A263 MICE CHALLENGED WITH DNBS FOUR DAYS AFTER INFECTION WITH THE RAT TAPEWORM HYMENOLEPIS DIMINUTA ARE PROTECTED FROM COLITIS

Background

Helminth therapy for colitis is supported by data from murine models, including infection with H. diminuta inhibiting dinitrobenzene sulphonic-acid (DNBS)-induced colitis. Considering H. diminuta as a candidate helminth therapy the kinetics of infection in the context of inflammation should be addressed. Reciprocally, it is important to know if colitis alters the immune response to the helminth.

Aims

1) Assess DNBS-colitis in mice infected 4-days previously with H. diminuta. 2) Determine in DNBS-induced colitis affects the outcome of infection with H. diminuta.

Methods

Male BALB/c mice were infected by gavage with five H. diminuta and four days later were challenged with DNBS (3 mg, ir.). Disease was assessed 3 days later (i.e. day 7-post H. diminuta) by colon length, disease activity score and histopathology (n=9–14 mice, 3 experiments). Alternatively, on day three post-DNBS, mice were infected with H. diminuta and worm infectivity and splenocyte Th2-cytokine production assessed at 8 days post-infection (n=5–9 mice, 1 experiment).

Results

Mice challenged with DNBS at 4-days post-infection were significantly protected from colitis, with 2/14 mice requiring humane euthanization for disease severity compared to 6/13 in the DNBS-only group. Splenocyte production of IL-4, IL-5 and IL-10 was increased in the H. diminuta-only group compared to control mice: DNBS-only treated mice showed reduced levels of all three cytokines and H. diminuta+DNBS mice had cytokine levels not different from H. diminuta-only infected mice. DNBS-colitis prior to infection did not affect the increase in systemic TH2 immunity evoked by H. diminuta, but did result in greater intestinal worm burdens.

Conclusions

The data suggest (1) the window of opportunity for H. diminuta to suppress colitis in a prophylactic regimen is at least 4–8 days post-infection, and (2) H. diminuta administered to mice at the peak of colitis severity mobilizes TH2 immunity that could promote quicker recovery from colitis.

Funding Agencies

CAG, CCC, NRCNSERC

A74 HELMINTH ANTIGENS OR REGULATORY MACROPHAGES REDUCE THE SEVERITY OF COLORECTAL CANCER

Background

Infection with helminth parasites is a potent stimulus of immunity, and murine model systems reveal that a bystander benefit of this response to helminths is suppression of colitis. Unraveling the mechanism of this inhibition of colitis, the regulatory macrophage has emerged as a cell of interest in ‘helminth therapy’. Given the relationship between inflammation and cancer – patients with inflammatory bowel disease (IBD) have a higher risk of colorectal cancer (CRC).

Aims

To test the hypothesis that intraperitoneal administration of excretory/secretory products from the tapeworm Taenia crassiceps (TcES) or IL-4-treated macrophages (M(IL-4)) (characteristic of the immune response to helminths) would affect the outcome of CRC.

Methods

CRC was induced in female BALB/c and male C57Bl/6 mice using azoxymethane (AOM) (10 mg, ip) and three cycles of Dextran sulfate sodium (DSS: 7 days, 1–2% wt./vol.) separated by 2 weeks of normal tap water. Following initiation of CRC, mice received TcES (200 μg, ip.) - or M(IL-4) (106, ip). On necropsy, CRC incidence, number, and size of the tumour were recorded and tumors assessed histologically.

Results

Mice receiving TcES or M(IL-4)s were substantially protected from AOM-DSS induced CRC, as shown by statistically significant reductions in tumor number and size, although the number of mice developing tumors was unchanged (n=4–8 mice). The suppression of CRC in TcES-treated mice correlated with reduced mobilization of STAT3 and NF-κB signaling cascades in the as determined by immunostaining and immunoblot of whole tissue extracts.

Conclusions

With the speculation that helminth-derived molecules or transfer of in vitro educated macrophages could be used to treat IBD comes the specter of the putative oncogenic effects of regulatory macrophages. Contrary to this, the data herein show that the TcES reduced CRC; and, that murine macrophages (M(IL4)) also actually limit the severity of inflammation-driven CRC by directly targeting the cancer cells or reducing the inflammatory stimulus. These findings add emphasis to the consideration of autologous regulatory macrophage transfer to treat IBD and CRC

Funding Agencies

CCCCONACYT (Mexico)

A47 ENTERIC TUFT CELL HYPERPLASIA FOLLOWING INFECTION WITH THE TAPEWORM HYMENOLEPIS DIMINUTA IS AFFECTED BY NEURONAL BUT NOT BACTERIAL FACTORS

Background

Tuft cells are a rare chemosensory population of the intestinal epithelium that detect intestinal parasitic nematodes and release IL-25 to mobilize innate lymphoid type 2 cells (ILC2), which then drive a Th2- dominant nematode expulsion response. Immunocompetent mice develop tuft cell hyperplasia in the small intestine during infection with Hymenolepis diminuta, a non-abrasive lumen dwelling small intestinal cestode parasite. Helminth infections are accompanied by alterations in sensory motor functions of the gut as well as the composition of the microbiota. It is poorly understood if tuft cell hyperplasia is regulated by these immunomodulatory influences.

Aims

To test if mice lacking (1) a functional adaptive immune system, (2) TRPV1+ gut-innervating sensory nerves and (3) a microbiome, display enteric tuft cell hyperplasia following infection with H. diminuta.

Methods

RAG-1-/- (male and female) and germ-free mice (n=3–6) were infected with 5 cysticercoids of H. diminuta and age matched non-infected mice served as control groups. Male C57BL/6j mice were treated with resiniferatoxin (RTX) to ablate TRPV1 +sensory neurons before infection. Mid-jejunum cryostat or paraffin embedded sections immunostained against doublecortin-like kinase -1 (DCLK-1) were blindly scored for tuft cell enumeration at 5–14 days post-infection.

Results

Tuft cell hyperplasia (~10-15-fold increase) was observed in the jejunum of wild-type mice at 11 days post infection with H. diminuta, by which time worms are expelled. Infected RAG-1-/- mice develop tuft cell hyperplasia of lesser magnitude than wild-type mice. Germ-free mice displayed tuft cell hyperplasia and kinetics of worm expulsion that were not different from wild-type mice. RTX-treated mice with confirmed loss of TRPV1+ nerve fibers in the gut and their cell soma in the dorsal root and nodose ganglia, had a greater increase (~2-fold) in tuft cell numbers compared to H. diminuta-only mice at 11 days post-infection.

