The Role of Postoperative Radiotherapy in T4 Rectal Cancer with Synchronous Distant Metastasis

PURPOSE/OBJECTIVE(S)

Studieson the role of surgery and local treatment in M1 rectal cancer have been actively studied recently. However, there is still controversy because no significant results have been reported for local control. The purpose of this study was to analyze the local control rates of postoperative radiotherapy for tumor stage T4 in M1 rectal cancer.

MATERIALS/METHODS

We investigated local recurrence after surgery for M1 rectal cancer that was operated at Seoul St. Mary's Hospital between 1995 and 2021. Locoregional recurrence rates were compared in patients who received postoperative pelvic radiotherapy and those who did not. In addition, an analytical comparison was performed only for patients with T4 rectal cancer. Statistical analysis was performed using the log rank test, and a p-value of less than 0.05 was considered significant.

RESULTS

During the investigation period, a total of 206 patients underwent surgery for M1 rectal cancer. There were 55 patients with T4 tumor stage. Of the 55 patients, 11 patients received radiotherapy after surgery, and 44 patients received systemic treatment such as chemotherapy after surgery without radiotherapy. During a median follow-up of 22 months, locoregional recurrence occurred in 1 (RT group) and 25 (no RT group) patients, respectively. Log-rank analysis of locoregional recurrence showed a significant difference between the two groups (p- value = 0.008). Death occurred in 10 (RT group) and 38 (no RT group) patients, respectively. The 2-year locoregional recurrence free-survival rates were 45.5% and 53.0%, respectively, and there was no significant difference between the two groups in the log-rank analysis.

CONCLUSION

Pelvic radiotherapy could be expected to improve locoregional recurrence in stage T4 of rectal cancer with synchronous distant metastasis. It would be warranted to prove this in a large-scale prospective study.

Evaluation of Usefulness of Yeast-Based Biological Phantom and Preliminary Study for Verification of Hypoxic Effect of Flash Radiotherapy

PURPOSE/OBJECTIVE(S)

As a basic hypothesis for the effectiveness of flash radiation therapy, the effect of preserving normal tissue during flash radiation is due to the instantaneous chemical depletion of oxygen. A yeast-based biological phantom was created to verify the hypoxic effect of flash radiation therapy. A study to upgrade the previously developed X-Band LINAC to a flash irradiation mode is in progress, and a preceding study is conducted to evaluate the usefulness of a yeast-based biological phantom manufactured by analyzing the change in oxygen by irradiating a high dose in a general radiation therapy device.

MATERIALS/METHODS

Freeze-dried yeast sample (Saccharomyces cerevisiae, S288C) is activated and sub-cultured. For mass production of yeast samples, yeast culture medium is prepared by adding yeast colonies to the ypd medium. This study was conducted to verify the hypoxic effect among the biological mechanisms that occur during flash radiation therapy at the basic stage, and the oxygen concentration change during general radiation irradiation was measured in real time using a DO (Dissolved oxygen) meter and fiber optic sensor designed to do that. To prevent scatter, which is a concern during flash irradiation, the fiber form was used, and precise experiments are possible as a non-invasive oxygen concentration measurement method. Based on 10MV of general radiation therapy device, high-dose radiation of 500-10,000 cGy is irradiated to measure real-time oxygen concentration change.

RESULTS

As a result of irradiation with high-dose (500-10,000 cGy) radiation of general LINAC, it was confirmed that the oxygen concentration of the yeast culture medium decreased by 5.7-63.2%, and the usefulness of the biological phantom fabricated based on the yeast culture medium was evaluated.

CONCLUSION

Prior to the analysis of oxygen concentration change in yeast cells during X-Band LINAC flash irradiation, a preliminary study was conducted at a high dose in a general LINAC to obtain a significant result of oxygen concentration change and confirm the usefulness of the yeast-based biological phantom. Prior research was conducted and verified as a general irradiation experiment using a yeast-based biological phantom manufactured based on a DO meter and a fiber optic oxygen sensor. After irradiation with high-dose radiation, the oxygen concentration of the yeast culture medium was measured 5 times, and it was confirmed that there was a change in oxygen concentration of 5.7-63.2%, verifying the usefulness and stability of the biological phantom. The usefulness of the yeast-based biological phantom for high doses was confirmed, and it is expected that the usefulness of the biological phantom for flash radiation can be verified by additionally measuring the change in oxygen concentration of the biological phantom according to the high dose rate in the future.

Evaluation of off-label medication use and drug safety in a pediatric intensive care unit

Safety and efficacy are essential in the process of disease treatment. However, off-label medication use is inevitable because various medications do not contain regulatory labels for pediatric use. We aimed to examine off-label medication use and analyze the risk factors correlated with adverse drug reactions (ADRs). This study was performed retrospectively using electronic medical data from a pediatric intensive care unit (PICU) of a tertiary hospital in Korea from July 2019 to June 2020. A total 6,183 prescribed medications from 502 PICU patients were examined in the present study. A total of 80% were infants or children, and 96.0% of them were treated with off-label medications. It was discovered that 4,778 off-label cases (77.2%) of the top 100 drugs had prescriptions with dosage (67.8%). Drugs prescribed to patients admitted to the cardiothoracic department (odds ratio [OR], 3.248; p = 0.019), total number of medications (OR, 1.116; p = 0.001), and length of PICU stay of ≥ 7 days (OR, 4.981; p = 0.008) were significantly associated with ADRs. ADRs were noted to be more severe in off-label use (p = 0.0426). For appropriate medication use, evidence regarding the safety of off-label medications is required and ultimately reflected in the official regulation.

Novel innovative computer-based test (Inno-CBT) item types for national licensing examinations for health care professionals

BACKGROUND

An effective test mechanism to evaluate clinical knowledge and skills of the entry-level healthcare professionals is important for providing clinical competency and improving patient care. This study aimed to develop novel, innovative computer-based test (Inno-CBT) item types for application in the national examination of Korean healthcare professionals.

METHODS

This exploratory study was conducted from May 2021 to March 2022 by a team of faculty members from pharmacy schools in South Korea. A literature search using PubMed, Google Scholar, RISS, Web of Science, and KoreaMed was performed. Forum presentations, media articles, and previous reports by the Korea Health Personnel Licensing Examination Institute (KHPLEI) were included. Workshops were held, information and ideas were collected and conceptualized, and item types were designed, drafted, and refined. By repeating this process, the Inno-CBT item types were finalized.

RESULTS

Forty-one Inno-CBT item types with 28 subtypes were developed. New digital technologies, such as a reactive responsive media interface, an animation insertion, multimedia embedding, and network surfing, were utilized in these novel types. It was anticipated that these Inno-CBT item types would effectively measure abilities in healthcare knowledge, problem-solving skills, and professional behaviors. Some potential barriers to implementing the Inno-CBT item types include item difficulty, operational unfamiliarity, complexity in scoring protocols, and network security.

CONCLUSIONS

A variety of styles of novel Inno-CBT item types were developed to evaluate the multifaceted and in-depth professional abilities required for healthcare professionals. Prior to implementing these item types in the national examination, item validation and technical support should be conducted.

Potentially inappropriate medication use as predictors of hospitalization for residents in nursing home

BACKGROUND

Hospitalization of nursing home (NH) residents impose a significant healthcare burden. However, there is still a lack of information regarding the risk of hospitalization from inappropriate prescribing in NH residents. We aimed to estimate the nationwide prevalence of potentially inappropriate medication (PIM) use among NH residents using the Korean tool and 2019 Beers criteria and to assess their associations with hospitalization or emergency department (ED) visits.

METHODS

We included older adults aged 65 years or above who were admitted to NHs between July 2008 and December 2018 using national senior cohort database. The prevalence of PIM use based on the Korean medication review tool and Beers criteria on the date of admission to NH was estimated. And the adjusted hazard ratios (aHRs) of polypharmacy, numbers of PIM, each PIM category for hospitalization/ED visits within 30 days of admission to NH was calculated using Cox proportional hazard model to show the association.

RESULTS

Among 20,306 NH residents, the average number of medications per person was 7.5 ± 4.7. A total of 89.3% and 67.9% of the NH residents had at least one PIM based on the Korean tool and 2019 Beers criteria, respectively. The risk of ED visits or hospitalization significantly increased with the number of PIMs based on the Korean tool (1-3: aHR = 1.24, CI 1.03-1.49; ≥4: aHR = 1.46, CI 1.20-1.79). Having four or more PIMs based on the Beers criteria increased the risk significantly (aHR = 1.30, CI 1.06-1.53) while using 1-3 PIMs was not significantly associated (aHR = 1.07, CI 0.97-1.19). Residents with any potential medication omission according to the Korean criteria, were at 23% higher risk of hospitalization or ED visits (aHR = 1.23, CI 1.07-1.40).

CONCLUSIONS

This study demonstrated that PIMs, based on the Korean tool and Beers criteria, were prevalent among older adults living in NHs and the use of PIMs were associated with hospitalization or ED visits. The number of PIMs based on the Korean tool showed dose-response increase in the risk of hospitalization or ED visits.

