflammation (Klintrup-Mäkinen (KM)) and tumour stroma percentage (TSP). However, it is not known if the location of disease recurrence is influenced by the GMS category.

METHODS

Seven hundred and eighty-three TNM I-III colorectal cancers (CRC) were included. GMS (GMS0-high KM; GMS1-low KM, low TSP; GMS2-low KM, high TSP) and cancer-specific survival (CSS), overall survival (OS) and disease recurrence were assessed using Cox regression analysis.

RESULTS

Of the 783 patients, 221 developed CRC recurrence; 65 developed local recurrence + systemic disease. GMS was independent for CSS (HR 1.50, 95% CI 1.17-1.92, p < 0.001) and OS (HR 1.23, 1.05-1.44, p = 0.01). Higher GMS category was associated with T-stage, N-stage, emergency presentation and venous invasion. GMS was independent for local+systemic recurrence (HR 11.53, 95% CI 1.45-91.85, p = 0.04) and distant-only recurrence (HR 3.01, 95% CI 1.59-5.71, p = 0.002). GMS 2 disease did not appear to have statistically better outcomes with adjuvant chemotherapy in high-risk disease.

CONCLUSION

Although confounded by a higher rate of T4 and node-positive disease, GMS 1 and 2 are associated with an increased risk of local and distant recurrence. GMS is an independent poor prognostic indicator for recurrent colorectal cancer. Higher GMS patients may benefit from enhanced postoperative surveillance.

Effect of Helicobacter pylori infection and its eradication on the expression of tight junction proteins in the gastric epithelium in relation to gastric carcinogenesis

BACKGROUND

Tight junction proteins (TJPs) play a role in epithelial defense mechanisms. However, the effect of Helicobacter pylori (Hp) on TJPs remains unclear. This study aimed to evaluate the expression of TJPs in relation to Hp infection and eradication in gastric carcinogenesis.

METHODS

In total, 510 subjects (284 controls and 226 gastric cancer [GC] patients) were prospectively enrolled in the study. The expression of claudin-1 and -2 (CLDN-1, -2), occludin (OCLN), and tight junction protein 1 (TJP1) was measured based on their Hp infection status in normal corpus mucosa and evaluated following Hp eradication using quantitative real-time polymerase chain reaction (qPCR) and immunohistochemistry (IHC).

RESULTS

The expression of TJP1 in Hp⁺ controls was significantly lower than that in Hp^- controls (p = 0.006), whereas it was higher in Hp⁺ than in Hp^- GC patients (p = 0.001). Moreover, the increased expression of TJP1 in Hp⁺ GC patients was reduced to levels in Hp^- within a year after Hp eradication and was maintained for more than 5 years. Furthermore, IHC results for TJP1 were similar to qPCR results. In particular, the higher IHC staining intensity of TJP1 in the cytosol of GC patients (p = 0.019) decreased after Hp eradication (p = 0.040).

CONCLUSION

Hp infection affects TJP expression. The high expression of TJP1 in Hp⁺ GC patients was restored to control levels after Hp eradication, suggesting that TJP1 plays a role in gastric carcinogenesis.

Determination of the 95% effective dose of remimazolam to achieve loss of consciousness during anesthesia induction in different age groups

BACKGROUND

Remimazolam is a new ultra short-acting benzodiazepine originally developed as an improved version of midazolam. Recent studies have demonstrated non-inferiority of remimazolam to propofol in general anesthesia. However, to date, few studies have investigated the induction bolus dose of remimazolam required to achieve general anesthesia. We aimed to determine the 95% effective dose (ED95) of remimazolam bolus required to achieve loss of consciousness (LOC) and the appropriate doses for different age groups.

METHODS

Patients aged 20-79 years with the American Society of Anesthesiologists physical status of I or II were enrolled in this study. A total of 120 patients were included representing young, middle-aged, and elderly groups. Loss of eyelash reflex and verbal response after the administration of remimazolam was considered successful LOC. The ED95 of remimazolam was determined using a biased coin up-and-down design with sequential allocation and the isotonic regression method.

RESULTS

The ED95 of remimazolam for induction of general anesthesia was 0.367 mg/kg (95% CI [0.277, 0.392]) in the young group, 0.369 mg/kg (95% CI [0.266, 0.394]) in the middle-aged group, and 0.249 mg/kg (95% CI [0.199, 0.288]) in the elderly group. During the study period, none of the patients required rescue medications for hypotension or bradycardia.