Conclusions

Knowledge of how the host senses helminths in the gut lumen is central to the host-parasite interaction. Using the H. diminuta-mouse model system we find that tuft cell hyperplasia is largely, but not entirely dependent on adaptive immunity, occurs independent of the gut microbiota, and, intriguingly, TRPV1+ sensory nerves appear to act as a brake on the system, limiting the magnitude of the hyperplasia.

Funding Agencies

CIHRNSERC, Henry Koopman’s Memorial scholarship

A264 HELMINTH-INFECTION MOBILIZES HOST AND MICROBIAL FACTORS THAT CO-OPERATE TO SUPPRESS CHEMICAL-INDUCED COLITIS IN MICE

Background

Infection with helminth parasites suppresses inflammation in murine model systems; for example, IL-10 is important in Hymenolepis diminuta-inhibition of DNBS-induced colitis. Bacteria-derived products can have anti-inflammatory effects. Given that infection with H. diminuta, or other parasitic worms, results in perturbation of the gut microbiota, the present study tested a role for bacteria in helminth-suppression of colitis by assessing reciprocity between IL-10 and butyrate signaling in the amelioration of colitis.

Aims

To determine if a functional relationship exists between IL-10 and butyrate in the inhibition of colitis observed following infection with the lumen-dwelling tapeworm, Hymenolepis diminuta.

Methods

Colitis was induced in male BALB/c mice by intra-rectal dinitrobenzene sulphonic acid (DNBS) (3 mg/~22g mouse), with necropsy and assessment 3 days later. Mice received either infection with five H. diminuta cysticercoids by gavage or daily butyrate enemas or acetate in their drinking water. Immunostaining assessed IL-10R protein expression on formalin-fixed sections of colon. The murine IEC4.1 epithelial cell line and epithelial organoids were treated with butyrate and mRNA for the IL10Rα chain assessed, as was colonic tissue from mice.

Results

Mice infected with H. diminuta or receiving butyrate enemas (n=8–12) were protected from DNBS-induced colitis as gauged by colon length, and macroscopic disease and histopathology scores. Addition of acetate to the drinking water resulted in a more modest anti-colitic effect. Suppression of colitis was accompanied by increased epithelial expression of IL-10 in butyrate- and H. diminuta-treated mice, with the later also showing upregulation of the IL-10R on lamina propria cells; an effect negated by co-treating the mice with broad spectrum antibiotics. In vitro analyses revealed increased IL10Rα mRNA in butyrate-treated epithelia (n=4).

Conclusions

This study begins to tease apart the host (i.e. IL-10) and bacterial (i.e. butyrate) molecules that mediate H. diminuta-evoked suppression of colitis in a murine model. These proof-of-principle data suggest that knowledge of the individual patient (i.e. immunological basis of their disease and their microbiota) may be a critical determinant of the success or failure of helminth therapy.

Funding Agencies

CAG, CCCNSERC

Association of plasma C-reactive protein with ischaemic stroke: a Mendelian randomization study

BACKGROUND AND PURPOSE

Elevated C-reactive protein (CRP) is associated with an increased risk of ischaemic stroke (IS). However, the causality of this association is uncertain. The aim is to investigate whether genetically raised plasma CRP concentration levels are associated with IS on the basis of the Mendelian randomization method.

METHODS

Based on the National Center for Biotechnology Information single nucleotide polymorphism (SNP) database, the Chinese online genetic database as well as previously published studies, four CRP-associated SNP alleles (rs1130864, rs1205, rs876537 and rs3093059) with minor allele frequency ≥0.15 were selected and the concentration levels of CRP were measured in 378 first-ever IS patients and 613 healthy controls.

RESULTS

Three SNPs were chosen and used as instrumental variables. The adjusted odds ratios (ORs) [95% confidence interval (95% CI)] of IS per addition of the modelled allele were 1.07 (0.79-1.45) for rs876537, 0.99 (0.73-1.35) for rs1205 and 1.08 (0.71-1.65) for rs3093059. The OR (95% CI) of IS for plasma CRP ≥2.0 mg/l was 2.19 (1.06-4.53) compared with <2.0 mg/l. The adjusted OR (95% CI) of IS per genetically predicted 10% higher CRP concentration, based on the three SNPs as the instruments, was 1.02 (0.94-1.11). Furthermore, similar results were obtained with adjusted ORs (95% CI) of 1.00 (0.88-1.13) and 1.04 (0.93-1.16), respectively, for large-artery atherosclerosis and small-artery occlusion per genetically predicted 10% higher CRP concentration.

CONCLUSIONS

This Mendelian randomization study provides no clear support that elevated CRP concentration is causally associated with the risk of IS.

Cytology cell blocks are suitable for immunohistochemical testing for PD-L1 in lung cancer

Background

PD-L1 immunohistochemistry (IHC) testing is usually carried out on tissue blocks from core needle biopsy or surgical resections. In this study, we assessed the feasibility of using cytology cell blocks for PD-L1 IHC assay.

Methods

A total of 1419 consecutive cases of non-small-cell lung cancer (NSCLC), including 371 cytology cell blocks, 809 small biopsies, and 239 surgical specimens, were included in the study. The cytology cell blocks were prepared with formalin only, methanol/alcohol only or both. PD-L1 expression was examined by staining with Dako PD-L1 IHC 22C3 pharmDx kit. A Tumor Proportion Score (TPS) was categorized as <1%, 1%-49% and ≥50% tumor cells. A total of 100 viable tumor cells were required for adequacy.

Results

Of the cytology cell blocks, 92% of the specimens had an adequate number of tumor cells, not significantly different from small biopsies. The rate of TPS ≥50% differed between sample types and was observed in 42% of cytology cell blocks versus 36% of small biopsies (P = 0.04), and 29% of surgical resections (P = 0.001). The fixative methods did not affect the immunostaining, with overall PD-L1 high expression (TPS ≥50%) rates of 42% in formalin-fixed specimens versus 40% in specimens with combined fixation by methanol/alcohol and formalin (NS). The PD-L1 high expression rate was not associated with EGFR, ALK or KRAS molecular alterations. Higher stage (IV) was associated with higher PD-L1 TPS (P= 0.001).

