Abstract 5056: Exercise and inflammation on the risk of cancer

Introduction: High systemic inflammation and low levels of exercise are associated with increased risk of cancer. We hypothesized that in the setting of inflammation, exercise mitigates cancer risk.

Methods: To address this, we identified 6,388 participants, free of cancer and cardiovascular disease, enrolled in the Multi-Ethnic Study of Atherosclerosis. Regular moderate/vigorous intentional exercise was categorized as present or absent based on self-report from validated questions. A composite inflammatory score was created with a point given for C-reactive protein, IL-6, fibrinogen, and GlycA above normal, with composite scores > 2 points categorized as high. Cancer incidence was ascertained based on ICD codes abstracted from hospitalization or cancer registry data. Cox proportional hazard models were used to calculate subsequent risk of incident cancer. Models were adjusted for baseline age, gender, race, pack years smoking, education, income, health insurance status, body mass index, high-density lipoprotein levels, healthy diet adherence, statin and aspirin use.

Results: The mean age was 62 years (±10.2 years), 53% female, 39% white, 26% black, 22% Hispanic, and 12% Chinese-American. Compared to the reference group (individuals reporting no exercise and with low levels of inflammation), in multi-variable adjusted models, individuals with high levels of inflammation and no exercise were at highest risk of cancer (hazard ratio = 1.17; 95% confidence interval 1.00 – 1.37), while those with low levels of inflammation who exercised were at the lowest risk of cancer (HR 0.80, 95% CI 0.68-0.95). Those who had high levels of inflammation, but regular exercise had no increased risk of cancer (HR 0.94, 95% CI 0.68-1.30). There was no significant interaction between exercise and inflammation. When considering individual inflammatory markers, there was a similar pattern (Table).

Conclusion: Intentional moderate/vigorous exercise may lower the risk of cancer in individuals with high versus low levels of chronic inflammation.

Cox proportional hazard models for incident cancer by exercise and measures of inflammation, adjusteno exerciseany exerciseHR95% CIHR95% CILow composite score (0 - 1)Ref0.800.680.95High composite score (>2)1.171.001.370.940.681.30P for interaction = 0.25Low CRP (<2 mg/L)Ref0.800.680.95High CRP (>2 mg/L)1.231.051.430.980.711.35P for interaction = 0.94Low IL-6 (< 1.8 pg/mL)Ref0.800.680.95High IL-6 (>1.8 pg/mL)1.070.911.260.860.621.19P for interaction = 0.18Low GlycA (<400 µmol/L)Ref0.800.680.95High GlycA (>400 µmol/L)1.191.021.390.960.691.32P for interaction = 0.73Low fibrinogen (<450 mg/dL)Ref0.800.680.95High fibrinogen (>450 mg/dL)0.970.751.250.770.511.18P for interaction = 1.00

Citation Format: Catherine Handy Marshall, Zeina Dardari, Miguel Cainzos-Achirica, Martin B. Mortensen, Khurram Nasir, Mouaz H. Al-Mallah, Michael D. Miedema, Ron Blankstein, Roger S. Blumenthal, Kala Visvanathan, Michael J. Blaha. Exercise and inflammation on the risk of cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 5056.

Multicentre study of multidisciplinary team assessment of pancreatic cancer resectability and treatment allocation

BACKGROUND

Multidisciplinary team (MDT) meetings have been adopted widely to ensure optimal treatment for patients with cancer. Agreements in tumour staging, resectability assessments and treatment allocation between different MDTs were assessed.

METHODS

Of all patients referred to one hospital, 19 patients considered to have non-metastatic pancreatic cancer for evaluation were selected randomly for a multicentre study of MDT decisions in seven units across Northern Europe. Anonymized clinical information and radiological images were disseminated to the MDTs. All patients were reviewed by the MDTs for radiological T, N and M category, resectability assessment and treatment allocation. Each MDT was blinded to the decisions of other teams. Agreements were expressed as raw percentages and Krippendorff's α values, both with 95 per cent confidence intervals.

RESULTS

A total of 132 evaluations in 19 patients were carried out by the seven MDTs (1 evaluation was excluded owing to technical problems). The level of agreement for T, N and M categories ranged from moderate to near perfect (46·8, 61·1 and 82·8 per cent respectively), but there was substantial variation in assessment of resectability; seven patients were considered to be resectable by one MDT but unresectable by another. The MDTs all agreed on either a curative or palliative strategy in less than half of the patients (9 of 19). Only fair agreement in treatment allocation was observed (Krippendorff's α 0·31, 95 per cent c.i. 0·16 to 0·45). There was a high level of agreement in treatment allocation where resectability assessments were concordant.

CONCLUSION

Considerable disparities in MDT evaluations of patients with pancreatic cancer exist, including substantial variation in resectability assessments.

