Impact of in-hospital medical management for COVID-19 pandemic on door-to-balloon time in patients with ST-elevation myocardial infarction

Background

Delayed door-to-balloon (DTB) time and deterioration of in-hospital mortality during the coronavirus disease 2019 (COVID-19) pandemic have been reported. Little is known about the impact of changes in in-hospital medical management before primary percutaneous coronary intervention (PCI) for COVID-19 such as screening test (antigen or polymerase chain reaction (PCR) tests, chest CT for excluding the pneumoniae) and primary PCI under full personal protective equipment (PPE) on DTB time and in-hospital mortality.

Purpose

The purpose of this study was to evaluate the impact of in-hospital medical management for COVID-19 on DTB time and in-hospital mortality during COVID-19 pandemic period.

Methods

We compared DTB time and in-hospital mortality of 502 ST-elevation myocardial infarction (STEMI) patients during COVID-19 pandemic (February 2020 and January 2021) with 2035 STEMI patients before pandemic (February 2016 and January 2020) using date from Mie ACS registry, a retrospective and multicenter registry.

Results

The COVID-19 screening tests before primary PCI and/or primary PCI under full PPE was performed on 173/502 (34.5%) patients (antigen or PCR tests; 39 (7.8%), chest CT; 156 (31.3%), full PPE; 11 (2.2%)). These patients had lower rate of achievement of DTB time ≤90 min compared with others (Figure 1A). Moreover, In-hospital management of COVID-19 screening tests and/or primary PCI under full PPE was an independent factor of DTB time>90 min with odds ratio of 1.94 (95% confidential interval: 1.37–2.76, p<0.001). In addition, in-hospital mortality of those patients was higher compared with others (Figure 1B).

Conclusion

In-hospital medical management for COVID-19 screening tests before primary PCI and/or primary PCI under full PPE was the independent factor of DTB time>90 min. This study reinforces the need to focus efforts on shortening DTB time, while controlling the epidemic of infection.

Funding Acknowledgement

Type of funding sources: None.

Horizontal orientation facilitates pollen transfer and rain damage avoidance in actinomorphic flowers of Platycodon grandiflorus

In zoophilous plants, floral orientation evolved under both biotic and abiotic pressure to enhance pollination success. However, the adaptive significance of horizontal orientation in radially symmetrical (actinomorphic) flowers remains largely unknown, although that of bilaterally symmetrical flowers has been well studied. We experimentally altered floral angle in a population of insect-pollinated Platycodon grandiflorus flowers to examine the effects of floral orientation on pollinator behaviour, pollination success and pollen rain damage avoidance. To further investigate the potential pollen damage by rain, we obtained past precipitation records for the study area during the flowering season, and experimentally tested P. grandiflorus pollen damage by water. Horizontally oriented flowers received more pollinator visits and had pollen grains on the stigma in male and/or female phases than downward- and/or upward-oriented flowers and avoided pollen damage by rainfall better than upward-oriented flowers. A pollen germination experiment showed that approximately 30% of pollen grains burst in distilled water, indicating that pollen damage by rainfall may be significant in P. grandiflorus. Our field experiments revealed that upward-oriented flowers cannot avoid pollen damage by rainfall during the flowering period, and that both upward- and downward-oriented flowers experience pollinator limitation in female success. Therefore, horizontal flower orientation appears to be adaptive in this insect-pollinated actinomorphic species that blooms during the rainy season.

Expression and roles of N-type Ca channel in cardiaomyocytes

Background

Voltage dependent Ca channels are divided to L-, T-, N-, P/Q-, and R-types, and N-type Ca channel (NCC) is mainly expressed in nerve terminal and regulates neurotransmitter release. Recently, NCC has been reported to express in adrenal gland and renal tubular cells. We examined whether NCC is expressed in cardiac myocytes and if so, the roles of this channel.

Methods

Expression of NCC mRNA and protein in cardiomyocytes were assessed by quantitative real time PCR and Western blot analysis using neonatal rat cultured cardiomyocytes, infant, and adult rat hearts. Expression site of NCC in cardiomyocytes was examined by confocal imaging of immunofluorescent staining. The roles of NCC in physiological Ca transient in neonatal myocytes were examined using fluorescence imaging of Fluo4, an intracellular Ca indicator. To examine the effects of pathological condition, such as heart failure and ischemia-reperfusion, on NCC expression, cultured cardiomyocytes were treated with norepinephrine (10 μmol/L, 24 hours) or subjected to 5 hours of hypoxia followed by 30 minutes of reoxygenation. In addition, adult rats were subjected to myocardial infarction by ligating the left anterior coronary artery. Lethal myocyte injury was examined by LDH activity in culture medium and myocyte apoptosis was examined by nuclear staining with DAPI and caspase 3 activity. To clarify the roles of NCC in neonatal myocytes in these pathological conditions, we examine the effect of ω-conotoxin, a selective NCC blocker.

Results

NCC mRNA and protein were expressed in neonatal cardiomyocytes. Immunocytochemical staining showed NCC was expressed in myocyte plasma membrane. During physiological spontaneous beating, ω-conotoxin did not affect beating rate and intra cellular Ca transient, suggesting that the roles of NCC on physiological beating are little. After birth level of NCC mRNA expression in cardiac tissue gradually decreased within 2 weeks and low level of mRNA expressed continuously in adult cardiac tissue. However, in pathological condition, mRNA and protein levels of NCC in non-infarcted region were increased 4 weeks after myocardial infarction. In addition, hypoxia-reoxygenation and norepinephrine administration increased LDH release and myocyte apoptosis in association with increase in NCC expression in neonatal cultured myocytes. ω-conotoxin significantly suppressed hypoxia/reoxygenation- and norepinephrine-induced LDH release and caspase 3 activation.

