Study of twice-weekly injections of Teriparatide by comparing efficacy with once-weekly injections in osteoporosis patients: the TWICE study

A 48-week, multicenter, randomized, double-blind, double-dummy, active-controlled, non-inferiority trial (the TWICE study) conducted in Japanese primary osteoporosis patients with a high risk of fractures demonstrated that a 28.2-μg twice-weekly regimen of teriparatide can provide comparable efficacy to a 56.5-μg once-weekly regimen of teriparatide, while also improving safety.

INTRODUCTION

While a 56.5-μg once-weekly regimen of teriparatide has high efficacy for osteoporosis, treatment continuation rates are low, with one of the major causes being adverse drug reactions such as nausea or vomiting. The TWICE study was therefore conducted to investigate whether a twice-weekly regimen with 28.2-μg teriparatide can provide comparable efficacy to the 56.5-μg once-weekly regimen while improving safety.

METHODS

A 48-week, multicenter, randomized, double-blind, double-dummy, active-controlled, non-inferiority trial was conducted in Japan. Patients with primary osteoporosis aged ≥ 65 years at high risk of fractures (n = 553) were randomly allocated to the 28.2-μg twice-weekly group (n = 277) or the 56.5-μg once-weekly group (n = 276). The primary endpoint was the percentage change in lumbar spine (L2-L4) bone mineral density (BMD) at final follow-up.

RESULTS

The percentage changes in lumbar spine (L2-L4) BMD at final follow-up in the 28.2-μg twice-weekly and 56.5-μg once-weekly groups were 7.3% and 5.9%, respectively; the difference (95% confidence interval [CI]) in percentage change was 1.3% (0.400-2.283%). Since the lower limit of the 95% CI was above the pre-specified non-inferiority margin (- 1.6%), non-inferiority of the 28.2-μg twice-weekly group was demonstrated. Adverse drug reactions were significantly less frequent in the 28.2-μg twice-weekly group (39.7% vs 56.2%; p < 0.01); the incidence of major adverse drug reactions was lower, and the number of subjects who discontinued due to adverse drug reactions was less in the 28.2-μg twice-weekly group.

CONCLUSIONS

A 28.2-μg twice-weekly regimen of teriparatide can provide comparable efficacy to a 56.5-μg once-weekly regimen while improving safety.

CLINICAL TRIAL REGISTRATION

JapicCTI-163477 .

P3615The number of coronary risk factors and mortality in patients with acute myocardial infarction from Japanese nation-wide real-world database

Background

Hypertension, diabetes, dyslipidemia and smoking are so-called coronary risk factors for coronary heart disease, which were established by extensive epidemiological research. However, in Japanese patients with acute myocardial infarction (AMI), the impact of number of coronary risk factors on in-hospital morality has not been elucidated.

Methods

The Japan Acute Myocardial Infarction Registry (JAMIR) is a nationwide real-world database integrated form 10 regional registries. We examined the association between number of coronary risk factors and in-hospital mortality from this JAMIR registry.

Results

The data were obtained from total of 20462 AMI patients (mean age, 68.8±13.3 years old; 15281 men, 5181 women). Figure 1 shows the prevalence of each coronary risk factors stratified by sex and decade. The prevalence of hypertension became higher with the advanced age while the prevalence of smoking became lower with the advanced age. Prevalence of diabetes and dyslipidemia were highest in middle age. Majority (76.9%) of the patients with AMI had at least 1 of these coronary risk factors and, 23.1% had none of them. Overall, except women under 50, number of coronary risk factor was relatively less in older age (Figure 2). In-hospital mortality by sex and decades was shown in figure 3. In-hospital mortality rates were 10.7%, 10.5%, 7.2%, 5.0% and 4.5% with 0, 1, 2, 3 and 4 risk factors, respectively (Figure 4A). After adjusting age and sex, there was an inverse association between the number of coronary risk factors and in-hospital mortality (adjusted odds ratio [1.68; 95% CI, 1.20–2.35] among individuals with 0 vs. 4 risk factors, Figure 4B).

Conclusion

In the present study of Japanese patients with AMI, who received modern medical treatment, in-hospital mortality was inversely related to the number of coronary risk factors.

