Metagenomic Analysis of Bacterial Microflora in Dental and Atherosclerotic Plaques of Patients With Internal Carotid Artery Stenosis

Background

Internal carotid artery stenosis is primarily attributed to atherosclerosis in the carotid artery bifurcation. Previous studies have detected oral bacteria in atherosclerotic lesions, suggesting an association between oral bacteria and atherosclerosis. In this study, we compared the bacterial flora of the atherosclerotic plaque in the carotid artery and dental plaque of patients with internal carotid artery stenosis using 16S ribosomal RNA (16S rRNA) metagenomic sequencing.

Methods

Fifty-four patients who underwent internal carotid endarterectomy for internal carotid artery stenosis at the Showa University Hospital between April 2016 and February 2018 were included. Polymerase chain reaction targeting the 16S rRNA gene detected bacterial DNA in the carotid plaques of 11 cases, of which only 5 could be further analyzed. Thereafter, DNA extracted from the carotid and oral plaques of these 5 cases were analyzed using metagenomic sequencing targeting 16S rRNA. In addition, their general condition and oral conditions were evaluated. The patients were classified into symptomatic and asymptomatic groups based on the presence or absence of symptoms of transient ischemic attack, and their bacterial flora was evaluated.

Results

The results demonstrated that the microflora of carotid plaques (n = 5) contained bacterial species from 55 families and 78 genera. In addition, 86.5% of the bacteria detected in the carotid plaques were also detected in oral plaques. Cariogenic and periodontopathic bacteria accounted for 27.7% and 4.7% of the bacteria in the carotid plaques, respectively.

Conclusions

These results suggest that oral bacteria are directly or indirectly involved in the pathogenesis of atherosclerosis. More extensive studies of oral commensal bacteria detected in extra-oral lesions are warranted to comprehensively investigate the role of oral bacteria in the pathogenesis of systemic diseases.

Erratum: Search for Cosmic-Ray Boosted Sub-GeV Dark Matter Using Recoil Protons at Super-Kamiokande [Phys. Rev. Lett. 130, 031802 (2023)]

This corrects the article DOI: 10.1103/PhysRevLett.130.031802.

Surgical treatment for extremely rare solitary fibrous tumors of the central nervous system originating from cranial nerve VIII: new clinicopathological findings. Illustrative case

BACKGROUND

Reports of solitary fibrous tumors (SFTs) of the central nervous system (CNS) originating from cranial nerves are extremely rare. The origins of these neurogenic SFTs of the CNS have been determined only by intraoperative findings, and there is no pathological evidence of whether they really originated from cranial nerves.

OBSERVATIONS

A 54-year-old female with hearing loss and facial paralysis presented with a giant right cerebellopontine angle tumor. She was diagnosed with a petrous meningioma based on preoperative imaging, and the tumor was removed via the retrosigmoid approach after embolization of the tumor-feeding vessels. Intraoperatively, the tumor was not attached to the dura mater but extended from the internal auditory canal to the cisternal portion. The acoustic nerve was not identified, but it was possible to separate the tumor from the facial nerve. The tumor was removed as an acoustic schwannoma intraoperatively. Postoperative pathological examination revealed an SFT. Immunostaining revealed peripheral nerve bundles entrapped within the tumor tissue. The patient was diagnosed with an SFT of the CNS originating from the acoustic nerve.

LESSONS

A neurogenic SFT of the CNS was diagnosed based on both intraoperative and pathological findings.

New evidence for the Ontong Java Nui hypothesis

The formation of the Ontong Java Nui super oceanic plateau (OJN), which is based on the model that the submarine Ontong Java Plateau (OJP), Manihiki Plateau (MP), and Hikurangi Plateau (HP) were once its contiguous fragments, could have been the largest globally consequential volcanic event in Earth's history. This OJN hypothesis has been debated given the paucity of evidence, for example, the differences in crustal thickness, the compositional gap between MP and OJP basalts and the apparent older age of both plateaus relative to HP remain unresolved. Here we investigate the geochemical and ⁴⁰Ar-³⁹Ar ages of dredged rocks recovered from the OJP's eastern margin. Volcanic rocks having compositions that match the low-Ti MP basalts are reported for the first time on the OJP and new ~ 96-116 Ma and 67-68 Ma ⁴⁰Ar-³⁹Ar age data bridge the temporal gap between OJP and HP. These results provide new evidence for the Ontong Java Nui hypothesis and a framework for an integrated tectonomagmatic evolution of the OJP, MP, and HP. The isotopic data imply four mantle components in the source of OJN that are also expressed in present-day Pacific hotspots sources, indicating origin from (and longevity of) the Pacific Large Low Shear-wave Velocity Province.

Degassing of early-formed planetesimals restricted water delivery to Earth

The timing of delivery and the types of body that contributed volatiles to the terrestrial planets remain highly debated1,2. For example, it is unknown if differentiated bodies, such as that responsible for the Moon-forming giant impact, could have delivered substantial volatiles3,4 or if smaller, undifferentiated objects were more probable vehicles of water delivery5-7. Here we show that the water contents of minerals in achondrite meteorites (mantles or crusts of differentiated planetesimals) from both the inner and outer portions of the early Solar System are ≤2 μg g-1 H2O. These are among the lowest values ever reported for extraterrestrial minerals. Our results demonstrate that differentiated planetesimals efficiently degassed before or during melting. This finding implies that substantial amounts of water could only have been delivered to Earth by means of unmelted material.

Search for Cosmic-Ray Boosted Sub-GeV Dark Matter Using Recoil Protons at Super-Kamiokande

We report a search for cosmic-ray boosted dark matter with protons using the 0.37  megaton×years data collected at Super-Kamiokande experiment during the 1996-2018 period (SKI-IV phase). We searched for an excess of proton recoils above the atmospheric neutrino background from the vicinity of the Galactic Center. No such excess is observed, and limits are calculated for two reference models of dark matter with either a constant interaction cross section or through a scalar mediator. This is the first experimental search for boosted dark matter with hadrons using directional information. The results present the most stringent limits on cosmic-ray boosted dark matter and exclude the dark matter-nucleon elastic scattering cross section between 10^{-33}cm^{2} and 10^{-27}cm^{2} for dark matter mass from 1  MeV/c^{2} to 300  MeV/c^{2}.

Relationships between dietary diversity and gut microbial diversity in the elderly

Diet is considered as a major driver of gut microbiota composition. However, little is known about the relationship between overall dietary balance and gut microbiota, especially in the elderly. Here, using the Quantitative Index for Dietary Diversity (QUANTIDD), we analysed the relationships between dietary diversity and gut microbiota diversity in 445 Japanese subjects aged 65-90 years. We also examined the effect of age by comparing the young-old group aged 65 to 74 years (<75 years group; n=246) and the old-old group aged 75 years and older (≥75 years group; n=199). QUANTIDD showed significant positive relationships with Pielou's evenness and Shannon indices, two α-diversity indices related to the uniformity of species distribution. This suggests that a more diverse diet is associated with a more uniform abundance of various bacterial groups, rather than a greater variety of gut bacteria. QUANTIDD also showed significant positive associations with the abundance of Anaerostipes, Eubacterium eligens group, and Eubacterium ventriosum group, which produce short-chain fatty acids (SCFAs) and are beneficial to health. Negative association was found with the abundance of Ruminococcus gnavus group, which produces inflammatory polysaccharides. Positive associations between QUANTIDD and α-diversity indices or the abundance of specific bacterial groups were identified among all subjects and in the <75 years group, but not in the ≥75 years group. Our results suggest that dietary diversity contributes to the diversity of the gut microbiota and increases the abundance of SCFAs-producing bacteria, but only up to a certain age. These findings help to understand the complex relationship between diet and gut microbiota, and provide hints for specific dietary interventions to promote beneficial gut microbiota in the elderly.

COT-12 ANALYSIS OF 5-ALA STRONGLY POSITIVE FINDINGS USING IMAGE J FOR MALIGNANT BRAIN TUMOR

For brain tumor surgery using 5-ALA during surgery, we analyze the brightness using image analysis software Image J, we report the results to date for strongly positive findings. Thirty-nine patients who were suspected of having malignant glioma before surgery and who were strongly positive for 5-ALA during surgery were included. (21 malignant glioma, 14 metastatic brain tumor, 3 meningioma, and 1 germ cell tumor.) Intraoperative 5-ALA-positive findings were analyzed with image analysis software Image J (Wayne Rasband: NIH), brightness was measured with histograms, and maximum brightness was compared. The average maximum brightness titer was 106.38 (50-225) in 21 cases of malignant glioma. The brightness titer was 84.5 (28-121) in 14 cases of metastatic brain tumor, 80 (59-97) in meningioma, and 43 in 1 case of germ cell tumor. No clear correlation was found between brightness, tumor grading, and MIB-1 LI. In addition, a clear difference in luminance was observed between the tumor and the ventricle in one case.By analyzing brightness with Image J, it will be possible to obtain informations about tumors from different perspectives.