Conclusion

NCC is expressed in neonatal cardiac myocytes and the expression level was decreased after birth. Pathological condition, such as ischemic heart disease and heart failure, upregulated NCC expression in cardiomyocytes and NCC exacerbated lethal myocyte injury, while roles of NCC in physiological beating are little.

Funding Acknowledgement

Type of funding sources: None.

Creation of mortality risk calculator using a I-123 mIBG-based machine learning model: differential prediction of arrhythmic death and heart-failure death

Funding Acknowledgements

Type of funding sources: None.

Background

Although I-123 meta-iodobenzylguanidine (mIBG) has been applied to patients with chronic heart failure (CHF), a diagnostic tool for differential prediction of fatal arrhythmic events (ArE) and heart-failure death (HFD) has been pursued. 

Purpose

The aim of this study was to create a calculator of mortality risk for differentiating mode of cardiac death using a machine learning (ML) method, and to test the accuracy in a new cohort of patients with CHF.

Methods

A total of 529 patients with CHF was used as the training database for ML. The ArE group consisted of patients with arrhythmic death, sudden cardiac death and appropriate therapy by implantable cardioverter defibrillator. A heart-to-mediastinum ratio (H/M) standardized to the medium-energy collimator condition was calculated with a planar anterior mIBG scintigram. The best classifier models for predicting HFD and ArE were determined by four-fold cross validation. Input variables included age, sex, New York Heart Association (NYHA) functional class, left ventricular ejection fraction, ischemic etiology, mIBG H/M and washout rate, and b-type natriuretic peptide (BNP) or NT Pro BNP, estimated glomerular filtration rate, hemoglobin, and complications such as diabetes and hypertension. After creating the ML-based model, the constructed classifier functions for ArE, HFD, and survival were exported for subsequent use. A new cohort of patients (n = 312, age 67 ± 13 years, 2015 or later) was used to test the ML-based model.

Results

The training database included 141 events (27%) with ArE (7%) and HFD (20%). Receiver-operating characteristic analysis by four-fold validation showed area under the curve value of 0.90 for HFD and 0.73 for ArE. Among various ML methods, the logistic regression method demonstrated the most stable calculation of the probability of ArE followed by random forest and gradient boosted tree methods. Therefore, the logistic-regression method was used for calculating both HFD and ArE probabilities. In the test cohort, patients with a high HFD probability >8% resulted in 6.3-fold higher HFD than those with low probability (≤ 8%). Patients with high ArE probability >8% showed 2.5-fold higher ArE than those with low probability (≤ 8%).

Conclusion

The ML-based mortality risk calculator could be used for stratifying patients at high and low risks, which might be useful for estimating appropriate treatment strategy.

Premature acute coronary syndrome patients do not have a better prognosis for their age than mature ACS patients by propensity score match analysis

Background

Acute coronary syndrome (ACS) is the most important cardiovascular (CV) disease with a prevalence that increases with age. There is no data which compared the prognosis with premature ACS and mature ACS using propensity score matched analysis

Purpose

The purpose of this study was to compare the prognosis of premature ACS patients and mature ACS patients using propensity score matched analysis.

Methods

We analyzed of 4249 ACS patients (69.1±12.6, male 77%) including 773 premature ACS patients (50.1±6.8, male 78%) and 3476 mature ACS (73.3±9.3, male 77%) from January 2013 to December 2018, using data from Mie ACS Registry, a prospective and multicenter registry in Japan.

Premature onset of ACS was defined as younger than 65 years old in male and 55 years old in female.

Primary end point was as major adverse cardiac event (MACE) including cardiovascular death, non-fetal myocardial infarction, heart failure requiring admission and unstable angina.

Results

During median follow duration of 742 days ranging from409 to 828 days, 502 MACE were occurred. Premature ACS patients were younger and showed higher body mass index compared to mature ACS patients (50.1±6.8 vs 73.3±9.3 y.o., 25.5 vs 23.0, P<0.001, respectively). However, premature ACS patients were more likely to be associated with ST elevation myocardial infarction, dyslipidemia, family history of coronary artery disease (CAD) and lower Killip classification compared to mature ACS patients (P<0.01, respectively). Common CAD risk factors such as hypertension, diabetes mellitus and past history of CAD were less associated with premature ACS patients compared to mature ACS patients (P<0.01, respectively). Unadjusted Kaplan-Meier survival curves demonstrated the favorable prognosis in premature ACS patients compared to mature ACS patients with hazard ratio of 0.57 (95% CI 0.45–0.71, P<0.001, see Figure 1A). We compared a 1:1 propensity score-matched cohort of 1208 patients with or without premature onset of ACS adjusting the several factors mentioned above (n=604, respectively). Age could not be introduced as a factor of propensity score match when comparing premature and mature ACS patients. After propensity score-match, premature ACS patients is about 18 years younger than mature ACS patients (50.7±6.5 vs 68.5±8.2 y.o., P<0.001). The average age of premature ACS was younger than that of mature ACS, but MACE by Kaplan-Meier survival analysis for premature ACS patients was equivalent to mature ACS patients (P=0.77, see Figure 1B).

