[Does Early Olaparib Administration Improve Prognosis in Patients with HER2-Negative Metastatic Breast Cancer and BRCA1 and/or BRCA2 Pathogenic Variants?-A Case Report]

We herein describe our experience with patients who had been diagnosed with BRCA1/2 pathogenic variants and metastatic breast cancer. Three patients who experienced postoperative recurrences had received chemotherapy before recurrence, while an additional patient with stage Ⅳ disease at diagnosis required chemotherapy before olaparib administration. Prior anthracycline and/or taxane-based therapies needed prior to administration of poly(adenosine diphosphate ribose) polymerase inhibitors might still be controversial in terms of patient benefits.

Ramucirumab plus FOLFIRI as second-line treatment for patients with RAS wild-type metastatic colorectal cancer previously treated with anti-EGFR antibody: JACCRO CC-16

BACKGROUND

Chemotherapy in combination with anti-epidermal growth factor receptor (EGFR) antibody is considered a first-line treatment regimen for RAS wild-type and left-sided metastatic colorectal cancer (mCRC), whereas second-line treatment regimens have not yet been established. Few studies have prospectively evaluated second-line treatment with anti-vascular endothelial growth factor antibody after first-line anti-EGFR antibody therapy for RAS wild-type mCRC.

PATIENTS AND METHODS

This non-randomized phase II trial investigated the clinical outcomes of second-line ramucirumab (RAM) plus fluorouracil, levofolinate, and irinotecan (FOLFIRI) after first-line anti-EGFR antibody in combination with doublet or triplet regimen in patients with RAS wild-type mCRC. The primary endpoint was the 6-month progression-free survival (PFS) rate. The secondary endpoints were PFS, overall survival (OS), objective response rate (ORR), rate of early tumor shrinkage (ETS), and safety. We hypothesized a threshold 6-month PFS rate of 30% and an expected 6-month PFS rate of 45%. Treatment was considered effective if the lower limit of the 90% confidence interval (CI) of the 6-month PFS rate was >0.30.

RESULTS

Ninety-two patients were enrolled in the study. The primary tumor was located on the left side in 86 (95.6%) patients. Twenty (22.0%) patients had received triplet plus cetuximab as previous therapy. Six-month PFS rate was 58.2% (90% CI 49.3% to 66.2%) with a median PFS of 7.0 months (95% CI 5.7-7.6 months). Median OS was 23.6 months (95% CI 16.5-26.3 months). The ORR and ETS rate were 10.7% and 16.9%, respectively, in 83 patients with measurable lesions. The 6-month PFS rate was comparable between patients previously treated with doublet and triplet regimens; however, median PFS was longer for the doublet regimen (7.4 versus 6.4 months, P = 0.036).

CONCLUSIONS

Our study demonstrated prospectively that RAM plus FOLFIRI is an effective second-line treatment after anti-EGFR antibody-containing first-line therapy in RAS wild-type and left-sided mCRC. Furthermore, the results were similar for patients who were previously treated with triplet regimen.

Disease modeling and gene correction of LGMDR21 iPSCs elucidates the role of POGLUT1 in skeletal muscle maintenance, regeneration, and the satellite cell niche

Autosomal recessive limb-girdle muscular dystrophy 21 (LGMDR21) is caused by pathogenic variants in protein O-glucosyltransferase 1 (POGLUT1), which is responsible for O-glucosylation of specific epidermal growth factor (EGF) repeats found in ∼50 mammalian proteins, including Notch receptors. Previous data from patient biopsies indicated that impaired Notch signaling, reduction of muscle stem cells, and accelerated differentiation are probably involved in disease etiopathology. Using patient induced pluripotent stem cells (iPSCs), their corrected isotypes, and control iPSCs, gene expression profiling indicated dysregulation of POGLUT1, NOTCH, muscle development, extracellular matrix (ECM), cell adhesion, and migration as involved pathways. They also exhibited reduced in vitro POGLUT1 enzymatic activity and NOTCH signaling as well as defective myogenesis, proliferation, migration and differentiation. Furthermore, in vivo studies demonstrated significant reductions in engraftment, muscle stem cell formation, PAX7 expression, and maintenance, along with an increased percentage of mislocalized PAX7+ cells in the interstitial space. Gene correction in patient iPSCs using CRISPR-Cas9 nickase led to the rescue of the main in vitro and in vivo phenotypes. These results demonstrate the efficacy of iPSCs and gene correction in disease modeling and rescue of the phenotypes and provide evidence of the involvement of muscle stem cell niche localization, PAX7 expression, and cell migration as possible mechanisms in LGMDR21.

Dipole-moment-induced supramolecular assembly of a donor-acceptor-type molecule on a metal surface and in a crystal

The conformation and alignment of molecules in organic materials are important because they affect the materials' bulk physical properties. Because two-dimensional (2D) materials offer a simpler model of three-dimensional (3D) materials, the conformation and alignment of molecules in 2D assemblies have been investigated at the atomic scale by scanning tunnelling microscopy (STM). However, differences in the conformation and alignment of molecules between 2D and 3D assemblies have not been clarified. In this work, the conformation and alignment of a donor-acceptor-type molecule, 4-(3,3-dimethyl-2,3-dihydro-1H-indol-1-yl)benzonitrile (IBN), are studied in 2D and 3D assemblies. Thus, the 2D assembly of IBN on the Au(111) surface was investigated by STM and the 3D assembly of IBN in a single crystal was investigated by X-ray crystallography. Our survey revealed that the conformation of IBN is planar in both 2D and 3D assemblies because of the electron-delocalised structure resulting from the electron-donating and electron-accepting groups of IBN; thus, the values of the dipole moment of IBN in 2D and 3D assemblies are essentially the same. In both the 2D and 3D assemblies, IBN molecules align to cancel out the dipole moment even though the self-assembled structures differ. In the 2D assemblies, the orientation and self-assembled structure of IBN are changed by the surface density of IBN, and they are affected by the crystal orientation and superstructure of Au(111) because of the strong interaction between IBN and Au(111). In addition, scanning tunnelling spectroscopy revealed that the coordination structure is not included in the self-assembled structure of IBN on Au(111).

Adverse effects of long-term drain placement and the importance of direct aspiration: a retrospective cohort study

BACKGROUND

Long-term placement of prophylactic drains may result in retrograde infections.

AIM

To investigate the association between the timing of drain removal and clinical outcomes.

METHODS

This retrospective, single-centre cohort study evaluated 110 patients who underwent elective gastrointestinal or hepatopancreatobiliary surgery and developed subsequent organ/space surgical site infection (SSI) between 2016 and 2020. The difference between the culture-positive species of prophylactic drains and direct aspiration was evaluated; whether the prophylactic drains functioned effectively at the time of SSI diagnosis; and whether the empirical antibiotics administered before drainage were effective against all the detected bacteria. Finally, clinical outcomes were compared between early (i.e. cases wherein the prophylactic drain had already been removed or replaced at the time of SSI diagnosis) and late (removal after diagnosis) drain removal.

FINDINGS

The prophylactic drains functioned effectively in only 27 (25%) patients at the time of SSI diagnosis. Due to the results of direct aspiration cultures, 43% of patients required antibiotic escalation. The median time to drain removal or first replacement was seven postoperative days. The early removal group included 43 patients (39%). Compared with early removal, late removal resulted in a higher frequency of vancomycin use (7.0% vs 22.4%; P = 0.037).

CONCLUSION

Prolonged prophylactic drain placement is associated with complicated infections requiring vancomycin; therefore, the drains should be removed as soon as possible. Additionally, obtaining the cultures of direct aspiration should be actively considered, as escalation of antimicrobial therapy is often performed based on culture results.

Cancer-associated Notch receptor variants lead to O-fucosylation defects that deregulate Notch signaling

NOTCH1 is a transmembrane receptor that initiates a signaling pathway involved in embryonic development of adult tissue homeostasis. The extracellular domain of NOTCH1 is composed largely of epidermal growth factor-like repeats (EGFs), many of which can be O-fucosylated at a specific consensus sequence by protein O-fucosyltransferase 1 (POFUT1). O-fucosylation of NOTCH1 is necessary for its function. The Notch pathway is deregulated in many cancers, and alteration of POFUT1 has been reported in several cancers, but further investigation is needed to assess whether there is deregulation of the Notch pathway associated with mutations that affect O-fucosylation in cancers. Using Biomuta and COSMIC databases, we selected nine NOTCH1 variants that could cause a change in O-fucosylation of key EGFs. Mass spectral glycoproteomic site mapping was used to identify alterations in O-fucosylation of EGFs containing the mutations. Cell-based NOTCH-1 signaling assays, ligand-binding assays, and cellsurface analysis were used to determine the effect of each mutation on Notch activation. Two variants led to a gain of function (GOF), six to a loss of function (LOF), and one had minimal effects. Most GOF and LOF were associated with a change in O-fucosylation. Finally, by comparing our results with known NOTCH1 alterations in cancers from which our mutations originated, we were able to establish a correlation between our results and the known GOF or LOF of NOTCH1 in these cancers. This study shows that point mutations in N1 can lead to alterations in O-fucosylation that deregulate the Notch pathway and be associated with cancer processes.