STMO-4 INITIAL EXPERIENCE WITH BRAIN TUMOR SURGERY USING STEALTH AUTOGUIDE

Tissue sampling of brain tumors is generally performed by biopsy with large or small craniotomy and stereotaxic brain biopsy. Recently, Stealth Autoguide, a robotic system for stereotactic deep electrode implantation and brain tumor biopsy in epilepsy, has become available. We report the initial experience of brain tumor surgery using stealth Autoguide in our hospital.Case: A man in his 70s. Left paralysis occurred during chemotherapy for esophageal cancer. Magnetic resonance imaging (MRI) revealed a ring-enhanced lesion from the right basal ganglia to the coronal radiatum. Because he was under steroid administration, he was diagnosed with metastatic brain tumor, malignant lymphoma, malignant glioma, or demyelinating disease. Since paralysis was progressing and MRS was suspected to be a malignant tumor, a stereotactic biopsy using a stealth autoguide was performed. Biopsies were performed with skin incisions of 1 cm or less from two locations that were automatically positioned based on the preoperative planning, and a sufficient amount of tissue was collected from the lesions. No complications such as bleeding were observed. Since the histological diagnosis was glioblastoma, chemotherapy with temozolomide and radiotherapy were promptly started.Brain tumor biopsy using stealth Autoguide allows accurate tissue sampling in a short period of time, and is a very useful tool for brain tumor diagnosis in the future.

Different changes in the biomarker C-terminal telopeptides of type II collagen (CTX-II) following intra-articular injection of high molecular weight hyaluronic acid and oral non-steroidal anti-inflammatory drugs in patients with knee osteoarthritis: a multi-center randomized controlled study

OBJECTIVES

We previously reported, based on a multicenter randomized-control study, that the efficacy of intra-articular injections of hyaluronic acid (IA-HA) was not inferior to that of oral non-steroidal anti-inflammatory drugs (NSAIDs) in patients with knee osteoarthritis (OA). However, the molecular effects on the pathophysiology of knee OA remain unclear. C-terminal telopeptides of type II collagen (CTX-II) is reported to primarily originate from the interface between articular cartilage and subchondral bone, which is a site of potential remodeling in OA. We performed a predefined sub-analysis of the previous study to compare the changes of urinary CTX-II (uCTX-II) in response to IA-HA to those in response to NSAID for knee OA.

DESIGN

A total of 200 knee OA patients were registered from 20 hospitals and randomized to receive IA-HA (2,700 kDa HA, 5 times at 1-week intervals) or NSAID (loxoprofen sodium, 180 mg/day) for 5 weeks. The uCTX-II levels were measured before and after treatment.

RESULTS

The uCTX-II levels were significantly increased by IA-HA treatment (337.7 ± 193.8 to 370.7 ± 234.8 ng/μmol Cr) and were significantly reduced by NSAID treatment (423.2 ± 257.6 to 370.3 ± 250.9 ng/μmol Cr). The %changes of uCTX-II induced by IA-HA (11.6 ± 29.5%) and NSAID (-9.0 ± 26.7%) was significantly different (between-group difference: 20.6, 95% confidence intervals: 10.6 to 30.6).

CONCLUSIONS

While both IA-HA and NSAID improved symptoms of knee OA, uCTX-II levels were increased by IA-HA and reduced by NSAIDs treatment, suggesting these treatments may improve symptoms of knee OA through different modes of action.

Visualization of ictal networks using gamma oscillation regularity correlation analysis in focal motor epilepsy: Illustrative cases

Background:

Focal motor epilepsy is difficult to localize within the epileptogenic zone because ictal activity quickly spreads to the motor cortex through ictal networks. We previously reported the usefulness of gamma oscillation (30–70 Hz) regularity (GOR) correlation analysis using interictal electrocorticographic (ECoG) data to depict epileptogenic networks. We conducted GOR correlation analysis using ictal ECoG data to visualize the ictal networks originating from the epileptogenic zone in two cases — a 26-year-old woman with negative motor seizures and a 53-year-old man with supplementary motor area (SMA) seizures.

Case Description:

In both cases, we captured several habitual seizures during monitoring after subdural electrode implantation and performed GOR correlation analysis using ictal ECoG data. A significantly high GOR suggestive of epileptogenicity was identified in the SMA ipsilateral to the lesions, which were connected to the motor cortex through supposed ictal networks. We resected the high GOR locations in the SMA and the patients’ previously identified tumors were removed. The patients were seizure-free without any neurological deficits after surgery.

Conclusion:

The GOR correlation analysis using ictal ECoG data could be a powerful tool for visualizing ictal networks in focal motor epilepsy.

Surgical treatment of hemifacial spasm caused by fusiform vertebral artery aneurysm: case report and literature review

BACKGROUND

Root exit zone (REZ) compression by a fusiform vertebral artery (VA) aneurysm is a rare cause of hemifacial spasm (HFS). We report a case of successful microvascular decompression (MVD) for the treatment of HFS caused by a fusiform VA aneurysm. We also review the relevant literature and demonstrate the effectiveness of surgical treatment.

CASE DESCRIPTION

A 64-year-old man presented with a 2-year and 4-month history of progressive involuntary facial twitching on the right side. Radiological examination revealed a fusiform right VA aneurysm. The REZ that was compressed by the aneurysm and the underlying anterior inferior cerebellar artery (AICA) was surgically decompressed by transposing the VA and AICA and wrapping the aneurysm. Immediately post-operation, the patient's symptoms disappeared. For 7 years and 4 months postoperatively, there was no symptom recurrence or increase in aneurysm size.

CONCLUSION

MVD is an effective treatment for HFS caused by a fusiform VA aneurysm because symptoms are likely to improve immediately after treatment.

Factors Related to the Delayed Cure of Hemifacial Spasm after Microvascular Decompression: An Analysis of 175 Consecutive Patients

Detailed studies assessing the factors related to delayed cure of hemifacial spasm (HFS) after microvascular decompression (MVD) are sparse. We aimed to evaluate the effect of 11 clinical factors on the time until the patient became spasm free after MVD. We enrolled 175 consecutive patients with HFS who underwent MVD between 2012 and 2018. The end point was defined as the time point at which the patient became spasm free based on the outpatient interview. Patients were divided into six groups depending on when they became spasm free after the operation, as follows: <7 days ( n  = 62), 7 days to 1 month ( n  = 28), 1 to 3 months ( n  = 38), 3 to 6 months ( n  = 25), 6 to 12 months ( n  = 17), and >12 months ( n  = 5). The median time to become spasm free after MVD was 30.0 days. Association of 11 factors (age, sex, laterality, number of offending arteries, vertebral artery compression, number of compression sites, compression at root detachment zone, preoperative Botox treatment, indentation of the brain stem on preoperative magnetic resonance image, transposition, and interposition) with spasm-free rate was assessed using the Cox's proportional hazards model. Spasm-free rate curve after MVD for the significant factor was obtained using the Kaplan-Meier method. In univariate and multivariate analyses, nontransposition was significantly related to delayed HFS cure after MVD (hazard ratio [HR], 0.60; 95% confidence interval [CI], 0.42, 0.87; p  = 0.0068 and HR, 0.60; CI, 0.43, 0.85; p  = 0.042, respectively). The spasm-free rate was higher in the transposition than in the nontransposition group ( p  = 0.0013). As shortening the time until spasm free after MVD improves patients' quality of life, transposition should be recommended. Prediction of spasm-free time could relieve the anxiety of postoperative patients.

Retraction: Pressure-Induced Superconducting State of Europium Metal at Low Temperatures [Phys. Rev. Lett. 102, 197002 (2009)]

Retraction of DOI: 10.1103/PhysRevLett.102.197002.

COT-13 Luminance analysis of 5-aminolevulinic acid using Image J for malignant brain tumor

Purpose: For malignant brain tumor surgery, photodynamic diagnosis (PDD) with 5-aminolevulinic acid (5-ALA) is useful for maximal removal of the tumor. Although it has the advantage of identifying the presence or absence of residual tumors during surgery, there are variations in positive rates, and the classification is limited, based on visual inspection such as Stummer’s classification (strong, vague, none). We analyzed the luminance of positive findings using software Image J for brain tumor surgery using 5-ALA, and we report the results. Materials and Methods: From April 2018 to March 2021, 31 patients with suspected malignant glioma before surgery were included. Intraoperative 5-ALA positive findings were analyzed by software Image J (Wayne Rasband: NIH), the luminance was measured with a histogram, and compared the maximum luminance titer. Results: Among the positive cases, the average maximum luminance value for malignant glioma was 101 (50–168), which consisted of 11 cases of Glioblastoma, 1 case of Oligodendroglioma, and 1 case of anaplastic astrocytoma. The average maximum brightness of metastatic brain tumors is lower than that of malignant gliomas, even if they are visually strong, 83.5 (28–121). Conclusions: Even if it is visually strong in the conventional Stummer classification, it may be possible to classify in detail by analyzing luminance with Image J. In addition, more objective index is necessary to classify the vague findings.