Severe peritoneal sclerosis after repeated pressurized intraperitoneal aerosol chemotherapy with oxaliplatin (PIPAC OX): report of two cases and literature survey

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a new laparoscopic administration of chemotherapy for peritoneal metastasis (PM). PIPAC is repeated every 5th week, and seems to stabilize or improve quality of life, and might improve survival. So far, PIPAC has been well tolerated. With this paper, we aim to highlight a potential severe adverse reaction, as we describe the first cases of severe peritoneal sclerosis (SPS) caused by PIPAC. Patients with isolated PM were included in a prospective PIPAC protocol. Following insufflation of normothermic CO₂, laparoscopy was performed at an intraabdominal pressure of 12 mmHg. After peritoneal lavage and quadrant biopsies of the PM, the patients were treated with oxaliplatin 92 mg/m² (flowrate 0.5 ml/s, maximum pressure of 200 per square inch). Treatment related toxicity was evaluated after 2 weeks. Response was evaluated histologically by the Peritoneal Regression Grading Score (PRGS) and cytologically by analysis of the lavage fluid. In a series of 24 PIPAC patients treated with oxaliplatin, two patients developed SPS. Patient one had a mucinous adenocarcinoma of the appendix with PM, the mean PRGS was reduced from 2.75 to 1.75 during the course of therapy. Patient two had an appendiceal goblet cell carcinoid with a dominating mucinous adenocarcinoma component with PM, the mean PRGS was reduced from 2.00 to 1.67. Repeated applications of PIPAC with oxaliplatin can lead to SPS.

Kringle IV Type 2, Not Low Lipoprotein(a), as a Cause of Diabetes: A Novel Genetic Approach Using SNPs Associated Selectively with Lipoprotein(a) Concentrations or with Kringle IV Type 2 Repeats

BACKGROUND

Low plasma lipoprotein(a) concentrations are associated with type 2 diabetes. Whether this is due to low lipoprotein(a) concentrations per se or to a large number of kringle IV type 2 (KIV-2) repeats remains unclear. We therefore aimed to identify genetic variants associated selectively with lipoprotein(a) concentrations or with the number of KIV-2 repeats, to investigate which of these traits confer risk of diabetes.

METHODS

We genotyped 8411 individuals from the Copenhagen City Heart Study for 778 single-nucleotide polymorphisms (SNPs) in the proximity of the LPA gene, and examined the association of these SNPs with plasma concentrations of lipoprotein(a) and with KIV-2 number of repeats. SNPs that were selectively associated with lipoprotein(a) concentrations but not with KIV-2 number of repeats, or vice versa, were included in a Mendelian randomization study.

RESULTS

We identified 3 SNPs (rs12209517, rs12194138, and rs641990) that were associated selectively with lipoprotein(a) concentrations and 3 SNPs (rs1084651, rs9458009, and rs9365166) that were associated selectively with KIV-2 number of repeats. For SNPs selectively associated with lipoprotein(a) concentrations, an allele score of 4-6 vs 0-2 had an odds ratio for type 2 diabetes of 1.03 (95% CI, 0.86-1.23). In contrast, for SNPs selectively associated with KIV-2 number of repeats, an allele score of 4-6 vs 0-2 had an odds ratio for type 2 diabetes of 1.42 (95% CI, 1.17-1.69).

CONCLUSIONS

Using a novel genetic approach, our results indicate that it is a high number of KIV-2 repeats that are associated causally with increased risk of type 2 diabetes, and not low lipoprotein(a) concentrations per se. This is a reassuring finding for lipoprotein(a)-lowering therapies that do not increase the KIV-2 number of repeats.

Randomized clinical trial of laparoscopic ultrasonography before laparoscopic colorectal cancer resection

BACKGROUND

Intraoperative ultrasonography during open surgery for colorectal cancer may be useful for the detection of unrecognized liver metastases. Laparoscopic ultrasonography (LUS) for the detection of unrecognized liver metastasis has not been studied in a randomized trial. This RCT tested the hypothesis that LUS would change the TNM stage and treatment strategy.

METHODS

Patients with colorectal cancer and no known metastases were randomized (1 : 1) to laparoscopic examination (control or laparoscopy plus LUS) in three Danish centres. Neither participants nor staff were blinded to the group assignment.

RESULTS

Three hundred patients were randomized, 150 in each group. After randomization, 43 patients were excluded, leaving 128 in the control group and 129 in the LUS group. Intraoperative T and N categories were not altered by LUS, but laparoscopy alone identified previously undetected M1 disease in one patient (0·8 per cent) in the control group and three (2·3 per cent) in the LUS group. In the latter group, LUS suggested that an additional six patients (4·7 per cent) had M1 disease with liver (4) or para-aortal lymph node (2) metastases. The change in treatment strategy was greater in the LUS than in the control group (7·8 (95 per cent c.i. 3·8 to 13·8) and 0·8 (0 to 4·2) per cent respectively; P = 0·010), but the suspected M1 disease was benign in half of the patients.

CONCLUSION

Routine LUS during resection of colorectal cancer is not recommended. Registration number: NCT02079389 (http://www.clinicaltrials.gov).

