Clinical significance of vitamin D in idiopathic normal pressure hydrocephalus

BACKGROUND

Although recent studies show vitamin D deficiency is associated with cognitive decline, urinary incontinence, and gait instability, there has been no study on the effect of vitamin D on idiopathic normal pressure hydrocephalus (iNPH) characterized by the classic symptom triad of cognitive decline, urinary incontinence, and gait instability. We investigated the clinical significance of vitamin D in patients with iNPH.

METHODS

Between 2017 and 2020, 44 patients who underwent ventriculoperitoneal shunt surgery were divided into low (< 15 ng/mL) and high (≥ 15 ng/mL) vitamin D groups according to the concentration of 25(OH)D, an effective indicator of vitamin D status. They were respectively evaluated according to clinical and radiological findings.

RESULTS

The low vitamin D group (n = 24) showed lower preoperative cognition compared to the high vitamin D group (n = 20) in terms of Korean-Mini Mental Status Examination (K-MMSE) and iNPH grading scale (iNPHGS) (K-MMSE: 20.5 ± 5.4 versus 24.0 ± 4.5, p = 0.041; iNPHGS cognitive score: 2 ± 0.9 versus 1 ± 0.6, p = 0.025). And the low vitamin D group showed pre- and postoperatively more severe urinary incontinence (preoperative iNPHGS urinary score: 1 ± 1.0 versus 0 ± 0.9, p = 0.012; postoperative iNPHGS urinary score:1 ± 1.0 versus 0 ± 0.9, p = 0.014). The score of narrow high-convexity sulci for the low vitamin D group was lower (low vitamin D group: 1 ± 0.7 versus high vitamin D group: 2 ± 0.4, p = 0.031).

CONCLUSION

Lower concentration of vitamin D in iNPH may be related to lower preoperative cognition, pre- and postoperative urinary incontinence, and brain morphological change.

Off-label underdosed apixaban use in Asian patients with non-valvular atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

In Asian patients with atrial fibrillation (AF), off-label underdosed prescriptions of direct oral anticoagulants (DOACs) are common

Purpose

We aimed to compare the effectiveness and safety of off-label underdosed apixaban with on-label standard dose apixaban in Asian patients with AF.

Methods

Using the Korean nationwide claims database, we identified patients who prescribed apixaban and did not fulfill the dose reduction criteria of apixaban between January 2015 and December 2017. Multivariable Cox hazard regression model was performed and hazard ratios (HRs) for ischemic stroke, major bleeding (MB), all-cause death, and the composite clinical outcome were analyzed.

Results

Compared to patients prescribed on-label standard dose apixaban (n = 4,194), patients prescribed off-label underdosed apixaban (n = 2,890) were associated with higher risks of ischemic stroke (adjusted HR [aHR] 1.38, 95% confidence interval [CI] 1.06-1.81), all-cause death (aHR 1.19, 95% CI 1.01-1.39) and the composite clinical outcome (aHR 1.17, 95% CI 1.03-1.34), but with no significant differences in MB between the two groups (Figure). In patients without any dose reduction criteria, off-label underdosed apixaban use was associated with a significantly higher risk of ischemic stroke than on-label standard dose apixaban use (aHR 1.85, 95% 1.25-2.73); however, in patients who had single dose reduction criteria (age ≥80 years, serum creatinine ≥1.5mg/dL, or bodyweight ≤60 kg), off-label underdosed apixaban use did not show a significant overall benefit in the composite clinical outcome compared with on-label standard dose apixaban, but was associated with a higher risk of all-cause death (aHR 1.32, 95% CI 1.07-1.64).

Conclusion

Off-label underdosed apixaban use was associated with higher risks of ischemic stroke, all-cause death, and composite clinical outcome and comparable risk of MB compared with on-label standard dose apixaban use. Label-adherence of apixaban dosing should be emphasized to achieve the best clinical outcome for Asian patients with non-valvular AF, especially in those without any dose reduction criteria. Abstract Figure.

Transversus abdominis plane block for lumboperitoneal shunt surgery in idiopathic normal pressure hydrocephalus: a case report

The transversus abdominis plane (TAP) block is an ideal pain control method used in surgeries that require abdominal wall incisions through the injection of an anesthetic solution into the plane between the internal oblique muscle and transversus abdominis muscle. Herein, we report an 83-year-old man who was diagnosed with idiopathic normal pressure hydrocephalus (iNPH) and underwent lumboperitoneal shunt surgery (LPS). The TAP block was performed before LPS, and the numerical rating scale for pain was 0 at day 1 after the surgery. The patient was discharged early at day 3 after surgery despite the patient being extremely old, as he reported quick relief from the postoperative abdominal pain. The TAP block can hence be considered for use before LPS in elderly patients with iNPH.

Investigation of the optimal medium and application strategy for foot-and-mouth disease vaccine antigen production

AIMS

For the effective production of 146S particles, which determines foot-and-mouth disease (FMD) vaccine efficacy, we aimed to identify the optimal medium that is easy-to-use, productive and economically affordable for the large-scale production of FMD vaccine.

METHODS AND RESULTS

Nine combinations of cell growth media and replacement media were tested for virus propagation. Apart from the replacement strategy, we tested a simple addition strategy involving the addition of 30% v/v of fresh medium to the total spent medium using the Cellvento BHK-200 (Vento). Unlike other tested media that produced poor yields of 146S particles when the spent media were not eliminated, Vento exhibited high productivity with the 30% addition strategy.

CONCLUSIONS

Considering its lower price and media consumption compared to those of other media that require media replacement, the 30% addition strategy of Vento is highly effective. Furthermore, owing to its simple application strategy, it makes the scale-up process easy and helps in saving the time and labour involved in spent media removal.