Conclusion

Premature ACS patients are required very careful management because they might have factors with unfavorable prognosis, such as lifestyle habit and genetics, that may be beyond age.

Figure 1

Funding Acknowledgement

Type of funding source: None

Evaluation of temporal changes in longitudinal strain distribution during the systolic period to determine left ventricular activation sequence: a study using 2D speckle-tracking echocardiography

Background

Evaluation of two-dimensional (2D) speckle-tracking longitudinal strain (LS) is useful for assessing global and regional left ventricular (LV) dysfunction.

Purpose

The purpose of this study was to test the hypothesis that temporal changes in regional 2D-LS distribution, (i.e., changes in area and intensity of the negative strain), during the systolic period may reflect the LV activation sequence.

Methods

We studied 52 patients with an ejection fraction <35% who were classified into four groups: complete left bundle branch block (LBBB, QRS 162±17 ms, n=17); right ventricular pacing from inferior septum (RVP, QRS 180±29 ms, n=16); left VP from lateral branch of the coronary sinus (LVP, QRS 182±21 ms, n=9); and no conduction block (Narrow QRS, QRS 100±9 ms, n=19). Longitudinal strain was evaluated in three standard apical views, and then bulls-eye distribution maps were constructed every 50 ms from the QRS onset to aortic valve closing (AVC) and at the time of the end of QRS. Segments indicating negative strain at the end of QRS were regarded as an early contraction site. Segments with intensifying negativity of strain as it got closer to the AVC were regarded as a late contraction site.

Results

In patients with LBBB, negative strain appeared initially in the septum region. Then, the contracted area enlarged including the apical region, and the basal lateral region contracted late. On the other hand, Narrow QRS showed a few regional differences in strain at the end of QRS (standard deviation in 17-segments: Narrow QRS 1.3±0.4%*, LBBB 3.3±1.1%, RVP 3.2±1.0%, LVP 3.3±1.1%, *p<0.001), and contracted homogeneously during the systolic period. RVP and LVP showed negative strain at the end of QRS in septum and lateral regions respectively, with the contracted area becoming enlarged towards the opposite regions of the early contracted regions.

Conclusion

The 2D-LS distribution during the systolic period reflects the LV contraction process in patients with an altered ventricular activation sequence, and may have potential for identifying the regions of early activation site and subsequent activation propagation.

Funding Acknowledgement

Type of funding source: None

Growth hormone activates X-box binding protein 1 in a sexually dimorphic manner through the extracellular signal-regulated protein kinase and CCAAT/enhancer-binding protein β pathway in rat liver

Growth hormone (GH) has multiple physiological roles, acting on many organs. In order to investigate its roles in rat liver, we tried to identify novel genes whose transcription was regulated by GH. We identified X-box binding protein 1 (Xbp1) as a candidate gene. XBP1 is a key transcription factor activated in response to endoplasmic reticulum (ER) stress. The purpose of this study was to investigate the mode of action of GH on XBP1, including the relation with ER stress, sex-dependent expression of the mRNA, and the signaling pathway. Intravenous administration of GH rapidly and transiently increased Xbp1 mRNA in hypophysectomized rat livers. Neither phosphorylated inositol-requiring-1α (IRE1α) nor phosphorylated PKR-like ER kinase (PERK) increased, suggesting that Xbp1 expression is induced by an ER stress-independent mechanism. The active form of XBP1(S) protein was increased by GH administration and was followed by an increased ER-associated dnaJ protein 4 (ERdj4) mRNA level. XBP1(S) protein levels were predominantly identified in male rat livers with variations among individuals similar to those of phosphorylated signal transducer and activator of transcription 5B (STAT5B), suggesting that XBP1(S) protein levels are regulated by the sex-dependent secretary pattern of GH. The GH signaling pathway to induce Xbp1 mRNA was examined in rat hepatoma H4IIE cells. GH induced the phosphorylation of CCAAT/enhancer-binding protein β (C/EBPβ) following extracellular signal-regulated protein kinase (ERK) phosphorylation. Taken together, the results indicated that XBP1 is activated by GH in rat liver in a sexually dimorphic manner via ERK and C/EBPβ pathway.

P37 Long-term outcomes of patients at risks for Fontan operation: role of temporary fenestration

Purpose

Whereas fenestration at Fontan operation was reported to be effective for smooth initiation to Fontan circulation, subsequently developed aortopulmonary collateral arteries under the presence of remaining hypoxia were a matter of concern.So as our institutional policy, it is closed as much and early as possible (temporary fenestration). This study aimed to reveal long-term outcomes for patients at riskswho underwent Fontan operation with temporary fenestration.

Methods

Of 107 patients undergoing Fontan operation from 1995 to 2004, 79 patients (73.8%) were free from any risks (NR group) and 28 patients (26.2%) had risks for Fontan operation (R group). Hypoplastic left heart syndrome, heterotaxy syndrome with obstructive total anomalous of pulmonary venous connection, and individual cases with high preoperative pulmonary artery pressure (PAP), systemic ventricular end diastolic pressure (SVEDP) or low ejection fraction (SVEF) were defined as a risk for Fontan completion.Age at Fontan operation was older in R group (6.6 vs 2.3years-old, p = 0.0004). Preoperative PAP (12.8 vs 11.3mmHg, p = 0.03) and SVEDP (8.8 vs 7.1mmHg, p = 0.02) were higher and SVEF (53.7 vs 60.0%, p = 0.002) was lower in R group. Pulmonary vascular resistance (PVR) was not different. Fenestration was created in all patients in R group, then it was closed at the mean duration of 2.9 years after Fontan operation.

