Sodium-glucose cotransporter 2 inhibitors not only suppress recurrence after atrial fibrillation ablation but also cause atrial reverse remodeling

Background

Sodium-glucose cotransporter 2 (SGLT2) inhibitors have shown fewer heart failure (HF) hospitalization and cardiovascular death in patients with type-2 diabetes mellitus (DM). Atrial fibrillation (AF) is associated with both HF and DM, and we reported SGLT2 suppressed AF recurrence after catheter ablation (CA) than dipeptidyl peptidase-4 (DPP4) inhibitor.

Purpose

We evaluated whether SGLT2 itself induces atrial reverse remodeling.

Methods

This is a sub-analysis of a prospective randomized controlled open-label clinical study for comparing the suppressive effect of SGLT2 inhibitor with DPP4 inhibitor on AF recurrence after CA. Eighty AF patients with type-2 DM were randomized to Tofogliflozin group or Anagliptin group with a computer-generated random sequence, which was stratified by left atrial diameter and AF type at screening. Primary outcome is AF recurrence at 12 months after CA, and secondary outcomes include the echocardiographic findings.

Results

70 patients (70.3±8.1 years, 58 male, 30 paroxysmal AF, 38 Tofogliflozin) were analyzed. Recurrent AF was detected in 24 patients (34.3%), and the AF recurrence ratio was higher in the Anagliptin group than the Tofogliflozin group. In 46 patients without AF recurrence (17 Anagliptin, 29 Tofogliflozin), LAVI has shrunk in 12 months compared to the baseline (42.8±11.9 to 36.6±11.2ml/m2) and the reduction of LAVI was larger in Tofogliflozin group than Anagliptin group (−8.6±2.0ml/m2 vs. −2.0±2.6ml/m2, P=0.0471).

Conclusion

Tofogliflozin not only suppressed AF recurrence after CA but also caused atrial reverse remodeling than Anagliptin in type-2 DM patients.

Funding Acknowledgement

Type of funding sources: None.

Thromboembolic risk of movable type left atrial appendage thrombi in patients with atrial fibrillation under widespread use of anticoagulants

Background

Left atrial appendage thrombi (LAAT), especially movable type LAAT, have been reported to be high-risk for thromboembolic events in patients with atrial fibrillation (AF). However, thromboembolic risk of the movable-type LAAT under widespread use of anticoagulant therapy remains unclear.

Methods

We retrospectively studied 65 LAAT patients taking anticoagulants out of 1381 consecutive patients who underwent transthoracic echocardiography prior to cardioversion or catheter ablation for AF. Patients with significant valvular disease and coagulation disorder were excluded. Clinical data were evaluated at the time of TEE. The LAAT were classified into movable and fixed type LAAT by three independent observers.

Results

Sixteen of 65 LAAT patients showed movable type LAAT. During follow-up (42±34 months), one patient underwent emergency thrombectomy, 5 patients developed thromboembolic event, and 12 patients died. There were no differences in clinical data, parameters, thrombectomy/thromboembolic event, and survival rate between patients with movable and fixed type LAAT.

Conclusion

Thromboembolic risk of the movable-type LAAT is the same as fixed type LAAT, under widespread use of anticoagulant therapy.

Funding Acknowledgement

Type of funding sources: None.

The impact of abnormal conduction zone on outcomes after catheter ablation for atrial fibrillation

Background

The abnormal conduction zone (ACZ) in the left atrium (LA) has attracted attention as an arrhythmia substrate in atrial fibrillation (AF).

Purpose

We investigated whether the ACZ affects outcomes after catheter ablation (CA) for AF.

Methods

We studied 78 patients (42 Non-paroxysmal AF, 49 males, and 68±10 years) who received CA for AF. High-density LA mapping during high right atrial pacing was constructed gaining than 2000 points (average 4377±846 points). Isochronal activation maps created at 5-ms interval setting. ACZ was identified by locating a site with isochronal crowding of ≥3 isochrones, and ≥8 isochrones were defined as the conduction block zone (CBZ) in a 4-mm diameter tag (conduction velocity were calculated as ≤27 cm/s and≤10 cm/s, respectively).

Result

Recurrent AF was detected in 25/78 patients (32%) during the follow-up period (9.2±3.0 month). ACZ and CBZ were distributed linearly, and ACZ was observed in 73 of 78 patients and 8 of these 73 patients had the CBZ. Univariate analysis revealed that elevated body mass index (26.2±3.8 vs. 24.3±3.3 kg/m2, P=0.0303), the higher prevalence of non-paroxysmal AF (72% vs. 45%, P=0.0272), larger LA diameter (47.6±6.6 vs. 42.1±6.9 mm, P=0.0014), and longer length of ACZ (79.7±45.1 vs. 52.9±35.7 mm, P=0.0058) were associated with recurrent AF after CA. On multivariate analysis, longer ACZ was independently associated with recurrent AF. Moreover, patients with longer ACZ (cutoff value: 84 mm) had a higher risk of recurrent AF than shorter ACZ (12/22; 55% vs 13/56; 23%, log-rank P=0.0024).

Conclusion

The length of ACZ was associated with recurrent AF after CA.

Funding Acknowledgement

Type of funding sources: None.

Assessment and incidence of PV gaps as determined by HD Grid and circular mapping catheters

Funding Acknowledgements

Type of funding sources: None.

Background

Many tools and techniques are utilized to assess pulmonary vein isolation (PVI), such as evaluation of entrance and exit block, voltage mapping, and use of drugs such as adenosine. It is unclear which tools and techniques may provide greater sensitivity in the identification and elimination of pulmonary vein (PV) gaps, leading to better long-term outcomes. The HD Grid simultaneously records orthogonal bipolar EGMs to reduce directional sensitivity. Previously published data suggest that the use of HD Grid may improve sensitivity for gap identification.

Purpose

To determine, in a large cohort of procedures, the rate of gap detection when using HD Grid to check for PVI as compared to circular mapping catheters (CMC).

Methods

Anonymized, acute procedural data was prospectively collected in de novo AF ablation procedures in which either a 10- or 20-pole CMC or HD Grid catheter was used to assess PVI. Procedural data including gap detection and PVI assessment method were analyzed using chi-squared test.

