Severe behavioral and psychological symptoms of dementia successfully treated at home with a blonanserin transdermal patch: A case report

AIM

Behavioral psychological symptoms of dementia (BPSD) are sometimes difficult to treat due to severe psychiatric symptoms such as delusions of poisoning and violent behavior. Moreover, in cases of parental neglect, the management of these psychiatric symptoms becomes more difficult. Therefore, home-visiting doctors sometimes have to manage patients with BPSD and severe psychiatric symptoms, and a new approach is needed. In this case report, the effect of blonanserin transdermal patch on these patients is to be highlighted.

METHODS

The patient is a 91-year-old woman diagnosed with Alzheimer's disease. She had severe BPSD such as delusion of robbery and violent behavior, and refused oral medications including memantine and yokukansan. Then she was treated with blonanserin transdermal patch (20 mg/day). The severity of psychiatric symptoms of BPSD was assessed over time using the Neuropsychiatric Inventory (NPI) score. Moreover, the patient's cognitive function was also assessed over time by Mini-Mental State Examination (MMSE).

RESULTS

After the introduction of blonanserin patch, the patient's psychiatric symptoms were stabilized markedly, and both NPI and MMSE scores improved. The patient was able to stay at home calmly and was mentally well stabilized to the extent that she did not require hospitalization. No apparent side effects were admitted.

CONCLUSIONS

The blonanserin transdermal patch may be able to manage BPSD at home and is effective in patients who refuse oral medications. Home-visiting doctors may consider the use of blonanserin patches at home for patients with severe BPSD, manifesting as delusions of poisoning and refusing oral drugs.

Impact of contact force on the lesion characteristics of very high-power short-duration ablation using a QDOT-MICRO catheter

Background

Lesion size is reported to become larger as contact force (CF) increases. However, this has not been systematically evaluated in temperature-guided very high-power short-duration (vHPSD) ablation, which was therefore the purpose of this study.

Methods

Radiofrequency applications (90 W/4 s, temperature-control mode) were performed in excised porcine myocardium with four different CFs of 5, 15, 25, and 35 g using QDOT-MICRO™ catheter. Ten lesions for each combination of settings were created, and lesion metrics and steam-pops were compared.

Results

A total of 320 lesions were analyzed. Lesion depth, surface area, and volume were smallest for CF of 5 g than for 15, 25, and 35 g (depth: 2.7 mm vs. 2.9 mm, 3.0 mm, 3.15 mm, p < .01; surface area: 38.4 mm2 vs. 41.8 mm2, 43.3 mm2, 41.5 mm2, p < .05; volume: 98.2 mm3 vs. 133.3 mm3, 129.4 mm3, 126.8 mm3, p < .01 for all pairs of groups compared to CF = 5 g). However, no significant differences were observed between CFs of 15-35 g. Average power was highest for CF of 5 g, followed by 15, 25, and 35 g (83.2 W vs. 82.1 W vs. 77.1 W vs. 66.1 W, p < .01 for all pairs), reflecting the higher incidence of temperature-guided power titration with greater CFs (5 g:8.8% vs. 15 g:52.5% vs. 25 g:77.5% vs. 35 g:91.2%, p < .01 for all pairs except for 25 g vs. 35 g). The incidence of steam-pops did not significantly differ between four groups (5 g:3.8% vs. 15 g:10% vs. 25 g:6.2% vs. 35 g:2.5%, not significant for all pairs).

Conclusions

For vHPSD ablation, lesion size does not become large once the CF reaches 15 g, and the risk of steam-pops may be mitigated through power titration even in high CFs.

Effect of reference electrode on intracardiac electrograms: Close indifferent electrode vs Wilson central terminal

BACKGROUND

Unipolar electrograms (uni-EGMs) are an essential part of intracardiac mapping. Although Wilson central terminal (WCT) is conventionally used as a reference for signals, avoidance of contamination by far-field and nonphysiologic signals is challenging.

OBJECTIVE

The aim of the study was to explore the impact of an intracardiac indifferent reference electrode close to the recording electrodes, in lieu of WCT, on electrograms.

METHODS

Sinus node activation was mapped in patients undergoing catheter ablation by a multielectrode array with a close indifferent electrode (CIE) embedded in the distal end of the catheter shaft. An equal number of points was sequentially acquired at each site with use of CIE as a reference first and subsequently with WCT. Uni-EGMs, bipolar EGMs, and the earliest activation area (defined as the area activated in the first 10 ms of the beat) were compared between CIE- and WCT-based activation maps.

RESULTS

Seventeen patients (61 ± 18 years; 76% male) were studied. Uni-EGM voltages acquired with CIE were significantly larger than (n = 11) or comparable to (n = 4) those acquired with WCT. When points from the entire cohort were analyzed altogether, unipolar voltages and their maximum negative dV/dT and bipolar voltages recorded with CIE were significantly larger than those recorded with WCT (2.36 [1.42-3.79] mV vs 1.96 [1.25-3.03] mV, P < .0001; 0.40 [0.18-0.77] mV/s vs 0.35 [0.15-0.71] mV/s, P < .0001; and 1.46 [0.66-2.81] mV vs 1.33 [0.54-2.64] mV, P < .0001, respectively). The earliest activation area was significantly smaller in CIE-based activation maps than in WCT-based ones (0.3 [0.7-1.4] cm2 vs 0.6 [1.0-1.8] cm2, P = .01).

CONCLUSION

CIE-based maps were associated with an approximately 20% increase in unipolar voltage and may highlight the origin of a focal activation more clearly than WCT-based ones.

TUNEL-positive structures in activated microglia and SQSTM1/p62-positive structures in activated astrocytes in the neurodegenerative brain of a CLN10 mouse model

Neuronal ceroid lipofuscinosis is a group of pediatric neurodegenerative diseases. One of their causative genes, CLN10/CtsD, encodes cathepsin D, a major lysosomal protease. Central nervous system (CNS)-specific CtsD-deficient mice exhibit a neurodegenerative disease phenotype with accumulation of ceroid lipofuscins, granular osmiophilic deposits, and SQSTM1/p62. We focused on activated astrocytes and microglia in this neurodegenerative mouse brain, since there are few studies on the relationship between these accumulators and lysosomes in these glial cells. Activated microglia and astrocytes in this mouse thalamus at p24 were increased by approximately 2.5- and 4.6-fold compared with the control, while neurons were decreased by approximately half. Granular osmiophilic deposits were detected in microglial cell bodies and extended their processes in the thalamus. LAMP1-positive lysosomes, but not SQSTM1/p62 aggregates, accumulated in microglia of this mouse thalamus, whereas both lysosomes and SQSTM1/p62 aggregates accumulated in its astrocytes. TUNEL-positive signals were observed mainly in microglia, but few were observed in neurons and astrocytes. These signals were fragmented DNA from degenerated neurons engulfed by microglia or in the lysosomes of microglia. Abnormal autophagic vacuoles also accumulated in the lysosomes of microglia. Granular osmiophilic deposit-like structures localized to LAMP1-positive lysosomes in CtsD-deficient astrocytes. SQSTM1/p62-positive but LAMP1-negative membranous structures also accumulated in the astrocytes and were less condensed than typical granular osmiophilic deposits. These results suggest that CtsD deficiency leads to intracellular abnormalities in activated microglia and astrocytes in addition to neuronal degeneration.

Safety verification of a novel irrigation catheter with flexible tip of laser-cut kerfs and contact force sensor

BACKGROUND AND AIMS

The safety evaluation of TactiFlex, a novel contact-force sensing catheter with a flexible 4-mm tip irrigated through laser-cut kerfs, has been ongoing. This study aimed to verify the safety of this type of catheter.

METHODS

Study 1: Radiofrequency (RF) applications at a range of powers (30-50 W), contact forces (10-20 g), and durations (10-60 s) using perpendicular/parallel catheter orientation with half-normal (HNS) or normal saline irrigation were compared between TactiFlex (4-mm tip) and TactiCath (3.5-mm tip) with temperature-controlled mode in excised porcine hearts. Study 2: The relation between RF applications using TactiFlex and the incidence of steam-pops in the real clinical cases were examined.