Effects of CYP3A4*22 polymorphism on trough concentration of tacrolimus in kidney transplantation: a systematic review and meta-analysis

Purpose: Tacrolimus (Tac) is a widely used immunosuppressive agent in kidney transplantation. Cytochrome P450 (CYP), especially CYP3A4 enzymes are responsible for the metabolism of drugs. However, the correlation between plasma Tac concentration and CYP3A4*22 gene variants is controversial. This meta-analysis aims to evaluate the association between CYP3A4*22 polymorphism and the dose-adjusted trough concentration (C0/D) of Tac in adult kidney transplant patients. Methods: We conducted a literature review for qualifying studies using the PubMed, Web of Science, and Embase databases until July 2023. For the continuous variables (C0/D and daily dose), mean difference (MD) and corresponding 95% confidence intervals (CIs) were calculated to evaluate the association between the CYP3A4 * 22 and Tac pharmacokinetics. We performed an additional analysis on the relationship of CYP3A5*3 with Tac PKs and analyzed the effects of CYP3A4*22 in CYP3A5 non-expressers. Results: Overall, eight eligible studies with 2,683 renal transplant recipients were included in this meta-analysis. The CYP3A4*22 allele was significantly associated with a higher C0/D (MD 0.57 ng/mL/mg (95% CI: 0.28 to 0.86; p = 0.0001) and lower mean daily dose requirement (MD -2.02 mg/day, 95% CI: -2.55 to -1.50; p < 0.00001). An additional meta-analysis demonstrated that carrying the CYP3A5*3 polymorphism greatly impacted Tac blood concentration. From the result with CYP3A5 non-expressers, CYP3A4*22 showed significant effects on the Tac C0/D and dose requirement even after adjusting the effect of CYP3A5*3. Conclusion: Patients with CYP3A4*22 allele showed significantly higher plasma C0/D of Tac and required lower daily dose to achieve the therapeutic trough level after kidney transplantation. These findings of our meta-analysis may provide further evidence for the effects of genetic polymorphism in CYP3A4 on the PKs of Tac, which will improve individualized treatment in a clinical setting.

Comparison of pharmacogenomic information for drug approvals provided by the national regulatory agencies in Korea, Europe, Japan, and the United States

Pharmacogenomics, which is defined as the study of changes in the properties of DNA and RNA associated with drug response, enables the prediction of the efficacy and adverse effects of drugs based on patients' specific genetic mutations. For the safe and effective use of drugs, it is important that pharmacogenomic information is easily accessible to clinical experts and patients. Therefore, we examined the pharmacogenomic information provided on drug labels in Korea, Europe, Japan, and the United States (US). The selection of drugs that include pharmacogenomic information was based on the drug list that includes genetic information from the Korea Ministry of Food and Drug Safety (MFDS) and US Food and Drug Administration (FDA) websites. Drug labels were retrieved from the sites of MFDS, FDA, European Medicines Agency, and Japanese Pharmaceuticals and Medical Devices Agency. Drugs were classified as per the Anatomical Therapeutic Chemical code, and the biomarkers, labeling sections, and necessity of genetic tests were determined. In total, 348 drugs were selected from 380 drugs with available pharmacogenomic information in Korea and the US after applying the inclusion and exclusion criteria. Of these drugs, 137, 324, 169, and 126 were with pharmacogenomics information in Korea, the US, Europe, and Japan, respectively. The most commonly represented drug class was antineoplastic and immunomodulating agents. Regarding the classification as per the mentioned biomarkers, the cytochrome P450 enzyme was the most frequently mentioned information, and the targeted anticancer drugs most commonly required genetic biomarker testing. The reasons for differences in drug labeling information based on country include differences in mutant alleles according to ethnicity, frequencies at which drug lists are updated, and pharmacogenomics-related guidelines. Clinical experts must continuously strive to identify and report mutations that can explain drug efficacy or side effects for safe drug use.

Improving adaptive behaviors for autistic adults without intellectual disability through executive function training

Executive functioning (EF) is a cognitive process used to perform various daily activities throughout one's lifespan. Autistic adults without intellectual disabilities (ID) also experience difficulties with EF, which is closely associated with adaptive behaviors. For this reason, it is important to improve adaptive behaviors through enhanced use of EF for autistic adults to transition into adulthood successfully. This study aims to conduct a randomized controlled trial to evaluate the effectiveness of a newly developed and modified intervention program. Thirty autistic adults without ID were randomly assigned to the treatment or waitlist group. The participants and caregivers completed various assessments and self-report questionnaires to measure everyday EF and adaptive behaviors. We performed linear mixed-effect modeling to compare the two groups. Data collected at pre-, middle, post-, and follow-up based on participants who completed the program were used to explore changes across time. While there were significant differences in the EF utility-scale (F=5.46, p = .027) between the treatment and waitlist groups, no group x time interactions were detected in other measures. Everyday EF and adaptive behaviors improved when comparing measurements at different time points (p < .001). Our program is Korea's first evidence-based intervention to improve everyday EF and adaptive behaviors for autistic adults without ID.

Increased Risk of Anemia in Patients with Asthma

Purpose

Asthma can cause a systemic inflammatory response, and anemia of chronic disease (ACD) is known to be caused by other disorders with a chronic inflammatory state. However, it is unclear whether the incidence of anemia is increased in patients with asthma. The objective of this study was to compare the incidence of anemia in patients with asthma and healthy adults.

Patients and Methods

This retrospective cohort study included patients newly diagnosed with asthma at Seoul National University Hospital from 2010 to 2017. Patients with comorbidities before the first visit (index date) that may increase anemia risk were excluded. Cox regression models adjusting for patient age, sex, and obesity were used to compare anemia hazard ratios (HRs) between asthma patients (n=1354) and healthy adults (n=1731).

Results

This study included 3085 patients. During 5-y follow-up, anemia occurred in 203 (15.0%) patients with asthma and 79 (4.6%) healthy adults. Compared with healthy adults, the HR for anemia after adjusting for age, sex, and obesity was 4.06 (95% CI: 2.70-6.09) in patients with asthma. In patients aged 18-64.9 y, the adjusted HR of anemia was 3.27 (95% CI: 2.12-5.04) in patients with asthma, compared to healthy patients. In patients >65 y, this adjusted HR was 5.56 (95% CI: 1.31-23.67).

Conclusion

The risk of anemia was increased in patients with asthma after adjusting for sex, age, and obesity and excluding comorbidities that can cause anemia. These results suggest the need for regular monitoring for anemia in patients with asthma.

Impact of obesity paradox between genders on in-hospital mortality in cardiogenic shock: a retrospective cohort study

Background

In a few studies, obesity was associated with better outcomes in patients with cardiogenic shock (CS). Although this phenomenon, the “obesity paradox”, reportedly manifests differently based on sex in other disease entities, it has not yet been investigated in CS patients.

Methods and results

1,227 patients with CS from The REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy of left ventricular assist device for Korean patients with cardiogenic shock (RESCUE) registry in Korea were analyzed. The study population was classified into obese and non-obese groups according to Asian-Pacific criteria (BMI &gt;25.0 kg/m2 for obese). Clinical impact of obesity on in-hospital mortality according to sex was analyzed using logistic regression analysis and restricted cubic spline curves. In-hospital mortality rate was significantly lower in obese men than non-obese men (34.2% vs. 24.1%, p=0.004) while the difference was not significant in women (37.3% vs. 35.8%, p=0.884). As a continuous variable, higher BMI showed a protective effect in men conversely, BMI was not associated with clinical outcomes in women. Comparing to normal-weight patients, obesity was associated with a decreased risk of in-hospital death in men (multivariable-adjusted OR 0.63, CI 0.43–0.92, p=0.016), not in women (multivariable-adjusted OR 0.94, 95% CI 0.55–1.61, p=0.828). Interaction P value for the association between BMI and sex was 0.023.

Conclusions

Obesity paradox exists and apparently occurs in men among CS patients. The differential effect of BMI on in-hospital mortality was observed according to sex.

Funding Acknowledgement

Type of funding sources: None.

Risk factors and clinical effects of late leaflet thrombosis after transcatheter aortic valve replacement

Background

As the indications for trans-catheter aortic valve replacement (TAVR) expand, it is expected that the number of TAVR patients would increase and the follow-up duration would be longer. It is known that the incidence of leaflet thrombosis is higher in TAVR than in surgical aortic valve replacement (SAVR), but not much is known about the risk factors of late leaflet thrombosis in TAVR.

Aim

Therefore, in this study, the incidence and risk factors of late leaflet thrombosis at late term after TAVR and the effect on clinical course of late leaflet thrombosis would be investigated.

Method

There were 176 patients undergone TAVR from January 2015 to October 2020 in one tertiary hospital of south korea. 94 patients had follow-up cardiovascular computed tomography (CT) between 3 months and 2 years after TAVR. Among 94 patients, late leaflet thrombosis was discovered at 20 patients, and risk factors were analyzed by comparing clinical factors, echocardiographic and cardiovascular CT information, and angiographic data between the group with and without late leaflet thrombosis. And the difference in aortic valve hemodynamics between the group with and without leaflet thrombosis was examined and clinical outcomes were compared. Clinical outcome was defined as the composite of all-cause death, stroke, heart failure (HF) admission, redo-aortic valve (AV) replacement and major bleeding after detection of late leaflet thrombosis.