Results

559 cases from over 60 institutions in 8 countries were analyzed. Of the 559 cases, 47.4% (265/599) used HD Grid, and 52.6% (294/599) used a CMC. PV gaps were found in 52.5% (139/265) of HD Grid procedures and in 36.7% (108/294) of CMC procedures (p < 0.001). The most common PVI assessment method in both HD Grid and CMC groups was entrance/exit block (90.9%, 92.5%, respectively). Mapping as a post-ablation assessment method was used in 69.1% (183/265) of HD Grid procedures whereas it was only used in 42.8% (126/294) of CMC procedures (p < 0.001). Of the 183 HD Grid procedures that utilized mapping for PV assessment, 57.9% (106/183) used both voltage and activation mapping, 41.0% (75/183) used voltage only and 1.1% (2/183) used activation mapping only. Significantly more gaps were found in the HD Grid group that used both activation and voltage mapping (83.0%, 88/106) as compared to voltage mapping only (49.3%, 37/75, p < 0.001). At the end of the procedure, 95.8% of patients in the HD Grid group were in sinus rhythm, as compared to 84.7% of the CMC group.

Conclusions

While this analysis does not represent a direct comparison of the sensitivity of the two different technologies, HD Grid detected significantly more PV gaps compared to CMC in AF procedures. Previous publications have attributed similar findings to HD Grid’s ability to reduce voltage amplitude dependence on wavefront directionality. The significantly larger number of HD Grid cases that utilized mapping as a method of determining PVI could be explained by the need to maneuver the HD Grid around the circumference of the vein, which may naturally lead to map collection. This data also suggests that using both voltage and activation mapping identifies significantly more gaps as compared to only voltage mapping, however, further analysis could be warranted to better understand how these maps were collected and what map settings were used.

The impact of oral direct thrombin inhibitors on activated clotting time during catheter ablation in patients with atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

Direct thrombin inhibitors (DTIs) unlike factor Xa-inhibitors (Xa-inhibitors) is associated with fewer bleeding complications than warfarin in patients who had catheter ablation (CA) for atrial fibrillation (AF). However, the mechanisms remains unclear, and activated clotting time (ACT) is used to control heparin-dose for thromboembolic prevention during CA. Methods: We retrospectively studied 543 patients taking direct oral anticoagulant (DOAC) who underwent CA for AF (375 males, age 67 ± 10, 251 non-paroxysmal AF, 142 DTIs). Patients with off-label usage of DOAC were excluded. ACT was measured before (Pre-ACT) and after (post-ACT) initial heparin administration (3000U + 100U/kg), and total heparin-dose was evaluated. Results: Pre-ACT and post-ACT were extended in patients with DTIs (150 ± 21 vs 123 ± 15; P < 0.0001 and 322 ± 39 vs 309 ± 42 sec; P = 0.0013). Patients with Xa-inhibitors required higher total heparin-dose (199 ± 43 vs 175 ± 34 U/kg; P < 0.0001). During and after CA, none had thromboembolic events and 14 patients (3 DTIs, 11 Xa-inhibitor) showed bleeding events (Figure). Conclusions: ACT is extended in patients taking DTIs. Xa-inhibitors might have anticoagulant effects which are not reflected in ACT. Abstract Figure.

Increased left ventricular stiffness assessed by diastolic wall strain causes symptoms in patients with premature ventricular contraction

Background

Premature ventricular contraction (PVC) is one of common arrhythmias and only some patients complain of PVC-related symptoms, however the mechanisms which cause the symptoms remain unclear in patients with PVCs.

Purpose

We investigated whether the left ventricular (LV) stiffness assessed by diastolic wall strain (DWS) relate symptoms or not in patients with PVC.

Methods

We studied 109 patients (48 males, age 60±19) with frequent monomorphic PVCs who underwent 12-leads electrocardiogram (ECG), signal-averaged electrocardiogram (SAECG), 24h-Holter ECG recording, and transthoracic echocardiography (TTE). Patients with structural heart disease or other arrhythmias such as atrial fibrillation were excluded. Clinical factors, blood samples for atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP), and filtered QRS duration (f-QRS) and root mean square voltage of the terminal 40ms of the QRS complex (RMS40) obtained by SAECG were evaluated. We assessed PVC-SV (stroke volume during PVC), PVC-CI (CI between the previous sinus beat and VPC), and left ventricular (LV) stiffness assessed by diastolic wall strain (DWS). DWS was calculated from the M-mode echocardiographic measurement of the LV posterior wall thickness at end-systole (PWs) and end-diastole (PWd) during sinus rhythm, and DWS was defined as (PWs − PWd)/PWs.

Results

31patients (28%) had PVC-related symptoms (18 palpitation and 13 pulse deficit). Patients with PVC-related symptoms showed shorter PVC coupling interval index (52±10 vs. 58±11%, p=0.0140), reduced PVC-SV (21±12 vs. 29±17ml, p=0.0103) and decreased DWS (0.38±0.06 vs. 0.42±0.06, p=0.0011). Meanwhile, the level of BNP and ANP, f-QRS, RMS40, QRS morphology of PVC and the total number of PVC per day were not associated with PVC-related symptoms. On multivariate analysis, decreased DWS was only independently associated with PVC-related symptoms (p=0.0357, OR 2.3629 for each 0.1 decrease in DWS 95% CI 1.0583–5.5815).

Conclusion

The reduced diastolic wall strain relates with PVC-related symptoms. The increased left ventricular stiffness might cause symptoms in patients with PVC.

Funding Acknowledgement

Type of funding source: None

Conduction gaps after pulmonary vein isolation due to high contact force ablation in patients with atrial fibrillation

Background

Catheter ablation for atrial fibrillation (AF) with high contact force (CF) has been reported to lead to the gaps after pulmonary vein isolation (PVI), and the appearance of the gaps depends on the site in the left atrium (LA).

Purpose

The aim of this study is to clarify the relationship between the gaps appearance and high CF.

Methods

In the clinical study, 74 consecutive patients (39 males, age 71±9, 46 with paroxysmal AF) underwent conventional PVI with a point-by-point radiofrequency (RF) ablation using a CF sensing catheter (TactiCath SETM). RF energy (J), number of RF point, Lesion index (LSI), force-time integral (FTI), average CF (g), and the degree of LA depression with high CF were evaluated. In the experimental study (figure), the relationship between the ablation area and the degree of depression with high CF using bovine left ventricular wall.