Acknowledgement/Funding

Grant-in-Aid for Scientific Research

P1864Primary predictor of esophageal injury after catheter ablation of atrial fibrillation

Background

It has been demonstrated that the short distance between the esophagus and the posterior left atrium (LA) is closely associated with the occurrence of esophageal injury (EI) after catheter ablation of atrial fibrillation (AF). Meanwhile, it has not been fully elucidated whether esophageal temperature monitoring sufficiently prevent EI.

Objectives

The purpose of this study was to examine the usefulness of esophageal temperature monitoring for avoiding EI. Further we analyzed the relation between the incidence of EI and the distance between the esophagus and the posterior LA measured on the contrast computed tomography (CT).

Methods

Among 403 patients who underwent catheter ablation of AF, upper gastrointestinal tract endoscopy was performed the next day after ablation to examine for EI. The incidence of EI was compared between 95 patients who used esophageal temperature probe (ETP) (ETP Group) and 308 patients who did not used ETP (Non-ETP Group) during ablation. The shortest distance between esophagus and posterior LA measured on contrast CT (SD-CT) was also compared between the ETP and Non-ETP Groups.

Results

In all patients, EI was found in 35 patients (8.6%). The SD-CT in patients with EI was significantly lower than that in patients without EI (2.3±0.6 vs 4.1±0.8 mm, p<0.001).

No differences were observed between the two groups in terms of age, body mass index, LA diameter, esophageal course, total number of radiofrequency (RF) energy applications, total amount of RF energy applications, or the location of SD-CT. Also, EI occurred at nealy the same frequency between the ETP Group and Non-ETP Group (8/95 patients; 8.4% vs 27/308 patients; 8.8%, p=0.553). The severity diagnosed as moderate (erosion) in 3 patients and mild (erythema) in 5 patients of ETP Group, and as severe (ulcer) in 23 patients and mild (erythema) in 4 patients of Non-ETP Group. There was no significant difference in the SD-CT between the ETP Group and Non-ETP Group (3.96±0.98 vs 4.19±1.01 mm, p=0.54). However, the SD-CT in patients with EI was significantly shorter than the SD-CT in patients without EI, both in the ETP Group (2.3±0.6 vs 4.1±0.9 mm, p<0.001) and in the Non-ETP Group (2.5±0.2 vs 4.2±0.9 mm, p=0.017), respectively. Multiple regression analysis revealed that only SD-CT significantly correlated with EI. The area under a receiver operating characteristic curve using ST-CT as a predictive marker in EI patients was 0.971 (p<0.001). When the cut-off value of EI was set at 2.9mm, the sensitivity and specificity for EI diagnosis were 96.6% and 87.5%.

Conclusions

The incidence of EI was significantly correlated with SD-CT. Esophageal temperature monitoring did not reduce EI, however, the use of monitoring alleviated the severity of EI, especially in patients with short SD-CT.

Acknowledgement/Funding

None

P3632Prognostic impact of aortic valve stenosis in patients with acute myocardial infarction

Background

Aortic valve stenosis (AS) is associated with the presence and severity of coronary artery disease independently of clinical risk factors, which leads to increased cardiovascular mortality. However, the prevalence of AS and its prognostic value among patients with acute myocardial infarction (AMI) remain unknown.

Purpose

The purpose of this study was to investigate the prevalence and prognostic impact of AS in AMI patients.

Methods

We studied 2,803 AMI patients using data from Mie ACS registry, a prospective and multicenter registry. Patients were divided into subgroups according to the presence and severity of AS based on maximal aortic flow rate by Doppler echocardiography before hospital discharge: non-AS <2.0 m/s, 2.0 m/s≤mild AS <3.0 m/s, 3.0 m/s≤moderate AS <4.0m/s and severe AS≥4.0 m/s. The primary outcome was defined as 2-year all-cause mortality.