Results

Indexed mean sinus of Valsalva diameter, AV calcium score and post procedure estimated orifice area (EOA) had predictability of late leaflet thrombosis with AUC value of 0.670 (95% CI [0.546–0.795], p value = 0.020), AUC value of 0.698 (95% CI [0.544–0.851], p value = 0.012) and AUC value of 0.665 (95 percent CI [0.548–0.782], p value = 0.031), respectively (Figure 1).

In echocardiography performed at the time of follow-up CT, AV max velocity and AV mean pressure gradient were higher in thrombosis group and EOA and Doppler velocity index were lower in thrombosis group than in no thrombosis group within normal range (Figure 2). Clinical outcome was not significant different between the two groups (log rank p value = 0.560).

Conclusion

Larger indexed sinus of Valsalva diameter, higher AV calcium score and smaller post procedure AV EOA were risk factors for late leaflet thrombosis after TAVR. Subclinical late leaflet thrombosis have a benign course when properly managed.

Funding Acknowledgement

Type of funding sources: None.

Association between SLCO1B1 polymorphism and methotrexate-induced hepatotoxicity: a systematic review and meta-analysis

Reports on the association between the solute carrier organic anion transporter 1B1 (SLCO1B1) T521C polymorphism and methotrexate-induced hepatotoxicity in patients with malignancies are inconsistent. This meta-analysis evaluated the association between the SLCO1B1 T521C polymorphism and methotrexate-induced hepatotoxicity. We performed a systematic review of previous reports from the PubMed, Web of Science, and EMBASE databases, and a meta-analysis was conducted. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated to evaluate the effect of the SLCO1B1 T521C polymorphism on the occurrence of methotrexate-induced hepatotoxicity. In total, data from five studies including 465 patients were analyzed. Patients had received a high-dose methotrexate regimen (1-5 g/m2). The SLCO1B1 variant allele (C allele) carriers had a 1.9-fold higher risk of hepatotoxicity than wild-type homozygote carriers (TT; OR, 1.94; 95% CI, 1.14-3.31). This meta-analysis demonstrated that C allele carriers of the SLCO1B1 polymorphism had a higher risk of hepatotoxicity than patients with the TT genotype. The SLCO1B1 T521C polymorphism may be a useful predictor for methotrexate-induced hepatotoxicity in patients with malignancies.

P–205 Epothilone D as an actin cytoskeleton stabilizer improved mitochondria bioenergenesis and blastocyst formation of mouse preimplantation embryo

Study question

What is primary factor of bioenergetics product activity between microtubule instability and the functional activity of mitochondria in embryo?

Summary answer

The actin cytoskeleton instability is presumably the primary cause for the bioenergenesis of mitochondrial function to the preimplantation embryo development.

What is known already

Mitochondria are cellular organelles dynamically moving and morphological changes. It provides for homeostatic energy to the cell. The dynamic property of the mitochondria is associated with the microtubule network in the cell. However, the stability of the microtubule was clearly identified for preimplantation embryo development.

Study design, size, duration

This study is designed to assess the ATP productivity of the mitochondria, and specifically to observe what its primary factor is in terms of providing microtubule stability in mammalian cells. Additionally, we investigated the relationship between blastocyst formation and actin cytoskeleton stabilization by EpD with 2-cell mice.

Participants/materials, setting, methods

We prepared the microtubule stability regulation model with the HEK293 cell line by using the microtubule stabilizer as an Epothilone D (EpD). Then we analyzed the metabolic activity of the cells through oxidative phosphorylation (OXP) ratios analysis. Also, we performed confocal live imaging to observe mitochondria morphology depending on the cells’ microtubule. Next, we treated EpD to 2-cell culture media for the analysis of blastocyst development ratios.

Main results and the role of chance

EpD significantly increased fusion form. Also, EpD enhance bioenergy ratios like OXP in the mitochondria and functional activity related marker, like mTOR compared with the control. These results suggest that microtubule stabilization enhances mitochondrial metabolism by increasing oxygen consumption. Also, EpD in 2-cell culture media led to a significant increase in the speed of development and 50% higher hatched out blastocyst formation ratios compared to the control group.

Limitations, reasons for caution

This study had limited animal experiments. For the next study, we are planning with an aim to improve the quality and development ratios of human embryos by EpD.

Wider implications of the findings: Microtubule stabilizer has a possibility to recover the mitochondria’s functional activity in the preimplantation embryo development. Mitochondrial functional activity along the actin cytoskeleton may play a pivotal role in determining the embryo quality and development ratios for archive pregnancy.

Trial registration number

non-clinical trials

P–657 Prostaglandin D2 is correlated with follicles development and a reliable marker of ovarian reserve of poor ovarian responder patients

Study question

Is the prostaglandin D2 (PGD2) associated with growing follicles and ovarian reserve of poor ovarian responders?

Summary answer

PGD2 is correlated with ovarian stimulation activity and follicle growth. Especially, poor ovarian responders show a significant decrease in the level of follicular fluid.

What is known already

Prostaglandins (PGs) are involved in the female reproductive process, mainly ovulation, fertilization, and implantation.

Study design, size, duration

We investigated the PGD2 level in the follicular fluid of poor ovarian responders. The collection of human follicular fluid was approved by the Institutional Research and Ethical Committees of CHA University (approval number: 1044308–201611-BR–027–04) from January to December 2019. Follicular fluid was collected from patients with normal ovarian response and patients with POR.

Participants/materials, setting, methods

We studied whether prostaglandin has related to POR in the clinical key factor by measuring human follicular fluid. Follicular fluid was collected from patients with normal ovarian response and patients with POR. The concentration of PGD2 in follicular fluid was determined with ELISA kits following the manufacturer’s protocol.

Main results and the role of chance

We analyzed the level of PGD2 in the follicular fluid of patients with normal ovarian response and patients with POR using an ELISA. The PGD2 concentration was significantly lower in the follicular fluid of patients with POR than in the follicular fluid of young and old patients with normal ovarian response.

Limitations, reasons for caution

This study has an identification of biomarker of the clinical samples as POR criteria patients. Therefore, further investigations aimed at specific recovery of low PGD2 metabolic activity in the CCs during control ovarian stimulation.

Wider implications of the findings: Until now there is no specific biomarker of POR. AMH is just an ovary reserve marker for an indication of ovary function. PGD2 is one of the metabolites in steroid metabolism in the ovary. Therefore, we can find some cure through further study for improved PGD2 production to POR patients.

Trial registration number

none

P–658 Lovastatin promotes the expression of LDL receptor and enhances E2 production in the cumulus cells

Study question

Lovastatin enhanced E2 productive ratios in the cumulus cells through promoted expression of Low-density lipoprotein receptor (LDLR).

Summary answer

Lovastatin up-regulated gene expression of LDLR in the CCs. And the high expression of LDLR promoted E2 productive ratios from CCs.

What is known already

We already reported that the up-regulation of LDLR correlated with clinical pregnancy. Therefore, we found lovastatin as an up-regulator of LDLR expression of clinical pregnancy.

Study design, size, duration

This is an expended study of LDLR to enhance steroidogenesis regarding the effect of lovastatin in the CCs. The collection of human cumulus cells was approved by the Institutional Research and Ethical Committees of CHA University (approval number: 1044308–201611-BR–027–04) from January to December 2019. The CCs were collected from 12 patients with normal ovarian response after oocyte denudation for ICSI.

Participants/materials, setting, methods

We studied whether lovastatin has up-regulated LDLR expression in human CCs. Cumulus cells were collected from patients with young (∼ 36) and old aged patients (37 ∼). After culturing human CCs, they were treated lovastatin for one day. The concentration of E2 in culture medium was measured using Chemiluminescence immunoassay. The mRNA isolated from CCs was analyzed gene expression level through real time-PCR.

Main results and the role of chance

The concentration of E2 was significantly increased in the culture medium treated with lovastatin. The CCs treated with lovastatin increased the expression of LDLR and StAR which are components of the steroidogenesis pathway.

Limitations, reasons for caution

We have found that the role of lovastatin promotes the E2 production by increasing the ldlr gene of CCs. Therefore, further investigations aimed at lovastatin effect on human oocytes embryo whether enhanced quality of oocytes or not.

Wider implications of the findings: Previous data show that high activation of LDLR and StAR was associated with embryo quality and clinical pregnancy in infertile women. Our data suggest that lovastatin is stimulated LDLR expression to enhanced pregnancy ratios of IVF patients.

