Analysis of Incidence, Risk Factors and Outcomes Associated With Abdominal Hypertension in Major Burn Patients

The objective of this study is to analyze incidence and risk factors for intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) in major burn patients. Aprospective cohort study was conducted at a Burns Treatment Center, including all patients with a burned body surface area ≥20% admitted from August 2015 to January 2018. Intra-abdominal pressure was measured periodically during the first week of ICU stay. Sixty-four patients were analyzed, with median age of 39 years (interquartile range ITQ: 28-53) and 66% were male. Median burned body surface area was 30% (ITQ: 20-46). Twenty-eight (56%) patients presented criteria for IAH and seven (14%) developed clinical signs compatible with ACS. Burn severity was greater in the group that developed IAH, represented by the ABSI score. This group also presented higher values of creatinine and positive fluid balance. The group of patients with ACS showed a higher frequency of alterations in renal and respiratory functions. The organ systems most frequently affected in groups with diagnostic criteria for IAH and ACS were renal, cardiovascular and respiratory. Mortality rate at hospital outcome was 56%. In conclusion, the incidence of IAH during the study period was high in patients with extensive burns. The occurrence of ACS was associated with organic dysfunctions of the respiratory, cardiovascular and renal systems. The factors associated with intra-abdominal hypertension were age, extension of burned body surface, inhalation injury, and need for mechanical ventilation.

Melanogenic effect of dersimelagon (MT-7117), a novel oral melanocortin 1 receptor agonist

Background

The activation of melanocortin 1 receptor (MC1R) on melanocytes stimulates the production of eumelanin. A tridecapeptide α melanocyte‐stimulating hormone (αMSH) is known to induce skin pigmentation.

Objectives

We characterised the properties of a novel oral MC1R agonist dersimelagon (MT‐7117) with respect to its specific binding to MC1R, downstream signalling and eumelanin production in experimental models.

Methods

The competitive binding and production of intracellular cyclic adenosine 3′, 5′‐monophosphate in cells expressing recombinant melanocortin receptors were examined. A mouse melanoma cell line B16F1 was used for the evaluation of in vitro melanin production. The in vitro activity of MT‐7117 was determined with αMSH and [Nle⁴, D‐Phe⁷]‐αMSH (NDP‐αMSH) as reference comparators. The change of coat colour and skin pigmentation were evaluated after repeat administration of MT‐7117 by oral gavage to C57BL/6J‐A^y/+ mice and cynomolgus monkeys, respectively.

Results

MT‐7117 showed the highest affinity for human MC1R compared to the other melanocortin receptors evaluated and agonistic activity for human, cynomolgus monkey and mouse MC1R, with EC₅₀ values in the nanomolar range. In B16F1 cells, MT‐7117 increased melanin production in a concentration‐dependent manner. In vivo, MT‐7117 (≥0.3 mg/kg/day p.o.) significantly induced coat colour darkening in mice. MT‐7117 (≥1 mg/kg/day p.o.) induced significant skin pigmentation in monkeys and complete reversibility was observed after cessation of its administration.

Conclusions

MT‐7117 is a novel oral MC1R agonist that induces melanogenesis in vitro and in vivo, suggesting its potential application for the prevention of phototoxic reactions in patients with photodermatoses, such as erythropoietic protoporphyria and X‐linked protoporphyria.

Adaptive statistical iterative reconstruction for computed tomography of the spine

INTRODUCTION

The utility of evaluating a sagittal view of CT of the spine is well-known. In many clinical cases, the sagittal view includes noise generated from surrounding objects and may degrade the image quality. Iterative reconstruction (IR) techniques are useful for noise reduction; however, they can reduce spatial resolution. The aim of this study was to evaluate the effectiveness of the adaptive statistical iterative reconstruction (ASiR) for generating sagittal CT images of the spine when compared to filtered back projection (FBP).

METHODS

The image quality of clinical images from 25 patients were subjectively assessed. Three radiologists rated spatial resolution, image noise, and overall image quality using a five-point scale. For objective assessment, z-direction modulation transfer function (z-MTF) was measured using a custom-made phantom. Additionally, z-axis noise power spectrum (z-NPS) was measured using a water phantom. An improved adaptive statistical iterative reconstruction algorithm called ASiR-V was used in this study. Blending levels were 50%, and 100% (ASiR-V50, ASiR-V100, respectively).

RESULTS

For subjective assessments, images using ASiR-V100 were determined to have the best overall image quality, despite having received the worst score in the assessment of spatial resolution. For objective assessments, the image using ASiR-V50 and ASiR-V100 curves were slightly degraded in terms of low contrast z-MTF when compared to FBP.

CONCLUSION

ASiR-V was effective to improve the image quality when compared with FBP when reviewing sagittal reformats of the spine.

IMPLICATIONS FOR PRACTICE

This study suggests that high resolution is not the only thing that is key when reviewing sagittal CT spinal reformats. Such images should be provided as part of routine CT spine protocols, where available.

Negative impact of ultra-thin strut on neointimal coverage condition within one year after implantation as compared to thin sturt in biogradable-polymer sirorimus eluting stents

Background

BIOSCIENCE randomized trial which compared biodegradable-polymer sirolimus-eluting stents with ultra-thin (60μm) strut (ultra-thin BP-SES) and durable-polymer everolimus-eluting stents with thin (81μm) strut (thin DP-EES) have reported that definite stent thrombosis within 1 year had more frequently occurred in ultra-thin BP-SES (0.9%) than in thin DP-EES group (0.4%) although it was not statistically significant. It suggests that neointimal coverage after stent implantation within 1 year might be different between ultra-thin BP-SES and thin DP-EES. Recently, two types of biogradable-polymer sirorimus eluting stents, thin (80μm) strut type (thin BP-SES) and ultra-thin (60μm) strut type (ultra-thin BP-SES), can be available in clinical settings.