Results

AS was detected in 79 patients (2.8%) including 49 mild AS, 23 moderate AS and 6 severe AS. AS patients were significantly older (79.9±9.8 versus 68.3±12.6 years), and higher killip classification than non-AS patients (P<0.01, respectively). However, left ventricular ejection fraction, and prevalence of primary PCI was similar between the 2 groups. During the follow-up periods (median 725 days), 333 (11.9%) patients experienced all-cause death. AS patients demonstrated the higher all-cause mortality rate compared to that of non-AS patients during follow up (47.3% versus 11.3%, P<0.0001, chi square). Kaplan-Meier curves showed that the probability of all-cause mortality was significantly higher among AS patients than non-AS patients, and was highest among moderate and severe AS (See figure A and B). Cox regression analyses for all-cause mortality demonstrated that the severity of AS was the strongest and independent poor prognostic factor (HR 1.71, 95% CI 1.30–2.24, P<0.001, See table).

Cox hazard regression analysis Hazard ratio 95% Confidential interval P-value Severity of aortic valve stenosis 1.71 1.30–2.24 <0.001 Killip classification 1.63 1.46–1.82 <0.001 Age 1.07 1.06–1.09 <0.001 Serum creatinine level 1.05 1.03–1.08 <0.001 Max CPK level 1.00 1.00–1.01 <0.001 Left ventricular ejection fraction 0.96 0.95–0.97 <0.001 Primary percutaneous coronary intervention 0.67 0.47–0.96 0.03 CPK suggests creatinine phosphokinase.

All cause mortality

Conclusions

The presence of AS of any severity contributes to worsening of patients' prognosis following AMI independently of other known risk factors.

Acknowledgement/Funding

None

P5007Acute natriuretic activity of sodium-glucose cotransporter 2 inhibitor in heart failure patients with type 2 diabetes mellitus

Background

Sodium-glucose cotransporter 2 (SGLT2) inhibitor promotes diuresis and reduces the risk of hospitalization for heart failure (HF). However, the mechanisms of diuretic effects of SGLT2 inhibitor in HF patients with type 2 diabetes mellitus (T2DM) remain under investigation.

Purpose

The purpose of this study was to investigate the mechanisms of acute diuretic effects of SGLT2 inhibitor and to identify its predictor in HF patients with T2DM.

Methods

We prospectively enrolled 40 hospitalized HF patients with T2DM (68±13 years, 63% male, and hemoglobin A1c 7.1±0.9%) between July 2014 and June 2018. All patients received ipragliflozin at a dose of 50 mg once daily after breakfast. They underwent 24-hour urine test and first-morning blood and urine tests before and after ipragliflozin therapy.

Results

Urine volume significantly increased from 1,365±511 ml/day on day 0 to 1,698±595 ml/day on day 3 (p<0.001). Multivariate linear regression analyses showed that the increase of 24-hour urine sodium but not urine sugarwas significantlyand independently associated with the increase of 24-hour urine volume (β-Coefficient=0.80; P<0.001). Univariate and multivariate logistic regression analyses showed that higher dosage of furosemide-equivalent loop diuretics and lower level of first-morning urine sodium concentration (per 1 mEq/L) at baseline were significantly associated with the diuretic effect of ipragliflozin therapy, and the latter independently predicted increase of 24-hour urine volume (Table).

Predictors for increase of urine volume Univariate Multivariate Odds ratio (95% CI) P value Odds ratio (95% CI) P value Dosage of furosemide, mg 1.09 (1.01–1.18) 0.04 – – HbA1c, % 1.45 (0.56–3.78) 0.44 Fasting blood glucose, mg/dL 1.02 (0.99–1.04) 0.24 eGFR, mL/min/1.73m2 1.01 (0.97–1.05) 0.65 Plasma BNP, pg/mL 1.00 (0.99–1.01) 0.12 Left ventricular ejection fraction, % 0.98 (0.94–1.02) 0.24 First-morning urine sugar, mg/dL 1.20 (0.96–1.50) 0.12 First-morning urine sodium, mEq/L 0.96 (0.93–0.99) 0.02 0.96 (0.93–0.99) 0.02 24-hour urine sugar, g/day 3.49 (0.13–93.40) 0.46 24-hour urine sodium, mEq/day 0.98 (0.96–1.01) 0.20 eGFR, estimated glomerular filtration rate; BNP, brain natriuretic peptide.

Conclusion

SGLT2 inhibitor has acute natriuretic activity and may restore loop-diuretic resistance in HF patients with T2DM.