STMO-12 Efforts for safe malignant brain tumor surgery at our hospital

Although maximal safe resection is the current standard for glioblastoma surgery, its safety and removal rate conflict with each other. Electrophysiological monitoring, such as motor evoked potential monitoring and awake craniotomy, can be utilized as safety measures; not all facilities can perform them. Herein, we present a representative case report on our efforts for a safe malignant brain tumor surgery.

Case: A 77-year-old woman with glioblastoma in the premotor cortex presented with seizure of the upper left lower limb. Her pyramidal tract ran from the medial bottom to the posterior of the tumor. We performed excision from the site using the lowest gamma entropy. We then removed all parts of the tumor, with the exception of the pyramidal tract infiltration, and no paralysis was observed. She was definitively diagnosed with glioblastoma and is currently on maintenance chemotherapy.

As a preoperative examination, we performed cerebrovascular angiography. We then performed various other tests to ascertain the patient’s condition. Considering lesions that affect language, Wada tests were performed regardless of laterality. For all patients with epilepsy onset, preoperative 256-channel electroencephalogram measurement and intraoperative the gamma entropy analysis were performed to confirm epileptogenicity. Considering lesions that affect eloquence, subdural electrodes were placed and brain function mapping was performed the next day. Based on the results, the safest cortical incision site and excision range were determined, and excision was performed on the following day.

Of the 14 operated glioblastoma cases after November 2018, more than 85% of the contrast-enhanced lesions were completely removed in 7 cases, partially removed in 5 cases, and underwent biopsy in 2 cases. Postoperative Karnofsky performance status scores remained unchanged in 11 cases, improved in 1 case, and deteriorated in 2 cases.

Our efforts have resulted in safe and sufficient removal of malignant brain tumors during surgery.

New methods for determination of the keyhole position in the lateral suboccipital approach to avoid transverse-sigmoid sinus injury: Proposition of the groove line as a new surgical landmark

PURPOSE

The asterion is frequently used as an anatomical landmark to determine the location of a keyhole in the lateral suboccipital approach used in craniotomies. However, the asterion may not be ideal because of large individual differences among patients. We examined a simple and safe method for determining an optimal keyhole position (KP) using the digastric groove as a new landmark in the lateral suboccipital approach.

METHODS

Thirty-three patients with trigeminal neuralgia who underwent surgery in our institute between April 2014 and December 2018 were included. The groove line (GL) was designed accurately, extending the digastric groove on the surface of the occipital bone, as the x-axis. The y-axis was depicted from the posterior edge of the digastric groove (the groove point: GP) vertical to the GL. The x-y coordinates represented the distances from GP on each axis. The x-y coordinates of median edge of the transverse-sigmoid sinus (TSJ point), asterion, and the intersection of the GL and transverse sinus (the transverse point: TP) were investigated, based on intraoperative findings and recorded videos.

RESULTS

The x-y coordinated of the TSJ point were (23.9±3.9, 7.2±3.6). In all patients, the TSJ point was located superior to the GL. The x-y coordinates of the asterion were (27.3±6.0, 8.9±4.1), and in 28 of the 33 patients, their coordinates exceeded the TSJ points. The x-coordinate of the TP was 29.5±4.5, and was located behind the TSJ point on the GL in all patients. The shortest distance between the TSJ points and TP was approximately 3mm. According to these measurements, we decided that the optimal KP would be at 20mm from the GP, subjacent to the GL.

CONCLUSIONS

Our methods of using the GL as a new surgical landmark for setting the optimal KP is simple, safe, and useful.

HGG-29. A CASE OF CIRCUMSCRIBED HIGH-GRADE ASTROCYTOMA WITH ATRX AND CDKN2A/B ALTERNATIONS WHO WAS INITIALLY DIAGNOSED AS GLIOBLASTOMA AND HAS 20 YEARS SURVIVAL

Pediatric high-grade gliomas are rare and often hard to classify, which grow locally and show longer survival than diffuse high-grade gliomas in adults. We report a case of circumscribed high-grade astrocytoma who was initially diagnosed as glioblastoma and has 20 years survival. A 7-year-old girl suffered from epileptic seizure due to a left occipital lobe tumor. The tumor was resected in another hospital and diagnosed as glioblastoma. The tumor disappeared after extended local irradiation and chemotherapy using nimustine hydrochloride (ACNU) and cisplatin (CDDP). Eighteen years after initial onset, first recurrence was confirmed as the intra-tumoral hemorrhage. The tumor was resected and diagnosed as anaplastic oligoastrocytoma. After 6 courses of temozolomide (TMZ), the tumor disappeared. Twenty years after initial onset, the second local recurrence was confirmed. Although gamma knife and TMZ was performed, the tumor did not disappear. The tumor was surgically resected. Histopathology showed localized growth with some infiltration and mitosis but lacked pseudopallisading and microvascular proliferation. The tumor was diagnosed as circumscribed high-grade astrocytoma. Immunostaining revealed ATRX nuclear loss and CDKN2A / B homozygous deletion. After 10 courses of TMZ, the third local recurrence was confirmed. The tumor was completely removed and has not occurred recurrence more than 3 months after the last operation. Circumscribed high-grade glioma is expected to survive longer than invasive glioma. Pediatric gliomas should differ from adult gliomas in the genes of tumorigenesis. Care should be taken for its diagnosis and treatments. We also need a new classification based on histology and gene profile. HGG-30, ANALYSIS OF PEDIATRIC GLIOMAS IN OUR INSTITUTE Kaoru Tamura, Mai Fujioka, Masae Kuroha, Motoki Inaji, Yoji Tanaka, Tadashi Nariai, and Taketoshi Maehara; Tokyo Medical and Dental University, Tokyo, Japan. PURPOSE: Recent advances in genetic interrogation of pediatric glioma increase the importance of molecular diagnosis using surgical specimen. However, surgical resection may be avoided to preserve quality of life, especially in brain stem glioma cases. We retrospectively examined diagnosis and treatment of pediatric gliomas in our hospital. METHODS: This study includes 14 consecutive glioma patients under the age of 18 who underwent initial treatment at our hospital from 2000 to 2019. Histopathological diagnosis, clinical course and molecular status such as IDH, H3F3A and BRAF were analyzed. RESULTS: 5 patients (1 pilocytic astrocytoma (PA), 3 diffuse astrocytomas, 1 oligodendroglioma were treated only by surgical resection (group A). 7 patients (1 PA, 1 anaplastic oligodendroglioma, 2 diffuse midline gliomas and 3 glioblastomas (GBM)) received radiation and/or chemotherapy after surgical resection (group B). 2 diffuse intrinsic pontine gliomas (DIPG) received radiation and chemotherapy without surgical resection (Group C). No IDH mutation was observed in all pathological specimen obtained cases. BRAF alteration was observed in all PA cases. 1 case of GBM had BRAF V600Emutation and the other had H3K27M mutation. During a median of 7.7 years of follow-up, group A patients have no recurrence. Group B includes various diagnosis and prognosis. 2 group C patients diagnosed DIPG by MRI showed different clinical courses. CONCLUSION: Pediatric gliomas include diverse biological subgroups and show broad range of clinical behavior. Since pediatric glioma has a low incidence and a wide variety of genetic mutations, multicenter study is important to improve the treatment of pediatric glioma.

COT-11 Administration of Bevacizumab for patients who failed to complete Stupp regimen after glioblastoma surgery

Stupp regimen is widely used as the standard treatment after glioblastoma surgery, but in some cases treatment must be discontinued for various reasons. We experienced Bevacizumab in two patients who were unable to continue treatment in the Stupp regimen, and report our experience with literature review. First patient is a man in his 60s. Resection of glioblastoma of the left cerebral hemisphere was performed, and postoperatively right hemiparesis and aphasia remained. Irradiation and administration of Temozolomide were performed, but Temozolomide was unable to continue because of side effects. After systemic management, Bevacizumab was administered, and reduction of residual tumor and peripheral edema were observed, and the patient began to speak. After 12 cycles of administration, the tumor regrew, and he died. Second patient is a woman in her 80s. Craniotomy was performed for hemorrhagic infarction of the left cerebral hemisphere, postoperatively, aphasia, right hemiparesis remained, bedridden, and was unable to eat. Four months after initial surgery, a tumor was found in left parietal lobe and was resected. The pathological diagnosis was glioblastoma. For the treatment of recurrence, the patient was unable to be transferred for radiochemotherapy, so the patient was treated with Temozolomide and Bevacizumab. The patient’s condition became better, eat by herself, and could play in rehabilitation facility on the wheelchair. After 12 cycles of bevacizumab, the tumor subsequently enlarged, and died. Although the effect is limited, there are some cases in which Bevacizumab administration could maintain patient’s condition by controlling tumor growth for a certain period of time. From the experience of these patients, it seems that even in patients with postoperative poor Karnofsky Performance Status (KPS)and elderly people, Bevacizumab administration would be an option before transitioning to end-of-life care.