Purpose

We compared neointimal coverage conditions between ultra-thin BP-SES and thin BP-SES by optical coherence tomography (OCT).

Methods

Consecutive Forty-six patients who underwent 21 ultra-thin BP-SESs or 25 thin BP-SESs implantation were enrolled. We compared incidences of acute coronary syndrome, type B2/C lesion, atherectomy device use, stent size, stent length, maximum inflation pressure, and 8-month follow-up OCT parameters including proportions of uncovered struts (%Uncovered), malapposed struts, (%Mallaposed) and mean neointimal hyperplasia thickness (mean NHT) between the two groups.

Results

%Uncovered and %malapposed were significantly higher and mean NHT was significantly lower in ultra-thin BP-SES than in thin BP-SES (Table). The other parameters were similar between the two groups.

Conclusion

Ultra-thin BP-SES showed worse neointimal coverage as compared to thin BP-SES within 1 year after stent implantation, which may increase stent thrombosis.

Funding Acknowledgement

Type of funding source: None

Real-world clinical impact of external elastic lamina-based stent sizing criteria using optical coherence tomography

Introduction

ILUMIEN III trial has reported that non-inferiority of optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) to intravascular ultrasound-guided PCI for postprocedural minimum stent area. In the trial, external elastic lamina (EEL)-based stent sizing criteria was introduced, however OCT has limitations including incomplete visualization of EEL in severale lesions.

Purpose

The aim of the study is to investigate real-world clinical impact of EEL-based stent sizing criteria.

Methods

The study included consecutive patients who underwent OCT-guided percutaneous coronary intervention (PCI) for de novo lesions in our institution between September 2016 and April 2018. EEL visibility, mean EEL diameter, mean lumen diameter and plaque morphology were assessed at proximal and distal references. The plaque morphology at references was categorized according to its most prevalent component as follows: normal, fibrous plaque, lipid plaque, and calcified plaque. Both references were divided into 3 groups according to visibility of EEL.

Results

Among 205 lesions, 31 lesions had artifacts at references (16 proximal and 17 distal references). EEL visibility was summarized in a table. Out of 174 lesions with both analyzable references, 111 lesions (63.8%) had >180-degree EEL visibility at both references. Proportion of plaque morphology were significantly different among 3 groups at proximal and distal references as shown in a figure.

Conclusions

EEL-based stent sizing criteria was usable for 63.8% of all the lesions. Vessel size and plaque morphology were significantly associated with EEL visibility.

Proportion of plaque morphology

Funding Acknowledgement

Type of funding source: None

Difference of myocardial injury, inflammation and early recurrence after pulmonary vein isolation among laser balloon ablation, radiofrequency catheter ablation and cryoballoon ablation

Background

Pulmonary vein isolation (PVI) has become well-established as the main therapy for patients with drug-refractory paroxysmal atrial fibrillation (PAF) and various isolation methods including radiofrequency ablation (RFA), cryoballoon ablation (CBA) and laser balloon ablation (LBA) were available. Pathological findings in each ablation methods such as myocardial injury and inflammation are thought to be different. High sensitive cardiac troponin I (hs-TnI), subunit of cardiac troponin complex, is a sensitive and specific marker of myocardium injury. High-sensitive C-reactive protein (hs-CRP) is a biomarker of inflammation and is elevated following cardiomyocyte necrosis. Relationship between myocardial injury and inflammation after ablation using RFA, CBA and LBA and early recurrence of atrial fibrillation (ERAF) remains unclear.

Methods

We enrolled consecutive PAF patients from Osaka Rosai Atrial Fibrillation (ORAF) registry who underwent PVI from January 2019 to October 2019. We compared the clinical characteristics including age, gender, hypertension, diabetes mellitus, history of heart failure, CHADS2Vasc score, renal function, serum BNP level and echocardiographic parameters including left ventricular dimensions, left atrial diameter (LAD) and left ventricular ejection fraction (LVEF) between RFA, CBA and LBA groups. We investigated the difference of relationship between myocardial injury marker (hs-TnI), inflammation markers (white blood cell change (DWBC) from post to pre PVI, neutrophil-to-lymphocyte ratio change (DNLR) from after to before PVI and hs-CRP) at 36–48 hours after PVI and ERAF (<3 months after PVI) between each group.

Results

We enrolled 187 consecutive PAF patients who underwent PVI. RFA, CBA and LBA groups comprised 108, 57 and 22 patients, respectively. There were no significant differences of age, gender, hypertension, diabetes mellitus, history of heart failure, CHADS2Vasc score, renal function, serum BNP level and echocardiographic parameters between each group. Serum hs-TnI in RFA group and LBA group were significantly lower than in CBA group (2.643 ng/ml vs 5.240ng/ml, 1.344 ng/ml vs 5.240 ng/ml, p<0.001, p=0.002, respectively, Figure). DWBC was significantly higher in LBA group than CBA group (1157.3/μl vs 418.4/μl, p=0.045). DNLR did not differ between each group. Hs-CRP in RFA group and LBA group were significantly higher than in CBA group (1.881 mg/dl vs 1.186 mg/dl, 2.173 mg/dl vs 1.186 mg/dl, p=0.010, p=0.003, respectively, Figure). Incidence of ERAF was significantly higher in LBA group than RFA group (36.4% vs 16.7%, p=0.035). Incidence of ERAF tended to be higher in LBA group than CBA group (36.4% vs 19.3%, p=0.112).

Conclusion

LBA may cause less myocardial injury than RFA and CBA, on the contrary LBA may cause more inflammation than CBA. Incidence of ERAF in LBA was highest between each procedure.

