Real-world Experience of Carotid Artery Stenting in Japan: Analysis of 8458 Cases from the JR-NET3 Nationwide Retrospective Multi-center Registries

We aimed to clarify the outcomes of carotid artery stenting (CAS) in the Japanese population. For this purpose, we reviewed data from the Japanese Registry of NeuroEndovascular Therapy 3 (JR-NET3), a retrospective, nation-wide, multi-center, observational study of neuroendovascular treatments in Japan. Of the 9207 patients who underwent CAS between January 2010 and December 2014, 8458 satisfied the inclusion criteria for our analysis. The outcome statistics of this JR-NET3 cohort were compared to those of JR-NET1 and 2 cohorts fitting the same inclusion criteria. Of the 8458 JR-NET3 patients analyzed, 8042 (95.1%) were treated by surgeons with board certification from the Japanese Society for NeuroEndovascular Therapy. Technical success was achieved in 8417 patients (99.5%), whereas 198 patients (2.3%) had clinically significant complications (CSCs). These findings mirrored those obtained for the JR-NET1 and 2 cohorts. On multivariate analysis, risk factors for CAS-associated CSC included symptomatic lesion [odds ratio (OR), 1.91; 95% confidence interval (CI), 1.23-3.00; P = 0.003] and hypoechoic lesion on carotid artery ultrasound (OR, 1.85; 95% CI, 1.21-2.84; P = 0.005), whereas use of closed-cell stents was a predictor of better outcome (OR, 0.53; 95% CI, 0.35-0.79; P = 0.002). The findings of JR-NET3 reflect good outcomes of CAS, but non-modifiable risk factors reflecting lesion characteristics remain of concern. Using closed-cell stents is advisable. Technological advances such as the introduction of new materials may help further improve CAS outcomes in Japanese patients.

Sarcopenia, the depletion of muscle mass, an independent predictor of respiratory complications after oncological esophagectomy

Surgery for esophageal carcinoma is known to be associated with high morbidity. Recent studies have reported a correlation of nutritional and inflammatory parameters with postoperative course. This study aims to clarify the risk factors for operative morbidity after resection of esophageal carcinoma. Consecutive patients who underwent esophagectomy for esophageal squamous cell carcinoma at our institute were included (n = 102; 89 males and 13 females; mean age: 67.3 years). Clinicopathological characteristics, presence or absence of sarcopenia, and modified Glasgow prognostic score were assessed, and their correlation with postoperative complications was investigated using univariate and multivariate analyses. Sarcopenia was defined using a combination of muscle mass area and body mass index. Of the included 102 patients, 45 (44.1%) exhibited sarcopenia (sarcopenia group), while 57 (55.9%) did not (non-sarcopenia group). No significant difference was observed between the groups regarding surgical procedures and tumor stage; furthermore, there was no mortality. Twenty-six patients developed respiratory complications (including 20 cases of pneumonia). On univariate analysis, sarcopenia, modified Glasgow prognostic score, and American Society of Anesthesiologists physical status were found to be significantly associated with the development of postoperative respiratory complications. On multivariate analysis, sarcopenia was found to be an independent risk factor for postoperative respiratory complications after esophagectomy. We believe that identifying patients at risk and providing preoperative nutritional support as well as physical therapy aimed at strengthening of body muscles may help reduce the incidence of postoperative respiratory complications in such patients.

Abstract P1-11-07: Risk analysis for chemotherapy induced nausea and vomiting (CINV) in patients receiving FEC100 treatment

BACKGROUND:

Anthracycline-containing regimens are standard treatment options in adjuvant and neoadjuvant chemotherapy in breast cancer. Chemotherapy-induced nausea and vomiting (CINV) is experienced frequently in patients receiving these regimens, but the risk factors for CINV are unknown.

OBJECTIVE:

The aim of this study was to investigate risk factors for CINV in anthracycline-containing regimens retrospectively.

