Determination of physiological cardiac myosin-binging protein levels (cMyc) in healthy populations

Background

Cardiac myosin–binding protein C (cMyC) is a cardiac-restricted protein that has more abundant, rapid release and clearance kinetics than cardiac troponin. The current ESC guideline suggests the cMyC may provide value as an alternative to cardiac troponin. The 99th percentile value is universally endorsed as the reference cut off to aid in the diagnosis of acute myocardial infarction (AMI), however, none of the report of healthy population of cMyC.

Purpose

The aim of this study was to evaluate the distribution of cMyC values in healthy subjects.

Methods

We used two cohorts in this retrospective study. 1) Healthy subjects; a total of 500 subjects (250 men and 250 women) who had annual health examinations in 2012 in the area of Kamigoto, a suburb of Nagasaki city in Southern Japan were enrolled. All participants showed none of abnormal findings including cell blood counts, chemical analysis, liver function tests, general urine tests, occult blood tests of stool, barium swallow, mammography for women, abdominal ultrasound sonography, and electrocardiogram. All blood samples were obtained in a fasting state in the morning. 2) Chest pain subjects; we collected samples from 250 subjects including 50 with non-ST elevation myocardial infarction visited admitted to a university hospital for measurement of high-sensitivity troponin T and coronary artery assessment by coronary angiography. We measured cMyC level in both cohorts by HISCL™-800 system (Sysmex corporation, Japan). The assay has a limit of detection of 0.5 ng/L and a lower limit of quantification of 1.3 ng/L.

Result

In healthy subjects, median age (IQR) was 44 (20, 82) in men and 50 (23, 91) in women. The 99th percentile of cMyC was 27.3 ng/L, which was around one-third lower than that in previous report (87 ng/L). In chest pain subjects, the concentrations of cMyC at presentation were significantly higher in those with versus without AMI (median, 66 ng/L versus 10 ng/L, P<0.001). Discriminatory power for AMI, as quantified by the area under the receiver-operating characteristic curve (AUC), was comparable for cMyC (AUC, 0.85 (95% CI 0.79–0.91) and hs-cTnT (AUC, 0.81 (95% CI 0.76–0.88)).

Conclusion

We defined the normal range of cMyC in healthy Japanese subjects. The level of cMyC at presentation provides discriminatory power comparable to hs-cTnT in the diagnosis of AMI. To determine the physiological value of a biomarker may be necessary to evaluate enough information about their health status.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant-in-Aid for Scientific Research

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

Background

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Funding Acknowledgement

Type of funding sources: None.

Exploration of electrocardiographic and echocardiographic findings to screen transthyretin amyloid cardiomyopathy in patients with mild left ventricular hypertrophy

Background

The transthyretin amyloid cardiomyopathy (ATTR-CM), a common condition in the elderly, is a life-threatening disease; however, it is treatable. The early accurate diagnosis is, therefore, an important key to improve the patient's outcomes. Electrocardiography and echocardiography are instant diagnostic tools with red flags for the screening of the ATTR-CM. In fact, ATTR-CM often mimics left ventricular hypertrophy (LVH), and the differential diagnosis is difficult to establish. Thus, the characteristics of cardiac amyloidosis may be obscured in ATTR-CM patients with mild LVH, possibly making the disease difficult to diagnose. Therefore, in this study, the effect of LVH on the occurrence of electrocardiographic and echocardiographic parameters for ATTR-CM was investigated, and their incremental value over the age for the screening of ATTR-CM in the patients with mild LVH was recorded.

Methods

This study retrospectively studied 319 consecutive nonischemic LVH patients with a sinus rhythm who underwent detailed diagnostic tests. The light chain-associated amyloidosis was an exclusion criterion. The mean left ventricular wall thickness (MWT) <12 mm was defined as mild LVH, while MWT ≥12 mm was defined as moderate to severe LVH. The ATTR-CM was diagnosed with biopsy or 99 mTc-PYP scintigraphy. The elderly were defined as people aged ≥65 years in males and ≥70 years in females, according to the literature. Each electrocardiographic and echocardiographic parameter was binarized with an external cut-off point to increase the external validity, being the incremental benefit of each parameter over age for identifying ATTR-CM assessed using a receiver operating characteristic curve analysis and comparisons of the area under the curve (AUC).

