Prevalence and risk factors of postoperative laryngeal edema in patients undergoing neck dissection

PURPOSE

Postoperative laryngeal edema (PLE) is a common complication in patients undergoing head and neck surgery, leading to symptoms such as odynophagia, dysphagia, or potential airway obstruction. However, the prevalence and risk factors of PLE in patients undergoing neck dissection (ND) have not been well investigated.

METHODS

A retrospective analysis was conducted in three steps. Initially, a pilot study of 50 consecutive ND patients revealed a preliminary PLE prevalence of 0.34. Then, the medical records of an additional 295 ND patients were reviewed to estimate the prevalence of PLE with a total width of 95% confidence interval (CI) of ± 5%. Finally, multivariable logistic regression analyses were performed to identify risk factors for PLE (n = 343).

RESULTS

PLE occurred in 29.4% [95%CI 24.4-34.4%] of patients undergoing any type of ND, with the most common symptoms of odynophagia (75.0%) and dyspnea (11.1%). Hospital stay was just one day longer in PLE patients, responding well with short-term steroid treatment (p = 0.0057). In multivariable analyses, no significant association was found between PLE occurrence and airway management. However, body mass index and the American Society of Anesthesiologists classification correlated with PLE. More importantly, surgery for oro-hypopharynx or supraglottis tumors (odds ratio, OR = 3.019, [95%CI 1.166-7.815]) and lymph node level 2(3) ND (OR = 4.214 to 5.279, [95%CI 1.160-20.529]) were significant risk factors for PLE.

CONCLUSIONS

PLE developed in approximately 30% of ND patients, causing uncomfortable symptoms. Early diagnosis and intervention of PLE in high-risk patients can improve patient care and outcomes.

Clinical Effect of Endosonography on Overall Survival in Patients with Radiological N1 Non-Small Cell Lung Cancer

PURPOSE

It is unclear whether performing endosonography first in non-small cell lung cancer (NSCLC) patients with radiological N1 (rN1) has any advantages over surgery without nodal staging. We aimed to compare surgery without endosonography to performing endosonography first in rN1 on the overall survival (OS) of patients with NSCLC.

MATERIALS AND METHODS

This is a retrospective analysis of patients with rN1 NSCLC between 2013 and 2019. Patients were divided into 'no endosonography' and 'endosonography first' groups. We investigated the effect of nodal staging through endosonography on OS using propensity score matching (PSM) and multivariable Cox proportional hazard regression analysis.

RESULTS

In the no endosonography group, pathologic N2 occurred in 23.0% of patients. In the endosonography first group, endosonographic N2 and N3 occurred in 8.6% and 1.6% of patients, respectively. Additionally, 51 patients were pathologic N2 among 249 patients who underwent surgery and mediastinal lymph node dissection (MLND) in endosonography first group. After PSM, the 5-year OSs were 68.1% and 70.6% in the no endosonography and endosonography first groups, respectively. However, the 5-year OS was 80.2% in the subgroup who underwent surgery and MLND of the endosonography first group. Moreover, in patients receiving surgical resection with MLND, the endosonography first group tended to have a better OS than the no endosonography group in adjusted analysis using various models.

CONCLUSION

In rN1 NSCLC, preoperative endosonography shows better OS than surgery without endosonography. For patients with rN1 NSCLC who are candidates for surgery, preoperative endosonography may help improve survival through patient selection.

A phase II open-label randomized clinical trial of preoperative durvalumab or durvalumab plus tremelimumab in resectable head and neck squamous cell carcinoma

PURPOSE

Clinical implications of neoadjuvant immunotherapy in patients with locally advanced but resectable head and neck squamous cell carcinoma (HNSCC) remain largely unexplored.

PATIENTS AND METHODS

Patients with resectable HNSCC were randomized to receive a single dose of preoperative durvalumab (D) with or without tremelimumab (T) before resection, followed by postoperative (chemo)radiation based on multidisciplinary discretion and 1-year D treatment. Artificial intelligence (AI)-powered spatial distribution analysis of tumor-infiltrating lymphocytes and high-dimensional profiling of circulating immune cells tracked dynamic intratumoral and systemic immune responses.

RESULTS

Of the 48 patients enrolled (D: 24 patients, D+T: 24 patients), 45 underwent surgical resection per protocol (D: 21 patients; D+T: 24 patients). D+/-T had a favorable safety profile and did not delay surgery. Distant recurrence-free survival (DRFS) was significantly better in patients treated with D+T than in those treated with D monotherapy. AI-powered whole-slide image analysis demonstrated that D+T significantly reshaped the tumor microenvironment toward immune-inflamed phenotypes, in contrast to D monotherapy or cytotoxic chemotherapy. High-dimensional profiling of circulating immune cells revealed a significant expansion of T cell subsets characterized by proliferation and activation in response to D+T therapy, which was rare following D monotherapy. Importantly, expansion of specific clusters in CD8+ T cells and non-regulatory CD4+ T cells with activation and exhaustion programs was associated with prolonged DRFS in patients treated with D+T.

CONCLUSIONS

Preoperative D+/-T is feasible and may benefit patients with resectable HNSCC. Distinct changes in the tumor microenvironment and circulating immune cells were induced by each treatment regimen, warranting further investigation.

Extra-Capsular Spread of Lymph Node Metastasis in Oral, Oropharyngeal and Hypopharyngeal Cancer: A Comparative Subsite Analysis

BACKGROUND

The extra-capsular spread (ECS) of lymph node metastasis (LNM) is a hallmark of aggressive primary tumor phenotype in head and neck cancer (HNC); however, the factors influencing ECS are poorly understood.

PATIENTS AND METHODS

This was a retrospective study, including 190 cases of oral tongue cancer (OTC), 148 cases of oropharyngeal cancer (OPC) (118 HPV-positive and 30 HPV-negative), and 100 cases of hypopharyngeal cancer (HPC). Tumor dimension, tumor biological variables (lymphovascular/perineural invasion and histologic grade), and LNM variables (LNM number and size) were analyzed according to the presence of ECS using multivariable logistic regression and receiver operating characteristic (ROC) curve analyses.

RESULTS

LNM variables were significant factors for ECS in all subsites of HNC (p < 0.05), except HPV-positive OPC. In OTC, tumor dimensional variables were significantly related to ECS (p < 0.01). Meanwhile, in OPC and HPC, neither the primary tumor dimension nor the T status were significant factors for ECS occurrence. The predictability of ECS by ROC curve using multiple variables was 0.819 [95% confidence interval: 0.759-0.878] in OTC, 0.687 [0.559-0.815] in HPV-positive OPC, 0.823 [0.642-1.000] in HPV-negative OPC, and 0.907 [0.841-0.973] in HPC.

CONCLUSION

LNM variables were correlated with ECS occurrence for most HNC subsites, and site-dependent primary tumor characteristics might contribute differentially to the ECS development of LNM in HNC.

Gut microbiome-derived butyrate inhibits the immunosuppressive factors PD-L1 and IL-10 in tumor-associated macrophages in gastric cancer

Early detection and surgical treatment are essential to achieve a good outcome in gastric cancer (GC). Stage IV and recurrent GC have a poor prognosis. Therefore, new treatments for GC are needed. We investigated the intestinal microbiome of GC patients and attempted to reverse the immunosuppression of the immune and cancer cells of GC patients through the modulation of microbiome metabolites. We evaluated the levels of programmed death-ligand 1 (PD-L1) and interleukin (IL)-10 in the peripheral blood immunocytes of GC patients. Cancer tissues were obtained from patients who underwent surgical resection of GC, and stained sections of cancer tissues were visualized via confocal microscopy. The intestinal microbiome was analyzed using stool samples of healthy individuals and GC patients. Patient-derived avatar model was developed by injecting peripheral blood mononuclear cells (PBMCs) from advanced GC (AGC) patients into NSG mice, followed by injection of AGS cells. PD-L1 and IL-10 had higher expression levels in immune cells of GC patients than in those of healthy controls. The levels of immunosuppressive factors were increased in the immune and tumor cells of tumor tissues of GC patients. The abundances of Faecalibacterium and Bifidobacterium in the intestinal flora were lower in GC patients than in healthy individuals. Butyrate, a representative microbiome metabolite, suppressed the expression levels of PD-L1 and IL-10 in immune cells. In addition, the PBMCs of AGC patients showed increased levels of immunosuppressive factors in the avatar mouse model. Butyrate inhibited tumor growth in mice. Restoration of the intestinal microbiome and its metabolic functions inhibit tumor growth and reverse the immunosuppression due to increased PD-L1 and IL-10 levels in PBMCs and tumor cells of GC patients.