SIGNIFICANCE AND IMPACT OF THE STUDY

Through the first comparative assessment of commercial media for the 146S particle recovery, this study suggests the best practical medium for the industrial-scale production of FMD vaccines.

A transdiagnostic examination of anxiety and stress on executive function outcomes in disorders with social impairment

BACKGROUND

Executive function (EF) difficulties characterise a number of psychiatric conditions and EF impairment may be a predisposing factor and/or consequence of anxiety and stress. The aim of the study was to examine EF factors in a mixed clinical cohort (Autism Spectrum Disorder and Social Anxiety Disorder) characterised by social impairment and investigate the influence of trait anxiety and state-based depression, anxiety and stress.

METHODS

In Study 1, a factor analysis identified EF and non-EF latent factor structures (N=205). In Study 2, (N=137) multiple regression analyses investigated the association between trait anxiety and state based depression, anxiety and stress, on EF and non-EF cognitive domains and on the two composite indices of the Behavioural Rating Inventory of Executive Function (BRIEF).

RESULTS

Trait anxiety was associated with better performance on neuropsychological measures of EF while state-based stress was associated with lower EF performance. A dissociation was observed between trait anxiety and state stress on the two behavioural indices of the BRIEF. Depression, anxiety and stress did not predict performance on non-EF cognitive domains.

LIMITATIONS

The cross-sectional design precludes cause-effect conclusions, further only self-report measures of affect were utilised and our performance measures of EF did not include a working memory test.

CONCLUSIONS

The results demonstrate that trait anxiety and state-based stress influence EF processes across disorders with social impairment. The transdiagnostic efficacy of this finding can facilitate remediation strategies, it may also contribute to individuals with Autism Spectrum Disorder gaining better access to mental health services.

Filamentous anti-influenza agents wrapping around viruses

Owing to the emerging resistance to current anti-influenza therapies, strategies for blocking virus-cell interaction with agents that mimic interactions with host cell receptors are garnering interest. In this context, a multivalent presentation of sialyl groups on various types of scaffold materials such as dendrimers, liposomes, nanoparticles, and natural/synthetic polymers has been investigated for the inhibition of influenza A virus infection. However, the development of versatile antiviral agents based on monodisperse scaffolds capable of precise molecular design remains challenging. Whether an anisotropically extended filamentous nanostructure can serve as an effective scaffold for maximum inhibition of viral cell attachment has not been investigated. In this study, the preparation of a series of sialyllactose-conjugated filamentous bacteriophages (SLPhages), with controlled loading levels, ligand valencies, and two types of sialyllactose (α2,3' and α2,6'), is demonstrated. With optimal ligand loading and valency, SLPhages showed inhibitory activity (in vitro) against influenza A viruses at concentrations of tens of picomolar. This remarkable inhibition is due to the strong interaction between the SLPhage and the virus; this interaction is adequately potent to compensate for the cost of the bending and wrapping of the SLPhage around the influenza virus. Our study may open new avenues for the development of filamentous anti-viral agents, in which virus-wrapping or aggregation is the primary feature responsible for the blocking of cell entry.

A randomized phase III trial comparing adjuvant single-agent S1, S-1 with oxaliplatin, and postoperative chemoradiation with S-1 and oxaliplatin in patients with node-positive gastric cancer after D2 resection: the ARTIST 2 trial☆

BACKGROUND

Adjuvant chemotherapy and chemoradiotherapy are some of the standards of care for gastric cancer (GC). The Adjuvant chemoRadioTherapy In Stomach Tumors (ARTIST) 2 trial compares two adjuvant chemotherapy regimens and chemoradiotherapy in patients with D2-resected, stage II or III, node-positive GC.

PATIENTS AND METHODS

The ARTIST 2 compared, in a 1:1:1 ratio, three adjuvant regimens: oral S-1 (40-60 mg twice daily 4 weeks on/2 weeks off) for 1 year, S-1 (2 weeks on/1 week off) plus oxaliplatin 130 mg/m² every 3 weeks (SOX) for 6 months, and SOX plus chemoradiotherapy 45 Gy (SOXRT). Randomization was stratified according to surgery type (total or subtotal gastrectomy), pathologic stage (II or III), and Lauren histologic classification (diffuse or intestinal/mixed). The primary endpoint was disease-free survival (DFS) at 3 years; a reduction of 33% in the hazard ratio (HR) for DFS with SOX or SOXRT, when compared with S-1, was considered clinically meaningful. The trial is registered at clinicaltrials.gov (NCT0176146).

RESULTS

A total of 546 patients were recruited between February 2013 and January 2018 with 182, 181, and 183 patients in the S-1, SOX, and SOXRT arms, respectively. Median follow-up period was 47 months, with 178 DFS events observed. Estimated 3-year DFS rates were 64.8%, 74.3%, and 72.8% in the S-1, SOX, and SOXRT arms, respectively. HR for DFS in the control arm (S-1) was shorter than that in the SOX and SOXRT arms: S-1 versus SOX, 0.692 (P = 0.042) and S-1 versus SOXRT, 0.724 (P = 0.074). No difference in DFS was found between SOX and SOXRT (HR 0.971; P = 0.879). Adverse events were as anticipated in each arm, and were generally well-tolerated and manageable.

CONCLUSIONS

In patients with curatively D2-resected, stage II/III, node-positive GC, adjuvant SOX or SOXRT was effective in prolonging DFS, when compared with S-1 monotherapy. The addition of radiotherapy to SOX did not significantly reduce the rate of recurrence after D2 gastrectomy.