Conclusion

Our results show that when the TPS ≥50% is used as the end point, PD-L1 IHC performs well with cytology cell blocks. Cell blocks should be considered as a valuable resource for PD-L1 testing in advanced NSCLC. The clinical significance of higher PD-L1 IHC scores in cytology specimens needs to be evaluated prospectively.

Proliferation effects of cinnamon extract on human HeLa and HL-60 tumor cell lines

OBJECTIVE

To investigate the possible anti-cancer properties of cinnamon extract on two human tumor cell lines, HeLa cells and HL-60 cells.

MATERIALS AND METHODS

Two human tumor cell lines, HeLa cells and HL-60 cells, were exposed to increased concentrations of an extract prepared from cinnamon. The cell proliferation and cell cycle distribution were evaluated using MTT assay and flow cytometry, respectively. The possible action mechanism was also investigated by Western blot.

RESULTS

The results showed that cinnamon extract strongly inhibited tumor cell proliferation in a dose-dependent manner and exhibited dramatic increases in the percentage of cells in G2/M in parallel with exposure to increasing concentration of cinnamon extract. The Western blot results showed that cinnamon extract reduced the cyclin A, cyclin B1, ERK2, and p-ERK proteins expression.

CONCLUSIONS

Our study suggested that cinnamon extract inhibit the tumor cell survival by both down-regulated their target cell cycle regulation molecules and mitosis regulation molecules.

HMGA1-mediated miR-671-5p targets APC to promote metastasis of clear cell renal cell carcinoma through Wnt signaling

This study aimed to investigate the effect of miR-671-5p on metastasis of clear cell renal cell carcinoma (ccRCC) and underlying mechanism involved. The migration and invasion of ccRCC cells were determined by transwell and boyden assays in vitro and in vivo. Genes mRNA and protein expression were detected by quantitative polymerase chain reaction (qPCR) and western blot analysis, respectively. The target gene of miRNA was confirmed by luciferase reporter assays. Transcriptional regulation of miRNA by transcription factor was detected by chromatin immunoprecipitation assay (ChIP). The expression of miRNA in clinical specimens were detected by in situ hybridization (ISH). miR-671-5p promoted migration and invasion of ccRCC in vivo and in vitro. Moreover, miR-671-5p directly targeted APC to activate Wnt signaling, thus inducing the epithelial-mesenchymal transition (EMT) in ccRCC. Intriguingly, miR-671-5p expression was transcriptionally enhanced by HMGA1. Consistently, bioinformatics analysis suggested that HMGA1 was positively correlated with miR-671 expression, however, miR-671 was negatively correlated with APC. In situ hybridization analysis showed that miR-671-5p was upregulated in ccRCC compared with paracarcinoma and correlated with poor prognosis of ccRCC patients. In addition, univariate and multivariate analysis indicated that miR-671-5p expression was an independent prognostic factor for overall survival in ccRCC patients. Our data suggest that miR-671-5p is a tumor enhancer in regulating of ccRCC metastasis, and miR-671-5p may be utilized as a factor for the clinical diagnosis and prognosis of ccRCC.

228Long-term safety and effectiveness of mavacamten in symptomatic obstructive hypertrophic cardiomyopathy (oHCM) patients (pts): update from PIONEER open-label extension (PIONEER-OLE) study

Background

In a phase 2 PIONEER-HCM study, pts with symptomatic, obstructive hypertrophic cardiomyopathy (oHCM) showed improvement in left ventricular outflow tract (LVOT) obstruction, exercise capacity, and symptoms after 12 wk of treatment with the novel myosin modulator, mavacamten (Mava).

Purpose

To examine the long-term safety and effectiveness of Mava in PIONEER-OLE study

Methods

PIONEER-OLE (NCT03496168) is an ongoing 2-y multicenter study for adults with symptomatic oHCM who completed PIONEER-HCM (NCT02842242). The starting dose of Mava is 5 mg/d with titration at wk 6 to an individualized therapeutic dose (5, 10, or 15 mg). Evaluations are at wk 4, 6, 8, 12 and every 12 wk thereafter to monitor LV ejection fraction (LVEF), LVOT gradient, New York Heart Association (NYHA) class, NT-proBNP, drug concentration, and safety.

Results

13 pts (mean age, 57.8 y; 9 male; 12 on beta-blockers) were enrolled. Mean baseline LVOT obstruction and LVEF, and wk 12 changes from baseline, were similar to those in PIONEER-HCM (Table). Mava significantly reduced resting and provoked LVOT gradients and NT-proBNP at wk 12 and 24 compared with baseline (P<0.004). Of 10 pts who reached wk 24, 8 reported improvement in NYHA class (1 improved Class III to II; 7 improved Class II to I), and 2 pts remained Class II. Mava has been well tolerated up to 40 wk; 31 adverse events (AEs; 22 mild, 5 moderate) were reported in 8 pts; 1 pt had 3 severe and 1 serious AE (cholangiocarcinoma); all AEs were unrelated to study drug.

Results from PIONEER-OLE Parameter PIONEER-HCMa PIONEER-OLE Baseline Wk 12 Baselineb Wk 12 Change at Wk 12 Wilcoxon Signed Wk 24 Change at Wk 24 Wilcoxon Signed Mean ± SD Mean ± SD Mean ± SD Mean ± SD Mean ± SD Rank Mean ± SD Mean ± SD Rank (n=13) (n=13) (n=13)c (n=12)c (n=12)c P value (n=10)c (n=10)c P value LVOT Rest gradient, mmHg 69.7±53.9 27.8±31.3 67.3±42.8 12.0±5.4 −57.9±43.2 0.0005 10.5±4.8 −66.6±42.4 0.0020 LVOT Valsalva gradient, mmHg 93.7±55.6 36.8±37.5 89.9±30.7 (n=12) 23.6±20.0 −66.4±35.3 (n=11) 0.0020 21.1±11.5 −67.3±33.5 (n=9) 0.0039 LVEF, % 73.0±5.6 64.6±10.5 72.0±4.9 67.6±7.2 −4.4±5.5 0.0269 68.2±6.5 −3.2±3.3 0.0195 NT-proBNP, pg/mL 1601.3±2782 (n=12) 684±980 1836±2886 181±211 −1759±2789 0.0005 170±225 −2128±3104 0.0039 Data extraction date January 24, 2019. aCombined results shown for pts from PIONEER-HCM originally in cohort A (n=5) and cohort B (n=8). bBaseline in PIONEER-OLE occurred 6–18 months after completion of PIONEER-HCM. cNumber of pts with data available for analysis, unless otherwise specified.