Dynamic changes in RAS gene status in circulating tumour DNA: a phase II trial of first-line FOLFOXIRI plus bevacizumab for RAS-mutant metastatic colorectal cancer (JACCRO CC-11)

Background

Few prospective studies have used liquid biopsy testing in RAS-mutant metastatic colorectal cancer (mCRC), and its clinical significance remains unknown. Therefore, this study aimed to carry out a biomarker analysis by liquid biopsy using updated data of the phase II trial of FOLFOXIRI plus bevacizumab as first-line chemotherapy for RAS-mutant mCRC.

Materials and methods

A total of 64 patients who received modified FOLFOXIRI regimen (irinotecan 150 mg/m², oxaliplatin 85 mg/m², levofolinate 200 mg/m², and fluorouracil 2400 mg/m²) plus bevacizumab biweekly were enrolled. The primary endpoint was the objective response rate (ORR). Plasma samples were collected at pre-treatment, 8 weeks after treatment, and progression in participants included in the biomarker study. The levels of circulating tumour DNA (ctDNA) and specific KRAS and NRAS variants were evaluated using real-time PCR assays.

Results

There were 62 patients (median age: 62.5 years, 92% performance status 0, 27% right side) who were assessable for efficacy and 51 for biomarker analysis. ORR was 75.8% (95% confidence interval 65.1% to 86.5%). The median progression-free survival was 12.1 months, and the median overall survival (OS) was 30.2 months. In 78% of patients, RAS mutations disappeared in the ctDNA at 8 weeks after treatment; these patients tended to have better outcomes than those with RAS mutations. Interestingly, RAS mutations remained undetectable during progression in 62% of patients. Survival analysis indicated that the median OS from progression was significantly longer in patients with RAS mutation clearance than in those with RAS mutation in the ctDNA at disease progression (15.1 versus 7.3 months, hazard ratio: 0.21, P = 0.0046).

Conclusions

Our biomarker study demonstrated no RAS mutations in ctDNA at disease progression in 62% of patients with RAS-mutant mCRC. Both OS and post-progression survival were better in patients with clearance of RAS mutations in ctDNA after triplet-based chemotherapy.

•

First-line FOLFOXIRI plus bevacizumab is effective for RAS-mutant mCRC with comparable efficacy in elderly patients.

•

RAS mutations disappeared in ctDNA after intensive chemotherapy in 62% of patients with mCRC with RAS-mutant tumours.

•

Survival time was longer in patients with RAS mutation clearance than in those with RAS mutations in ctDNA.

Inappropriate Metacognitive Status Increases State Anxiety in Genetic Counseling Clients

Background

Many genetic counseling (GC) studies have focused on anxiety status because clients of GC often feel anxious during their visits. Metacognition is known to be one of the causes of having an inappropriate thinking style. In this study, we examined the relationship between anxiety and the metacognitive status of GC clients according to their characteristics.

Methods

The participants were 106 clients who attended their first GC session in our hospital from November 2018 to March 2021. The survey items were the clients’ characteristics, anxiety status at the time of the visit, and metacognitive status.

Results

High state anxiety and high trait anxiety were observed in 34.9 and 11.3% of clients, respectively. Clients who were a relative or had a family history were significantly more likely to have high state anxiety. As for metacognitive status, only negative beliefs about thoughts concerning uncontrollability and danger were associated with having an anxiety status. Furthermore, multivariate analysis showed that negative beliefs about thoughts concerning uncontrollability and danger were an independent determinant of higher state anxiety, but not being a relative or having a family history. Metacognitive status scores were significantly lower in clients than in the control group.

Conclusion

State anxiety was shown to be more dependent on negative beliefs about thoughts concerning uncontrollability and danger of GC clients than their characteristics such as being a relative or having a family history. The results of this study will contribute to the development of new GC psychosocial support measures to address the anxiety of GC clients.

Automatic surgical phase recognition in laparoscopic inguinal hernia repair with artificial intelligence

BACKGROUND

Because of the complexity of the intra-abdominal anatomy in the posterior approach, a longer learning curve has been observed in laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair. Consequently, automatic tools using artificial intelligence (AI) to monitor TAPP procedures and assess learning curves are required. The primary objective of this study was to establish a deep learning-based automated surgical phase recognition system for TAPP. A secondary objective was to investigate the relationship between surgical skills and phase duration.

METHODS

This study enrolled 119 patients who underwent the TAPP procedure. The surgical videos were annotated (delineated in time) and split into seven surgical phases (preparation, peritoneal flap incision, peritoneal flap dissection, hernia dissection, mesh deployment, mesh fixation, peritoneal flap closure, and additional closure). An AI model was trained to automatically recognize surgical phases from videos. The relationship between phase duration and surgical skills were also evaluated.

RESULTS

A fourfold cross-validation was used to assess the performance of the AI model. The accuracy was 88.81 and 85.82%, in unilateral and bilateral cases, respectively. In unilateral hernia cases, the duration of peritoneal incision (p = 0.003) and hernia dissection (p = 0.014) detected via AI were significantly shorter for experts than for trainees.

CONCLUSION

An automated surgical phase recognition system was established for TAPP using deep learning with a high accuracy. Our AI-based system can be useful for the automatic monitoring of surgery progress, improving OR efficiency, evaluating surgical skills and video-based surgical education. Specific phase durations detected via the AI model were significantly associated with the surgeons' learning curve.

Comparison of clinical effect of living alone between urban area and rural area in patient with acute coronary syndrome

Background and objective

Living alone is reported as an independent risk factor for worse clinical outcomes after percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). Manifestations of psychological stress such as depression and anxiety in patients living alone is thought to be associated with subsequent cardiovascular events. The impact of living alone on the psychological factors of patients may be differ depending on their living environment. However, comparison of the effects of living alone in different living environment on the prognosis of patients with ACS has not been reported.

Purpose

The aim of the present study was to compare the clinical effect of living alone on clinical outcomes in patients with ACS between urban area and rural area.

Methods

Data from a multi-center, observational study of consecutive patients who underwent emergency PCI for ACS between January 2012 and December 2016 were analyzed. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE). MACCE was defined as composite of cardiovascular death, ACS, and stroke.

Results

In this study, 1349 patients were enrolled and divided into two population according to their living environment: urban area population (n=417), and rural area population (n=932). In urban area population, 87 patients (20.9%) were living alone, and 330 (79.1%) were living together. In rural area population, 169 (18.1%) were living alone, and 763 (81.9%) were living together. There are no significant differences in baseline characteristics between the living alone group and the living together group in both urban area population and rural area population. During a median follow-up period of 2.1 years, Kaplan-Meier curves showed the living alone group had higher risk of MACCE than the living together group in urban area population (log-rank, p=0.01). On the other hands, there are no significant differences in the incidences of MACCE between two groups in rural area population (p=0.86). After adjustment for other covariates, the living alone was significantly associated with MACCE (hazard ratio [HR], 2.83; 95% confidential interval [CI], 1.16–6.91; p=0.02) compared with the living together group in urban area population. However, in rural area population, the living alone group was not significantly associated with MACCE (HR, 1.02; 95% CI, 0.66–1.57; p=0.92) compared with the living together group.

Conclusion

Living alone was significantly associated with worse clinical outcomes after emergency PCI of ACS in urban area but not in rural area.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Comparison of clinical outcomes between percutaneous coronary intervention for the de novo lesion versus in-stent restenosis lesion

Background and objective

Percutaneous coronary intervention (PCI) with metallic coronary stent (bare-metal stents [BMS] and drug-eluting stents [DES]) implantation is most frequently performed therapeutic procedures for coronary artery disease. In-stent restenosis (ISR) is a critical drawback of metallic coronary stents. Incidence of ISR has been reported in up to 30% after BMS implantation. The use of DES has greatly reduced the proportion of restenosis compared with the BMS. However, ISR still remains the primary concern after PCI even in the contemporary DES era, and thought to be associated with worse clinical outcomes. However, comparative data on ISR and de novo lesions are rare.

Purpose

The aim of the present study was to compare the clinical outcomes after PCI for the de novo lesion and the ISR lesion.

Methods

We performed a retrospective analysis of patients who underwent PCI between 2013 and 2020. The incidences of major adverse cardiac and cerebrovascular events (MACCE) and all-cause death were evaluated. MACCE was defined as composite of cardiovascular death, non-fatal myocardial infarction, and stroke.

Results

In this study, 1538 patients were enrolled and divided into two groups: PCI for de novo lesion group (n=1258, 81.8%), and PCI for ISR lesion group (n=280, 18.2%). Patients in the ISR lesion group were significantly older and had higher prevalence of hypertension, diabetes mellitus, dyslipidemia and chronic kidney disease than patients in the de novo lesion group. During a median follow-up period of 1.9 years, Kaplan-Meier curves showed no significant differences in the incidences of MACCE (log-rank, p=0.86) and all-cause death (p=0.84) between two groups. After adjustment for other covariates, PCI for ISR lesion were not significantly associated with MACCE (hazard ratio [HR], 1.10; 95% confidential interval [CI], 0.61–1.97; p=0.76) and all-cause death (HR, 0.93; 95% CI, 0.56–1.56; p=0.79)

Conclusion

PCI for the ISR lesion was not associated with worse clinical outcomes compared with PCI for the de novo lesion.