Inflammation markers and ERAF

Funding Acknowledgement

Type of funding source: None

Outcome of contact force-guided radiofrequency catheter ablation or second generation cryoballoon ablation for paroxysmal atrial fibrillation: propensity score matched analysis

Background

Little has been reported on the outcome of contact force (CF)-guided radiofrequency catheter ablation (RFCA) and second generation cryoballoon ablation (CBA).

Purpose

The purpose of this study was to compare the outcome of CF-guided RFCA and second generation CBA for paroxysmal atrial fibrillation (PAF).

Methods

We enrolled the consecutive 364 patients with PAF who underwent initial ablation between September 2014 and July 2018 in our hospital. We compared the late recurrence of atrial tachyarrhythmia more than three months after ablation between RFCA group and CBA group. All RFCA procedures were performed using CF-sensing catheter and all CBA procedures were performed using second generation CB.

Results

There were significant differences in background characteristics: chronic kidney disease, serum brain natriuretic peptide level, and left ventricular ejection fraction. After propensity score matched analysis (Table), atrial tachyarrhythmia free survival was significantly higher in CBA group than in RFCA group (Figure).

Conclusions

Second generation CBA showed a significantly lower late recurrence rate compared to CF-guided RFCA.

Kaplan-Meier Curve

Funding Acknowledgement

Type of funding source: None

Clinical characteristics and outcomes after pulmonary vein isolation in atrial fibrillation patients with complete right bundle branch block

Background

Complete right bundle branch block (CRBBB) is one of the most frequent alterations of the electrocardiogram (ECG). Several studies have shown that CRBBB was a risk factor for cardiovascular diseases and the appearance of CRBBB in patients hospitalized for exacerbated heart failure (HF) was associated with a worse prognosis. Various alternations of ECG such as early repolarization pattern and intraventricular conduction disturbance were associated with high recurrence ratio of atrial fibrillation (AF) after pulmonary vein isolation (PVI). However clinical outcome after PVI in patients with CRBBB remains unclear.

Methods

We enrolled consecutive AF patients who underwent PVI from September 2014 to November 2018 rom Osaka Rosai Atrial Fibrillation (ORAF) registry. We excluded patients with other wide QRS (left bundle branch block, ventricular pacing and unclassified intraventricular conduction disturbance) and divided into 2 groups; CRBBB (QRS duration ≥120msec) group and no-CRBBB (QRS duration <120) group. We compared the clinical characteristics including age, gender, hypertension, diabetes mellitus, history of heart failure, history of stroke, CHADS2Vasc score, paroxysmal AF (PAF), renal function, plasma brain natriuretic peptide (BNP) level and echocardiographic parameters including left ventricular end-diastolic diameter (LVDd), left ventricular end-systolic diameter (LVDs), left atrial diameter (LAD) and left ventricular ejection fraction (LVEF) between the 2 groups. We also compared the incidence of late recurrence of AF/atrial tachycardia (AT) between the 2 groups. We investigated whether CRBBB was an independent predictor of late recurrence of AF/AT after PVI by multivariate Cox analysis.

Results

We enrolled 736 consecutive AF patients who underwent PVI. CRBBB patients comprised 55 patients (7.5%). There were no significant differences of age, gender, hypertension, diabetes mellitus, history of heart failure, history of stroke, CHADS2Vasc score, PAF, renal function, plasma BNP level and echocardiographic parameters (LVDd, LVDs, LVEF and LAD) between the 2 groups. Incidence of AF/AT recurrence after PVI was significantly higher in CRBBB group than no-CRBBB group (Figure). CRBBB was an independently and significantly associated with late recurrence of AF/AT after PVI by multivariate Cox analysis (hazard ratio: 1.923, 95% CI: 1.190–2.961, p=0.009) in addition to female (p<0.001), no-PAF (p=0.005) and left atrial diameter (p=0.042).

Conclusion

CRBBB may be a strong predictor of AF/AT late recurrence after PVI.

AF/Ar recurrence after PVI

Funding Acknowledgement

Type of funding source: None

Ablation index guide pulmonary vein isolation can reduce early recurrence of atrial fibrillation: a propensity score-matched analysis

Background

Ablation index (AI) is a novel marker of ablation lesion quality for radiofrequency ablation (RFA). It has been reported that AI guided pulmonary vein isolation (PVI) reduced pulmonary vein reconnection and late recurrence of atrial fibrillation (AF). However, little is known about the impact of AI guided PVI on early recurrence of AF (ERAF).

Purpose

The aim of this study is to clarify whether AI guided PVI can reduce ERAF.

Methods

From September 2014 to August 2019, consecutive AF patients who underwent 1st session PVI were enrolled. We compared prevalence of ERAF between AI guided PVI group (AI group) and conventional contact force guided PVI group (CF group) using propensity score-matched analysis, which adjusted patient backgrounds (age, sex, and body mass index (BMI)), type of AF, the history of heart failure, hypertension, diabetes and stroke, laboratory findings including estimated glomerular filtration rate (eGFR) and b-type natriuretic peptide (BNP), and echocardiographic parameters including left ventricular ejection fraction (LVEF) and left atrial diameter.

Results

Total 711 patients were enrolled. AI group comprised 233 patients and CF group comprised 233 patients. Prevalence of ERAF were significantly lower in AI group than in CF group significantly (21.5% vs 36.1%, p=0.001, Table).

Conclusions

AI guided PVI can reduce ERAF as compared to conventional method.

Funding Acknowledgement

Type of funding source: None

S-1 and irinotecan plus bevacizumab versus mFOLFOX6 or CapeOX plus bevacizumab as first-line treatment in patients with metastatic colorectal cancer (TRICOLORE): a randomized, open-label, phase III, noninferiority trial

Background

Combination therapy with oral fluoropyrimidine and irinotecan has not yet been established as first-line treatment of metastatic colorectal cancer (mCRC). We carried out a randomized, open-label, phase III trial to determine whether S-1 and irinotecan plus bevacizumab is noninferior to mFOLFOX6 or CapeOX plus bevacizumab in terms of progression-free survival (PFS).