Impact of stress myocardial blood flow as an important predictor for major adverse cardiac and cerebrovascular event in hemodialysis patients, even in patients without myocardial perfusion abnormality

Background

In the clinical setting, ischemic heart disease (IHD) is a major problem not only in general patients but also in regular hemodialysis (HD) patients. Positron emission tomography (PET) is becoming a reliable modality for detecting coronary artery disease. Of course, PET illustrates myocardial perfusion (MP), PET also measures myocardial blood flow (MBF) directly. We have reported stress MBF is an independent predictor in HD population. Although some prior studies show CFR is an independent predictor for their prognosis in patients without MP abnormality, there is limited data about the predictability of stress MBF in HD patients without MP abnormality.

Methods

A total 438 of HD patients who undergone 13NH3PET for suspected IHD were enrolled. All patients were undergone13NH3PET at Nagoya Radiological Diagnosis Foundation. After we excluded patients whose summed stress score (SSS) &lt;4, we identified 182 eligible patients. Patients were divided into two group according to the median value of CFR levels; low stress MBF group (≤2.56) and high stress MBF group (&gt;2.56). We followed up them up to 4.2 years (median 2.4 years) and collected their data. We evaluated their major adverse cardiac cerebrovascular event. We performed Kaplan-Meyer analysis and multivariable cox regression models. Furthermore, we evaluated the incremental value with C-index, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) when CFR added into a model with established risk factors.

Result

There were intergroup difference in baseline characteristics: age, gender, prior CVD and diabetes. Kaplan-Meyer analysis shows statistically intergroup difference [log rank p=0.013, hazard ratio (HR) 0.413, 95% confidential interval (CI) 0.220–0.775]. Multivariable cox regression model for MACCE shows CFR is an independent risk factor (p=0.004, HR 0.311, 95% CI 0.137–0.684). As regarding model discrimination, all of C-index (0.832 vs 0.796, p=0.15), NRI (0.513, p=0.008) and IDI (0.032, p=0.033) were greatest in a predicting model with established risk factors plus stress MBF.

Conclusion

The low stress MBF group has poor prognosis in MACCE comparing to the high stress MBF group. Stress MBF is an independent risk factor for MACCE. Adding stress MBF on conventional risk factors could more accurately predict MACCE in HD patients, even in patients without MP abnormality.

Funding Acknowledgement

Type of funding source: None

Japanese multicenter registry evaluating the antegrade dissection reentry with cardiac computed tomography for chronic coronary total occlusion

Objective

This study was performed to evaluate the efficacy of cardiac computed tomography (CT) for antegrade dissection re-entry (ADR) technique in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

Background

Although PCI of CTO is a rapidly evolving field, procedure success rate remains suboptimal. Recently, ADR with Stingray device for CTO-PCI has also evolved to one of the pillar technique of the hybrid algorithm. Although the success rate of the device could be improved, it also remains not always high especially as first crossing strategy.

Methods

Forty eight patients with total occlusion suitable for revascularization evaluated by baseline coronary angiography and cardiac CT were enrolled in this study from April 2017 to April 2019 from 30 enrolled centers. The primary observation was procedural success. Furthermore, all puncture point with Stingray were analyzed by cardiac CT. In each point, 1) plaques on the isolated myocardial side at distal puncture site (+1 point), 2) any plaques excluded above definition at distal puncture site (+2 points), 3) calcification on both 1 and 2 at distal puncture site (+1 point) were analyzed and calculated the score (Score 0–3) (Figure 1).

Results

Overall procedure success rate was 95.8% (46/48) and antegrade success rate was 91.3% (42/46). Sixteen cases were succeeded with single guidewire escalation and 32 cases were attempted ADR with Stingray system. Within them, 25 cases were succeeded and 7 cases were observed puncture failure. And 3cases were succeeded with IVUS guide and 2 cases were with retrograde appTechnical success rate with stingray was 78.1% (25/32). Cardiac CT was analyzed 60 puncture sites in 32 cases which were attempted ADR with stingray system (1.88 sites/case). CT score at ADR success point was significantly smaller compare to that at ADR failure point (0.68±1.09 vs 1.77±1.09, p&lt;0.0001).

Conclusions

Pre procedure Cardiac CT and CT score might be useful for ADR technique in CTO PCI not only for case selection but also for puncture site selection.

Figure 1

Funding Acknowledgement

Type of funding source: None

Diabetes and hemodialysis are important factor for decrease coronary flow reserve even in the patients with normal myocardial perfusion

Background

In clinical setting, patients with traditional coronary risk factors are at high risk for coronary artery disease (CAD). Such patients who complain chest discomfort are usually performed nuclear myocardial perfusion (MP) test. We sometimes find patients whose PET result shows normal MP and abnormal coronary flow reserve (CFR). However, there are limited data about the predictors for decreased CFR. In the view of describe above, we have investigated the parameters for decreased CFR in the patients without MP abnormality.

Methods and results

From 20th April 2013 to 21st December 2018, we performed 2,930 13N- ammonia PET for suspected CAD. After excluding the follows; 966 patients with repeated test, 54 patients with incomplete data, one patient missed, we investigated 1,909 eligible patients' data. We performed least square to identify the factors decreased CFR. Hemodialysis (HD), age, prior revascularization, diabetes (DM) and body mass index (BMI) were independent risk factor for decreased CFR in all population. On the other hand, HD, age, DM, hypertension and BMI were independent risk factor for decreasing CFR in patients without MP abnormality. According to the result of least square methods, we classified all patients into four groups; without DM/ without HD group, with DM/ without HD group, without DM/ with HD group and with DM/ with HD group. The value of CFR in each group were as follows: without DM/ without HD group (median, 1st quartile-3rd quartile; 2.88, 2.21–3.52), with DM/ without HD group (2.65, 2.00–3.38), without DM/ with HD group (2.29, 1.67–2.95) and with DM/ with HD group (1.97, 1.43–2.68). There were statistically significant intergroup differences. The value of CFR in the patients without MP abnormality were as follows: without DM/ without HD group (3.04, 2.47–3.65), with DM/ without HD group (2.98, 2.40–3.61), without DM/ with HD group (2.52, 2.10–3.08) and with DM/ with HD group (2.38, 1.86–2.97). Even in the patients without MP abnormality, there were also statistically significant intergroup differences.

Conclusion

According to our 13N-ammonia PET data analysis, DM and HD were important and independent factors for decreased CFR. Even in the patients without MP abnormality, DM and HD were important factor for decreased CFR.

Funding Acknowledgement

Type of funding source: None

COT-18 TWO CASES OF GLIOBLASTOMA WITH ASYMPTOMATIC PULMONARY ARTERY EMBOLISM AND DEEP VEIN THROMBOSIS FROM ADMISSION TO HOSPITAL

Patients with malignant tumors are susceptible to concurrent venous thromboembolism. We report two cases of glioblastomas that showed asymptomatic pulmonary embolism and deep vein thrombosis on admission. The first case was a 77-year-old male. He was referred to our clinic for a tumor found in the left temporal lobe on computed tomography scan performed when he suffered pneumonia. On admission,he had a Karnofsky performance status (KPS) score of 50 and an elevated D-dimer level (16.46 μg/ml). Pulmonary embolism and deep vein thrombosis were noted on detailed examination. Direct oral anticoagulant (DOAC) therapy resulted in the disappearance of pulmonary embolism. On biopsy,the tumor was diagnosed as glioblastoma. The patient underwent radiation therapy in combination with chemotherapy. The second case was a 71-year-old female. She developed a disorder of consciousness and was admitted to a clinic. Brain magnetic resonance imaging (MRI) revealed a high T2 signal area in the left temporal lobe. The patient was initially diagnosed with encephalitis. Though the consciousness disorder improved quickly,she was referred to our clinic after a hyperintense area was observed on MRI. On admission,she had a KPS score of 100,and an elevated D-dimer level (7.59μg/ml),revealing pulmonary embolism and deep vein thrombosis. She was started on a DOAC and underwent surgical removal of the tumor via craniotomy. She was diagnosed with glioblastoma and underwent radiation therapy in combination with chemotherapy. Approximately 20% of the patients with glioblastomas suffer concurrent symptomatic venous thromboembolism. The incidence of venous thromboembolism is further elevated in patients with a poor KPS score or elderly people. Many patients with glioblastomas suffer asymptomatic venous thromboembolism. In this report,asymptomatic venous thromboembolism was noted in patients with a good KPS score. In glioblastoma patients,it is necessary to test for venous thromboembolism by measuring D-dimer levels before surgery.