Trial registration number

none

Analysis of Risk Factors for Hepatotoxicity Induced by Immune Checkpoint Inhibitors

Although hepatotoxicity induced by immune checkpoint inhibitors (ICPIs) can cause severe clinical complications, the risk factors associated with hepatotoxicity have rarely been investigated. The purpose of this study was to determine the potential risk factors for the incidence of hepatotoxicity and for time to ICPI-induced hepatotoxicity. Patients who received ICPIs (atezolizumab, nivolumab, pembrolizumab, and ipilimumab) were included in this retrospective 2-center study. Collected data included sex, age, body weight, body surface area, Eastern Cooperative Oncology Group performance status, underlying disease, liver metastasis, programmed cell death ligand-1 expression, interval from previous chemotherapy, and concomitant drug use. Among the 194 patients, patients who experienced hepatotoxicity after ICPI administration was 64.4% (n=125) in all grade and 10.8% (n=21) in grade III or higher. Multivariate analysis showed that patients aged 30-50 and 50-70 years had increased risks of hepatotoxicity by 4.9-fold (95% confidence interval, 1.3-18.0) and 2.7-fold (95% confidence interval, 1.3-5.5), respectively, compared with those older than 70 years. The use of acetaminophen increased the occurrence of hepatotoxicity by 2.1 times; the attributable risk was 53.2%. Male patients and patients younger than 65 years had around 1.5-fold increased hazard of time to reach hepatotoxicity. Patients treated with 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase inhibitors had a 4.7-fold higher risk of grade III-IV hepatotoxicity compared with those without HMG-CoA reductase inhibitors; the attributable risk was 78.8%. In conclusion, close monitoring of liver function is recommended, especially in male patients, patients younger than 65 years old, and when there is concomitant use of hepatotoxic drugs including acetaminophen and HMG-CoA reductase inhibitors.

Risk factors and renal outcomes of low bone mineral density in patients with non-dialysis chronic kidney disease

Bone disorder is a common complication of chronic kidney disease (CKD). The clinical usefulness of bone mineral density (BMD) in CKD is not well known. Our study shows that low BMD is associated with physical activity and dietary Na/K intake ratio and can predict poor renal outcome in non-dialysis CKD.

PURPOSE

Despite evidence of a link between bone mineral disorders and chronic kidney disease (CKD), the clinical implications of bone mineral density (BMD) in CKD are not well established. We investigated risk factors and renal outcomes of low BMD in CKD.

METHODS

We analyzed data from the KNOW-CKD. BMD measured by dual-energy x-ray absorptiometry was classified by T score: normal (T score ≥ - 1.0), osteopenia (- 1.0 > T score > - 2.5), and osteoporosis (T score ≤ - 2.5) of the lumbar spine, hip, or femoral neck. Logistic regression analysis to assess risk factors of low BMD (T score < - 1.0) and Cox proportional hazards models to estimate risk of incident end-stage renal disease (ESRD).

RESULTS

Low BMD was prevalent (osteopenia 33%; osteoporosis 8%) in 2128 adults with CKD (age 54 ± 12 years; male 61%). Over a median follow-up of 4.3 years, there were 521 cases of incident ESRD. Lower BMD was associated with female sex, older age, low eGFR, low BMI, and lifestyle factors of physical activity (odds ratio (OR) = 0.62, 95% confidence interval (0.49-0.77)) and spot urine Na/K ratio (1.07 (1.00-1.15)). In adjusted Cox models, low BMD was associated with increased incident ESRD (hazard ratio (HR) = 1.14 (0.92-1.41) for osteopenia; 1.43 (1.01-2.04) for osteoporosis, P for trend < 0.05) compared with the reference of normal BMD. The association between low BMD and ESRD was similar according to T score discordance classification.

CONCLUSIONS

Low BMD was associated with modifiable lifestyle factors including low physical activity and high dietary Na/K intake ratio. The presence of low BMD is associated with poor renal outcomes in non-dialysis CKD.

Dose response relationship of cumulative anticholinergic exposure with incident dementia: validation study of Korean anticholinergic burden scale

Background

The dose response relationship of nine-year cumulative anticholinergic exposure and dementia onset was investigated using the Korean version anticholinergic burden scale (KABS) in comparison with the Anticholinergic Cognitive Burden Scale (ACB). We also examined the effect of weak anticholinergics in the prediction of dementia.

Methods

A retrospective case-control study was conducted comprising 86,576 patients after 1:2 propensity score matching using the longitudinal national claims database. For cumulative anticholinergic burden estimation, average daily anticholinergic burden score during the 9 years prior to dementia onset was calculated using KABS and ACB and categorized as minimal, < 0.25; low, 0.25–1; intermediate, 1–2; and high, ≥ 2. Adjusted odds ratio (aOR) between cumulative anticholinergic burden and incident dementia was estimated.

Results

Patients with high exposure according to KABS and ACB comprised 3.2 and 3.4% of the dementia cohort and 2.1 and 2.8% of the non-dementia cohort, respectively. Dose-response relationships were observed between anticholinergic burden and incident dementia. After adjusting covariates, compared with minimal exposure, patients with high exposure according to KABS and ACB had a significantly higher risk for incident dementia with aOR of 1.71 (95% confidence interval (CI) 1.55–1.87) and 1.22 (CI 1.12–1.33), respectively. With the exclusion of weak anticholinergics, the association became stronger, i.e., 1.41 (CI 1.14–1.75) with ACB whereas the association became slightly weaker with KABS, i.e., 1.60 (CI 1.38–1.86).

Conclusion

This study confirmed the dose response relationship for cumulative anticholinergic burden measured using the Korean specific anticholinergic burden scale with incident dementia.

Access to Dental Care and Depressive Illness: Results from the Korea National Health Nutrition Examination Survey

Background and Objectives: Recent evidence suggests that oral health is associated with various systemic diseases including psychiatric illnesses. This study examined the association between depression and access to dental care in Korean adults. Materials and Methods: A cross-sectional evaluation was performed using data from the Sixth Korea National Health and Nutrition Examination Survey 2014. The general characteristics of the participants, the current depression status, and issues with access to dental care were collected to evaluate the factors for not being able to make dental visits according to care needs. Results: The study population comprised a total of 5976 participants who were 19 years of age and older and represented 40.7 million Koreans. A multivariable logistic regression analysis with weighted observations revealed that participants with current depressive illness were about two times more likely to express that they could not make dental visits in spite of their perceived care needs (adjusted odds ratio (OR) = 2.097; 95% confidence interval (CI) 1.046–4.203). The reasons for not making dental visits included financial problems, perceived importance of the dental problem, and fear of visiting dental professionals. Conclusions: Korean adults with current depressive illness were less likely to make dental visits when they had dental care needs. To improve dental health accessibility for patients with depressive illness, coordinated efforts can be considered involving multidisciplinary health care professionals.

P5989Effect of neprilysin inhibitor for ischemic mitral regurgitation after myocardial injury

Background

After myocardial infarction (MI), mitral valve (MV) tethering and fibrosis stimulate functional mitral regurgitation (MR), resulting in high morbidity of heart failure and cardiac mortality. However, pharmacological treatment has not been proven effective in reducing ischemic MR. MV change post-MI is associated with an excessive endothelial-to-mesenchymal transition (EMT) by transforming growth factor (TGF)-β overexpression and also with left ventricular (LV) remodeling. In a recent clinical study using echocardiography, angiotensin receptor neprilysin inhibitor (ARNI) reduced functional MR to a greater extent than did valsartan, but the mechanism was not revealed.

Purpose

This study tested the hypothesis that treatment of neprilysin inhibitor attenuates functional MR after MI by facilitating LV reverse remodeling and suppressing EMT which mitigates inadequate leaflet adaptation.

Methods

In male Sprague-Dawley rats (n=31), functional MR was induced by occluding the left circumflex coronary artery. Two weeks after MI, MR and LV dilatation were confirmed by echocardiography and magnetic resonance imaging (MRI). Rats were randomly assigned to LCZ696 treatment (ARNI, 60 mg/kg/d, n=10), valsartan treatment (30mg/kg/d, n=10), or corn oil only (MR control group; n=11). After 6 weeks, LV volumes, functions and MR extent were quantified by using echocardiography, cardiac MRI and pressure-volume loop analysis. Also, excised mitral leaflets and LV were analyzed by histopathology and primary cultured valvular endothelial cells (VECs) were evaluated focusing on molecular changes.

Results

LCZ696 significantly attenuated post-MI LV dilatation after 6 weeks when compared with the control group (LV end-diastolic volume (EDV), 461.3±41.3 uL versus 525.1±78.2 uL; p<0.05), while valsartan did not (LV EDV, 471.2±26.8 uL; p>0.05 to control). There were no significant differences in the change of arterial pressure and ejection fraction between the treatment groups, however, dP/dt was greater in the LCZ696 group than in the MR control group (8203±286 mmHg/s for LCZ696 versus 6936±555 mmHg/s for MR control; p=0.01). MR extent and LA volume were significantly decreased in the LCZ696 group compared with the valsartan group. Pathological analysis showed that fibrosis was more prominent in the MR control than in the LCZ696 group. LCZ696 strongly reduced leaflet thickness, TGF-β, and downstream phosphorylated extracellular-signal-regulated kinase and EMT (25.4±11.8% vs. 53.4±12.6% α-smooth muscle actin-positive VECs; p<0.05). Leaflet area increased comparably (5%) in the LCZ696 group compared with the valsartan group.