Patients and methods

Patients from 53 institutions who had previously untreated mCRC were randomly assigned (1 : 1) to receive either mFOLFOX6 or CapeOX plus bevacizumab (control group) or S-1 and irinotecan plus bevacizumab (experimental group; a 3-week regimen: intravenous infusions of irinotecan 150 mg/m2 and bevacizumab 7.5 mg/kg on day 1, oral S-1 80 mg/m2 twice daily for 2 weeks, followed by a 1-week rest; or a 4-week regimen: irinotecan 100 mg/m2 and bevacizumab 5 mg/kg on days 1 and 15, S-1 80 mg/m2 twice daily for 2 weeks, followed by a 2-week rest). The primary end point was PFS. The noninferiority margin was 1.25; noninferiority would be established if the upper limit of the 95% confidence interval (CI) for the hazard ratio (HR) of the control group versus the experimental group was less than this margin.

Result

Between June 2012 and September 2014, 487 patients underwent randomization. Two hundred and forty-three patients assigned to the control group and 241 assigned to the experimental group were included in the primary analysis. Median PFS was 10.8 months (95% CI 9.6-11.6) in the control group and 14.0 months (95% CI 12.4-15.5) in the experimental group (HR 0.84, 95% CI 0.70-1.02; P < 0.0001 for noninferiority, P = 0.0815 for superiority). One hundred and fifty-seven patients (64.9%) in the control group and 140 (58.6%) in the experimental group had adverse events of grade 3 or higher.

Conclusion

S-1 and irinotecan plus bevacizumab is noninferior to mFOLFOX6 or CapeOX plus bevacizumab with respect to PFS as first-line treatment of mCRC and could be a new standard treatment.

Clinical trials number

UMIN000007834.

Safety and efficacy of nivolumab in combination with S-1/capecitabine plus oxaliplatin in patients with previously untreated, unresectable, advanced, or recurrent gastric/gastroesophageal junction cancer: interim results of a randomized, phase II trial (ATTRACTION-4)

BACKGROUND

Nivolumab is approved as an option for third- or later-line treatment of advanced gastric/gastroesophageal junction (G/GEJ) cancer in several countries after ATTRACTION-2. To further improve the therapeutic efficacy of first-line therapy, exploration of a nivolumab-chemotherapy combination is warranted. In part 1 (phase II) of ATTRACTION-4, the safety and efficacy of nivolumab combined with S-1 plus oxaliplatin (SOX) or capecitabine plus oxaliplatin (CapeOX) as first-line therapy for unresectable advanced or recurrent human epidermal growth factor receptor 2 (HER2)-negative G/GEJ cancer were evaluated.

PATIENTS AND METHODS

Patients were randomized (1 : 1) to receive nivolumab (360 mg intravenously every 3 weeks) plus SOX (S-1, 40 mg/m2 orally twice daily for 14 days followed by 7 days off; oxaliplatin, 130 mg/m2 intravenously on day 1 every 3 weeks) or CapeOX (capecitabine, 1000 mg/m2 orally twice daily for 14 days followed by 7 days off; oxaliplatin, 130 mg/m2 intravenously on day 1 every 3 weeks) until disease progression, unacceptable toxicity, or consent withdrawal.

RESULTS

Of 40 randomized patients, 39 (nivolumab plus SOX, 21; nivolumab plus CapeOX, 18) and 38 (21 and 17, respectively) comprised the safety and efficacy populations, respectively. Most frequent (>10%) grade 3/4 treatment-related adverse events were neutropenia (14.3%) in the nivolumab plus SOX group, and neutropenia (16.7%), anemia, peripheral sensory neuropathy, decreased appetite, type 1 diabetes mellitus, and nausea (11.1% each) in the nivolumab plus CapeOX group. No treatment-related death occurred. Objective response rate was 57.1% (95% confidence interval 34.0-78.2) with nivolumab plus SOX and 76.5% (50.1-93.2) with nivolumab plus CapeOX. Median overall survival was not reached (NR) in both groups. Median progression-free survival was 9.7 months (5.8-NR) and 10.6 months (5.6-12.5), respectively.

CONCLUSION

Nivolumab combined with SOX/CapeOX was well tolerated and demonstrated encouraging efficacy for unresectable advanced or recurrent HER2-negative G/GEJ cancer. ATTRACTION-4 has proceeded to part 2 (phase III) to compare nivolumab plus SOX/CapeOX versus placebo plus SOX/CapeOX.

CLINICALTRIALS.GOV ID

NCT02746796.

Abstract P2-11-07: Duration of fasting before taking lapatinib is associated with skin toxicity in neoadjuvant treatment of HER2 positive breast cancer: A cohort study from JBCRG-16/Neo-LaTH

Background: In neoadjuvant dual HER2 blockade, over 30% of patients fail to complete treatment as planned because of lapatinib-induced diarrhea, rash, and hepatotoxicity. Lapatinib bioavailability, which affects both efficacy and toxicity, is influenced by prandial conditions.

Methods: To investigate the association between lapatinib dosage timing and toxicity, we reviewed the medical records of patients who were enrolled in the JBCRG-16/Neo-LaTH randomized phase II multicenter trial evaluating the efficacy and safety of neoadjuvant 1000 mg/day lapatinib (La) and trastuzumab (T) therapy for 6 or 12 weeks followed by 750 mg/day La, T and weekly paclitaxel for 12 weeks in Japanese patients with primary HER2 positive breast cancer. Lapatinib dosage timing was divided into three groups: after overnight fasting, between meals, and at bedtime. We also measured serum lapatinib concentrations at steady state and dosage timing on the day prior to pharmacokinetic blood sampling. The primary endpoint was to investigate the association between lapatinib dosage timing and frequency of ≥grade 2 diarrhea. The secondary endpoint was to assess the association between dosage timing and other toxicities, pharmacokinetics, efficacy, and treatment discontinuation. Statistical analyses performed included one-way ANOVA, Welch's test and logistic regression.