Results

Freedom from death or protein-losing enteropathy rate at 5, 10, and 15 years after Fontan operation were 97, 96, and 93% in NR group and 96, 93, and 86% in R group (log-rank: p = 0.20). Fifty-one patients (64.6%) in NR group and 17 patients (60.7%) in R group underwent serial catheter examinations at 5, 10, and 15 years after Fontan operation and exercise capacity testing at 15 years after Fontan operation (Figure). In R group, arterial oxygen saturation was lower and PVR was higher even after close of fenestration (Figure). In addition, 12 patients (71%) in R group developed significant veno-venous collaterals, which were defined by more than 3mm in diameter of collateral veins or a condition where pulmonary veins were contrasted in venography. On the contrary, cardiac index (CI), SVEDP, and PAP were not different and no significant difference on peak oxygen uptake and anaerobic threshold were observed between in 2 groups. 

Conclusions

Although the mild cyanosis remained due to the development of veno-venous collaterals after the closure of temporary fenestration, CI, SVEDP and PAP well maintained in patients at risk for Fontan operation. These results might to lead acceptable life prognosis and freedom fromprotein-losing enteropathy rate for patients at risk for Fontan operation.

Abstract P37 Figure

P713Short term treatment of a low dose erythropoietin improves vascular function in a rat model of insulin resistance

Background/Introduction

Erythropoietin (EPO) exerts haematopoiesis-independent cardiovascular and renal protective effects by binding to EPO receptors expressed in hearts, arteries, and kidneys. We have reported that EPO inhibits vascular and renal injury in rat models of hypertension and type 1 diabetes. Recent studies report that EPO improves glucose tolerance in insulin resistant animals.

Purpose

This study investigated whether EPO would inhibit vascular and renal dysfunction in the setting of insulin resistance.

Methods

Rats were treated with sucrose (12% in drinking water) for 10 weeks to induce insulin resistance. EPO (3 times/week, s.c) was administered at the dose of 150U/kg for 10 weeks from the beginning (group A) or at the dose of 75U/kg for the last 4 weeks (group B) of sucrose treatment. Blood pressure was measured every second week by the tail-cuff method. HOMA-IR, haematocrit, and urinary protein excretion were measured. Using isolated aortas, acetylcholine-induced vasorelaxation under phenylephrine-induced pre-contraction was examined. Aortic sections were stained with haematoxylin-eosin.

Results

Both groups A and B showed higher haematocrit levels compared with the control and sucrose alone-treated groups. Sucrose treatment increased HOMA-IR (7.7±2.0 vs. 24±4.5, p<0.05), which was attenuated in groups A (3.6±0.9) and B (9.7±4.0). EPO treatment (150U/kg) had no effects on blood pressure for the first 4 weeks but caused time-dependent increases in blood pressure from the 6th week. Increased proteinuria and impaired aortic vasorelaxation in sucrose-treated rats were exacerbated by EPO (150U/kg) maybe because of hypertension (Control 122±2mmHg, Sucrose 125±2mmHg, group A 148±5mmHg), one of the major side effects of EPO. According to these results, we treated a half dose of EPO only for the last 4 weeks (group B). A lower dose of EPO treatment for a shorter period did not increase proteinuria (Control 15±2mg/day, Sucrose 25±3mg/day, group B 24±3mg/day) despite a mild increase in blood pressure (132±2mmHg). Impaired endothelium-dependent vasodilation and aortic thickening in the aorta of sucrose alone-treated rats were attenuated by lower and shorter EPO treatment (group B).

Conclusions

EPO inhibited insulin resistance and vascular injury in sucrose-induced insulin resistant rats. Further investigation into the mechanisms of tissue protective effects of EPO, especially focusing on the effects on insulin signalling in not only hepatic and muscle cell but also vascular and renal cells, will be needed.

P6275Role of autophagy in imatinib-induced cardiotoxicity

Background

Cardiotoxicity is one of the severe adverse effects of chemotherapeutic agents. Imatinib, a therapeutic agent for chronic myelogenous leukemia, has been reported to induce cardiotoxicity. Autophagy is an intracellular bulk protein and organelle degradation process, but it is unclear whether autophagy functions as pro-death or pro-survival program during disease conditions. We examined whether imatinib induces myocyte autophagy and the role of autophagy in imatinib-induced cardiotoxicity in in vitro and in vivo experiments.

Methods

In in vitro experiments, neonatal rat cardiac myocytes were treated with imatinib (1, 5, 10 μM; 1–6 hrs). Inhibition of autophagy was performed using 3-methyl-adenine (3MA), an autophagic inhibitor, and transfection with Atg5-targeted siRNA. Myocyte apoptosis was detected by morphological change in nuclei and caspase 3 activity. Mitochondria-derived reactive oxygen species production was detected using MitoSOX and mitochondrial membrane potential was assessed by TMRM staining. Expressions of cytochrome c in mitochondria and cytosole were examined by Werstern blotting. Myocyte autophagy was assessed by monodansylcadaverine staining and microtubule-associated protein light chain (LC) 3-II expression. In in vivo experiments, C57BL6 mice were treated with imatinib (50 and 200 mg/kg/day) for 5 weeks in the presence or absence of 3MA. Cardiac function was examined by echocardiography. In cardiac tissue, apoptotic myocytes were examined by TUNEL assay and autophagy was examined by LC3-II expression.