Conclusion

Despite management with current therapies, pts enrolled in PIONEER-OLE with similar levels of obstruction and hypercontractility as in PIONEER-HCM. In this longest observation period, Mava significantly reduced obstruction (LVOT gradient) in pts with oHCM beyond standard HCM therapy, while maintaining normal LVEF and improving symptoms.

Acknowledgement/Funding

MyoKardia

Microbial community responses reduce soil carbon loss in Tibetan alpine grasslands under short-term warming

Changes in labile carbon (LC) pools and microbial communities are the primary factors controlling soil heterotrophic respiration (R_h ) in warming experiments. Warming is expected to initially increase R_h but studies show this increase may not be continuous or sustained. Specifically, LC and soil microbiome have been shown to contribute to the effect of extended warming on R_h . However, their relative contribution is unclear and this gap in knowledge causes considerable uncertainty in the prediction of carbon cycle feedbacks to climate change. In this study, we used a two-step incubation approach to reveal the relative contribution of LC limitation and soil microbial community responses in attenuating the effect that extended warming has on R_h . Soil samples from three Tibetan ecosystems-an alpine meadow (AM), alpine steppe (AS), and desert steppe (DS)-were exposed to a temperature gradient of 5-25°C. After an initial incubation period, soils were processed in one of two methods: (a) soils were sterilized then inoculated with parent soil microbes to assess the LC limitation effects, while controlling for microbial community responses; or (b) soil microbes from the incubations were used to inoculate sterilized parent soils to assess the microbial community effects, while controlling for LC limitation. We found both LC limitation and microbial community responses led to significant declines in R_h by 37% and 30%, respectively, but their relative contributions were ecosystem specific. LC limitation alone caused a greater R_h decrease for DS soils than AMs or ASs. Our study demonstrates that soil carbon loss due to R_h in Tibetan alpine soils-especially in copiotrophic soils-will be weakened by microbial community responses under short-term warming.

P14.33 Adult brainstem gliomas in neurofibromatosis type 1 (NF1)

BACKGROUND

The brainstem is the second location of brain tumors after optic pathways in NF1. In NF1 children, brainstem gliomas are usually indolent and have a better prognosis than their counterparts in non NF1 children. In contrast, the natural history and prognosis of adult brainstem gliomas in NF1 are nearly unknown.

MATERIAL AND METHODS

We conducted a retrospective analysis of medical records and MRI of adult NF1 patients followed for a brainstem glioma in 8 centers over a 17 years period (2000–2017). Clinical and imaging characteristics, management and outcome were analyzed.

RESULTS

Twenty five patients were included in the study (13 males and 12 females) with a median age of 32 (range 17–58). The epicenter of the tumor was located into the pons n=13 (52%), the mesencephalon n=7 (28%), the medulla oblongata n=5 (20%). On MRI, contrast enhancement was seen in 19 tumors (76%). Pathological examination was available in 13 tumors (52%) and showed a high grade astrocytoma (III or IV) in 9 tumors. Five patients were asymptomatic, 3 remained asymptomatic during the follow-up (median follow-up: 86 months, range 22–124). Twenty patients were symptomatic with a median duration of symptom of 2.5 months (range 1–10) before diagnosis. Among these symptomatic patients, 15 died from tumor progression despite treatment with radiation therapy and or chemotherapy. The median overall survival of symptomatic patients was 36 months.

CONCLUSION

Brainstem gliomas are rare tumors in adults with NF1. Unlike children, adult brainstem gliomas seem to have an unexpected poor prognosis, suggesting the disease may be different in adulthood.

Discoidin domain receptor 1 interactions with myosin motors contribute to collagen remodeling and tissue fibrosis

Discoidin Domain Receptor (DDR) genes and their homologues have been identified in sponges, worms and flies. These genes code for proteins that are implicated in cell adhesion to matrix proteins. DDRs are now recognized as playing central regulatory roles in several high prevalence human diseases, including invasive cancers, atherosclerosis, and organ fibrosis. While the mechanisms by which DDRs contribute to these diseases are just now being delineated, one of the common themes involves cell adhesion to collagen and the assembly and organization of collagen fibers in the extracellular matrix. In mammals, the multi-functional roles of DDRs in promoting cell adhesion to collagen fibers and in mediating collagen-dependent signaling, suggest that DDRs contribute to multiple pathways of extracellular matrix remodeling, which are centrally important processes in health and disease. In this review we consider that interactions of the cytoplasmic domains of DDR1 with cytoskeletal motor proteins may contribute to matrix remodeling by promoting collagen fiber alignment and compaction. Poorly controlled collagen remodeling with excessive compaction of matrix proteins is a hallmark of fibrotic lesions in many organs and tissues that are affected by infectious, traumatic or chemical-mediated injury. An improved understanding of the mechanisms by which DDRs mediate collagen remodeling and collagen-dependent signaling could suggest new drug targets for treatment of fibrotic diseases.

Relationship Between Bone Mineral Density T-Score and Nonvertebral Fracture Risk Over 10 Years of Denosumab Treatment

Although treat-to-target strategies are being discussed in osteoporosis, there is little evidence of what the target should be to reduce fracture risk maximally. We investigated the relationship between total hip BMD T-score and the incidence of nonvertebral fracture in women who received up to 10 years of continued denosumab therapy in the FREEDOM (3 years) study and its long-term Extension (up to 7 years) study. We report the percentages of women who achieved a range of T-scores at the total hip or femoral neck over 10 years of denosumab treatment (1343 women completed 10 years of treatment). The incidence of nonvertebral fractures was lower with higher total hip T-score. This relationship plateaued at a T-score between -2.0 and -1.5 and was independent of age and prevalent vertebral fractures, similar to observations in treatment-naïve subjects. Reaching a specific T-score during denosumab treatment was dependent on the baseline T-score, with higher T-scores at baseline more likely to result in higher T-scores at each time point during the study. Our findings highlight the importance of follow-up BMD measurements in patients receiving denosumab therapy because BMD remains a robust indicator of fracture risk. These data support the notion of a specific T-score threshold as a practical target for therapy in osteoporosis. © 2019 The Authors Journal of Bone and Mineral Research published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research (ASBMR).