CONCLUSIONS

This study investigated the ED95 of remimazolam bolus for anesthesia induction. The precise dosing of the ED95 can help maintain hemodynamic stability during the induction of anesthesia.

Potential Inflammatory Biomarker in Patients with Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disorder that can diminish the quality of life of both children and adults in academic, occupational, and social contexts. The kynurenine pathway (KP) contains a set of enzymatic reactions involved in tryptophan (TRP) degradation. It is known to be associated with the risk of developing ADHD. This review will address the KP and underlying mechanism of inflammation in ADHD. Potential inflammatory biomarkers reported in the most recent studies are summarized. Although a strong neuroimmunological basis has been established due to the advances of recent neurobiological research, the pathophysiology of ADHD remains unclear.

High-resolution metabolomics-based biomarker discovery using exhaled breath condensate from patients with lung cancer

Early diagnosis and treatment are critical for improving the survival of patients with lung cancer, which is the leading cause of cancer-related deaths worldwide. In this study, we investigated whether the metabolomics analysis of exhaled breath condensate (EBC) from patients with lung cancer can provide biomarkers that can be used for noninvasive screening for lung cancer diagnosis. EBC samples obtained from patients with lung cancer (n = 20) and healthy individuals (n = 5) were subjected to high-resolution metabolomics (HRM) using liquid chromatography–mass spectrometry (LC–MS). Univariate analysis, with a false discovery rate (FDR), q = 0.05, and hierarchical clustering analysis were performed to discover significantly different metabolites between the healthy controls and patients with lung cancer. This was followed by the identification of the metabolites using the METLIN database. Pathway analysis based on the identified metabolites revealed that arachidonic acid (AA) metabolism was the most significantly affected pathway. Finally, 5-hydroxyicosatetraenoic acid (HETE) (m/z 343.2233, [M + Na]+), a metabolite involved in AA metabolism, was found to be significantly higher in patients with lung cancer than in healthy counterparts. Our finding suggested that the HRM of EBC samples is a useful approach for identifying biomarkers for noninvasive screening for lung cancer diagnosis.

Fingolimod Does Not Reduce Infarction After Focal Cerebral Ischemia in Mice During Active or Inactive Circadian Phases

Background:

It has been reported that the S1P (sphingosine 1-phosphate) receptor modulator fingolimod reduces infarction in rodent models of stroke. Recent studies have suggested that circadian rhythms affect stroke and neuroprotection. Therefore, this study revisited the use of fingolimod in mouse focal cerebral ischemia to test the hypothesis that efficacy might depend on whether experiments were performed during the inactive sleep or active wake phases of the circadian cycle.

Methods:

Two different stroke models were implemented in male C57Bl/6 mice—transient middle cerebral artery occlusion and permanent distal middle cerebral artery occlusion. Occlusion occurred either during inactive or active circadian phases. Mice were treated with 1 mg/kg fingolimod at 30- or 60-minute postocclusion and 1 day later for permanent and transient middle cerebral artery occlusion, respectively. Infarct volume, brain swelling, hemorrhagic transformation, and behavioral outcome were assessed at 2 or 3 days poststroke. Three independent experiments were performed in 2 different laboratories.

Results:

Fingolimod decreased peripheral lymphocyte number in naive mice, as expected. However, it did not significantly affect infarct volume, brain swelling, hemorrhagic transformation, or behavioral outcome at 2 or 3 days after transient or permanent focal cerebral ischemia during inactive or active circadian phases of stroke onset.

Conclusions:

Outcomes were not improved by fingolimod in either transient or permanent focal cerebral ischemia during both active and inactive circadian phases. These negative findings suggest that further testing of fingolimod in clinical trials may not be warranted unless translational studies can identify factors associated with fingolimod’s efficacy or lack thereof.

The long-term cardiac events after coronary bifurcation stenting with second-generation drug-eluting stents in elderly patients are comparable to those of younger patients

Background

Elderly patients undergoing percutaneous coronary intervention (PCI) generally have a high risk of adverse clinical outcomes. We investigated the long-term clinical impact of PCI on coronary bifurcation disease in elderly patients in Korea and Italy.