Long-term clinical outcomes of endoscopic submucosal dissection for colorectal neoplasia with or without the hybrid technique

AIM

The main aim of this study was to compare the long-term outcome of a conventional colorectal endoscopic submucosal dissection (ESD) in which submucosal dissection was continued throughout until the completion of resection (ESD-T) to hybrid endoscopic submucosal dissection (ESD-H) in the colorectum.

METHOD

Medical records of 836 colorectal neoplasia patients treated by ESD-T or ESD-H were reviewed. ESD-H was defined as colorectal ESD with additional snaring in the final stage of the procedure. Primary outcomes were the overall and metastatic recurrence rates. Secondary outcomes were short-term outcomes such as the en bloc resection rate, procedure time and adverse events.

RESULTS

The overall recurrence rate was higher in the ESD-H than in the ESD-T group (5.7% vs 0.7%, P = 0.001). The metastatic recurrence rate showed no significant difference between these groups (1.4% vs 1.4%, P = 1.000). Multivariate analysis revealed that a failed en bloc resection (hazard ratio 24.097; 95% CI 5.446-106.237; P < 0.001) and larger tumour size (hazard ratio 1.042; 95% CI 1.014-1.070; P = 0.003) were independently associated with overall recurrence. The ESD-H group showed a lower en bloc resection rate (56.8% vs 96.5%, P < 0.001), shorter procedure time (45.6 vs 54.3 min, P < 0.001) and higher perforation rate (10.3% vs 6.0%, P = 0.029).

CONCLUSION

Although long-term outcomes in terms of overall recurrence are inferior following ESD-H, a failed en bloc resection and large tumour size are the only independent risk factors for recurrence. Further investigations are warranted to improve the long-term outcomes of ESD-H.

Low-dose CT angiography of the lower extremities: a comparison study of image quality and radiation dose

AIM

To investigate the image quality and radiation dose of ultralow-dose (ULD) and low-dose (LD) lower-extremity computed tomography (CT) angiography (LE-CTA) using the advanced modelled iterative reconstruction (ADMIRE) algorithm to detect peripheral arterial disease (PAD) in comparison with standard-dose (SD) CT.

MATERIALS AND METHODS

One hundred and seven consecutive patients were examined using LE-CTA at 70 kVp and a dual-source scanner to achieve three image sets using 30% (ULD), 70% (LD), and 100% (SD) tube loads. Qualitative analysis was conducted by examining the three image sets for overall quality. The image quality of arterial segments was analysed by two independent readers. In addition, the CT dose index (CTDI_vol) was measured in the three image sets.

RESULTS

The mean overall quality scores were 3.4±0.6 for ULD CT, 3.9±0.3 for LD CT, and 3.9±0.2 for SD CT. Both readers scored the arterial segments as 2-4 (adequate-excellent) in the three image sets. In addition, 89.4% (93/104) and 54.8% (57/104) segments of PAD with calcified plaques were scored 4 between SD and LD CT and between SD and ULD CT, respectively, and 45.2% (47/104) segments had a lower score by one point in ULD CT compared with SD CT. The mean CTDI_vol was 4.1±1.1 mGy for SD CT, 2.9±0.8 mGy for LD CT, and 1.2±0.3 mGy for ULD CT.

CONCLUSIONS

LD/ULD CT at 70 kVp using ADMIRE reconstruction enables a reduction in the radiation dose while enabling adequate evaluation or follow-up of PAD based on LE-CTA.

Development of a Stereotactic Radiosurgery Frame Adapter for a Multichannel MRI Coil

BACKGROUND

The usage of multichannel brain MRI coils, which have several advantages over single-channel brain coils used for stereotactic radiosurgery (SRS), requires a frame adapter device to fit the frames inside the multichannel brain coils. However, such a frame adapter has not been developed until now.

OBJECTIVE

to develop an SRS frame adapter for multichannel MRI coils and verify the geometrical accuracy and signal-to-noise ratio (SNR) of the MR images obtained using multichannel MRI coils.

METHODS

We fabricated an SRS frame adapter for a 48-channel MRI coil using a three-dimensional (3D) printer. Furthermore, we obtained phantom and human-brain MR images with a 3.0 Tesla MRI scanner using multi- and single-channel coils. Computed tomography (CT) phantom images were also obtained as reference. We compared the coordinate errors of the multi- and single-channel coils to evaluate the geometrical accuracy. Two neurosurgeons measured the coordinates. In addition, we compared the SNR differences between multi- and single-channel coils using the T1- and T2-weighted brain images.

RESULTS

For the CT coordinate measurements, the correlation coefficient r = 1 and p < 0.001 with respect to the 3 axes (Δx, Δy, and Δz) and 3D errors (Δr) showed no interpersonal differences between the 2 neurosurgeons. The results obtained using the T1-weighted images showed that a multichannel coil had smaller coordinate errors in Δx, Δy, Δz, and Δr than that observed in case of a single-channel coil (p < 0.001). In case of the SNR measurements, most of the brain areas showed higher SNRs when using a multichannel coil compared with that observed when using a single-channel coil in the T1- and T2-weighted images.

CONCLUSION

Compared with single-channel coils, the use of multichannel MRI coils with a newly developed frame adapter is expected to ensure successful SRS treatments with improved geometrical accuracy and SNR.

A laboratory study to detect simulated pulpal blood flow in extracted human teeth using ultrasound Doppler flowmetry

AIM

To develop a laboratory-based tooth model of simulated blood flow in teeth and evaluate it using ultrasound Doppler flowmetry (UDF).