Conclusions

Neprilysin inhibitor has positive effects on LV reverse remodeling and also directly modulates profibrotic changes of MV leaflets post-MI without eliminating adaptive growth. Understanding the mechanisms could provide new opportunities to ARNI reducing ischemic MR.

Acknowledgement/Funding

This work was supported by the National Research Foundation of Korea (NRF) funded by the Ministry of Education (NRF-2014R1A6A3A04056205). It was also

P1711The association of multidisciplinary team approach with clinical outcomes in patients with acute myocardial infarction underwent veno-arterial extracorporeal membrane oxygenation

Background

Multidisciplinary team approach is necessary for the management of critically-ill patients. However, limited data are available on the impact of specialized extracorporeal membrane oxygenation (ECMO) team on clinical outcomes in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock.

Objectives

This study aimed to identify whether specialized ECMO team is associated with improved in-hospital mortality in AMI patients underwent venoarterial ECMO.

Methods

A total of 255 AMI patients underwent venoarterial ECMO from May 2004 to July 2018 were enrolled. In January 2014, multidisciplinary ECMO team was founded at our institution. Eligible patients were classified into pre-ECMO team group (n=131) and post-ECMO team group (n=124). The primary outcome was in-hospital mortality.

Results

In-hospital mortality (54.2% vs. 33.9%, p=0.002) and cardiac intensive care unit mortality (45.0% vs. 25.0%, p=0.001) were significantly lower after the implantation of multidisciplinary ECMO team (pre ECMO team vs. post-ECMO team). On binary logistic regression model, the multidisciplinary ECMO team approach was associated with lower risk of in-hospital mortality (odds ratio 0.36, 95% confidence interval 0.19–0.67, p=0.001). Incidence of all-cause mortality (58.3% vs. 35.2%, p<0.001) and rehospitalization due to heart failure (28.2% vs. 6.4%, p=0.001) at 6-months follow-up were also significantly lower in the post-ECMO team group than in the pre-ECMO team group.

Clinical outcomes Variables Total (N=255) Pre-ECMO team (N=131) Post-ECMO team (N=124) P value In-hospital mortality 113 (44.3) 71 (54.2) 42 (33.9) 0.002 Cardiovascular death 90 (35.3) 59 (45.0) 31 (25.0) 0.001 Noncardiovascular death 23 (9.0) 12 (9.2) 11 (8.9) >0.99 Cardiac intensive care unit mortality 106 (41.6) 68 (51.9) 38 (30.6) 0.001 Successful weaning of ECMO 169 (66.3) 75 (57.3) 94 (75.8) 0.002 Data are presented as n (%). Abbreviations: ECMO, extracorporeal membrane oxygenation.

Incidence of death, readmission for HF

Conclusions

The multidisciplinary ECMO team approach was associated with improved clinical outcomes in AMI patients complicated by cardiogenic shock. Our data support that specialized ECMO team is indispensable to improve outcomes in patients with AMI with refractory cardiogenic shock.

Analysis of genetic and clinical risk factors of post-transplant thrombocytopenia in kidney allograft recipients

BACKGROUND

Hematological abnormalities after transplantation are complications that may arise after renal transplantation, of which thrombocytopenia is associated with increased risk of bleeding and other complications. The development of thrombocytopenia is affected by various clinical conditions, and the stromal-derived factor 1 (SDF1) and platelet factor 4 (PF4) genes are known to be involved in the production or destruction of platelets. The purpose of this study was to investigate the prevalence of posttransplant thrombocytopenia and its association with other clinical conditions and genetic polymorphisms of SDF1 and PF4 genes a long time after transplantation.

METHODS

This is a retrospective study that includes a total of 305 kidney transplant (KT) recipients between 2008 and 2012 at St. Vincent Medical Center, Los Angeles, CA. In this study, posttransplant thrombocytopenia was defined as a 30% reduction in platelet count from the baseline in the first week or a decrease of <100 (×10³/μL) within 1 year after KT. The subjects were divided into posttransplant thrombocytopenia and control groups. The chi-square test, t-test, and logistic regression were used for the analyses.

RESULTS

In the first week, 65 patients had a 30% reduction in platelet count (21.3%). Gender, simultaneous kidney-pancreas transplantation, induction therapy (IT), and only alleles of rs2297630 of SDF1, among the SDF1 and PF4 genes, showed statistically significant differences. The rs2297630 alleles were consistently significant risk factors (non G vs. G: odds ratio = 0.445; 95% confidence interval, 0.224-0.884; p = .021) in the multiple logistic regression. In the 1-year study, 61 patients (20.0%) had platelet counts of <100 × 10³/μL and had statistically significant differences in patients who had delayed graft function and induction therapy.

CONCLUSIONS

In this study, non-G group of rs2297630 in SDF1 significantly increased the risk of post-transplant thrombocytopenia in the first week of kidney transplantation.

Accuracy of Plain Abdominal Radiography in the Differentiation between Small Bowel Obstruction and Small Bowel Ileus in Acute Abdomen Presenting to Emergency Department

Introduction

Our purpose was to evaluate whether plain abdominal radiography (PAR) could accurately differentiate between small bowel obstruction (SBO) and small bowel ileus (SBI) in an emergency setting. We also evaluated the value of known classic signs on the PAR for differentiating between SBO and SBI.

Methods

This retrospective study included 216 emergency room patients who had small bowel distension (maximal small bowel diameter ≥2.5 cm) on the PAR and who underwent successive abdominal computed tomography. One radiologist and one emergency physician retrospectively reviewed PAR in consensus, unaware of the patients' clinical data; they divided the patients into an SBO group and an SBI group according to the radiographic findings. Presence or numeric values of 10 radiographic signs were also recorded. Final diagnoses of SBO and SBI were established by a combined analysis of medical charts, surgical records, radiographic findings on abdominal computed tomography, and small bowel studies. The differential diagnoses based on PAR and the final diagnoses were compared, and the sensitivity and specificity of PAR were calculated. We also evaluated the differences among 10 radiographic signs between the final SBO and SBI groups.

Results

Sensitivity and specificity of PAR for SBO were 82.0% and 92.4%, respectively. Among the 10 radiographic signs, all except maximal colon diameter were statistically significant predictors on the final diagnosis.

Conclusions

PAR is an accurate and effective initial imaging modality for differentiating between SBO and SBI in an emergency setting, and most of the classic radiographic signs have a diagnostic value.

Regulation of PLK1 through competition between hnRNPK, miR-149-3p and miR-193b-5p

Polo-like kinase 1 (PLK1) is a critical regulator of cell cycle progression and apoptosis. However, its regulation remains poorly understood. In the present study, we investigated the molecular mechanism underlying the post-transcriptional regulation of PLK1. We observed that heterogeneous nuclear ribonucleoprotein K (hnRNPK) and PLK1 were positively associated in several different cancers and high expression levels of them correlated with poor prognosis in patients with cancer. Knockdown of hnRNPK resulted in reduced expression of PLK1, whereas conversely, PLK1 expression was increased in hnRNPK-overexpressing cells. We found that hnRNPK regulated PLK1 expression through KH1- and KH2-dependent interactions with the 3'UTR of PLK1 mRNA. In addition, microRNA-149-3p (miR-149-3p) and miR-193b-5p suppressed PLK1 expression by targeting the 3'UTR of PLK1 mRNA. MicroRNA-elicited enrichment of PLK1 mRNA in Ago2 immunoprecipitation was altered by the presence or absence of hnRNPK. Furthermore, the deletion of the cytosine (C)-rich sequences of the 3'UTR of PLK1 mRNA abolished the decreased PLK1 expression observed via hnRNPK silencing and administration of miRNAs, a finding that suggests that hnRNPK shares this C-rich motif with miR-149-3p and miR-193b-5p. We also found that downregulation of PLK1 by either silencing hnRNPK or overexpression of miR-149-3p and miR-193b-5p decreased clonogenicity and induced apoptosis. Our findings from this study demonstrate that hnRNPK regulates PLK1 expression by competing with the PLK1-targeting miRNAs, miR-149-3p and miR-193b-5p.

Persistence with antihypertensives in uncomplicated treatment-naïve very elderly patients: a nationwide population-based study

BACKGROUND

Limited studies have evaluated the medication-taking behavior in very elderly hypertensive patients. The aim of this study was to evaluate the persistence and adherence with antihypertensive agents in treatment-naïve patients, along with other related factors, according to age.

METHODS

Adult (19-64 years), elderly (65-79 years), and very elderly (≥80 years) uncomplicated hypertensive patients starting antihypertensive monotherapy were identified from the National Health Insurance claims database. The first-year treatment persistence and adherence rates measured using the medication possession ratio were assessed and compared in these three age cohorts.