Results

In the clinical study, the gaps were found in 175 of 1182 sites after first path PVI ablation. The CF in the gap sites was higher than without the gap sites in RPV roof, anterior RSPV and anterior RPV carina (18.9±6.8 vs 15.0±5.7g p=0.0262, 26.4±11.6 vs 19.5±6.0g p=0.0029, 22.7±6.4 vs 19.1±5.5g, p=0.0161). Meanwhile, there were no differences in RF energy, number of RF point, LSI, FTI. High CF (≥30g) showed a depression of 3 mm or more in only RPV roof and anterior RPV (figure). In the experimental study, the ablation range narrowed as the indentation deepened with more than 30g CF (r=0.6417, p=0.0625).

Conclusion

Catheter ablation for AF with high contact force might lead to the gaps in RPV roof and anterior RPV site by the reduction of the ablation area due to depression caused by the pressure.

Extension of each contact force

Funding Acknowledgement

Type of funding source: None

Left ventricular stiffness assessed by diastolic wall strain predicts asymptomatic atrial high rate episodes in patients with pacemaker implantation

Background

Asymptomatic atrial fibrillation has been reported to be associated with an increased risk of embolism.

Purpose

We investigated whether the left ventricular (LV) stiffness assessed by diastolic wall strain (DWS) predicts atrial high rate episodes (AHREs) in patients with pacemaker implantation (PMI).

Methods

One hundred forty seven patients (76 males, 75.2±8.9 years, 62 with sick sinus syndrome; SSS and 85 with atrioventricular block) who did not show atrial tachyarrhythmia before PMI were studied. DWS and other measurements were assessed using transthoracic echocardiography before DDD-pacemaker implantation. DWS was calculated from the M-mode echocardiographic measurement of the LV posterior wall thickness at end-systole (PWs) and end-diastole (PWd), and DWS was defined as (PWs-PWd)/PWs.

Results

AHREs (>5 min and >180 beats/min) were detected in 50/147 patients during follow-up periods (38.3±13.8 months). Patients with AHREs showed reduced DWS (0.29±0.07 vs. 0.39±0.06, p<0.0001), larger left atrial volume index, elevated E/e' ratio, thicker LV PWd, higher prevalence of SSS, and left bundle branch block pattern during ventricular pacing. On multivariate analysis, DWS was only independently associated with AHREs (p<0.0001, HR 1.987 for each 0.1 decrease in DWS, 95% CI 1.553–2.650). Patients with reduced DWS (<0.33) had a higher risk of incidences of AHREs (Figure 1).

Conclusions

LV stiffness assessed by DWS predicts AHREs in patients with PMI.

Figure 1

Funding Acknowledgement

Type of funding source: None

Slow conduction zone as an early electrical remodeling change in patients with atrial fibrillation

Background

The slow conduction zone (SCZ) in the left atrium (LA) detected using 3-D mapping and high-resolution imaging system has attracted attention as an arrhythmia substrate of atrial fibrillation (AF). However, the occurrence mechanism of SCZ remains unclear.

Purpose

This aim of this study is to clarify whether SCZ is related to the low voltage zone (LVZ) or the LA anatomical contact areas with other organs such as aorta or thoracic spine in patients with AF.

Methods

We studied 36 patients (21 males, 68±10 years, 14 paroxysmal AF; PAF, 17 persistent AF; PeAF, 5 long-standing persistent AF; LS-PeAF) who received catheter ablation for AF. High-density LA mapping during sinus rhythm or right atrial pacing after pulmonary vein isolation were constructed by acquiring more than 2000 endocardial points in each patient. Isochronal activation maps were created at 5-ms interval setting, and the SCZ was identified on the activation map by finding a site with isochronal crowding of ≥3 isochrones, which are calculated as ≤27 cm/s (figure). The LVZ was defined as the following; mild (<1.5 mV), moderate (<1.0 mV), and severe LA-LVZ (<0.5 mV). The LA contact areas (CoAs; ascending aorta-anterior LA, descending aorta-posterior LA, and vertebrae-posterior LA) were assessed using computed tomography.

Results

The SCZ was distributed linearly (figure), and observed in 35 of 36 patients (97.2%). The SCZ was often found in the anterior (89%), roof (64%), and septal wall (47%) of LA, and longest in patients with LS-PeAF (PAF: 56±34 mm, PeAF; 79±41 mm, LS-PeAF; 107±34mm, P=0.0351). The prevalence rate of SCZ (97.2%) was higher than LVZ (figure, mild LA-LVZ; 91.7%, moderate LA-LVZ: 66.7%, severe LA-LVZ; 25%). The 55.8% of SCZ overlapped with mild LA-LVZ, 37.6% of SCZ with moderate LA-LVZ, and 19.1% of SCZ with severe LA-LVZ. The LA CoAs were found in all patients. A total of 72 CoAs (average surface area, 7.0±4.0 cm2) were identified. A CoA was found in each of the three representative regions, ascending aorta-anterior LA (4.1±2.0 cm2, 36 of 36 patients, 100%), descending aorta-posterior LA (2.3±1.2 cm2, 12 of 36 patients, 33%), and vertebrae-posterior LA (3.4±2.1 cm2, 24 of 36 patients, 67%). However, only 22% of SCZ matched with the LA anatomical contact areas.

Conclusion

The slow conduction zone reflects LA electrical remodeling and may be a precursor finding of the low voltage zone, not LA contact areas in patients with atrial fibrillation.

Funding Acknowledgement

Type of funding source: None

Evaluating a child-rearing family friendly community from user’s aspect in Japan

Backgrounds

In Japan, some parents with an infant have limited network with others and are feeling anxious and less confident about their child rearing. Many measures for promoting a child-rearing family friendly community are implemented to promote families' healthy development in communities. However, a situation surrounding child-rearing in a community is diverse. The aim of this study is to examine possible indices to monitor and evaluate child-rearing family friendly community.

Methods

This was a cross sectional study with using two kinds of data in one city in Japan. The first one was public data providing information about physical environment related to child-rearing of each community. The second data was on questionnaire answered by a parent of infants from 3 months to 48 months through 2013 to 2019. We merged two kinds of data and examined the association between environment and parents' willingness to raise up children in their community (4 scales) by mixed effect regression model stratified by age of months (under 1 year, 1- and 2-years and 3-years).

Results

Targets of analysis included 2,952 parents of infant under 1 year, 2,342 of 1- and 2-years and 1,977 of 3-year. For parents of infant of 1- and 2-years and 3-years, the closer a child-rearing support center was, the bigger the willingness to raise up a child in their community (β[95%CI]:-0.007[-0.014-/-0.0004], -0.007[-0.012/-0.002, respectively). Also, for parents of 1- and 2-years infant, the closer the park was, the bigger the willingness (-0.014[-0.028/-0.0008]). On the other hand, for parents of infant under 1 year, environment was not statistically significant on their willingness.