Results

Fourteen patients (8%) among the 170 patients with mild LVH had ATTR-CM, while 27 patients (18%) among the 149 patients with moderate to severe LVH had ATTR-CM. The patients with mild LVH had fewer electrocardiographic and echocardiographic parameters, showing a significant difference between ATTR-CM and non-ATTR-CM patients than those with moderate to severe LVH (Table 1). Among several binarized parameters, the voltage-to-mass ratio, E/A ratio, the global longitudinal strain, and also the relative apical sparing pattern demonstrated additive value for identifying the ATTR-CM over aging (Table 2). In addition, the discriminative ability of the propensity score calculated from these four variables and age was considered excellent for the screening of ATTR-CM (AUC = 0.98).

Conclusion

The patients with mild LVH appear to have fewer electrocardiographic and echocardiographic specific findings of the ATTR-CM compared to patients with moderate to severe LVH. However, several red flags may be useful for screening ATTR-CM even in patients with a mild LVH.

Funding Acknowledgement

Type of funding sources: None. Table 1Table 2

Reappraising the role of baseline plasma C-reactive protein levels on recurrence after catheter ablation of persistent atrial fibrillation: insight from EARNEST-PVI trial

Background

Subclinical inflammation is an important pathogenesis of developing and sustaining atrial fibrillation (AF). Because AF itself contribute to the inflammatory response, the role of baseline subclinical inflammation on AF recurrence after catheter ablation (CA) remains controversial in patients with persistent AF.

Purpose

To evaluate whether baseline plasma C-reactive protein (CRP) levels, a sensitive marker of inflammation, are associated with AF recurrence following CA.

Methods

The analysis was performed from the EARNEST-PVI trial, a randomized controlled trial designed to assess a CA strategy for persistent AF, which was conducted in the Osaka region of Japan. A total of 441 patients (median age, 67 years; 26% female; 25% long-standing persistent AF) whose plasma CRP levels were measured at baseline were included in this study.

Results

At baseline, a median (interquartile range) of plasma CRP level was 0.10 [0.06–0.19] mg/dl. Plasma CRP levels significantly increased at discharge (0.83 [0.21–1.84] mg/dl, p<0.001) and decreased 1 year after CA (0.10 [0.05–0.20] mg/dl, p=0.040) compared to the baseline value. During the follow-up of 1 year, 115 patients (26%) experienced AF recurrence, and the incidence was significantly higher in 124 patients with low CRP levels at baseline (cut-off ≤0.06 mg/dl) than the other 317 patients (33.9% vs. 23.0%, p=0.017). After adjustment of age, gender, body mass index, long-standing persistent AF, CA strategy, and plasma brain natriuretic peptide levels, low plasma CRP levels was a significant predictor of AF recurrence (hazard ratio, 1.51; 95% confidence interval, 1.02–2.24; p=0.042).

Conclusions

Low plasma CRP levels at baseline predicted AF recurrence in the EARNEST-PVI trial. Reappraising the role of CRP on AF recurrence may be needed in patients with persistent AF.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Johnson & Johnson KK

Left atrial dysfunction still exists in patients who obtain normal left atrial volume after successful ablation of atrial fibrillation

Introduction

Atrial fibrillation (AF) promotes left atrial (LA) remodeling and vice versa. LA volume index (LAVI) ≥34 mL/m2 is an established cut-off value for identifying an enlarged left atrium. Catheter ablation has become an established therapy for AF and provides a reduction of LA volume by maintaining sinus rhythm (reverse remodeling). However, the definition of LA reverse remodeling after AF ablation is undetermined.

Purpose

We hypothesized that patients with LA dilatation who obtain normal LA volume (LAVI <34 mL/m2) after AF ablation would have better long-term outcomes than those who do not. Furthermore, we investigated whether patients with a normal LA volume could also obtain normal LA function with AF ablation.

Methods

We enrolled 140 AF patients with baseline LAVI ≥34 mL/m2, without AF recurrence for 1 year after the initial AF ablation. We acquired conventional and speckle-tracking echocardiographic parameters within 24 h and at 1 year after the procedure. Late recurrence was defined as AF recurrence >1 year after the initial ablation. To define the normal range of LA function, age-and sex-matched 140 controls without a history of AF were also enrolled.