Funding Acknowledgement

Type of funding sources: None.

The relationship among extent of lipid-rich plaque, factors associated with a reduction of lipid-rich plaque and late lumen loss: a near-infrared spectroscopy and intravascular ultrasound study

Background

Near-infrared spectroscopy (NIRS) and intravascular ultrasound (IVUS) are useful imaging modalities to identify lipid-rich plaque (LRP) which is associated with an increased risk of future cardiovascular events in individuals undergoing PCI. Pathological studies have raised concerns that treating LRP with stents may impair vascular healing. However, the impact of stent implantation to LRP lesions was less known. Moreover, little information is available about changes in the extent of LRP at before and after PCI.

Purpose

The aim of this study was to investigate changes in LRP by NIRS between pre- and post-stent implantation, and to evaluate an association among impact of LRP by NIRS at pre- and post-stenting and late lumen loss (LLL) by angiography.

Methods

We studied 175 lesions in 149 patients who underwent PCI under NIRS-IVUS guidance and follow-up angiography at 8-month later from 2017 to 2020. Plaque characteristics on IVUS, the extent of LRP [defined as a long segment with a 4-mm maximum lipid core burden index (maxLCBI4mm)] on NIRS, and quantitative coronary angiography measurements were analyzed. We evaluated a change of the extent of LRP between pre- and post-stenting at index PCI procedure, and association between the extent of LRP and a 8-month LLL at follow-up coronary angiography. A large LRP was defined as maxLCBI4mm>400 at pre-stenting.

Results

Mean age was 64.5 years old, and 123 (82%) patients were male. The prevalence of large LRP was 51% and median plaque burden at minimum lumen area was 81%. The extent of LRP at culprit lesion significantly decreased from pre- to post-stenting (median maxLCBI4mm [interquartile range (IQR)]: 407 [199, 580] to 133 [13, 319], p<0.001) (Figure 1). In multivariable liner regression analysis, independent predictors for the reduction of LRP were a pre-stenting LRP (β coefficient = −57.0, 95% confidence interval (CI) [−65.1 to −48.8], p<0.001) and plaque burden (β coefficient = −30.0, 95% CI [−56.6 to −3.4], p<0.001), respectively. On the other hands, patient comorbidities, lipid profile and inflammatory markers were not associated with the reduction of LRP (all p>0.05). Median LLL at follow-up angiogram was 0.17 [0.07–0.35] mm. Both the extent of pre- and post-stenting LRP were not associated with LLL (r=0.018, p=0.80 and r=0.022, p=0.76, respectively) (Figure 2). In addition, there was no significant difference in LLL between the post-stenting large and non-large LRP (median [IQR] 0.18 [0.08–0.35] vs. 0.17 [0.07–0.35]; P=0.95).

Conclusions

This study showed coronary stent implantation significantly reduced the NIRS-derived LRP in patients undergoing PCI. Although the extent of pre-stenting LRP and IVUS plaque burden predicted the reduction of LRP, the extent of pre- and post-stenting LRP were not associated with LLL. These findings suggest that stent implantation for LRP, even in a large LRP, is safe and does not affect LLL.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Scatter plotsFigure 2. CENTRAL Figure

Coronary lipid-rich plaque characteristics with acute coronary syndrome and chronic coronary syndrome: a near infrared spectroscopy and intravascular ultrasound study

Background

Asians have a much lower incidence of adverse coronary events than Caucasians, and the characteristics of vulnerable plaque might be different among the ethnics.

Purpose

The aim of this study was to investigate the clinical characteristics of lipid-rich plaque (LRP) in the Asian population and we also aimed to distinguish the characteristics of an acute coronary syndrome (ACS) culprit lesion and a chronic coronary syndrome (CCS) culprit lesion. Furthermore, we evaluated the association between lipid core burden index (LCBI) and cardiovascular risk factors, lipid profiles, and inflammatory biomarkers, as determined in vivo by near infrared spectroscopy intravascular ultrasound (NIRS-IVUS) imaging in patients undergoing percutaneous coronary intervention (PCI).

Methods

We evaluated 207 patients (ACS, n=75; CCS, n=132) who underwent PCI under NIRS-IVUS. Plaque characteristics and the extent of LRP [defined as a long segment with a 4-mm maximum LCBI (maxLCBI4mm)] on NIRS in de-novo culprit and non-culprit segments were analyzed.

Results

The mean age was 65 years old and 82% of patients were male. The ACS culprit lesions had a significantly higher maxLCBI4mm (median [interquartile range (IQR)]: 533 [385–745] vs. 361 [174–527], p<0.001) than the CCS culprit lesions. Whereas, no significant difference was seen in maxLCBI4mm between ACS and CCS non-culprit lesion segments (246 [53, 342] vs. 185 [37, 350], p=0.47) (Figure 1). Receiver-operating characteristic analysis showed that the NIRS maxLCBI4mm could distinguish the ACS culprit segment from the CCS culprit segment, with a sensitivity of 73% and a specificity of 69% (c-statistic = 0.69; p<0.001, cut-off value of max LCBI4mm = 408) (Figure 2). On multivariate logistic analysis, a large LRP (defined as maxLCBI4mm ≥400) was the strongest independent predictor of the ACS culprit segment (odds ratio, 3.87; 95% confidence interval, 1.95–8.02). In non-culprit segments, 19.8% of patients had at least one large LRP without a small lumen. No significant correlation was found between the extent of LRP and circulating lipid profiles and inflammatory makers biomarkers (hs-CRP, IL-6, TNF-α) in both the culprit and non-culprit lesion segments, whereas the extent of LRP was positively correlated with IVUS plaque burden (r=0.24, p<0.001).

Conclusions

We confirmed that NIRS-IVUS plaque assessment could be useful to differentiate ACS from CCS culprit lesions, and that a threshold maxLCBI4mm ≥400 was clinically suitable in Japanese patients. No systemic surrogate markers were found to be associated with the extent of LRP by NIRS in culprit and non-culprit segments. Consequently, we believe that direct intravascular evaluation of coronary plaque characteristics remains important for identification of high-risk LRP.

Funding Acknowledgement

Type of funding sources: None. Figure 1. The difference of maxLCBI4mmFigure 2. ROC curve

Modulation of the NOTCH1 Pathway by LUNATIC FRINGE Is Dominant over That of MANIC or RADICAL FRINGE

Fringes are glycosyltransferases that transfer a GlcNAc to O-fucose residues on Epidermal Growth Factor-like (EGF) repeats. Three Fringes exist in mammals: LUNATIC FRINGE (LFNG), MANIC FRINGE (MFNG), and RADICAL FRINGE (RFNG). Fringe modification of O-fucose on EGF repeats in the NOTCH1 (N1) extracellular domain modulates the activation of N1 signaling. Not all O-fucose residues of N1 are modified by all Fringes; some are modified by one or two Fringes and others not modified at all. The distinct effects on N1 activity depend on which Fringe is expressed in a cell. However, little data is available on the effect that more than one Fringe has on the modification of O-fucose residues and the resulting downstream consequence on Notch activation. Using mass spectral glycoproteomic site mapping and cell-based N1 signaling assays, we compared the effect of co-expression of N1 with one or more Fringes on modification of O-fucose and activation of N1 in three cell lines. Individual expression of each Fringe with N1 in the three cell lines revealed differences in modulation of the Notch pathway dependent on the presence of endogenous Fringes. Despite these cell-based differences, co-expression of several Fringes with N1 demonstrated a dominant effect of LFNG over MFNG or RFNG. MFNG and RFNG appeared to be co-dominant but strongly dependent on the ligands used to activate N1 and on the endogenous expression of Fringes. These results show a hierarchy of Fringe activity and indicate that the effect of MFNG and/or RFNG could be small in the presence of LFNG.

Asparagine Tautomerization in Glycosyltransferase Catalysis. The Molecular Mechanism of Protein O-Fucosyltransferase 1

O-glycosylation is a post-translational protein modification essential to life. One of the enzymes involved in this process is protein O-fucosyltransferase 1 (POFUT1), which fucosylates threonine or serine residues within a specific sequence context of epidermal growth factor-like domains (EGF-LD). Unlike most inverting glycosyltransferases, POFUT1 lacks a basic residue in the active site that could act as a catalytic base to deprotonate the Thr/Ser residue of the EGF-LD acceptor during the chemical reaction. Using quantum mechanics/molecular mechanics (QM/MM) methods on recent crystal structures, as well as mutagenesis experiments, we uncover the enzyme catalytic mechanism, revealing that it involves proton shuttling through an active site asparagine, conserved among species, which undergoes tautomerization. This mechanism is consistent with experimental kinetic analysis of Caenorhabditis elegans POFUT1 Asn43 mutants, which ablate enzyme activity even if mutated to Asp, the canonical catalytic base in inverting glycosyltransferases. These results will aid inhibitor development for Notch-associated O-glycosylation disorders.