RESULTS

After propensity score matching, three age cohorts with 6689 patients each were assembled from 228,925 uncomplicated hypertensive patients who began antihypertensive monotherapy in 2012. The treatment persistence and adherence rates over the first year were the lowest in the very elderly (59.5% and 62.8%, respectively) and highest in the elderly (65.2% and 67.9%, respectively) patients among the three age cohorts (p < 0.001). The adjusted risk for treatment non-persistence was significantly higher in the very elderly (adjusted hazard ratio, 1.20; 95% confidence interval, 1.13-1.27) compared with the elderly. Having more comorbidities, being a beneficiary of medical aid, and having a diagnosis of dementia were unique positive predictors for treatment persistence in the very elderly, along with common predictors such as female sex, dyslipidemia, and an initially chosen antihypertensive therapeutic class other than beta blockers and thiazide diuretics.

CONCLUSIONS

Very elderly patients were less likely to continue antihypertensive therapy over the first year compared with their younger counterparts. Our findings suggest that a low comorbidity index and lack of medical aid support negatively affect the treatment persistence in this population.

Population genetic characterization of the Japanese oak silkmoth, Antheraea yamamai (Lepidoptera: Saturniidae), using novel microsatellite markers and mitochondrial DNA gene sequences

The Japanese oak silkmoth, Antheraea yamamai Guérin-Méneville, 1861 (Lepidoptera: Saturniidae), is an important natural resource of industrial value for silk fiber production. Owing to a lack of geographic and population genetic information, systematic domestication of An. yamamai has not been possible yet. In this study, 10 microsatellite markers developed using next-generation sequencing and two mitochondrial DNA (mtDNA) gene sequences (COI and ND4) were used to investigate the genetic variation and geographic structure of An. yamamai populations in South Korea. The two mtDNA gene sequences revealed very low total genetic variation and, consequently, low geographic variation, validating the use of more variable molecular markers. Genotyping of 76 An. yamamai individuals from nine localities in South Korea showed that the observed number of alleles at each locus ranged from 3 to 26, the polymorphism information content was 0.2990-0.9014, the observed and expected heterozygosities were 0.3252-0.9076 and 0.2500-0.9054, respectively, and F_IS was -0.654-0.520. The population-based F_IS, F_ST, R_ST, and global Mantel tests all suggested that the An. yamamai populations were overall well-interconnected, suggesting that any population can be used as a genetic source for domestication. Nevertheless, STRUCTURE analyses using microsatellite data and mtDNA sequences indicated the presence of two genetic pools in many populations, although a plausible explanation for this observation requires further studies.

MicroRNA-296-5p Promotes Invasiveness through Downregulation of Nerve Growth Factor Receptor and Caspase-8

Glioblastomas (GBM) are very difficult to treat and their aggressiveness is one of the main reasons for this as well as for the frequent recurrences. MicroRNAs post-transcriptionally regulate their target genes through interaction between their seed sequence and 3'UTR of the target mRNAs. We previously reported that miR-296-3p is regulated by neurofibromatosis 2 (NF2) and enhances the invasiveness of GBM cells via SOCS2/STAT3. In this study, we investigated whether miR-296-5p, which originates from the same precursor miRNA as miR-296-3p, can increase the invasiveness of GBM cells. It was observed that miR-296-5p potentiated the invasion of various GBM cells including LN229, T98G, and U87MG. Through bioinformatics approaches, two genes were identified as miR-296-5p targets: caspase-8 (CASP8) and nerve growth factor receptor (NGFR). From results obtained from Ago2 immunoprecipitation and luciferase assays, we found that miR-296-5p downregulates CASP8 and NGFR through direct interaction between seed sequence of the miRNA and 3'UTR of the target mRNA. Knockdown of CASP8 or NGFR also increased the invasive ability of GBM cells, indicating that CASP8 and NGFR are involved in potentiation of invasiveness by miR-296-5p. Consistent with our findings, CASP8 was downregulated in brain metastatic lung cancer cells, which have a high level of miR-296-5p, compared to parental cells, suggesting that miR-296-5p may be generally associated with the acquisition of invasiveness. Collectively, our results implicate miR-296-5p as a potential cause of invasiveness in cancer and suggest it as a promising therapeutic target for GBM.

Implication of different initial beta blockers on treatment persistence: atenolol vs new-generation beta blocker, a population-based study

AIM

Potential heterogeneity within the same class of drug in terms of persistence may lead to different clinical implications. Given that the increased risks of mortality and cardiovascular events are due, in part, to the lack of persistent use of antihypertensive medications, the objective of this study was to evaluate 1-year persistence of new-generation beta blockers compared to atenolol in antihypertensive treatment-naïve patients.

METHODS

A total of 9978 patients aged 18 years or older with hypertension newly diagnosed in 2012, without hypertension-related complication and initiated treatment with beta blocker monotherapy during 2012 were included in the analysis. Rate and duration of treatment and drug persistence were compared between atenolol and new-generation beta blockers. Hazards of discontinuation in nonatenolol compared to atenolol were evaluated using a multivariate Cox proportional model.

RESULTS

The rate of treatment persistence was higher in the nonatenolol group (57.35% vs 53.40%, P<.0001), and the time to treatment discontinuation was earlier in the atenolol group with a minimal difference in the average (243.2 vs 254 days, P<.0001). New-generation beta blockers demonstrated a lower risk of treatment discontinuation (HR: 0.91, 95% CI: 0.86-0.96) compared to atenolol; a notable improvement was observed with carvedilol and nebivolol (HR: 0.74, 95% CI: 0.69-0.80 and HR: 0.79, 95% CI: 0.70-0.89, respectively), whereas betaxolol showed a substantially greater hazard for discontinuation compared to atenolol.

CONCLUSIONS

This study demonstrated a meaningful improvement in treatment persistence with new-generation beta blockers compared to atenolol, with betaxolol as exception.

Cognitive remediation for individuals with psychosis: efficacy and mechanisms of treatment effects

BACKGROUND

The popularity of cognitive remediation (CR) interventions for individuals with psychosis is in part based on the well-established link between cognition and functioning and the assumption that by targeting cognition, function can improve. While numerous trials have reported CR's efficacy, it is still not considered an evidence-based treatment. Importantly, little is known about the mechanisms through which it may affect functioning.

METHOD

In this study, we evaluated CR's proximal and distal effects, and examined potential mechanisms. A total of 75 individuals with psychotic disorders were randomized to a combination of strategy-based and drill-and-practice CR or wait-list control, with assessments of training task performance, neurocognition, functional capacity, symptoms and functioning conducted at baseline, end of the 2-month intervention, and 2-month follow-up.

RESULTS

Compared with treatment as usual, CR was associated with large post-training improvements on training tasks targeting attention, visuospatial memory, and verbal learning and memory, with persisting group differences at the 2-month follow-up. These generalized to mostly large improvements on neuropsychological measures targeting visuospatial memory, verbal learning and memory, delayed verbal memory and verbal working memory. While there were no CR-associated improvements on measures of functional capacity, symptoms, or a self-report measure of independent living skills, there was an effect on an interviewer-rated measure of functioning (Quality of Life Scale), which appeared primarily driven by the Intrapsychic Foundations subscale. Finally, for those randomized to CR, there were significant, medium-sized correlations between training task improvement, neuropsychological improvement and functioning measures.

CONCLUSIONS

This suggests a complex, multifactorial relationship between CR, and cognitive and functional change.

Late-onset bulky naevocytoma of the perineum masquerading as a malignant melanoma

Bulky naevocytoma of the perineum is a very rare variant of giant congenital melanocytic naevus (GCMN). It presents as a bulky naevocytic tumour in the perineal region with characteristic histological findings, such as extensive areas with a neural appearance called 'lames foliacees', formation of a pseudofollicular structure and extension of naevus cells between collagen bundles in a row called 'Indian-file' pattern. We report a case of late-onset bulky naevocytoma of the perineum in a 13-year-old girl. The patient presented with two bulky, pedunculated, heavily pigmented masses in the vulvar area that developed in a pre-existing GCMN lesion, which began around puberty and caused severe gait disturbance. Given the possibility of malignant transformation, we conducted staged reduction surgery of the tumour masses, which were found to be intradermal naevi without evidence of malignancy. The patient's gait disturbance improved markedly after surgery.

Target molecule expression profiles in metastatic renal cell carcinoma: Development of individual targeted therapy

The aim of this study is to analyze the level of target molecule expression in metastatic renal cell carcinoma (RCC) to determine whether there is a correlation between molecular marker expression and clinical response. Ten patients with metastatic RCC, who received receptor tyrosine kinase (RTK) targeted therapy after cytoreductive or radical nephrectomy, were included. The expression of target molecules relating to the RTK, mammalian target of rapamycin, hypoxia inducible factor, mitogen activated protein kinase, and adenosine monophosphate-activated protein kinase pathways were analyzed using real-time polymerase chain reaction and immunohistochemistry. We correlated the level of target molecule expression with clinical response, including efficacy and adverse events experience during RTK targeted therapy. All patients showed similar histological subtype and grade on pathological examination; however, the expression of RCC target molecules was very different among the patients. The expression of molecules related to the RTK pathway in RCC tissue as well as relative expression of molecules in RCC tissue compared to normal kidney tissue, were higher in patients who showed a good response to RTK targeted therapy compared to those that showed a poor response. Target molecule expression in normal kidney tissue was higher in patients who experienced high-grade adverse events than in patients who experienced low-grade events. Target molecule expression in metastatic RCC correlates with targeted therapy clinical response including efficacy and adverse events. Personalized target molecule expression profiles could be used to predict clinical response to different targeted therapies, thus helping optimization of targeted therapies for patients with metastatic RCC.