RESULTS

Study-1: 576 RF lesions were examined. TactiFlex demonstrated a significantly lower risk of steam-pops (5[1.7%] vs. 59[20.5%], p < .0001). Compared to 3.5-mm-tip catheter (TactiCath), 4-mm-tip catheter (TactiFlex) produced smaller lesion volume at perpendicular (193[98-554]mm3 vs. 263[139-436]mm3 , p < .0001), but relatively similar lesion volume at parallel contact (243[105-443]mm3 vs. 278[180-440]mm3 , p = .06). HNS-irrigation tended to increase the lesion volume in both catheters and to increase the incidence of steam-pops with TactiCath, but not with TactiFlex. The cut-off value of %impedance-drop ( = absolute impedance-drop/initial impedance) of 20% predicted steam-pops with a sensitivity = 100% and specificity = 89.6% in TactiFlex. Study-2: 5496 RF applications in 84 patients (51AFs/8ATs/3AVNRTs/4AVRTs/17PVCs/4VTs) using TactiFlex were analyzed. Four steam-pops (0.07%) in three patients with pericardial effusion were observed (%impedance-drop = 24%/26%/29%/35%, respectively). The cut-off value of %impedance-drop = 20%, derived from ex-vivo study, showed sensitivity = 100% and specificity = 90.1% in detecting steam-pops.

CONCLUSION

TactiFlex reduced the risk of steam-pops than TactiCath. %impedance-drop ≤ 20% may be reasonable for safely use with a sufficient safety margin. For 4-mm-tip catheter, parallel-contact may be recommended for larger lesion creation.

Superiority of the Combination of Input and Output Parameters to the Single Parameter for Lesion Size Estimation

BACKGROUND

For lesion size prediction, each input parameter, including ablation energy (AE), and output parameter, such as impedance, is individually used. We hypothesize that using both parameters simultaneously may be more optimal.Methods and Results: Radiofrequency applications at a range of power (30-50 W), contact force (10 g and 20 g), duration (10-60 s), and catheter orientation with normal saline (NS)- or half-normal saline (HNS)-irrigation were performed in excised porcine hearts. The correlations, with lesion size of AE, absolute impedance drop (∆Imp-drop), relative impedance drop (%Imp-drop), and AE*%Imp-drop were examined. Lesion size was analyzed in 283 of 288 lesions (NS-irrigation, n=142; HNS-irrigation, n=141) without steam pops. AE*%Imp-drop consistently showed the strongest correlations with lesion maximum depth (NS-irrigation, ρ=0.91; HNS-irrigation, ρ=0.94), surface area (NS-irrigation, ρ=0.87; HNS-irrigation, ρ=0.86), and volume (NS-irrigation, ρ=0.94; HNS-irrigation, ρ=0.94) compared with the other parameters. Moreover, compared with AE alone, AE*%Imp-drop significantly improved the strength of correlation with lesion maximum depth (AE vs. AE*%Imp-drop, ρ=0.83 vs. 0.91, P<0.01), surface area (ρ=0.73 vs. 0.87, P<0.01), and volume (ρ=0.84 vs. 0.94, P<0.01) with NS-irrigation. This tendency was also observed with HNS-irrigation. Parallel catheter orientation showed a better correlation with lesion depth and volume using ∆Imp-drop, %Imp-drop, and AE*%Imp-drop than perpendicular orientation.

CONCLUSIONS

The combination of input and output parameters is more optimal than each single parameter for lesion prediction.

The effect of half-normal saline irrigation on lesion characteristics in temperature-flow-controlled ablation

PURPOSE

Radiofrequency (RF) ablation with half-normal saline (HNS) irrigation is reported to potentially enlarge local lesion compared to normal saline (NS) in power-controlled ablation (PC-Abl). However, the effect of HNS-irrigation in temperature-flow-controlled ablation (TFC-Abl) on lesion characteristics is unknown. We compared this between TFC-Abl with QDOT-Micro™ catheter and PC-Abl with Thermocool SmartTouch SF™ catheter (STSF).

METHODS

RF-application with NS (n = 480) and HNS (n = 480) irrigation were performed on swine myocardium placed in a circulating saline bath. Lesion characteristics without steam-pops under various conditions (target AI, 400/550; ablation power, 30/50 W; contact force, 10/20/30 g; catheter orientation, perpendicular/parallel) were assessed and compared between two irrigants.

RESULTS

After matching, 343 lesions without steam-pops in each group were evaluated. In PC-Abl, lesion size did not differ between two groups (NS, 188 ± 97 vs. HNS, 200 ± 95 mm3, p = 0.28 in volume; 33.9 ± 7.3 vs. 34.8 ± 9.5 mm2, p = 0.34 in surface area; and 4.0 ± 1.0 vs. 4.0 ± 1.0 mm, p = 0.81 in depth), but steam-pops were more frequently observed with HNS-irrigation (23.8% vs. 37.9%, p = 0.001). Contrary, in TFC-Abl, HNS-irrigation produced significantly larger (214 ± 106 vs. 243 ± 128 mm3, p = 0.017) and deeper (4.0 ± 1.0 vs. 4.3 ± 1.1 mm, p = 0.002) lesions without increasing the risk of steam-pops (15.0% vs 15.0%, p = 0.99). Automatic temperature-guided titration was more frequently observed in HNS-irrigation (54.8% vs. 78.5%, p < 0.001).

CONCLUSIONS

TFC-Abl with QDOT-Micro™ catheter utilizing HNS-irrigation might increase volume and depth of local lesion without increasing the risk of stem-pops compared to NS-irrigation. Power-controlled ablation with HNS-irrigation showed similar focal lesion with higher incidence of steam-pops (SPs) compared to normal saline (NS) irrigation. Contrary, temperature-flow-controlled ablation with HNS-irrigation provided larger and deeper lesion than NS-irrigation with similar incidence of SPs. ns, p > 0.05; *, 0.01 < p ≤ 0.05; **, 0.005 < p ≤ 0.01. HNS, half-normal saline; NS, normal saline.

Recent advances in in-resin correlative light and electron microscopy of Epon-embedded cells

Correlative fluorescent and electron microscopic images of the same section of epoxy (or other polymer)-embedded samples, hereafter referred to as 'in-resin CLEM', have been developed to improve the positional accuracy and Z-axis resolution limitations of conventional correlative light and electron microscopy (CLEM). High-pressure freezing and quick-freezing substitution result in in-resin CLEM of acrylic-based resin-embedded cells expressing green fluorescent protein, yellow fluorescent protein, mVenus and mCherry, which are sensitive to osmium tetroxide. The identification of osmium-resistant fluorescent proteins leads to the development of in-resin CLEM of Epon-embedded cells. Using subtraction-based fluorescence microscopy with a photoconvertible fluorescent protein, mEosEM-E, its green fluorescence can be observed in thin sections of Epon-embedded cells, and two-color in-resin CLEM using mEosEM-E and mScarlet-H can be performed. Green fluorescent proteins, CoGFP variant 0 and mWasabi, and far-red fluorescent proteins, mCherry2 and mKate2, are available for in-resin CLEM of Epon-embedded cells using the standard procedure for Epon-embedding with additional incubation. Proximity labeling is applied to in-resin CLEM to overcome the limitations of fluorescent proteins in epoxy resin. These approaches will contribute significantly to the future of CLEM analysis.

Impact of an Electronic Medical Record-Connected Questionnaire on Efficient Nursing Documentation: Usability and Efficacy Study

BACKGROUND

Documentation tasks comprise a large percentage of nurses' workloads. Nursing records were partially based on a report from the patient. However, it is not a verbatim transcription of the patient's complaints but a type of medical record. Therefore, to reduce the time spent on nursing documentation, it is necessary to assist in the appropriate conversion or citation of patient reports to professional records. However, few studies have been conducted on systems for capturing patient reports in electronic medical records. In addition, there have been no reports on whether such a system reduces the time spent on nursing documentation.

OBJECTIVE

This study aims to develop a patient self-reporting system that appropriately converts data to nursing records and evaluate its effect on reducing the documenting burden for nurses.

METHODS

An electronic medical record-connected questionnaire and a preadmission nursing questionnaire were administered. The questionnaire responses entered by the patients were quoted in the patient profile for inpatient assessment in the nursing system. To clarify its efficacy, this study examined whether the use of the electronic questionnaire system saved the nurses' time entering the patient profile admitted between August and December 2022. It also surveyed the usability of the electronic questionnaire between April and December 2022.

RESULTS

A total of 3111 (78%) patients reported that they answered the electronic medical questionnaire by themselves. Of them, 2715 (88%) felt it was easy to use and 2604 (85%) were willing to use it again. The electronic questionnaire was used in 1326 of 2425 admission cases (use group). The input time for the patient profile was significantly shorter in the use group than in the no-use group (P<.001). Stratified analyses showed that in the internal medicine wards and in patients with dependent activities of daily living, nurses took 13%-18% (1.3 to 2 minutes) less time to enter patient profiles within the use group (both P<.001), even though there was no difference in the amount of information. By contrast, in the surgical wards and in the patients with independent activities of daily living, there was no difference in the time to entry (P=.50 and P=.20, respectively), but there was a greater amount of information in the use group.

CONCLUSIONS

The study developed and implemented a system in which self-reported patient data were captured in the hospital information network and quoted in the nursing system. This system contributes to improving the efficiency of nurses' task recordings.