Primary Prevention With Statins: ACC/AHA Risk-Based Approach Versus Trial-Based Approaches to Guide Statin Therapy

BACKGROUND

Guidelines recommend initiating primary prevention for atherosclerotic cardiovascular disease (ASCVD) with statins based on absolute ASCVD risk assessment. Recently, alternative trial-based and hybrid approaches were suggested for statin treatment eligibility.

OBJECTIVES

This study compared these approaches in a direct head-to-head fashion in a contemporary population.

METHODS

The study used the CGPS (Copenhagen General Population Study) with 37,892 subjects aged 40 to 75 years recruited in 2003 to 2008, all free of ASCVD, diabetes, and statin use at baseline.

RESULTS

Among the population studied, 42% were eligible for statin therapy according to the 2013 American College of Cardiology/American Heart Association (ACC/AHA) risk assessment and cholesterol treatment guidelines approach, versus 56% with the trial-based approach and 21% with the hybrid approach. Among these statin-eligible subjects, the ASCVD event rate per 1,000 person-years was 9.8, 6.8, and 11.2, respectively. The ACC/AHA-recommended absolute risk score was well calibrated around the 7.5% 10-year ASCVD risk treatment threshold and discriminated better than the trial-based or hybrid approaches. Compared with the ACC/AHA risk-based approach, the net reclassification index for eligibility for statin therapy among 40- to 75-year-old subjects from the CGPS was -0.21 for the trial-based approach and -0.13 for the hybrid approach.

CONCLUSIONS

The clinical performance of the ACC/AHA risk-based approach for primary prevention of ASCVD with statins was superior to the trial-based and hybrid approaches. Our results indicate that the ACC/AHA guidelines will prevent more ASCVD events than the trial-based and hybrid approaches, while treating fewer people compared with the trial-based approach.

Abstract P2-12-06: Prevention of seroma formation after mastectomy by local methylprednisolone injection - A randomized controlled clinical trial

Objective: To investigate the effect of local steroid administration on seroma formation until 14 days of dryness.

Background: Seroma formation, the most prevalent postoperative complication after mastectomy, is an inflammatory process that is potentially preventable via local steroid administration.

Methods: This double-blind, randomized, placebo-controlled intervention study included 212 women who were scheduled for mastectomy for primary breast cancer. The patients were classified according to the surgical axillary procedure: mastectomy with sentinel lymph node biopsy (M+SLNB) or mastectomy with level I-II axillary lymph node dissection (M+ALND). The participants received either 80 mg of methylprednisolone or saline intracavitary via the drain orifice upon drain removal.

Results: After M+SLNB, 46% (32 of 69) of the patients developed seromas in the steroid group vs. 78% (52 of 67) in the saline group (p<0.0001). The mean cumulative seroma volume in the intention-to-treat material for the first 10 and 30 days was significantly lower in the steroid group than in the saline group (24 vs.127 mL and 177 vs. 328 mL, respectively) (p<0.0001). After M+ALND, 94% of the patients developed seromas in both the steroid (35 of 37) and saline (34 of 36) groups, and steroid administration displayed no significant effect on seroma formation. Additionally, no difference in the infection rate was observed.

Conclusion: Methylprednisolone administered intracavitary on the first postoperative day after M+SLNB exerted a highly significant preventive effect against seroma formation during the first 30 days. Future studies may clarify whether higher or repeated steroid doses enhance these effects.

Citation Format: Qvamme G, Axelsson CK, Lanng C, Wegeberg B, Mortensen MB, Okholm M, Arpi MR, Szecsi PB. Prevention of seroma formation after mastectomy by local methylprednisolone injection - A randomized controlled clinical trial. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-12-06.

Diabetes with poor glycaemic control does not promote atherosclerosis in genetically modified hypercholesterolaemic minipigs

AIMS/HYPOTHESIS

Diabetes is associated with an increased risk of atherosclerotic cardiovascular disease, but whether there is a direct and independent role for impaired glucose control in atherogenesis remains uncertain. We investigated whether diabetes with poor glycaemic control would accelerate atherogenesis in a novel pig model of atherosclerosis, the D374Y-PCSK9(+) transgenic minipig.

METHODS

Nineteen minipigs were fed a cholesterol-enriched, high-fat diet; ten of these pigs were injected with streptozotocin to generate a model of diabetes. Restricted feeding was implemented to control the pigs' weight gain and cholesterol intake. After 49 weeks of high-fat feeding, the major arteries were harvested for a detailed analysis of the plaque burden and histological plaque type.

RESULTS

Stable hyperglycaemia was achieved in the diabetic minipigs, while the plasma total and LDL-cholesterol and creatinine levels were unaffected. Diabetes failed to increase atherosclerosis in any of the vessels examined. The plaque burden in the aorta and right coronary artery was comparable between the groups, and was even reduced in the left anterior descending (LAD) coronary and iliofemoral arteries in the diabetic pigs compared with the controls. The distribution of plaque types and the collagen and macrophage contents were similar between the groups, except for a reduced infiltration of macrophages in the LAD arteries of the diabetic pigs.