Fast-response electrochemical biosensor based on a truncated aptamer and MXene heterolayer for West Nile virus detection in human serum

West Nile virus (WNV) is a mosquito-borne flavivirus that can cause West Nile fever, meningitis, encephalitis, and polio. Early detection of WNV is important to prevent infection spread on the field. To commercialize the electrochemical biosensor for WNV, rapid target detection with the cheap manufacture cost is essential. Here, we developed a fast-response electrochemical biosensor consisting of a truncated WNV aptamer/MXene (Ti3C2Tx) bilayer on round-type micro gap. To reduce the target binding time, the application of the alternating current electrothermal flow (ACEF) technology reduced the target detection time to within 10 min, providing a rapid biosensor platform. The MXene nanosheet improved electrochemical signal amplification, and the aptamer produced through systematic evolution of ligands by exponential enrichment process eliminated unnecessary base sequences via truncation and lowered the manufacturing cost. Under optimized conditions, the WNV limit of detection (LOD) and selectivity were measured using electrochemical measurement methods, including cyclic voltammetry and square wave voltammetry. The LOD was 2.57 pM for WNV diluted in deionized water and 1.06 pM for WNV diluted in 10% human serum. The fabricated electrochemical biosensor has high selectivity and allows rapid detection, suggesting the possibility of future application in the diagnosis of flaviviridae virus.

Effect of Blade Size on the First-Pass Success Rate of Endotracheal Intubation Using the C-MAC Video Laryngoscope

We sought to determine whether blade size influences the first-pass success (FPS) rate when performing endotracheal intubation (ETI) with a C-MAC video laryngoscope (VL) in emergency department (ED) patients. This single-center, retrospective, observational study was conducted between August 2016 and July 2022. A total of 1467 patients was divided into two categories based on the blade size used during the first ETI attempt: blade-3 (n = 365) and blade-4 groups (n = 1102). The primary outcome was the FPS rate. The secondary outcomes included the glottic view, multiple attempt rate, and ETI-related complications. We used propensity score matching to reduce the potential confounders between the two groups. Among these, 363 pairs of matched propensity scores were generated. The FPS rate did not differ between the blade-3 (84.8%) and blade-4 groups (87.3%) in the matched cohort (p = 0.335). The multiple attempt rate did not differ significantly between groups (p = 0.289) and was 3.9% and 2.5% in the blade-3 and blade-4 groups, respectively. The difficult glottic view (11.3 vs. 6.9%, p = 0.039) and complication rates (15.4% vs. 10.5%, p = 0.047) were significantly higher in the blade-3 group than in the blade-4 group. The FPS rates of ETI with the blade-3 and blade-4 groups in adult patients in the ED did not differ significantly.

The Prevalence and Clinical Characteristics of Borderline Personality Disorder in South Korea Using National Health Insurance Service Customized Database

PURPOSE

The purpose of the present study was to identify the prevalence and clinical characteristics of borderline personality disorder (BPD) in South Korea using the Korean National Health Insurance database (DB).

MATERIALS AND METHODS

We used the National Health Insurance Service (NHIS)'s research DB (NHIS-2021-1-790) from January 1, 2010 to December 31, 2019, to make customized DB including sociodemographic information and absence or presence of BPD and other psychiatric disorders. The prevalence and the age of onset of BPD was estimated. To compare medical service utilization between the BPD group and the control group, a 1:1:1 propensity score matching was employed, and the regression analysis was conducted.

RESULTS

The prevalence of BPD per 10000 people was 0.96 in 2010 and 1.06 in 2019. The prevalence ratio of males to females was 1:1.38 in 2010 and 1:1.65 in 2019, showing that BPD was more prevalent in females. The patients' overall average age of onset was 33.19±14.6 years, with the highest prevalence shown in 8503 people in their 20s. By administrative district, the highest prevalence of BPD per 10000 people was shown in Seoul with 8.71 and the lowest in Jeollanam-do with 2.35. The BPD patients showed a pattern of extensive use of general and mental healthcare services.

CONCLUSION

This study identified the prevalence of BPD on a national DB set in South Korea. Although the prevalence of BPD in South Korea was relatively low compared to other countries, there was a steady increase in the number of BPD patients over a decade, which may be possibly due to an increased awareness of mental health and campaigns among healthcare providers and users in the country.

Incorporating axillary-lateral thoracic vessel juncture dosimetric variables improves model for predicting lymphedema in patients with breast cancer: A validation analysis

Background

A relationship between the axillary-lateral thoracic vessel juncture (ALTJ) dose and lymphedema rate has been reported in patients with breast cancer. The purpose of this study was to validate this relationship and explore whether incorporation of the ALTJ dose-distribution parameters improves the prediction model's accuracy.

Methods

A total of 1,449 women with breast cancer who were treated with multimodal therapies from two institutions were analyzed. We categorized regional nodal irradiation (RNI) as limited RNI, which excluded level I/II, vs extensive RNI, which included level I/II. The ALTJ was delineated retrospectively, and dosimetric and clinical parameters were analyzed to determine the accuracy of predicting the development of lymphedema. Decision tree and random forest algorithms were used to construct the prediction models of the obtained dataset. We used Harrell's C-index to assess discrimination.

Results

The median follow-up time was 77.3 months, and the 5-year lymphedema rate was 6.8 %. According to the decision tree analysis, the lowest lymphedema rate (5-year, 1.2 %) was observed in patients with ≤ six removed lymph nodes and ≤ 66 % ALTJ V_35Gy. The highest lymphedema rate was observed in patients with > 15 removed lymph nodes and an ALTJ maximum dose (D_max) of > 53 Gy (5-year, 71.4 %). Patients with > 15 removed lymph nodes and an ALTJ D_max ≤ 53 Gy had the second highest rate (5-year, 21.5 %). All other patients had relatively minor differences, with a rate of 9.5 % at 5 years. Random forest analysis revealed that the model's C-index increased from 0.84 to 0.90 if dosimetric parameters were included instead of RNI (P <.001).

Conclusion

The prognostic value of ALTJ for lymphedema was externally validated. The estimation of lymphedema risk based on individual dose-distribution parameters of the ALTJ seemed more reliable than that based on the conventional RNI field design.

Prevalence of Carbon Monoxide Poisoning and Hyperbaric Oxygen Therapy in Korea: Analysis of National Claims Data in 2010-2019

This study aimed to investigate the prevalence of carbon monoxide (CO) poisoning and the provision of hyperbaric oxygen therapy (HBOT) in South Korea. We used data from the Korea Health Insurance Review and Assessment service. In total, 44,361 patients with CO poisoning were identified across 10 years (2010-2019). The prevalence of CO poisoning was found to be 8.64/10,000 people, with a gradual annual increment. The highest prevalence was 11.01/10,000 individuals, among those aged 30-39 years. In 2010, HBOT was claimed from 15 hospitals, and increased to 30 hospitals in 2019. A total of 4,473 patients received HBOT in 10 years and 2,684 (60%) were treated for more than 2 hours. This study suggested that the prevalence of both CO poisoning and HBOT in Korea gradually increased over the past 10 years, and disparities in prevalence were observed by region.

Recent Developments in DNA-Nanotechnology-Powered Biosensors for Zika/Dengue Virus Molecular Diagnostics

Zika virus (ZIKV) and dengue virus (DENV) are highly contagious and lethal mosquito-borne viruses. Global warming is steadily increasing the probability of ZIKV and DENV infection, and accurate diagnosis is required to control viral infections worldwide. Recently, research on biosensors for the accurate diagnosis of ZIKV and DENV has been actively conducted. Moreover, biosensor research using DNA nanotechnology is also increasing, and has many advantages compared to the existing diagnostic methods, such as polymerase chain reaction (PCR) and enzyme-linked immunosorbent assay (ELISA). As a bioreceptor, DNA can easily introduce a functional group at the 5' or 3' end, and can also be used as a folded structure, such as a DNA aptamer and DNAzyme. Instead of using ZIKV and DENV antibodies, a bioreceptor that specifically binds to viral proteins or nucleic acids has been fabricated and introduced using DNA nanotechnology. Technologies for detecting ZIKV and DENV can be broadly divided into electrochemical, electrical, and optical. In this review, advances in DNA-nanotechnology-based ZIKV and DENV detection biosensors are discussed.