Results

After restoration of sinus rhythm, overall LA structural and functional parameters were significantly improved, and 75 patients (54%) had normal LA volume at the time of follow-up (Table). During a median follow-up of 44 (31–61) months, 32 patients (23%) experienced a late recurrence of AF. Patients who obtained normal LA volume after AF ablation had fewer late recurrences than those who did not (P<0.01) (Figure). However, LA functional abnormalities still existed in AF patients, even if LA volume was normalized as in controls (Table).

Conclusion

Patients who obtain normal LA volume have better long-term outcomes of AF ablation than those who do not. Although AF ablation promotes beneficial effects on LA structure and function, LA function cannot be normalized even in patients who obtain normal LA volume after successful ablation. Thus, physicians should carefully consider long-term follow-up and residual AF risks, regardless of sinus rhythm restoration by catheter ablation.

Funding Acknowledgement

Type of funding sources: None.

Renal function and arrhythmia outcomes in persistent atrial fibrillation patients after catheter ablation: subanalysis of the EARNEST-PVI trial

Background

Atrial fibrillation (AF) reduces the renal function. Renal dysfunction and AF often coexist. Catheter ablation (CA) of persistent AF can maintain a sinus rhythm and may improve the renal function.

Purpose

We sought to elucidate whether the estimated glomerular filtration rate (eGFR) in patients with persistent AF was increased after CA, especially with the presence of an AF recurrence.

Methods

We enrolled 487 persistent AF patients whose eGFR data were available both before and 1-year after the CA out of 512 patients in the EARNEST-PVI trial.

Results

The mean age was 65±9 year and 113 patients (24.8%) had long-standing persistent AF. We compared the eGFR at baseline with that 1-year after the CA. AF recurrences were recognized in 118 patients (25.8%). The eGFR was similar between the group without recurrence and that with recurrence at baseline (without AF recurrence vs. with AF recurrence; 63.8±14.3 vs. 62.7±13.6 mL/min/1.73m2, p=0.46). In patients without AF recurrence, the G1, G2, G3a, G3b, G4, and G5 were 13 (3.8%), 198 (58.4%), 98 (28.9%), 26 (7.7%), 3 (0.9%), and 1 (0.3%), respectively at baseline. In the patients with AF recurrence, the G1, G2, G3a, G3b, G4, and G5 were 3 (2.5%), 68 (57.8%), 38 (32.2%), 6 (5.1%), 3 (2.5%), and 0 (0%), respectively at baseline. The ΔeGFR was significantly higher in the patients without AF recurrence than in those with AF recurrence (without AF recurrence vs. with AF recurrence; 5.1 [−0.3, 10.8] vs. 3.0 [−3.0, 7.6], p=0.0033). In the patients without AF recurrence, a better eGFR class at 1-year after the CA than in those before the CA was recognized in 75 patients (22.1%), while it was recognized in 19 patients (16.1%) with AF recurrences.

Conclusion

Successful catheter ablation in patients with persistent AF led to a better renal outcome.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This study was funded by Medtronic, Johnson & Johnson, and Abbott.

Left ventricular longitudinal shortening at cardiac base as a determinant of left atrial reservoir function in cardiac amyloidosis

Objective

To investigate a mechanistic determinant of left atrial (LA) reservoir function in patients presenting left ventricular (LV) hypertrophy, and clarify diagnostic and prognostic values of LA reservoir strain in patients with cardiac amyloidosis (CA).

Methods

Three-hundred sixty patients (median age: 68 years, male gender: 65%) with left ventricular hypertrophy (LVH) assessed by echocardiography were retrospectively included. The LVH etiologies were diagnosed by any of biopsy, cardiac magnetic resonance imaging or 99mTc-PYP scintigraphy. LV segmental longitudinal strain was estimated from apical three views, and LA reservoir strain was measured from an apical 4-chamber view.