Impact of baseline pool impedance on lesion metrics and steam pops in catheter ablation

INTRODUCTION

Little is known about the impact of blood-pool local impedance (LI) on lesion characteristics and the incidence of steam pops.

METHODS

Radiofrequency applications at a range of powers (30, 40, and 50 W), contact forces (CF) (5, 15, and 25 g), and durations (15, 30, 45, and 120 s) using perpendicular/parallel catheter orientation were performed in 40 excised porcine preparations, using a catheter capable of monitoring LI (StablePoint©, Boston Scientific). To simulate the variability in blood-pool impedance, the saline-pool LI was modulated by calibrating saline concentrations. Lesion characteristics were compared under three values of saline-pool LI: 120, 160, and 200 Ω.

RESULTS

Of 648 lesions created, steam pops occurred in 175 (27.0%). When power, CF, time, and catheter orientation were adjusted, ablation at a saline-pool impedance of 160 or 200 Ω more than doubled the risk of steam pops compared with a saline-pool impedance of 120 Ω (Odds ratio = 2.31; p = .0002). Lesions in a saline-pool impedance of 120 Ω were significantly larger in surface area (50 [38-62], 45 [34-56], and 41 [34-60] mm2 for 120, 160, and 200 Ω, p < .05), but shallower in depth (4.0 [3-5], 4.4 [3.2-5.3], and 4.5 [3.8-5.5] mmfor 120, 160, and 200 Ω, respectively, p < .05) compared with the other two settings. The correlation between the absolute LI-drop and lesion size weakened as the saline-pool LI became higher (e.g., 120 Ω group (r2  = .30, r2  = .18, and r2  = .16, respectively for 120, 160, and 200 Ω), but the usage of %LI-drop (= absolute LI-drop/initial LI) instead of absolute LI-drop may minimize this effect.

CONCLUSIONS

In an experimental model, baseline saline-pool impedance significantly affects the lesion metrics and the risk of steam pops.

Application of immuno- and affinity labeling with fluorescent dyes to in-resin CLEM of Epon-embedded cells

In-resin CLEM (Correlative Light and Electron Microscopy) of Epon-embedded cells involves correlating fluorescence microscopy with electron microscopy in the same Epon-embedded ultrathin section. This method offers the advantage of high positional accuracy compared to standard CLEM. However, it requires the expression of recombinant proteins. In order to detect the localization of endogenous target(s) and their localized ultrastructures of Epon-embedded samples using in-resin CLEM, we investigated whether immunological and affinity-labeling using fluorescent dyes applied to in-resin CLEM of Epon-embedded cells. The orange fluorescent (λ_em ∼550 nm) and far-red (λ_em ∼650 nm) fluorescent dyes examined maintained a sufficient level of fluorescent intensity after staining with osmium tetroxide and subsequent dehydration treatment with ethanol. Immunological in-resin CLEM of mitochondria and the Golgi apparatus was achieved using anti-TOM20, anti-GM130 antibodies, and fluorescent dyes. Two-color in-resin CLEM revealed that wheat germ agglutinin-puncta showed the ultrastructures of multivesicular body-like structures. Finally, taking the advantage of high positional accuracy, volume in-resin CLEM of mitochondria in the semi-thin section (2 μm thick) of Epon-embedded cells was performed by focused ion beam scanning electron microscopy. These results suggested that the application of immunological reaction and affinity-labeling with fluorescent dyes to in-resin CLEM of Epon-embedded cells is suitable for analyzing the localization of endogenous targets and their ultrastructures by scanning and transmission electron microscopy.

Histone chaperone NUCLEOSOME ASSEMBLY PROTEIN 1 proteins affect plant growth under nitrogen deficient conditions in Arabidopsis thaliana

Nitrogen (N) availability is one of the most important factors regulating plant metabolism and growth as it affects global gene expression profiles. Dynamic changes in chromatin structure, including histone modifications and nucleosome assembly/disassembly, have been extensively shown to regulate gene expression under various environmental stresses in plants. However, the involvement of chromatin related changes in plant nutrient responses has been demonstrated only in a few studies to date. In this study, we investigated the function of histone chaperone NUCLEOSOME ASSEMBLY PROTEIN1 (NAP1) proteins under N deficient conditions in Arabidopsis. In the nap1;1 nap1;2 nap1;3 triple mutant (m123-1), the expression of N-responsive marker genes and growth of lateral roots were decreased under N deficient conditions. In addition, the m123-1 plants showed a delay in N deficiency-induced leaf senescence. Taken together, these results suggest that NAP1s affect plant growth under N deficient conditions in Arabidopsis.

Comparison of lesion characteristics using temperature-flow-controlled versus conventional power-controlled ablation with fixed ablation index

INTRODUCTION

The QDOT-Micro^TM catheter is a novel irrigated contact force (CF) sensing catheter which benefits from thermocouples for temperature monitoring, allowing temperature-flow-controlled (TFC) ablation. We compared lesion metrics at fixed ablation index (AI) value during TFC-ablation and conventional power-controlled (PC)-ablation.

METHODS

A total of 480 RF-applications were performed on ex-vivo swine myocardium with predefined AI targets (400/550) or until steam-pop occurred, using the QDOT-Micro^TM (TFC-ablation) and Thermocool SmartTouch SF^TM (PC-ablation).

RESULTS

Both TFC-ablation and PC-ablation produced similar lesions in volume (218 ± 116 vs. 212 ± 107 mm³ , p = .65); however, lesions using TFC-ablation were larger in surface area (41.3 ± 8.8 vs. 34.8 ± 8.0  mm² , p < .001) and shallower in depth (4.0 ± 1.0 vs. 4.2 ± 1.1 mm, p = .044). Average power tended to be lower in TFC-alation (34.2 ± 8.6 vs. 36.9 ± 9.2, p = .005) compared to PC-ablation due to automatic regulation of temperature and irrigation-flow. Although steam-pops were less frequent in TFC-ablation (24% vs. 15%, p = .021), they were particularly observed in low-CF (10 g) and high-power ablation (50 W) in both PC-ablation (n = 24/240, 10.0%) and TFC-ablation (n = 23/240, 9.6%). Multivariate analysis revealed that high-power, low-CF, long application time, perpendicular catheter orientation, and PC-ablation were risk factors for steam-pops. Furthermore, activation of automatic regulation of temperature and irrigation-flow was independently associated with high-CF and long application time while ablation power had no significant relationship.

CONCLUSIONS

With a fixed target AI, TFC-ablation reduced the risk of steam-pops, producing similar lesions in volume, but with different metrics in this ex-vivo study. However, lower CF and higher power in fixed-AI ablation may increase the risk of steam-pops.

Comparison of three different approaches to very high-power short-duration ablation using the QDOT-MICRO catheter

BACKGROUND/OBJECTIVES

The QDOT-MICRO™ catheter allows very high-power and short-duration (vHPSD) ablation. This study aimed to investigate lesion characteristics using different ablation settings.

METHODS

Radiofrequency applications (90 W/4 s, temperature-control mode with 55°C or 60°C target) were performed in excised porcine myocardium using three different approaches: single (SA), double nonrepetitive (DNRA), and double repetitive applications (DRA). Applications were performed with an interval of 1 min for DNRA, and without interval for DRA.

RESULTS

A total of 480 lesions were analyzed. Lesion depth and volume were largest for DRA followed by DNRA and SA regardless of catheter direction (depth: 3.8 vs. 3.3 vs. 2.6 mm, p < .001 for all comparisons; volume: 176.6 vs. 145.1 vs. 97.0 mm³ , p < .001 for all comparisons). Surface area was significantly larger for DRA than for SA (45.1 vs. 38.3 mm² , p < .001) and larger for DNRA than for SA (44.5 vs. 38.3 mm² , p < .001), but was similar between DRA and DNRA (45.1 vs. 44.5 mm² , p = .54). Steam-pops more frequently occurred for DRA than for SA (15.6% vs. 4.4%, p = .004) and DNRA (15.6% vs. 6.9%, p = .061), but the incidence was similar between SA and DNRA (4.4% vs. 6.9%, p = 1). Although surface area and lesion volume were larger in lesions with steam-pops than without steam-pops (46.5 vs. 38.1 mm² , p = .018 and 128.3 vs. 96.8 mm³ , p = .068, respectively), lesions were not deeper (pop(+): 2.5 mm vs. pop(-): 2.6 mm, p = .75).

CONCLUSIONS

DNRA produces larger lesions than SA without increasing the risk of steam-pops. DRA produces the largest lesions among the three groups, but with an increased risk of steam-pops. Even with steam-pops, lesions do not become deeper in vHPSD ablation.