Results

In in vitro experiments, imatinib increased apoptotic nuclei and caspase 3 activity, in a dose-dependent manner. Consequently, imatinib augmented production of mitochondria-derived reactive oxygen species, loss of mitochondrial membrane potential, and the release of cytochrome c from mitochondria to cytosole, suggesting that imatinib induced mitochondrial-apoptotic pathway. On the other hand, imatinib significantly increased monodansylcadaverine stained dots and LC3-II expression, suggesting that imatinib increased autophagy. 3MA and Atg5 siRNA augmented imatinib-induced apoptosis by 60% and 30%, respectively. In in vivo experiments, imatinib (200 mg) exhibited the dilatation of left ventricle by 15% and the depression of left ventricular fractional shortening by 23%. Ratio of apoptotic myocytes was significantly increased and LC3-II expression in cardiac tissue was enhanced by imatinib in a dose-dependent fashion. Co-treatment with 3MA and imatinib further impaired imatinib-induced myocyte apoptosis by 3 fold and LV dysfunction by 20%.

Conclusion

These results indicate that imatinib induced myocyte apoptosis, leading to cardiac dysfunction. Imatinib enhanced myocyte autophagy as a consequence of apoptosis and autophagy was a beneficial phenomenon in this condition.

P1603Nicorandil suppresses ischemia-induced cardiac interstitial norepinephrine enhancement and ventricular arrhythmia in hypertrophic hearts

Background

Myocardial infarction (MI) is a major cause of death in western countries and Japan, and hypertension is a major risk factor of MI. In hypertensive heart, acute myocardial infarction often leads to lethal ventricular arrhythmia. Nicorandil, an ATP sensitive potassium channel (KATP) opener, is usually used in the treatment of acute myocardial infarction. The effects of nicorandil on ischemic myocyte are fully defined. On the other hand, KATP in neuroterminals is known to regulate norepinephrine release, but the effect of nicorandil on ischemic norepinephrine release in cardiac tissue has remained unexplored.

Purpose

We examined whether nicorandil suppressed norepinephrine release via neuronal KATP and ventricular arrhythmia during acute ischemia in pressure overload-induced hypertrophic hearts.

Methods

SD Rats were divided into two groups; abdominal aortic constriction (AAC) group and sham-operated (Sham) group. Four weeks after constriction, cardiac geometry and function were examined using echocardiography. Then, myocardial ischemia was induced by the left anterior descending artery occlusion for 100 minutes in the presence or absence of intravenous infusion of nicorandil. Cardiac interstitial norepinephrine concentration in ischemic region was measured using the microdialysis method and concentration of cyclic AMP, a second messenger of norepinephrine, in cardiac tissue was measured by ELISA. Ventricular arrhythmias were monitered by ECG during whole ischemic period.

Results

Four weeks after constriction, remarkable left ventricular wall thickening was observed in AAC group. Before ischemia, ventricular arrhythmia was not found in both groups. Number of ventricular arrhythmia, including ventricular tachycardia and ventricular fibrillation, was increased in early ischemic period (- 40 min) in both groups, and was grater in AAC group. Before ischemia, interstitial norepinephrine concentration in cardiac tissue was higher level in AAC group than in Sham group. Ischemia obviously increased norepinephrine concentration in both groups time dependently and AAC further increased norepinephrine than Sham group. Concentration of cyclic AMP in cardiac tissue was raised in early ischemic period (- 40 min) and then gradually decreased. Nicorandil significantly suppressed the number of ventricular arrhythmias, and abolished the ventricular tachycardia and fibrillation without hemodynamic alterations. Nicorandil also attenuated norepinephrine and cAMP enhancement in acute ischemic period in both groups.

Conclusion

Ischemia-induced ventricular arrhythmia was more frequent and severe in hypertrophic hearts and interstitial norepinephrine enhancement may play a role in this ischemic arrhythmia. Nicorandil suppressed ischemia-induced interstitial norepinephrine release by neuronal KATP opening, which attenuated ventricular arrhythmias in normal and hypertrophic hearts.

Safety, tolerability, pharmacokinetics, and pharmacodynamics of the afucosylated, humanized anti-EPHA2 antibody DS-8895a: a first-in-human phase I dose escalation and dose expansion study in patients with advanced solid tumors

Background

Erythropoietin-producing hepatocellular receptor A2 (EPHA2) is overexpressed on the cell surface in many cancers and predicts poor prognosis. DS-8895a is a humanized anti-EPHA2 IgG1 monoclonal antibody afucosylated to enhance antibody-dependent cellular cytotoxicity activity. We conducted a two-step, phase I, multicenter, open-label study to determine the safety, tolerability, and pharmacokinetics of DS-8895a in patients with advanced solid tumors.

Methods

Step 1 was a dose escalation cohort in advanced solid tumor patients (six dose levels, 0.1–20 mg/kg) to determine Step 2 dosing. Step 2 was a dose expansion cohort in EPHA2-positive esophageal and gastric cancer patients. DS-8895a was intravenously administered every 2 weeks for the duration of the study, with a 28-day period to assess dose-limiting toxicity (DLT). Safety, pharmacokinetics, tumor response, and potential biomarkers were evaluated.