Conclusions

It was indicated that user's easiness to visit a consulting space or playing place such as a child-rearing support center or a park become one of indicators for evaluating child-rearing family friendly community in Japan.

Key messages

Child-rearing family friendly environment in a community should be evaluated from the user’s aspect. Further studies including evaluation quality of places or services are needed.

P3704Silent ischemic brain lesion detected in patients with subclinical paroxysmal atrial fibrillation

Background

Long-lasting atrial fibrillation (AF) has been reported to be associated with an increased risk of dementia, independent of clinical stroke. However, the mechanisms or association in patients with subclinical paroxysmal AF (S-PAF) remain unclear. We evaluated whether S-PAF is associated with silent ischemic brain lesion (S-IBL), one of causes of dementia.

Methods

We studied 46 patients (35 male, 68±15 yrs) without a history of stroke/transient ischemic attack and AF, who implanted insertable cardiac monitoring (ICM) for unexplained syncope (n=33) or embolic stroke of undetermined source (ESUS) (n=13). All patients underwent cerebral magnetic resource imaging (c-MRI), and S-IBL was defined as infarction, lacuna and microbleeds. The lesions in an acute stage were excluded in patients with ESUS.

Results

AF was detected in 15/46 patients (11 with unexplained syncope and 4 with ESUS) during follow-up of 7.0±6.6 months, and S-IBL was observed in 18/46 patients (9 infarction, 8 lacuna, or 8 microbleeds). Univariate analysis revealed that higher prevalence of AF (61% vs. 14%, p=0.0015), elder age (73±10yrs vs. 65±16yrs, p=0.0445), dyslipidemia (67% vs. 25%, p=0.007), structural heart disease (44% vs. 14%, p=0.0383), and larger left atrium diameter (41±6 mm vs. 37±5 mm, p=0.0267) were related to S-IBL. On multivariate analysis, prevalence of AF was independently associated with S-IBL (p=0.0070, OR 13.4, 95% CI 1.945–155.813). When receiver-operating-characteristics (ROC) curve analysis and prevalence of AF were used to detect S-IBL, the area under the ROC curve was 0.7341 (sensitivity: 61.1%, specificity: 85.7%).

Conclusion

Subclinical paroxysmal AF is associated with silent ischemic brain lesion and might cause to dementia.

P5654Brain natriuretic peptide and left atrial volume predict the reduced flow velocity of left atrial appendage during sinus rhythm in patients with atrial fibrillation

Background

It remains controversial whether or not to discontinue anticoagulation therapy after catheter ablation (CA) for atrial fibrillation (AF). The reduced flow velocity of the left atrial appendage (FV-LAA) during AF causes left atrial appendage thrombus and increases the risk of stroke. However, some AF patients show reduced FV-LAA even during sinus rhythm (SR).

Methods

398 patients who showed SR during transesophageal echocardiography (TEE) before CA for AF were studied (259 males, 68±10 years, 77 with non-paroxysmal AF). Clinical factors, transthoracic echocardiography and blood samples were obtained before TEE. Reduced FV-LAA was defined as <35 cm/sec of FV-LAA.

Results

Reduced FV-LAA was observed 70/398 patients (18%). Reduced FV-LAA was significantly associated with elevated brain natriuretic peptide (BNP) (p<0.0001), increased LA volume index (p<0.0001), reduced left ventricular ejection fraction (p=0.0017), high prevalence of non-paroxysmal AF (p=0.0048), prior history of heart failure (p=0.0172), and no administration of angiotensin converting enzyme inhibitor/angiotensin II receptor blocker (ACEI/ARB) (p=0.0403), while CHADS2 factors were not significantly associated.

On multivariate analysis, LA volume index (p<0.0001, OR 1.049 for each 1 increase in LA volume index, 95% CI 1.025–1.073) and no administration of ACEI/ARB (p=0.0015, OR 0.339 for administration, 95% CI 0.173–0.662) and BNP (p=0.0048, OR 1.035 for each 10 pg/ml increase in BNP, 95% CI 1.011–1.061) and were associated with reduced FV-LAA.

Rate of reduced flow velocity

Conclusion

The elevated BNP level and large LA volume index predict reduced FV-LAA during SR. AF patients with increased BNP and larger LA volume index might require long-term anticoagulation taking after CA procedure.

P3790Left ventricular stiffness assessed by diastolic wall strain predicts infrequent atrial fibrillation

Background

Left ventricular (LV) stiffness as the passive LV filling property in the LV diastolic function has been reported to be related with the prevalence of atrial fibrillation (AF). On the other hand, a novel insertable monitoring (ICM) system is a powerful tool to detect AF with rare appearance in patients with embolic stroke of undetermined source (ESUS). We investigated whether the LV stiffness assessed by diastolic wall strain (DWS) predicts infrequent atrial fibrillation.

Methods

Fifty-five patients (41 males, 68±14 years) who underwent ICM implantation for ESUS (n=19) or unexplained syncope (n=36) were studied. DWS, left atrial (LA) stiffness and other measurements were assessed using transthoracic echocardiography before the ICM implantation. DWS was calculated from the M-mode echocardiographic measurement of the LV posterior wall thickness at end-systole (PWs) and end-diastole (PWd) during sinus rhythm, and DWS was defined as PWd/PWs. LA stiffness index was defined as the ratio of E/e' to LA peak strain.

Results

AF was detected in 20 patients (36%) during the follow-up periods (280±243 days). Patients with AF showed reduced DWS (0.30±0.07 vs. 0.41±0.08, p<0.0001), larger LA volume index (39.0±10.9 vs. 32.3±9.0, p=0.0174), and higher age (74.6±10.4 vs. 64.6±14.9, p=0.0105). On the other hand, LA stiffness index, LA function (reservoir, booster, and conduit function estimated by LA volume), and LV relaxation function (E wave, E/A ratio, deceleration time) were not associated with detection of AF. There was no difference on AF detection rate between ESUS and unexplained syncope (26% vs. 42%, p=0.2604). On multivariate analysis, DWS was only independently associated with detection of AF (p<0.0001, OR 5.647 for each 0.1 decrease in DWS, 95% CI 1.084–1.338). Moreover, patients with reduced DWS (<0.38) had a higher risk of incidences of AF than patients with preserved DWS (figure).

Figure 1

Conclusions

LV stiffness assessed by DWS predicts infrequent AF. Reduced LV stiffness rather than LA dysfunction or LV relaxation dysfunction may be the main cause of AF in the early stages.