Influence of initial angiotensin receptor blockers on treatment persistence in uncomplicated hypertension: A nation-wide population-based study

We identified 55 504 uncomplicated, treatment-naïve hypertensive patients who started angiotensin II receptor blockers (ARBs) in 2012 from national claims data. The proportion of patients remaining on any hypertension treatment at 12 months and the adherence rate were similar between the losartan cohort (66.82% and 68.25%) and the nonlosartan ARB cohort (67.48% and 69.01%). After adjusting for confounding factors, there was no difference in persistence (aHR 0.98, 95% confidence interval (CI) 0.95-1.01) on hypertension treatment between losartan and nonlosartan ARB cohort. Post hoc analysis showed that patients initially prescribed eprosartan, irbesartan (both, aHR 1.33), and telmisartan (aHR 1.11) were more likely to discontinue the initial drug, whereas valsartan initiators (aHR 0.96) were less likely compared with losartan initiators.

Inhibitory Activity of (+)-Usnic Acid against Non-Small Cell Lung Cancer Cell Motility

Lichens are symbiotic organisms that produce various unique chemicals that can be used for pharmaceutical purposes. With the aim of screening new anti-cancer agents that inhibit cancer cell motility, we tested the inhibitory activity of seven lichen species collected from the Romanian Carpathian Mountains against migration and invasion of human lung cancer cells and further investigated the molecular mechanisms underlying their anti-metastatic activity. Among them, Alectoria samentosa, Flavocetraria nivalis, Alectoria ochroleuca, and Usnea florida showed significant inhibitory activity against motility of human lung cancer cells. HPLC results showed that usnic acid is the main compound in these lichens, and (+)-usnic acid showed similar inhibitory activity that crude extract have. Mechanistically, β-catenin-mediated TOPFLASH activity and KITENIN-mediated AP-1 activity were decreased by (+)-usnic acid treatment in a dose-dependent manner. The quantitative real-time PCR data showed that (+)-usnic acid decreased the mRNA level of CD44, Cyclin D1 and c-myc, which are the downstream target genes of both β-catenin/LEF and c-jun/AP-1. Also, Rac1 and RhoA activities were decreased by treatment with (+)-usnic acid. Interestingly, higher inhibitory activity for cell invasion was observed when cells were treated with (+)-usnic acid and cetuximab. These results implied that (+)-usnic acid might have potential activity in inhibition of cancer cell metastasis, and (+)-usnic acid could be used for anti-cancer therapy with a distinct mechanisms of action.

Persistence with Antihypertensive Medications in Uncomplicated Treatment-Naïve Patients: Effects of Initial Therapeutic Classes

We aimed to assess one-year persistence with antihypertensive therapy (AHT) among newly treated uncomplicated hypertensive patients in Korea and to evaluate the effect of initial therapeutic classes on persistence. We retrospectively analyzed a random sample of 20% of newly treated uncomplicated hypertensive patients (n = 45,787) in 2012 from the National Health Insurance claims database. This group was classified into six cohorts based on initial AHT class. We then measured treatment persistence, allowing a prescription gap of 60 days. Adherence to AHT was assessed with the medication possession ratio. Calcium channel blockers (CCB, 43.7%) and angiotensin receptor blockers (ARB, 40.3%) were most commonly prescribed as initial monotherapy. Overall, 62.1% and 42.0% were persistent with any AHT and initial class at one year, respectively, and 64.2% were adherent to antihypertensive treatment. Compared with ARBs, the risk of AHT discontinuation was significantly increased with initial use of thiazide diuretics (hazard ratio [HR], 3.16; 95% confidence interval [CI] 2.96-3.74) and beta blockers (HR, 1.86; CI, 1.77-1.95) and was minimally increased with CCBs (HR, 1.12; CI, 1.08-1.15). In conclusion, persistence and adherence to AHT are suboptimal, but the differences are meaningful in persistence and adherence between initial AHT classes.

Clinical assessment of lipid profiles in live kidney donors

BACKGROUND

Abnormal serum lipid profiles are an issue in chronic kidney disease (CKD), but the clinical ramifications of dyslipidemia in live kidney donors are unclear. Thus, we explored the relationship between serum lipids and residual renal function in living donors post-nephrectomy.

METHODS

Charts of living donors who underwent nephrectomy between January 2010 and March 2013 were reviewed, targeting those with 6-month follow-up examinations at minimum. Altogether, 282 donors were studied, examining total cholesterol (TC), triglyceride (TG), low-density lipoprotein (LDL), and high-density lipoprotein (HDL) levels assayed before donation by standard techniques. Median follow-up time was 14 months. The relationship between postoperative renal function and allograft biopsy results was assessed. Recursive partitioning was applied to identify optimal cut-off points for each parameter.

RESULTS

Median (interquartile range) serum TC, TG, LDL, and HDL levels were 183 (161-205) mg/dL, 86 (63-131) mg/dL, 108 (92-128) mg/dL, and 53 (44-62) mg/dL, respectively. The glomerular filtration rate at last follow-up was associated with TC (r = -0.187; P = .002) and LDL (r = -0.172; P = .005) levels, but showed no correlation with TG and HDL. Root nodes of TC and LDL determinations in recursive partitioning were 170.5 mg/dL and 80.5 mg/dL, respectively, serving as thresholds for further evaluation. On logistic regression analysis, the likelihood of CKD (glomerular filtration rate < 60 mL/min/1.73 m(2)) at last follow-up was greater in donors with elevated TC and LDL levels (odds ratio = 1.96 and 3.33; P = .021 and .029, respectively).

CONCLUSION

Kidney donors with serum TC and LDL elevations require close observation, given their demonstrable predisposition to CKD after donation.

Impact of metabolic syndrome on postdonation renal function in living kidney donors

INTRODUCTION

Optimization of kidney donor selection is critical to ensure recovery of the donor. The goal of this study was to determine the influence of metabolic syndrome on renal histology and perioperative renal function in living kidney donors.

PATIENTS AND METHODS

Between January 2010 and March 2013, a total of 363 living kidney donors who underwent donor nephrectomy at our institution were enrolled. Metabolic syndrome was diagnosed in patients according to the National Cholesterol Education Program's Adult Treatment Panel III, and renal histology of implantation biopsy specimens and perioperative renal function were compared in participants with or without metabolic syndrome. Using multivariate regression analysis, the goal was to identify which component of metabolic syndrome induces chronic histologic changes and delayed renal function recovery.

RESULTS

We identified 30 donors (8.45%) with metabolic syndrome. Donors with metabolic syndrome were older (48.4 ± 9.2 years vs 39.7 ± 11.4 years; P < .001) and more likely to have chronic histologic changes (36.8% vs 9.7%; P = .001) than subjects without metabolic syndrome. Results of the multivariate regression analysis indicated that obesity, hyperglycemia, and hypertriglyceridemia were independently associated with chronic histologic changes. Perioperative renal function was correlated with the presence of metabolic syndrome rather than with chronic histologic changes, and patients with metabolic syndrome were more likely to experience delayed renal function recovery. Linear regression models found that the sum of the metabolic components correlated with renal function 6 months postoperatively, but among all risk factors, only obesity was significantly associated with the occurrence of delayed renal function recovery (odds ratio, 2.67; P = .001).

CONCLUSIONS

Although metabolic syndrome in living kidney donors is characterized by chronic histologic changes, perioperative renal function is affected by the syndrome itself rather than by the histologic changes. Obesity is the most important metabolic factor for predicting delayed renal function recovery in living kidney donors, providing an important clinical indicator of postoperative renal function in these patients.

The Inhibitory Effect of Alisol A 24-Acetate from Alisma canaliculatum on Osteoclastogenesis

Osteoporosis is a disease that decreases bone mass. The number of patients with osteoporosis has been increasing, including an increase in patients with bone fractures, which lead to higher medical costs. Osteoporosis treatment is all-important in preventing bone loss. One strategy for osteoporosis treatment is to inhibit osteoclastogenesis. Osteoclasts are bone-resorbing multinucleated cells, and overactive osteoclasts and/or their increased number are observed in bone disorders including osteoporosis and rheumatoid arthritis. Bioactivity-guided fractionations led to the isolation of alisol A 24-acetate from the dried tuber of Alisma canaliculatum. Alisol A 24-acetate inhibited RANKL-mediated osteoclast differentiation by downregulating NFATc1, which plays an essential role in osteoclast differentiation. Furthermore, it inhibited the expression of DC-STAMP and cathepsin K, which are related to cell-cell fusion of osteoclasts and bone resorption, respectively. Therefore, alisol A 24-acetate could be developed as a new structural scaffold for inhibitors of osteoclast differentiation in order to develop new drugs against osteoporosis.