Combination gemcitabine plus S-1 versus gemcitabine plus cisplatin for advanced/recurrent biliary tract cancer: the FUGA-BT (JCOG1113) randomized phase III clinical trial

BACKGROUND

Gemcitabine plus cisplatin (GC) is the standard treatment of advanced biliary tract cancer (BTC); however, it causes nausea, vomiting, and anorexia, and requires hydration. Gemcitabine plus S-1 (GS) reportedly has equal to, or better, efficacy and an acceptable toxicity profile. We aimed to confirm the non-inferiority of GS to GC for patients with advanced/recurrent BTC in terms of overall survival (OS).

PATIENTS AND METHODS

We undertook a phase III randomized trial in 33 institutions in Japan. Eligibility criteria included chemotherapy-naïve patients with recurrent or unresectable BTC, an Eastern Cooperative Oncology Group Performance Status of 0 - 1, and adequate organ function. The calculated sample size was 350 with a one-sided α of 5%, a power of 80%, and non-inferiority margin hazard ratio (HR) of 1.155. The primary end point was OS, while the secondary end points included progression-free survival (PFS), response rate (RR), adverse events (AEs), and clinically significant AEs defined as grade ≥2 fatigue, anorexia, nausea, vomiting, oral mucositis, or diarrhea.

RESULTS

Between May 2013 and March 2016, 354 patients were enrolled. GS was found to be non-inferior to GC [median OS: 13.4 months with GC and 15.1 months with GS, HR, 0.945; 90% confidence interval (CI), 0.78-1.15; P = 0.046 for non-inferiority]. The median PFS was 5.8 months with GC and 6.8 months with GS (HR 0.86; 95% CI 0.70-1.07). The RR was 32.4% with GC and 29.8% with GS. Both treatments were generally well-tolerated. Clinically significant AEs were observed in 35.1% of patients in the GC arm and 29.9% in the GS arm.

CONCLUSIONS

GS, which does not require hydration, should be considered a new, convenient standard of care option for patients with advanced/recurrent BTC.

CLINICAL TRIAL NUMBER

This trial has been registered with the UMIN Clinical Trials Registry (http://www.umin.ac.jp/ctr/index.htm), number UMIN000010667.

Detection rates and sites of unruptured intracranial aneurysms according to sex and age: an analysis of MR angiography-based brain examinations of 4070 healthy Japanese adults

OBJECTIVIE

The purpose of this study was to evaluate the detection rate and occurrence site according to patient sex and age of unruptured intracranial aneurysms detected through MRI and MR angiography (MRA).

METHODS

A total of 4070 healthy adults 22 years or older (mean age [± SD] 50.6 ± 11.0 years; 41.9% women) who underwent a brain examination known as “Brain Dock” in the central Tokyo area between April 2014 and March 2015 were checked for unruptured saccular aneurysm using 3-T MRI/MRA. The following types of cases were excluded: 1) protrusions with a maximum diameter < 2 mm at locations other than arterial bifurcations, 2) conical protrusions at arterial bifurcations with a diameter < 3 mm, and 3) cases of suspected aneurysms with unclear imaging of the involved artery. When an aneurysm was definitively diagnosed, the case was included in the aneurysm group. The authors also investigated the relationship between aneurysm occurrence and risk factors (age, sex, smoking history, hypertension, diabetes, and hyperlipidemia).

RESULTS

One hundred eighty-eight aneurysms were identified in 176 individuals (detection rate 4.32%), with the detection rate for women being significantly higher (6.2% vs 3.0%, p < 0.001). The average age in the aneurysm group was significantly higher than in the patients in whom aneurysms were not detected (53.0 ± 11.1 vs 50.5 ± 11.0 years). The detection rate tended to increase with age. The detection rates were 3.6% for people in their 30s, 3.5% for those in their 40s, 4.1% for those in their 50s, 6.9% for those in their 60s, and 6.8% for those in their 70s. Excluding persons in their 20s and 80s—age groups in which no aneurysms were discovered—the detection rate in women was higher in all age ranges. Of the individuals with aneurysms, 12 (6.81%) had multiple cerebral aneurysms; no sex difference was observed with respect to the prevalence of multiple aneurysms. Regarding aneurysm size, 2.0–2.9 mm was the most common size range, with 87 occurrences (46.3%), followed by 3.0–3.9 mm (67 [35.6%]) and 4.0–4.9 mm (20 [10.6%]). The largest aneurysm was 13 mm. Regarding location, the internal carotid artery (ICA) was the most common aneurysm site, with 148 (78.7%) occurrences. Within the ICA, C1 was the site of 46 aneurysms (24.5%); C2, 57 (30.3%); and C3, 29 (15.4%). The aneurysm detection rates for C2, C3, and C4 were 2.23%, 1.23%, and 0.64%, respectively, for women and 0.68%, 0.34%, and 0.21%, respectively, for men; ICA aneurysms were significantly more common in women than in men (5.27% vs 2.20%, p < 0.001). Multivariate logistic regression analysis revealed that age (p < 0.001, OR 1.03, 95% CI 1.01–1.04), female sex (p < 0.001, OR 2.28, 95% CI 1.64–3.16), and smoking history (p = 0.011, OR 1.52, 95% CI 1.10–2.11) were significant risk factors for aneurysm occurrence.

CONCLUSIONS

In this study, both female sex and older age were independently associated with an increased aneurysm detection rate. Aneurysms were most common in the ICA, and the frequency of aneurysms in ICA sites was markedly higher in women.

P1618A polymethoxy flavonoid, Nobiletin, Has a therapeutic potency against the development of heart failure through NBP1 activation

Introduction

Maladaptive hypertrophy is being recognized as a critical event during the development of heart failure. The control of cardiac hypertrophy may be one of the therapeutic strategy for heart failure therapy. In our previous study, we screened natural compound library and found that a natural compound, Nobiletin, could inhibit cardiomyocyte hypertrophy in culture. Nobiletin has various useful effects such as anti-cancer, anti-inflammation, and anti-oxidant and may be applicable to pharmacological therapy for heart failure.

Hypothesis

We thought that nobiletin might prevent the development of heart failure in vivo and investigated the target molecule of Nobiletin in the heart.

Methods and results

In primary cardiomyocytes, Nobiletin significantly inhibited phenylephrine (PE)-induced hypertrophic responses such as increases in cell size and hypertrophic gene transcription, such as ANF and BNP. C57BL6 mice were subjected to sham or transarotic constriction (TAC). Oral administrations of Nobiletin (20 mg/kg/day) or vehicle were repeated for 8 weeks. Nobiletin treatment significantly prevented TAC-induced increases in PWT and systolic dysfunction. Nobiletin also suppressed TAC-induced myocardial cell hypertrophy, perivascular fibrosis, and hypertrophic gene transcriptions. To investigate the target molecule of Nobiletin, Nobiletin-binding proteins were purified from rat heart using biotin-conjugated Nobiletin. We identified 162 novel binding protein of Nobiletin by LC/MS-MS. One of them, Nobiletin-binding protein 1 (NBP1) related to cellular metabolic pathway. Pulldown assay demonstrated that biotin-conjugated Nobiletin, but not biotin, directly interacted with recombinant NBP1. In vitro enzyme assay showed that Nobiletin enhanced NBP1 activity. Although NBP1 knockdown could not affect PE-induced hypertrophic response gene transcriptions and cardiomyocyte hypertrophy, NBP1 knockdown failed to exhibit Nobiletin-mediated anti-hypertrophic effects. NBP1-KO mice and WT mice were subjected to sham or TAC and randomly divided into two groups: Nobiletin (20 mg/kg/day) and vehicle. After 8 weeks, Nobiletin significantly improved TAC-induced cardiac hypertrophy and systolic dysfunction in WT mice but not in NBP1-KO mice. Nobiletin also prevented TAC-induced increases in HW/BW rate, myocardial cell hypertrophy, and mRNA levels of ANF and β-MHC in WT mice but not in NBP1-KO mice.

Conclusions

In this study, we demonstrate that Nobiletin inhibits cardiomyocyte hypertrophy and the development of heart failure in vivo. NBP1 activity is required to exhibit therapeutic potency of Nobiletin for heart failure. These finding suggest that a natural compound, nobiletin, might be a candidate for heart failure agent in human.

Acknowledgement/Funding

This work was supported by JSPS KAKENHI Grant.

P5410Combination assessment of renal and hepatic dysfunction improves the predictability of prognosis in patients with acute decompensated heart failure

Background

Renal dysfunction is associated with poor mortality in patients with heart failure (HF). Hepatic dysfunction, assessed by Fibrosis-4 (FIB4) index, has also prediction ability in acute decompensated HF (ADHF) patients. We investigated whether the assessment of the combination of FIB4 index and renal dysfunction improves predictability in patients with ADHF.