Results

Thirty-seven patients (Step 1: 22, Step 2: 15 [9: gastric cancer, 6: esophageal cancer]) were enrolled. Although one DLT (Grade 4 platelet count decreased) was observed in Step 1 (dose level 6, 20 mg/kg), the maximum tolerated dose was not reached; the highest dose (20 mg/kg) was used in Step 2. Of the 37 patients, 24 (64.9%) experienced drug-related adverse events (AEs) including three (8.1%) with Grade ≥ 3 AEs. Infusion-related reactions occurred in 19 patients (51.4%) but were manageable. All patients discontinued the study (evident disease progression, 33; AEs, 4). Maximum and trough serum DS-8895a concentrations increased dose-dependently. One gastric cancer patient achieved partial response and 13 patients achieved stable disease. Serum inflammatory cytokines transiently increased at completion of and 4 h after the start of DS-8895a administration. The proportion of CD16-positive natural killer (NK) cells (CD3⁻CD56⁺CD16⁺) decreased 4 h after the start of DS-8895a administration, and the ratio of CD3⁻CD56⁺CD137⁺ to CD3⁻CD56⁺CD16⁺ cells increased on day 3.

Conclusions

Twenty mg/kg DS-8895a infused intravenously every 2 weeks was generally safe and well tolerated in patients (n = 21) with advanced solid tumors. The exposure of DS-8895a seemed to increase dose-dependently and induce activated NK cells.

Trial registration

Phase 1 Study of DS-8895a in patients with advanced solid tumors (NCT02004717; 7 November 2013 to 2 February 2017); retrospectively registered on 9 December 2013.

Electronic supplementary material

The online version of this article (10.1186/s40425-019-0679-9) contains supplementary material, which is available to authorized users.

Dose escalation and expansion cohort study for DS-8895a in patients with advanced solid tumors

99

Background: Erythropoietin-producing hepatocellular receptor A2 (EPHA2) is overexpressed on the cell surface of many tumors and is associated with poor prognosis, suggesting EPHA2 as a target for cancer therapy. DS-8895a is an afucosylated, humanized anti-EPHA2 IgG1 monoclonal antibody with potent cytotoxicity. We report results from a phase I clinical trial to determine safety, tolerability, and pharmacokinetics (PK) of DS-8895a in Japanese patients with advanced solid tumors (NCT02004717). Methods: Step 1 (dose escalation cohort) had patients with advanced solid tumors and comprised of six dose levels (0.1–20 mg/mL, intravenous infusion, every 2 weeks [Q2W]) with a 28-day dose limiting toxicity (DLT) evaluation period. Step 2 (expansion cohort) patients had gastric or esophageal cancer confirmed to be EPHA2 positive by immunohistochemistry. Dose level in Step 2 was determined based on results obtained in Step 1. We evaluated safety, PK, potential biomarkers including circulating NK cells and cytokines, and tumor response. Results: Maximum tolerated dose was not reached in Step 1 (n = 22). DS-8895a was administered at 20 mg/kg Q2W in Step 2 (n = 15). Among 37 patients in the safety analysis set, adverse events (AEs) were reported in 97.3% (64.9% drug-related); 35.1% presented grade ≥ 3 AEs (8.1% drug-related). Dose delay and study discontinuation due to AEs (treatment related: grade 4 platelet decrease, hypoesthesia, hypotension, peripheral coldness, nausea, and vomiting) were observed in one and four patients (20 mg/kg), respectively. Infusion-related reactions occurred in 51.4% of patients resulting in 10 dose interruptions with one discontinuation. Serum inflammatory cytokines were transiently increased 4 h from the end of infusion drug administration. Serum DS-8895a maximum and trough concentrations increased dose-dependently. Biomarkers had no apparent relationship to best overall response. Seven patients in Step 1 achieved stable disease; in Step 2, six patients achieved stable disease and one patient achieved partial response. Conclusions: DS-8895a was safe and well tolerated up to 20 mg/kg. The PK of DS-8895a was dose-dependent as expected. Clinical trial information: NCT02004717.

Longitudinal Findings of MRI and PET in West Syndrome with Subtle Focal Cortical Dysplasia

BACKGROUND AND PURPOSE

Despite the development of neuroimaging, identification of focal cortical dysplasia remains challenging. The purpose of this study was to show the longitudinal changes of MR imaging and FDG-PET in patients with West syndrome and subtle focal cortical dysplasia.

MATERIALS AND METHODS

Among 52 consecutive patients with West syndrome, 4 were diagnosed with subtle focal cortical dysplasia on 3T MR imaging. MR imaging and PET findings were evaluated longitudinally at onset and at 12 and 24 months of age.

RESULTS

At the onset of West syndrome, MR imaging demonstrated focal signal abnormalities of the subcortical white matter in 2 patients. In the other 2 patients, focal subcortical high-intensity signals became visible on follow-up T2WI as myelination progressed. PET at onset showed focal cortical hypometabolism in 3 patients, with 1 of these patients also having focal hypermetabolism and 1 having normal findings. On PET at 24 months, hypometabolism persisted in 2 patients and disappeared in 1, and hypermetabolism disappeared in 1. In 1 patient with normal MR imaging and PET findings at onset, focal hyperintensity and hypometabolism first appeared at 24 months of age. The findings on MR imaging and PET in these patients evolved differently with brain maturation and the clinical course.

CONCLUSIONS

Subtle focal cortical dysplasia can be undetectable on MR imaging at the onset of West syndrome and is not always accompanied by hypometabolism or hypermetabolism on PET. Longitudinal MR imaging and PET studies may be useful for detecting such lesions. Even in West syndrome with a congenital structural abnormality, PET findings evolve differently with brain maturation and the clinical condition.