P5974Prognostic value of global tangential strain by three-dimensional echocardiography heart failure patients with intermediate ECG criteria for cardiac resynchronization therapy

Background

In the current clinical guidelines, cardiac resynchronization therapy (CRT) is recommended in heart failure (HF) patients with left bundle branch block (LBBB) with QRS width ≥150ms as Class I indication. In terms of HF patients with intermediate ECG criteria, prediction for benefit of CRT is still controversial in routine echocardiography.

Purpose

The aim was to assess whether three-dimensional (3D) echocardiographic indexes of global LV function at baseline has a prognostic value following CRT implantation in patients who fulfilled with intermediate ECG criteria.

Methods

We studied 62 HF patients who fulfilled with the indication criteria of CRT implantation according to current the clinical guidelines. In addition to routine two-dimensional echo, 3D echo dataset was acquired for determination of 3D global tangential strain (GTS) and 3D global longitudinal strain (GLS). We tracked predefined unfavorable outcomes for 3 years after CRT implantation: death, hospitalization due to worsening HF.

Results

LBBB with QRS width ≥150ms was evident in 26 of 62 patients (aged 68±11 years with 160±26 ms of QRS duration and 29±7% of LV ejection fraction), and the other 36 patients only fulfilled intermediate ECG criteria (QRS width 120–149ms or non-LBBB). Unfavorable events occurred in 21 patients (34%). The median GTS was −15.4%. Although GLS was not predictive, GTS greater than −15.4% had high probability of unfavorable outcomes over 3 years (Log-rank, p<0.05). There is no difference in the probability of unfavorable outcomes between LBBB and intermediate ECG criteria. Baseline GTS in patients with intermediate ECG criteria was associated with unfavorable outcomes: −12.6±2.6% vs. −17.3±3.8% (p<0.05). Outcome was better in the intermediate ECG criteria patients with GTS ≤−15.4% than in those with LBBB and in those with intermediate ECG criteria patients with GTS >−15.4% (Log-rank: p<0.05, p<0.0001, respectively).

Conclusions

Baseline GTS by 3D echocardiography is useful for predicting outcome over 3 years after CRT implantation regardless of the ECG criteria for CRT indication.

Relationship between Sensory Perception and Frailty in a Community-Dwelling Elderly Population

BACKGROUND

Aging anorexia, defined as loss of appetite and/or reduced food intake, has been postulated as a risk factor for frailty. Impairments of taste and smell perception in elderly people can lead to reduced enjoyment of food and contribute to the anorexia of aging.

OBJECTIVE

To evaluate the relationship between frailty and taste and smell perception in elderly people living in urban areas.

DESIGN

Data from the baseline evaluation of 768 residents aged ≥ 65 years who enrolled in a comprehensive geriatric health examination survey was analyzed. Fourteen out of 29-items of Appetite, Hunger, Sensory Perception questionnaire (AHSP), frailty, age, sex, BMI, chronic conditions and IADL were evaluated. AHSP was analyzed as the total score of 8 taste items (T) and 6 smell items (S). Frailty was diagnosed using a modified Fried's frailty criteria.

RESULTS

The area under the receiver operator curves for detection of frailty demonstrated that T (0.715) had moderate accuracy, but S (0.657) had low accuracy. The cutoffs, sensitivity, specificity and Youden Index (YI) values for each perception were T: Cutoff 26.5 (YI: 0.350, sensitivity: 0.639, specificity: 0.711) and S: Cutoff 18.5 (YI: 0.246, sensitivity: 0.690, specificity: 0.556). Results from multiple logistic regression models, after adjusting for age, sex, IADL and chronic conditions showed that participants under the T cutoff were associated with exhaustion and those below the S cutoff were associated with slow walking speed. The adjusted logistic models for age, sex, IADL and chronic conditions showed significant association between T and frailty (OR 2.81, 95% CI 1.29-6.12), but not between S and frailty (OR 1.73, 95% CI 0.83-3.63).

CONCLUSIONS

Taste and smell perception, particularly taste perception, were associated with a greater risk of frailty in community-dwelling elderly people. These results suggest that lower taste and smell perception may be an indicator of frailty in old age.

Meta-analysis: the risk of venous thromboembolism in patients with inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD), which includes Crohn's disease (CD) and ulcerative colitis (UC), is a systemic disorder that predominantly affects the bowels but is also associated with venous thromboembolism (VTE).

AIM

To provide a quantitative assessment of the association of IBD with venous thromboembolism risk and to explore the possible sources of heterogeneity in the current literature, a meta-analysis of case-control and cohort studies was conducted.

METHODS

Studies were identified by a literature search of the PubMed and Scopus databases (from inception inclusive 31 December 2012) for English language studies. Summary relative risks (RRs) with 95% confidence intervals (CIs) were calculated with fixed- and random-effects models. Several subgroup analyses were performed to explore potential study heterogeneity and bias.

RESULTS

Eleven studies met our inclusion criteria. The summary RR for deep venous thromboembolism (DVT) and pulmonary embolism (PE) comparing subjects both with and without IBD was 2.20 (95% CI 1.83-2.65). After adjusting for obesity and smoking, summary relative risks near 2.0 were seen for venous thromboembolism in both UC and CD patients.

CONCLUSION

This meta-analysis showed that inflammatory bowel disease is associated with an approximately two-fold increase in the risk of venous thromboembolism.

Double-balloon endoscopy versus magnet-imaging enhanced colonoscopy for difficult colonoscopies, a randomized study

BACKGROUND AND STUDY AIMS

Studies have estimated that failure of cecal intubation occurs with conventional colonoscopy in up to 10 % of cases. Double-balloon endoscopy (DBE) systems, magnetic endoscope imaging (MEI), and transparent cap have been shown to improve success rates for colonoscopy. This study evaluated the utility of DBE for complete examination of the colon compared with MEI plus cap (MEI-Cap) after incomplete or technically difficult colonoscopy in a randomized comparative manner.

PATIENTS AND METHODS

A total of 94 patients with incomplete or technically difficult colonoscopy were randomly assigned to receive either DBE (n = 47) or colonoscopy with MEI-Cap (n = 47). The primary end point was cecal intubation rate within 30 minutes. Secondary end points included intubation time, pain score using a visual analog scale, abdominal pressure attempts, doses of sedative medication, and changes in patient position during colonoscopy.