CONCLUSIONS/INTERPRETATION

Poorly controlled diabetes with no alterations in plasma cholesterol or creatinine concentrations did not augment the plaque burden or promote the development of more advanced lesions in this large-animal model of human-like atherosclerosis. This is consistent with clinical studies in patients with type 1 diabetes, indicating that hyperglycaemia per se is not an independent promoter of atherosclerotic disease, but that other diabetes-associated risk factors are important.

The high-density lipoprotein-adjusted SCORE model worsens SCORE-based risk classification in a contemporary population of 30,824 Europeans: the Copenhagen General Population Study

Aims

Recent European guidelines recommend to include high-density lipoprotein (HDL) cholesterol in risk assessment for primary prevention of cardiovascular disease (CVD), using a SCORE-based risk model (SCORE-HDL). We compared the predictive performance of SCORE-HDL with SCORE in an independent, contemporary, ‘low-risk’ European population, focusing on ability to identify those in need of intensified CVD prevention.

Methods and results

Between 2003 and 2008, 46 092 individuals without CVD, diabetes, or statin use were enrolled in the Copenhagen General Population Study (CGPS). During a mean of 6.8 years of follow-up, 339 individuals died of CVD. In the SCORE target population (age 40–65; n = 30 824), fewer individuals were at baseline categorized as high risk (≥5% 10-year risk of fatal CVD) using SCORE-HDL compared with SCORE (10 vs. 17% in men, 1 vs. 3% in women). SCORE-HDL did not improve discrimination of future fatal CVD, compared with SCORE, but decreased the detection rate (sensitivity) of the 5% high-risk threshold from 42 to 26%, yielding a negative net reclassification index (NRI) of −12%. Importantly, using SCORE-HDL, the sensitivity was zero among women. Both SCORE and SCORE-HDL overestimated risk of fatal CVD. In well-calibrated models developed from the CGPS, HDL did not improve discrimination or NRI. Lowering the decision threshold from 5 to 1% led to progressive gain in NRI for both CVD mortality and morbidity.

Conclusion

SCORE-HDL did not improve discrimination compared with SCORE, but deteriorated risk classification based on NRI. Future guidelines should consider lower decision thresholds and prioritize CVD morbidity and people above age 65.

Abstract 591: Increased Retention of LDL From Type 1 Diabetic Patients in an Atherosclerosis-prone Area of the Murine Arterial Wall

Background: Individuals with type 1 diabetes mellitus (T1DM) are at high risk of developing atherosclerotic cardiovascular disease but the exact mechanisms by which T1DM accelerates atherosclerosis remain unknown. In the present study, we investigated whether modifications of low density lipoprotein (LDL) in T1DM patients causes an increased retention of LDL in the vessel wall.

Methods and Results: Fluorescently-labeled human LDL from either T1DM patients (n=10) or healthy non-diabetic subjects (control) (n=7) was injected into mice with T1DM. After 24 hours, when LDL was completely cleared from the circulation, cryosections of the inner curvature of the aortic arch (i.e. atherosclerosis prone area) was analyzed for retained LDL by fluorescence microscopy (Red in figure A). We found significantly more retained T1DM LDL (n=10) compared to LDL from non-diabetic subjects (n=7) with a fold change of 4.35 (p < 0.05). Nuclear magnetic resonance (NMR) spectroscopy analysis of LDL revealed no differences in the level of the atherogenic small dense LDL between T1DM LDL (274.4±47.8 nmol/L) and non-diabetic LDL (263.8±55.3 nmol/L). Using LiCor Odyssey infrared imaging scanning of the whole aorta en face, we found that in vitro glycation of LDL from a non-diabetic subject significantly increased retention (n=8) compared to LDL prepared similarly but without glucose (n=8), with a fold change of 8.87 (p < 0.001) (Figure B).

Conclusion: LDL from patients with T1DM as well as ex vivo glycated LDL showed increased retention at atherosclerosis-prone sites in the arterial wall of mice. This may contribute to the accelerated development of atherosclerosis in T1DM.

The incidence and prognosis of true duodenal carcinomas

INTRODUCTION

Primary duodenal carcinoma (PDC) is a rare gastrointestinal tumor. The difficult distinction between PDC and other types of carcinoma (e.g. within the periampullary region) is reflected in the scarce literature on true duodenal carcinomas. However, this distinction may be important in relation to the overall prognosis as well as in the choice of adjuvant or palliative treatment strategies. The aim of this study was to evaluate the incidence, management and prognosis of patients with true PDC within a well-defined geographical area.

METHODS

Retrospective analysis of all patients diagnosed with true PDC from 1997 to 2012 within the Region of Southern Denmark. Only patients where the surgeon and the pathologist agreed on the tumor being classified as originating from the duodenum were included.