Dietary Zinc Intake and All-Cause and Cardiovascular Mortality in Korean Middle-Aged and Older Adults

We aimed to investigate the association between dietary zinc intake and total deaths, cancer, and cardiovascular disease death. In this prospective, 10-year, community-based cohort analysis, data from 143,050 adult participants (aged 40 years and older) were analyzed. Dietary zinc intake at baseline was assessed using a food frequency questionnaire. Harrell’s C-index was used to determine the optimal cut-off of dietary zinc intake with the log-rank test. Using the Cox proportional hazards regression models, the association between dietary zinc intake and all-cause, cancer, and cardiovascular disease mortality was estimated using hazard ratios and 95% confidence intervals. During the mean 10.1 years of follow-up, 5436 participants expired, of whom 2355 died due to cancer and 985 died due to cardiovascular causes. After adjustment for confounders, dietary zinc intake was inversely associated with all-cause mortality (≤5.60 mg/day vs. >7.98 mg/day; hazard ratio, 1.13; 95% confidence interval, 1.01−1.25) and cardiovascular disease mortality (≤5.12 mg/day vs. >7.28 mg/day; hazard ratio, 1.42; 95% confidence interval, 1.11−1.81) but not with cancer mortality (≤5.60 mg/day vs. >10.08 mg/day; hazard ratio, 1.09; 95% confidence interval, 0.90−1.33). Dietary zinc intake was associated with a lower risk of all-cause mortality and cardiovascular disease mortality but not with cancer mortality. Our findings could suggest that recommending optimal dietary zinc intake is helpful for human health.

Association between dietary sodium, potassium, and the sodium-to-potassium ratio and mortality: A 10-year analysis

There is inconclusive evidence of the association between dietary sodium, potassium, and the sodium-to-potassium ratio and all-cause and cardiovascular disease mortality. To investigate the association between dietary sodium, potassium, and the sodium-to-potassium ratio and all-cause and cardiovascular disease mortality risks. Data from 143,050 adult participants were analyzed from prospective 10-year community-based cohort analysis. Dietary sodium, potassium, and the sodium-to-potassium ratio at baseline were assessed by a food frequency questionnaire. In Cox proportional hazards regression models, the association between dietary sodium, potassium, and their ratio and all-cause and cardiovascular disease mortality was estimated using hazard ratios and 95% confidence intervals, and their predictive ability as mortality predictors was evaluated using Harrell's c-index. During the mean (range) 10.1 (0.2-15.9) years of follow-up, 5,436 participants died, of whom 985 died of cardiovascular causes. After adjustment for age, sex, body mass index, alcohol intake, smoking, regular exercise, total calorie intake, dyslipidemia, hypertension, diabetes, chronic kidney diseases (CKDs), and potassium or sodium intake, respectively, sodium intake was unassociated with all-cause mortality whereas potassium intake was significantly associated inversely with all-cause (Quintile-5 vs. Quintile-1, hazard ratio, 95% confidence interval, 1.09, 0.97-1.22, and 0.79, 0.69-0.91, respectively). The sodium-to-potassium ratio was not significantly associated with all-cause mortality in the adjusted model, and similar trends were observed for cardiovascular disease mortality.

PRE-OPerative ECHOcardiograhy for prevention of cardiovascular events after non-cardiac surgery in intermediate- and high-risk patients: protocol for a low-interventional, mixed-cohort prospective study design (PREOP-ECHO)

Background

Cardiac evaluation using transthoracic echocardiography before noncardiac surgery is common in real-world practice. However, evidence supporting preoperative echocardiography is lacking. This study aims to evaluate the additional benefit of preoperative echocardiography in predicting postoperative cardiovascular events (CVE) in noncardiac surgery.

Methods

This study is designed as a multicenter, prospective study to assess the utility of preoperative echocardiography in patients undergoing intermediate- or high-risk noncardiac surgery. This trial comprises two studies: (1) a randomized controlled trial (RCT) for patients undergoing intermediate-risk surgery with fewer than three clinical risk factors from the revised cardiac risk index (intermediate-risk group) and (2) a prospective cohort study for patients undergoing intermediate-risk surgery with three or more clinical risk factors, or who undergo high-risk surgery regardless of the number of clinical risk factors (high-risk group). We hypothesize that the use of preoperative echocardiography will reduce postoperative CVEs in patients undergoing intermediate- to high-risk surgery through discovery of and further intervention for unexpected cardiac abnormalities before elective surgery. A total of 2330 and 2184 patients will be enrolled in the two studies. The primary endpoint is a composite of all-cause death; aborted sudden cardiac arrest; type I acute myocardial infarction; clinically diagnosed unstable angina; stress-induced cardiomyopathy; lethal arrhythmia, such as sustained ventricular tachycardia or ventricular fibrillation; and/or newly diagnosed or acutely decompensated heart failure within 30 days after surgery.

Discussion

This study will be the first large-scale prospective study examining the benefit of preoperative echocardiography in predicting postoperative CVE. The PREOP-ECHO trial will help doctors identify patients at risk of postoperative CVE using echocardiography and thereby reduce postoperative CVEs.

Trial registration

The Clinical Research Information Service KCT0006279 for RCT and KCT0006280 for prospective cohort study. Registered on June 21, 2021.

Selection of DNA aptamer and its application as an electrical biosensor for Zika virus detection in human serum

Zika virus is a highly infectious virus that is part of the flavivirus group. Precise diagnosis of the Zika virus is significant issue for controlling a global pandemic after the COVID-19 era. For the first time, we describe a zika virus aptamer-based electrical biosensor for detecting Zika virus in human serum. The electrical biosensor composed of a Zika virus aptamer/MXene nanoparticle heterolayer on Au micro-gap electrode (AuMGE)/print circuit board (PCB) system. The Zika virus aptamer was designed to bind the envelope protein of the Zika virus by systematic evolution of ligands by exponential enrichment (SELEX) technique. The binding affinity of the aptamer was determined by fluorescence. For improving the sensor signal sensitivity, Ti₃C₂T_x MXene was introduced to surface of Au micro-gap electrode (AuMGE). The immobilization process was confirmed by atomic force microscopy (AFM). The prepared aptamer/MXene immobilized on AuMGE can detect the Zika virus through capacitance change according to the target concentration. The capacitance signal from the biosensor increased linearly according to increment of envelope proteins in the human serum. The limit of detection was determined to 38.14 pM, and target proteins could be detected from 100 pM to 10 μM. Thus, the developed electrical aptabiosensor can be a useful tool for Zika virus detection.

Bone regeneration at extraction sockets filled with leukocyte-platelet-rich fibrin: An experimental pre-clinical study

Background

We aimed to histomorphometrically evaluate the effects of Leucocyte-Platelet-Rich Fibrin (L-PRF), with and without the combination of a bone grafting material, for alveolar ridge preservation using an in vivo canine model.

Material and Methods

Seven dogs (Female Beagles, ~18-month-old) were acquired for the study. L-PRF was prepared from each individual animal by drawing venous blood and spinning them through a centrifuge at 408 RCF-clot (IntrasSpin, Intra-Lock, Boca Raton, FL). L-PRF membranes were obtained from XPression fabrication kit (Biohorizons Implant Systems, Inc., AL, USA). A split mouth approach was adopted with the first molar mesial and distal socket defects treated in an interpolated fashion of the following study groups: 1) Empty socket (negative control); 2) OSS filled defect 3) L-PRF membrane; and 4) Mix of Bio-Oss® with L-PRF. After six weeks, samples were harvested, histologically processed, and evaluated for bone area fraction occupancy (BAFO), vertical/horizontal ridge dimensions (VRD and HRD, respectively), and area of coronal soft tissue infiltration.

Results

BAFO was statistically lower for the control group in comparison to all treatment groups. Defects treated with Bio-Oss® were not statistically different then defects treated solely with L-PRF. Collapsed across all groups, L-PRF exhibited higher degrees of BAFO than groups without L-PRF. Defects filled with Bio-Oss® and Bio-Oss® with L-PRF demonstrated greater maintenance of VRD relative to the control group. Collapsed across all groups, Bio-Oss® maintained the VRD and resulted in less area of coronal soft tissue infiltration compared to the empty defect. Soft tissue infiltration observed at the coronal area was not statistically different among defects filled with L-PRF, Bio-Oss®, and Bio-Oss® with L-PRF.

Conclusions

Inclusion of L-PRF to particulate xenograft did not promote additional bone heading at 6 weeks in vivo. However, we noted that L-PRF alone promoted alveolar socket regeneration to levels comparable to particulate xenografts, suggesting its potential utilization for socket preservation.

Key words:L-PRF, bone healing, socket preservation.