Morphological Alterations of the Sarcotubular System in Permanent Myopathy of Hereditary Hypokalemic Periodic Paralysis with a Mutation in the CACNA1S Gene

We investigated the immunohistochemical localization of several proteins related to excitation-contraction coupling and ultrastructural alterations of the sarcotubular system in biopsied muscles from a father and a daughter in a family with permanent myopathy with hypokalemic periodic paralysis (PMPP) due to a mutation in calcium channel CACNA1S; p. R1239H hetero. Immunostaining for L-type calcium channels (LCaC) showed linear hyper-stained regions indicating proliferation of longitudinal t-tubules. The margin of vacuoles was positive for ryanodine receptor, LCaC, calsequestrin (CASQ) 1, CASQ 2, SR/ER Ca2+-ATPase (SERCA) 1, SERCA2, dysferlin, dystrophin, α-actinin, LC3, and LAMP 1. Electron microscopy indicated that the vacuoles mainly originated from the sarcoplasmic reticulum (SR). These findings indicate impairment of the muscle contraction system related to Ca2+ dynamics, remodeling of t-tubules and muscle fiber repair. We speculate that PMPP in patients with a CACNA1S mutation might start with abnormal SR function due to impaired LCaC. Subsequent induction of muscular contractile abnormalities and the vacuoles formed by fused SR in the repair process including autophagy might result in permanent myopathy. Our findings may facilitate prediction of the pathomechanisms of PMPP seen on morphological observation.

Characterization of xanthine oxidase from Cellulosimicrobium funkei possessing hypoxanthine-metabolizing activity

AIMS

Purine-degrading enzymes are favourable as medications and diagnostic tools for hyperuricemia. This study aimed to characterize enzymes isolated from micro-organisms, which may be useful for developing a new prophylaxis for hyperuricemia.

METHODS AND RESULTS

Cellulosimicrobium funkei A153 was found to be a good catalyst for hypoxanthine degradation and could oxidize hypoxanthine to xanthine and further to uric acid. The enzyme catalysing this oxidation was purified, and its partial amino acid sequences were examined. Based on this information and genome sequencing results, this xanthine dehydrogenase family protein was cloned and expressed in Rhodococcus erythropolis L88. The recombinant enzyme with a His-tag was characterized. The enzyme was a xanthine oxidase as it could utilize molecular oxygen as an electron acceptor. It was stable under 50°C and exhibited maximum activity at pH 7·0. The k_cat , K_m and k_cat /K_m values for xanthine were 1·4 s^-1 , 0·22 mmol l^-1 and 6·4 s^-1  mmol^-1  l, respectively.

CONCLUSIONS

Xanthine oxidase is favourable for hyperuricemia medication because it oxidizes hypoxanthine, an easily adsorbed purine, to xanthine and further to uric acid, which are hardly adsorbed purines.

SIGNIFICANCE AND IMPACT OF THE STUDY

The enzyme is useful for decreasing serum uric acid levels via conversion of easily absorbed purines to hardly absorbed purines in the intestine. Enzymes from micro-organisms may be used as a novel prophylaxis for hyperuricemia.

Prognosis and cause of death in patients with left atrial appendage thrombus treated with or without anticoagulation therapy

Background

Thrombus in left atrial appendage (LAA) is associated with cardiogenic ischemic stroke; however, little is known about prognosis of patients with LAA thrombus detected by transoesophageal echocardiography (TOE).

Purpose

This study is to investigate the prognosis of patients with LAA thrombus and their cause of death.

Methods

Between 2005 and 2016, the patients who were performed TOE in our hospital were enrolled in this retrospective observational study. Five-year stroke free and survival curves were constructed by Kaplan-Meir method and cause of death were assessed.

Results

Among the 1263 study patients, LAA thrombus was detected in 146 (12%) patients. The patients with LAA thrombus were elder (74 y [66–79 y] vs. 70 y [62–76 y], P<0.001), than those without LAA thrombus, respectively. The prevalence of male sex (67% vs. 69%, P=0.63) were similar between the 2 groups. The prevalence of CHA2DS2-VASc score ≥2, d-dimer (1.7 mcg/ml [0.9–3.5 mcg/ml] vs. 0.8 mcg/ml [0.5–2.2 mcg/ml], P<0.001), and plasma brain natriuretic peptide (315 pg/ml [128–515 pg/ml] vs. 126 pg/ml [47–284 pg/ml], P<0.001) were higher in the patients with LAA thrombus than those without (89% vs. 78%, P=0.003). The LAA velocity was slower in the patients with LAA thrombus than those without (23 cm/s [15–34 cm/s] vs. 51 cm/s [35–72 cm/s], P<0.001). The prevalence of receiving anticoagulation therapy before (34% vs. 24%, P=0.01) and after (98% vs. 66%, P<0.001) TOE 1 month were higher in the patients with LAA thrombus than those without. The 5-year stroke free rate was lower in the patients with LAA thrombus than those without (82% vs. 93%, P<0.001); however, the 5-year survival were similar between the 2 groups (84% vs. 84%, P=0.93) (Figure). The cause of death as ischemic stroke was only 7% (1/14) and 3% (3/94), (P=0.43); the cardiac cause (14% vs. 43%, P=0.07) and the malignancy (35% vs. 29%, P=0.75) were the frequent cause of death in the patient with LAA thrombus and those without, respectively.

Conclusions

The patients who were detected thrombus in the LAA had higher incidence of ischemic stroke; however, the 5-y survival were similar. The ischemic stroke was not major cause of death in the patients with and without LAA thrombus. The higher rate of receiving anticoagulation therapy may be one of the causes of the discrepancy.

Figure 1

Funding Acknowledgement

Type of funding source: None

Clinical factors affecting evoked magnetic fields in patients with Parkinson's disease

Studies on evoked responses in Parkinson's disease (PD) may be useful for elucidating the etiology and quantitative evaluation of PD. However, in previous studies, the association between evoked responses and detailed motor symptoms or cognitive functions has not been clear. This study investigated the characteristics of the visual (VEF), auditory (AEF), and somatosensory (SEF) evoked magnetic fields in patients with Parkinson’s disease (PD), and the correlations between evoked fields and the patient’s clinical characteristics, motor symptoms, and cognitive functions. Twenty patients with PD and 10 healthy controls (HCs) were recruited as participants. We recorded VEF, AEF, and SEF, collected clinical characteristics, performed physical examinations, and administered 10 cognitive tests. We investigated differences in the latencies of the evoked fields between patients with PD and HCs. We also evaluated the correlation of the latencies with motor symptoms and cognitive functioning. There were significant differences between the two groups in 6 of the cognitive tests, all of which suggested mild cognitive impairment in patients with PD. The latencies of the VEF N75m, P100m, N145m, AEF P50m, P100m, and SEF P60m components were greater in the patients with PD than in the HCs. The latencies mainly correlated with medication and motor symptoms, less so with cognitive tests, with some elements of the correlations remaining significant after Bonferroni correction. In conclusion, the latencies of the VEF, AEF, and SEF were greater in PD patients than in HCs and were mainly correlated with medication and motor symptoms rather than cognitive functioning. Findings from this study suggest that evoked fields may reflect basal ganglia functioning and are candidates for assessing motor symptoms or the therapeutic effects of medication in patients with PD.

[Relationship between HER2 Gene Amplification and the Therapeutic Effect of Pertuzumab in HER2-Positive Breast Cancer]

OBJECTIVE

We examined the therapeutic effect of adding of pertuzumab in combination with trastuzumab as neoadjuvant chemotherapy for HER2-positive breast cancer.

PARTICIPANTS

Overall, 27 patients with HER2-positive breast cancer who had completed neoadjuvant chemotherapy and undergone surgery between January 2014 and January 2020 were included in the study. We performed a retrospective analysis of the relationship between HER2 gene amplification and the therapeutic effect of pertuzumab in this group. For the anti-HER2 treatment, only trastuzumab was administered to all patients until December 2018, and then a combination of trastuzumab and pertuzumab was administered to 4 patients from January 2019.

RESULTS

The case distribution based on histological therapeutic effect was: 4 patients with Grade 1, 12 patients with Grade 2, and 11 patients with Grade 3. Patients with immunohistochemistry scores of 3+ and high signal ratios of HER2/ CEP17 in FISH testing tended to have better therapeutic outcomes than other patients.

DISCUSSION

Outcomes similar to those observed in this study were reported in other cases where pertuzumab was used for anti-HER2 treatment. We expected that the therapeutic effects of pertuzumab would be better in patients with high HER2 expression. However, further research is required to understand the effects of pertuzumab in patients with cT1c that were not included in the Neo Sphere trial. The therapeutic effects of adding pertuzumab to the treatment in patients with cT1c and lymph node-positive breast cancer were indicated by comparison with our cases.