RESULTS

Patient characteristics were comparable in both groups. Cecal intubation rate within 30 minutes was significantly higher for DBE (45 /47, 95.7 %) than for MEI-Cap (34 /47, 72.3 %) (P = 0.0049). Mean time to reach the cecum was significantly lower in the DBE group (13.0 ± 5.3 minutes) than in the MEI-Cap group (16.4 ± 4.8 minutes; P = 0.0003). No complications were encountered in either group.  

CONCLUSION

DBE is more useful for complete examination of the colon than MEI-Cap in patients with incomplete or technically difficult colonoscopy.

Expression of RANKL/OPG during bone remodeling in vivo

The interaction between receptor activator of nuclear factor κB ligand (RANKL) and osteoprotegerin (OPG) plays a dominant role in osteoclastogenesis. As both proteins are produced by osteoblast lineage cells, they are considered to represent a key link between bone formation and resorption. In this study, we investigated the expression of RANKL and OPG during bone remodeling in vivo to determine the relationship between osteoclastogenic stimulation and osteoblastic differentiation. Total RNA was prepared from rat femurs after marrow ablation on days 0, 3, 6, and 9. The temporal activation patterns of osteoblast-related genes (procollagen α1 (I), alkaline phosphatase, osteopontin, and osteocalcin) were examined by Northern blot analysis. An appreciable increase in the expression of these osteoblast markers was observed on day 3. The peak increase in gene expression was observed on day 6 followed by a slight reduction by day 9. Real-time PCR analysis showed that the OPG mRNA expression was markedly upregulated on day 6 and slightly decreased on day 9. In contrast, RANKL mRNA expression was increased by more than 20-fold on day 9. The RANKL/OPG ratio, an index of osteoclastogenic stimulation, peaked on day 9. Histological analysis showed that RANKL and OPG immunoreactivity were predominantly associated with bone marrow cells. The expression of bone formation markers was activated in the bone formation phase, followed by the stimulation of RANKL/OPG expression in the bone resorption phase, which confirmed that these molecules are key factors linking bone formation to resorption during bone remodeling.

A Study on Conditions for Microbial Transport through Compacted Buffer Material

In order to assess microbial transport through compacted buffer material consisting of bentonite and silica sand with a density of 1.2, 1.6 or 1.8 g/cm3, sterilized test pieces with the diameter of 50 mm and the depth of 25 mm were fed with bacteria, Escherichia coli. The bacteria freely diffused when the proportion of Na-bentonite was 20 wt% or that of Ca-bentonite was 50 wt%. Bacterial movement was less than 5 mm in three weeks when the proportion of Na-bentonite was 70-100 wt% or that of Ca-bentonite was 100 wt%. A high proportion of bentonite is essential to slow down microbial entrance to the surface of a nuclear-waste container.

Phase II study of S-1 in combination with paclitaxel as a first-line treatment for patients with advanced/recurrent gastric cancer

e15615

Background: Taxanes and S-1 have been shown to be effective in patients with advanced gastric cancer and they have a considerable single-agent activity, respectively. We evaluated the combination of paclitaxel and S-1 as first-line chemotherapy for advanced or recurrent gastric cancer (AGC). Methods: All patients with histologically confirmed AGC with unresectable or metastatic diseases, measurable lesions, PS 0–2, age between 18 and 75, and no contraindication to chemotherapy were eligible in this study. Prior adjuvant chemotherapy finished at least 6 months before enrollment was allowed. Treatment included S-1 80 mg/m2 p.o. twice daily on days 1–14 and paclitaxel 60 mg/m2 i.v. on day 1, 8, 15 with a 2-week interval until disease progression or unacceptable toxicities. Results: Between MAY 2004 and Match 2008, total 20 pts were enrolled in this study. The median age was 56.5 years (range, 38–73). Nine pts had recurrent disease after previous curative gastrectomy and 8 had previous adjuvant chemotherapy. After a median 4 (range, 1–9) cycles of chemotherapy, 12 pts were evaluable for toxicity and 20 pts for response. In intention-to-treat analysis, the overall response rate was 62.9% (95% C.I., 36.2–69.6%), including 0 CR, 6 PRs, 8 SDs, and 6 PDs. After a median follow-up of 8.6 months (range, 0.9–17.9), median time to progression was 6.3 months (95% C.I., 3.6–6.9) and median overall survival was 11.6 months (95% C.I., 8.5–20.7). Commonly observed grade 3/4 adverse events were neutropenia (40% of patients), anemia (10%). There was no neutropenic fever or treatment-related death. Conclusions: The combination of paclitaxel and S-1 appear to have well efficacy, manageable toxicity and is well tolerated in patients with AGC. Further studies of this combination should be considered.

No significant financial relationships to disclose.

Immunological evaluation of personalized peptide vaccination with gemcitabine for advance pancreatic cancer patients

14029

Background: A phase I clinical study was performed to determine safety and immunogenicity of personalized peptide vaccination with gemcitabine (GEM) in advanced pancreatic cancer patients (APC). Methods: Thirteen human histocompatibility leukocyte antigen (HLA)-A24+ or A2+ patients with unresectable (n=10) or recurrent (n=3) pancreatic cancer were treated with GEM plus up to four peptides that were positive for pre-vaccination measurement of peptide-specific IgG antibodies and/or cytotoxic T lymphocyte (CTL) precursors in the circulation (personalized peptide vaccine). GEM was administered at 1000mg/m2 as a 30-min intravenous infusion once a week for three week, followed by 1 week of rest. All patients were treated on outpatient basis. The cycle was repeated every 8 weeks. Results: Peptide doses of vaccination per week were planned as follows: level 1, 1mg; level 2, 2mg; and level 3, 3mg. The main grade 3 toxicities observed during the first cycle in each level were neutropenia (15%), anemia (23%) and thrombocytopenia (15%). No significant differences in the toxicities were found between each level. There was no dose limiting toxicity (DLT) observed in each level. Augmentation of peptide-specific CTL responses in the post-vaccination peripheral blood mononuclear cells was observed in each level, while increased titer of peptide-specific IgG antibodies was observed in the post-vaccination plasma in level 2 and level 3. Applicable responses were no complete response, two partial responses (15%), and 7 stable diseases (55%). Nevertheless 7 patients of them (54%) were under the second-line chemotherapy, disease control rate was 70%, the median TTP (time to progression) was 18.5 weeks and the MST (median survival time) was 7.6 months in this study. Conclusions: The combination therapy of personalized peptide vaccination with GEM for APC patients is feasible and safe. Because of positive immune responses under a full dose of GEM, the peptide vaccination of 3 mg is recommended.