Association between non-high-density lipoprotein cholesterol levels and asymptomatic vulnerable carotid atherosclerotic plaques

BACKGROUND AND PURPOSE

Carotid atherosclerosis, especially rupture of plaques, is related to cerebrovascular diseases. Non-high-density lipoprotein cholesterol (non-HDL-C) is relevant to cerebrovascular diseases and may be a potential risk factor. We designed this study to investigate the association between non-HDL-C and the prevalence of asymptomatic vulnerable carotid atherosclerotic plaques.

METHODS

We enrolled 2888 participants who underwent carotid atherosclerotic plaque detection and non-HDL-C measurement, with no history of taking lipid-lowering agents, from the Asymptomatic Polyvascular Abnormalities in Community study. We used multivariable logistic regression to estimate the association between non-HDL-C levels and the presence of asymptomatic vulnerable carotid atherosclerotic plaques.

RESULTS

In our study, 1505 subjects had asymptomatic vulnerable carotid atherosclerotic plaques and 1383 subjects had stable plaques. After adjustment for confounding factors, the odds ratios for vulnerable plaques of non-HDL-C levels in the middle and highest tertile groups were 1.02 (95% confidence interval, 0.84-1.23) and 1.50 (95% confidence interval, 1.23-1.82), respectively (P trend < 0.01).

CONCLUSION

In our community-based observational and cross-sectional study, non-HDL-C level was a significant risk factor for the occurrence of asymptomatic vulnerable carotid plaques.

Feed preference and feeding behaviours in grower broilers fed diets containing wheat naturally contaminated with fusarium mycotoxins

1. Two trials were conducted to determine the effect of feeding diets contaminated with fusarium mycotoxins (primarily deoxynivalenol (DON)) on broiler chicken feed preference, feeding behaviour and growth performance. 2. A total of 120 male Ross 308 chicks (4 birds/cage, 30 cages) were fed a common corn-based starter diet from 1 to 20 d of age. At 21 d, 15 cages were randomly assigned to the feed preference trial or a feeding behaviour trial. Three wheat-based experimental diets (0.14, 2.27 and 5.84 mg/kg DON) were prepared with a clean wheat and a naturally contaminated wheat. Broilers were ad libitum fed the experimental diets during 21-27 d. 3. In the preference trial, each cage's feeder was split into two equal-sized compartments so birds were provided a choice of two diets (control vs. low, control vs. high and low vs. high DON). In the feeding behaviour trial, diets were randomly assigned to 15 cages (5 cages/diet). Feeding and drinking behaviour was recorded for 1 h before and after the dark period and 1-h period at 9 h after the light was turned on (middle of day). Growth performance was assessed at 27 d. 4. In the preference trial, broilers preferred the control diet over low (93.0 vs. 66.1 g/d, P < 0.01) and high (104.4 vs. 50.4 g/d, P < 0.01) DON diets. At all three timepoints, where behaviour was recorded, birds offered the DON diets spent more time at the feeder compared to birds provided control diets (P < 0.05). Control birds had lower feed to gain ratio (1.65) than birds fed low (1.82) and high (1.94) DON diets (P < 0.01). 5. It is clear that broilers are sensitive to the presence of fusarium mycotoxins and that moderate levels of DON negatively affect feed preference and growth performance when fed during the grower period.

Oxidative lipoprotein markers predict poor functional outcome in patients with minor stroke or transient ischaemic attack

BACKGROUND AND PURPOSE

Oxidative stress plays an important role in acute ischaemic stroke. However, the association of oxidative lipoprotein markers, including oxidized low-density lipoprotein (oxLDL), oxLDL:high-density lipoprotein (HDL) and oxLDL:low-density lipoprotein (LDL), with functional outcome of minor stroke or transient ischaemic attack (TIA) remains unclear. We aimed to investigate the association between oxidative lipoprotein markers and poor functional outcome in patients with minor stroke or TIA.

METHODS

All patients with minor stroke or TIA were recruited from the Clopidogrel in High-Risk Patients With Acute Non-Disabling Cerebrovascular Events (CHANCE) trial. The poor functional outcome included modified Rankin Scale (mRS) score 2-6 and 3-6 at 90-day and 12-month follow-up. Multivariate logistic regression was used to investigate the associations of oxLDL, oxLDL:HDL and oxLDL:LDL with poor functional outcome.

RESULTS

Among 3019 patients included in this study, the median (interquartile range) oxLDL, oxLDL:HDL and oxLDL:LDL were 13.96 (6.65-28.81), 4.52 (2.08-9.32) and 11.73 (5.27-24.85) μg/dL, respectively. After adjusted for confounding factors, patients in the highest oxLDL quartile had a higher proportion of mRS score 2-6 at 90 days [hazard ratio (HR), 1.78; 95% confidence interval (CI), 1.26-2.52] and 12 months (HR, 1.42; 95% CI, 1.01-1.99), and mRS score 3-6 at 90 days (HR, 1.98; 95% CI, 1.29-3.04) and 12 months (HR, 1.77; 95% CI, 1.09-2.89) when compared with the lowest oxLDL quartile (P < 0.05). Similar results were found for oxLDL:HDL and oxLDL:LDL.

CONCLUSIONS

Higher levels of oxidative lipoprotein markers are independent predictors of poor functional outcome in patients with minor stroke or TIA at 90 days and 12 months.

Clinical implications of cardiovascular outcome trials in type 2 diabetes

Cardiovascular disease (CVD) is the main reason for premature death in patients with type 2 diabetes. Hyperglycemia, the hallmark of diabetes, has long been considered the link between diabetes and CVD, and many trials focused on preventing CVD manifestations by means of tight glucose control. However, diabetes is a multifactorial disease in which, e. g., insulin resistance, endothelial dysfunction, and factors such as hypertension and dyslipidemia contribute. Thus, treatment needs to be multifactorial and take cardiovascular aspects into account. Newer classes of drugs, originally launched for glucose lowering, among them dipeptidyl-peptidase (DPP)-4 inhibitors, sodium-glucose cotransporter (SGLT)-2 inhibitors, and glucagon-like peptide (GLP)-1 receptor agonists, have been studied in large cardiovascular outcome trials (CVOT). Several SGLT-2 inhibitors and GLP-1 receptor agonists are associated with a reduction of cardiovascular events (cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke). Although the mechanisms behind the effects are not fully understood, an important reason for the benefits of SGLT-2 inhibitors seems be a reduction in heart failure, while GLP-1 receptor agonists may retard the development of the atherosclerotic vascular disease or may be effective by stabilizing plaques. The outcomes of these studies have been taken into account in recently issued guidelines and an important task for diabetologists, cardiologists, and general practitioners is to incorporate the findings of these trials into clinical practice.