Can digital breast tomosynthesis improve identification of malignant calcifications?

Digital breast tomosynthesis (DBT) is an emerging imaging tool for both the screening and diagnosis of breast cancers. However, the use of DBT in diagnosis of calcifications remains ambiguous. In this study, we investigated DBT findings that might help differentiate between benign and malignant calcifications. We enrolled 256 subjects and evaluated 303 breasts with grouped or segmental calcifications. All imaging examinations were performed using two-directional full-field digital mammography (FFDM) and DBT. We divided subjects into two groups, namely, "dense" and "fatty," based on the quantity of breast tissue and evaluated whether the growth of cancer causes increased the density overlapping with calcifications. Increased overlapping density was significantly associated with malignant calcifications (p < 0.001), and the identification of increased density was more accurate using DBT than using FFDM. Furthermore, we used DBT to evaluate whether segmental calcifications were continuous or discontinuous. Significantly more malignant than benign calcifications were associated with a continuous distribution (p = 0.035). Increased density overlapping with grouped calcifications was significantly associated with invasive cancers (p = 0.017). The findings of this study suggest that DBT improves the ability to differentiate between benign and malignant calcifications.

ADAMTS9 and ADAMTS20 are differentially affected by loss of B3GLCT in mouse model of Peters plus syndrome

Peters plus syndrome (MIM #261540 PTRPLS), characterized by defects in eye development, prominent forehead, hypertelorism, short stature and brachydactyly, is caused by mutations in the β3-glucosyltransferase (B3GLCT) gene. Protein O-fucosyltransferase 2 (POFUT2) and B3GLCT work sequentially to add an O-linked glucose β1-3fucose disaccharide to properly folded thrombospondin type 1 repeats (TSRs). Forty-nine proteins are predicted to be modified by POFUT2, and nearly half are members of the ADAMTS superfamily. Previous studies suggested that O-linked fucose is essential for folding and secretion of POFUT2-modified proteins and that B3GLCT-mediated extension to the disaccharide is essential for only a subset of targets. To test this hypothesis and gain insight into the origin of PTRPLS developmental defects, we developed and characterized two mouse B3glct knockout alleles. Using these models, we tested the role of B3GLCT in enabling function of ADAMTS9 and ADAMTS20, two highly conserved targets whose functions are well characterized in mouse development. The mouse B3glct mutants developed craniofacial and skeletal abnormalities comparable to PTRPLS. In addition, we observed highly penetrant hydrocephalus, white spotting and soft tissue syndactyly. We provide strong genetic and biochemical evidence that hydrocephalus and white spotting in B3glct mutants resulted from loss of ADAMTS20, eye abnormalities from partial reduction of ADAMTS9 and cleft palate from loss of ADAMTS20 and partially reduced ADAMTS9 function. Combined, these results provide compelling evidence that ADAMTS9 and ADAMTS20 were differentially sensitive to B3GLCT inactivation and suggest that the developmental defects in PTRPLS result from disruption of a subset of highly sensitive POFUT2/B3GLCT targets such as ADAMTS20.

P768 Potential utility of fully automated Doppler flow velocity tracing software in patients with atrial fibrillation

Purpose

We aimed to determine the usefulness of the software, and to validate the minimum number of beats required to approximate SV in patients with AF.

Methods

We selected 21 AF patients who had undergone 2D echocardiography using GE ultrasound machine (E95, GE healthcare). LVOT area was calculated by 3.14×(LVOT diameter/2)². LVOT pulse-wave Doppler velocity was recorded from an apical approach with a quiet breathing. To maximize the number of flow envelope on the screen, sweep speed was set at 12.5 mm/s. LVOT velocity time integral was measured by both manual tracing method and fully automated method (Cardiac Auto Doppler, GE healthcare). The grand truth of mean SV (reference SV) in each patient was defined as the averaged values of SV from all consecutive beats. We also calculated the mean SV value with the successive addition of sequential beats started from the 1st beat. Each value was compared with the reference SV and % variability was calculated. We determined the minimum number of beats showing %variability becoming &lt;5%.

Results

Mean age was 77 years. Mean heart rate and reference SV index (SVI) were 80 ± 12 bpm and 35 ± 10 mL/m2. A total number of beats for recording was ranged from 16 to 25 in each patient. The fully automated software could analyze Doppler envelope in 395 out of 412 beats (Feasibility: 96%). Although there was a good correlation of SV in individual beats between the manual and automatic method (r = 0.92), the automatic method significantly overestimated SV (mean bias: 2.6 mL, p &lt; 0.001) compared with the manual method. The median values of minimum number of beats showing % variability &lt; 5% were 4 (interquartile range: 2 -7) for manual tracing method. The corresponding values were 5 (2 -6) for automatic method. If we used mean values of SV during consecutive 10 beats, 92% of patients using manual method and 96% of patients using automatic method showed % variability &lt; 5%. There were excellent correlation between reference SV and averaged SV from the 1st beat to 10th beat (manual: r = 0.98, automatic: r = 0.99). If we defined low flow status as &lt; 35 mL/m2, averaged SVI during consecutive 10 beats using the automatic method had a correct diagnosis in 20 out of 21 patients.

Conclusions

We concluded that minimum number of required beats for averaging was 10 in most AF patients. Rapid and reliable SV analysis with a novel fully automated Doppler software has a potential for its adoption in busy echocardiography laboratories.

P695 Is reference value of left atrial strain using 2D echocardiography really reliable?

Funding Acknowledgements

MT received research grant from GE Healthcare.

Background

Left atrial (LA) longitudinal strain (LALS) assessed by two-dimensional echocardiography (2DE) speckle tracking analysis is increasingly popular for the estimation of left ventricular diastolic dysfunction and the prediction of adverse outcome. Since standard apical 4-chamber and 2-chamber views often maximize the long-axis of the left ventricle, and the long axis of the left ventricle and that of the left atrium do not lie on the same 2D cutting plane, these views have a risk for the foreshortening of the left atrium. It may cause overestimation of LALS due to the reduction of initial perimeter of region of interest that is a denominator for the strain calculation.

Purpose

The aim of this study was to compare LALS values between 2DE and 3D echocardiography (3DE) in healthy subjects, and investigate whether 2DE speckle tracking analysis overestimates reference value of LALS.

Methods

LALS and LA longitudinal length were measured by both 2DE and 3DE in 105 healthy subjects (median age, 42 years; 59 men). For 2DE, LA longitudinal length from the mitral annulus to the roof of the left atrium were measured on apical 4-chamber and 2-chamber views at end-diastole and at end-systole, and the values were averaged. Apical 4-chamber and 2-chamber LALS was also measured using 2DE speckle tracking software (EchoPac PC, GE Healthcare) for calculating biplane LALS. 3DE LALS was measured using new 3DE LA strain software (4D Auto LAQ, GE Healthcare). 3DE determined LA longitudinal length at both end-diastole and end-systole was also measured using the same 3DE datasets.

Results

Mean values of biplane LALS was 39.6 ± 11.8%. 2DE LA longitudinal length at both end-diastole (r=-0.43) and end-systole (r=-0.54) was negatively correlated with biplane LALS. Multivariable regression analysis revealed that both end-diastolic and end-systolic LA longitudinal length had a significant negative association for biplane LALS after adjusting anthropometric and echocardiography image quality parameters. 3DE LALS analysis was not possible in 11 subjects due to the erroneous LA border determination (Feasibility: 90%). 3DE LALS (23.7 ± 7.6%) was significantly lower than biplane LALS (39.5 ± 12.0%, p &lt; 0.001) with a weak correlation (r = 0.33) in 94 subjects who were possible in both analyses. Paired comparison of LA longitudinal length between 2DE and 3DE revealed that 2DE determined LA length at end-diastole (3.51 ± 0.72 cm vs. 4.85 ± 0.56 cm, p &lt; 0.001) and at end-systole (4.63 ± 0.69 cm vs. 5.84 ± 0.54 cm, p &lt; 0.001) was significantly shorter than that obtained from 3DE.

Conclusions

Our results highlighted that LA cavity visualizing on the standard apical 4-chamber and 2-chamber views are often longitudinally foreshortened, and this is a potential cause for the overestimation of LALS. 3DE may overcome this limitation.