Acknowledgement/Funding

None

P5437The BNP reporter mouse by knock-in technology is useful for the analysis of mechanism in reactivation of BNP in adult heart

Background

It has been thought BNP is induced by undetermined stretch-activated receptors, however, which receptor is associated remains unknown. The stretch-activated receptors include mechanically gated channels, which can be activated by a mechanical stimulus alone, and mechanically modulated channels, which require nonmechanical stimuli such as agonists. It has been recently shown that 1.1kb segment of mouse NPPB promoter dose not reproduce the pattern of reactivation of BNP in adult heart, although it could monitor the expression of BNP in neonatal cardiomyocytes.

Purpose

Our aim is to develop a true BNP reporter mouse and examine whether this mouse is useful or not for the investigation of BNP reactivation mechanism in adult heart and for the measurement of serum-induced BNP expression in patients with heart failure.

Methods

We generated the BNP reporter mice by knocking luciferase cDNA in the initiation site of NPPB. In vivo imaging of luciferase was performed in the BNP reporter mice after the intraperitoneal injection of luciferin. The luciferase activity was examined in neonatal cardiomyocyte, isolated adult cardiomyocytes, adult cardiac dissected tissue with or without 120–150% stretch or angiotensin II stimulation. Left anterior descending (LAD) coronary artery was ligated to study myocardial infarction. Cardiac dissected tissue segments from the BNP reporter mouse were incubated for 8 hours with 20% serum from patients with or without heart failure and the luciferase activity was measured after homogenization.

Results

The in vivo imaging system showed the activity of BNP was high in 1 day-old neonates and the reactivation of BNP in the adult heart after LAD ligation could be monitored by the luciferase activity (figure). The treatment of Ang II could increase the activity of pBNP more than ten folds in heart tissue from adult mice. On the other hand, the 120–150% stretch did not show any effect on the activity of pBNP in this system. We could not observe any activation of pBNP in cultured neonatal or adult cardiomyocytes demonstrated by immunostain with antibodies against luciferase after 120–150% stretch. Interestingly, the luciferase activity was extensively higher in cultured heart tissue segments from the BNP reporter mice after the treatment of serum from patients with heart failure than without heart failure.

In vivo imaging of BNP reporter mice

Conclusion

These results indicate the BNP reporter mouse by knock-in technology is useful for the analysis of mechanism in reactivation of BNP in adult heart and the elevation of BNP in patients of heart failure partly due to the serum-derived induction of BNP from heart.

P4432Coronary microvascular dysfunction in inflammatory bowel disease: Restored after enterectomy

Background

Inflammatory bowel disease (IBD) is a complex multisystem disease characterized by chronic inflammation, which can lead to coronary microvascular dysfunction (CMD).

Purpose

We aimed to investigate the presence and the severity of CMD in Crohn's disease (CD) and ulcerative colitis (UC) by assessing coronary flow reserve (CFR) using transthoracic Doppler echocardiography, and to elucidate the influence of enterectomy on CMD.

Methods

Thirty-seven IBD patients (22 CD patients: 39±12 years, 15 UC patients: 52±17 years), and 30 age- and gender-matched control subjects (46±12 years) who have comparable risk factors for coronary artery disease were enrolled. Smokers were excepted from the present study. For CFR measurement, coronary flow velocity was recorded at rest and during hyperemia in the left anterior descending coronary artery induced by intravenous infusion of adenosine triphosphate (0.14 mg/kg/min), and a CFR ≤2.5 calculated as the ratio of hyperemic to basal peak and mean diastolic velocity defined CMD. CFR measurement was repeated before and within 1 year after enterectomy. Serum or plasma cytokines were also measured before and after enterectomy.