Breeding phenology and winter activity predict subsequent breeding success in a trans-global migratory seabird

Inter-seasonal events are believed to connect and affect reproductive performance (RP) in animals. However, much remains unknown about such carry-over effects (COEs), in particular how behaviour patterns during highly mobile life-history stages, such as migration, affect RP. To address this question, we measured at-sea behaviour in a long-lived migratory seabird, the Manx shearwater (Puffinus puffinus) and obtained data for individual migration cycles over 5 years, by tracking with geolocator/immersion loggers, along with 6 years of RP data. We found that individual breeding and non-breeding phenology correlated with subsequent RP, with birds hyperactive during winter more likely to fail to reproduce. Furthermore, parental investment during one year influenced breeding success during the next, a COE reflecting the trade-off between current and future RP. Our results suggest that different life-history stages interact to influence RP in the next breeding season, so that behaviour patterns during winter may be important determinants of variation in subsequent fitness among individuals.

KISS1 gene expression in the developing brain of female pigs in pre- and peripubertal periods

Puberty is associated with an increase in gonadotropin secretion as a result of an increase in gonadotropin-releasing hormone (GnRH) secretion. Kisspeptin is considered to play a key role in puberty onset in many mammalian species, including rodents, ruminants and primates. The present study aimed to determine if changes in hypothalamic expression of the KISS1 gene, encoding kisspeptin, are associated with the onset of puberty in pigs. The animals (n=4 in each group) were perfused with 4% paraformaldehyde at 0, 1, 2, 3 and 4 months old, as prepubertal stages, and at 5 months old, as the peripubertal stage, following each blood sampling. KISS1 gene expressions in coronal sections of brains were visualized by in situ hybridization. Plasma luteinizing hormone (LH) was measured by radioimmunoassay. KISS1 mRNA signals were observed in the arcuate nucleus (ARC) at all ages examined without any significant difference in the number of KISS1-expressing cells, indicating that the KISS1 gene is constantly expressed in the ARC throughout pubertal development in pigs. The plasma LH concentration was the highest in 0-month-old piglets and significantly decreased in the 1- and 2 month-old groups (P<0.05), suggesting a developing negative feedback mechanism affecting gonadotropin release during the prepubertal period. Considering the potent stimulating effect of kisspeptin on gonadotropin release in prepubertal pigs, kisspeptin secretion rather than kisspeptin synthesis may be responsible for the onset of puberty in pigs.

Switching to an L/N-type calcium channel blocker shows renoprotective effects in patients with chronic kidney disease: the Kyoto Cilnidipine Study

OBJECTIVE

This open-label, randomized controlled trial investigated the effects of cilnidipine, an L/N-type calcium channel blocker (CCB), in patients with chronic kidney disease (CKD).

METHODS

Sixty patients with CKD and well-controlled hypertension being treated with a renin- angiotensin system (RAS) inhibitor and an L-type CCB (L-CCB) were randomly assigned either to switch from the L-CCB to cilnidipine after a 4-week observation period or to continue with L-CCB treatment. Blood pressure, heart rate and renal function were monitored for 12 months. Data were available for analysis from 50 patients: 24 from the cilnidipine group and 26 from the L-CCB group.

RESULTS

Blood pressure was well controlled in both groups. After 12 months, proteinuria and heart rate were significantly decreased in the cilnidipine group, but proteinuria increased and heart rate remained unchanged in the L-CCB group. There was a significant positive correlation between the percentage changes in proteinuria and heart rate.

CONCLUSIONS

Cilnidipine has antihypertensive effects equivalent to those of L-CCBs. In patients with CKD, proteinuria can be decreased by switching from an L-CCB to cilnidipine, thereby improving renal function.

Aerodynamics of a bio-inspired flexible flapping-wing micro air vehicle

MAVs (micro air vehicles) with a maximal dimension of 15 cm and nominal flight speeds of around 10 m s⁻¹, operate in a Reynolds number regime of 10⁵ or lower, in which most natural flyers including insects, bats and birds fly. Furthermore, due to their light weight and low flight speed, the MAVs' flight characteristics are substantially affected by environmental factors such as wind gust. Like natural flyers, the wing structures of MAVs are often flexible and tend to deform during flight. Consequently, the aero/fluid and structural dynamics of these flyers are closely linked to each other, making the entire flight vehicle difficult to analyze. We have recently developed a hummingbird-inspired, flapping flexible wing MAV with a weight of 2.4-3.0 g and a wingspan of 10-12 cm. In this study, we carry out an integrated study of the flexible wing aerodynamics of this flapping MAV by combining an in-house computational fluid dynamic (CFD) method and wind tunnel experiments. A CFD model that has a realistic wing planform and can mimic realistic flexible wing kinematics is established, which provides a quantitative prediction of unsteady aerodynamics of the four-winged MAV in terms of vortex and wake structures and their relationship with aerodynamic force generation. Wind tunnel experiments further confirm the effectiveness of the clap and fling mechanism employed in this bio-inspired MAV as well as the importance of the wing flexibility in designing small flapping-wing MAVs.