Results: Out of 213 patients enrolled in JBCRG-16/Neo LaTH, we obtained dosage timing data from 143 (67%) patients: 16 (11%) after overnight fasting, 53 (37%) between meals, and 74 (52%) at bedtime. Serum lapatinib concentrations were obtained in 34/143 (24%) of patients. Dosage timing was not associated with ≥grade 2 diarrhea (8/16 (50%) after overnight fasting, 18/53 (34%) between meals, and 26/74 (35%) at bedtime; p = 0.48). However, multivariate analysis revealed that the after overnight fasting group is less likely to develop acne-like rash during La + T treatment regardless of age, BMI, or treatment.

Multivariate logistic regression analysis of factors predicting rash during La + T treatmentFactor Adjusted odds ratio95% confidence intervalp valueAge (years)≥55Reference   &lt;552.671.18-6.310.018*BMI (kg/m2)≥23Reference   &lt;231.040.45-2.390.933La + T duration6 weeksReference   12 weeks3.621.49-9.770.004*Concurrent endocrine treatmentYesReference   No2.170.94-5.150.068Dosage timingAfter overnight fastingReference   Others3.681.16-11.90.027*BMI cut off is based on Asian criteria for overweight status. La: Lapatinib, T: Trastuzumab, *statistically significant

In addition, serum lapatinib trough concentration and it's variability were significantly reduced in the after overnight fasting group (mean ± standard deviation (SD) = 0.35 ± 0.15 µg/ml, coefficient of variation (CV) = 42.7%) as compared to the others (mean ± SD = 0.77 ± 0.44 µg/ml, CV = 57.8%) (p&lt;0.01) . The chance of pCR was not associated with dosage timing (8/16 (50%) after overnight fasting, 24/53, (45%) between meals, and 38/74 (51%) at bedtime; p = 0.79).

Conclusions: These data suggest that overnight fasting stabilizes the bioavailability of lapatinib, which may aid in managing lapatinib-induced rash without diminishing its therapeutic efficacy.

Citation Format: Tsuda M, Ishiguro H, Toriguchi N, Masuda N, Bando H, Ohgami M, Homma M, Morita S, Yamamoto N, Kuroi K, Takano T, Shimizu S, Toi M. Duration of fasting before taking lapatinib is associated with skin toxicity in neoadjuvant treatment of HER2 positive breast cancer: A cohort study from JBCRG-16/Neo-LaTH [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-11-07.

Detection of Vascular Disease Risk in Women by Panoramic Radiography

Low bone mineral density and rapid bone loss of the skeleton are associated with mortality risk from vascular diseases in post-menopausal women. Panoramic radiographic measurements are considered as indicators of skeletal bone mineral density or bone turnover. We hypothesize that such measurements may be associated with vascular disease risk in post-menopausal women. Associations of mandibular cortical shape and width on panoramic radiographs with skeletal bone mineral density and risk factors related to vascular diseases were investigated in 87 post-menopausal women. Cortical shape was associated with skeletal bone mineral density, low-density lipoprotein cholesterol, apolipoprotein B, resting heart rate, and endothelial dysfunction. Cortical width was associated with skeletal bone mineral density, low-density lipoprotein cholesterol, and apolipoprotein A1. Dentists may be able to refer women with increased risk of vascular diseases, as well as low bone mineral density, to medical professionals for further examination by panoramic findings.

A clinical tool for predicting survival in ALS

BACKGROUND

Amyotrophic lateral sclerosis (ALS) is a progressive and usually fatal neurodegenerative disease. Survival from diagnosis varies considerably. Several prognostic factors are known, including site of onset (bulbar or limb), age at symptom onset, delay from onset to diagnosis and the use of riluzole and non-invasive ventilation (NIV). Clinicians and patients would benefit from a practical way of using these factors to provide an individualised prognosis.

METHODS

575 consecutive patients with incident ALS from a population-based registry in South-East England register for ALS (SEALS) were studied. Their survival was modelled as a two-step process: the time from diagnosis to respiratory muscle involvement, followed by the time from respiratory involvement to death. The effects of predictor variables were assessed separately for each time interval.

FINDINGS

Younger age at symptom onset, longer delay from onset to diagnosis and riluzole use were associated with slower progression to respiratory involvement, and NIV use was associated with lower mortality after respiratory involvement, each with a clinically significant effect size. Riluzole may have a greater effect in younger patients and those with longer delay to diagnosis. A patient's survival time has a roughly 50% chance of falling between half and twice the predicted median.

INTERPRETATION

A simple and clinically applicable graphical method of predicting an individual patient's survival from diagnosis is presented. The model should be validated in an independent cohort, and extended to include other important prognostic factors.

Randomized phase III study of bevacizumab plus FOLFIRI and bevacizumab plus mFOLFOX6 as first-line treatment for patients with metastatic colorectal cancer (WJOG4407G)

BACKGROUND

FOLFIRI and FOLFOX have shown equivalent efficacy for metastatic colorectal cancer (mCRC), but their comparative effectiveness is unknown when combined with bevacizumab.