METHODOLOGY

A laboratory-based tooth model for UDF was created based on a microfluidic experimental model proposed by Kim & Park (2016 a,b). Twenty-one maxillary or mandibular anterior human teeth within 1 month of extraction were used. Four holes were made in each tooth to fit 1.6-mm diameter polytetrafluoroethylene (PTFE) tubes: at the apical foramen, palatal surface in the centre of the crown, palatal surface apical to the cementoenamel junction (CEJ) and the root centre. Fluid mimicking pulsating blood was pumped (pressure range: 0-200 mbar, flow rate range: 0-80 μL min^-1 ) into the apical foramen via the PTFE tubes, which exited the tooth through the palatal surface in the centre of the crown (control group), palatal surface below the CEJ (group 1) and the palatal surface at the mid-root level (group 2). An UDF transducer of 20 MHz was placed at a 60° angle to the labial surface of tooth and was used to measure the fluid flow velocity (Vs, Vas, Vm, Vam, Vd, Vad and Vakd). The flow velocity of the different groups was compared using the Wilcoxon signed-rank test, with a 95% confidence level.

RESULTS

UDF facilitated the detection of the simulated pulpal blood flow in the control group and group 1, but not in group 2. The mean and standard deviations of Vas, Vam and Vakd were 0.921 ± 0.394, 0.479 ± 0.208 and 0.396 ± 0.220 cm s^-1 , respectively, in the control group, and 0.865 ± 0.368, 0.424 ± 0.215 and 0.487 ± 0.279 cm s^-1 , respectively, in group 1. The pulpal blood flow values of the control group and group 1 were not significantly different (p > 0.05).

CONCLUSIONS

This laboratory study revealed that ultrasound Doppler flowmetry enabled the detection of simulated blood flow below the level of the CEJ but not at the mid-root level.

Induction of cell cycle arrest and apoptosis by tomentosin in hepatocellular carcinoma HepG2 and Huh7 cells

Tomentosin, a sesquiterpene lactone, is known to possess various biological activities. However, its anticarcinogenic activity against human hepatocellular carcinoma (HCC) cells has not been investigated in detail. Thus, this study aimed to elucidate the cytotoxic mechanism of tomentosin in human HCC cell lines HepG2 and Huh7. WST-1, cell counting, and colony formation assay results showed that treatment with tomentosin decreased the viability and suppressed the proliferation rate of HepG2 and Huh7 cells in a dose- and time-dependent manner. Cell cycle analysis revealed increased population of cells at the SubG1 and G2/M stage, and decreased population of cells at the G0/1 stage in HepG2 and Huh7 cells treated with tomentosin. Annexin V/propidium iodide double staining and TUNEL assay results showed increased apoptotic cell population and DNA fragmentation in HepG2 and Huh7 cells treated with tomentosin. Western blotting analysis results showed that tomentosin treatment significantly increased the expression level of Bax, Bim (short form), cleaved PARP1, FOXO3, p53, pSer15p53, pSer20p53, pSer46p53, p21, and p27, but decreased the expression of Bcl2, caspase3, caspase7, caspase9, cyclin-dependent kinase 2 (CDK2), CDK4, CDK6, cyclinB1, cyclinD1, cyclinD2, cyclinD3, and cyclinE in a dose-dependent manner. Taken together, this study revealed that tomentosin, which acted through cell cycle arrest and apoptosis, may be a useful therapeutic option against HCC.

Robotic-assisted latissimus dorsi muscle flap for autologous chest reconstruction in poland syndrome

BACKGROUND

As chest reconstructions in Poland syndrome are performed for patients at young ages, patients are generally concerned about conspicuous scars. Meanwhile, a robotic-assisted latissimus dorsi (LD) muscle harvest with inconspicuous scars has been performed for autologous breast reconstruction. As our experience with robotic-assisted LD flap harvest has increased over the years, we have made improvements in surgical techniques to optimize results. The purpose of this study was to introduce and identify the role of the refined robotic-assisted LD muscle flap harvest technique in autologous chest reconstruction in patients with Poland syndrome.

METHODS

Autologous chest reconstruction using a robotic-assisted LD muscle flap harvest was performed for 21 patients with Poland syndrome. Subjective assessments were performed to evaluate improvement in chest deformity, patient satisfaction with overall outcomes, chest symmetry, and scars. Assessments by the operator and two independent evaluating investigators were carried out with patients' photographs. The complication rates and the time for robotic surgery were also evaluated.

RESULTS

At the last visit, the average patient grades for improvement in chest deformity, satisfaction with overall outcomes, chest symmetry, and scars were 4.80, 4.72, 4.18, and 4.87, respectively. Assessments by the operator and two independent evaluating investigators demonstrated that improvement in chest deformity was achieved in all patients. No serious complications such as flap loss were recorded for any patient. The time for robotic surgery markedly decreased as experience accumulated.

CONCLUSIONS

Surgical refinements for robotic-assisted LD flap harvest might be effective and reduce operative times for patients with Poland syndrome.

Intrinsically p-type cuprous iodide semiconductor for hybrid light-emitting diodes

Cuprous halides, characterized by a direct wide band-gap and a good lattice matching with Si, is an intrinsic p-type I-VII compound semiconductor. It shows remarkable optoelectronic properties, including a large exciton binding energy at room temperature and a very small piezoelectric coefficient. The major obstacle to its application is the difficulty in growing a single-crystal epitaxial film of cuprous halides. We first demonstrate the single crystal epitaxy of high quality cuprous iodide (CuI) film grown on Si and sapphire substrates by molecular beam epitaxy. Enhanced photoluminescence on the order of magnitude larger than that of GaN and continuous-wave optically pumped lasing were found in MBE grown CuI film. The intrinsic p-type characteristics of CuI were confirmed using an n-AlGaN/p-CuI junction that emits blue light. The discovery will provide an alternative way towards highly efficient optoelectronic devices compatible with both Si and III-nitride technologies.