RNF213 R4810K Variant in Suspected Unilateral Moyamoya Disease Predicts Contralateral Progression

Background Early-stage unilateral moyamoya disease (MMD) is difficult to discriminate from isolated intracranial atherosclerotic stenosis, and identification of contralateral progression may aid in the diagnosis of MMD. The RNF213 (ring finger protein 213) R4810K variant is a strong genetic susceptibility factor for MMD; however, the role of contralateral progression in unilateral MMD is unknown. Methods and Results Patients who had undergone RNF213 R4810K genotyping with suspected unilateral MMD between January 2017 and August 2021 from 2 tertiary university hospitals were retrospectively reviewed. We compared the clinical features and radiographic outcomes of patients with and without this variant. The risk factors of contralateral progression in patients with suspected unilateral MMD were evaluated. The RNF213 R4810K variant was observed in 72 of 123 patients with suspected unilateral MMD, all of which were heterozygous. The allele frequency of the R4810K variant was significantly higher in the suspected unilateral MMD group compared with the historical control group (29.3% versus 1.2%; P<0.0001). Family history of MMD was significantly more common in patients with the variant than in those without (17% versus 4%; P=0.003). Eleven of 72 patients with the variant developed contralateral progression, whereas only 1 of 51 patients without the variant developed contralateral progression during a median follow-up period of 28 months (log-rank test; P=0.03). The presence of the RNF213 R4810K variant significantly correlated with contralateral progression (adjusted odds ratio, 6.39 [95% CI, 1.11-36.63]; P=0.04). Conclusions Contralateral progression is more likely to occur in patients with suspected unilateral MMD with the RNF213 R4810K variant than in those without the variant. However, because our study used a small sample size, this finding should be carefully interpreted and requires further studies with more patients and longer follow-up periods.

Association of Dietary Fiber Intake with All-Cause Mortality and Cardiovascular Disease Mortality: A 10-Year Prospective Cohort Study

Although previous studies have established that dietary fiber (DF) intake reduces the total cardiovascular disease (CVD) mortality in general populations, limited studies have been conducted in individuals with pre-existing chronic conditions, especially in Asian countries. We aimed to investigate the association of DF intake with all-cause and CVD mortality in the general population and in the subpopulation with hypertension, diabetes, and dyslipidemia. We examined the relationship between DF intake and all-cause and CVD mortality using the Korean genome and epidemiology study. Diet was assessed using a food-frequency questionnaire at baseline. Cox proportional hazard models were used to estimate the hazard ratio (HR) and 95% confidence intervals (CIs) after adjusting for confounders. During the mean 10.1 years of follow-up, higher DF intake was significantly associated with a lower risk of all-cause mortality after adjusting for confounders (HR and 95% CIs for Q5 vs. Q1: 0.84 (0.76−0.93); p < 0.001). DF intake was inversely associated with a lower risk of CVD mortality after adjusting for the same confounders (HR and 95% CIs for Q5 vs. Q1: 0.61 (0.47−0.78); p < 0.001). Total DF intake was inversely associated with all-cause and CVD mortality in middle-aged and older adults.

Application of Machine Learning Approaches to Predict Postnatal Growth Failure in Very Low Birth Weight Infants

PURPOSE

The aims of the study were to develop and evaluate a machine learning model with which to predict postnatal growth failure (PGF) among very low birth weight (VLBW) infants.

MATERIALS AND METHODS

Of 10425 VLBW infants registered in the Korean Neonatal Network between 2013 and 2017, 7954 infants were included. PGF was defined as a decrease in Z score >1.28 at discharge, compared to that at birth. Six metrics [area under the receiver operating characteristic curve (AUROC), accuracy, precision, sensitivity, specificity, and F1 score] were obtained at five time points (at birth, 7 days, 14 days, 28 days after birth, and at discharge). Machine learning models were built using four different techniques [extreme gradient boosting (XGB), random forest, support vector machine, and convolutional neural network] to compare against the conventional multiple logistic regression (MLR) model.

RESULTS

The XGB algorithm showed the best performance with all six metrics across the board. When compared with MLR, XGB showed a significantly higher AUROC (p=0.03) for Day 7, which was the primary performance metric. Using optimal cut-off points, for Day 7, XGB still showed better performances in terms of AUROC (0.74), accuracy (0.68), and F1 score (0.67). AUROC values seemed to increase slightly from birth to 7 days after birth with significance, almost reaching a plateau after 7 days after birth.

CONCLUSION

We have shown the possibility of predicting PGF through machine learning algorithms, especially XGB. Such models may help neonatologists in the early diagnosis of high-risk infants for PGF for early intervention.

AB0344 EFFICACY OF SUBCUTANEOUS INFLIXIMAB (CT-P13 SC) COMPARED WITH INTRAVENOUS INFLIXIMAB IN RHEUMATOID ARTHRITIS: A POST-HOC ANALYSIS OF A PHASE 3 RANDOMIZED CONTROLLED TRIAL

Background

Subcutaneous (SC) CT-P13 is the first and only subcutaneous formulation of infliximab (IFX) approved by the EMA.1 In the pivotal study (NCT03147248), non-inferiority of SC IFX to intravenous (IV) was demonstrated in rheumatoid arthritis (RA) patients using 28-joint Disease Activity Score (DAS28) C-reactive protein (CRP) improvement at Week 22, with a statistically significant treatment difference of 0.27 (95% CI 0.02, 0.52) favoring the SC versus the IV arm.2,3 At Week 30, numerical differences in efficacy outcomes were shown between SC and IV IFX favoring SC IFX. IV group patients switched to SC IFX by Week 30, and the difference between the groups was reduced at Week 54.2

Objectives

To investigate whether there was a statistically significant difference between SC and IV IFX at Weeks 30 and 54 in the phase 3 pivotal study of CT-P13 SC using conservative missing imputation methods.

Methods

Patients with active RA who had an inadequate response to MTX received IV IFX 3mg/kg at Weeks 0 and 2 for induction and were randomized at a 1:1 ratio to receive SC IFX 120mg every 2 weeks or IV 3mg/kg every 8 weeks thereafter for maintenance. Patients who were randomized to receive IV IFX switched to SC at Week 30. In this post-hoc analysis, non-responder imputation (NRI) and last observation carried forward (LOCF) methods were used to investigate whether the difference in efficacy outcomes between SC and IV IFX at Weeks 30 and 54 was statistically significant. Assessments included EULAR (CRP/ESR)/ACR response; remission rate and low disease activity (LDA) rate based on DAS28 (CRP/ESR), Clinical Disease Activity Index (CDAI) and Simplified Disease Activity Index (SDAI); Boolean remission rate; and the proportion of patients achieving a minimal clinically important difference (MCID) in Health Assessment Questionnaire (HAQ).

Results

Of the 343 randomized patients, 165 patients who received SC IFX and 174 patients who received IV IFX from the efficacy population were included in the analysis. There was a statistically significant difference in SC IFX compared to IV treated patients at Week 30 using both NRI and LOCF methods in almost all the clinical variables. However, the difference in efficacy outcomes between SC IFX and IV was reduced at Week 54 after the IV group switched to SC. This supports the improved efficacy of SC IFX at Week 30. Some of the key results (EULAR [CRP] responses, LDA rates based on DAS28 [CRP], CDAI, and SDAI) were presented in Figure 1. Analysis using LOCF and NRI methods yielded consistent results across most of the efficacy outcomes.

Figure 1.

Comparison of clinical outcomes between SC IFX and IV IFX in patients with active rheumatoid arthritis.

*P<0.05.

P-value for difference in proportion between SC and IV treatment group was obtained by asymptotic Wald test.

Low disease activity based on DAS28 (CRP) (< 3.2), CDAI (eatment group AI (≤ 11.0).

Conclusion

Statistical analyses using conservative missing imputation methods showed significantly greater improvements in clinical outcomes with SC IFX compared to IV at Week 30 in patients with RA. Between-group differences was reduced at Week 54, suggesting improved responses after switching from IV to SC.

References

[1]Remsima summary of product characteristics. https://www.ema.europa.eu/en/documents/product-information/remsima-epar-product-information_en.pdf. Published 2021. Accessed 10 January 2022.

[2]Westhovens R, Wiland P, Zawadzki M, et al. Efficacy, pharmacokinetics and safety of subcutaneous versus intravenous CT-P13 in rheumatoid arthritis: a randomized phase I/III trial. Rheumatology (Oxford). 2021;60(5):2277-2287.

[3]Combe B, Allanore Y, Alten R, et al. Comparative efficacy of subcutaneous (CT-P13) and intravenous infliximab in adult patients with rheumatoid arthritis: a network meta-regression of individual patient data from two randomised trials. Arthritis Res Ther. 2021;23(1):119.