Methods

From the BIFURCAT (comBined Insights from the Unified RAIN and COBIS bifurcAtion regisTries) data, we evaluated 5,537 patients who underwent PCI for coronary bifurcation disease. The primary outcome was major adverse cardiac events (MACEs), defined as the composite of target vessel myocardial infarction, target lesion revascularisation, and stent thrombosis. Kaplan–Meier estimates and Cox proportional hazard models were used to compare elderly patients (aged ≥75 years) and younger patients (aged &lt;75 years).

Results

A total of 1,415 patients (26%) were aged ≥75 years. Elderly patients were more frequently female, had higher rates of hypertension and chronic kidney disease (CKD), and presented more frequently with left main (LM) disease. After a median follow-up of 2.1 years, MACEs were comparable between elderly and younger patients. In multivariable analysis, old age was not an independent predictor of MACEs (p=0.977). In elderly patients, CKD and LM disease were independent predictors of MACEs, whereas in younger patients, hypertension, diabetes, CKD, reduced left ventricular ejection fraction, LM disease, and two-stent strategy usage were independent predictors.

Conclusions

Elderly patients who underwent coronary bifurcation PCI with second-generation drug-eluting stents demonstrated similar clinical outcomes to those of younger patients. Both CKD and LM disease were independent predictors of MACEs, regardless of age after coronary bifurcation PCI.

Funding Acknowledgement

Type of funding sources: None.

Age-related difference in the impact of diabetes mellitus on all-cause mortality after acute myocardial infarction

Background

Diabetes mellitus (DM) is highly prevalent among individuals hospitalized with acute myocardial infarction (AMI) and is associated with increased risk for cardiovascular complications and short-term and long-term mortality. However, most existing data are from older patients. Little is known about the incidence of diabetes in individuals who experience AMI at a young age. Whether the presence of DM is associated with worse outcomes in these patients is not clear.

Purpose

To test the hypothesis that the impact of DM on clinical outcomes after AMI can vary by age.

Methods

A total of 12,600 AMI patients from the Korea Acute Myocardial Infarction Registry-National Institute of Health (KAMIR-NIH) between November 2011 and December 2015 was classified into young (n=3,590 [28.5%]) and elderly (n=9,010 [71.5%]). Those less than 55 years of age were considered young. We performed comparisons of baseline characteristics, in-hospital treatments, and long-term clinical outcomes between patients with and without diabetes after stratification according to age group.

Results

The prevalence of diabetes mellitus was 26.5% in the young AMI group. In the multivariable-adjusted model of the entire cohort, diabetes mellitus was associated strongly with 3-year all-cause mortality (12.6% vs. 6.8%; adjusted hazard ratio [HR], 1.318; 95% confidence interval [CI], 1.138–1.526; P&lt;0.001). When the entire cohort was subdivided into two age groups, young diabetic patients showed a 107.0% higher mortality rate than those without diabetes (adjusted HR, 2.070; 95% CI, 1.150–3.724; P=0.015). Meanwhile, elderly diabetic patients had a 25.3% higher risk of mortality than non-diabetic patients (adjusted HR, 1.253; 95% CI, 1.076–1.459; P=0.004). The interaction of diabetes with age was significant (adjusted P for interaction = 0.008).

Conclusion

DM is not uncommon in younger AMI patients, and the relative risk of long-term mortality is significantly higher in young patients than in older counterparts. More aggressive treatments are needed to prevent future cardiovascular events in younger patients after AMI.

Funding Acknowledgement

Type of funding sources: None.

The differential effects of antihypertensive drugs on central blood pressure: nebivolol versus telmisartan (ATD-CBP)

Background

Central blood pressure and central pulse pressure have a better correlation with the risk of cardiovascular disease compared to those of peripheral measurement. In a previous study, a second-generation beta-blocker showed poor CBP-lowering effects. However, the effect on CBP by third-generation beta-blockers is not fully elucidated. Thus, this randomised study investigated whether nebivolol-based hypertension treatment may confer advantages over telmisartan, an angiotensin II receptor-blocker, in reducing CBP.