P643 A case of Fabry cardiomyopathy refractory to enzyme replacement therapy; the importance of early diagnosis and treatment in Fabry cardiomyopathy

A 56-year-old male was referred in order to identify Fabry disease after his older brother was confirmed as Fabry disease of cardiac variant type. He had been treated with hypertrophic cardiomyopathy (HCMP) five years ago. He didn’t have a history of hypertension. Blood pressure was 118/65 mmHg and pulse rate was 75 beats per minute. Serum creatinine was 1.07 mg/dl and estimated glomerular filtration rate was 75.2 ml/min. Cardiac enzymes including CK-MB and troponin-T were normal. There was no proteinuria on urinalysis. A 12-leads electrocardiogram revealed normal sinus rhythm with severe left ventricular hypertrophy (LVH) and strain pattern. Transthoracic echocardiogram (TTE) showed diffuse severe concentric hypertrophy of the left ventricle (LV) of an average ventricular wall thickness of 17 mm with normal systolic function (left ventricular ejection fraction (LVEF), 56%). TTE also revealed left ventricular outflow tract obstruction with systolic anterior motion of mitral valve. Right ventricle (RV) was also hypertrophied (RV free wall thickness, 7mm). Also, echocardiography revealed findings of diastolic dysfunction; left atrial enlargement, mitral inflow of a pseudo-normal pattern on pulsed wave Doppler image and an increased left ventricular filling pressure on tissue Doppler image (E/e’=20). Cardiac magnetic resonance imaging (MRI) revealed diffuse LV and RV hypertrophy and preserved LV systolic function with hypokinesia of mid-septal LV wall. Delayed hyper-enhancement (DHE) was not found within entire myocardium. A coronary CT angiography was performed because of regional wall motion abnormality but did not show any significant stenoses. He was confirmed as Fabry disease with the same genetic mutation as his brother. He did not present symptoms and signs of any other organs besides only myocardial hypertrophy. He received enzyme replacement therapy (ERT) with intravenous agalsidase-beta every other week via outpatient department for 3 years. Recently, TTE was performed and showed diffuse severe concentric LVH of an average ventricular wall thickness increased to 19 mm despite regularly ERT. Focal intramural and subepicardial DHE was newly developed at LV basal lateral and septal wall on cardiac MRI. Neutralizing antibody against agalsidase -beta was not found in serum.

Fabry disease of cardiac variant type can be delayed in diagnostic aspect because of absence of typical symptoms and signs. Despite the absence of neutralizing antibody, ERT did not prevent both further myocardial hypertrophy and myocardial fibrosis in patient with advanced myocardial hypertrophy caused by delayed diagnosis of Fabry disease. Suspicion of Fabry disease through detailed history taking including family history in patients with diffuse ventricular hypertrophy on an echocardiography can lead to early diagnosis and treatment and can result in improvement in a clinical outcome.

430 Relation of blood pressure to coronary artery calcium and mortality

Background

Diastolic blood pressure has a J-curve relation with coronary heart disease and death, but it is debating whether a J-curve association exists in general population. We aimed to assess the relation of blood pressure to mortality, and whether their association is interacted with presence of high coronary artery calcium (CAC).

Methods

The KOICA registry is a retrospective, multicenter observational study designed to investigate the effectiveness and prognostic value of CAC score for primary prevention of cardiovascular disease in asymptomatic Korean adults. The association between CAC score and blood pressure was assessed. Patients were divided into 2 groups according to the baseline CACS (&gt; 300 and ≤ 300), and all-cause mortality was assessed.

Results

The study population composed 48903 subjects with a mean age of 54 ± 9. There were 425 (0.9%) deaths during follow-up. At baseline, SBP (systolic blood pressure) more than 110 mmHg and DBP (diastolic blood pressure) more than 80 mmHg was associated with increased risk for CACS &gt; 300. In patients with baseline CACS ≤ 300, all-cause mortality was increased in patients with SBP of 110-119 mmHg (HR 1.47, p = 0.023), 130-139 mmHg (HR 1.72, p = 0.002) and ≥ 140 mmHg (HR 1.47, p = 0.042) compared to SBP of 120-129 mmHg, whereas DBP did not predict all-cause mortality. In contrast, SBP was not associated to all-cause mortality in patients with CACS &gt; 300, whereas DBP &lt; 60 mmHg (HR 3.53, p =0.018) and 70-79 mmHg (HR 2.21, p = 0.042) was associated with increased risk for all-cause mortality compared to DBP of 80-89 mmHg.

Conclusion

Low DBP was associated with increased risk for all-cause mortality in subjects with high CAC score, suggesting high-risk for coronary artery disease. However, this J-curve relation was not shown in the population with low CAC score.

Prognostic Predictions for Patients with Glioblastoma after Standard Treatment: Application of Contrast Leakage Information from DSC-MRI within Nonenhancing FLAIR High-Signal-Intensity Lesions

BACKGROUND AND PURPOSE

Attempts have been made to quantify the microvascular leakiness of glioblastomas and use it as an imaging biomarker to predict the prognosis of the tumor. The purpose of our study was to evaluate whether the extraction fraction value from DSC-MR imaging within nonenhancing FLAIR hyperintense lesions was a better prognostic imaging biomarker than dynamic contrast-enhanced MR imaging parameters for patients with glioblastoma.