Abstract P4-01-13: Molecular characterization of circulating tumor DNA in Chinese metastatic breast cancer (mBC) patients

Background: Circulating tumor DNA (ctDNA) have been increasingly used as a minimal invasive test to detect genomic alterations of cancer patients.

Methods: We performed a retrospective analysis of blood samples from mBC patients (pts) collected at baseline, on-treatment, and disease progression. A highly sensitive, plasma-derived ctDNA-based NGS assay (PredicinePLUS, a comprehensive 180 key cancer gene panel) was used to detect somatic mutations and copy number variations in ctDNA with an in-house propriety algorithm.

Results: In this study, we evaluated 162 blood samples from 109 mBC pts who underwent systematic therapy at Beijing Cancer Hospital with approval from Research Ethics Committee. 129 samples from 92 pts passed NGS quality check, and were included in the analysis. Among these pts, the percent of HR+, HER2+ and Triple-Negative pts is 36.8%, 29.5% and 31.5%, respectively. About 86% samples contain somatic mutations and/or copy number variations. Collectively, 372 somatic mutations (SNV and Indels) were detected on 76 genes, among which TP53 (44.2%), PIK3CA (25.3%), BRCA2(10.5%) and ATM (10.5%) were frequently altered with frequency varying across different subtypes. ESR1 hotspot mutations ((D538G and Y537S/N/C) were also detected in a subset of HR+ patients. Copy number gain or loss was detected on 32 genes, including amplification of ERBB2, PIK3CA, FGFR1 and deletion of CDKN2A, ATM, RB1 etc. Importantly, ERBB2 copy number amplifications were only detected in HER2 IHC positive cases for base-line samples, leading to 68% sensitivity and 100% specificity. Interestingly, ctDNA yield increased as disease progressed, suggesting ctDNA yield may serve as a potential biomarker for predicting treatment response and monitoring disease progression. Additional genomic alterations that change dynamically along with the course of treatment or associate with drug response and/or resistance were also identified.

Conclusions: This study demonstrated ctDNA-based genomic analysis was highly sensitive and specific in detecting various genomic alterations, consistent with other published studies. It also suggests that HER2 copy number amplification could be robustly assessed in a non-invasive manner.

Citation Format: Yu J, Li H, Zhang S, Wang A, Zhao Z, Liu X-R. Molecular characterization of circulating tumor DNA in Chinese metastatic breast cancer (mBC) patients [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-01-13.

Abstract P3-10-09: Relationship between tumor infiltrating lymphocytes (TILs) and response to pembrolizumab (Pembro)+chemotherapy (Chemo) as neoadjuvant treatment (NAT) for triple-negative breast cancer (TNBC): phase Ib KEYNOTE-173 trial

Background:Increasing quantities of stromal TILs (sTILs) are associated with higher pathologic complete response (pCR) rates with conventional chemo in early-stage TNBC. We evaluated the association between sTILs and PD-L1 expression with response to pembro+chemo as NAT for TNBC in the KEYNOTE-173 trial (NCT02622074).

Methods: sTILs were quantified using light microscopy of H&E-stained slides from pretreatment and on-treatment (during first 3 weeks of pembro monotherapy) tumor biopsies by a pathologist blind to response data. Pretreatment PD-L1 expression was assessed using the PD-L1 IHC 22C3 pharmDx assay and reported as combined positive score (CPS). Endpoints were pCR rate by ypT0 ypN0 and ypT0/Tis ypN0 and objective response rate (ORR; RECIST v1.1) after the first 4 cycles of NAT (taxane±carboplatin+pembro) by MRI. sTILs and PD-L1 CPS were evaluated as continuous variables. Association between sTILs and PD-L1 CPS with response was assessed using logistic regression and area under the reciever operating curve (AUROC) analyses, with a 1-sided alpha level of 0.10. Correlation between PD-L1 and sTILs was assessed by Spearman's rank correlation coefficient. Multivariate analysis included sTILs (pretreatment and on-treatment) and PD-L1 CPS. Likelihood ratio tests were used to evaluate the added value of factors in predicting pCR rate.

Results: Of 60 total pts, 34 had tumors evaluated for pretreatment sTILs, 52 for PD-L1 CPS, and 33 for both sTILs and CPS. On-treatment sTILs were evaluated in 31 pts. Overall pCR rates were 56.7% and 60% by ypT0 ypN0 and ypT0/Tis ypN0, respectively; ORR was 78.3%. In pts evaluated for sTILs and CPS (individually), pCR rates and ORR were comparable with overall pCR rates and ORR. There was a significant correlation between pretreatment sTILs and PD-L1 CPS (ρ=0.65, P&lt;0.001).Higher pretreatment sTILs were significantly associated with response: ypT0 ypN0 P= 0.011; ypT0/Tis ypN0 P=0.006; ORR P=0.061. On-treatment sTILs were also significantly associated with response: ypT0 ypN0 P=0.061; ypT0/Tis ypN0 P=0.041; ORR P=0.031. Pretreatment PD-L1 CPS was significantly associated with response: ypT0 ypN0 P=0.073; ypT0/is ypN0 P=0.030; and ORR P=0.021. AUROC of pretreatment sTIL association with pCR was numerically higher than with on-treatment sTILs and PD-L1 CPS (0.69 vs 0.61 vs 0.56 for ypT0ypN0 and 0.72 vs 0.67 vs 0.62 for ypT0/Tis ypN0). Responders had higher median pretreatment sTIL levels vs nonresponders: 45% [10, 75] vs 10% [5, 20] for pCR rate by ypT0 ypN0 and 52.5% [10, 73.8] vs 10% [5, 20] for pCR rate by ypT0/Tis ypN0; 25% [5, 70] vs 10% [6.3, 27.5] for ORR. In multivariate analysis, only pretreatment sTILs were significant for both pCR endpoints (ypT0 ypN0 P=0.031; ypT0/Tis ypN0 P=0.034). Likelihood ratio tests demonstrated that for both pCR endpoints, PD-L1 CPS (P=0.683/P=0.422) and on-treatment sTILs (P=0.984/P=0.568) did not add significantly more value to pretreatment sTILs when predicting pCR.