Methods

We retrospectively enrolled consecutive 758 patients who admitted due to ADHF from January 2011 to February 2018 and followed up for one year. FIB4 index on admission was calculated by the formula: age (yrs) × AST[U/L] / (platelets [103/μL] × (ALT[U/L])1/2). Study subjects were divided into high FIB4 index (>3.25) and low FIB4 index (≤3.25), furthermore each group were classified by the presence/absence of CKD (estimated glomerular filtration rate <60 ml/min/1.73m). We have generated four groups; low FIB4/without CKD (n=154), low FIB4/with CKD (n=294), high FIB4/without CKD (n=56), and high FIB4/with CKD (n=254). The primary outcome was defined as all-cause mortality in one year. We performed Kaplan-Meyer analysis and multivariable Cox regression models. Furthermore, we evaluated the incremental value with C-index, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) when FIB4 index and renal dysfunction added to a baseline model.

Results

In total, 106 patients died in one year. High FIB4 index and CKD showed significantly higher 1-year mortality (high FIB4 index: 19.7% vs 10.3%, p<0.001, CKD: 17.0% vs 6.7%, p<0.001, respectively). Kaplan-Meyer analysis shows that high FIB4 index with CKD showed statistically higher mortality than the others (vs low FIB4/without CKD, p<0.001, vs high FIB4/without CKD, p=0.031, vs low FIB4/with CKD, p<0.001, respectively).

Multivariate Cox regression model revealed that both high FIB4 index and CKD were an independent risk predictor of 1-year mortality (FIB4 index: p<0.001, HR 1.06, 95% CI 1.035–1.087, CKD: p=0.004, HR 1.834, 95% CI 1.213–2.773, respectively) in patients with ADHF.

A baseline model for prediction of 1-year mortality was determined by multivariable logistic regression including age, body mass index, systolic blood pressure, and serum albumin (C-index: 0.688). Adding high FIB4 index and CKD to the baseline model, all of C-index (0.738, p=0.04), NRI (0.122, p=0.067), and IDI (0.024, p=0.004) were improved.

Receiver operating characteristic curves

Conclusions

Combination assessment of renal and hepatic dysfunction could improve the predictability of prognosis in patients with ADHF.

Acknowledgement/Funding

None

P4551Prognostic utility of Palliative Prognostic Index for prediction of 30-day and 1-year outcome in patients with acute decompensated heart failure

Background

The prognosis of heart failure remains poor similar to the terminal cancer patients, although recent progress in medical treatment. Palliative Prognostic Index (PPI) is a widely used prognostic index for terminal cancer patients (PPI includes: Palliative Performance Scale, oral intake, oedema, dyspnea at rest and delirium), suggesting the short-term prognostic marker of terminal cancer patients.

Purpose

The purpose of this study was to evaluate the impact of PPI on 30-day mortality, 1-year mortality and 1-year events (including all-cause mortality, readmission due to heart failure and new onset of cerebral infarction after hospital discharge) among acute decompensated heart failure (ADHF) patients.

Method

Study subjects comprised of consecutive 764 patients who admitted due to ADHF and followed up for 1-year. PPI were calculated at the time of hospital admission. Study subjects were divided into two groups based on the PPI: L-PPI (PPI<6) and H-PPI (6≤PPI). We calculated the C-index, net reclassification improvement (NRI) and the integrated discrimination improvement (IDI) to evaluate the improvement of prediction ability on 30-day mortality.

Result

H-PPI showed significantly higher 30-day mortality than L-PPI [7.9% vs 2.0%, log rank p<0.001, Hazard retio (HR): 1.26, 95% confidential interval(CI): 1.14–1.37, p<0.001], 1-year mortality [20.0% vs 12.7%, log rank p=0.022, HR 1.15, 95% CI 1.09–1.21, p<0.001]and 1-year events [45.5% vs 31.1%, log rank p<0.001, HR 1.13, 95% CI 1.09–1.17, p<0.001]. Multivariate cox proportional hazard models adjusted with several covariates revealed that PPI was an independent predictor of 30-day mortality (HR: 1.23, 95% CI: 1.10–1.36, p<0.001), 1-year mortality (HR: 1.10, 95% CI: 1.04–1.16, p<0.001) and 1-year events (HR: 1.11, 95% CI: 1.07–1.15, p<0.001), respectively.

A reference model for prediction of 30-day mortality was determined including left ventricular ejection fraction and serum albumin concentration by multivariable logistic regression analysis. (P<0.05) (C-index: 0.720) Adding PPI to the reference model (C-index: 0.773) significantly improved both NRI (0.458, p=0.038) and IDI (0.046, p=0.007), respectively.

Conclusion

We suggest that assessment of PPI showed good prognostic ability for 30-day and 1-year outcome, while PPI provided additional prognostic information in patients with ADHF.

P6240The impact of stress myocardial blood flow as a very strong predictor for all-cause mortality, cardiovascular mortality and adverse cardiac and cerebrovascular event in hemodialysis population

Background

In the clinical setting, ischemic heart disease (IHD) is a major problem not only in general patients but also in regular hemodialysis (HD) patients. 13ammonia positron emission tomography (13NH3PET) is an established and excellent diagnostic device for IHD. Although coronary flow reserve is the most important index in IHD diagnosis, there are limited data about stress myocardial blood flow (MBF). We investigated the prognosis predictability of stress MBF in all-cause mortality, cardiovascular (CV) mortality and adverse cardiac and cerebrovascular event (MACCE).

Methods and results

A total 438 of HD patients who undergone 13NH3PET for suspected IHD were enrolled. 29 cases were excluded due to revascularization therapy in 60 days. In total we collected 409 eligible cases. All patients were undergone13NH3PET at Nagoya Radiological Diagnosis Foundation. Patients were divided into two group according to the median value of stress MBF levels; low stress MBF group (<2.12) and high stress MBF group (≥2.12). We followed up them up to 4.2 years (median 2.4 years) and collected their data. We evaluated their all-cause mortality, CV mortality and MACCE. Kaplan-Meyer analysis shows that intergroup difference in all-cause mortality (log rank p=0.001, hazard ratio [HR] 0.411, 95% confident interval [CI] 0.261–0.632), CV mortality (log rank p=0.002, HR 0.324, 95% CI 0.157–0.625) and MACCE (log rank p<0.001, HR 0.465, 95% CI 0.324–0.657). Multiple cox analysis that include established risk factors shows CFR is an independent risk factor for all-cause mortality (HR 0.261, 95% CI 0.154–0.442), CV mortality (HR 0.172, 95% CI 0.079–0.374) and MACCE (HR 0.329, 95% CI 0.213–0.503). As a result of the incremental value with C-index, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) when CFR added into a model with established risk factors, each indicator shows adding stress MBF on established risk factors improve the predictability in all-cause mortality, CV mortality and MACCE (all-cause mortality; NRI 0.642, p<0.001, IDI 0.091, p<0.001, CV mortality NRI 0.809, p<0.001, IDI 0.116, p<0.001, MACCE; NRI 0.646, p<0.001, IDI 0.072, p<0.001).

Conclusion

Considering prognosis of HD population, stress MBF is an important and independent predictor for all-cause mortality, CV mortality and MACCE. As a result of our investigation, stress MBF is one of most strong predictors in HD population.

P1608Inhibition of GATA4 dimerization suppress hypertrophic responses

Introduction

Hypertrophic signals eventually reach the nuclei of cardiomyocytes, change patterns of gene expression, and cause the development of heart failure. During the development of heart failure, intrinsic histone acetyltransferase called p300 induce GATA4 acetylation. Acetylated GATA4 increases its DNA binding, up-regulates cardiac hypertrophic response genes, and lead to heart failure. A zinc finger protein, GATA4 is the transcription factor that expression level is high in heart. It has been reported that GATA1, the same GATA family, regulates transcriptional activity through its homo-dimerization. However, GATA4 homo-dimerization and its relationship to hypertrophic responses are still unknown.

Purpose

To clarify the relationship between GATA4 homo-dimerization and transcriptional activity and investigate whether inhibition of this homo-dimerization become therapeutic target for cardiac hypertrophy.

Methods

GST pull-down and DNA pull-down assay were performed using GST fusion full length and deletion mutants of GATA4 and biotin-conjugated ET-1 promoter probe including a GATA element. Recombinant C-zinc finger domain (256–326), including C-zinc finger motif (256–295) and acetylation site (308–326) was cross-linked using glutaraldehyde and subjected to silver staining. An expression plasmid with three GATA4-acetylation site mutant-conjugated with nuclear localization sequence (3xG4D) was constructed. Immunoprecipitation and western blotting were performed using nuclear extract from HEK293T cells expressing p300, GATA4, and 3xG4D. Luciferase assay was using ANF and ET-1 promoter sequences. Neonatal rat cultured cardiomyocyte expressed 3xG4D and then stimulated with phenylephrine (PE) for 48 hours. Next cardiomyocytes stained with α-actinin antibody and measured the cell surface area.