PATIENTS AND METHODS

WJOG4407G was a randomized, open-label, phase III trial conducted in Japan. Patients with previously untreated mCRC were randomized 1:1 to receive either FOLFIRI plus bevacizumab (FOLFIRI + Bev) or mFOLFOX6 plus bevacizumab (mFOLFOX6 + Bev), stratified by institution, adjuvant chemotherapy, and liver-limited disease. The primary end point was non-inferiority of FOLFIRI + Bev to mFOLFOX6 + Bev in progression-free survival (PFS), with an expected hazard ratio (HR) of 0.9 and non-inferiority margin of 1.25 (power 0.85, one-sided α-error 0.025). The secondary end points were response rate (RR), overall survival (OS), safety, and quality of life (QoL) during 18 months. This trial is registered to the University Hospital Medical Information Network, number UMIN000001396.

RESULTS

Among 402 patients enrolled from September 2008 to January 2012, 395 patients were eligible for efficacy analysis. The median PFS for FOLFIRI + Bev (n = 197) and mFOLFOX6 + Bev (n = 198) were 12.1 and 10.7 months, respectively [HR, 0.905; 95% confidence interval (CI) 0.723-1.133; P = 0.003 for non-inferiority]. The median OS for FOLFIRI + Bev and mFOLFOX6 + Bev were 31.4 and 30.1 months, respectively (HR, 0.990; 95% CI 0.785-1.249). The best overall RRs were 64% for FOLFIRI + Bev and 62% for mFOLFOX6 + Bev. The common grade 3 or higher adverse events were leukopenia (11% in FOLFIRI + Bev/5% in mFOLFOX6 + Bev), neutropenia (46%/35%), diarrhea (9%/5%), febrile neutropenia (5%/2%), peripheral neuropathy (0%/22%), and venous thromboembolism (6%/2%). The QoL assessed by FACT-C (TOI-PFC) and FACT/GOG-Ntx was favorable for FOLFIRI + Bev during 18 months.

CONCLUSION

FOLFIRI plus bevacizumab was non-inferior for PFS, compared with mFOLFOX6 plus bevacizumab, as the first-line systemic treatment for mCRC.

CLINICAL TRIALS NUMBER

UMIN000001396.

The novel function of CD82 and its impact on BCL2L12 via AKT/STAT5 signal pathway in acute myelogenous leukemia cells

The aim of this study was to explore the biological functions of a tetraspanin family protein CD82 expressed aberrantly in chemotherapy-resistant CD34(+)/CD38(-) acute myelogenous leukemia (AML) cells. Microarray analysis of patient-isolated CD34(+)/CD38(-) AML cells revealed that the levels of anti-apoptotic protein BCL2L12 were downregulated after CD82 depletion by specific short hairpin RNA (shRNA). Western blot analysis indicated that BCL2L12 was aberrantly expressed in patient-isolated AML cells and AML cell lines. Furthermore, CD82 blockade by a specific antibody downregulated BCL2L12 in parallel with dephosphorylation of signal transducer and activator of transcription 5 (STAT5) and AKT, whereas pharmacological inhibition of STAT5 and AKT activation decreased BCL2L12 expression in leukemia cells. In addition, shRNA-mediated downregulation of BCL2L12 increased the levels of cleaved caspase-3 and suppressed proliferation of leukemia cells, impairing their engraftment in immunodeficient mice. Taken together, our results indicate that CD82 regulated BCL2L12 expression via STAT5A and AKT signaling and stimulated proliferation and engrafting of leukemia cells, suggesting that CD82 and BCL2L12 may be promising therapeutic targets in AML.

Phase III study comparing oxaliplatin plus S-1 with cisplatin plus S-1 in chemotherapy-naïve patients with advanced gastric cancer

BACKGROUND

We evaluated the efficacy and safety of S-1 plus oxaliplatin (SOX) as an alternative to cisplatin plus S-1 (CS) in first-line chemotherapy for advanced gastric cancer (AGC).

PATIENTS AND METHODS

In this randomized, open-label, multicenter phase III study, patients were randomly assigned to receive SOX (80-120 mg/day S-1 for 2 weeks with 100 mg/m(2) oxaliplatin on day 1, every 3 weeks) or CS (S-1 for 3 weeks with 60 mg/m(2) cisplatin on day 8, every 5 weeks). The primary end points were noninferiority in progression-free survival (PFS) and relative efficacy in overall survival (OS) for SOX using adjusted hazard ratios (HRs) with stratification factors; performance status and unresectable or recurrent (+adjuvant chemotherapy) disease.

RESULTS

Overall, 685 patients were randomized from January 2010 to October 2011. In per-protocol population, SOX (n = 318) was noninferior to CS (n = 324) in PFS [median, 5.5 versus 5.4 months; HR 1.004, 95% confidence interval (CI) 0.840-1.199; predefined noninferiority margin 1.30]. The median OS for SOX and CS were 14.1 and 13.1 months, respectively (HR 0.958 with 95% CI 0.803-1.142). In the intention-to-treat population (SOX, n = 339; CS, n = 337), the HRs in PFS and OS were 0.979 (95% CI 0.821-1.167) and 0.934 (95% CI 0.786-1.108), respectively. The most common ≥grade 3 adverse events (SOX versus CS) were neutropenia (19.5% versus 41.8%), anemia (15.1% versus 32.5%), hyponatremia (4.4% versus 13.4%), febrile neutropenia (0.9% versus 6.9%), and sensory neuropathy (4.7% versus 0%).

CONCLUSION

SOX is as effective as CS for AGC with favorable safety profile, therefore SOX can replace CS.

CLINICAL TRIAL NUMBER

JapicCTI-101021.

Analysis of amyotrophic lateral sclerosis as a multistep process: a population-based modelling study

Background

Amyotrophic lateral sclerosis shares characteristics with some cancers, such as onset being more common in later life, progression usually being rapid, the disease affecting a particular cell type, and showing complex inheritance. We used a model originally applied to cancer epidemiology to investigate the hypothesis that amyotrophic lateral sclerosis is a multistep process.