Conclusions:Higher quantities of pretreatment sTILs and PD-L1 CPS and on-treatment sTILs were significantly associated with higher pCR rates and ORR in primary TNBC treated with pembro and NAT.

Citation Format: Loi S, Schmid P, Cortés J, Park YH, Muñoz-Couselo E, Kim S-B, Sohn J, Im S-A, Holgado E, Foukakis T, Kuemmel S, Dent R, Wang A, Aktan G, Karantza V, Salgado R. Relationship between tumor infiltrating lymphocytes (TILs) and response to pembrolizumab (Pembro)+chemotherapy (Chemo) as neoadjuvant treatment (NAT) for triple-negative breast cancer (TNBC): phase Ib KEYNOTE-173 trial [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-10-09.

Synthesis and antibacterial activity of novel icariin derivatives

A series of aromatic sulfonyls substituted icariin derivatives was synthesized and their antibacterial activities against S. aureus (including drug-sensitive bacteria and drug-resistant bacteria) were evaluated. Among them, compound 9 exhibited high potency against methicillin-sensitive (MSSA) and resistant strains of S. aureus (MRSA) with MIC values of 1-2 mmol/L. Reverse virtual screening and molecule docking analysis indicated that compound 9 might bind the allosteric site of PBP2a that may inhibit cell wall synthesis, with the advantage of activity against multidrug resistant S. aureus. SPR experiment further confirmed the binding affinity. Therefore, we consider aromatic sulfonyls at C-3 position substituted icariin derivatives to be a novel class of anti-MRSA agents worth of further investigation.

Logistic regression model to predict acute uncomplicated and complicated appendicitis

INTRODUCTION

While patients with acute uncomplicated appendicitis may be treated conservatively, those who suffer from complicated appendicitis require surgery. We describe a logistic regression equation to calculate the likelihood of acute uncomplicated appendicitis and complicated appendicitis in patients presenting to the emergency department with suspected acute appendicitis.

MATERIALS AND METHODS

A cohort of 895 patients who underwent appendicectomy were analysed retrospectively. Depending on the final histology, patients were divided into three groups; normal appendix, acute uncomplicated appendicitis and complicated appendicitis. Normal appendix was considered the reference category, while acute uncomplicated appendicitis and complicated appendicitis were the nominal categories. Multivariate and univariate regression models were undertaken to detect independent variables with significant odds ratio that can predict acute uncomplicated appendicitis and complicated appendicitis. Subsequently, a logistic regression equation was generated to produce the likelihood acute uncomplicated appendicitis and complicated appendicitis.

RESULTS

Pathological diagnosis of normal appendix, acute uncomplicated appendicitis and complicated appendicitis was identified in 188 (21%), 525 (59%) and 182 patients (20%), respectively. The odds ratio from a univariate analysis to predict complicated appendicitis for age, female gender, log2 white cell count, log2 C-reactive protein and log2 bilirubin were 1.02 (95% confidence interval, CI, 1.01, 1.04), 2.37 (95% CI 1.51, 3.70), 9.74 (95% CI 5.41, 17.5), 1.57 (95% CI 1.40, 1.74), 2.08 (95% CI 1.56, 2.76), respectively. For the same variable, similar odds ratios were demonstrated in a multivariate analysis to predict complicated appendicitis and univariate and multivariate analysis to predict acute uncomplicated appendicitis.

CONCLUSIONS

The likelihood of acute uncomplicated appendicitis and complicated appendicitis can be calculated by using the reported predictive equations integrated into a web application at www.appendistat.com. This will enable clinicians to determine the probability of appendicitis and the need for urgent surgery in case of complicated appendicitis.

Lymphovascular invasion as a poor prognostic indicator in thoracic esophageal carcinoma: a systematic review and meta-analysis

The ability to further stratify patients with esophageal carcinoma (EC) in the same stage into high-risk patients by the presence of lymphovascular invasion (LVI) may permit refinement of multi-modality therapy. However, the role of LVI in the prognosis of EC is not definite. A meta-analysis was conducted to investigate the relationship between LVI and EC prognosis. We searched PubMed, Embase, Web of Science, and Cochrane Library databases for studies on the association between LVI and prognosis of EC. Only studies with patient survival data related to LVI were included. The effect size for this analysis was the hazard ratio (HR) with 95% confidence intervals (CI) for overall survival (OS) and recurrence-free survival (RFS). Thirty-five studies with 9876 patients were included according to the defined inclusion and exclusion criteria. LVI was a poor indicator for the OS (HR = 1.64, 95% CI: 1.44-1.87, P < 0.001) and RFS (HR = 1.79, 95% CI: 1.38-2.34, P < 0.001). However, the heterogeneity was medium in OS (I2 = 61.2%, P < 0.001) and extreme in RFS (I2 = 77.5%, P < 0.001). In subgroup analysis, heterogeneity was originated from the staining method and proportion of early disease (stage (I + II)). We concluded that LVI was a poor prognostic indicator in patients with EC, especially in those studies with the IHC staining method and a high proportion of early disease (stage (I + II)).

The risk of subsequent osteoporotic fractures is decreased in subjects experiencing fracture while on denosumab: results from the FREEDOM and FREEDOM Extension studies

This post-hoc analysis queried whether women experiencing fracture on denosumab indicates inadequate treatment response or whether the risk of subsequent fracture remains low with continuing denosumab. Results showed that denosumab decreases the risk of subsequent fracture and fracture sustained while on denosumab is not necessarily indicative of inadequate treatment response.

INTRODUCTION

This analysis assessed whether a fracture sustained during denosumab therapy indicates inadequate treatment response and if the risk of a subsequent fracture decreases with continuing denosumab treatment.

METHODS

In FREEDOM, a clinical trial to evaluate the efficacy and safety of denosumab, postmenopausal women with osteoporosis were randomized to placebo or denosumab for 3 years. In the 7-year FREEDOM Extension, all participants were allocated to receive denosumab. Here we compare subsequent osteoporotic fracture rates between denosumab-treated subjects during FREEDOM or the Extension and placebo-treated subjects in FREEDOM.