Disclosure of Interests

Arnaud Constantin Speakers bureau: Abbvie, Amgen, Boehringer, Celltrion, Galapagos, Janssen, Lilly, Novartis, Sanofi, UCB, Consultant of: Abbvie, Amgen, Boehringer, Celltrion, Galapagos, Janssen, Lilly, Novartis, Sanofi, UCB, Roberto Caporali Speakers bureau: Abbvie, Amgen, BMS, Celltrion, Galapagos, Lilly, Pfizer, Fresenius-Kabi, MSD, UCB, Roche,Janssen, Novartis, Sandoz, Consultant of: Abbvie, Amgen, BMS, Celltrion, Galapagos, Lilly, Pfizer, MSD, UCB, Janssen, Novartis, Sandoz, Christopher John Edwards Speakers bureau: Abbvie, Astra Zeneca, Celltrion, Chugai, Fresenius, Galapagos, Gilead, GSK, Lilly, Janssen, Pfizer, Roche, Consultant of: Abbvie, Astra Zeneca, Chugai, Galapagos, Gilead, GSK, Lilly, Janssen, Pfizer, Roche, Grant/research support from: Celltrion, Pfizer, Abbvie, Joao Eurico Fonseca Speakers bureau: Abbvie, Ache, Janssen, Lilly, Medac, Novartis, Pfizer, Consultant of: Abbvie, Celltrion, Janssen, Lilly, Pfizer, Grant/research support from: Abbvie, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, Florenzo Iannone Speakers bureau: Abbvie, BMS, Celltrion, Galapagos, MSD, Eli-Lilly, Janssen, Novartis, Pfizer, UCB, Consultant of: Abbvie, BMS, Celltrion, Galapagos, MSD, Eli-Lilly, Janssen, Pfizer, Grant/research support from: BMS, MSD, Edward Keystone Speakers bureau: Amgen, AbbVie, Celltrion, F. Hoffmann-La Roche Inc., Janssen Inc., Merck, Pfizer Pharmaceuticals, Sandoz, Sanofi Genzyme, Consultant of: AbbVie, Amgen, Celltrion, Myriad Autoimmune, F. Hoffmann-La Roche Inc, Janssen Inc, Lilly Pharmaceuticals, Merck, Pfizer Pharmaceuticals, Sandoz, Sanofi-Genzyme, Samsung Bioepsis, Grant/research support from: Amgen, Merck, Pfizer Pharmaceuticals, Hendrik Schulze-Koops Consultant of: Celltrion, Taeksang Kwon Employee of: Celltrion Healthcare, Seungmin Kim Employee of: Celltrion Healthcare, Sangwook Yoon Employee of: Celltrion Healthcare, Dong-Hyeon Kim Employee of: Celltrion Healthcare, Gahee Park Employee of: Celltrion Inc., DaeHyun Yoo Speakers bureau: Celltrion, Celltrion Healthcare

Preoperative durvalumab (D) with or without tremelimumab (T) for resectable head and neck squamous cell carcinoma (HNSCC): Updated results with high dimensional profiling of circulating immune cells

6072

Background: Although PD-1 blockade has improved survival in patients with recurrent and/or metastatic HNSCC, safety and efficacy of neoadjuvant immunotherapy with PD-L1 inhibitor with or without CTLA-4 inhibitor has not been investigated. Here, we report the updated results of the safety and efficacy of a preoperative D with or without T (D+/-T) in patients with resectable HNSCC, accompanied with high dimensional profiling of circulating immune cells. Methods: Patients with locally advanced but resectable HNSCC were eligible. Enrolled patients were randomized into D or D+T, stratified by primary site and human papilloma virus (HPV) infection status. A single dose of preoperative D (1500mg) or D+T (1500mg+75mg) was administered, with surgery planned 2 to 8 weeks later for curative resection. Postoperative (chemo) radiation was prescribed based on standard guidelines, followed by maintenance with D every 4 weeks for 1 year. Dynamic changes in circulating immune cells were tracked with mass cytometry. The primary objective was to determine the local recurrence rate. Secondary endpoints included pathologic response, safety, survival outcome, and exploration of immune dynamics. Results: As of January 25th 2022 for the interim analysis, a total of 45 patients were completely enrolled and received surgical resection (D: 21 patients, D+T: 24 patients). Oropharyngeal cancer was most common (n = 23; 51.1%) and HPV-mediated cancer was observed in 20 patients (44.4%). Neoadjuvant D+/-T had acceptable safety profiles and was not associated with delays in surgery or unexpected adverse events. Tumor shrinkage was observed in 31 patients (68.9%), with 15.6% of average tumor shrinkage (range; 100.0% to -80.0%). Major pathologic response (no more than 10% of viable tumor cells) was achieved in 3 patients (6.7%), including 2 cases with pathologic complete response (4.4%). During median follow-up duration of 407 days after surgery, local recurrence and systemic recurrence were documented in 9 patients (20.0%) and 7 patients (15.6%), respectively. Median disease-free survival and overall survival was 910 days and not reached, respectively. High dimensional immune profiling with mass cytometry revealed that D+T disproportionally increased the frequency of regulatory T cells accompanied with the upregulation of their functional markers, which was absent in patients treated with D monotherapy. Conclusions: These updated data suggested that preoperative D+/-T was safe and feasible and had the potential to provide clinical benefits for patients with resectable HNSCC. Distinct immunologic changes in circulating immune cells were induced by each treatment regimen, warranting further investigation. The trial is ongoing and the updated outcomes with immune correlates will be presented in this ASCO. Clinical trial information: NCT03737968.

Hippocampal Metastasis Rate Based on Non-Small Lung Cancer TNM Stage and Molecular Markers

Hippocampal-avoidance whole-brain radiation therapy (HA-WBRT) is justified because of low hippocampal brain metastases (BM) rate and its prevention of cognitive decline. However, we hypothesize that the risk of developing BM in the hippocampal-avoidance region (HAR) may differ depending on the lung-cancer stage and molecular status. We retrospectively reviewed 123 patients with non-small cell lung cancer (NSCLC) at the initial diagnosis of BM. The number of BMs within the HAR (5 mm expansion) was counted. The cohort was divided into patients with and without BMs in the HAR, and their clinical variables, TNM stage, and epidermal growth factor receptor (EGFR) status were compared. The most influential variable predicting BMs in the HAR was determined using multi-variable logistic regression, classification and regression tree (CART) analyses, and gradient boosting method (GBM). The feasibility of HAR expansion was tested using generalized estimating equation marginal model. Patients with BMs in the HAR were more frequently non-smokers, and more likely to have extra-cranial metastases and EGFR mutations (p<0.05). Multi-variable analysis revealed that extra-cranial metastases were independently associated with the presence of BM in the HAR (odds ratio=8.75, p=0.04). CART analysis and GBM revealed that the existence of extra-cranial metastasis was the most influential variable predicting BM occurrence in the HAR (variable importance: 23% and relative influence: 37.38). The estmated BM incidence of patients without extra-cranial metastases in th extended HAR (7.5-mm and 10-mm expansion) did not differ significantly from that in the conventional HAR. In conclusion, NSCLC patients with extra-cranial metastases were more likely to have BMs in the HAR than those without extra-cranial metastases.

Comparison of the Modified TyG Indices and Other Parameters to Predict Non-Alcoholic Fatty Liver Disease in Youth

Simple Summary

Non-alcoholic fatty liver disease (NAFLD) is associated with cardio-metabolic risk factors, including obesity, dyslipidemia, insulin resistance, and hepatic cirrhosis. The increasing prevalence of NAFLD among youths has become a public health concern. However, studies about reliable markers for assessing NAFLD in youths are limited. Thus, we investigated the markers including the triglycerides-glucose (TyG) index, modified TyG indices, hepatic steatosis index (HSI), aspartate transaminase-to-platelet ratio index (APRI), and modified APRIs for the prediction of NAFLD. This study demonstrated that the modified TyG indices, APRI-body mass index standard deviation score, and HSI are strongly associated with NAFLD in children and adolescents. Thus, these markers may be useful for identifying youths who require hepatic ultrasonography and early treatment.

Abstract

We investigated the modified triglycerides-glucose (TyG) indices and other markers for non-alcoholic fatty liver disease (NAFLD) in 225 participants aged 10–19 years, and the participants were divided into subgroups according to their NAFLD grade. We performed logistic regression analysis and calculated the odds ratios (ORs) with 95% confidence intervals (CIs) of tertiles 2 and 3 for each parameter, with those of tertile 1 as a reference. The area under the receiver operating characteristic (ROC) curve was calculated to compare the parameters for identifying NAFLD. TyG and modified indices, aspartate transaminase-to-platelet ratio index (APRI)-body mass index (BMI), APRI-BMI standard deviation score (SDS), APRI waist-to-hip ratio, fibrosis-4 index (FIB)-4, and hepatic steatosis index (HSI) were higher in participants with NAFLD than in those without NAFLD. The ORs and 95% CIs for NAFLD progressively increased across tertiles of each parameter. TyG and modified TyG indices, FIB-4, HSI, and modified APRIs, except APRI waist-to-height ratio, predicted NAFLD significantly through ROC curves. Modified TyG indices, APRI-BMI SDS, and HSI were superior to the other markers for NAFLD prediction. Modified TyG indices, APRI-BMI SDS, and HSI appear to be useful for assessing NAFLD in youths.