Results

The median disease duration of CD and UC patients were 12 and 6 years. Although none of control subjects had CMD, 38% in IBD patients (CD: 41%, UC: 33%) had CMD. CFR was similarly and significantly lower in CD and UC patients than Control subjects (CD: 2.92±1.03*, UC: 2.99±0.65*, and Control: 3.84±0.75, *p<0.05 vs. Control). Serum levels of TNF-α, IL-6 and hs-CRP were significantly higher in CD and UC patients than Control subjects. Multiple linear regression analysis showed that the presence of IBD and mean diastolic flow velocity at baseline were independently associated with reduced CFR among all study participants (β=−0.324 and −0.614, p=0.001, respectively). CFR in IBD patients with both CMD and non-CMD significantly improved after enterectomy, and the extent of CFR improvement was greater in patients with CMD than those with non-CMD (Figure). Serum levels of IL-6 and hs-CRP significantly reduced among all IBD patients.

Conclusion

IBD was associated with CMD, which improved after enterectomy.

P1717The clinical impact of intra-aortic balloon pumping for acute coronary syndrome from Mie ACS registry

Background

Intra-Aortic Balloon Pumping (IABP) was widespread used in cases of Acute Coronary Syndrome (ACS) at daily clinical situation in Japan, even though the efficacy of IABP in AMI patients with cardiogenic shock was not proved. The aim of this study was to investigate the efficacy of IABP use in ACS patients in Japan.

Methods

We investigated 2-year all-cause-mortality of 2,660 enrolled ACS patients including 358 patients with IABP and 2,302 patients without IABP from Mie ACS registry.

Results

We compared a 1:1 propensity score-matched cohort of 426 ACS patients with or without IABP (n=213, respectively). 2-year mortality was significantly higher in patients with IABP than without IABP (p=0.02, Figure A). In addition, IABP usage was independent predictor of mortality with hazard ratio of 1.6 by multivariate analysis. However, 2-year mortality was not statistically different between 2 groups only when analyzed patients with shock (p=0.60, Figure B).

Figure 1

Conclusion

IABP was not commonly recommended in ACS patients. However, IABP was might as well used in some situation especially in shock.

P5301Impacts of lifestyle behavior and shift Work on visceral fat accumulation and progression of atherosclerosis in middle-aged workers

Background

Work style, and particularly shift work, can affect an individual's health through disrupting circadian rhythms. Moreover, lifestyle habits including dietary and exercise routines might be altered by irregular shift hours. We thus hypothesized that an individual's lifestyle including working habits could influence the prevalence of visceral fat obesity and the progression of atherosclerosis.

Purpose

The present study investigated how lifestyle and shift work affect the accumulation of visceral fat and the progression of subclinical atherosclerosis in middle-aged workers.

Methods

This study enrolled employees undergoing their periodic health check-up (n=10883). The Cardio-Ankle Vascular Index (CAVI) was measured to assess arterial stiffness, followed by ultrasound examination and computed tomography imaging to measure carotid intima-media thickness (IMT) and visceral fat area (VFA), respectively. Lifestyle was evaluated by the following items: 1) eating breakfast, 2) nighttime eating, 3) regular exercise, 4) habitual drinking, 5) habitual smoking, 6) sleeping hours, and 7) working hours. With regard to work factors, subjects were categorized into fixed daytime workers or shift workers (including subjects working with an irregular schedule, outside of daytime hours, or at nighttime).

Results

Among all subjects enrolled, 6820 subjects were fixed daytime workers and 4063 subjects were shift workers. Most of the employees engaged in fixed daytime work were clerical workers, while the employees engaged in shift work were mainly physical workers in this company. Fixed daytime workers had significantly greater VFA than shift workers, but the prevalence of metabolic syndrome, CAVI values, and carotid IMT were similar between groups. Reduced regular exercise, long sleeping hours, and fixed daytime work were independently associated with visceral fat accumulation by both multivariate regression and logistic regression analyses. However, the logistic regression analysis with the presence of metabolic syndrome as the endpoint revealed that skipping breakfast, reduced regular exercise, long sleeping hours, and short working hours were independent determinants of metabolic syndrome. On the other hand, univariate and multivariate regression analysis showed that habitual smoking, but not shift work, were significantly associated with CAVI and carotid IMT. Logistic regression analysis with the endpoint of carotid atherosclerosis (presence of plaque) showed that habitual smoking was an independent determinant of carotid atherosclerosis.

Conclusions

Reduced regular exercise, long sleeping hours, and fixed daytime work were significantly associated with visceral fat accumulation, while habitual smoking has a consistent association with the progression of atherosclerosis. These findings support the concept that unhealthy lifestyles should be modified before considering intervention in work styles.