RESULTS

Seventy-one patients (43 M, 28 F) with a mean age of 67 years (range 35-87) met the criteria for true PDC. The incidence was 5.4 per 1,000,000, and the pathological classification was: Adenocarcinoma 87%, mucinous adenocarcinoma 7%, carcinoma 4% and signet ring cell carcinoma 1%. Intended curative resection was performed in 28 patients (39%) (22 Whipple procedures and 6 local resections), and all but one patient had negative resection margins. Thirteen patients (46%) had lymph node metastasis. Twenty-nine (67%) of the palliative treated patients had a single (n = 24) or double by-pass procedure (n = 5). The median and 5-year survival for the resected patients were 23 months (CI 7-44) and 27% (CI 10-44). The median survival in the palliative group was 5 months (CI 2-11), and none of the patients were alive after three years.

CONCLUSION

The incidence of true PDC within a geographical and histopathologically completely monitored area was 5.4 per 1,000,000. Less than 40% of the patients could be resected and they had a median survival of 23 month and an estimated 5-year survival of 27%. The prognosis of true PDC seemed lower than expected according to previously published data.

Targeting sortilin in immune cells reduces proinflammatory cytokines and atherosclerosis

Genome-wide association studies have identified a link between genetic variation at the human chromosomal locus 1p13.3 and coronary artery disease. The gene encoding sortilin (SORT1) has been implicated as the causative gene within the locus, as sortilin regulates hepatic lipoprotein metabolism. Here we demonstrated that sortilin also directly affects atherogenesis, independent of its regulatory role in lipoprotein metabolism. In a mouse model of atherosclerosis, deletion of Sort1 did not alter plasma cholesterol levels, but reduced the development of both early and late atherosclerotic lesions. We determined that sortilin is a high-affinity receptor for the proinflammatory cytokines IL-6 and IFN-γ. Moreover, macrophages and Th1 cells (both of which mediate atherosclerotic plaque formation) lacking sortilin had reduced secretion of IL-6 and IFN-γ, but not of other measured cytokines. Transfer of sortilin-deficient BM into irradiated atherosclerotic mice reduced atherosclerosis and systemic markers of inflammation. Together, these data demonstrate that sortilin influences cytokine secretion and that targeting sortilin in immune cells attenuates inflammation and reduces atherosclerosis.

Real-life evaluation of European and American high-risk strategies for primary prevention of cardiovascular disease in patients with first myocardial infarction

OBJECTIVE

To determine the detection rate (sensitivity) of the high-risk strategy recommended in the European Society of Cardiology (ESC) and National Institute for Health and Care Excellence (NICE/UK) and American College of Cardiology/American Heart Association (ACC/AHA) guidelines on cardiovascular disease (CVD) prevention. In particular, to evaluate the ability to ensure statin therapy to contemporary Europeans destined for a first myocardial infarction (MI).

DESIGN

393 consecutive statin-naïve, CVD-free patients without diabetes hospitalised for a first MI, 247 of whom were 40-75 years of age. We assumed they had undergone a health check the day before their MI and estimated the predicted risk.

PRIMARY OUTCOME

Sensitivity of the risk-based eligibility for primary prevention with statins recommended by the guidelines.

RESULTS

All recommended risk scores rank-ordered patients similarly, but the sensitivity of the cut point above which statin therapy should be considered differed substantially. In younger patients (age 40-60), 62% of men and 13% of women qualified for statin therapy by ACC/AHA criteria, compared with only 2% of men and no women using the ESC criteria recommended for most non-Eastern European countries. In those 60-75 years of age, the ACC/AHA guidelines captured all men and 85% of women, compared with 12% and 2%, respectively, using the new ESC guideline. This guideline restricted the eligibility for primary prevention with statins substantially by reclassifying many European countries from 'high-risk' to 'low-risk', whereas the eligibility was expanded in the ACC/AHA and the new NICE/UK guidelines by lowering the decision threshold.

CONCLUSIONS

The 2012 ESC guidelines differ substantially from the 2013 ACC/AHA and 2014 NICE/UK guidelines in ability to secure statin therapy to those destined for a first MI. A great opportunity for primary prevention with statins remains unexploited in Europe.

Abstract 661: Targeting Sortilin in Immune Cells Reduces Atherosclerosis

Targeting sortilin in immune cells reduces atherosclerosis.

Background: SNPs at 1p13.3 have been strongly associated with myocardial infarction and plasma cholesterol levels in genome-wide association studies. This locus covers 3 genes; SORT1, CELSR2 and PSRC1. Previous studies on sortilin in cardiovascular disease have focused on sortilins role in hepatic lipoprotein metabolism. In the present study, we demonstrate that sortilin also modulates atherogenesis independent of its effect on lipoprotein metabolism.