Results

The acetylation site of GATA4 was required for the dimerization of GATA4. But, C-zinc finger motif (256–295) and the acetylation site were required for the DNA binding. Recombinant C-zinc finger domain formed not only a homo-dimer but also a multimer. Co-expression of p300 increased the formation of homo-dimer as well as the acetylation of GATA4 in HEK293T cells. The GATA4 homo-dimer was disrupted by acetyl-deficient GATA4 or HAT-deficient p300 mutant. Overexpression of 3xG4D prevented the dimerization of GATA4, but not acetylation of GATA4. The result of luciferase assay showed that overexpression of 3xG4D prevented p300/GATA-induced ANF and ET-1 promoter activities. Furthermore, overexpression of 3xG4D inhibited phenylephrine-induced cardiomyocyte hypertrophy.

Conclusions

These results suggest that GATA4 dimerization may play an important role in hypertrophy-response gene activation. Thus, it is likely that inhabitation of GATA4 dimerization become therapeutic target for cardiac hypertrophy.

P4998Novel GATA4 binding proteins, RbAp48/46, regulate cardiomyocyte hypertrophy with depending on the phosphorylate State of GATA4

Introduction

Cardiac hypertrophy is being recognized as a critical event during the development of heart failure. A zinc finger protein GATA4 associates with an intrinsic histone acetyltransferase p300 and regulates myocardial transcriptional activities in response to hypertrophic stimuli. Here, we show that Retinoblastoma protein (Rb)-associated protein 48 and 46 (RbAp48, RbAp46) are novel components of p300/GATA4 complex. Both RbAp48 and 46 form a repressor complex with HDACs and has been implicated in chromatin remodeling and transcriptional repression. However, the precise functional relationships among p300, GATA4, RbAp48, and RbAp46 remain unknown.

Hypothesis

We assessed the hypothesis that RbAp48/46 form a functional complex with p300/GATA4 and regulated hypertrophic responses in cardiomyocytes.

Methods and results

IP-WB using nuclear extract from rat heart demonstrated that GATA4 formed a complex with RbAp48, RbAp46, HDAC1, and HDAC2. GST pull down assay using recombinant proteins showed that GATA4 physically interacted with both RbAp48 and RbAp46 but not HDAC1 and HDAC2. Deletion mutant assay revealed that N-terminal domain of GATA4 interacted with RbAp48/46. In HEK293T cell, overexpression of RbAp48/46 recruited HDAC1/2 to GATA4, inhibited p300-induced GATA4 acetylation and suppressed p300/GATA4-dependent ANF and ET-1 promoter activations. Conversely, the knockdown of RbAp48/46 reversed these changes. Although overexpression of HDAC1/2 did not change p300/GATA4-induced these promoter activities, co-expression of HDAC1 or HDAC2 with RbAp48/46 enhanced RbAp48/46-mediated inhibitory actions. In cardiomyocytes, overexpression of RbAp48/46 significantly inhibited phenylephrine (PE)-induced GATA4 acetylation, activation of ANF and ET-1 promoters, and cardiomyocyte hypertrophy. The knockdown of RbAp48/46 reversed these changes. Moreover, the knockdown of HDAC1/2 deteriorated PE-induced hypertrophy-responsive events and did not exhibit RbAp48/46-induced inhibitory actions. Finally, MEK1/ERK-mediated S105 phosphorylation of GATA4 by PE stimulus induced the dissociation of RbAp48/46 with GATA4, the increase of p300-induced GATA4-acetylation, the synergistic activation of ANF and ET-1 promoters with p300/GATA4, and the decrease of RbAp48/46 recruitments onto the GATA element of the ANF promoter. Conversely, PD98059, a MEK1 inhibitor, treatment inhibited GATA4-phosphorylation and these changes.

Conclusion

In this study, we demonstrate that RbAp48/46 mediate the binding between GATA4 and HDAC1/2 and regulate p300/GATA4 axis. The phosphorylation of S105 GATA4 has a critical role on the dissociation of GATA4/RbAp48/46/HDAC repressor complex, the formation of 300/GATA4 activator complex, and the increase of GATA4 acetylation and hypertrophic responses. These findings suggest that RbAp48/46 may regulate hypertrophic responses involved in modulating the posttranslational modification crosstalk of GATA4.

Acknowledgement/Funding

This work was supported by JSPS KAKENHI Grant.

P2527Accumulative impact of poor nutrition and frailty on 1-year mortality among acute decompensated heart failure patients

Background

Several studies have proved that both poor nutrition (PN) and Frail are associated with poor prognosis among heart failure patients. However, it has not been fully revealed whether PN and frail could have impact on prognosis accumulatively.

Purpose

The purpose of the present study was to evaluate the impact of nutritional and Frailty status on 1-year mortality among hospitalized patients with acute decompensated heart failure (ADHF).

Methods

Study subjects comprised of 315 hospitalized patients with ADHF. To evaluate the nutritional and Frailty status, we calculated the controlling nutritional status (CONUT) score and the Study of Osteoporotic Fractures (SOF) index at hospital admission. PN and Frailty were defined as the CONUT score ≥5 and SOF index ≥2, respectively.

Results

z Sixty-nine subjects (21.9%) were died within 1-year. PN and Frailty were observed in 33.3% and 55.6% of study subjects, respectively. Both PN and Frailty were similarly related to the 1-year mortality by univariate cox regression analysis (Hazard Ratio (HR) 2.43, 95% confidence interval (CI) 1.51–3.91, p=0.0003: HR 3.13, 95% CI 1.83–5.66, p<0.0001, respectively).

Study subjects were classified into 4 groups according to the nutritional and frailty status: control (normal nutrition without Frailty, n=110), PN alone (PN without Frailty, n=30), Frailty alone (Frailty without PN, n=100), and PN + Frailty (PN with Frailty, n=75). The Kaplan-Meier event curves for 1-year all-cause mortality illustrated that subjects with PN + Frailty had a significantly higher mortality than in subjects with control, PN alone and Frailty alone (log rank p=0.0001, 0.0180, 0.0070, respectively).

As well as, cox regression analysis revealed that PN + Frailty showed significantly higher mortality than control, PN alone and Frailty alone. (HR 5.33, 95% CI 2.75–11.1, p<0.0001: HR 2.99, 95% CI 1.26–8.78, p=0.011: HR 2.07, 95% CI 1.21–3.61, p=0.008, respectively). Moreover, multivariate cox regression analysis also revealed that PN with Frailty was independently associated with 1-year mortality even after adjustment for age, body mass index, systolic blood pressure, and chronic kidney disease. (HR 3.40, 95% CI 1.69–7.32, adjusted p<0.001)

Kaplan-Meier curve for 1year mortality

Conclusions

The combination assessment consisted with nutrition and frailty could identify poor prognosis patients with ADHF.

P1607Epigenetic modifications via histone acetylation by p300 are changed during the transition from cardiac hypertrophy to heart failure

Background

An intrinsic histone acetyltransferase (HAT), p300, is required for acetylation and the transcriptional activity of GATA4, as well as pathological left ventricular hypertrophy (LVH) and the development of heart failure (HF) in vivo. Recently, studies of histone modification have been performed within the flexible tails, such as H3K9 and H3K14. Although most previously studied histone modifications are within the flexible tails of histones, H3K122 is reportedly a novel site of the histone globular domain acetylated by p300, and its acetylation activates gene transcriptions by destabilizing histone-DNA binding and increasing the accessibility of transactional factors to DNA. However, little is known about the extent histone modifications directly affect LVH and HF.

Hypothesis

We hypothesized that p300 could induce epigenetic changes by acetylation of the globular domain as well as tail domain of histone during the development of LVH and HF.

Methods

First, to investigate whether the acetylation of H3K122 in the globular domain of histones as well as those of H3K9 and H3K14 in the tail domain of histones increased in cardiomyocytes hypertrophy, western blotting and chromatin-immunoprecipitation (ChIP) assays were performed using neonatal rat cultured cardiomyocytes with phenylephrine (PE) stimulus. Second, neonatal rat cultured cardiomyocytes were treated with p300 knockdown by siRNA or curcumin, a p300-specific HAT inhibitor. Third, to investigate the role of p300 HAT activity in histone acetylation in vivo, we utilized mice overexpressing p300 in the heart, which induced LVH. Final, to investigate whether these acetylation changes during the development of LVH and HF, in vivo ChIP assay was performed using hypertensive heart disease model of Dahl salt-sensitive rats.