Results

The LVH etiologies were confirmed with CA in 81 patients, hypertensive heart disease in 87 patients, hypertrophic cardiomyopathy in 143 patients, and miscellaneous disorders in 49 patients. The median (25th, 75th percentile) value of LV ejection fraction was 59% (48–67). LV basal longitudinal strain and LA reservoir strain were significantly reduced in patients with CA compared with those with other etiologies; LV basal strain: 5.4% (3.9–8.7) vs. 11.9% (9.3–14.6), LA reservoir strain: 9.2% (6.3–12.3) vs. 17.5% (11.3–24.1), p<0.01 respectively. LV basal strain was significantly correlated with LA reservoir strain in patients with CA (r=0.57, p<0.01) and in those with other etiologies (r=0.45, p<0.01). The area under the receiver-operating characteristic curves of LA reservoir strain and E/e' (0.78 and 0.74) to identify CA etiology were significantly larger than that of LA volume index (0.62) (p<0.01). During the follow-up period (median 2.9 years), 53 patients experienced heart failure hospitalization. The Cox regression model including age, gender, LV ejection fraction, E/e' and LA reservoir strain showed that male gender (hazard ratio: 0.46, p=0.03), E/e' (hazard ratio: 1.04, p<0.01) and LA reservoir strain (hazard ratio: 0.94, p<0.01) independently predicted heart failure hospitalization.

Conclusions

The decrease of LV longitudinal shortening at cardiac base could worsen LA reservoir function especially in patients with CA. LA reservoir strain might be an alternative measure to identify CA etiology and have a predictive value of heart failure hospitalization in patients with LV hypertrophy.

Funding Acknowledgement

Type of funding sources: None.

Differences in quality of life improvement with pulmonary vein isolation alone vs. more extensive ablation of persistent atrial fibrillation: insights from the EARNEST-PVI trial

Background

Improving the quality of life (QoL) is one of the main purposes of catheter ablation (CA) of persistent atrial fibrillation (AF). QoL improvement in persistent AF patients has not been fully clarified. The EARNEST-PVI trial was a multi-center randomized trial comparing clinical outcomes of pulmonary vein isolation (PVI) alone and more intensive ablation in addition to PVI including complex fractionated atrial electrogram (CFAE) and linear ablation (PVI plus).

Purpose

To investigate the QoL change after persistent AF ablation and the differences between the PVI-alone strategy and the PVI plus strategy.

Methods

In the EARNEST-PVI trial, patients with persistent AF who underwent an initial catheter ablation (n=512) were randomly assigned in a 1:1 ratio to either PVI alone or PVI plus. Quality of life was assessed at baseline and at 12 months after ablation for AF using the 36-Item Short Form Health Survey. Scores were also converted to a physical health component summary (PCS), a mental health component summary (MCS) and a role/social component summary (RCS).

Results

In the EARNEST-PVI trial, the PVI alone strategy was associated with higher recurrence rate compared with the PVI plus additional ablation strategy. After excluding 68 patients for whom preoperative or postoperative QoL assessment was not available, 222 patients were evaluated respectively. Overall, significant improvements in PCS (46.2±11.4 to 48.7±11.4]), MCS (50.1±8.8 to 54.3±8.6) and RCS (44.6±13.3 to 48.6±11.3) occurred 12 months after ablation (P<0.001, respectively). Although significant QoL improvement occurred in both PVI alone and PLI plus strategies, the changes in PCS was greater in the PVI-plus than that in PVI-alone (3.5±10.3 vs 1.5±10.6, P=0.04).

Conclusions

Ablation for persistent atrial fibrillation improved both physical and mental quality of life. The PVI-plus strategy showed greater improvement in physical QoL.

Funding Acknowledgement

Type of funding sources: None. QoL improvement

Two cases of immunoglobulin G4-related disease diagnosed by transvaginal urethral needle biopsy

INTRODUCTION

Immunoglobulin G4-related disease is a systemic disease characterized by multifocal systemic involvement. We report two cases of women diagnosed with immunoglobulin G4-related disease in the urethra.

CASE PRESENTATION

Case 1: A 67-year-old woman presented with discomfort around her perineum. Magnetic resonance imaging revealed a well-defined mass around the urethra. She underwent an ultrasound-guided core needle biopsy of the mass. The pathologic specimen showed immunoglobulin G4 positive cells. Steroid therapy was initiated, causing improvement of symptoms, decreased serum immunoglobulin G4 levels, and shrinking of the mass. Case 2: An 89-year-old woman was accidentally diagnosed with renal pelvic wall thickening on computed tomography. The pathologic specimen captured by ultrasound-guided needle biopsy showed immunoglobulin G4 positive cells. She had no symptoms and received no medical treatment.