Methods and results: The effect of sortilin deficiency on atherosclerosis was studied in Apoe -/- mice. Absence of sortilin ( Sort1 -/- ) did not influence plasma cholesterol levels or the distribution between lipoprotein fractions, yet significantly reduced development of atherosclerosis after both 6 and 18 weeks of Western diet. To examine the possible mechanism we performed studies on murine bone marrow-derived macrophages (BMM) and th1-cells. Loss of sortilin did not impact foam-cell formation or cell activation, but specifically reduced the secretion of interleukin-6 (Il-6) and interferon-gamma (IFN-) from macrophages and th1 cells, respectively. Further, surface plasmon resonance analysis demonstrated that sortilin binds these two cytokines with high affinity. These results suggest that sortilin is involved in regulation of Il-6 and IFN- secretion and indicates that sortilin in immune cells may influence atherosclerosis.

To test this hypothesis, 8 weeks old Apoe -/- were lethally irradiated and rescued with age- and sex-matched bone marrow from Sort1 +/+ Apoe -/- or Sort1 -/- Apoe -/- donor mice. Mice with a sortilin deficient bone marrow transplant had reduced development atherosclerosis compared to mice with a Sort1 +/+ transplant. Although these mice had normal numbers of circulating immune cells, they had reduced levels of circulating tumor necrosis factor-α and Il-6 in plasma, suggesting that absence of sortilin attenuates the inflammatory response.

Conclusions: We conclude that targeting sortilin in immune cells reduces atherosclerosis by attenuation of the inflammatory response.

A randomised crossover comparison of mouth-to-face-shield ventilation and mouth-to-pocket-mask ventilation by surf lifeguards in a manikin

Thirty surf lifeguards (mean (SD) age: 25.1 (4.8) years; 21 male, 9 female) were randomly assigned to perform 2 × 3 min of cardiopulmonary resuscitation on a manikin using mouth-to-face-shield ventilation (AMBU LifeKey) and mouth-to-pocket-mask ventilation (Laerdal Pocket Mask). Interruptions in chest compressions, effective ventilation (visible chest rise) ratio, tidal volume and inspiratory time were recorded. Interruptions in chest compressions per cycle were increased with mouth-to-face-shield ventilation (mean (SD) 8.6 (1.7) s) compared with mouth-to-pocket-mask ventilation (6.9 (1.2) s, p < 0.0001). The proportion of effective ventilations was less using mouth-to-face-shield ventilation (199/242 (82%)) compared with mouth-to-pocket-mask ventilation (239/240 (100%), p = 0.0002). Tidal volume was lower using mouth-to-face-shield ventilation (mean (SD) 0.36 (0.20) l) compared with mouth-to-pocket-mask ventilation (0.45 (0.20) l, p = 0.006). No differences in inspiratory times were observed between mouth-to-face-shield ventilation and mouth-to-pocket-mask ventilation. In conclusion, mouth-to-face-shield ventilation increases interruptions in chest compressions, reduces the proportion of effective ventilations and decreases delivered tidal volumes compared with mouth-to-pocket-mask ventilation.

A randomised crossover comparison of manikin ventilation through Soft Seal®, i-gel™ and AuraOnce™ supraglottic airway devices by surf lifeguards

Forty surf lifeguards attempted to ventilate a manikin through one out of three supraglottic airways inserted in random order: the Portex® Soft Seal®; the Intersurgical® i-gel™; and the Ambu® AuraOnce™. We recorded the time to ventilate and the proportion of inflations that were successful, without and then with concurrent chest compressions. The mean (SD) time to ventilate with the Soft Seal, i-gel and AuraOnce was 35.2 (7.2)s, 15.6 (3.3)s and 35.1 (8.5) s, respectively, p < 0.0001. Concurrent chest compression prolonged the time to ventilate by 5.0 (1.3-8.1)%, p = 0.0072. The rate of successful ventilations through the Soft Seal (100%) was more than through the AuraOnce (92%), p < 0.0001, neither of which was different from the i-gel (97%). The mean (SD) tidal volumes through the Soft Seal, i-gel and AuraOnce were 0.65 (0.14) l, 0.50 (0.16) l and 0.39 (0.19) l, respectively. Most lifeguards (85%) preferred the i-gel. Ventilation through supraglottic airway devices may be considered for resuscitation by surf lifeguards.

Familial hypercholesterolemia and atherosclerosis in cloned minipigs created by DNA transposition of a human PCSK9 gain-of-function mutant

Lack of animal models with human-like size and pathology hampers translational research in atherosclerosis. Mouse models are missing central features of human atherosclerosis and are too small for intravascular procedures and imaging. Modeling the disease in minipigs may overcome these limitations, but it has proven difficult to induce rapid atherosclerosis in normal pigs by high-fat feeding alone, and genetically modified models similar to those created in mice are not available. D374Y gain-of-function mutations in the proprotein convertase subtilisin/kexin type 9 (PCSK9) gene cause severe autosomal dominant hypercholesterolemia and accelerates atherosclerosis in humans. Using Sleeping Beauty DNA transposition and cloning by somatic cell nuclear transfer, we created Yucatan minipigs with liver-specific expression of human D374Y-PCSK9. D374Y-PCSK9 transgenic pigs displayed reduced hepatic low-density lipoprotein (LDL) receptor levels, impaired LDL clearance, severe hypercholesterolemia, and spontaneous development of progressive atherosclerotic lesions that could be visualized by noninvasive imaging. This model should prove useful for several types of translational research in atherosclerosis.