No significant financial relationships to disclose.

Immunological evaluation of personalized peptide vaccination for patients with malignant glioma: The results of a clinical phase I trial

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Purpose: To investigate the safety and immunological responses of personalized peptide vaccination in patients with malignant glioma. Patients and Methods: Twenty-six patients with recurrent malignant glioma entered in the phase I clinical study of personalized peptide vaccination. Peripheral blood mononuclear cells (PBMCs) and plasma prior to vaccination were provided for cellular and humoral responses in vitro to each of 31 or 36 peptides in cases of HLA-A24+ or HLA-A2+ patients, respectively, and then only the reactive peptides (maximum: 4) were allowed to in vivo administration. Post-vaccination PBMCs and plasma, and also pre-and post-vaccination cerebrospinal fluid, were provided for their reactivity to the vaccinated peptides. Expression of class 1 molecule on glioma cell was evaluated using EMR 8–5 antibody by immunohistochemical analysis. Results: The protocol was generally well tolerated, although the majority of patients developed grade 1 or 2 local redness and swelling at the injection site. Increase in cellular and humoral responses specific to at least one of the vaccinated peptides was observed in the post vaccination (6th)-PBMCs and -plasma from 62%, 73% respectively. More importantly, peptide-specific IgG were found in the post-vaccination cerebrospinal fluid of tumor sites. Clinical responses were 4 partial response, 8 stable disease, and 8 progressive disease. The clinical response was correlated to the expression of MHC class 1 on the glioma cell. The median overall survival for patients with recurrent glioblastoma multiforme in this study was 622 days. Conclusion: Personalized peptide vaccination is well tolerated and has ability to induce immune responses to the majority of malignant glioma patients along with several cases of major tumor regression. These results would encourage the phase II clinical study of personalized peptide vaccination to patients with recurrent malignant glioma.

No significant financial relationships to disclose.

Effect of CYP2C19 polymorphism on the safety and efficacy of omeprazole in Japanese patients with recurrent reflux oesophagitis

BACKGROUND

The polymorphic enzyme cytochrome P450 2C19 affects omeprazole metabolism. This influence on metabolism might affect serum gastrin levels, and safety, during long-term treatment of reflux oesophagitis.

AIM

To examine the relationship between cytochrome P450 2C19 genotype and the safety profile of long-term omeprazole treatment.

METHODS

A total of 119 Japanese patients with recurrent reflux oesophagitis underwent cytochrome P450 2C19 genotyping prior to receiving daily omeprazole 10 mg or 20 mg for 6-12 months, during which adverse event frequency, serum gastrin levels and endoscopic findings were monitored.

RESULTS

The incidences of adverse events, serious adverse events and adverse events leading to withdrawal did not differ between homozygous extensive metabolizer (n = 46), heterozygous extensive metabolizer (n = 53) or poor metabolizer (n = 20) groups. In all genotype groups, serum gastrin increased during the first 3 months of dosing but stabilized thereafter. No significant differences were seen either in the rate of reflux oesophagitis healing or symptom improvement among genotype groups.

CONCLUSIONS

Long-term treatment with omeprazole was well-tolerated in Japanese patients, irrespective of their cytochrome P450 2C19 metabolic genotype, indicating that dose adjustment depending on metabolic genotype is not required during treatment with omeprazole.

Role of early insulin secretion in postglucose-loading hyperglycaemia and postfat-loading hyperlipidaemia: comparing nateglinide and glibenclamide for acute effects on insulin secretion in OLETF rats

AIM

The aim of this study was to clarify the role of an early insulin secretion in postprandial hyperglycaemia and hyperlipidaemia; a study using spontaneously type 2 diabetic Otsuka Long-Evans Tokushima Fatty rats with visceral obesity was performed to investigate the acute effect of nateglinide (NAT) vs. glibenclamide (GB) on increases in glucose after glucose loading and on increases in triglyceride (TG) after fat loading.

METHODS

Fasting rats were given 50 mg/kg of NAT, 1 mg/kg of GB or 5% methyl cellulose (vehicle) as control and then immediately given oral glucose 1 g/kg.

RESULTS

An acute increase in insulin levels in portal blood peaked at 15 min in the NAT group, while insulin levels in the GB group continued to increase significantly after 60 min. Glucose levels in peripheral blood were significantly lower in the NAT group at 30 and 60 min and in the GB group at 120, 180 and 270 min after glucose loading, compared with those in the vehicle group. Subsequently, fasting rats were given NAT, GB or vehicle and then immediately given oral fat emulsion (soy oil 2 g/kg). An acute increase in insulin secretion was seen with NAT, peaking at 30 min, while TG, chylomicron and very low-density lipoprotein levels after fat loading were shown to be significantly lower with NAT than with vehicle. However, the continued insulin secretion observed with GB led to no significant decrease in TG levels after fat loading. In addition, lipoprotein lipase mRNA expression in adipose tissue increased significantly 120 min after NAT administration in comparison with baseline. This increase was not noted with GB administration.

CONCLUSION

Abnormalities in early insulin secretion are closely associated with the pathogenesis of various disease conditions that combine to characterize type 2 diabetes, suggesting that normalizing early insulin response in portal blood represents an important treatment not only for postprandial hyperglycaemia but also for postprandial hyperlipidaemia.

Intramucosal adenocarcinoma of the appendix: how to find and how to treat

A colonoscopic examination of a 58-year-old man revealed a small elevated lesion inside the orifice of the appendix. Using a polypectomy snare, a nodular polypoid lesion with a diameter of ca. 20 mm was removed from the lumen of the appendix. Histopathology showed that it was a well-differentiated adenocarcinoma. This is the first report of an intramucosal adenocarcinoma of the appendix diagnosed preoperatively; laparoscopy-assisted colectomy with a D2 lymph-node dissection was carried out. Endoscopists should consider an appendiceal tumor when an erosion, elevation, or deformity is seen in the head of the cecum.