Methods

This was a prospective, randomised, multicentre, open-label, controlled trial that evaluated 98 hypertensive patients. Patients received either nebivolol- (N=49) or telmisartan-based (N=49) treatment for hypertension for 12 weeks with a target BP of ≤140/80. The primary outcome was the difference in change from baseline central systolic BP (cSBP) after 12 weeks.

Results

There were no significant differences between the two groups in baseline central and peripheral SBP. The mean change in cSBP from baseline (ΔcSBP) was −17.2±3 mmHg for nebivolol group (P&lt;0.001) and −29.9±3 mmHg for telmisartan group (P&lt;0.001). The difference in ΔcSBP between the two groups was significant (12.7mmHg, 95% confidence interval [CI], 4.13 to 21.2; P=0.004). Peripheral SBP (pSBP) decreased less in nebivolol group compared to telmisartan group (−18.0±3 in nebivolol group vs. −26.3±3 in telmisartan group, P=0.032). After adjusting for reduction in pSBP, reduction in cSBP was higher in telmisartan group compared to nebivolol group, as shown by the ratio of changes in cSBP and pSBP (ΔcSBP/ΔpSBP; 0.67 for nebivolol group vs. 1.11 for telmisartan group, P=0.080), albeit without statistical significance.

Conclusions

Nebivolol-based hypertension treatment may have less potent CBP-lowering effects compared to telmisartan. However, larger-scale studies are warranted to further elaborate our findings.

Funding Acknowledgement

Type of funding sources: None.

Effect of an early invasive strategy based on time of symptom onset in patients with non-ST elevation myocardial infarction

Background

A limitation of the current guidelines of the timing of invasive coronary angiography (ICA) for patients with non-ST-segment elevation (NSTE) acute coronary syndrome is based on randomization time. So far, no study has reported the clinical outcomes of invasive strategy timing based on the time of symptom onset. Herein, we aimed to investigate the effect of invasive strategy timing from the time of symptom onset on the 3-year clinical outcomes of patients with NSTE myocardial infarction (MI).

Methods and results

Among 13,104 patients from the Korea Acute Myocardial Infarction Registry-National Institutes of Health, we evaluated 5,856 patients with NSTEMI. The patients were categorized according to symptom-to-catheter (StC) time (&lt;48 h and ≥48 h). The primary outcome was 3-year all-cause mortality, and the secondary outcome was a 3-year composite of all-cause mortality, recurrent MI, and hospitalization for heart failure. Overall, 3,919 (66.9%) patients were classified into the StC time &lt;48 h group. This group had lower all-cause mortality than the StC time ≥48 h group (7.3% vs. 13.4%, p&lt;0.001). The continuous association of StC time and risk of primary and secondary endpoints showed shorter StC time (reference: 48 h), and lower adjusted hazard ratio reduction was observed. In multivariable analysis, independent predictors of delayed ICA were older age, non-specific symptoms, no use of emergency medical services, no ST-segment deviation, chronic kidney disease, and Global Registry of Acute Coronary Events score &gt;140.

Conclusion

Early invasive strategy based on the StC time improves all-cause mortality in patients with NSTEMI.

Funding Acknowledgement

Type of funding sources: None.

Influence of endothelial function and arterial stiffness on the behavior of cervicocephalic arterial dissections: An observational study

Background

The mechanical and physiological properties of the arterial wall might affect the behavior of spontaneous cervicocephalic arterial dissections (CCAD). We aimed to determine the effects of endothelial function and arterial stiffness on the clinical characteristics and outcomes of CCAD using brachial flow-mediated dilation (FMD) and brachial-ankle pulse wave velocity (PWV).

Methods

From a single-center database, we identified patients admitted from April 2011 to December 2021 with a diagnosis of CCAD who underwent both FMD and PWV. FMD was classified as normal and decreased according to institutional thresholds. PWV was categorized into tertiles. Comparative and multivariable analyses were performed to determine the effects of FMD and PWV values on major clinical outcomes.

Results

A total of 146 patients (age: 47 ± 11 years; men: 77.4%) were included. The main presentation was ischemic stroke in 76.7% of the patients, while 23.3% presented with headache or other symptoms. Healing of the dissection was observed in 55.8%. In multivariable analysis, Normal FMD levels (vs. decreased; adjusted OR: 4.52, 95% CI [1.95 −10.52]) were associated with spontaneous healing of the dissection. Highest PWV tertile (vs. lowest; adjusted OR: 17.05, 95% CI [3.07–94.82]) was associated with ischemic presentation. There was a higher ischemic stroke recurrence in the 3rd PWV tertile, and more frequent aneurysmal enlargement in the lowest PWV tertile, but their frequency was low, precluding multivariable analysis.