Traditional SCORE-based health check fails to identify individuals who develop acute myocardial infarction

INTRODUCTION

Atherosclerotic cardiovascular disease (CVD), including acute myocardial infarction (AMI), is caused by well-known risk factors. They constitute important therapeutic targets, but their predictive value is disputed. We evaluated the effectiveness of the risk scoring system (SCORE) and thresholds for pharmacotherapy re-commended in the European guidelines on CVD prevention.

MATERIAL AND METHODS

The medical records of 605 consecutive patients hospitalized for a first AMI were reviewed. Patients with pre-existing CVD, diabetes, or incomplete information on risk factors were excluded. Those not treated with statin before AMI were risk stratified based on risk factors. A SCORE ≥ 5% or ≥ 10% was considered to qualify for preventive medication in young adults (age ≤ 60 years) or elderly (age > 60 years), respectively.

RESULTS

Before AMI, 40 (9%) used statin. Among non-statin users, only five of the 109 young adults had a SCORE ≥ 5%, and 23 of the 284 elderly had a SCORE ≥ 10%. Among women, only three elderly qualified for treatment. More than four times more patients would have qualified for treatment with the high-risk country chart used in 2011. The incremental value of the novel high-density lipoprotein adjusted SCORE charts was limited.

CONCLUSION

Few patients admitted with a first AMI used statin. Among non-statin users, SCORE and the recommended thresholds for pharmacotherapy identified no women and less than one out of ten men who untreated were destined for an AMI before 61 years of age. The preventive potential of a traditional risk factor-based health check is limited.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

Characteristics, therapy and outcome in an unselected and prospectively registered cohort of pancreatic cancer patients

PURPOSE

Pancreatic cancer (PC) is associated with a dismal prognosis. Few studies have examined characteristics and outcome in an unselected population-based cohort of PC patients. Therefore, we investigated patient baseline characteristics, therapy choices and survival in a complete cohort of patients with PC.

METHODS

All cases diagnosed with PC between 2007 and 2009 in the Region of Southern Denmark (pop: 1,200,000) were prospectively registered. Patient characteristics including performance status, information about haematology, liver function and therapy were retrieved from patient charts, and used to compare differently treated and untreated groups.

RESULTS

Six-hundred-eighteen cases were registered as PC; 25 of which did not have adenocarcinomas. Patients were divided in 3 clinical groups based on initial therapy; group 1: resection (n=64), group 2: chemotherapy or chemo-radiotherapy (n=191), group 3: no tumour directed therapy (n=324). Median survival (mOS) (95% confidence interval (CI)) in the three groups was 25.7 months (18-30), 8.1 months (7.0-9.5) and 1.1 months (1.0-1.3) respectively. Three percent of patients participated in clinical trials. An evaluation of baseline factors prognostic value suggested that treated patients differed significantly from non-treated patients.

CONCLUSION

This study reports survival in treated groups comparable to results obtained from clinical trials with highly selected patients. However the majority of patients with PC do not receive cancer directed therapy. This group was significantly different in several baseline factors, which could suggest a different biology. Improving the outcome of PC patients calls for research into the large group of untreated patients, as only a minority of patients receive cancer directed therapy.

Endoscopic ultrasound, endoscopic sonoelastography, and strain ratio evaluation of lymph nodes with histology as gold standard

BACKGROUND AND STUDY AIMS

Accurate lymph node staging is essential for the selection of an optimal treatment in patients with upper gastrointestinal cancer. Endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) are considered to be the most accurate method for locoregional staging. Endoscopic sonoelastography (ESE) assesses the elasticity of lymph nodes and has been used to differentiate lymph nodes with promising results. The aim of this study was to evaluate the use of EUS, EUS - FNA, ESE, and ESE-strain ratio using histology as the gold standard.

PATIENTS AND METHODS

Patients with upper gastrointestinal cancer who were referred for EUS examination were enrolled if surgical treatment was planned and the patient had a lymph node that was accessible for EUS - FNA and EUS-guided fine-needle marking (FNM). The lymph node was classified using EUS, ESE, and ESE-strain ratio. Finally, EUS - FNA and EUS - FNM were performed. The marked lymph node was isolated during surgery for histological examination.

RESULTS

The marked lymph node was isolated for separate histological examination in 56 patients, of whom 22 (39 %) had malignant lymph nodes and 34 (61 %) had benign lymph nodes. There were no complications of EUS - FNM. The sensitivity of EUS for differentiation between malignant and benign lymph nodes was 86 % compared with 55 % - 59 % for the different ESE modalities. The specificity of EUS was 71 % compared with 82 % - 85 % using ESE modalities.

CONCLUSION

The use of the EUS - FNM technique enabled the identification of a specific lymph node and thereby the use of histology as gold standard. ESE and ESE-strain ratio were no better than standard EUS in differentiating between malignant and benign lymph nodes in patients with resectable upper gastrointestinal cancer.