2421Immunosuppressive therapy and prognosis in biopsy-proven fulminant lymphocytic myocarditis requiring veno-arterial extracorporeal membranous oxygenation support

Background

Fulminant myocarditis is one of the fatal diseases for which effective management has not yet been established. Immunosuppressive therapy (IST) using corticosteroid has been actively applied to giant cell or eosinophilic myocarditis, there is no consensus on the efficacy of lymphocytic myocarditis, which is suspected of involving viral infection. Actually, IST for lymphocytic myocarditis is not recommended in the European Society of Cardiology guidelines, but in the Japanese Circulation Society guidelines, it is approved for use in refractory cases in the absence of curative therapy for myocarditis established.

Purpose

The purpose of this study was to explore the potential efficacy of immunosuppressive therapy on acute phase in fulminant lymphocytic myocarditis (FLM) requiring veno-arterial extracorporeal membranous oxygenation (VA-ECMO) support.

Method

We conducted CHANGE-PUMP study that was retrospectively enrolled 99 patients with fulminant myocarditis required VA-ECMO support in the Tokai area (central part of Japan) for the past 20 years. Lymphocytic myocarditis was defined by pathological category. Patients were divided into two groups depending on whether IST using corticosteroid was performed in the clinical course. Results: Sixty-six patients were pathologically diagnosed as fulminant myocarditis by endomyocardial biopsy, of which only 49 patients were FLM. IST were indicated in 8 (16%) out of 49 patients of FLM (IST group; n=8, non-IST group; n=41). Kaplan-Meier survival analysis showed a lower survival rate in the IST group than in the non-IST group (p=0.073). However, in all cases, based on our guidelines, IST was initiated after becoming refractory to MCS treatment.

Immunosupressive therapy and prognosis

Conclusion

In the retrospective analysis, biopsy-proven FLM patients with IST required VA-ECMO support had low survival rates. However, the timing of IST introduction was late and concerned. In the present era when advanced mechanical support appears and the survival rate of fulminant myocarditis is expected to improve, a multicenter prospective study is needed to establish an indication of IST in the acute phase of fulminant myocarditis.

P2659Difference of prognostic impact of Killip classification in ACS patients with or without hemodialysis

Background

Cardiovascular deaths are more frequently in hemodialysis (HD) patients compared to general population. However, difference of prognosis of acute coronary syndrome (ACS) patients with or without HD were not well evaluated.

Purpose

The purpose of this study was to evaluate the clinical and prognostic characteristics of ACS patients with HD compared to that of ACS patients without HD.

Methods

We investigated 3427 ACS patients including 63 HD and 3364 non-HD patients between 2013 and 2017 using date from Mie ACS registry, a retrospective and multicenter registry. The primary outcome was defined as all-cause mortality.

Results

HD patients showed significantly higher prevalence of diabetes mellitus, past treatment of coronary artery disease, history of myocardial infarction and Killip ≥2 compared to non-HD patients (p<0.05, respectively). During the follow-up periods (median 719 days), 425 (12.4%) patients experienced all-cause death. HD patients demonstrated the higher all-cause mortality rate compared to that of non-HD patients during the follow-up (11.9% versus 38.1%, p<0.001, chi square). Kaplan Meier survival curves demonstrated that HD and non-HD patients with Killip 1 showed similar 30-day mortality, and Killip ≥2 patients also showed similar prognosis (Left side of figure). On the other hand, all cause mortality at 2 years were higher in Killip 1 HD patients compared to Killip 1 non-HD patients and similar between Killip 1 HD patients and Killip ≥2 non-HD patients in the 30 days landmark analysis (Right side of figure). In addition, cox regression analyses for all cause mortality demonstrated that HD was a strongest independent prognostic factor not of 30-day mortality but of after 30-day mortality with hazard ratio of 4.09 (95% confidential interval: 2.32–7.21, p<0.001).

Figure 1

Conclusion

Careful management are required in chronic phase for ACS patients with HD even in Killip 1 classification.