RNA-sequencing of the brain transcriptome implicates dysregulation of neuroplasticity, circadian rhythms and GTPase binding in bipolar disorder

RNA-sequencing (RNA-seq) is a powerful technique to investigate the complexity of gene expression in the human brain. We used RNA-seq to survey the brain transcriptome in high-quality postmortem dorsolateral prefrontal cortex from 11 individuals diagnosed with bipolar disorder (BD) and from 11 age- and gender-matched controls. Deep sequencing was performed, with over 350 million reads per specimen. At a false discovery rate of <5%, we detected five differentially expressed (DE) genes and 12 DE transcripts, most of which have not been previously implicated in BD. Among these, Prominin 1/CD133 and ATP-binding cassette-sub-family G-member2 (ABCG2) have important roles in neuroplasticity. We also show for the first time differential expression of long noncoding RNAs (lncRNAs) in BD. DE transcripts include those of serine/arginine-rich splicing factor 5 (SRSF5) and regulatory factor X4 (RFX4), which along with lncRNAs have a role in mammalian circadian rhythms. The DE genes were significantly enriched for several Gene Ontology categories. Of these, genes involved with GTPase binding were also enriched for BD-associated SNPs from previous genome-wide association studies, suggesting that differential expression of these genes is not simply a consequence of BD or its treatment. Many of these findings were replicated by microarray in an independent sample of 60 cases and controls. These results highlight common pathways for inherited and non-inherited influences on disease risk that may constitute good targets for novel therapies.

Effects of probiotics for the treatment of atopic dermatitis: a meta-analysis of randomized controlled trials

BACKGROUND

The effects of probiotics on the treatment of atopic dermatitis (AD) are inconclusive.

OBJECTIVE

To determine the clinical effect of probiotics in the management of AD overall and in different age groups.

METHODS

A comprehensive search of databases through December 2013 was performed. For this meta-analysis, randomized controlled trials measuring the treatment effects of probiotics or synbiotics in patients diagnosed with AD were included. The primary outcome was a difference in Scoring of Atopic Dermatitis (SCORAD) values between the treatment and placebo groups overall and in different age populations.

RESULTS

Twenty-five randomized controlled trials (n = 1,599) were available for this meta-analysis. Significant differences in SCORAD values favoring probiotics over the control were observed overall (mean -4.51, 95% confidence interval -6.78 to -2.24), in children 1 to 18 years old (-5.74, 95% confidence interval -7.27 to -4.20), and in adults (-8.26, 95% confidence interval -13.28 to -3.25). However, the effectiveness of probiotics in infants (<1 year old) with AD was not proved. The effect of synbiotic use was not significantly different from that of probiotic use. Treatment with a mixture of different bacterial species or of Lactobacillus species showed greater benefit than did treatment with Bifidobacterium species alone.

CONCLUSION

The overall result of this meta-analysis suggests that probiotics could be an option for the treatment of AD, especially for moderate to severe AD in children and adults. However, no evidence was found supporting the beneficial role of probiotics in infants.

Methemoglobinemia associated with metaflumizone poisoning

CONTEXT

Metaflumizone is a voltage-dependent sodium channel blocker insecticide, which is chemically similar to indoxacarb. Although indoxacarb poisoning is known as a cause of methemoglobinemia, the effect of metaflumizone poisoning in humans is still unknown.

CASE DETAILS

A 57-year-old man presented with a decreased mentality following ingestion of 100 ml of metaflumizone, 150 ml of glyphosate and alcohol. Although initial methemoglobin (MetHb) level was slightly higher than the normal limit, it gradually rose to reach a maximum level of 27.8%, on the 19 h after ingestion. After hemodialysis, MetHb level was reduced to 15.8%, which decreased further to the level of 6%, following methylene blue administration.

DISCUSSION

Metaflumizone shares a similar chemical structure to indoxacarb, which is known to be a cause of methemoglobinemia. Physicians should be alert for the development of methemoglobinemia in symptomatic patients when facing potential pesticide poisoning such as metaflumizone poisoning.

Mosaic double aneuploidy (45,X/47,XX,+8) with aortic dissection

Chromosomal aneuploidy is considerably frequent and may involve either autosomes or sex chromosomes. While double aneuploidy involving both autosomal and sex chromosomes is rare, several reports described the cases of sex chromosomal aneuploidies in combination with trisomy 21, such as Down-Klinefelter and Down-Turner syndrome. However, trisomy 8-Turner syndrome has been rarely described to date. Here we report a case of a 28-year-old female with mosaic trisomy 8-Turner syndrome. The patient was referred to our hospital for aortic dissection. On physical evaluation, features of her phenotype, which included short stature, webbed neck and cubitus valgus, suggested congenital anomalies such as Turner syndrome. Chest CT revealed aortic dissection with bicuspid aortic valve and coarctation. G-banding cytogenetic analysis of peripheral blood showed mosaicism with two cell lines (45,X[17]/47,XX,+8[33]). FISH analysis indicated that 15% of the cells were of monosomy X karyotype and 85% of the cells were with XX karyotype and trisomy 8 was detected only in XX cells. Though the patient exhibited clinical features of Turner syndrome, somatic stigmas present were not clearly distinguishable from those of trisomy 8, such as short stature, skeletal and cardiac abnormalities. Observations from most of the double aneuploidy cases indicated that the patient's phenotype was not necessarily in correlation to the ratio of autosomal and sex chromosomal aberrations. Mosaicism in trisomy 8-Turner syndrome was rarely documented and we believe this is the first reported case of mosaicism in trisomy 8-Turner syndrome presenting with aortic dissection and surviving into adulthood.

Nontransected ventral onlay-augmented urethroplasty using autologous saphenous vein graft in a rabbit model of urethral stricture

OBJECTIVE

To evaluate the efficacy and feasibility of nontransected ventral onlay-augmented urethroplasty using an autologous saphenous vein graft in a rabbit model of urethral stricture.

METHODS

Ten white male rabbits weighing 3.0-3.5 kg were selected, and a long tract urethral stricture was generated by excising an 0.8-cm wide and 2-cm long portion of the distal urethra. One month after the procedure, the rabbits were randomized into a urethral stricture group (n = 5) or urethroplasty with saphenous vein graft group (n = 5). Another 5 rabbits served as a normal control group. Retrograde urethrography was performed at 2, 4, 8, and 12 weeks after surgery in all groups, and the rabbits were killed at 12 weeks postoperatively for histopathologic and immunohistochemical evaluation.

RESULTS

The mean operated urethral width of the normal, stricture, and vein graft group was 10.2 ± 0.84, 4.3 ± 0.97, and 10.04 ± 2.35 mm at 2 weeks postoperatively, respectively (P = .008). The 4-, 8-, and 12-week postoperative urethrograms revealed results similar to those of the 2-week postoperative urethrograms. Histologic analysis showed the neourethra was epithelialized with urothelium in the vein graft group. All the rabbits survived throughout the study period without fistula formation or infection.

CONCLUSION

Nontransected ventral onlay-augmented urethroplasty using an autologous saphenous vein graft can be an effective and feasible procedure for the surgical management of long tract urethral stricture.

Woman with hemorrhagic spots on her abdomen

Abstract Lipodissolve is a product that is composed of phosphatidylcholine and deoxycholate mixture, and other adjuvant. Lipodissolve injection seems to be performed in many countries for local fat reduction without any legal and scientific evidences of its safety and efficacy despite the US FDA warning.1 Herein, we report a case with agitation and metabolic acidosis following lipodissolve injection.

Cortical-striatal gene expression in neonatal hippocampal lesion (NVHL)-amplified cocaine sensitization

Cortical-striatal circuit dysfunction in mental illness may enhance addiction vulnerability. Neonatal ventral hippocampal lesions (NVHL) model this dual diagnosis causality by producing a schizophrenia syndrome with enhanced responsiveness to addictive drugs. Rat genome-wide microarrays containing >24 000 probesets were used to examine separate and co-occurring effects of NVHLs and cocaine sensitization (15 mg/kg/day × 5 days) on gene expression within medial prefrontal cortex (MPFC), nucleus accumbens (NAC), and caudate-putamen (CAPU). Two weeks after NVHLs robustly amplified cocaine behavioral sensitization, brains were harvested for genes of interest defined as those altered at P < 0.001 by NVHL or cocaine effects or interactions. Among 135 genes so impacted, NVHLs altered twofold more than cocaine, with half of all changes in the NAC. Although no genes were changed in the same direction by both NVHL and cocaine history, the anatomy and directionality of significant changes suggested synergy on the neural circuit level generative of compounded behavioral phenotypes: NVHL predominantly downregulated expression in MPFC and NAC while NVHL and cocaine history mostly upregulated CAPU expression. From 75 named genes altered by NVHL or cocaine, 27 had expression levels that correlated significantly with degree of behavioral sensitization, including 11 downregulated by NVHL in MPFC/NAC, and 10 upregulated by NVHL or cocaine in CAPU. These findings suggest that structural and functional impoverishment of prefrontal-cortical-accumbens circuits in mental illness is associated with abnormal striatal plasticity compounding with that in addictive disease. Polygenetic interactions impacting neuronal signaling and morphology within these networks likely contribute to addiction vulnerability in mental illness.