Results

Western blotting indicated that treatment with PE increased the acetylation of H3K122 as well as those of H3K9 and H3K14 in cardiomyocytes hypertrophy. ChIP assay demonstrated that PE increased the recruitment of acetylated H3K122 and H3K9 onto ANF and BNP promoters containing the GATA element and peaks of acetylation of these domains were 4 hours after PE stimulation. Next, these acetylations were significantly inhibited by p300 knockdown by siRNA or treatment with curcumin. Conversely, in vivo ChIP assays in mice overexpressing p300 indicated that p300 overexpression increased recruitment of acetylated H3K122 and H3K9 onto ANF and BNP promoters containing the GATA element. Next, in hypertensive heart disease model of Dahl salt-sensitive rats, in vivo ChIP assays reviled that acetylation of H3K9 was increased around ANF and BNP promoters containing the GATA element at the LVH stage but that of H3K122 was increased at the HF stage.

Conclusion

Our data indicate that acetylation of H3K122 in globular domain of histones by p300 is the key event of the transition from LVH to HF.

P2528Responsiveness to nutritional intervention would impact on future cardiovascular prognosis in poor fitness patients

Purpose

Nutritional improvement has been proposed for long-term cardiovascular prognosis as well as fitness recovery. We aimed to examine whether “responsiveness” to nutritional and exercise interventions would impact patients' cardiovascular prognosis even patients in low baseline fitness level.

Methods

We included 254 consecutive patients who participated in the phase II comprehensive cardiovascular rehabilitation (CCR) for at least three months. All patients underwent cardiopulmonary exercise test (CPX) at the initial and completion phases of CCR. Nutritional guidance was periodically performed individually during CCR. Peak oxygen uptake (PVO2) was measured through CPX to evaluate the fitness level, whereas nutritional status was evaluated using the geriatric nutritional risk index (GNRI). Patients were divided into “low fitness” and “normal fitness” groups based on the median of baseline PVO2. Each group was further classified into four categories according to the changes in VO2 and GNRI during CCR: “Both NOT improved”, “Only GNRI improved”, “Only PVO2 improved”, and “Both improved”.

Results

Cox proportional regression analysis showed that the category of “both NOT improved” was an independent predictor for cardiovascular risk among the baseline low fitness group (Hazard ratio: 4.5, p=0.007); whereas no significant difference among the normal fitness group. Kaplan-Meier analysis revealed that the event-free survival rate was significantly lower in the “both NOT improved” category (log rank p=0.002) among the baseline low fitness group (figure); whereas no significant difference among the normal fitness group.

GNRI/PVO2 improvement vs. prognosis

Conclusion

Responsiveness to nutritional and exercise intervention could be a predictive factor of cardiovascular prognosis even in low fitness patients.

P2434Digital zoom decreases radiation exposure dose up to 30% in percutaneous coronary intervention

Background

Interventional cardiology is gaining greater popularity worldwide with each passing year. Reduction of exposure dose is a very imminent and an important issue in cardiology procedure. Although a newer radiation reduction technique, device and procedure are very valuable and expected, we should consider about therapy technique, radiation technique, devices, and the way to protection. Digital zoom digitally enlarges images in real time by up to 2.5-fold at lower doses than those used with traditional field of view changes. In our phantom examination the average dose reduction of digital zoom was 27%.

Methods and results

This study is designated as single-center, retrospective, not-randomized, observation study. 2101 eligible cases were collected. We assigned the cases of PCI without the use of Digital zoom to the Conventional group and those involving the use of Digital zoom to the Digital zoom group. There were 806 patients in the Conventional group and 1195 in the Digital zoom group. Because we had begun using Digital zoom from January 2015 onwards, all patients in the Conventional group had undergone PCI from January 2013 to December 2014 and all patients in the Digital zoom group had undergone PCI from January 2015 to December 2016. In addition, we calculated the RAK/minute and DAP/minute for an accurate assessment. To minimize the difference of characteristics between two groups, propensity score including all baseline variables was performed. Furthermore, Predictors of radiation exposure were investigated using multivariable least square methods. Inter group differences were observed in DAP, RAK, DAP/min, and RAK/min (Digital zoom group vs conventional group: DAP, 16000 cGy cm2 [from 1st quartile to 3rd quartile; 10300–24400] vs 20700 [13400–29500], p<0.001; DAP/min, 557 cGy cm2/min [392–737] vs 782 [571–1010], p<0.01; RAK, 1590 Gy [990–2410] vs 1850 [1220–2720], p<0.01; RAK/min, 54.7 Gy/min [38.5–73.2] vs 71.2 [51.5–93.0], p<0.01). Even after propensity score matching, intergroup differences in DAP (810 cases), DAP/min (811 cases), RAK (746 cases), and RAK/min (744 cases) persisted. Furthermore, the least squares method showed that Digital zoom is an important predictor of DAP (β=0.17, p<0.01) and RAK (β=0.12, p<0.01).

Conclusion

Digital zoom is an old and cost-free technique, but one of most powerful reduction of exposure method. Propensity score adjustment and least square methods show that digital zoom is one of independent effective method.

P6243Impact of coronary flow reserve as an important predictor for major adverse cardiac and cerebrovascular event in hemodialysis patients even in patients without myocardial perfusion abnormality

Background

In the clinical setting, ischemic heart disease (IHD) is a major problem not only in general patients but also in regular hemodialysis (HD) patients. 13N-ammonia positron emission tomography (13NH3PET) is an established and excellent diagnostic test for IHD. We have reported about the predictability of coronary flow reserve (CFR) in poor prognosis in HD population. Some prior studies show that low CFR predicts poor prognosis for not only cardiovascular event but also all-cause mortality. Although it is well-known that CFR is an important predictor, there are limited data about CFR of patients without myocardial perfusion (MP) abnormality. We investigated the prognostic predictability of adverse cardiac and cerebrovascular event (MACCE) in HD patients without MP abnormality.

Methods

A total 438 of HD patients who underwent 13NH3PET for suspected IHD were enrolled. All patients were underwent 13NH3PET at our facility. After we excluded patients whose summed stress score (SSS) >3, we identified 182 eligible patients. Patients were divided into two group according to the median value of CFR; low CFR group (≤2.405) and high CFR group (>2.405). We followed up them up to 4.2 years (median 2.4 years) and collected their data. We evaluated their major adverse cardiac cerebrovascular event. We performed Kaplan-Meyer analysis and multivariable cox regression models. Furthermore, we evaluated the incremental value with C-index, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) when CFR added into a model with established risk factors.

Results

There were intergroup difference in baseline characteristics: age, gender, prior CVD and diabetes. Kaplan-Meyer analysis shows statistically intergroup difference [log rank p=0.04, hazard ratio (HR) 0.54, 95% confidential interval (CI) 0.30–0.97]. Multivariable cox regression model for MACCE shows CFR is an independent risk factor (p=0.04, HR 0.54, 95% CI 0.30–0.97). As regarding model discrimination, all of C-index (0.82 vs 0.80, p=0.23), NRI (0.51, p<0.01) and IDI (0.03, p=0.03) were greatest in a predicting model with established risk factors plus CFR.

Conclusions

The low CFR group had poor prognosis in MACCE comparing to the high CFR group. CFR would be an independent risk factor for MACCE. Adding CFR on conventional risk factors could more accurately predict MACCE in HD patients, even in patients without MP abnormality.

Lateral Basal Approach to CPA in Supine No-Retractor Method: Microvascular Decompression for Hemifacial Spasm

Objectives  In this video, we demonstrate our more basal approach in microvascular decompression for hemifacial spasm. Design  The patient is in supine position with the head rotated maximally to the opposite side on the U -shaped head rest. The small cranial window is made at the lateral bottom of occipital cranium with the adequate superficial manipulation on the muscles layers in the craniocervical junction. Results  The more basal approach enables the surgeon to access all the segments of the VIIth nerve tract without cerebellar retraction by spatula, especially in the case with vertebral artery associated compression. Conclusion  This approach safely provides the ideal operative corridor promising sufficient decompression in micorvascular decompression for the VIIth nerve. The link to the video can be found at: https://youtu.be/_nKSjGEHoB4 .

Erratum: Structural and Valence Changes of Europium Hydride Induced by Application of High-Pressure H_{2} [Phys. Rev. Lett. 107, 025501 (2011)]

This corrects the article DOI: 10.1103/PhysRevLett.107.025501.

Chondroma in the hypoglossal canal: A case report

Background:

Intracranial chondromas are rare tumors arising from the skull base. They are usually accompanied by functional impairments of some cranial nerves. However, hypoglossal nerve dysfunction is rare.

Case Description:

We report on a 57-year-old woman presenting with chondroma of the right hypoglossal canal leading to right hypoglossal nerve palsy.

Conclusions:

This report suggests that chondroma should be considered as a differential diagnosis in cases of hypoglossal lesions.