Pharmacological inhibition of mTORC1 but not mTORC2 protects against human disc cellular apoptosis, senescence, and extracellular matrix catabolism through Akt and autophagy induction

OBJECTIVE

The mammalian target of rapamycin (mTOR) is a serine/threonine kinase that integrates nutrients to execute cell growth. We hypothesized that mTOR is influential in the intervertebral disc-largest avascular, low-nutrient organ. Our objective was to identify the optimal mTOR inhibitor for treating human degenerative disc disease.

DESIGN

mTOR complex 1 (mTORC1) regulates p70/ribosomal S6 kinase (p70/S6K), negatively regulates autophagy, and is controlled by Akt. Akt is controlled by phosphatidylinositol 3-kinase (PI3K) and mTOR complex 2 (mTORC2). mTORC1 inhibitors-rapamycin, temsirolimus, everolimus, and curcumin, mTORC1&mTORC2 inhibitor-INK-128, PI3K&mTOR inhibitor-NVP-BEZ235, and Akt inhibitor-MK-2206-were applied to human disc nucleus pulposus (NP) cells. mTOR signaling, autophagy, apoptosis, senescence, and matrix metabolism were evaluated.

RESULTS

mTORC1 inhibitors decreased p70/S6K but increased Akt phosphorylation, promoted autophagy with light chain 3 (LC3)-II increases and p62/sequestosome 1 (p62/SQSTM1) decreases, and suppressed pro-inflammatory interleukin-1 beta (IL-1β)-induced apoptotic terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) positivity (versus rapamycin, 95% confidence interval (CI) -0.431 to -0.194; temsirolimus, 95% CI -0.529 to -0.292; everolimus, 95% CI -0.477 to -0.241; curcumin, 95% CI -0.248 to -0.011) and poly (ADP-ribose) polymerase (PARP) and caspase-9 cleavage, senescent senescence-associated beta-galactosidase (SA-β-gal) positivity (versus rapamycin, 95% CI -0.437 to -0.230; temsirolimus, 95% CI -0.534 to -0.327; everolimus, 95% CI -0.485 to -0.278; curcumin, 95% CI -0.210 to -0.003) and p16/INK4A expression, and catabolic matrix metalloproteinase (MMP) release and activation. Meanwhile, dual mTOR inhibitors decreased p70/S6K and Akt phosphorylation without enhanced autophagy and suppressed apoptosis, senescence, and matrix catabolism. MK-2206 counteracted protective effects of temsirolimus. Additional disc-tissue analysis found relevance of mTOR signaling to degeneration grades.

CONCLUSION

mTORC1 inhibitors-notably temsirolimus with an improved water solubility-but not dual mTOR inhibitors protect against inflammation-induced apoptosis, senescence, and matrix catabolism in human disc cells, which depends on Akt and autophagy induction.

Anatomy of the smooth muscle structure in the female anorectal anterior wall: convergence and anterior extension of the internal anal sphincter and longitudinal muscle

AIM

The anatomy of the region between the vagina and anal canal plays an essential role when performing a proctectomy for low-lying tumours. However, the anatomical characteristics of this area remain unclear. The purpose of the present study was to clarify the configuration, and both lateral and inferior extensions, of the muscle bundles in the anorectal anterior wall in females.

METHODS

Using cadaveric specimens, macroscopic anatomical and histological evaluations were conducted at the anatomy department of our institute. Macroscopic anatomical specimens were obtained from six female cadavers. Histological specimens were obtained from eight female cadavers.

RESULTS

The smooth muscle fibres of the internal anal sphincter and longitudinal muscle extended anteriorly in the anorectal anterior wall of females and the muscle bundles showed a convergent structure. The anterior extending smooth muscle fibres merged into the vaginal smooth muscle layer, distributed subcutaneously in the vaginal vestibule and perineum and spread to cover the anterior surface of the external anal sphincter and the levator ani muscle. Relatively sparse space was observed in the region anterolateral to the rectum on histological analysis.

CONCLUSION

Smooth muscle fibres of the rectum and vagina are intermingled in the median plane, and there is relatively sparse space in the region anterolateral to the rectum. Therefore, when detaching the anorectal canal from the vagina during proctectomy, an approach from both the lateral sides should be used.