RESULTS

During FREEDOM, 438 placebo- and 272 denosumab-treated subjects had an osteoporotic fracture. Exposure-adjusted subject incidence per 100 subject-years was lower for denosumab (6.7) vs placebo (10.1). Combining all subjects on denosumab from FREEDOM and the Extension for up to 10 years (combined denosumab), 794 (13.7%) had an osteoporotic fracture while on denosumab. Of these, one or more subsequent fractures occurred in 144 (18.1%) subjects, with an exposure-adjusted incidence of 5.8 per 100 subject-years, similar to FREEDOM denosumab (6.7 per 100 subject-years) and lower than FREEDOM placebo (10.1 per 100 subject-years). Adjusting for prior fracture, the risk of having a subsequent on-study osteoporotic fracture was lower in the combined denosumab group vs placebo (hazard ratio [95% CI]: 0.59 [0.43-0.81]; P = 0.0012).

CONCLUSIONS

These data demonstrate that denosumab decreases the risk of subsequent fracture and a fracture sustained while on denosumab is not necessarily indicative of inadequate treatment response.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

The effect of maternal low flow oxygen administration during the second stage of labour on umbilical cord artery pH: a randomised controlled trial

OBJECTIVE

To assess the effect of maternal low flow oxygen administration during the second stage of labour on umbilical cord artery pH.

DESIGN

A randomised controlled trial.

SETTING

A tertiary teaching hospital in China.

POPULATION

Women in the second stage of labour with no complications.

METHODS

About 443 women were randomly allocated to receive either supplemental oxygen at a flow rate of 2 l/min or a sham supplementation by nasal cannula. Healthcare providers, women and outcome assessors were blinded to allocation.

MAIN OUTCOME MEASURES

Umbilical cord artery pH and fetal heart rate (FHR) pattern.

RESULTS

Baseline characteristics were similar between the two groups. There were no significant differences between the two groups in the umbilical cord artery pH [median 7.261, interquartile range (IQR) 7.228-7.295 versus 7.266 (IQR 7.232-7.297), P = 0.64], the proportion with pH less than 7.2 [30/219 versus 34/224, P = 0.66, RR (relative risk) 0.9, 95% CI 0.57-1.42], and the proportion with normal FHR pattern (147/219 versus 153/224, P = 0.79, RR 0.98, 95% CI 0.86-1.12). Maternal partial pressure of dissolved oxygen was significantly higher in the oxygen group than in the sham group [median 150.0 mmHg (IQR 142.6-156.7) versus 112.0 (IQR 104.8-118.3), P < 0.001], whereas carbon dioxide was significantly lower in the oxygen group than in the sham group (mean difference -1.1, 95% CI -2.1 to -0.1, P = 0.03).

CONCLUSION

The use of 2 l/min maternal oxygen during the second stage of labour did not adversely affect either the umbilical artery pH or the FHR pattern distribution.

TWEETABLE ABSTRACT

No difference in abnormal fetal acid base or normal heart rate if maternal O₂ given, randomised trial finds.

Association of serum galectin-3 with risks of death and vascular events in acute ischaemic stroke patients: the role of hyperglycemia

BACKGROUND AND PURPOSE

Whether the association between galectin-3 and stroke outcome is modified by fasting plasma glucose (FPG) is unknown. The aim was to evaluate the prognostic effect of galectin-3 amongst ischaemic stroke patients stratified by FPG.

METHODS

In all, 3082 ischaemic stroke patients were included in this study and serum galectin-3 was tested at baseline. The primary outcome was a composite outcome of death and vascular events, and secondary outcomes were death, stroke recurrence and vascular events within 1 year after stroke.

RESULTS

Increased galectin-3 was significantly associated with the primary outcome, stroke recurrence and vascular events in the patients with hyperglycemia but not in those with normoglycemia (P for interaction < 0.05 for all). The multivariate-adjusted hazard ratios (95% confidence intervals) were 1.72 (1.05-2.84), 2.64 (1.14-6.12) and 2.68 (1.33-5.38) for the primary outcome, stroke recurrence and vascular events, respectively. A linear association between galectin-3 and the primary outcome was observed in hyperglycemic patients (P for linearity = 0.007).

CONCLUSION

Increased galectin-3 was associated with the primary outcome, stroke recurrence and vascular events within 1 year after stroke in the patients with hyperglycemia, suggesting that galectin-3 may be an important prognostic factor for ischaemic stroke patients with hyperglycemia.

Hemorrhagic transformation after stroke: inter- and intrarater agreement

BACKGROUND AND PURPOSE

Hemorrhagic transformation (HT) is a complication of stroke that can occur spontaneously or after treatment. We aimed to assess the inter- and intrarater reliability of HT diagnosis.

METHODS

Studies assessing the reliability of the European Cooperative Acute Stroke Study (ECASS) classification of HT or of the presence (yes/no) of HT were systematically reviewed. A total of 18 raters independently examined 30 post-thrombectomy computed tomography scans selected from the Aspiration versus STEnt-Retriever (ASTER) trial. They were asked whether there was HT (yes/no), what the ECASS classification of the particular scan (0/HI1/HI2/PH1/PH2) (HI indicates hemorrhagic infarctions and PH indicates parenchymal hematomas) was and whether they would prescribe an antiplatelet agent if it was otherwise indicated. Agreement was measured with Fleiss' and Cohen's κ statistics.

RESULTS

The systematic review yielded four studies involving few (≤3) raters with heterogeneous results. In our 18-rater study, agreement for the presence of HT was moderate [κ = 0.55; 95% confidence interval (CI), 0.41-0.68]. Agreement for ECASS classification was only fair for all five categories, but agreement improved to substantial (κ = 0.72; 95% CI, 0.69-0.75) after dichotomizing the ECASS classification into 0/HI1/HI2/PH1 versus PH2. The inter-rater agreement for the decision to reintroduce antiplatelet therapy was moderate for all raters, but substantial among vascular neurologists (κ = 0.70; 95% CI, 0.57-0.84).

CONCLUSION

The ECASS classification may involve too many categories and the diagnosis of HT may not be easily replicable, except in the presence of a large parenchymal hematoma.