Adenocarcinoma and multiple adenomas of the large intestine, associated with Cronkhite-Canada syndrome

The Cronkhite-Canada syndrome is a rare non-hereditary disorder with generalised gastrointestinal polyposis, associated with ectodermal changes. We report here a case of adenocarcinoma and multiple adenomas of the large intestine associated with Cronkhite-Canada syndrome in a 61-year-old Japanese man. Histologically, the rectal tumour was composed of well-differentiated tubular adenocarcinoma, admixed with foci of adenomatous components, and associated with hyperplastic mucosa of Cronkhite-Canada syndrome. Multiple polyps, >20 polyps < or = 2.0 cm in diameter, were found near the carcinoma of the resected rectum. Histologically, superficial parts of the polyps were composed of tubular adenomas, and basal parts of the polyps were hyperplastic dilated glands. It was speculated that, in the present case, the rectal adenocarcinoma arose from mucosal hyperplasia (Cronkhite-Canada polyp)-adenoma-carcinoma pathway. This suggested that Cronkhite-Canada syndrome has definite malignant potential, although the frequency of malignant transformation is thought to be low in Cronkhite-Canada syndrome.

Non-mutated tumor-rejection antigen peptides elicit type-I allergy in the majority of healthy individuals

IgE-mediated type-I allergy is generally considered to be a hypersensitivity reaction to foreign antigens, and it is believed that self-antigens do not evoke this type of allergy. We report here, for the first time, that non-mutated self-antigen peptides identified as tumor-rejection antigen peptides recognized by HLA class I-restricted and tumor-specific cytotoxic T lymphocytes (CTLs) elicited a type-I allergy in the majority of healthy individuals. Peptide-specific IgE was detectable in sera from certain cases, although the levels did not always correlate with those of type-I allergy. Repeated vaccinations of nonallergic peptides derived from the same antigens possessing allergic peptides resulted in the suppression of both allergic peptide-specific IgE responses and type-I allergy, providing evidence for a new approach to the development of peptide-based desensitization.

Induction of cellular immune responses to tumor cells and peptides in colorectal cancer patients by vaccination with SART3 peptides

The tumor-rejection antigen SART3 possesses two antigenic epitopes (SART3(109-118) and SART3(315-323)) capable of inducing HLA-A24-restricted and tumor-specific CTLs. To determine its safety and ability to generate antitumor immune responses, 12 patients with advanced colorectal cancer were administered s.c. vaccinations of these peptides. No severe adverse events were associated with the vaccinations. Significant levels of increased cellular immune responses to both HLA-A24+ colon cancer cells and the vaccinated peptide were observed in the postvaccination peripheral blood mononuclear cells in 7 of 11 and 7 of 10 patients tested, respectively, and the higher responses were observed in those patients vaccinated with the highest dose (3 mg/injection) of the peptides. These results encourage further development of SART3 peptide vaccine for colorectal cancer patients.

Proto-oncogene WNT10B is up-regulated by tumor necrosis factor alpha in human gastric cancer cell line MKN45

WNT10A and WNT10B genes are human orthologues of mouse proto-oncogene Wnt-10b. We have previously cloned and characterized WNT10A, and demonstrated up-regulation of WNT10A by tumor necrosis factor alpha (TNFalpha) in gastric cancer. Here, we cloned and characterized human WNT10B, which showed Gly60Asp amino-acid substitution compared with human WNT10B previously reported by another group. Gly60 WNT10B allele was identified in 2 human genome draft sequences and 7 human ESTs, while Asp60 WNT10B allele was not identified in any human genome draft sequences or ESTs. The Gly60-type WNT10B cDNA isolated in this study might be derived from more common WNT10B allele. WNT10B was most homologous to WNT10A (64.5% total amino-acid identity) among human WNTs. Variable region in the WNT core domain of WNT10B and WNT10A were longer than that of other WNTs, such as WNT2B1, WNT2B2, WNT3, WNT3A, WNT5B, WNT7B, WNT8A, WNT11, WNT14, and WNT14B/WNT15. We next investigated expression of WNT10B in human gastric cancer. WNT10B was moderately expressed in MKN45 and MKN74 cells, and weakly expressed in Okajima, TMK1, MKN7, MKN28, and KATO-III cells. Because interferon gamma (IFNgamma) and TNFalpha were frequently elevated in gastric mucosa with Helicobacter pylori infection, effects of IFNgamma and TNFalpha on WNT10B expression in MKN45 cells were investigated. TNFalpha induced transient up-regulation of WNT10B mRNA in MKN45 cells. Up-regulation of WNT10B in human gastric mucosa might lead to gastric carcinogenesis through activation of the beta-catenin - TCF signaling pathway, just like up-regulation of Wnt-10b in mouse mammary gland leads to mammary carcinogenesis.

Reversal of cisplatin and multidrug resistance by ribozyme-mediated glutathione suppression

gamma-Glutamylcysteine synthetase (gamma-GCS) is a key enzyme in glutathione (GSH) synthesis, and is thought to play a significant role in intracellular detoxification, especially of anticancer drugs. Increased levels of GSH are commonly found in the drug-resistant human cancer cells. We designed a hammerhead ribozyme against gamma-GCS mRNA (anti-gamma-GCS Rz), which specifically down-regulated gamma-GCS gene expression in the HCT-8 human colon cancer cell line. The aim of this study was to reverse the cisplatin and multidrug resistance for anticancer drugs. The cisplatin-resistant HCT-8 cells (HCT-8DDP cells) overexpressed MRP and MDR1 genes, and showed resistance to not only cisplatin (CDDP), but also doxorubicin (DOX) and etoposide (VP-16). We transfected a vector expressing anti-gamma-GCS Rz into the HCT-8DDP cells (HCT-8DDP/Rz). The anti-gamma-GCS Rz significantly suppressed MRP and MDR, and altered anticancer drug resistance. The HCT-8DDP/Rz cells were more sensitive to CDDP, DOX and VP-16 by 1.8-, 4.9-, and 1.5-fold, respectively, compared to HCT-8DDP cells. The anti-gamma-GCS Rz significantly down-regulated gamma-GCS gene expression as well as MRP/MDR1 expression, and reversed resistance to CDDP, DOX and VP-16. These results suggested that gamma-GCS plays an important role in both cisplatin and multidrug resistance in human cancer cells.

Analysis of effects and pharmacokinetics of subcutaneously administered BDNF

Brain-derived neurotrophic factor (BDNF) belongs to the neurotrophin family and has been shown to be a potent and effective trophic factor for motor neurons and other neurons of the peripheral and central nervous. Little is known, however, about the relationship between the efficacy and pharmacokinetics of s.c. administered BDNF. In this study, the efficacy of BDNF on motor neuron protection in sciatic or facial nerve axotomy models was examined and compared with the concommitant concentrations of BDNF in plasma. Delayed treatment (started at 1 week after surgery) of BDNF was also shown to retard choline acetyltransferase reduction in sciatic nerve axotomy models.