METHODS:

Data were collected from the JONIE study, which was conducted in order to estimate the efficacy of zoledronic acid in a neoadjuvant setting from March 2010 to June 2012 (UMIN000003261). A total of 180 patients were recruited, and we used CINV data from the first cycle of FEC100 treatment and patient backgrounds. As the protocol regulation allowed the use of antiemetic drugs,in the first cycle of the FEC100 regimen, patients received various types of antiemetic agents, which we classified into four groups: Dexamethasone (DEX)+5-HT3 receptor antagonist (5-HT3)+neurokinin-1 receptor antagonist (NK1) (DEX+5-HT3+NK1) group; Dexamethasone (DEX)+5-HT3 receptor antagonist (5-HT3) (DEX+5HT3) group; Dexamethasone (DEX)+5-HT3 receptor antagonist (5-HT3)+dopamine receptor antagonist (DRA) (DEX+5HT3+DRA) group; and Dexamethasone (DEX)+5-HT3 receptor antagonist (5-HT3)+neurokinin-1 receptor antagonist (NK1)+ dopamine receptor antagonist (DRA) (DEX+5-HT3+NK1+DRA) group. Risk factors were selected from patient backgrounds and the combinations of antiemetic drugs. In patient backgrounds, the body mass index (BMI) was stratified into 3 categories: Less than 18.5 (underweight group); equal to or more than 18.5 but less than 25 (standard BMI group); and equal to or more than 25 (overweight group). The risks for CINV were analyzed by univariate and multivariate analyses. P values of less than 0.05 were defined as significant.

RESULTS:

In a univariate analysis of nausea, the body mass index (BMI) was the only significant factor (P<0.05). On the other hand, BMI and the combination of antiemetic drugs were significant factors in vomiting. (P<0.05 and 0.005, respectively). In a multivariate analysis of nausea, the P value for BMI was 0.02. The odds ratio for the underweight group was 7.745 (confidence interval: 2.171 to 27.634) compared with the standard BMI group. In a multivariate analysis of vomiting, BMI and the combination of antiemetic drugs were significant risk factors (P=0.025 and 0.023, respectively). The odds ratio for the underweight group was 3.481 (confidence interval: 1.183 to 10.241)compared with the standard BMI group. Furthermore, the odds ratios in the DEX+5-HT3+DRA and DEX+5HT3 groups were 5.005 (confidence interval: 1.543 to 16.239) and 4.178 (confidence interval: 1.428 to 12.222), respectively, compared with the DEX+5-HT3+NK1 group, which was consistent with the CINV guidelines in 2011.

CONCLUSIONS:

This study revealed that BMI was the most important risk factor for nausea, and that BMI and the combination of antiemetic drugs were risk factors for vomiting. Underweight-patients tend to have CINV in anthracycline-containing regimen. The DEX+5-HT3+NK1 group was the best antiemetic drug combination. These result show that following the CINV guideline treatment is mandatory in order to prevent CINV.

Citation Format: Hayashi M, Nakazawa K, Hasegawa Y, Horiguchi J, Miura D, Ishikawa T, Takao S, Kim SJ, Yamagami K, Miyashita M, Konishi M, Shigeoka Y, Suzuki M, Taguchi T, Kubota T, Tanino Y, Yamada K, Kimura K, Akazawa K, Kohno N. Risk analysis for chemotherapy induced nausea and vomiting (CINV) in patients receiving FEC100 treatment [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 P1-11-07.

Asymptomatic moderate carotid artery stenosis with intraplaque hemorrhage: Progression of degree of stenosis and new ischemic stroke