152 An effective method of inducing oestrus in superovulation-treated Japanese Black donor cows after egg collection

The objective of this study was to evaluate the effect of inducing oestrus in superovulation-treated Japanese Black donor cows after egg collection using a controlled internal drug release (CIDR) device and prostaglandin F2α treatments. The test animals were 50 biparous or triparous Japanese Black cows that had been treated for superovulation during the period of 75-110 days post-calving and from each of which 10 or more ova or embryos had been recovered using a uterine reflux method. In the 25 cows of the control group that received the conventional treatment, a CIDR was not introduced into the vagina, the number of days from egg harvesting to standing oestrus was recorded, and AI was performed using frozen semen. At the time of AI, 50µg of gonadotrophin-releasing hormone (GnRH; Consultan, Aska Animal Health) was administered intramuscularly. The cows that did not conceive in the first AI attempt were again given the same AI and GnRH treatments in the next oestrus cycle. In the 25 cows of the treatment group, a CIDR (CIDR 1900, Zoetis) device was inserted in the vagina after egg harvesting and was kept there for 12 days. At the time of insertion and removal of the CIDR, 150µg of d-cloprostenol formulation (Dalmazin, Kyoritsu Seiyaku) was administered intramuscularly. The number of days from egg harvest to standing oestrus was recorded, and GnRH was administered at the time of AI. The cows that did not conceive in the first AI attempt were given the same AI and GnRH treatments in the next oestrus cycle. The control and treatment groups were compared for the number of days from egg harvesting to oestrus (t-test) and the conception rate after AI (chi-square test). The mean number of days from egg collection to standing oestrus in the control group was 38.6±11.9, and the conception rate was 60% (15/25). Among the animals that failed to conceive in the first AI attempt, the second standing oestrus occurred 60.7±13.1 days after egg collection, and 70% (7/10) of the cows conceived after the second AI. In the treatment group, on the other hand, the mean number of days from egg collection to standing oestrus was 15.8±3.9, and 72% (18/25) of the cows conceived after the first AI. Among the cows that failed to conceive, the second standing oestrus occurred 37.4±4.7 days after egg harvest, and 71% (5/7) of the cow conceived after the second AI. There was a significant difference between the two groups in the number of days from egg collection to the first standing oestrus (P&lt;0.05). The results described above suggest that keeping a CIDR in the vagina for 12 days and intramuscularly administering prostaglandin F2α at the time of insertion and removal of the CIDR in superovulated cows are effective for early onset of standing oestrus after egg collection and thus can reduce the number of days to conception.

P1408 Age and gender dependency of left ventricular and left atrial volume ratio assessed by three-dimensional echocardiography

Funding Acknowledgements

Dr. Takeuchi was supported by a Grant-in-aid for Scientific Research (19K12853) from the Japanese Society of Promotion of Science.

Background

Left ventricular (LV) and left atrial (LA) volumes may change according to advanced aging. Since both chambers affect each other, their ratio, LV and LA volume ratio (LVLAVR) may sensitively detect age- and gender-related change in left chamber volume and function.

Purpose

We aimed to (1) investigate age and gender dependency of LVLAVR and (2) determine reference values.

Methods

We simultaneously obtained both LV and LA volume curves using 3D echocardiography with novel speckle tracking software (4D LV analysis v.3 LA, TomTec Imaging systems), and generated LVLAVR curve throughout one cardiac cycle, from which we measured LVLAVR at end-diastole (ED) and at end-systole (ES) in 313 healthy subjects (age, 20-85 years; 51% men).

Results

The mean values of LVLAVR at ED and ES in male subjects were 5.74 ± 1.54 and 1.37 ± 0.35, respectively. Corresponding values in female subjects were significantly lower (5.20 ± 1.47, p = 0.003 and 1.13 ± 0.29, p &lt; 0.001) than those in male subjects. Their age and gender dependency are shown in table. LVLAVR at ED step wisely decreased to advanced aging, and had a highest F ratio compared with other left chamber volumetric parameters in both gender.

Conclusions

We proposed new index, LVLAVR which is a sensitive parameter to reflect age- and gender-related change in LV and LA volumes. Further studies should be required to validate clinical utility of this index over traditional volumetric parameters.

Male subjects (n = 160) 3rd decade (n = 35) 4th decade (n = 34) 5th decade (n = 34) 6th decade (n = 21) 7th decade (n = 24) F ratio p-value LVEDVI (ml/m2) 81 ± 12 72 ± 11 75 ± 14 71 ± 11 68 ± 12 4.22 0.003 LVESVI 38 ± 7 33 ± 6 35 ± 8 34 ± 5 32 ± 6 2.93 0.023 Maximum LAVI 25 ± 5 25 ± 4 27 ± 5 26 ± 6 30 ± 8 4.07 0.004 Minimum LAVI 12 ± 3 12 ± 3 14 ± 3 14 ± 3 18 ± 6 12.23 &lt;0.001 LVLAVR at ED 6.80 ± 1.54 6.36 ± 1.31 5.42 ± 1.00 5.23 ± 1.37 3.97 ± 0.85 19.72 &lt;0.001 LVLAVR at es 1.53 ± 0.42 1.39 ± 0.29 1.36 ± 0.31 1.35 ± 0.32 1.09 ± 0.26 5.85 &lt;0.001 Female subjects (n = 153) 3rd decade (n = 31) 4th decade (n = 23) 5th decade (n = 30) 6th decade (n = 22) 7th decade (n = 47) F ratio p-value LVEDVI 69 ± 11 68 ± 10 62 ± 8 60 ± 9 63 ± 9 4.29 0.003 LVESVI 29 ± 6 29 ± 6 27 ± 5 26 ± 7 28 ± 6 1.45 0.220 Maximum LAVI 24 ± 5 24 ± 5 24 ± 5 25 ± 5 27 ± 5 1.73 0.147 Minimum LAVI 11 ± 2 11 ± 2 12 ± 3 13 ± 4 16 ± 4 16.59 &lt;0.001 LVLAVR at ED 6.51 ± 1.36 6.20 ± 1.26 5.43 ± 1.28 4.67 ± 0.96 4.03 ± 0.81 25.46 &lt;0.001 LVLAVR at ES 1.22 ± 0.22 1.22 ± 0.32 1.14 ± 0.33 1.06 ± 0.29 1.06 ± 0.25 2.08 0.087 LVED(S)VI, left ventricular end-diastolic (end-systolic) volume index; LAVI, left atrial volume index; LVLAVR, left ventricular left atrial volume ratio

3076Individual patient meta-analysis of global longitudinal strain: is one normal range enough?

Background

Despite over a decade of evidence, uptake of GLS into guidelines and practice has been slow. Age, BP, and software have been reported to influence GLS, and have led to uncertainty about defining the normal range (NR). As there have been software changes since the last meta-analysis, we sought to define NR in the current era.

Methods

Pubmed, Cochrane, and EMBASE were searched using the keywords “Left Ventricle”, “Normal global longitudinal strain”, and “Speckle tracking Echocardiography” and relevant synonyms from 2011. Studies were included if they reported GLS based on speckle tracking techniques, included at least 20 healthy individuals, and had up to date contact details available. Healthy was defined as lack of known disease. Platforms used included General Electric, Philips, Canon and Tomtec. The authors of 8 of the 12 studies (67% response) provided individual patient data. Linear regression was used to determine predictors of GLS.

Results

There were 2396 pts, mean age 42 years (range 18–92), weight 66±12kg, height 169±9cm, BSA 1.7±0.2m2, and SBP 120±13 mmHg. Normal range for GLS was 21.0±2.6%. In multivariable analysis age (β=-0.02, p<0.01), weight (β=-0.03, p<0.01), SBP (β=-0.01, p<0.01) and platform were associated with GLS. GLS tends to vary with extremes of age and BP (see Figure 1 and Figure 2).

GLS vs Age group

Conclusion

Extremes of age and BP may lead to low GLS, but generally, GLS is <16% is abnormal.

Acknowledgement/Funding

None

92Transcatheter aortic valve implantation improves cerebral blood flow and cognitive function in elderly patients with aortic stenosis - Brain perfusion SPECT imaging study

Background

Cognitive impairment and depression are commonly noted in elderly frail patients with severe aortic stenosis (AS). However, their mechanisms and reversibility after treatment remain remain to be examined.

Purpose

In this study, we examined whether transcatheter aortic valve implantation (TAVI) increases cerebral blood flow (CBF) in cognitive/emotional brain areas, such as the hippocampus, in the elderly patients with severe AS.

Methods

We examined consecutive 15 right-handed patients with severe AS who were eligible for TAVI (median age 83.2 years, 12 (80%) women). We evaluated the following assessments both at baseline and 3 months after TAVI. Frailty was evaluated based on Fried scale, which consists of 5 items, including gait speed, cognitive function, weight loss, exhaustion, and inactivity. Frail and pre-frail were defined as greater than 3 and 1∼2 in the scale, respectively. Cognitive and emotional status were evaluated with Logical Memory (LM) II, Mini Mental State Examination (MMSE), and geriatric depression scale (GDS). Lower LM II (less than 4 points) and MMSE (less than 24 points) and higher GDS (more than 6 points) indicate worse memory, general cognitive function, and depressive symptoms, respectively. CBF images were recorded with 99mTc single-photon emission computed tomography and were analyzed using SPM12. Briefly, CBF images were firstly normalized to the standard Montreal Neurological Institute space. Then, a voxel-wise parametric analysis was conducted between normalized CBF images at baseline and those after TAVI (P<0.005 at each voxel). Continuous variables were presented as mean ± standard error (SE). Normality was assessed using the Shapiro-Wilk test. Continuous variables were compared with the use of paired t test. Linear mixed-model analysis was performed to evaluate changes in neuropsychological tests and CBF over time.