Conclusion

In spontaneous CCAD, preserved endothelial function was associated with spontaneous arterial healing. Arterial stiffness is associated with ischemic presentation.

Prediction of Mortality after Burn Surgery in Critically Ill Burn Patients Using Machine Learning Models

Severe burns may lead to a series of pathophysiological processes that result in death. Machine learning models that demonstrate prognostic performance can be used to build analytical models to predict postoperative mortality. This study aimed to identify machine learning models with the best diagnostic performance for predicting mortality in critically ill burn patients after burn surgery, and then compare them. Clinically important features for predicting mortality in patients after burn surgery were selected using a random forest (RF) regressor. The area under the receiver operating characteristic curve (AUC) and classifier accuracy were evaluated to compare the predictive accuracy of different machine learning algorithms, including RF, adaptive boosting, decision tree, linear support vector machine, and logistic regression. A total of 731 patients met the inclusion and exclusion criteria. The 90-day mortality of the critically ill burn patients after burn surgery was 27.1% (198/731). RF showed the highest AUC (0.922, 95% confidence interval = 0.902–0.942) among the models, with sensitivity and specificity of 66.2% and 93.8%, respectively. The most significant predictors for mortality after burn surgery as per machine learning models were total body surface area burned, red cell distribution width, and age. The RF algorithm showed the best performance for predicting mortality.

Glucocorticoids inhibit the maturation of committed osteoblasts via SOX2

During bone formation, mesenchymal progenitor cells mature into bone-forming osteoblasts after undergoing several stages of differentiation. Impaired bone formation is a predominant finding in glucocorticoid (GC)-induced osteoporosis (GIO). Osteoblasts at different stages of maturation can be affected by excessive endogenous or therapeutic GCs. Sex-determining region Y-box 2 (SOX2) is normally expressed in immature osteoblasts, but its overexpression can suppress osteoblast differentiation. This study aimed to evaluate whether GC affects SOX2 expression in osteoblasts, and whether SOX2 contributes to GC-induced inhibition of osteoblast differentiation. Treatment with GCs such as dexamethasone (Dex) or hydrocortisone enhanced SOX2 expression. Silencing SOX2 improved inhibition of GC-induced osteoblast differentiation, whereas SOX2 overexpression decreased mineralized nodule formation and RUNX2 and Osterix expression in MC3T3-E1 cells. On the contrary, when C3H10T1/2 uncommitted mesenchymal stem cells were subjected to SOX2 overexpression, RUNX2 expression increased. As a mechanism of Dex-induced SOX2 upregulation in preosteoblasts, we found that the STAT3 pathway or GC receptor (GR) is involved, using a GR antagonist, STAT3 regulators, and chromatin immunoprecipitation assays. Moreover, mice treated with Dex for 4 weeks showed a notable increase in SOX2 expression in the bones and an increased ratio of procollagen type 1 N-terminal propeptide to osteocalcin in the plasma than in control mice. This study demonstrated that GC enhances SOX2 expression in vitro in osteoblast and in vivo in the mice bone, which affects bone-forming activity differently depending on the differentiation stage of osteoblast-lineage cells. Our results provide new insights into prevention and treatment against impaired bone formation in GIO.

Taxonomic study of Collybiopsis (Omphalotaceae, Agaricales) in the Republic of Korea with seven new species