CONCLUSION

The frequency of urethral mass formation in female patients with immunoglobulin G4-related disease may also be high, and an echo-guided transvaginal urethral biopsy may be performed as a definitive diagnostic tool for immunoglobulin G4-related disease.

Risk factors for disease progression in Japanese patients with COVID-19 with no or mild symptoms on admission

BACKGROUND

Although the risk factors for coronavirus disease 2019 (COVID-19) mortality have been identified, there is limited information about the risk factors for disease progression after hospitalization among Japanese patients with COVID-19 exhibiting no or mild symptoms.

METHODS

All 302 consecutive patients who were admitted to our institutions and diagnosed with COVID-19 between March and December 2020 were retrospectively assessed. Ultimately, 210 adult patients exhibiting no or mild symptoms on admission were included in the analysis. They were categorized into the stable (no oxygen needed) and worsened (oxygen needed) groups, and their characteristics and laboratory data were compared.

RESULTS

Among 210 patients, 49 progressed to a severe disease stage, whereas 161 did not. The mean patient age was 52.14 years, and 126 (60.0%) patients were male. The mean body mass index (BMI) was 23.0 kg/m², and 71 patients were overweight (BMI ≥ 25 kg/m²). Multivariate logistic analysis showed that old age, overweight, diabetes mellitus (DM), and high serum ferritin levels were independent risk factors for disease progression.

CONCLUSIONS

Clinicians should closely observe patients with COVID-19, especially those with risk factors such as old age, overweight, DM, and high serum ferritin levels, regardless of whether they have no or mild symptoms.

Gender differences in self-perceived changes among Japanese workers with depression

BACKGROUND

The number of patients living with depression continues to increase in Japan. The economic effects of depression include loss of productivity due to both absenteeism and presenteeism. Gender differences have been reported in prevalence, onset pathways and subjective symptoms of depression.

AIMS

To understand how workers with major depressive disorder (MDD) perceive problems in the workplace and examine gender differences in their self-perceived levels of functioning at work, noticed during the initial stages of depression.

METHODS

This is a cross-sectional study of Japanese workers with MDD. Participants' self-perceived changes in the level of functioning at work were surveyed after the diagnosis during the first visit. The relationship between gender and changes in the level of functioning at work as initially perceived by the participants themselves was analysed using the chi-square test, supplemented by a residual analysis.

RESULTS

We administered the survey to 147 workers with MDD. In terms of gender differences in initial self-perceived changes in the level of functioning at work, the proportion of men reporting reduced work efficiency was significantly higher than that of women, while the proportion of women reporting deterioration in relationships with colleagues and superiors was significantly higher than that of men.

CONCLUSIONS

The findings suggest that greater attention to reduced work efficiency by men and to deterioration in work relationships by women with MDD should be essential components of self-care. Managers need to pay attention to the level of functioning and provide adequate social support for employees.

Gefitinib induction followed by chemoradiotherapy in EGFR-mutant, locally advanced non-small-cell lung cancer: LOGIK0902/OLCSG0905 phase II study

Background

The role of epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor (TKI) induction coupled with standard concurrent chemoradiotherapy (CRT) is unclear in unresectable, stage III, EGFR-mutant non-small-cell lung cancer (NSCLC). Therefore, a phase II trial was conducted to evaluate the efficacy and safety of gefitinib induction followed by CRT in this disease setting.

Patients and methods

Patients with unresectable, EGFR-mutant, stage III NSCLC were administered gefitinib monotherapy (250 mg/day) for 8 weeks. Subsequently, patients without disease progression during induction therapy were administered cisplatin and docetaxel (40 mg/m² each) on days 1, 8, 29, and 36 with concurrent radiotherapy at a total dose of 60 Gy. The primary endpoint was the 2-year overall survival (OS) rate, which was hypothesized to reach 85%, with a threshold of the lower limit of 60%.