Trends in Prediabetes and Non-Alcoholic Fatty Liver Disease Associated with Abdominal Obesity among Korean Children and Adolescents: Based on the Korea National Health and Nutrition Examination Survey between 2009 and 2018

Investigations on the trends of prediabetes and non-alcoholic fatty liver disease (NAFLD) among children are scarce. We aimed to analyze the trends of prediabetes and NAFLD, as well as their association, among Korean children and adolescents from 2009 to 2018. This study investigated the prevalence of prediabetes, NAFLD, and abdominal obesity among 6327 children and adolescents aged 10–18 years according to age, sex, and body mass index (BMI) using a nationally representative survey. The prevalence of prediabetes, NAFLD, and abdominal obesity increased from 5.14%, 8.17%, and 5.97% respectively, in 2009 to 10.46%, 12.05%, and 10.51% respectively, in 2018. In age-specific analyses, an adverse trend in NAFLD was significant only in participants aged 16–18 years while the prevalence of prediabetes worsened significantly in all age groups. In BMI-specific analyses, the prevalence of prediabetes and NAFLD increased significantly only in participants with normal BMI. In logistic regression analysis, the odds ratio of prediabetes for NAFLD was 1.85 and those of abdominal obesity for prediabetes and NAFLD was 1.85 and 9.34, respectively. Our results demonstrated that the prevalence of prediabetes and NAFLD was increasing in association with abdominal obesity in Korean children and adolescents.

Comparison of the Triglyceride Glucose Index and Modified Triglyceride Glucose Indices to Predict Nonalcoholic Fatty Liver Disease in Youths

OBJECTIVE

To assess the associations between the triglyceride glucose (TyG) index and modified TyG indices with nonalcoholic fatty liver disease (NAFLD) and evaluate their ability as predictors of NAFLD in youths.

STUDY DESIGN

We analyzed the cross-sectional data of 3728 individuals aged 10-19 years using the Korea National Health and Nutrition Examination Survey, a nationally representative survey. Logistic regression analysis was performed, and ORs and 95% CIs of tertiles 2 and 3 for each variable for predicting NAFLD were calculated and compared with those of tertile 1 as the reference. Receiver operating characteristic (ROC) curves were plotted to evaluate the ability of each variable for NAFLD prediction.

RESULTS

All TyG and modified TyG indices exhibited progressively increased ORs and 95% CIs for NAFLD across all tertiles (all P < .001). In addition, all TyG and modified TyG indices significantly predicted NAFLD through ROC curves. All modified TyG indices were superior to the TyG index for predicting NAFLD in all subjects and in males. Among females, the TyG-waist-to-height ratio was superior to the TyG index, TyG-body mass index (BMI), and TyG-waist circumference (WC), and the TyG-BMI SDS and TyG-WC were superior to the TyG index.

CONCLUSIONS

The TyG and modified TyG indices are markers for NAFLD prediction in youths, and the modified TyG indices are superior to the TyG index. Modified TyG indices have the potential to be simple and cost-effective markers in screening for NAFLD in youths.

Ability of dynamic preload indices to predict fluid responsiveness in a high femoral-to-radial arterial pressure gradient: a retrospective study

Background

Dynamic preload indices may predict fluid responsiveness in end-stage liver disease. However, their usefulness in patients with altered vascular compliance is uncertain. This study is the first to evaluate whether dynamic indices can reliably predict fluid responsiveness in patients undergoing liver transplantation with a high femoral-to-radial arterial pressure gradient (PG).

Methods

Eighty liver transplant recipients were retrospectively categorized as having a normal (n = 56) or high (n = 24, difference in systolic pressure ≥ 10 mmHg and/or mean pressure ≥ 5 mmHg) femoral-to-radial arterial PG, measured immediately after radial and femoral arterial cannulation. The ability of dynamic preload indices (stroke volume variation, pulse pressure variation [PPV], pleth variability index) to predict fluid responsiveness was assessed before the surgery. Fluid replacement of 500 ml of crystalloid solution was performed over 15 min. Fluid responsiveness was defined as ≥ 15% increase in the stroke volume index. The area under the receiver-operating characteristic curve (AUC) indicated the prediction of fluid responsiveness.

Results

Fourteen patients in the normal, and eight in the high PG group were fluid responders. The AUCs for PPV in the normal, high PG groups and total patients were 0.702 (95% confidence interval [CI] 0.553–0.851, P = 0.008), 0.633 (95% CI 0.384–0.881, P = 0.295) and 0.667 (95% CI 0.537–0.798, P = 0.012), respectively. No other index predicted fluid responsiveness.

Conclusion

PPV can be used as a dynamic index of fluid responsiveness in patients with end-stage liver disease but not in patients with altered vascular compliance.

Effect of Prehospital Epinephrine on Out-of-Hospital Cardiac Arrest Outcomes: A Propensity Score-Matched Analysis

PURPOSE

A pilot project using epinephrine at the scene under medical control is currently underway in Korea. This study aimed to determine whether prehospital epinephrine administration is associated with improved survival and neurological outcomes in out-of-hospital cardiac arrest (OHCA) patients who received epinephrine during cardiopulmonary resuscitation (CPR) in the emergency department.

MATERIALS AND METHODS

This retrospective observational study used a nationwide multicenter OHCA registry. Patients were classified into two groups according to whether they received epinephrine at the scene or not. The associations between prehospital epinephrine use and outcomes were assessed using propensity score (PS)-matched analysis. Multivariable logistic regression analysis was performed using PS matching. The same analysis was repeated for the subgroup of patients with non-shockable rhythm.

RESULTS

PS matching was performed for 1084 patients in each group. Survival to discharge was significantly decreased in the patients who received prehospital epinephrine [odds ratio (OR) 0.415, 95% confidence interval (CI) 0.250-0.670, p<0.001]. However, no statistical significance was observed for good neurological outcome (OR 0.548, 95% CI 0.258-1.123, p=0.105). For the patient subgroup with non-shockable rhythm, prehospital epinephrine was also associated with lower survival to discharge (OR 0.514, 95% CI 0.306-0.844, p=0.010), but not with neurological outcome (OR 0.709, 95% CI 0.323-1.529, p=0.382).

CONCLUSION

Prehospital epinephrine administration was associated with decreased survival rates in OHCA patients but not statistically associated with neurological outcome in this PS-matched analysis. Further research is required to investigate the reason for the detrimental effect of epinephrine administered at the scene.

Dyslipidemia Risk in Thyroid Cancer Patients: A Nationwide Population-Based Cohort Study

OBJECTIVE

Thyroid cancer (TC) prevalence has been rapidly increasing. While the relationship between thyroid hormones and lipids has been widely investigated, studies regarding dyslipidemia in patients with TC have been scarce and controversial. We aimed to investigate dyslipidemia risk after TC diagnosis compared to the general population without TC.

METHOD

A population-based prospective study was conducted using data from the Korean National Health Insurance Service-National Sample Cohort Database 2.0 (NHIS-NSC DB 2.0), with health insurance claim data of 1,108,369 subjects between 2002 and 2015. The final study sample comprised 466,735 adult subjects without TC or dyslipidemia diagnoses before the index year, 2009. Bidirectional analyses were performed using prospective and retrospective concepts. In the prospective analysis, Kaplan-Meier estimates were calculated and log-rank tests and univariable and multivariable Cox regression analyses were performed to determine the relationship between TC and dyslipidemia. The retrospective analysis involved 1:5 nested case-control matching based on dyslipidemia status and conditional logistic regression analysis.

RESULTS

No significant difference in dyslipidemia incidence was observed between TC patients and the control group, in either the prospective matched (log-rank P = 0.483) or non-matched (log-rank P = 0.424) analyses, or the retrospective analysis (P = 0.3724). In the prospective analysis, 193 patients after TC diagnosis showed similar risk of developing dyslipidemia with the 466,542 controls during the median 7 years of follow-up (unadjusted hazard ratio [HR], 1.102; 95% confidence interval [CI], 0.878-1.383; adjusted HR, 0.932; 95% CI, 0.707-1.230). Multiple propensity score-adjusted models showed similar results, and 114 patients and 570 matched controls showed an HR of 0.818 (95% CI, 0.598-1.120). In the retrospective comparison of dyslipidemia risk in 170 patients and 277,864 controls, the odds ratio was 0.822 (95% CI, 0.534-1.266).

CONCLUSIONS

Dyslipidemia risk was not significantly different between patients with TC and the general population, in both prospective and retrospective analyses.