MATERIALS AND METHODS

A total of 102 patients with glioblastoma who received a preoperative dynamic contrast-enhanced MR imaging and DSC-MR imaging were included in this retrospective study. Patients were classified into the progression (n = 87) or nonprogression (n = 15) groups at 24 months after surgery. We extracted the means and 95th percentile values for the contrast leakage information parameters from both modalities within the nonenhancing FLAIR high-signal-intensity lesions.

RESULTS

The extraction fraction 95th percentile value was higher in the progression-free survival group of >24 months than at ≤24 months. The median progression-free survival of the group with an extraction fraction 95th percentile value of >13.32 was 17 months, whereas that of the group of ≤13.32 was 12 months. In addition, it was an independent predictor variable for progression-free survival in the patients regardless of their ages and genetic information.

CONCLUSIONS

The extraction fraction 95th percentile value was the only independent parameter for prognostic prediction in patients with glioblastoma among the contrast leakage information, which has no statistically significant correlations with the DCE-MR imaging parameters.

Progressively enlarging childhood chronic subdural hematoma surgically treated 26 years after diagnosis

Pediatric chronic subdural hematoma (CSDH) is a relatively common disorder. Treatment often requires burr hole drainage or subduroperitoneal shunt placement; some patients are managed conservatively. However, the long-term outcome of untreated pediatric CSDH is unknown. The authors report a case of a huge, progressively enlarging subdural granuloma that was surgically treated 26 years after the initial diagnosis of CSDH. This 30-year-old male patient presented with worsening intermittent atonic seizure-like movements, which had been noted since he was 4 years old. At that time, the patient was diagnosed with CSDH at an outside hospital, but an operation was refused by the parents. Magnetic resonance imaging (MRI) performed at 23 years of age showed a huge subdural mass on the right frontoparietal region and a smaller mass on the left side with a significant midline shift. Upon presentation at the age of 30, MRI revealed worsening of the right subdural mass and midline shift. Subsequently, the patient underwent craniotomy and subtotal removal of the mass and capsule. The volume of the content was approximately 430 cc. Untreated pediatric CSDH can grow progressively, even over several decades. Patients with CSDH, especially those managed conservatively, should be closely monitored for worsening symptoms over a long-term follow-up period.

Gamma Knife Radiosurgery Using Co-Registration with PET-CT and MRI for Recurrent Nasopharyngeal Carcinoma with Previous Radiotherapy : A Single Center 14-Year Experience

Objective

We retrospectively evaluated the efficacy of Gamma Knife radiosurgery (GKS) for recurrent nasopharyngeal carcinoma (NPC) in patients who previously underwent radiotherapy, and analyzed the treatment outcomes over 14 years.

Methods

Ten patients with recurrent NPC who had previously received radiotherapy underwent stereotactic radiosurgery using a Gamma Knife^® (Elekta Inc, Atlanta, GA, USA) between 2005 and 2018. The median target volume was 8.2 cm³ (range, 1.7–17.8), and the median radiation dose to the target was 18 Gy (range, 12–30). The median follow-up period was 18 months (range, 6–76 months). Overall and local failure-free survival rates were determined using the Kaplan-Meier method.

Results

The NPCs recurred at the primary cancer site in seven patients (70%), as distant brain metastasis in two (20%), and as an extension into brain in one (10%). The recurrent tumors in seven of the 10 patients (70%) were found on the routine follow-up imaging studies. Two patients presented with headache and one with facial pain. Local failure after GKS occurred in five patients (50%) : two of whom died eight and 6 months after GKS, respectively. No adverse radiation effects were noted after GKS. The 1- and 3-year overall survival rates after GKS were 90% and 77%, respectively. The local failure-free survival rates at 6 months, 1 year, and 3 years after GKS were 80%, 48%, and 32%, respectively. The median interval from GKS to local failure was 8 months (range, 6–12). Univariate analysis revealed that using co-registration with positron emission tomography-computed tomography (PET-CT) and magnetic resonance imaging (MRI) was associated with a lower local failure rate of recurrent NPC (p=0.027).

Conclusion

GKS is an acceptable salvage treatment option for patients with recurrent NPC who previously received radiation therapy. PET-CT and MRI co-registration for dose planning can help achieve local control of recurrent NPC.

Impact of genomic alterations on lapatinib treatment outcome and cell-free genomic landscape during HER2 therapy in HER2+ gastric cancer patients

Background

To identify predictive markers for responders in lapatinib-treated patients and to demonstrate molecular changes during lapatinib treatment via cell-free genomics.

Patients and methods

We prospectively evaluated the efficacy of combining lapatinib with capecitabine and oxaliplatin as first line neoadjuvant therapy in patients with previously untreated, HER2-overexpressing advanced gastric cancer. A parallel biomarker study was conducted by simultaneously performing immunohistochemistry and next-generation sequencing (NGS) with tumor and blood samples.

Results

Complete response was confirmed in 7/32 patients (21.8%), 2 of whom received radical surgery with pathologic-confirmed complete response. Fifteen partial responses (46.8%) were observed, resulting in a 68.6% overall response rate. NGS of the 16 tumor specimens demonstrated that the most common co-occurring copy number alteration was CCNE1 amplification, which was present in 40% of HER2+ tumors. The relationship between CCNE1 amplification and lack of response to HER2-targeted therapy trended toward statistical significance (66.7% of non-responders versus 22.2% of responders harbored CCNE1 amplification; P = 0.08). Patients with high level ERBB2 amplification by NGS were more likely to respond to therapy, compared with patients with low level ERBB2 amplification (P = 0.02). Analysis of cfDNA showed that detectable ERBB2 copy number amplification in plasma was predictive to the response (100%, response rate) and changes in plasma-detected genomic alterations were associated with lapatinib sensitivity and/or resistance. The follow-up cfDNA genomics at disease progression demonstrated that there are emergences of other genomic aberrations such as MYC, EGFR, FGFR2 and MET amplifications.