Results

Twenty patients (median age: 66 years; male/female: 9/11; histology: 20 adenocarcinoma; stage IIIA/IIIB: 9/11; and exon 19/21: 10/10) were enrolled. The 2-year OS rate was 90% (90% confidence interval: 71.4% to 96.8%), indicating that this trial met the primary objective. The overall response rate and 1- and 2-year progression-free survival rates were 85.0%, 58.1%, and 36.9%, respectively. Grade ≥3 adverse events (>10%) included hepatic toxicity during the induction phase and neutropenia and febrile neutropenia in the CRT phase. Radiation pneumonitis grade ≥3 or treatment-related death did not occur.

Conclusions

This is the first prospective study to demonstrate the favorable efficacy and safety of EGFR-TKI induction followed by standard CRT in EGFR-mutant, stage III NSCLC. Further confirmatory studies are needed.

•

This is the first prospective study evaluating gefitinib induction followed by CRT in EGFR-mutated, locally advanced NSCLC.

•

The 2-year OS rate was 90% (90% confidence interval: 71.4% to 96.8%), indicating that this trial met the primary objective.

•

The objective response rate throughout the treatment protocol was 85.0% (17 of 20).

•

The safety findings were consistent with the known safety profiles of all agents administered.

•

Our results might raise a critical point that needs to be evaluated in further studies to improve the cure rate.

Impact of health-related quality of life on repeat protocol biopsy compliance on active surveillance for favorable prostate cancer: results from a prospective cohort in the PRIAS-JAPAN study

OBJECTIVES

This study aimed to evaluate how health-related quality of life (HRQOL) is related to repeat protocol biopsy compliance.

MATERIALS AND METHODS

We conducted a retrospective analysis using data from a prospective cohort in the Prostate Cancer Research International: Active Surveillance (PRIAS)-JAPAN study between January 2010 and August 2019. We used the Short Form 8 Health Survey (SF-8), as patient-reported outcomes, to assess HRQOL at AS enrollment and the first year of the protocol. The physical component summary (PCS) and mental component summary (MCS) were calculated from SF-8 questionnaires. The primary outcome was the evaluation of the association of HRQOL at enrollment on the first repeat biopsy compliance. The secondary outcome was the comparison of SF-8 scores during AS, stratified by repeat protocol biopsy compliance.

RESULTS

Of 805 patients who proceeded to the first year of the protocol, the non-compliance rate was 15% (121 patients). In the adjusted model, lower MCS at enrollment was significantly associated with the first repeat protocol biopsy non-compliance (odds ratio [OR], 2.134; 95% confidence interval [CI], 1.031-4.42; P = 0.041) but not in lower PCS (OR, 0.667; 95% CI, 0.294-1.514; P = 0.333). All subscales of SF-8 were lower in the non-compliance group than in the compliance group at any point. MCS in the non-compliance group improved over time from the time of AS enrollment (2.34 increased, P = 0.152).

CONCLUSION

Our data suggest that lower MCS at AS enrollment using patient-reported outcomes was negatively associated with the first repeat protocol biopsy compliance. Our study may support the availability of a simple questionnaire to extract non-compliance.

Geochemical characterization of monazite sands based on rare earth elements, thorium and uranium from a natural high background radiation area in Tamil Nadu, India

The Kanyakumari coastal area in the southernmost part of Tamil Nadu, India is a well-known natural high background radiation area due to the abundance of monazite in beach placer deposits. In the present study, the concentrations of major oxides, rare earth elements (REEs), Th and U were measured to understand geochemical characteristics of these monazite sands. Based on the ambient dose rate, 23 locations covering an area of about 60 km along the coast were selected for sample collection. The concentrations of U and Th ranged from 1.1 to 737.8 μg g^-1 and 25.2-12250.6 μg g^-1, respectively. The Th/U ratio ranged from 2.2 to 61.6, which clearly indicated that Th was the dominant contributing radionuclide to the enhanced natural radioactivity in this coastal region. The chondrite-normalized REEs pattern of the placer deposits showed enrichment in light REEs and depletion in heavy REEs with a negative Eu anomaly that indicated the monazite sands were derived from granite, charnockite, and granitoid rocks from the Nagercoil and the Trivandrum Blocks of the Southern Granulite Terrain.