Intra- and interobserver agreement of endoscopic sonoelastography in the evaluation of lymph nodes

PURPOSE

There is a lack of studies on the intra- and interobserver variability of endoscopic ultrasonography (EUS) and especially endoscopic sonoelastography (ES). The aim of this study was to evaluate the intra- and interobserver agreement of EUS and ES during the evaluation of a specific lymph node in patients with upper gastrointestinal malignancies (UGIM). The ES strain ratio was used to differentiate between benign and malignant lymph nodes and the interobserver agreement was evaluated.

MATERIALS AND METHODS

This study prospectively enrolled 62 patients with UGIM. EUS and ES were performed by two observers in randomized order of a specific lymph node using a linear Pentax echoendoscope and the Hitachi EUB-8500 US unit. The lymph node was classified as malignant or benign on the basis of EUS, ES, an ES scoring system, and 5 repeated strain ratio measurements. The intraobserver variation was evaluated by each observer performing 20 strain ratio measurements of the same lymph node. Finally, EUS fine needle aspiration was performed. The kappa statistic was used to test for interobserver variability.

RESULTS

One patient was excluded due to inadequate ES imaging. Thus, 61 patients were included in the analysis of the interobserver agreement. Using EUS, ES, and an ES scoring system, the kappa values were 0.80, 0.58, and 0.35, respectively. An ES strain ratio of 3.81 was defined as the cut-off value between benign and malignant lymph nodes using cytology as the gold standard (n = 55). Using this modality, a kappa value of 0.59 was obtained. A t-test comparison of the measured strain ratios for the two observers found no significant differences.

CONCLUSION

ES and ES strain ratio evaluation of lymph nodes were feasible and may be reproduced with good interobserver agreement in a blinded clinical setup. The predefined ES scoring system provided only poor interobserver agreement. Image selection should be part of the intra- and interobserver evaluation. ES strain ratio seemed promising but larger studies are needed to evaluate this new feature.

Circulating endothelial progenitor cells do not contribute to regeneration of endothelium after murine arterial injury

AIMS

Endothelial regeneration after vascular injury, including percutaneous coronary intervention, is essential for vascular homeostasis and inhibition of neointima formation. Circulating endothelial progenitor cells (EPCs) have been implicated to contribute by homing and differentiating into endothelial cells (ECs). We tested this theory in a murine arterial injury model using carotid artery transplants and fluorescent reporter mice.

METHODS AND RESULTS

Wire-injured carotid artery segments from wild-type mice were transplanted into TIE2-GFP transgenic mice expressing green fluorescent protein (GFP) in ECs. We found that the endothelium regenerated with GFP(+) ECs as a function of time, evolving from the anastomosis sites towards the centre of the transplant. A migration front of ECs at Day 7 was verified by scanning electron microscopy and by bright-field microscopy using recipient TIE2-lacZ mice with endothelial β-galactosidase expression. These experiments indicated migration of flanking ECs rather than homing of circulating cells as the underlying mechanism. To confirm this, we interposed non-injured wild-type carotid artery segments between the denuded transplant and the TIE2-GFP recipient mouse. Among 1186 ECs identified in re-endothelialized transplants (n= 5) by staining for von Willebrand Factor or vascular endothelial-cadherin, we did not find any blood-derived (GFP(+)) cells.

CONCLUSION

Endothelial regeneration after vascular injury did not involve circulating EPCs but was mediated solely by migration of ECs from the adjacent healthy endothelium.

Endoscopic ultrasound-guided fine-needle marking of lymph nodes

BACKGROUND AND STUDY AIMS

No previous studies have evaluated the ability of endoscopic ultrasonography to describe the anatomic location of lymph nodes on the basis of a node-to-node comparison. The aim of this study was to assess the feasibility and safety of a new endoscopic ultrasound (EUS)-guided fine-needle technique for marking lymph nodes.

PATIENTS AND METHODS

Twenty-five patients with suspected or confirmed malignancies of the upper gastrointestinal tract were prospectively included. EUS-guided fine-needle marking (EUS-FNM) was performed with a silver pin with a diameter that allowed it to fit into a 19-gauge needle. The position of the pin was verified by EUS. End points were the ability to identify and isolate the marked lymph node during surgery and a comparison between the location of the pin as suggested by EUS and the actual location found in the resected specimen.

RESULTS

Twenty-three lymph nodes were marked. Nineteen intended surgical isolations were performed. The lymph nodes were isolated in the resection specimens in 18 patients (95 %). In 2 out of 20 cases the pin was not localized by laparoscopic ultrasonography. In 89 % of the cases the marked lymph node was in the same location as described by EUS. One pin (5 %) was not retrieved. In three cases, a small hematoma was observed. There was no sign of long-term complications.

CONCLUSION

EUS-FNM with a silver pin in lymph nodes is feasible and safe. EUS-FNM seems to be a suitable tool for evaluating lymph nodes on the basis of a node-to-node comparison.