Carotid intraplaque hemorrhage (IPH) plays a critical role in the progression of carotid atherosclerotic disease. IPH was associated with high intensity signal (HIS) in the plaque on Maximum intensity projection (MIP) images from routine three dimensional magnetic resonance imaging (3D-TOF MRA). The aim of this study was to evaluate the relationships among HIS, new ipsilateral ischemic stroke and a progression rate in carotid plaques with moderate stenosis. We included 45 carotid plaques with moderate stenosis (50%-69%) in 45 patients who could be followed more than 12 months. Carotid IPH was defined as the presence of HIS on 3DTOF MRA using the criteria previously we published. We analyzed the relation between the presence of HIS and new ischemic strokes and annual progression rate of carotid stenosis. HIS was present in 21 (47%) carotid arteries. Over a follow-up period of 24 ± 9 months, six ischemic strokes occurred in ipsilateral side. New ipsilateral ischemic stroke occurred more frequently in HIS positive group (P group: 6 of 21, 29%) than negative group (N group: 0 of 24, 0%) (p = 0.017). Annual progression rate of carotid stenosis is significantly higher in P group (+3.35%/year) than N group (-0.02%/year) (p = 0.0026). In multivariate regression analysis, HIS positive was an independent predictor for annual progression rate of carotid stenosis (p = 0.003). Evaluation of HIS in asymptomatic moderate carotid stenosis can potentially provide risk stratification of new ipsilateral ischemic strokes.

Abstract 184: The Relationship Between Carotid Plaque on Magnetic Resonance Plaque Imaging and Time From Stroke Onset

Introduction: Previous studies report that rate of recurrent stroke, as well as the risk of carotid surgery, is highest in the early stages following cerebral infarction and decreases over time, which suggests a process of plaque healing and stabilization. The purpose of this study is to identify differences in carotid plaque components according to the time from stroke onset, using carotid magnetic resonance plaque imaging (MRPI) to evaluate the dynamic phase of plaque development following an acute cerebrovascular ischemic event.Methods and

Results: MRPI on 3T scanners was obtained in 128 patients enrolled in the Carotid Artery Stenting study (MRCAS). MRCAS is a non-randomized multicenter prospective observational study to compare the plaque characteristics evaluated by MRI and ischemic complications after CAS in Japan. Among the 128 subjects, 60 presented with TIA or stroke and 68 were asymptomatic. The 60 TIA/stroke cases were classified into four groups based on the interval from the onset of symptoms to the date of carotid MRPI (Group 1: <14 days [n=25]; Group 2: 15-30 days[n=13]; and Group 3: >31 days [n=22]). The 68 asymptomatic cases were classified as Group 4. The volume of intraplaque hemorrhage (IPH), necrotic core, calcification and loose matrix was quantified on MRPI using Radiant DICOM viewer. Further, the presence of inner Loose Matrix (iLM) was identified as a high intensity area located between the vessel lumen and necrotic core or IPH on both T2WI and proton density weighted images.Patients characteristics were not significantly different among all groups. The mean volume of loose matrix in Group 3 was significantly lower than Group 1 and Group 4 (0 mm3 vs 12.3 mm3 and 15.5 mm3; p= 0.01, 0.03, respectively). The prevalence of iLM in Group 1 was higher than in Group 3 and 4 (68% vs 18.2%, 38.3% ; p<0.01, <0.01, respectively).

Conclusions: The prevalence of inner Loose Matrix, located at the interface between the lumen surface and the necrotic core or IPH, is significantly higher in the early stage after stoke/TIA. This study suggests that carotid plaques undergo rapid evolution, especially adjacent to the luminal surface, after an acute cerebrovascular ischemic event.

Innate immune activation of astrocytes impairs neurodevelopment via upregulation of follistatin-like 1 and interferon-induced transmembrane protein 3

BACKGROUND

Polyriboinosinic-polyribocytidylic acid (polyI:C) triggers a strong innate immune response that mimics immune activation by viral infections. Induction of interferon-induced transmembrane protein 3 (Ifitm3) in astrocytes has a crucial role in polyI:C-induced neurodevelopmental abnormalities. Through a quantitative proteomic screen, we previously identified candidate astroglial factors, such as matrix metalloproteinase-3 (Mmp3) and follistatin-like 1 (Fstl1), in polyl:C-induced neurodevelopmental impairment. Here, we characterized the Ifitm3-dependent inflammatory processes focusing on astrocyte-derived Fstl1 following polyI:C treatment to assess the neuropathologic role of Fstl1.