Collybiopsis is a genus of the gymnopoid/marasmioid complex of the family Omphalotaceae. The classification system of Collybiopsis has recently undergone large changes through molecular approaches. The new classification system has not been applied for Collybiopsis in the Republic of Korea, and general research on this genus was also lacking. In this study, we analyzed the Collybiopsis species in the Republic of Korea by assessing all gymnopoid/marasmioid specimens collected nationwide for ten years by combining morphological approaches and multilocus (ITS + nrLSU) phylogenetic analysis. We thus confirmed that 16 species of Collybiopsis are present in the Republic of Korea, including two previously unreported species (Co.nonnulla and Co.dichroa) and seven new species (Co.albicantipessp. nov., Co.clavicystidiatasp. nov., Co.fulvasp. nov., Co.orientisubnudasp. nov., Co.subumbilicatasp. nov., Co.undulatasp. nov., and Co.vellereasp. nov.). A thorough examination of the Collybiopsis suggested that it is difficult to distinguish or identify the species based on morphological characteristics only; a combined molecular approach is needed for accurate identification. The Collybiopsis database of the Republic of Korea is updated, and information on the new species is provided. Five new combinations from Marasmiellus to Collybiopsis are also proposed (Co.istanbulensiscomb. nov., Co.koreanacomb. nov., Co.omphalodescomb. nov., Co.pseudomphalodescomb. nov., and Co.ramuliciolacomb. nov.).

Influence of cerebral microbleeds on mechanical thrombectomy outcomes

In ischemic stroke patients undergoing endovascular treatment (EVT), we aimed to test the hypothesis that cerebral microbleeds (CMBs) are associated with clinical outcomes, while estimating the mediating effects of hemorrhagic transformation (HT), small-vessel disease burden (white matter hyperintensities, WMH), and procedural success. From a multicenter EVT registry, patients who underwent pretreatment MR imaging were analyzed. They were trichotomized according to presence of CMBs (none vs. 1–4 vs. ≥ 5). The association between CMB burden and 3-month mRS was evaluated using multivariable ordinal logistic regression, and mediation analyses were conducted to estimate percent mediation. Of 577 patients, CMBs were present in 91 (15.8%); 67 (11.6%) had 1–4 CMBs, and 24 (4.2%) had ≥ 5. Increases in CMBs were associated with hemorrhagic complications (β = 0.27 [0.06–0.047], p = 0.010) in multivariable analysis. The CMB effect on outcome was partially mediated by post-procedural HT degree (percent mediation, 14% [0–42]), WMH (23% [7–57]) and lower rates of successful reperfusion (6% [0–25]). In conclusion, the influence of CMBs on clinical outcomes is mediated by small-vessel disease burden, post-procedural HT, and lower reperfusion rates, listed in order of percent mediation size.

Red cell distribution width/albumin ratio and 90-day mortality after burn surgery

Background

Red cell distribution width (RDW) and serum albumin concentration are associated with postoperative outcomes. However, the usefulness of the RDW/albumin ratio in burn surgery remains unclear. Therefore, we evaluated the association between RDW/albumin ratio and 90-day mortality after burn surgery.

Methods

Between 2013 and 2020, a retrospective review of patients in a burn intensive care unit (ICU) was performed. Receiver operating characteristic curve, multivariate Cox logistic regression, multivariate logistic regression and Kaplan–Meier analyses were conducted to evaluate the association between RDW/albumin ratio and 90-day mortality after burn surgery. Additionally, prolonged ICU stay rate (>60 days) and ICU stay were assessed.

Results

Ninety-day mortality was 22.5% (210/934) in burn patients. Risk factors for 90-day mortality were RDW/albumin ratio at postoperative day 1, age, American Society of Anesthesiologists physical status, diabetes mellitus, inhalation injury, total body surface area burned, hypotensive event and red blood cell transfusion volume. The area under the curve of the RDW/albumin ratio at postoperative day 1 to predict 90-day mortality, after adjusting for age and total body surface area burned, was 0.875 (cut-off value, 6.8). The 90-day mortality was significantly higher in patients with RDW/albumin ratio >6.8 than in those with RDW/albumin ratio ≤6.8 (49.2% vs 12.3%, p < 0.001). Prolonged ICU stay rate and ICU stay were significantly higher and longer in patients with RDW/albumin ratio >6.8 than in those with RDW/albumin ratio ≤6.8 (34.5% vs 26.5%; 21 [11–38] vs 18 [7–32] days).

Conclusion

RDW/albumin ratio >6.8 on postoperative day 1 was associated with higher 90-day mortality, higher prolonged ICU stay rate and longer ICU stay after burn surgery.