Albumin-bilirubin grade as a significant prognostic factor in patients with non-small cell lung cancer treated with anti-PD-1-based therapy: A multicenter retrospective study

e21125

Background: Albumin-bilirubin (ALBI) grade is calculated from albumin and bilirubin values as continuous variables, allowing an accurate evaluation of liver function. Some studies showed that ALBI grade was a prognostic and predictive biomarker for the efficacy of chemotherapy in cancer patients. However, no report has examined the association between ALBI grade and outcome in patients with non-small cell lung cancer (NSCLC) treated with anti-programmed cell death-1 (PD-1)-based therapy. Methods: We retrospectively enrolled 452 patients with advanced or recurrent NSCLC treated with anti-PD-1-based therapy (nivolumab or pembrolizumab monotherapy or pembrolizumab combination therapy) between 2016 and 2019 at three medical centers in Japan. With reference to previous reports, ALBI score was calculated using the formula (log10 (total bilirubin [mg/dL] x 17.1) x 0.66) + (albumin [g/dL] x 10 x −0.085), and the score was stratified as grade 1 (≤ −2.60), grade 2 (more than −2.60 to ≤ −1.39), and grade 3 (more than −1.39). We examined the clinical impact of ALBI grade on outcome in patients with NSCLC receiving anti-PD-1-based therapy using Kaplan–Meier survival analysis with the log-rank test and Cox proportional hazards regression analysis. Results: Of the 452 patients, 158 (35.0%) patients were classified as grade 1, 271 (60.0%) as grade 2, and 23 (5.0%) as grade 3. ALBI grade was strongly correlated with performance status (PS), clinical stage, and body mass index, and mutation status ( P < 0.0001, P = 0.0077, P = 0.0050, and P = 0.0302, respectively). The Kaplan–Meier curves showed that ALBI grade was significantly associated with progression-free survival (PFS) and overall survival (OS) ( P < 0.0001 and P < 0.0001, respectively). Multivariate analyses showed that PS ( P = 0.0044), combination therapy of anti-PD-1 and chemotherapy ( P = 0.0004), programmed cell death-ligand 1 (PD-L1) expression status ( P < 0.0001), and ALBI grade ( P < 0.0001) were independent prognostic factors for PFS. Multivariate analyses also showed that PS ( P = 0.0008), combination therapy of anti-PD-1 and chemotherapy ( P = 0.0066), PD-L1 expression status ( P = 0.0006), and ALBI grade ( P < 0.0001) were independent prognostic factors for OS. In the subgroup analysis, ALBI grade effectively stratified PFS and OS regardless of PD-L1 expression status. Conclusions: We report for the first time that ALBI grade was an independent prognostic factor for PFS and OS in patients with advanced or recurrent NSCLC receiving anti-PD-1-based therapy. These findings should be validated prospectively.

The role of comprehensive analysis with circulating tumor DNA in advanced non-small cell lung cancer patients considered for osimertinib treatment

Background

EGFR mutations are good predictive markers of efficacy of EGFR tyrosine kinase inhibitors (EGFR‐TKI), but whether comprehensive genomic analysis beyond EGFR itself with circulating tumor DNA (ctDNA) adds further predictive or prognostic value has not been clarified.

Methods

Patients with NSCLC who progressed after treatment with EGFR‐TKI, and with EGFR T790 M detected by an approved companion diagnostic test (cobas^®), were treated with osimertinib. Plasma samples were collected before and after treatment. Retrospective comprehensive next‐generation sequencing (NGS) of ctDNA was performed with Guardant360^®. Correlation between relevant mutations in ctDNA prior to treatment and clinical outcomes, as well as mechanisms of acquired resistance, were analyzed.

Results

Among 147 patients tested, 57 patients received osimertinib, with an overall response rate (ORR) of 58%. NGS was successful in 54 of 55 available banked plasma samples; EGFR driver mutations were detected in 43 (80%) and T790 M in 32 (59%). The ORR differed significantly depending on the ratio (T790 M allele fraction [AF])/(sum of variant AF) in ctDNA (p = 0.044). The total number of alterations detected in plasma by NGS was higher in early resistance patients (p = 0.025). T790 M was lost in 32% of patients (6 out of 19) after acquired resistance to osimertinib. One patient with RB1 deletion and copy number gains of EGFR, PIK3CA, and MYC in addition to T790 M, showed rapid progression due to suspected small cell transformation.