METHODS

Astrocytes were treated with PBS (control) or polyI:C (10 μg/mL). The conditioned medium was collected 24 h after the polyI:C treatment and used as astrocyte condition medium (ACM). The expression of Fstl1 mRNA and extracellular Fstl1 protein levels were analyzed by quantitative PCR and western blotting, respectively. For functional studies, neurons were treated with ACM and the effects of ACM on dendritic elongation were assayed. To examine the role of Fstl1, recombinant Fstl1 protein and siRNA for Fstl1 were used. To investigate the expression of Fstl1 in vivo, neonatal mice were treated with vehicle or polyI:C on postnatal day 2 to 6.

RESULTS

ACM prepared with polyI:C (polyI:C ACM) contained significantly higher Fstl1 protein than control ACM, but no increase in Fstl1 was observed in polyI:C ACM derived from Ifitm3-deficient astrocytes. We found that the production of Fstl1 involves the inflammatory responsive molecule Ifitm3 in astrocytes and influences neuronal differentiation. In agreement, the levels of Fstl1 increased in the hippocampus of polyI:C-treated neonatal mice. COS7 cells co-transfected with both Fstl1 and Ifitm3 had higher extracellular levels of Fstl1 than the cells transfected with Fstl1 alone. Treatment of primary cultured hippocampal neurons with recombinant Fstl1 impaired dendritic elongation, and the deleterious effect of polyI:C ACM on dendritic elongation was attenuated by knockdown of Fstl1 in astrocytes.

CONCLUSIONS

The extracellular level of Fstl1 is regulated by Ifitm3 in astrocytes, which could be involved in polyI:C-induced neurodevelopmental impairment.

FRAC: Fringing-RF-field-activated dc-to-pulse converter for low-energy ion beams

We developed a new type of dc-to-pulse converter, called FRAC (Fringing-RF-field-Activated dc-to-pulse Converter) for low-energy ion beams electrostatically accelerated from an ion source. FRAC is based on a radio-frequency quadrupole (RFQ) linear trap technique and works in principle under ultrahigh vacuum conditions. Ions continuously injected into FRAC are decelerated by an alternating longitudinal electric field produced in a distorted radio frequency field around the edge region of RFQ rods. These ions accumulate in FRAC for a significantly long time. This edge effect appears most notably when the energy of incoming ions exceeds the injection barrier potential by less than a few eV and the energy spread is quite small. The ions stacked during the FRAC operation period are ejected as a high intensity pulsed beam. We investigated the performance of FRAC and the capability of some FRAC operation methods developed to enhance the dc-to-pulse conversion efficiency. The maximum conversion efficiencies achieved were 22% and 5.6% at FRAC operation frequencies of 10 and 1 Hz, respectively. The number of ions contained in an output beam pulse with a duration of 500 μs was in practice 1.6 × 10⁹ ions/pulse at an injected dc beam intensity of 4.6 nA and an operation frequency of 1 Hz.

Genetic and animal model analyses reveal the pathogenic role of a novel deletion of RELN in schizophrenia

Reelin protein (RELN), an extracellular matrix protein, plays multiple roles that range from embryonic neuronal migration to spine formation in the adult brain. Results from genetic studies have suggested that RELN is associated with the risk of psychiatric disorders, including schizophrenia (SCZ). We previously identified a novel exonic deletion of RELN in a patient with SCZ. High-resolution copy number variation analysis revealed that this deletion included exons 52 to 58, which truncated the RELN in a similar manner to the Reln Orleans mutation (Reln^rl-Orl). We examined the clinical features of this patient and confirmed a decreased serum level of RELN. To elucidate the pathophysiological role of the exonic deletion of RELN in SCZ, we conducted behavioral and neurochemical analyses using heterozygous Reln^rl-Orl/+ mice. These mice exhibited abnormalities in anxiety, social behavior, and motor learning; the deficits in motor learning were ameliorated by antipsychotics. Methamphetamine-induced hyperactivity and dopamine release were significantly reduced in the Reln^rl-Orl/+ mice. In addition, the levels of GABAergic markers were decreased in the brain of these mice. Taken together, our results suggest that the exonic deletion of RELN plays a pathological role, implicating functional changes in the dopaminergic and GABAergic systems, in the pathophysiology of SCZ.