Osmium-Resistant Fluorescent Proteins and In-Resin Correlative Light-Electron Microscopy of Epon-Embedded Mammalian Cultured Cells

Postfixation with osmium tetroxide and Epon embedding are essential for the preservation and visualization of subcellular ultrastructures via electron microscopy. These chemical treatments diminish the fluorescent intensity of most fluorescent proteins in cells, creating a problem for the in-resin correlative light-electron microscopy (CLEM) of Epon-embedded mammalian cultured cells. We found that two green and two far-red fluorescent proteins retain their fluorescence after chemical fixation with glutaraldehyde, osmium tetroxide-staining, dehydration, and polymerization of Epon resins. Consequently, we could observe the fluorescence of fluorescent proteins in ultrathin sections of Epon-embedded cells via fluorescence microscopy, investigate ultrastructures of the cells in the same sections via electron microscopy, and correlate the fluorescent image with the electron microscopic image without chemical or physical distortion of the cells. In other words, referred as "in-resin CLEM" of Epon-embedded samples. This technique also improves the Z-axis resolution of fluorescent images. In this chapter, we introduce the detailed protocol for in-resin CLEM of Epon-embedded mammalian cultured cells using these fluorescent proteins.

GPHR-mediated acidification of the Golgi lumen is essential for cholesterol biosynthesis in the brain

The Golgi pH regulator (GPHR) is essential for maintaining the function and morphology of the Golgi apparatus through the regulation of luminal acidic pH. Abnormal morphology of the Golgi apparatus is associated with neurodegenerative diseases. Here, we found that knockout of GPHR in the mouse brain led to morphological changes in the Golgi apparatus and neurodegeneration, which included brain atrophy, neuronal cell death, and gliosis. Furthermore, in the GPHR knockout mouse brain, transcriptional activity of sterol regulatory element-binding protein 2 (SREBP2) decreased, resulting in a reduction in cholesterol levels. GPHR-deficient cells exhibited suppressed neurite outgrowth, which was recovered by exogenous expression of the active form of SREBP2. Our results show that GPHR-mediated luminal acidification of the Golgi apparatus maintains proper cholesterol levels and, thereby, neuronal morphology.

Lack of Cathepsin D in the central nervous system results in microglia and astrocyte activation and the accumulation of proteinopathy-related proteins

Neuronal ceroid lipofuscinosis is one of many neurodegenerative storage diseases characterized by excessive accumulation of lipofuscins. CLN10 disease, an early infantile neuronal ceroid lipofuscinosis, is associated with a gene that encodes cathepsin D (CtsD), one of the major lysosomal proteases. Whole body CtsD-knockout mice show neurodegenerative phenotypes with the accumulation of lipofuscins in the brain and also show defects in other tissues including intestinal necrosis. To clarify the precise role of CtsD in the central nervous system (CNS), we generated a CNS-specific CtsD-knockout mouse (CtsD-CKO). CtsD-CKO mice were born normally but developed seizures and their growth stunted at around postnatal day 23 ± 1. CtsD-CKO did not exhibit apparent intestinal symptoms as those observed in whole body knockout. Histologically, autofluorescent materials were detected in several areas of the CtsD-CKO mouse's brain, including: thalamus, cerebral cortex, hippocampus, and cerebellum. Expression of ubiquitin and autophagy-associated proteins was also increased, suggesting that the autophagy-lysosome system was impaired. Microglia and astrocytes were activated in the CtsD-CKO thalamus, and inducible nitric oxide synthase (iNOS), an inflammation marker, was increased in the microglia. Interestingly, deposits of proteinopathy-related proteins, phosphorylated α-synuclein, and Tau protein were also increased in the thalamus of CtsD-CKO infant mice. Considering these results, we propose thatt the CtsD-CKO mouse is a useful mouse model to investigate the contribution of cathepsin D to the early phases of neurodegenerative diseases in relation to lipofuscins, proteinopathy-related proteins and activation of microglia and astrocytes.

In-resin CLEM of Epon-embedded cells using proximity labeling

Biotin ligases have been developed as proximity biotinylation enzymes for analyses of the interactome. However, there has been no report on the application of proximity labeling for in-resin correlative light-electron microscopy of Epon-embedded cells. In this study, we established a proximity-labeled in-resin CLEM of Epon-embedded cells using miniTurbo, a biotin ligase. Biotinylation by miniTurbo was observed in cells within 10 min following the addition of biotin to the medium. Using fluorophore-conjugated streptavidin, intracellular biotinylated proteins were labeled after fixation of cells with a mixture of paraformaldehyde and glutaraldehyde. Fluorescence of these proteins was resistant to osmium tetroxide staining and was detected in 100-nm ultrathin sections of Epon-embedded cells. Ultrastructures of organelles were preserved well in the same sections. Fluorescence in sections was about 14-fold brighter than that in the sections of Epon-embedded cells expressing mCherry2 and was detectable for 14 days. When mitochondria-localized miniTurbo was expressed in the cells, mitochondria-like fluorescent signals were detected in the sections, and ultrastructures of mitochondria were observed as fluorescence-positive structures in the same sections by scanning electron microscopy. Proximity labeling using miniTurbo led to more stable and brighter fluorescent signals in the ultrathin sections of Epon-embedded cells, resulting in better performance of in-resin CLEM.

Conjugates of 3-phenyllactic acid and tryptophan enhance root-promoting activity without adverse effects in Vigna angularis

3-Phenyllactic acid (PLA) is a common secondary product of Lactobacillus sp. and promotes adventitious-root formation in Azuki beans (Vigna angularis). Root promotion activity of PLA is synergistically enhanced by tryptophan (Trp). In this study, stereoisomers of PLA and Trp amide conjugates and their alkyl esters were synthesized to investigate the structure-activity relationships on root-promotion activity. The rooting activity of D-PLA-L-Trp conjugate shows more than 40 times higher than that of the mixture of D-PLA and L-Trp. Modification of PLA-Trp with ethyl ester showed the highest activity at 3,400 times of a mixture of D-PLA and L-Trp. However, L-or D-PLA-D-Trp conjugate and the isopropyl ester of PLA-Trp conjugates, both lost the root promotion activity and implicated that a requirement for steric structure for PLA related root promotion mechanism. Unlike auxin substances, which are commonly used as rooting agents that displayed high activity in low concentrations, PLA-Trp ethyl ester exhibited far less phytotoxicity at high concentration of 1 mM, despite its high rooting activity. Innovation of PLA-Trp ethyl ester may be expected for agricultural aspects with low environmental impact.

3-Phenyllactic acid is converted to phenylacetic acid and induces auxin-responsive root growth in Arabidopsis plants

Many microorganisms have been reported to produce compounds that promote plant growth and are thought to be involved in the establishment and maintenance of symbiotic relationships. 3-Phenyllactic acid (PLA) produced by lactic acid bacteria was previously shown to promote root growth in adzuki cuttings. However, the mode of action of PLA as a root-promoting substance had not been clarified. The present study therefore investigated the relationship between PLA and auxin. PLA was found to inhibit primary root elongation and to increase lateral root density in wild-type Arabidopsis, but not in an auxin signaling mutant. In addition, PLA induced IAA19 promoter fused β-glucuronidase gene expression, suggesting that PLA exhibits auxin-like activity. The inability of PLA to promote degradation of Auxin/Indole-3-Acetic Acid protein in a yeast heterologous reconstitution system indicated that PLA may not a ligand of auxin receptor. Using of a synthetic PLA labeled with stable isotope showed that exogenously applied PLA was converted to phenylacetic acid (PAA), an endogenous auxin, in both adzuki and Arabidopsis. Taken together, these results suggest that exogenous PLA promotes auxin signaling by conversion to PAA, thereby regulating root growth in plants.

Deubiquitinating enzymes UBP12 and UBP13 stabilize the brassinosteroid receptor BRI1

Protein ubiquitination is a dynamic and reversible post-translational modification that controls diverse cellular processes in eukaryotes. Ubiquitin-dependent internalization, recycling, and degradation are important mechanisms that regulate the activity and the abundance of plasma membrane (PM)-localized proteins. In plants, although several ubiquitin ligases are implicated in these processes, no deubiquitinating enzymes (DUBs), have been identified that directly remove ubiquitin from membrane proteins and limit their vacuolar degradation. Here, we discover two DUB proteins, UBP12 and UBP13, that directly target the PM-localized brassinosteroid (BR) receptor BR INSENSITIVE1 (BRI1) in Arabidopsis. BRI1 protein abundance is decreased in the ubp12i/ubp13 double mutant that displayed severe growth defects and reduced sensitivity to BRs. UBP13 directly interacts with and effectively removes K63-linked polyubiquitin chains from BRI1, thereby negatively modulating its vacuolar targeting and degradation. Our study reveals that UBP12 and UBP13 play crucial roles in governing BRI1 abundance and BR signaling activity to regulate plant growth.