Conclusions

NGS of ctDNA could be a promising method for predicting osimertinib efficacy in patients with advanced NSCLC harboring EGFR T790 M.

Divalent metal transporter-related protein restricts animals to marine habitats

Utilization and regulation of metals from seawater by marine organisms are important physiological processes. To better understand metal regulation, we searched the crown-of-thorns starfish genome for the divalent metal transporter (DMT) gene, a membrane protein responsible for uptake of divalent cations. We found two DMT-like sequences. One is an ortholog of vertebrate DMT, but the other is an unknown protein, which we named DMT-related protein (DMTRP). Functional analysis using a yeast expression system demonstrated that DMT transports various metals, like known DMTs, but DMTRP does not. In contrast, DMTRP reduced the intracellular concentration of some metals, especially zinc, suggesting its involvement in negative regulation of metal uptake. Phylogenetic distribution of the DMTRP gene in various metazoans, including sponges, protostomes, and deuterostomes, indicates that it originated early in metazoan evolution. However, the DMTRP gene is only retained in marine species, and its loss seems to have occurred independently in ecdysozoan and vertebrate lineages from which major freshwater and land animals appeared. DMTRP may be an evolutionary and ecological limitation, restricting organisms that possess it to marine habitats, whereas its loss may have allowed other organisms to invade freshwater and terrestrial habitats.

Mieko Sassa et al. report a novel divalent metal transporter protein (DMTRP) in the crown-of-thorns starfish genome and determine that all organisms with a DMTRP gene are located in marine habitats. They also show in a functional yeast system that DMTRP can prevent uptake of certain metals, bringing insight into the evolution of metal regulation for marine organisms.

The effects of antibiotics on the efficacy of immune checkpoint inhibitors in patients with non-small-cell lung cancer differ based on PD-L1 expression

BACKGROUND

Immune checkpoint inhibitors (ICIs) are essential for treatment of various malignancies, including non-small-cell lung cancer (NSCLC). Recently, several studies have shown that the gut microbiome plays an important role in ICI treatment of solid cancers, and antibiotic (ATB) use had a negative impact on the outcomes of ICI treatment via dysbiosis in the gut. However, whether this is applicable to NSCLC remains unclear. The impact of ATBs based on PD-L1 expression also remains unclear.

METHODS

We retrospectively reviewed the medical records of patients with NSCLC who received ICI monotherapy (anti-PD-1 or anti-PD-L1 antibody) at nine institutions from December 2015 to May 2018. Outcomes with use of ATBs during the 2 months before or a month after initiation of ICI treatment, including progression-free survival (PFS) and overall survival (OS), were investigated using the Kaplan-Meier method. Multivariate analysis was also conducted using a Cox proportional hazards model.

RESULTS

A total of 531 patients were included in this study, among whom 98 (18.5%) received ATBs before or after ICI treatment. ATB use was significantly associated with a shorter median OS (11.7 months in the ATB group vs. 16.1 months in the non-ATB group; p = 0.028), whereas the difference in PFS was not significant (3.5 months in both the groups; p = 0.287). We next investigated the association based on PD-L1 expression in the 265 patients for whom PD-L1 expression was determined. There was no significant difference in the median OS or PFS between patients with NSCLC and PD-L1 expression <50% receiving ATBs and those not receiving ATBs (PFS: 3.3 vs. 2.8 months, p = 0.88; OS: 9.5 vs. 17.1 months, p = 0.24). Conversely, patients with NSCLC and PD-L1 expression ≥50% receiving ATBs showed significantly shorter median PFS and OS (PFS: 4.2 vs. 9.4 months, p = 0.012; OS: 11.9 vs. 28.4 months, p = 0.011). The impact of ATBs in patients with NSCLC and PD-L1 expression ≥50% was more significant than that in the entire cohort.

CONCLUSIONS

Our results indicate that the impact of ATB use on the efficacy of ICIs differed based on PD-L1 expression in patients with advanced NSCLC. A negative impact of ATB use was found in patients with NSCLC and PD-L1 expression ≥50% but not in those with PD-L1 expression <50%.