Conclusions

The present study showed that HER2+ GC patients respond differently according to concomitant genomic aberrations beyond ERBB2, high ERBB2 amplification by NGS or cfDNA can be a positive predictor for patient selection, and tumor genomic alterations change significantly during targeted agent therapy.

Phase III, randomised trial of avelumab versus physician's choice of chemotherapy as third-line treatment of patients with advanced gastric or gastro-oesophageal junction cancer: primary analysis of JAVELIN Gastric 300

Background

There currently are no internationally recognised treatment guidelines for patients with advanced gastric cancer/gastro-oesophageal junction cancer (GC/GEJC) in whom two prior lines of therapy have failed. The randomised, phase III JAVELIN Gastric 300 trial compared avelumab versus physician’s choice of chemotherapy as third-line therapy in patients with advanced GC/GEJC.

Patients and methods

Patients with unresectable, recurrent, locally advanced, or metastatic GC/GEJC were recruited at 147 sites globally. All patients were randomised to receive either avelumab 10 mg/kg by intravenous infusion every 2 weeks or physician’s choice of chemotherapy (paclitaxel 80 mg/m² on days 1, 8, and 15 or irinotecan 150 mg/m² on days 1 and 15, each of a 4-week treatment cycle); patients ineligible for chemotherapy received best supportive care. The primary end point was overall survival (OS). Secondary end points included progression-free survival (PFS), objective response rate (ORR), and safety.

Results

A total of 371 patients were randomised. The trial did not meet its primary end point of improving OS {median, 4.6 versus 5.0 months; hazard ratio (HR)=1.1 [95% confidence interval (CI) 0.9–1.4]; P = 0.81} or the secondary end points of PFS [median, 1.4 versus 2.7 months; HR=1.73 (95% CI 1.4–2.2); P > 0.99] or ORR (2.2% versus 4.3%) in the avelumab versus chemotherapy arms, respectively. Treatment-related adverse events (TRAEs) of any grade occurred in 90 patients (48.9%) and 131 patients (74.0%) in the avelumab and chemotherapy arms, respectively. Grade ≥3 TRAEs occurred in 17 patients (9.2%) in the avelumab arm and in 56 patients (31.6%) in the chemotherapy arm.

Conclusions

Treatment of patients with GC/GEJC with single-agent avelumab in the third-line setting did not result in an improvement in OS or PFS compared with chemotherapy. Avelumab showed a more manageable safety profile than chemotherapy.

Trial registration

ClinicalTrials.gov: NCT02625623.

Efficacy and safety findings from DREAM: a phase III study of DHP107 (oral paclitaxel) versus i.v. paclitaxel in patients with advanced gastric cancer after failure of first-line chemotherapy

Background

Paclitaxel is currently only available as an intravenous (i.v.) formulation. DHP107 is a novel oral formulation of lipid ingredients and paclitaxel. DHP107 demonstrated comparable efficacy, safety, and pharmacokinetics to i.v. paclitaxel as a second-line therapy in patients with advanced gastric cancer (AGC). DREAM is a multicenter, open-label, prospective, randomized phase III study of patients with histologically/cytologically confirmed, unresectable/recurrent AGC after first-line therapy failure.

Methods and materials

Patients were randomized 1 : 1 to DHP107 (200 mg/m2 orally twice daily days 1, 8, 15 every 4 weeks) or i.v. paclitaxel (175 mg/m2 day 1 every 3 weeks). Patients were stratified by Eastern Cooperative Oncology Group performance status, disease status, and prior treatment; response was assessed (Response Evaluation Criteria in Solid Tumors) every 6 weeks. Primary end point: non-inferiority of progression-free survival (PFS); secondary end points: overall response rate (ORR), overall survival (OS), and safety. For the efficacy analysis, sequential tests for non-inferiority were carried out, first with a non-inferiority margin of 1.48, then with a margin of 1.25.

Results

Baseline characteristics were balanced in the 236 randomized patients (n = 118 per arm). Median PFS (per-protocol) was 3.0 (95% CI 1.7-4.0) months for DHP107 and 2.6 (95% CI 1.8-2.8) months for paclitaxel (hazard ratio [HR] = 0.85; 95% CI 0.64-1.13). A sensitivity analysis on PFS using independent central review showed similar results (HR = 0.93; 95% CI 0.70-1.24). Median OS (full analysis set) was 9.7 (95% CI 7.1 - 11.5) months for DHP107 versus 8.9 (95% CI 7.1-12.2) months for paclitaxel (HR = 1.04; 95% CI 0.76-1.41). ORR was 17.8% for DHP107 (CR 4.2%; PR 13.6%) versus 25.4% for paclitaxel (CR 3.4%; PR 22.0%). Nausea, vomiting, diarrhea, and mucositis were more common with DHP107; peripheral neuropathy was more common with paclitaxel. There were only few Grade≥3 adverse events, most commonly neutropenia (42% versus 53%); febrile neutropenia was reported infrequently (5.9% versus 2.5%). No hypersensitivity reactions occurred with DHP107 (paclitaxel 2.5%).

Conclusions

DHP107 as a second-line treatment of AGC was non-inferior to paclitaxel for PFS; other efficacy and safety parameters were comparable. DHP107 is the first oral paclitaxel with proven efficacy/safety for the treatment of AGC.

ClinicalTrials.gov

NCT01839773.