The TGN/EE SNARE protein SYP61 and the ubiquitin ligase ATL31 cooperatively regulate plant responses to carbon/nitrogen conditions in Arabidopsis

Ubiquitination is a post-translational modification involving the reversible attachment of the small protein ubiquitin to a target protein. Ubiquitination is involved in numerous cellular processes, including the membrane trafficking of cargo proteins. However, the ubiquitination of the trafficking machinery components and their involvement in environmental responses are not well understood. Here, we report that the Arabidopsis thaliana trans-Golgi network/early endosome localized SNARE (soluble N-ethylmaleimide-sensitive factor attachment protein receptor) protein SYP61 interacts with the transmembrane ubiquitin ligase ATL31, a key regulator of resistance to disrupted carbon (C)/nitrogen/(N)-nutrient conditions. SYP61 is a key component of membrane trafficking in Arabidopsis. The subcellular localization of ATL31 was disrupted in knockdown mutants of SYP61, and the insensitivity of ATL31-overexpressing plants to high C/low N-stress was repressed in these mutants, suggesting that SYP61 and ATL31 cooperatively function in plant responses to nutrient stress. SYP61 is ubiquitinated in plants, and its ubiquitination level is upregulated under low C/high N-nutrient conditions. These findings provide important insights into the ubiquitin signaling and membrane trafficking machinery in plants.

Local Injection of Hydroxyapatite Electret Ameliorated Infarct Size After Myocardial Infarction

Background: Previous studies showed that hydroxyapatite electret (HAE) accelerates the regeneration of vascular endothelial cells and angiogenesis. This study investigated the effects of HAE in myocardial infarction (MI) model mice.

Methods and Results: MI was induced in mice by ligating the left anterior descending artery. Immediately after ligation, HAE, non-polarized hydroxyapatite (HAN), or water (control) was injected into the infarct border myocardium. Functional and histological analyses were performed 2 weeks later. Echocardiography revealed that HAE injection preserved left ventricular systolic function and the wall thickness of the scar, whereas HAN-injected mice had impaired cardiac function and thinning of the wall, similar to control mice. Histological assessment showed that HAE injection significantly attenuated the length of the scar lesion. There was significant accumulation of CD31-positive cells and increased expression of vascular endothelial growth factor (Vegf), intercellular adhesion molecule-1 (Icam1), vascular cell adhesion molecule-1 (Vcam1), hypoxia-inducible factor-1α (Hif1a), and C-X-C motif chemokine ligand 12 (Cxcl12) genes in the infarct border zone of HAE-injected mice. These effects were not induced by HAN injection. Anti-VEGFR2 antibody canceled the beneficial effect of HAE. In vitro experiments in a human cardiovascular endothelial cell line showed that HAE dose-dependently increased VEGFA expression.

Conclusions: Local injection of HAE attenuated infarct size and improved cardiac function after MI, probably due to angiogenesis. The electric charge of HAE may stimulate angiogenesis via HIF1α-CXCL12/VEGF signaling.

The clinical outcome of fractional flow reserve based coronary revascularization strategy of the patients on hemodialysis

Background

The optimal coronary revascularization strategy for the patients on hemodialysis is yet to be determined. In the real-world practice, we sometimes encounter the rapid deterioration after percutaneous coronary intervention (PCI) to angiographically intermediate but functionally significant stenosis. According to the fractional flow reserve (FFR) based revascularization strategy, the clinical outcome of the deferred lesions is reported to be almost equivalent to that of the lesions received PCI. However, whether the relationship also applies to hemodialysis patients is unclear.

Purpose

To assess the clinical outcome of the lesions for which revascularization strategy was determined by FFR in patients with hemodialysis.

Methods

Consecutive 147 vessels in 120 patients with hemodialysis whose revascularization strategy was decided according to the FFR were enrolled in this study. We compared the clinical outcomes of the deferred group (FFR ≥0.80, 87 vessels, 78 patients) with the PCI group (FFR&lt;0.80, 60 vessels, 42 patients). The primary endpoint of this study was target vessel failure (TVF) defined as a composite of TV revascularization and myocardial infarction evaluated by per-vessel analysis. The secondary endpoint was major adverse cardiovascular events (MACE) defined as all cause death, myocardial infarction, urgent revascularization evaluated by per-patient analysis.

Results

The median follow-up period was 2.3 years (interquartile range, 1.5–4.0 years). The beseline characteristics of the lesions and patients were well balanced between the 2 treatment groups except for the distribution of target vessels and FFR value. The cumulative TVF rate was not significantly different between the deferred group and PCI group (2-year event rate 26.7% vs. 17.7%; Log-rank p=0.23). The risk of MACE was also not significantly different between two groups (2-year event rate 35% vs. 30%; Log-rank p=0.48).

Conclusion

The clinical outcome of the lesions/patients for which received revascularization based on FFR was equivalent to the deferred lesions/patients even in the patients on hemodialysis (2,129/3,000).

Funding Acknowledgement

Type of funding sources: None. Table 1Figure 1

Practical use of a multicenter clinical research support system connected to electronic medical records

BACKGROUND

Electronic medical records (EMRs) are widely used, but in many cases, they are used within a network physically separated from the Internet. Multicenter clinical studies use Internet-connected electronic data capture (EDC) systems to collect data, where data entered into the EMR are manually transcribed into the EDC system. In addition, medical images for clinical research are also collected manually. Variations in EMRs and differing data structures among vendors hamper the use of data for clinical research.

METHODS

We solved this problem by developing a network infrastructure for clinical research between Osaka University Hospital and affiliated hospitals in the Osaka area and introducing a clinical data collection system (CDCS). In each hospital's EMR network, we implemented a CRF reporter that accumulated data for clinical research using a template and then sent the data to a management server in the Osaka University Hospital Data Center. To organize the patient profile data and clinical laboratory data stored in each EMR for use in clinical research, the data are retrieved from the template by an interface module developed by each vendor, according to our common data output interface specification. The data entered into the CRF reporter template for clinical research are also recorded in the EMR progress notes and sent to the data management server. This network infrastructure can also be used as a medical image collection system that automatically collects images for research from PACS at each hospital. These systems are managed under common subject numbers issued by the CDCS.

RESULTS

A network infrastructure was established among 19 hospitals, and a CRF reporter was incorporated into the EMR. A medical image transfer system was introduced in 13 hospitals. Since 2013, 28 clinical studies have been conducted using this system, and data for 9,987 cases have been collected as of December 31, 2020.

CONCLUSION

Incorporating a CRF reporter with medical image transfer system into the EMR has proven useful for collecting research data.

Membranous Structures Directly Come in Contact With p62/SQSTM1 Bodies

During autophagy, autophagosomes are formed to engulf cytoplasmic contents. p62/SQSTM-1 is an autophagic adaptor protein that forms p62 bodies. A unique feature of p62 bodies is that they seem to directly associate with membranous structures. We first investigated the co-localization of mKate2-p62 bodies with phospholipids using click chemistry with propargyl-choline. Propargyl-choline-labeled phospholipids were detected inside the mKate2-p62 bodies, suggesting that phospholipids were present inside the bodies. To clarify whether or not p62 bodies come in contact with membranous structures directly, we investigated the ultrastructures of p62 bodies using in-resin correlative light and electron microscopy of the Epon-embedded cells expressing mKate2-p62. Fluorescent-positive p62 bodies were detected as uniformly lightly osmificated structures by electron microscopy. Membranous structures were detected on and inside the p62 bodies. In addition, multimembranous structures with rough endoplasmic reticulum-like structures that resembled autophagosomes directly came in contact with amorphous-shaped p62 bodies. These results suggested that p62 bodies are unique structures that can come in contact with membranous structures directly.

3-Phenyllactic acid, a root-promoting substance isolated from Bokashi fertilizer, exhibits synergistic effects with tryptophan

Bokashi fertilizer, an organic fertilizer made of plant residue, has been used in Japan not only to fertilize plants but to regulate their growth. Lactic acid bacteria have been found to play an important role in the fermentation process of Bokashi, but the relationship between these bacteria and plant growth activity has not been clarified. Using the adzuki rooting assay, this study identified 3-phenyllactic acid (PLA) produced by lactic acid bacteria as a root promoting compound in Bokashi. PLA showed synergistic effect with tryptophan, but no stem elongation activity. Lactic acid bacteria produced equal quantities of the L- and D-forms of PLA, which have similar root promoting activity. PLA did not significantly affect the amount of endogenous indole-3-acetic acid (IAA), although the chemical structure of PLA is highly similar to that of L-2-aminooxy-3-phenypropionic acid (L-AOPP), which inhibits IAA biosynthesis. These results indicate that the root promoting activity of PLA is not simply due to its increase in the amount of active auxin.