Efficacy and safety of temperature-controlled intraductal radiofrequency ablation in advanced malignant hilar biliary obstruction: A pilot multicenter randomized comparative trial

PURPOSE

We aimed to evaluate the efficacy and safety of temperature-controlled intraductal radiofrequency ablation (ID-RFA) for advanced malignant hilar biliary obstruction (MHBO).

METHODS

Patients were randomly assigned to RFA group (ID-RFA and bilateral plastic stent [PS]) or non-RFA group (bilateral PS) at a 1:1 ratio. Exchange to self-expanding metal stent (SEMS) was performed after 3 months or when premature PS occlusion occurred. Total event-free stent patency, overall survival (OS), and adverse events (AEs) were analyzed.

RESULTS

A total of 30 patients from three hospitals were enrolled. Stent patency and OS did not differ between the two groups (178 days vs 122 days, P = .154; 230 days vs 144 days, P = .643; respectively). In patients with each stricture length ≥11 mm on both sides, stent patency was longer in the RFA group than in the non-RFA group (175 days vs 121 days, P = .028). More patients received elective exchange to SEMS without PS occlusion in the RFA group than in the non-RFA group (69.2% vs 23.1%, P = .018). AE rates did not differ between the two groups.

CONCLUSIONS

Temperature-controlled ID-RFA for advanced MHBO was safe and feasible. It could prevent premature PS occlusion within 3 months.

Outcome in Patients Treated with Intra-arterial thrombectomy: The optiMAL Blood Pressure control (OPTIMAL-BP) Trial

RATIONALE

Very early stage blood pressure (BP) levels may affect outcome in stroke patients who have successfully undergone recanalization following intra-arterial treatment, but the optimal target of BP management remains uncertain.

AIM

We hypothesized that the clinical outcome after intensive BP-lowering is superior to conventional BP control after successful recanalization by intra-arterial treatment.

SAMPLE-SIZE ESTIMATES

We aim to randomize 668 patients (334 per arm), 1:1.

METHODS AND DESIGN

We initiated a multicenter, prospective, randomized, open-label trial with a blinded end-point assessment (PROBE) design. After successful recanalization (thrombolysis in cerebral infarction score ≥ 2 b), patients with elevated systolic BP level, defined as the mean of two readings ≥ 140 mmHg, will be randomly assigned to the intensive BP-lowering (systolic BP < 140 mm Hg) group or the conventional BP-lowering (systolic BP, 140-180 mm Hg) group.

STUDY OUTCOMES

The primary efficacy outcomes are from dichotomized analysis of modified Rankin Scale (mRS) scores at three months (mRS scores: 0-2 vs. 3-6). The primary safety outcomes are symptomatic intracerebral hemorrhage and death within three months.

DISCUSSION

The OPTIMAL-BP trial will provide evidence for the effectiveness of active BP control to achieve systolic BP < 140 mmHg during 24 h in patients with successful recanalization after intra-arterial treatment.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04205305.

Clinical and genetic spectra in patients with dystrophinopathy in Korea: A single-center study

Dystrophinopathy is a group of inherited phenotypes arising from pathogenic variants in DMD. We evaluated the clinical and genetic characteristics of Korean patients with genetically confirmed dystrophinopathy. We retrospectively reviewed medical records (January 2004-September 2020) from the myopathy database maintained at the study hospital and found 227 patients from 218 unrelated families with dystrophinopathy. Clinical phenotypes included 120 (53%) Duchenne muscular dystrophy (DMD) cases, 20 (9%) intermediate phenotype muscular dystrophy (IMD) cases, 65 (29%) Becker muscular dystrophy (BMD) cases, 18 (8%) undetermined phenotypes, and 4 (2%) symptomatic carriers. The median ages at symptom onset and diagnosis were 5.0 years (interquartile range [IQR]: 3.8–8.0) and 12.0 years (IQR: 7.0–21.0), respectively. Total manual muscle test (MMT) scores decreased annually in patients with DMD, IMD, and BMD. Overall, when age increased by 1 year, total MMT scores decreased on average by -1.978, -1.681, and -1.303 in patients with DMD (p<0.001), IMD (p<0.001), and BMD (p<0.001), respectively. Exonic deletion and duplication were reported in 147 (67%) and 31 (14%) of the 218 unrelated probands, respectively. A total of 37 different small sequence variants were found in 40 (18%) of the 218 probands. The reading frame rule was applicable to 142 (94%) of the 151 probands. The present results highlight the long-term natural history and genetic spectrum of dystrophinopathy in a large-scale Korean cohort.

First-trimester screening model for small-for-gestational-age using maternal clinical characteristics, serum screening markers, and placental volume: prospective cohort study

OBJECTIVE

To examine predictive value of first trimester placental volume, maternal clinical characteristics, and serum biomarkers in predicting small-for-gestational-age (SGA) singleton pregnancy.

METHODS

We conducted a prospective study to determine whether SGA is associated with maternal clinical factors. Between November 2016 to May 2018, 351 women were enrolled. We included pregnant women who underwent an integrated test for aneuploidy screening. Placental volume, maternal clinical characteristics, and maternal serum pregnancy-associated plasma protein A (PAPP-A) levels in the first trimester (at 10⁺⁰-13⁺⁶weeks) and maternal serum biomarkers after 15⁺⁰-22⁺⁶weeks were measured. We measured the width, height, and thickness of the placenta and calculated the placental volume using an established mathematical formula; then, we analyzed the association between SGA at delivery, estimated placental volume (EPV), maternal clinical characteristics, and maternal serum biomarkers by multiple logistic regression analysis.

RESULTS

In this study, 12.3% (43/351) neonates were delivered before 37 weeks of gestation, and the birth weight of 23.6% (83/351) was below the 10th percentile according to gestational age. On multivariate logistic regression, the MSAFP multiples of the median (MoM) showed the strongest association with SGA in singleton pregnancy (p < .01), and the PAPP-A MoM showed a weaker association in the multiple logistic regression than in the univariate regression (p = .0073 and .0068, respectively). Our prediction model using maternal age, maternal smoking, PAPP-A, and EPV achieved an area under the curve of 0.668 in singleton pregnancy.

CONCLUSION

During the first trimester, maternal clinical characteristics, serum biomarkers, and EPV may be used for predicting the risk of SGA in singleton pregnancy.

Supercomputer-Based Ensemble Docking Drug Discovery Pipeline with Application to Covid-19

We present a supercomputer-driven pipeline for in silico drug discovery using enhanced sampling molecular dynamics (MD) and ensemble docking. Ensemble docking makes use of MD results by docking compound databases into representative protein binding-site conformations, thus taking into account the dynamic properties of the binding sites. We also describe preliminary results obtained for 24 systems involving eight proteins of the proteome of SARS-CoV-2. The MD involves temperature replica exchange enhanced sampling, making use of massively parallel supercomputing to quickly sample the configurational space of protein drug targets. Using the Summit supercomputer at the Oak Ridge National Laboratory, more than 1 ms of enhanced sampling MD can be generated per day. We have ensemble docked repurposing databases to 10 configurations of each of the 24 SARS-CoV-2 systems using AutoDock Vina. Comparison to experiment demonstrates remarkably high hit rates for the top scoring tranches of compounds identified by our ensemble approach. We also demonstrate that, using Autodock-GPU on Summit, it is possible to perform exhaustive docking of one billion compounds in under 24 h. Finally, we discuss preliminary results and planned improvements to the pipeline, including the use of quantum mechanical (QM), machine learning, and artificial intelligence (AI) methods to cluster MD trajectories and rescore docking poses.

Supercomputer-Based Ensemble Docking Drug Discovery Pipeline with Application to Covid-19

We present a supercomputer-driven pipeline for in-silico drug discovery using enhanced sampling molecular dynamics (MD) and ensemble docking. We also describe preliminary results obtained for 23 systems involving eight protein targets of the proteome of SARS CoV-2. THe MD performed is temperature replica-exchange enhanced sampling, making use of the massively parallel supercomputing on the SUMMIT supercomputer at Oak Ridge National Laboratory, with which more than 1ms of enhanced sampling MD can be generated per day. We have ensemble docked repurposing databases to ten configurations of each of the 23 SARS CoV-2 systems using AutoDock Vina. We also demonstrate that using Autodock-GPU on SUMMIT, it is possible to perform exhaustive docking of one billion compounds in under 24 hours. Finally, we discuss preliminary results and planned improvements to the pipeline, including the use of quantum mechanical (QM), machine learning, and AI methods to cluster MD trajectories and rescore docking poses.