Interstitial lung disease and risk of mortality: 11-year nationwide population-based study

BACKGROUND

Patients with interstitial lung disease (ILD) constitute a substantial disease burden. Although ILD outcomes have been investigated, the risk of death due to ILD has not been studied in the light of confounders and comorbidities. In this nationwide, 11-year longitudinal, population-based study, we aimed to discover if ILD is an independent risk factor for mortality.

DESIGN

Data on 1 031 392 (2.2%) randomly selected subjects from 47 279 373 Korean residents were collected from the 2002 Korean National Health Insurance database. The ILD group comprised patients with an initial diagnosis of ILD between January 2003 and December 2007. Each patient was followed until 2013. We used Cox proportional hazard regression analyses to calculate the risk of death adjusted for comorbidities and confounders.

RESULTS

ILD developed in 783 of the 303 385 subjects during the 5-year period (51 per 100 000 person-years). Death occurred in 157 (23.2%) cases and 272 controls (10.4%). ILD was significantly associated with the risk of death (hazard ratio 2.1, 95% confidence interval [CI] 1.6-2.7) and for those aged 40-59, 60-69 and 70 years. A high proportion of patients with ILD died due to respiratory causes.

CONCLUSION

ILD patients had a significantly higher risk of death than matched controls, after adjustment for potential confounders and comorbidities.

P6278Ageing is associated with increased endothelial sodium-glucose cotransporter 1 expression at arterial sites at risk promoting enhanced anthocyanin accumulation and improved vascular oxidative stress

Introduction

Ageing is characterized by endothelial dysfunction and vascular oxidative stress affecting initially arterial sites at risk. Anthocyanin-rich products are potent stimulators of the endothelial formation of nitric oxide. Sodium-glucose co-transporter 1 (SGLT1) expression has been shown to be increased by oxidative stress and mediate anthocyanin uptake in endothelial cells.

Purpose

The study determined whether ageing is associated with an upregulation of SGLT1 in arterio-susceptible (aortic arch) and resistant (aorta) sites, and evaluated the vascular SGLT1-mediated anthocyanin uptake. In addition, the impact of a 2-week ingestion of an anthocyanin-rich blackcurrant concentrate (ARBC) by old rats on vascular anthocyanin uptake and oxidative stress, and systolic blood pressure (SBP) was assessed.

Methods

Male Wistar rats (22-month old) were either untreated or treated with ARBC (60 and 120 mg/kg/day) in the drinking water for 2 weeks. SGLT1 expression was assessed by immunofluorescence, anthocyanin accumulation by Neu A reagent using a purified extract (BCE) prepared from ARBC, oxidative stress by dihydroethidium using confocal microscopy, and SBP by tail-cuff sphingomanometry.

Results

SGLT1 immunofluorescence was observed predominantly in the endothelium and was higher in the aortic arch than the aorta in old rats whereas only low levels were observed in young rats (12-week old). Exposure of vascular sections to BCE resulted in anthocyanin uptake exclusively in the endothelium, which was higher in the aortic arch than the aorta, and more pronounced in old than young rats. Anthocyanin uptake induced by BCE in the aorta was markedly reduced by LX4211 (a SGLT1/2 inhibitor) both in old and young rats. A high level of oxidative stress was observed throughout the aortic wall of old compared to young rats, which was inhibited by LX4211. Ingestion of ARBC by old rats resulted in a dose-dependent accumulation of anthocyanins throughout the aorta wall and the aortic arch. The tissue accumulation of anthocyanins was associated with a reduced level of oxidative stress. Ageing was associated with increased SBP by about 8 mmHg, which was reduced by ARBC 60 and 120 mg/kg/day treatment by about 5 and 7 mmHg, respectively.

Conclusion

The present findings indicate that ageing is associated with an upregulation of SGLT1 predominantly in the endothelium and that this effect is more pronounced at the aortic arch than the aorta. The increased endothelial expression level of SGLT1 promoted a greater accumulation of anthocyanins sensitive to LX4211. In addition, a 2-week ingestion of ARBC by old rats resulted in the accumulation of anthocyanins throughout the arterial wall of the aortic arch and aorta, and resulted in a reduced level of oxidative stress and systolic blood pressure. Thus, SGLT1 may be an attractive target to restore vascular protection at arterial sites at risk by promoting endothelial and vascular uptake of anthocyanins.

Prone positioning before extracorporeal membrane oxygenation for severe acute respiratory distress syndrome: A retrospective multicenter study

OBJECTIVE

To evaluate the clinical outcomes of patients with severe acute respiratory distress syndrome (ARDS) subjected to prone positioning before extracorporeal membrane oxygenation (ECMO).

DESIGN

A retrospective analysis of a multicenter cohort was carried out.

SETTING

Patients admitted to the Intensive Care Units of 11 hospitals in Korea.

PATIENTS

Patients were divided into those who underwent prone positioning before ECMO (n=28) and those who did not (n=34).

INTERVENTIONS

None.

VARIABLES OF INTEREST

Thirty-day mortality, ECMO weaning failure rate, mechanical ventilation weaning success rate, mechanical ventilation-free days at day 60.

RESULTS

The prone group had lower median peak inspiratory pressure and lower median dynamic driving pressure before ECMO. Thirty-day mortality was 21% in the prone group and 41% in the non-prone group (p=0.098). The prone group also showed a lower ECMO weaning failure rate, and a higher mechanical ventilation weaning success rate and more mechanical ventilation-free days at day 60. In the non-prone group, median dynamic compliance marginally decreased shortly after ECMO, but no significant change was observed in the prone group.

CONCLUSIONS

Prone positioning before ECMO was not associated to increased mortality and tended to exert a protective effect.