Sex and Gender Differences in Overlap Syndrome of Functional Gastrointestinal Disorder and Effect of Genetic Polymorphisms in South Korea: A Long-term Follow-up Study

BACKGROUND/AIMS

Overlap functional gastrointestinal disorder (FGID) is associated with more severe gastrointestinal symptoms and lower quality of life. The aim of this study is to evaluate clinical features of non-erosive reflux disease (NERD), functional dyspepsia, irritable bowel syndrome, their overlap in terms of sex and gender, and to assess the risk factors, including genetic polymorphisms.

METHODS

A total of 494 FGIDs and 239 controls were prospectively enrolled between 2004 and 2020. FGIDs were diagnosed based on the Rome III criteria and symptoms were evaluated using a questionnaire. Follow-up questionnaires were conducted to determine the change of symptoms during the 75.8-month mean observation period. Risk factors including genetic polymorphisms in neurotransmitter receptor (SLC6A4 5-HTTLPR, GNB3, ADRA2A, CCKAR, and TRPV1) and cytokine (TNFA and IL10) genes.

RESULTS

NERD was more prevalent in men, and functional dyspepsia in women. Overlap FGIDs (n = 239) were more prevalent than nonoverlap FGIDs (n = 255) in women (P = 0.019). Anxiety and depression scores were higher in the overlaps (P = 0.012 and P < 0.001, respectively). Symptoms were more frequent and severe in the overlap FGIDs than in the non-overlaps (P < 0.001). During followup, symptoms progressed more frequently in the overlap FGIDs, especially in patients with the L/S genotype of SLC6A4 5-HTTLPR and anxiety/depression.

CONCLUSIONS

Overlap FGID patients need attention given their association with anxiety/depression and more severe symptoms, especially in women. Genetic polymorphisms also may be associated with certain symptoms of overlap FGIDs.

Sex and Gender Differences in Overlap Syndrome of Functional Gastrointestinal Disorder and Effect of Genetic Polymorphisms in South Korea: A Long-term Follow-up Study

Background/Aims

Overlap functional gastrointestinal disorder (FGID) is associated with more severe gastrointestinal symptoms and lower quality of life. The aim of this study is to evaluate clinical features of non-erosive reflux disease (NERD), functional dyspepsia, irritable bowel syndrome, their overlap in terms of sex and gender, and to assess the risk factors, including genetic polymorphisms.

Methods

A total of 494 FGIDs and 239 controls were prospectively enrolled between 2004 and 2020. FGIDs were diagnosed based on the Rome III criteria and symptoms were evaluated using a questionnaire. Follow-up questionnaires were conducted to determine the change of symptoms during the 75.8-month mean observation period. Risk factors including genetic polymorphisms in neurotransmitter receptor (SLC6A4 5-HTTLPR, GNB3, ADRA2A, CCKAR, and TRPV1) and cytokine (TNFA and IL10) genes.

Results

NERD was more prevalent in men, and functional dyspepsia in women. Overlap FGIDs (n = 239) were more prevalent than non-overlap FGIDs (n = 255) in women (P = 0.019). Anxiety and depression scores were higher in the overlaps (P = 0.012 and P < 0.001, respectively). Symptoms were more frequent and severe in the overlap FGIDs than in the non-overlaps (P < 0.001). During follow-up, symptoms progressed more frequently in the overlap FGIDs, especially in patients with the L/S genotype of SLC6A4 5-HTTLPR and anxiety/depression.

Conclusions

Overlap FGID patients need attention given their association with anxiety/depression and more severe symptoms, especially in women. Genetic polymorphisms also may be associated with certain symptoms of overlap FGIDs.

Pulmonary nodular lymphoid hyperplasia presenting as multifocal subsolid nodules: A case report and literature review

Pulmonary nodular lymphoid hyperplasia (PNLH) is a rare, benign lymphoproliferative disease, which is characterized by nonclonal lymphoproliferation. PNLH is usually asymptomatic and usually detected incidentally on imaging studies. Common imaging findings include a solitary nodule, multiple nodules, or focal consolidation. Atypically, PNLH may present with persistent subsolid nodules, mimicking adenocarcinoma. Here, we report a rare case of PNLH presenting as multifocal subsolid nodules in both lower lobes. During follow-up, persistency and growth of the subsolid nodules suggested the possibility of malignancy. Wedge resection was performed bilaterally, and PNLH was confirmed on pathological examination.