Results

In the present study, all patients were not robust but pre-frail (47.3%) or frail (53.7%). LM II score was significantly improved at 3 months after TAVI compared with baseline (baseline, 8.7 vs. 3 months, 13.8, P<0.01) (Figure A), whereas no significant changes in MMSE or GDS scores were noted (baseline, 24.6 vs. 3 months, 25.2 for MMSE; baseline, 4.3 vs. 3 months, 4.2 for GDS). Importantly, although no patients showed clinical symptoms or signs for transient ischemic attack or stroke after TAVI, CBF in the local regions, including the right hippocampus, was significantly increased after TAVI compared with baseline (P<0.005 at each voxel) (green arrowheads) (Figure B). Furthermore, CBF in the right hippocampus were positively correlated with LM II scores (P=0.017) (Figure C).

Figure 1

Conclusions

These results provide the first evidence that TAVI improves cerebral perfusion (especially that in the hippocampus) and cognitive functions in elderly patients with severe AS.

P1745Clinical characteristics and long-term outcome in patients with helicopter-transported acute coronary syndrome after primary percutaneous coronary intervention

Background

Reducing delay to percutaneous coronary intervention improves functional outcome and reduces long-term mortality. Transportation by helicopter is often quicker than ground transport and thus may improve overall prognosis through reduced ischemic injury and infarction size. Our hospital is located on the medically-depopulated peninsula surrounded by mountain. The journey from the southern tip of the peninsula to the critical care medical center of our hospital take 1.5 hour by a ground ambulance but only 15 minutes by helicopter.

We compared the clinical characteristics and long-term mortality between air and ground transport of ACS patients for primary PCI.

Methods

We conducted an observational cohort study evaluating 2324 patients (mean age 68.5±12.0, male 75.2%) with ACS underwent primary PCI between April 2004 and December 2017 at our hospital.

We divided into three groups according to transportation system type (air, ground, walk-in).

The primary outcome was defined as all-cause death during the long-term follow-up.

Results

Among the entire cohort, 577 patients (24.8%) were transported by air. 1326 (57.1%) patients by ambulance, 421 (18.1%) patients by walk. Baseline characteristics were comparable, but patients by air had a higher prevalence of ST-elevation myocardial infarction.

The rate of long-term mortality was comparable during the median follow up of 6 years (air, 21.1% vs. ground, 21.4% vs. walk-in, 21.1%, respectively, log-rank p=0.72). Multivariate Cox regression analysis showed no significant association between air transportation and long-term mortality (Adjusted HR [vs ground] 1.05, 95% CI 0.60–1.78, p=0.85 and [vs walk-in] 0.94, 95% CI 0.62–1.43, respectively, p=0.77).

Kaplan-Meier curve

Conclusions

The rate of long-term mortality in patients with ACS transported by air was comparable with those transported by ground.

P628Association of outpatient cardiac rehabilitation with mortality and morbidities in patients with acute myocardial infarction

Background/Introduction

Outpatient cardiac rehabilitation (CR) is commonly recommended for patients with acute myocardial infarction (AMI). However, the survival benefit has recently been contested, especially with no survival benefit having been found in non-Western countries.

Purpose

To investigate whether outpatient CR, under current real-world clinical practice, is associated with lower mortality and morbidity risks in patients with AMI.

Methods

The retrospective cohort study was conducted from January 2011 to June 2016 (final date of follow-up: July 31, 2016) with a nation-wide administrative database for acute-care hospitals in Japan. Data for 7,411 patients were analyzed, with 5,654 fulfilling the inclusion criteria of being admitted for AMI and receiving both percutaneous coronary intervention and inpatient CR between January 2011 and December 2014. We compared patients who participated in outpatient CR at least once within 180 days of discharge and who did not. To account for measured baseline imbalances between outpatient CR participants and non-participants, 1:1 propensity-score matching was performed. The primary outcome was a composite of all-cause death and recurrence of AMI after the landmark time-point of day 180 after discharge. Secondary outcomes included all-cause death, recurrence of AMI, and heart failure.

Results

Among 5,654 patients (mean [SD] age, 66.8 [12.4] years; 21.2% female; median follow-up period [IQR] 1.44 [0.87 to 2.27] years), 730 (12.9%) received outpatient CR. Of 1,458 propensity-score matched patients, outpatient CR participants did not show a significantly lower risk of the primary outcome than non-participants (1.38 vs. 2.12 per 100 patient-years; hazard ratio [HR], 0.71 [95% CI, 0.32 to 1.61]). Similarly, outpatient CR participation was not associated with lower risks of all-cause death (0.68 vs. 1.31 per 100 patient-years; HR, 0.83 [95% CI, 0.25 to 2.73]), recurrence of AMI (0.69 vs. 0.88 per 100 patient-years; HR, 0.56 [95% CI, 0.19 to 1.66]) or heart failure (2.01 vs. 2.06 per 100 patient-years; HR, 0.89 [95% CI, 0.47 to 1.72]), respectively.

Conclusion

Among patients with AMI who received percutaneous coronary intervention and inpatient CR, outpatient CR was not associated with lower risks of mortality and morbidities. The survival benefit of outpatient CR should be reaffirmed under current real-world clinical practice, especially in non-Western countries.

P4548Early drop in systolic blood pressure and worsening renal function in the elderly acute heart failure: how does heart rate interact?

Background

Renal dysfunction is a frequent finding in patients hospitalized for acute heart failure (AHF). Worsening renal function (WRF) during hospitalization was found to be related with a poor outcome independently of baseline renal function. Early drop in systolic blood pressure (SBP) has shown to predict WRF in AHF. However, there have been few studies that reported the impact of on-admission heart rate (HR) on the relationship between early SBP drop and WRF in the elderly AHF.

Purpose

We assessed the hypothesis that early SBP drop predict WRF in the elderly patients with AHF, and investigated that on-admission HR might have an interaction with that relationship.

Methods

SBP and HR were measured on admission and 6 times during 48 hours in the 245 elderly AHF inpatients (82.9±6.0 years old, male 49.4%). WRF was defined as a serum creatinine increase of ≥0.3 mg/dL by Day 5. Early drop in SBP was calculated as the difference between admission and the lowest value measured during the first 48 hour of hospitalization.

Results

Early SBP drop (51.3 vs 32.5mmHg, p<0.01) and on-admission HR (79.3 vs 89.6bpm, p<0.05) were significantly different between the group with WRF (n=36) and the group without WRF (n=209). In the multiple logistic regression analysis adjusted for the confounders including age, gender, hypertension, left ventricular ejection fraction, total cholesterol, BNP, baseline creatinine, beta-blockade use, intravenous loop diuretic, isosorbide dinitrate and carperitide use, early SBP drop (OR: 1.003, 95% CI: 1.003–1.03, p<0.04) and on-admission HR (OR: 0.98, 95% CI: 0.96–0.99, p<0.01) were significantly associated with WRF. The interaction term of early SBP drop by on-admission HR did not have a significant association with WRF (p=0.3).

Conclusions

In the elderly AHF patients, exaggerated early SBP drop and lower on-admission HR were shown as significant independent predictors of WRF. These two factors were additively associated with WRF. Too much reduction in SBP and that in HR might be harmful to renal circulation in AHF.

3332Exercise training ameliorates vasodilator capacity of coronary microvessels in patients with vasospastic angina - A new therapeutic approach for the coronary functional disorder

Background

We have recently demonstrated that coronary vasospasm could develop in both epicardial coronary arteries and intramuscular coronary microvessels in patients with vasospastic angina (VSA). However, it remains to be examined whether vasodilator capacity of coronary microvessels is impaired in VSA patients and if so, whether exercise training could ameliorate vasodilator capacity of coronary microvessels on the top of calcium channel blockers. The effectiveness of exercise training is established for organic coronary artery disease but remained to be examined for VSA.

Purpose

We thus examined whether vasodilator capacity of coronary microvessels is impaired in VSA patients without organic coronary stenosis using an adenosine-stress dynamic computed tomography perfusion (CTP) that can measure absolute value of myocardial blood flow (MBF). We also examined whether exercise training ameliorates not only vasodilator capacity of coronary microvessels but also exercise capacity and frequency of angina attack.

Methods

In the first protocol, we measured MBF using CTP in consecutive 32 VSA patients with acetylcholine-induced diffuse coronary spasm in the left anterior descending coronary arteries (LAD) and 12 non-VSA controls. In the second protocol, we conducted a randomized controlled trial (RCT; Exercise VSA trial, UMIN: ehz745.008423996), where 20 VSA patients were randomly assigned to either exercise group (Ex group: supervised exercise training session for 30-min using bicycle ergometer, once/week at the hospital and more than 3 times/week at home) or non-exercise group (Non-Ex group) (n=10 each) (Figure A). Before and 3 months after exercise training, we measured MBF with adenosine-stress dynamic CTP and peak VO2 by cardiopulmonary exercise tests, and also assessed angina attack with Seattle Angina Questionnaire (SAQ).