Methods

We generated incidence data by age and sex from amyotrophic lateral sclerosis population registers in Ireland (registration dates 1995–2012), the Netherlands (2006–12), Italy (1995–2004), Scotland (1989–98), and England (2002–09), and calculated age and sex-adjusted incidences for each register. We regressed the log of age-specific incidence against the log of age with least squares regression. We did the analyses within each register, and also did a combined analysis, adjusting for register.

Findings

We identified 6274 cases of amyotrophic lateral sclerosis from a catchment population of about 34 million people. We noted a linear relationship between log incidence and log age in all five registers: England r²=0·95, Ireland r²=0·99, Italy r²=0·95, the Netherlands r²=0·99, and Scotland r²=0·97; overall r²=0·99. All five registers gave similar estimates of the linear slope ranging from 4·5 to 5·1, with overlapping confidence intervals. The combination of all five registers gave an overall slope of 4·8 (95% CI 4·5–5·0), with similar estimates for men (4·6, 4·3–4·9) and women (5·0, 4·5–5·5).

Interpretation

A linear relationship between the log incidence and log age of onset of amyotrophic lateral sclerosis is consistent with a multistage model of disease. The slope estimate suggests that amyotrophic lateral sclerosis is a six-step process. Identification of these steps could lead to preventive and therapeutic avenues.

Funding

UK Medical Research Council; UK Economic and Social Research Council; Ireland Health Research Board; The Netherlands Organisation for Health Research and Development (ZonMw); the Ministry of Health and Ministry of Education, University, and Research in Italy; the Motor Neurone Disease Association of England, Wales, and Northern Ireland; and the European Commission (Seventh Framework Programme).

Syntheses of Recombinant Yellowtail and Flounder Growth Hormones inEscherichia coli

For syntheses of recombinant yellowtail and flounder growth hormones (r-yGH and r-fGH) in E. coli, expression plasmids were constructed. The expression level of r-yGH and r-fGH in the host cells were very high, reaching 15 and 8% of the total protein, respectively. These product proteins were accumulated in inclusion bodies in the cells. The recombinant hormones were isolated from the pellets ina glutathione reduction/oxidation buffer. The refolded hormones were further purified by DEAE-Toyopearl 650M chromatography to homogeneity. The purified r-yGH and r-fGH were composed of 188 and 174 amino acid residues, respectively, having amino-terminal sequences starting with methionine. The recombinant hormones had potent growth-promoting activities on juvenile rainbow trout Salmo gairdneri in a dose-dependent manner.

Evidence of an environmental effect on survival in ALS

Amyotrophic lateral sclerosis (ALS, motor neuron disease) is a neurodegenerative disorder of motor neurons leading to paralysis and eventual death by respiratory failure. Median survival is 2-3 years. Susceptibility genes, environmental triggers and disease related prognostic factors have been established, but environmental effects on survival are yet to be investigated. We analysed survival in the South-East England ALS register (SEALS register). Kaplan-Meier and Cox regression analyses were used to investigate survival in London, coastal and rural areas according to postcode at diagnosis. Results showed that there were 933 cases of ALS identified in the catchment area during the study period (1994-January 2012). Cox regression demonstrated a highly significant model for survival with significant protective variables: coastal residency, riluzole use and younger age at onset. Significantly worse survival was associated with London residency, older age as well as definite and probable El Escorial classifications. In conclusion, these findings suggest the possibility of an environmental effect on survival in ALS.

Usefulness and Problems of Intraosseous Infusion with the Bone Injection Gun™ Using Simulators Under Confined Space Conditions

Introduction

It is important to have a venous line for infusion as an emergency treatment for patients suffering from crush syndrome or bleeding under confined space (CS) conditions in disaster medicine. However, it is not easy to for Emergency Life-Saving Technicians (ELSTs) to establish a venous line in such settings. Although previous studies have described the use of mechanical intraosseous (IO) devices and IO access while wearing chemical protection gears, problems for the use of IO devices under CS conditions have not been considered. This study aimed to investigate usefulness and problems of using a Bone Injection Gun™ (BIG) for IO infusion by ELSTs and rescue workers in CS conditions.

Methods

The time required and success rate for IO infusion using a BIG in a manikin leg were measured, and for administering intravenous infusion in a manikin arm using either rescue gloves or plastic gloves by ELSTs or rescue workers under CS conditions.

Results

Wearing rescue gloves, ELSTs were significantly faster in placing intraosseous infusion (IOI) compared with rescue workers. The success rate of the placement was not significantly different between ELSTs and rescue workers whether or not they wore rescue or plastic gloves.

Conclusions

Although the finite usefulness of IOI with BIG under CS conditions is indicated, some problems such as the timing of removal of the IOI and difficulty in finding the location of the trocar needle after activating BIG are pointed out. Therefore, there are rooms to consider using IOI with BIG under CS condition. (Hong Kong j.emerg. med. 2014;21:23-30)

Suppressive effect of RAS inhibitor manumycin A on aberrant crypt foci formation in the azoxymethane-induced rat colorectal carcinogenesis model

BACKGROUND AND AIM

The chemopreventive effect of RAS inhibitors on colorectal cancer is unknown. Because aberrant crypt foci (ACF), earliest preneoplastic lesions, are highly positive for K-RAS mutation, RAS inhibitors are likely to be effective for chemoprevention. Therefore, in the present study, the suppressive effect of a RAS inhibitor, manumycin A, on ACF formation in an azoxymethane (AOM)-induced rat colorectal carcinogenesis model was investigated.

METHODS

Rats injected with AOM were administered manumycin A (30 mg/kg) subcutaneously thrice weekly for 8 weeks or for 4 weeks (latter half), sacrificed at 8 weeks, and examined for ACF in the colorectum. Phosphorylated ERK and Ki-67 expression was evaluated by immunohistochemistry. Apoptosis was assessed by TUNEL staining.