Aberrant DNA Methylation Maker for Predicting Metachronous Recurrence After Endoscopic Resection of Gastric Neoplasms

Purpose

To investigate whether MOS methylation can be useful for the prediction of metachronous recurrence after endoscopic resection of gastric neoplasms.

Materials and Methods

From 2012 to 2017, 294 patients were prospectively enrolled after endoscopic resection of gastric dysplasia (n=171) or early gastric cancer (n=123). When H. pylori was positive, eradication therapy was performed. Among them, 124 patients completed the study protocol (follow-up duration > 3 years or development of metachronous recurrence during the follow-up.) Methylation levels of MOS were measured at baseline using quantitative MethyLight assay from the antrum.

Results

Median follow-up duration was 49.9 months. MOS methylation levels at baseline were not different by age, sex, and current H. pylori infection, but they showed a weak correlation with operative link on gastritis assessment (OLGA) or operative link on gastric intestinal metaplasia assessment (OLGIM) stages (Spearman's ρ = 0.240 and 0.174, respectively, p < 0.05). During the follow-up, a total of 20 metachronous gastric neoplasms (13 adenomas and 7 adenocarcinomas) were developed. Either OLGA or OLGIM stage was not useful in predicting the risk for metachronous recurrence. In contrast, MOS methylation high group (≥ 34.82 %) had a significantly increased risk for metachronous recurrence compared to MOS methylation low group (adjusted hazard ratio [95% confidence interval]. 4.76 [1.54,14.79], p=0.007).

Conclusion

MOS methylation can be a promising marker for predicting metachronous recurrence after endoscopic resection of gastric neoplasms. To confirm the usefulness of MOS methylation, validation studies are warranted in the future. (ClinicalTrials No.: NCT04830618).

Usefulness of Silent MRA for Evaluation of Aneurysm after Stent-Assisted Coil Embolization

OBJECTIVE

To determine the usefulness of Silent MR angiography (MRA) for evaluating intracranial aneurysms treated with stent-assisted coil embolization.

MATERIALS AND METHODS

Ninety-nine patients (101 aneurysms) treated with stent-assisted coil embolization (Neuroform atlas, 71 cases; Enterprise, 17; LVIS Jr, 9; and Solitaire AB, 4 cases) underwent time-of-flight (TOF) MRA and Silent MRA in the same session using a 3T MRI system within 24 hours of embolization. Two radiologists independently interpreted both MRA images retrospectively and rated the image quality using a 5-point Likert scale. The image quality and diagnostic accuracy of the two modalities in the detection of aneurysm occlusion were further compared based on the stent design and the site of aneurysm.

RESULTS

The average image quality scores of the Silent MRA and TOF MRA were 4.38 ± 0.83 and 2.78 ± 1.04, respectively (p < 0.001), with an almost perfect interobserver agreement. Silent MRA had a significantly higher image quality score than TOF MRA at the distal internal carotid artery (n = 57, 4.25 ± 0.91 vs. 3.05 ± 1.16, p < 0.001), middle cerebral artery (n = 21, 4.57 ± 0.75 vs. 2.19 ± 0.68, p < 0.001), anterior cerebral artery (n = 13, 4.54 ± 0.66 vs. 2.46 ± 0.66, p < 0.001), and posterior circulation artery (n = 10, 4.50 ± 0.71 vs. 2.90 ± 0.74, p = 0.013). Silent MRA had superior image quality score to TOF MRA in the stented arteries when using Neuroform atlas (4.66 ± 0.53 vs. 3.21 ± 0.84, p < 0.001), Enterprise (3.29 ± 1.59 vs. 1.59 ± 0.51, p = 0.003), LVIS Jr (4.33 ± 1.89 vs. 1.89 ± 0.78, p = 0.033), and Solitaire AB stents (4.00 ± 2.25 vs. 2.25 ± 0.96, p = 0.356). The interpretation of the status of aneurysm occlusion exhibited significantly higher sensitivity with Silent MRA than with TOF MRA when using the Neuroform Atlas stent (96.4% vs. 14.3%, respectively, p < 0.001) and LVIS Jr stent (100% vs. 20%, respectively, p = 0.046).

CONCLUSION

Silent MRA can be useful to evaluate aneurysms treated with stent-assisted coil embolization, regardless of the aneurysm location and type of stent used.