Results

In the first protocol, CTP showed that adenosine-stress MBF was significantly decreased in the VSA group compared with the non-VSA group (VSA, 137.2±6.6 vs. Non-VSA, 174.4±10.7 ml/100g/min, P<0.01) (Figure B), although patient characteristics were comparable between the 2 groups. In the second protocol, exercise training was performed safely in all patients, and RCT showed that MBF was significantly increased in the Ex group compared with the non-Ex group (Figures C, D), although patient characteristics were also comparable between the 2 groups. Furthermore, peak VO2 was significantly increased in the Ex group compared with the non-Ex group (Figure E), and frequency of angina was significantly decreased in the Ex group compared with the non-Ex group (Figure F). Finally, there was a significant positive correlation between the extents of the changes in peak VO2 and the SAQ score for angina frequency in the Ex group (P<0.01, R=0.67).

Figures

Conclusions

These results provide the first evidence that vasodilator capacity of coronary microvessels is impaired in VSA patients, which can be ameliorated by exercise training.

6066Equal significance of longitudinal and radial wall motion represents the normal right ventricular mechanical pattern: 3D echocardiographic study in 231 healthy volunteers

Three main mechanisms contribute to right ventricular (RV) pump function: (1) shortening of the longitudinal axis with traction of the tricuspid annulus towards the apex; (2) inward (radial) movement of the RV free wall, which is often referred as the “bellows effect”; and (3) bulging of the interventricular septum into the RV during the left ventricular contraction and stretching of the free wall over the septum (causing shortening in the anteroposterior direction). Despite the established clinical value of the functional changes among the aforementioned components, their relative importance remains to be quantified during physiological conditions.

Accordingly, the aim of our study was to evaluate the relative contribution of the different RV motion directions to global RV function on both global and segmental level in a large set of healthy individuals.

We have recruited 231 healthy volunteers (44% female, with a wide and balanced age range from 8 to 81 years) from two experienced centers performing transthoracic 3D echocardiography (3DE) on a routine basis. 3DE datasets focused on the RV were obtained using multi-beat acquisition. We determined RV volumes and subsequent ejection fraction (RVEF) by dedicated software. Using the ReVISION method, we have decomposed the motion of the RV to determine longitudinal (LEF), radial (REF) and anteroposterior ejection fraction (AEF). Their ratio to RVEF quantifies the relative contribution of the given component to global RV function. Moreover, regional subvolumes were also analyzed in a 15-segment model.

Mean value of RVEF was significantly higher in female subjects compared to male subjects (60±7 vs. 56±7%, p<0.001). The relative contributions of LEF and REF to RVEF were comparable, while the contribution of AEF was significantly lower (LEF/RVEF vs. REF/RVEF vs. AEF/RVEF: 0.48±0.08 vs. 0.49±0.07 vs. 0.39±0.11, p<0.001) in the pooled population as well as in the genders separately. In line with higher RVEF found in women, female gender was associated with a higher longitudinal and radial contribution compared to males, however, AEF was similar (women vs. men; LEF/RVEF: 0.49±0.08 vs. 0.47±0.07, p<0.05; REF/RVEF: 0.50±0.07 vs. 0.48±0.06, p<0.01; AEF/RVEF: 0.38±0.12 vs. 0.40±0.10, p=NS). Interestingly, AEF/RVEF showed a significant deterioration with age (r=−0.354, p<0.001), while age-dependency of the longitudinal and radial contributions were not observed concerning both genders. An age-related decrease could be demonstrated by the volume fractions of the 5 septal volumetric segments (r=−0.229, p<0.001).

Motion decomposition and the 15 segments

In physiological conditions, the relative importance of longitudinal and radial wall motions is similar in determining global RV function. Aging accompanied by a decrease in anteroposterior shortening, which may point to a deteriorating systolic LV-RV interaction. Our results may facilitate further research concerning the alterations of RV mechanical pattern in various disease states.

Nuclear magnetic resonance on $LaFeAsO_{0.4}H_{0.6}$ at 3.7 GPa

A prototypical electron-doped iron-based superconductor $LaFeAsO_{1-x}H_x$ undergoes an antiferromagnetic (AF) phase for $x  \geq 0.49$. We performed NMR measurements on $LaFeAsO_{0.4}H_{0.6}$ at 3.7 GPa to investigate the magnetic properties in the vicinity of a pressure-induced QCP. The linewidth of $~^1H$-NMR spectra broadens at low temperatures below 30 K, suggesting that the ordered spin moments remain at 3.7 GPa. The coexistence of gapped and gapless spin excitations was confirmed in the ordered state from the relaxation time $T_1$ of $~^{75}As$. The pressure-induced QCP is estimated to be 4.1 GPa from the pressure dependence of the gapped excitation.   Edited by: A. Goñi, A. Cantarero, J. S. Reparaz

195 Effect of feeding a licorice extract to Japanese Black cows on embryo production performance after superovulation treatment

The objective was to determine the effect of feeding a licorice extract that contains glycyrrhizic acid, which is known to have a liver function-enhancing effect, on embryo production performance after superovulation treatment in Japanese Black cows. Japanese Black breed cows (n=136) that had calved 1 to 4 times and had normal uteri as seen by ultrasonography after at least 40 days from the last calving were used as test animals. Animals in the treatment group (n=90) were continuously fed 20g head−1 d−1 of a licorice extract (Kanzou, Fabric Onishi Co. Ltd., Osaka, Japan), with at least 13% glycyrrhizic acid content) once a day, mixed with the formula feed, for 60 to 90 days starting from around the day of calving until ova/embryos were collected. The control group (n=46) received no Kanzou from the day of the last calving until ova/embryo collection. A total of 20 Armour units (AU) of FSH (Antorin R, Kyoritsu Seiyaku Corporation, Kanagawa, Japan) from porcine pituitary was given intramuscularly (IM) twice a day, morning and evening, for 3 consecutive days (decreasing dose schedule: 5 AU×2, 3 AU×2, and 2AU×2) as the superovulation treatment to the cows at 8 to 11 days post-oestrus in both groups. Prostaglandin F2α 25mg and 15mg (IM) were administered in the morning and evening, respectively, on the third day of FSH administration. Artificial insemination was done at 12 and 24h after the start of oestrus, and ova/embryos were collected using a uterine reflux method on Day 7 post-oestrus. The mean numbers of ova/embryos and transferable embryos collected and the mean embryo quality scores (according to the IETS guidelines) in the treatment and control groups were compared by t-test. A chi-squared test was used to compare the proportion of transferable embryos in the 2 groups. There was no significant difference in the mean number of ova/embryos retrieved between the treatment group (21.7±11.8) and the control group (15.8±11.3), although the former tended (P=0.07) to yield more ova/embryos. There was significant difference (P&lt;0.05) in the mean number of transferable embryos collected in the treatment group (13.1±8.3) than in the control group (8.1±5.3). The mean embryo quality score was significantly greater (P&lt;0.01) in the treatment group (1.6±0.4) than in the control group (2.2±0.6). The proportion of transferable embryos in the treatment group (60.3±26.4%) was also significantly higher (P&lt;0.05) than in the control group (51.2±26.0%). In conclusion, feeding a licorice extract to Japanese Black cows for 60 days or longer improves the quality of embryos obtained after superovulation treatment and leads to an increase in the mean number of transferable embryos per cow.

Variant in human POFUT1 reduces enzymatic activity and likely causes a recessive microcephaly, global developmental delay with cardiac and vascular features

Protein O-fucosyltransferase-1 (POFUT1) adds O-fucose monosaccharides to epidermal growth factor-like (EGF) repeats found on approximately 100 mammalian proteins, including Notch receptors. Haploinsufficiency of POFUT1 has been linked to adult-onset Dowling Degos Disease (DDD) with hyperpigmentation defects. Homozygous deletion of mouse Pofut1 results in embryonic lethality with severe Notch-like phenotypes including defects in somitogenesis, cardiogenesis, vasculogenesis and neurogenesis, but the extent to which POFUT1 is required for normal human development is not yet understood. Here we report a patient with a congenital syndrome consisting of severe global developmental delay, microcephaly, heart defects, failure to thrive and liver disease with a previously unreported homozygous NM_015352.1: c.485C>T variant (p.Ser162Leu) in POFUT1 detected by exome sequencing. Both parents are heterozygotes and neither manifests any signs of DDD. No other detected variant explained the phenotype. This variant eliminated a conserved N-glycosylation sequon at Asn160 in POFUT1 and profoundly decreased POFUT1 activity in patient fibroblasts compared to control fibroblasts. Purified p.Ser162Leu mutant protein also showed much lower POFUT1 activity with a lower affinity for EGF acceptor substrate than wild type POFUT1. Eliminating the N-glycan sequon by replacing Asn160 with Gln had little effect on POFUT1 activity, suggesting that loss of the glycan is not responsible for the defect. Furthermore, the p.Ser162Leu mutant showed weaker ability to rescue Notch activity in cell-based assays. These results suggest that this N-glycan of POFUT1 is not required for its proper enzymatic function, and that the p.Ser162Leu mutation of POFUT1 likely causes global developmental delay, microcephaly with vascular and cardiac defects.