Fabrication of arrays of tapered silicon micro-/nano-pillars by metal-assisted chemical etching and anisotropic wet etching

Fabrication of a 2D square lattice array of intentionally tapered micro-/nano-silicon pillars by metal-assisted chemical etching (MACE) of silicon wafers is reported. The pillars are square rod shaped with the cross-sections in the range 0.2 × 0.2-0.9 × 0.9 μm² and heights 3-7 μm. The spacing between pillars in the 2D square lattice was controlled between 0.5 and 3.0 μm. While the pillars after MACE had the high aspect ratio ∼1:5, subsequent anisotropic wet etching in potassium hydroxide solution led to 80°-89.5° tapers with smooth sidewalls. The resulting taper angle showed the relation with geometry of pillar structures; the spacing 0.5-3.0 μm led to the tapering angle 89.5°-80° for 3 and 5 μm tall pillars but 7 μm tall pillars showed no dependency between the tapering angle and the inter-pillar spacing. Such an array of silicon tapered-rods with smooth sidewalls is expected to be applicable as a mold in nanoimprinting applications.

Imaging Differences between Neuromyelitis Optica Spectrum Disorders and Multiple Sclerosis: A Multi-Institutional Study in Japan

BACKGROUND AND PURPOSE

Both clinical and imaging criteria must be met to diagnose neuromyelitis optica spectrum disorders and multiple sclerosis. However, neuromyelitis optica spectrum disorders are often misdiagnosed as MS because of an overlap in MR imaging features. The purpose of this study was to confirm imaging differences between neuromyelitis optica spectrum disorders and MS with visually detailed quantitative analyses of large-sample data.

MATERIALS AND METHODS

We retrospectively examined 89 consecutive patients with neuromyelitis optica spectrum disorders (median age, 51 years; range, 16-85 years; females, 77; aquaporin 4 immunoglobulin G-positive, 93%) and 89 with MS (median age, 36 years; range, 18-67 years; females, 68; relapsing-remitting MS, 89%; primary-progressive MS, 7%; secondary-progressive MS, 2%) from 9 institutions across Japan (April 2008 to December 2012). Two neuroradiologists visually evaluated the number, location, and size of all lesions using the Mann-Whitney U test or the Fisher exact test.

RESULTS

We enrolled 79 patients with neuromyelitis optica spectrum disorders and 87 with MS for brain analysis, 57 with neuromyelitis optica spectrum disorders and 55 with MS for spinal cord analysis, and 42 with neuromyelitis optica spectrum disorders and 14 with MS for optic nerve analysis. We identified 911 brain lesions in neuromyelitis optica spectrum disorders, 1659 brain lesions in MS, 86 spinal cord lesions in neuromyelitis optica spectrum disorders, and 102 spinal cord lesions in MS. The frequencies of periventricular white matter and deep white matter lesions were 17% and 68% in neuromyelitis optica spectrum disorders versus 41% and 42% in MS, respectively (location of brain lesions, P < .001). We found a significant difference in the distribution of spinal cord lesions between these 2 diseases (P = .024): More thoracic lesions than cervical lesions were present in neuromyelitis optica spectrum disorders (cervical versus thoracic, 29% versus 71%), whereas they were equally distributed in MS (46% versus 54%). Furthermore, thoracic lesions were significantly longer than cervical lesions in neuromyelitis optica spectrum disorders (P = .001), but not in MS (P = .80).

CONCLUSIONS

Visually detailed quantitative analyses confirmed imaging differences, especially in brain and spinal cord lesions, between neuromyelitis optica spectrum disorders and MS. These observations may have clinical implications.