Three-Dimensional Architecture of Glomerular Endothelial Cells Revealed by FIB-SEM Tomography

Focused-ion beam-scanning electron microscopic (FIB-SEM) tomography enables easier acquisition of a series of ultrastructural, sectional images directly from resin-embedded biological samples. In this study, to clarify the three-dimensional (3D) architecture of glomerular endothelial cells (GEnCs) in adult rats, we manually extracted GEnCs from serial FIB-SEM images and reconstructed them on an Amira reconstruction software. The luminal and basal surface structures were clearly visualized in the reconstructed GEnCs, although only the luminal surface structures could be observed by conventional SEM. The luminal surface visualized via the reconstructed GEnCs was quite similar to that observed through conventional SEM, indicating that 3D reconstruction could be performed with high accuracy. Thus, we successfully described the 3D architecture of normal GEnCs in adult rats more clearly and precisely than ever before. The GEnCs were found to consist of three major subcellular compartments, namely, the cell body, cytoplasmic ridges, and sieve plates, in addition to two associated subcellular compartments, namely, the globular protrusions and reticular porous structures. Furthermore, most individual GEnCs made up a “seamless” tubular shape, and some of them formed an autocellular junction to make up a tubular shape. FIB-SEM tomography with reconstruction is a powerful approach to better understand the 3D architecture of GEnCs. Moreover, the morphological information revealed in this study will be valuable for the 3D pathologic evaluation of GEnCs in animal and human glomerular diseases and the structural analysis of developmental processes in the glomerular capillary system.

Homeostatic p62 levels and inclusion body formation in CHCHD2 knockout mice

Inactivation of constitutive autophagy results in the formation of cytoplasmic inclusions in neurones, but the relationship between impaired autophagy and Lewy bodies (LBs) remains unknown. α-Synuclein and p62, components of LBs, are the defining characteristic of Parkinson's disease (PD). Until now, we have analyzed mice models and demonstrated p62 aggregates derived from an autophagic defect might serve as 'seeds' and can potentially be a cause of LB formation. P62 may be the key molecule for aggregate formation. To understand the mechanisms of LBs, we analyzed p62 homeostasis and inclusion formation using PD model mice. In PARK22-linked PD, intrinsically disordered mutant CHCHD2 initiates Lewy pathology. To determine the function of CHCHD2 for inclusions formation, we generated Chchd2-knockout (KO) mice and characterized the age-related pathological and motor phenotypes. Chchd2 KO mice exhibited p62 inclusion formation and dopaminergic neuronal loss in an age-dependent manner. These changes were associated with a reduction in mitochondria complex activity and abrogation of inner mitochondria structure. In particular, the OPA1 proteins, which regulate fusion of mitochondrial inner membranes, were immature in the mitochondria of CHCHD2-deficient mice. CHCHD2 regulates mitochondrial morphology and p62 homeostasis by controlling the level of OPA1. Our findings highlight the unexpected role of the homeostatic level of p62, which is regulated by a non-autophagic system, in controlling intracellular inclusion body formation, and indicate that the pathologic processes associated with the mitochondrial proteolytic system are crucial for loss of DA neurones.

Ultrasonographic evaluation of the caudal vena cava in dogs with right-sided heart disease

INTRODUCTION/OBJECTIVES

In humans with impaired right-sided cardiac function, the caudal vena cava (CVC) diameter serves as a marker of venous congestion. This study aimed to investigate whether ultrasonographic CVC variables could identify the presence of right-sided congestive heart failure (R-CHF) in dogs with right-sided heart disease (RHD).

ANIMALS

Fifty client-owned control dogs and 67 dogs with RHD were enrolled. The dogs with RHD were subdivided into the non-R-CHF (n = 43) and R-CHF (n = 24) groups.

MATERIALS AND METHODS

We measured and compared the ultrasonographic CVC variables and echocardiographic variables among the groups. Receiver operating characteristic (ROC) curve analysis was performed to calculate the sensitivity and specificity of the variables at optimal cutoff values.

RESULTS

We obtained the highest accuracies of the ratio of the shortest diameter (SD) of the minimal CVC area to the aorta diameter (Ao) during inspiration [SD(min)/Ao] and of the ratio of SD(min) to the longest diameter of the minimal CVC area during inspiration [LD(min),SD/LD(min)], with high sensitivities, specificities, and an area under the ROC curve greater than 0.925.

CONCLUSIONS

In addition to the echocardiographic assessment of right-sided cardiac function, the CVC variables in this study, especially SD(min)/Ao and SD/LD(min), would be useful diagnostic indices for identifying R-CHF in dogs with RHD.

Two-color in-resin CLEM of Epon-embedded cells using osmium resistant green and red fluorescent proteins

In-resin CLEM of Epon embedded samples can greatly simplify the correlation of fluorescent images with electron micrographs. The usefulness of this technique is limited at present by the low number of fluorescent proteins that resist CLEM processing. Additionally, no study has reported the possibility of two-color in-resin CLEM of Epon embedded cells. In this study, we screened for monomeric green and red fluorescent proteins that resist CLEM processing. We identified mWasabi, CoGFP variant 0, and mCherry2; two green and one red fluorescent proteins as alternatives for in-resin CLEM. We expressed mitochondria-localized mCherry2 and histone H2B tagged with CoGFP variant 0 in cells. Green and red fluorescence was detected in 100 nm-thin sections of the Epon-embedded cells. In the same thin sections, we correlated the fluorescent signals to mitochondria and the nucleus using a scanning electron microscope. Similar results were obtained when endoplasmic reticulum-localized mCherry2 and histone H2B tagged with CoGFP variant 0 were expressed in the cells. Two-color in-resin CLEM of two cytoplasmic organelles, mitochondria and endoplasmic reticulum, was also achieved using mitochondria-localized mCherry2 and endoplasmic reticulum-localized mWasabi. In summary, we report three new fluorescent protein-alternatives suitable for in-resin CLEM of Epon-embedded samples, and achieved Epon-based two-color in-resin CLEM.

Aggressive lipid lowering therapy with pitavastatin and ezetimibe improve cardiovascular outcomes in patients with ST segment elevation myocardial infarction: insights from the HIJ-PROPER Study

Aims

The purpose of this study was to evaluate the effect of aggressive lipid-lowering therapy with pitavastatin and ezetimibe in patients with ST-segment elevation myocardial infarction (STEMI) as compared with those with other classification of an acute coronary syndrome (ACS) including non-STEMI (NSTEMI) and unstable angina pectoris (UA).

Methods

This is a post hoc sub-analysis of the HIJ-PROPER study. In the original study, ACS patients with dyslipidemia were randomized to either pitavastatin + ezetimibe therapy or pitavastatin monotherapy. In the present analysis, we divided HIJ-PROPER participants into the STEMI group (n=880) and NSTEMI + UA group (n=841). Cardiovascular events were analyzed between the two groups. The primary endpoint was a composite of major advanced cardiovascular events (MACE; all-cause death, non-fatal myocardial infarction, non-fatal stroke, unstable angina pectoris, and ischemia-driven revascularization)

Result

During median follow-up period of 3.4 years, the cumulative incidence of the primary endpoint in STEMI group was 31.9% in the pitavastatin+ezetimibe therapy, compared with 39.7% in the pitavastatin-monotherapy (HR, 0.77; 95% CI, 0.62–0.97; p=0.02). However, there was no effect of pitavastatin+ezetimibe therapy on the primary endpoint in the NSTEMI + UA group. Concerning the individual components of the primary endpoint in STEMI group, the percentage of occurrence of all-cause death was significantly lower in the pitavastatin+ezetimibe therapy compared to pitavastatin mono-therapy (14 patients (3.2%) vs. 31 patients (6.9%), respectively; HR, 0.45; 95% CI, 0.23–1.84, p=0.01). Multivariate analysis revealed that use of ezetimibe and prevalence of diabetes mellitus at baseline were independent predictors of primary endpoints in STEMI group (HR, 0.79; 95% CI, 0.63–0.99; p=0.04 for use of ezetimibe, HR 1.54; 95% CI, 1.22–1.94, p=0.0003 for diabetes mellitus).

Conclusion

Patients with pitavastatin+ezetimibe therapy as compared with pitavastatin-monotherapy had lower cardiovascular event in patients with ST-segment elevation myocardial infarction.

Kaplan-Meier curves for primary endpoint

Funding Acknowledgement

Type of funding source: None

Impact of comprehensive management on clinical outcomes in hypertensive patients with coronary artery disease: HIJ-CREATE sub-study

Background

There are limited data on the effects of blood pressure (BP) control and lipid lowering in secondary prevention of coronary artery disease (CAD) patients. We report a secondary analysis of the effects of BP control and lipid management in participants of the HIJ-CREATE, a prospective randomized trial.