RESULTS

The mean number of ACF in the 8-week manumycin A group (72.9 ± 20.1) was significantly lower than in the vehicle group (155.6 ± 56.7, P < 0.01), and it was significantly lower even in the 4-week manumycin A group than in the vehicle group (92.2 ± 13.0 vs 222.3 ± 83.3, P < 0.01). The positive rate for phosphorylated ERK in the manumycin A group (13.5 ± 19.2%) was significantly lower than in the vehicle group (50.2 ± 19.8%, P < 0.01). The positive rate for Ki-67 in the manumycin A group (2.2 ± 3.4%) was significantly lower than in the vehicle group (14.7 ± 8.2%, P < 0.01). There were significantly more terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling-positive cells in tissue samples from the manumycin A group versus the vehicle group (8.6 ± 9.7% vs 2.9 ± 2.0%, P < 0.05).

CONCLUSION

Manumycin A suppressed ACF formation in the AOM-induced colorectal carcinogenesis model, demonstrating that RAS inhibitors may be very effective for chemoprevention of colorectal cancers.

Photoresponse and learning behavior of ascidian larvae, a primitive chordate, to repeated stimuli of step-up and step-down of light

Ascidians are lower chordates and their simple tadpole-like larvae share a basic body plan with vertebrates. Newly hatched larvae show no response to a stimulus of light. 4 h after hatching, the larvae were induced to swim upon a step-down of light and stop swimming upon a step-up of light. At weaker intensity of light, the larvae show the same response to a stimulus after presentation of repeated stimuli. When intensity of actinic light was increased, the larvae show sensitization and habituation of the swimming response to a stimulus after repeated stimuli of step-down and step-up of the light. Between 2 h 20 min and 3 h 40 min after hatching the larvae did not show any response to the first stimulus, but after several repeatedstimuli they show swimming response to a step-down of light. A repeated series of stimulus cause sensitization. Between 4 h and 7 h after hatching, the larvae show photoresponse to the first stimulus, but after several repetition of the stimuli, the larvae could not stop swimming to a stimulus of a step-up of the actinic light. A repeated series of stimulus cause greaterhabituation. Both sensitization and habituation depend upon intensity ofactinic light.

The multi-hit hypothesis of primary biliary cirrhosis: polyinosinic-polycytidylic acid (poly I:C) and murine autoimmune cholangitis

A void in understanding primary biliary cirrhosis (PBC) is the absence of appropriate animal models. Our laboratory has studied a murine model of autoimmune cholangitis induced following immunization with 2-octynoic acid (2OA), an antigen identified following extensive quantitative structural activity relationship (QSAR) analysis, using human autoantibodies and three-dimensional analysis of the mitochondrial autoantigen, the E2 subunit of the pyruvate dehydrogenase complex (PDC-E2). Mice immunized with 2OA coupled to bovine serum albumin (BSA) develop anti-mitochondrial antibodies (AMAs) of the identical specificity as humans with PBC, and in addition develop inflammatory portal cell infiltrates in liver. However, the natural history of disease is less severe than in humans and does not include fibrosis. Data from human and autoimmune murine models suggest that environmental and/or infectious agents can exacerbate autoimmune reactions, and a model of PBC has been described in which polyinosinic-polycytidylic acid (poly I:C), a viral RNA mimetic and Toll-like receptor 3 (TLR-3) agonist induces low-titre AMAs and in mild portal infiltrates. We took advantage of our established model to determine whether immunization with 2OA-BSA coupled with poly I:C alters the disease process. Indeed, the addition of poly I:C produces a profound exacerbation of autoimmune cholangitis, including a significant increase in CD8(+) infiltrating T cells, as well as a marked increase of proinflammatory cytokines. In addition, mice have evidence of fibrosis. These findings lend support to the concept that besides breakdown of self-tolerance, there is a requirement of a second 'hit' during the breakdown process that leads to disease which more faithfully mimics human PBC.

Primary processes in photolysis of octopus rhodopsin

The photolysis of octopus rhodopsin was studied by picosecond time-resolved spectroscopy at physiological temperature (8 degrees C) and by steady-state spectroscopy at very low temperature (10 K). Both hypsorhodopsin and bathorhodopsin were formed from a bathorhodopsin-like red-shifted intermediate "primerhodopsin," which was the primary photoproduct with our time resolution (36 ps). Though it was proposed that hypsorhodopsin is formed solely by a multiphoton process, the present results obtained by using blue light pulses (461 nm) of low intensity showed that hypsorhodopsin is formed by a single photon mechanism via thermal decay from primerhodopsin. When the excitation intensity is increased, a channel for the photochemical formation of hypsorhodopsin from primerhodopsin is opened. There are two thermal pathways leading from primerhodopsin. One process is the formation of hypsorhodopsin, which is later thermally converted to bathorhodopsin, and the other is the direct formation of bathorhodopsin from primerhodopsin. The formation efficiencies at room temperature of hypsorhodopsin and bathorhodopsin at very low excitation intensity were estimated to be larger than 0.6 and smaller than 0.4, respectively. The formation of hypsorhodopsin was also found in the early stages of the irradiation of octopus rhodopsin with weak continuous light at 10 K. However bathorhodopsin is formed three times more efficiently than hypsorhodopsin at 10 K.At physiological temperatures the formation of hypsorhodopsin in D(2)O takes place more slowly than in H(2)O. This indicates that the lifetime of primerhodopsin is decreased by H(2)O/D(2)O exchange. The rate constant for the primerhodopsin --> bathorhodopsin conversion is more sensitive than that for the primerhodopsin --> hypsorhodopsin conversion. The transformation of hypsorhodopsin to bathorhodopsin shows no deuterium effect at low temperature.