OP0046 TARGETING IRAK1 AND 4 SIGNALING WITH R835, A NOVEL ORAL SMALL MOLECULE INHIBITOR: A POTENTIAL NEW TREATMENT FOR SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Systemic lupus erythematosus (SLE) is a complex autoimmune disease characterized by loss of immunological tolerance, hyperactivation of immune cells, proinflammatory cytokine production and, ultimately, end organ damage due to immune complex deposition. Toll-like receptors (TLRs), which are essential to the innate immune response to microbes and other danger signals, play a key role in the pathogenesis of SLE by recognition of self-molecules (1). Interleukin receptor associated kinases (IRAK)1 and 4 are responsible for initiating MyD88-dependent signaling from most TLRs and Interleukin-1 Receptors (IL-1R) and represent attractive targets for the therapeutic treatment of SLE (2). We have identified a potent and selective IRAK1/4 inhibitor, R835, that substantially suppressed the elevation of LPS (TLR4 agonist)-induced serum cytokines in healthy human volunteers in a recently completed phase 1 study.

Objectives:

The aim of our study was to investigate the effect of IRAK1/4 selective inhibition as potential therapeutic approach for SLE. We evaluated the effect of our clinical candidate R835 on TLR7 signaling and in a mouse model of lupus-like disease.

Methods:

Human primary dendritic cells and whole blood were stimulated with gardiquimod (TLR7 agonist) to evaluate the effect of R835 on Interferon-alpha (IFN-α) production. R835 was further evaluated for its efficacy on survival and disease progression in lupus-prone NZB/W F1 mice with early or active signs of disease.

Results:

R835 inhibited TLR7-induced cytokine production in human dendritic cells and whole blood. Given orally to mice, R835 dose-dependently decreased serum IFN-α in response to administration of a TLR7 agonist. Furthermore, treatment of NZB/W F1 lupus-prone mice with R835 reversed the progression of lupus-like disease and the establishment of a pro-inflammatory environment, as demonstrated by decreased levels of proteinuria, blood urea nitrogen and autoantibodies, and reversal of renal pathology.

Conclusion:

To our knowledge, R835 is the first dual IRAK1/4 inhibitor to enter clinical development and provides an attractive approach to treat a range of autoimmune and rheumatic diseases, including lupus.

References:

[1]Signals via the Adaptor MyD88 in B cells and DCs Make Distinct and Synergistic Contributions to Immune Activation and Tissue Damage in Lupus. Lino L. Teichmann, Dominik Schenten, Ruslan Medzhitov, Michael Kashgarian, and Mark J. Shlomchik. Immunity. 2013 March 21; 38(3): 528–540.

[2]Suppression of IRAK1 or IRAK4 Catalytic Activity, but Not Type 1 IFN Signaling, Prevents Lupus Nephritis in Mice Expressing a Ubiquitin Binding-Defective Mutant of ABIN1. Nanda SK, Lopez-Pelaez M, Arthur JS, Marchesi F, Cohen P. J Immunol. 2016 Dec 1;197(11):4266-4273.

Disclosure of Interests:

Chrystelle Lamagna Shareholder of: Rigel Pharmaceuticals, Employee of: Rigel Pharmaceuticals, Meagan Chan Shareholder of: Rigel Pharmaceuticals, Employee of: Rigel Pharmaceuticals, Art Bagos Shareholder of: Rigel Pharmaceuticals, Employee of: Rigel Pharmaceuticals, Ernest Tai Shareholder of: Rigel Pharmaceuticals, Employee of: Rigel Pharmaceuticals, Chi Young Shareholder of: Rigel Pharmaceuticals, Employee of: Rigel Pharmaceuticals, Yan Chen Shareholder of: Rigel Pharmaceuticals, Employee of: Rigel Pharmaceuticals, Lu Chou Shareholder of: Rigel Pharmaceuticals, Employee of: Rigel Pharmaceuticals, Gary Park Shareholder of: Rigel Pharmaceuticals, Employee of: Rigel Pharmaceuticals, Esteban Masuda Shareholder of: Rigel Pharmaceuticals, Employee of: Rigel Pharmaceuticals, Vanessa Taylor Shareholder of: Rigel Pharmaceuticals, Employee of: Rigel Pharmaceuticals

OP0133 PRECLINICAL EFFICACY OF R835, A NOVEL IRAK1/4 DUAL INHIBITOR, IN RODENT MODELS OF JOINT INFLAMMATION

Background:

Interleukin receptor associated kinases (IRAK) 1 and 4 are kinases involved in Toll-Like Receptor (TLR) and Interleukin-1 Receptor (IL-1R) signaling pathways, which regulate innate immunity and inflammation. Dysregulation of IRAK1/4 signaling can lead to a variety of inflammatory conditions including rheumatoid and gouty arthritis. As a result, IRAK1/4 are promising therapeutic targets for rheumatic diseases (1). We have identified a potent and selective IRAK1/4 inhibitor, R835, that substantially suppressed the elevation of LPS (TLR4 agonist)-induced serum cytokines in healthy human volunteers in a recently completed phase 1 study.

Objectives:

The aim of our study was to investigate the effect of IRAK1/4 selective inhibition as a potential therapeutic approach for rheumatological diseases. We evaluated the inhibition by our clinical candidate, R835, on TLR-, IL-1R- and NLRP3 inflammasome-induced cytokine production, as well as in preclinical models of arthritis.

Methods:

The effect of R835 on TLR- or IL-1R-induced cytokine production was evaluated in vitro using THP-1, human primary endothelial cells and human primary dendritic cells. The activity of R835 on the NLRP3 inflammasome was also tested in vitro using THP-1 cells. The pharmacokinetic-pharmacodynamic relationship of R835 was evaluated in a mouse model of IL-1b-induced cytokine release. Mice were pre-treated orally with vehicle or R835 prior to challenge; serum cytokine and plasma compound levels were determined. The efficacy of IRAK1/4 inhibition by R835 in rodent models of joint inflammation was evaluated in a mouse model monosodium (MSU)-induced peritonitis, in rat model of MSU-induced gouty arthritis and in a rat model of collagen-induced arthritis (CIA).

Results:

In human cells, R835 blocked proinflammatory cytokine production in response to TLR, IL-1R and NLRP3 inflammasome activation. In mice, R835 dose-dependently decreased serum cytokines in response to administration of IL-1b. Mice pre-treated with R835 demonstrated dose-dependent reductions in MSU crystal-induced serum and peritoneal cytokine levels, as well as neutrophil influx in the peritoneal cavity. Prophylactic and therapeutic treatment with R835 also resulted in significant inhibition of MSU crystal-induced knee edema and pain in a rat model of human gouty arthritis. In the rat model of CIA, R835 blocked both onset and progression of disease, by reducing inflammation, cartilage degeneration and synovial inflammation.

Conclusion:

R835 is a promising clinical candidate for the treatment of a range of cytokine-driven rheumatological diseases. R835 has proven to have desirable pharmacokinetic properties, was well tolerated and suppressed LPS-induced serum cytokines in healthy volunteers in a recent phase 1 study.

References:

[1]Bahia M S, Kaur M, Silakari P, Silakari O. Interleukin-1 receptor associated kinase inhibitors: Potential therapeutic agents for inflammatory- and immune-related disorders. Cellular Signalling 27 (2015) 1039–1055.

Disclosure of Interests:

Chrystelle Lamagna Shareholder of: Rigel Pharmaceuticals, Employee of: Rigel Pharmaceuticals, Meagan Chan Shareholder of: Rigel Pharmaceuticals, Employee of: Rigel Pharmaceuticals, Ernest Tai Shareholder of: Rigel Pharmaceuticals, Employee of: Rigel Pharmaceuticals, Stacey Siu Shareholder of: Rigel Pharmaceuticals, Employee of: Rigel Pharmaceuticals, Roy Frances Shareholder of: Rigel Pharmaceuticals, Employee of: Rigel Pharmaceuticals, Sothy Yi Shareholder of: Rigel Pharmaceuticals, Employee of: Rigel Pharmaceuticals, Chi Young Shareholder of: Rigel Pharmaceuticals, Employee of: Rigel Pharmaceuticals, Vadim Markovtsov Shareholder of: Rigel Pharmaceuticals, Employee of: Rigel Pharmaceuticals, Yan Chen Shareholder of: Rigel Pharmaceuticals, Employee of: Rigel Pharmaceuticals, Lu Chou Shareholder of: Rigel Pharmaceuticals, Employee of: Rigel Pharmaceuticals, Gary Park Shareholder of: Rigel Pharmaceuticals, Employee of: Rigel Pharmaceuticals, Esteban Masuda Shareholder of: Rigel Pharmaceuticals, Employee of: Rigel Pharmaceuticals, Vanessa Taylor Shareholder of: Rigel Pharmaceuticals, Employee of: Rigel Pharmaceuticals