Methods

HIJ-CREATE was a multicenter, prospective, randomized, controlled trial that compared the effects of candesartan-based therapy with those of non-ARB-based standard therapy on major adverse cardiac events (MACE; a composite of cardiovascular death, non-fatal myocardial infarction, unstable angina, heart failure, stroke, and other cardiovascular events requiring hospitalization) in 2,049 hypertensive patients with angiographically documented CAD. In both groups, titration of antihypertensive agents was performed to reach the target BP of &lt;130/85 mmHg. The primary endpoint was the time to first MACE. Incidence of endpoint events in addition to biochemistry tests and office BP was determined during the scheduled 6, 12, 24, 36, 48, and 60-month visits. Achieved systolic BP and LDL-Cholesterol (LDL-C) level were defined as the mean values of these measurements in patients who did not develop MACEs and as the mean values of them prior to MACEs in those who developed MACEs during follow-up.

Results

During a median follow-up of 4.2 years (follow-up rate of 99.6%), the primary outcome occurred in 304 patients (30.3%). Among HIJ-CREATE participants, 905 (44.2%) were prescribed statins on enrollment. Kaplan–Meier curves for the primary outcome revealed that there was no relationship between statin therapy and MACEs in hypertensive patients with CAD. The original HIJ-CREATE population was divided into 9 groups based on equal tertiles based on mean achieved BP and LDL-C during follow-up. For the analysis of subgroups, estimates of relative risk and the associated 95% CIs were generated with a Cox proportional-hazards model (Figure 1). The relation between LDL cholesterol level and hazard ratios for MACEs was nonlinear, with a significant increase of MACEs only in the patients with inadequate controlled LDL-C level even in the patients with tightly controlled BP.

Conclusions

The results of the post-hoc analysis of the HIJ-CREATE suggest that clinicians should pay careful attention to conduct comprehensive management of lipid lowering even in the contemporary BP lowering for the secondary prevention in hypertensive patients with CAD.

Figure 1

Funding Acknowledgement

Type of funding source: None

Lower levels of high-density lipoprotein cholesterol are associated with increased cardiovascular events in patients with acute coronary syndrome receiving contemporary lipid-lowering therapy

Background

This study aimed to elucidate whether high-density lipoprotein cholesterol (HDL-C) at 3-month follow-up for patients receiving contemporary lipid-lowering therapy after acute coronary syndrome (ACS) could predict cardiac events.

Methods

The HIJ-PROPER study was a multicenter, prospective, randomized trial comparing intensive lipid-lowering therapy (pitavastatin + ezetimibe) and conventional lipid-lowering therapy (pitavastatin monotherapy) after ACS. For the present analysis, the entire cohort was divided into three groups according to HDL-C levels at 3-month follow-up (Group 1, HDL-C ≤43 mg/dL; Group 2, 43–53.6 mg/dL; Group 3; HDL-C ≥53.6 mg/dL). Baseline characteristics and the incidence of the primary endpoint (a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, unstable angina pectoris, or ischemia-driven revascularization) were compared among the three groups.

Results

The primary endpoint was reported in 34.8%, 30.1%, and 24.6% of patients in Groups 1, 2, and 3, respectively. The incidence of the primary endpoint was significantly higher in Group 1 than in Group 3 (hazard ratio [HR], 1.5; 95% confidence interval [CI], 1.19–1.9; p=0.001). Irrespective of the treatment regimen, Group 1 had a significantly higher rate of the primary endpoint than Group 3 (pitavastatin + ezetimibe therapy: HR, 1.6; 95% CI, 1.12–2.22; p=0.01 and pitavastatin monotherapy: HR, 1.4; 95% CI, 1.05–1.98; p=0.02). These trends remained even after adjustment for baseline characteristics and lipid profiles.

Conclusions

Lower levels of HDL-C at 3-month follow-up are associated with higher incidence of the cardiovascular events in patients with acute coronary syndrome receiving contemporary lipid-lowering therapy.

HDL-C levels and Cardiovascular events

Funding Acknowledgement

Type of funding source: None

Effects of PCSK9 inhibitor on adverse limb outcomes in patients with critical limb ischemia

Background

The proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9-I), evolocumab, reduced the risk of cardiovascular event in patients with peripheral artery disease in FOURIER trial. However, the effects of evolocumab on favorable limb outcomes in patients with critical limb ischemia (CLI) is still unclear.

Purpose

The aim of this study was to evaluate the impacts of evolocumab on favorable limb outcomes and lipid profile in patients with CLI.

Methods

This was a single center, prospective observational study. A total of 39 patients with CLI were enrolled between November 2016 to May 2019. The subjects were divided into 2 groups based on evolocumab administration: evolocumab-treated group: E group (mean 69.4±11.7 years, n=14) and evolocumab non-treated group: Non-E group (mean 74.0±8.8 years, n=25). Baseline characteristics were assessed at admission. Lipid profile was evaluated at admission, 1, 3, 6, 12 and 18 months. The primary outcome was defined 18-month amputation-free survival (AFS). The secondary outcomes were defined 18-month overall survival (OS) and wound-free limb salvage. Mean follow-up period was 18±11 months.

Results

The patients in E group had greater reduction in levels of LDL cholesterol and non-HDL cholesterol than those in Non-E group over time. The reduction in MDA-LDL level was maintained at 1, 3, 6, 12 months, respectively. The 18-month AFS rate in the E-group was significantly higher than those in the Non-E group (log-rank p=0.02). The patients receiving evolocumab had a lower hazard regarding AFS (hazard ratio, 0.12; 95% confidence interval, 0.02–0.94; P=0.043) and a higher proportion of wound-free limb salvage at 12 months (E group [92%] vs Non-E group [57%], P=0.034) and 18 months (92% vs 52%, P=0.03). Otherwise, evolocumab administration was not associated with 18-month OS (log-rank p=0.053).

Conclusions

Evolocumab administration may be associated with the favorable outcome of 18-month AFS in the patients with CLI. Additionally, long-term administration of evolocumab over 12 months may improve wound-free limb salvage.

Effects of evolocumab on limb outcomes

Funding Acknowledgement

Type of funding source: None

Suppression of gastric acid secretion decreased cardiovascular events independent of severe bleeding events in patients after percutaneous coronary intervention – sub-analysis from multicenter registry

Background

Suppression of gastric acid secretion by proton-pump inhibitor (PPI) or potassium-competitive acid blocker (P-CAB) has recently been developed as a standard strategy for preventing gastrointestinal bleeding for patients receiving antiplatelet therapy after percutaneous coronary intervention (PCI). However, there has been limited evidences on the association between PPI/P-CAB administration and adverse cardiovascular events in patients undergoing PCI.

Purpose

We aimed to evaluate the prognostic impact of the prescription of PPI/P-CAB on clinical outcomes in patients after PCI.

Methods

This study is a subanalysis from the TWINCRE registry that is a multicentral prospective cohort including patients who underwent PCI at 12 hospitals in Japan between 2017 and 2019. Among registered patients, we ultimately evaluated 1,428 patients who were followed-up. They were divided into two groups by the prescriptions of PPI or P-CAB at discharge for the index PCI; the PPI/P-CAB group (n=1,023), and the Non-PPI/P-CAB group (n=407). The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE) including death, acute coronary syndrome, stent thrombosis, hospitalization due to heart failure and ischemic stroke. Secondary endpoints was major bleeding events defined BARC3, 4 and 5.

Results

The average age of the study population was 70.3 years and 80.3% were male. Baseline clinical profiles were comparable between the groups, except that the PPI/P-CAB group included significantly higher rate of patients who had history of prior PCI (28.4% vs 18.7%, P=0.02). Additionally, there was no significant difference in the duration of dual antiplatelet therapy between the PPI/P-CAB group and Non-PPI/P-CAB group (average duration; 287±8 vs. 285±8 days, P=0.66). Overall, MACCE was developed in 132 patients (9.3%), and bleeding event was observed in 24 patients (1.7%) during 574 days of median follow-up period. Kaplan-Meier analysis showed that patients in the PPI/P-CAB group had a significantly lower rate of MACCE than those in the Non-PPI/P-CAB group (Log-rank test, p=0.0003, Figure 1A). Multivariate Cox regression analysis revealed that the prescription of PPI/P-CAB still was independently associated with the primary endpoint (hazard ratio 0.532, 95% confidence interval 0.369–0.766, p=0.0007), even after the adjustment by diverse covariates. Whereas, there was no significant difference in the bleeding event (p=0.64, Figure 1B).

Conclusion

PPI or P-CAB therapy was associated with better clinical outcomes after PCI, independent of the incidences of severe bleeding events.

Figure 1

Funding Acknowledgement

Type of funding source: None

Clinical outcome of pulmonary vein isolation alone ablation strategy using VISITAG SURPOINT in nonparoxysmal atrial fibrillation

BACKGROUND

Recent studies have shown the improvement in long-term effectiveness with standardized pulmonary vein isolation (PVI) aimed at creating durable and contiguous lesions with VISITAG SURPOINT (VS) in paroxysmal atrial fibrillation (PAF).

OBJECTIVE

We aimed to assess efficacy of PVI alone strategy using VS in non-PAF patients and evaluate factors associated with corresponding clinical outcomes.

METHODS

Consecutive patients who underwent PVI for persistent/long-standing persistent AF between May 2017 to July 2019 were studied retrospectively. PVI was performed with 30-50 W guided by VS (posterior target: 400-500, anterior target: 500). Left atrial voltage maps were created during atrial pacing after PVI.

RESULTS

A total of 140 patients (119 males, age 62 ± 10 years, long-standing persistent AF: 35) were included and followed for median of 454 days. No adverse events were reported in any patients during periprocedural and follow-up period of up to 28 months. Kaplan-Meier analysis estimated that freedom from atrial tachycardia or AF (AT/AF) without antiarrhythmics at 1-year was 70%. Radiofrequency delivery with higher power was associated with increased first-pass isolation rate, but not with freedom from AT/AF. In multivariate analysis, long-standing persistent AF and % low-voltage zone (%LVZ) were independent predictors of clinical outcome. The best cut-off value of %LVZ for predicting AT/AF recurrence was 3.24%. Freedom from AT/AF was 88% in patients with persistent AF and %LVZ < 3.24%, while 27% in those with long-standing persistent AF and %LVZ ≥ 3.24%.

CONCLUSIONS

PVI alone using VS was associated with excellent 1-year success in patients with persistent AF and %LVZ < 3.24%, but was insufficient in those with long-standing persistent AF and/or %LVZ ≥ 3.24%.

An Automatic Image Collection System for Multicenter Clinical Studies

The acquisition of medical images from multiple medial institutions has become important for high-quality clinical studies. In recent years, electronic data submission has enabled the transmission of image data to independent institutions more quickly and easily than before. However, the selection, anonymization, and transmission of medical images still require human resources in the form of clinical research collaborators. In this study, we developed an image collection system that works with the electronic data capture (EDC) system. In this image collection system, medical images are selected based on EDC input information, patient ID is anonymized to a subject ID issued by the EDC, and the selected anonymized images are transferred to the research institute without human intervention. In the research institute, clinical information registered by the EDC and clinical images collected by the image collection system are managed by the same subject ID and can be used for clinical studies. In October 2019, our image collection system was introduced to 13 medical institutions and has now begun collecting medical images from the in-hospital picture archiving and communication system (PACS) of those institutions.

Effect of circularly polarized light on germination, hypocotyl elongation and biomass production of arabidopsis and lettuce: Involvement of phytochrome B

Circular dichroism (CD), defined as the differential absorption of left- and right-handed circularly polarized light (CPL), is a useful spectroscopic technique for structural studies of biological systems composed of chiral molecules. The present study evaluated the effects of CPL on germination, hypocotyl elongation and biomass production of Arabidopsis and lettuce. Higher germination rates were observed when Arabidopsis and lettuce seedlings were irradiated with red right-handed CPL (R-CPL) than with red left-handed CPL (L-CPL). Hypocotyl elongation was effectively inhibited when Arabidopsis and lettuce seedlings were irradiated with red R-CPL than with red L-CPL. This difference was not observed when a phytochrome B (phyB) deficient mutant of Arabidopsis was irradiated, suggesting that inhibition of elongation by red R-CPL was mediated by phyB. White R-CPL induced greater biomass production by adult Arabidopsis plants, as determined by their fresh shoot weight, than white L-CPL. To determine the molecular basis of these CPL effects, CD spectra and the effect of CPL on the photoreaction of a sensory module of Arabidopsis phyB were measured. The red light-absorbing form of phyB showed a negative CD in the red light-absorbing region, consistent with the results of germination, inhibition of hypocotyl elongation and biomass production. L-CPL and R-CPL, however, did not differ in their ability to induce the interconversion of the red light-absorbing and far-red light-absorbing forms of phyB. These findings suggest that these CPL effects involve phyB, along with other photoreceptors and the photosynthetic process.

DJ-1 is indispensable for the S-nitrosylation of Parkin, which maintains function of mitochondria

The DJ-1 gene, a causative gene for familial Parkinson’s disease (PD), has been reported to have various functions, including transcriptional regulation, antioxidant response, and chaperone and protease functions; however, the molecular mechanism associated with the pathogenesis of PD remains elusive. To further explore the molecular function of DJ-1 in the pathogenesis of PD, we compared protein expression profiles in brain tissues from wild-type and DJ-1-deficient mice. Two-dimensional difference gel electrophoresis analysis and subsequent analysis using data mining methods revealed alterations in the expression of molecules associated with energy production. We demonstrated that DJ-1 deletion inhibited S-nitrosylation of endogenous Parkin as well as overexpressed Parkin in neuroblastoma cells and mouse brain tissues. Thus, we used genome editing to generate neuroblastoma cells with DJ-1 deletion or S-nitrosylated cysteine mutation in Parkin and demonstrated that these cells exhibited similar phenotypes characterized by enhancement of cell death under mitochondrial depolarization and dysfunction of mitochondria. Our data indicate that DJ-1 is required for the S-nitrosylation of Parkin, which positively affects mitochondrial function, and suggest that the denitrosylation of Parkin via DJ-1 inactivation might contribute to PD pathogenesis and act as a therapeutic target.

Long-Term Performance of Right Ventricular Implantable Cardioverter-Defibrillator Leads in Arrhythmogenic Right Ventricular Cardiomyopathy and Hypertrophic Cardiomyopathy

Patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) and hypertrophic cardiomyopathy (HCM) implanted with implantable cardioverter-defibrillators (ICDs) may show a large decrease in R-wave amplitude during long-term follow-up. However, it is unclear whether this decrease is higher in these patients than in those without structural heart disease. This study investigated ICD-lead intracardiac parameters over a long duration in patients with ARVC and HCM and compared these parameters with those of a control group. We included 50 patients (mean age, 55.2 ± 17.2 years; 26% female) with ICD leads in the right ventricular apex, and compared 7 ARVC and 14 HCM patients with 29 control patients without structural heart disease. ICD-lead parameters, including R-wave amplitude, pacing threshold, and impedance during follow-up, were compared. The difference in these parameters between the time of implantation and year 5 were also compared. There were no significant differences in R-wave amplitude at implantation among the 3 groups. The change in R-wave amplitude between the time of implantation and year 5 was significantly greater in the ARVC group (-3.3 ± 5.4 mV, P = 0.012) in comparison to the control group (1.3 ± 2.8 mV); the HCM group showed no significant difference (-0.4 ± 2.3 mV, P = 0.06). Thus, in the ARVC group, R-wave amplitude at year 5 was significantly lower than that in the control group (5.7 ± 4.8 mV versus 12.5 ± 4.5 mV, P = 0.001). In ARVC patients with ICDs, ventricular sensing is likely to deteriorate during long-term follow-up; however, in HCM patients, sensing may not deteriorate.

Protein Phosphorylation Dynamics Under Carbon/Nitrogen-Nutrient Stress and Identification of a Cell Death-Related Receptor-Like Kinase in Arabidopsis

Nutrient availability, in particular the availability of sugar [carbon (C)] and nitrogen (N), is important for the regulation of plant metabolism and development. In addition to independent utilization of C and N nutrients, plants sense and respond to the balance of C and N nutrients (C/N-nutrient) available to them. High C/low N-nutrient stress has been shown to arrest early post-germinative growth while promoting progression to senescence in Arabidopsis. Although several signaling components of the C/N-nutrient response have been identified, the inclusive molecular basis of plant C/N-nutrient response remains unclear. This proteome analysis evaluated phosphorylation dynamics in response to high C/low N-nutrient stress. Phosphoproteomics under conditions of C/N-nutrient stress showed a global change in the phosphorylation status of proteins, including plasma membrane H⁺-ATPase, carbon and nitrogen metabolic enzymes and signaling proteins such as protein kinases and transcription factors. Further analyses suggested that SNF1-related protein kinase 1 (SnRK1) is involved in primary C/N-nutrient signal mediation via the transcriptional regulation of C/N-regulatory kinases. We also identified a leucine-rich repeat receptor-like kinase with extracellular malectin-like domain, named as LMK1, which was shown to possess cell death induction activity in plant leaves. These results provide important insight into the C/N-nutrient signaling pathways connecting nutrition stress to various cellular and physiological processes in plants.