[Image assessment of the cartilage and subchondral bone in patients with osteoarthritis]

The most recommendable MRI sequence for the morphologic assessment of the cartilage damage due to osteoarthritis (OA) is gradient echo fat suppression T1 weighted image (SPGR: Spoiled gradient recalled acquisition in the steady state, FLASH: Fast low-angle shot). For the detection of the cartilage degeneration before the morphological change, T2 mapping, dGEMRIC (delayed Gd-DTPA2-Enhanced MRI of Cartilage), and T1ρ mapping are suggested. Subchondral bone structural changes such as bone sclerosis and cyst are deeply related to the etiology of OA, and quantitative evaluation for them using MDCT (Multi-Detector row CT) and 3TMRI are suggested.

Age-related changes in bone density, geometry and biomechanical properties of the proximal femur: CT-based 3D hip structure analysis in normal postmenopausal women

The geometry as well as bone mineral density (BMD) of the proximal femur contributes to fracture risk. How and the extent to which they change due to natural aging is not fully understood. We assessed BMD and geometry in the femoral neck and shaft separately, in 59 normal Japanese postmenopausal women aged 54-84 years, using clinical computed tomography (CT) and commercially available software, at baseline and 2-year follow-up. This system detected significant reductions over the 2-year interval in total BMD (%change/year = -0.900 ± 0.257, p < 0.0005), cortical cross-sectional area (CSA) (-0.800 ± 0.423%/year, p < 0.05) and cortical thickness (-1.120 ± 0.453%/year, p < 0.01) in the femoral neck. In the femoral shaft, cortical BMD decreased significantly (-0.642 ± 0.188%/year, p < 0.005). Regarding biomechanical parameters in the femoral neck, the cross-sectional moment of inertia (CSMI) and section modulus (SM) decreased (-1.38 ± 3.65%/year, p < 0.01 and -1.37 ± 2.96%/year, p < 0.005) and the buckling ratio (BR) increased significantly (1.48 ± 4.81%/year, p < 0.05), whereas no changes were found in the femoral shaft. The distinct patterns of age-related changes in the geometry and biomechanical properties in the femoral neck and shaft suggest that improved geometric measures are possible with the current non-invasive method using clinical CT.

Disease recurrence patterns after R0 resection of hilar cholangiocarcinoma

BACKGROUND

There is little information regarding the clinical behaviour of hilar cholangiocarcinoma after curative resection.

METHODS

A retrospective study was undertaken of 79 consecutive patients with hilar cholangiocarcinoma who had undergone major hepatectomy (three or more Couinaud segments) concomitant with caudate lobectomy, and had negative resection margins. Sites of initial disease recurrence were classified as locoregional (porta hepatis) or distant (intrahepatic, peritoneal, para-aortic lymph nodal or extra-abdominal). Univariable and multivariable analyses were performed to determine the factors potentially related to recurrence.

RESULTS

Disease recurrence was observed in 42 (53 per cent) of the 79 patients. Cumulative recurrence rates at 3 and 4 years after surgery were 52 and 56 per cent respectively. Locoregional recurrence alone was observed in eight (10 per cent) and distant metastasis in 34 (43 per cent) of the 79 patients after R0 resection. Positive nodal involvement and high International Union Against Cancer tumour (T) stage were independent prognostic factors associated with distant metastasis.

CONCLUSION

Distant metastases are more common than locoregional recurrence after R0 resection for hilar cholangiocarcinoma, and associated with nodal involvement and high T stage.

Expression Levels of Enzymes Related to In Situ Estrogen Synthesis and Clinicopathological Parameters in Breast Cancer Patients

Background: Local estrogen synthesis may play an important role of progression of breast cancer with hormone receptors. Local progression of breast cancer may depend on high concentration of estrogens and estrogen receptor status. To clarify correlation between expression levels of enzymes in breast cancer and clinicopathological parameters, we analyzed expression of steroid sulfatase(STS), estrogen sulfatase(EST), 17b-hydroxyl steroid dehydrogenase type I & II(17b-HSDI & II) and aromatase. In addition, mRNA expression of estrogens receptor alpha(ERa), estrogen receptor beta(ERb), cycline D1 and erbB2 were measured. Material and Methods: The mRNA expression levels of genes in 196 breast cancer tissues removed from surgery were assayed by RT-PCR. Results: The level of STS were significantly higher in patients with clinical stage. STS expressed none in stage 0 or I, 0.011 in stage II, and 0.013 amol/1 amol b-actin in stage 3 or 4. In addition, EST expressed 58.5 amol/1 amol b-actin in stage 2 and 36.8 in stage 3 or 4, otherwise, the expression level of EST in stage 0 or 1 revealed 15.3 amol/1 amol b-actin. There were no correlation between clinical stage and aromatase expression. Expression levels of ERa and cyclineD1 significantly correlated with protein levels of ER, and there were significant correlation between erbB2 expression and prognosis of patients. Conclusion: Up-regulation of STS play an important role in tumor progression of breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4155.

[Bronchial schwannoma diagnosis by surgical treatment; report of a case]

18-year-old male was referred to our hospital due to persistent cough. The patient was admitted for the investigation of the abnormal shadow on a chest X-ray and chest computed tomography (CT). Chest CT showed a 2.5 cm nodular shadow in the right lower lobe. Bronchofiberscopy revealed the polypoid lesion at the right lower lobe bronchus obstructing the entire lumen of B8-10. The tumor surface was smooth and rich in small vessels. Right lower lobectomy was peformed. The diagnosis of schwannoma was confirmd with the S-100 positive immunohistochemical stain. Bronchial schwannoma is relatively rare disease; less than 90 cases have been reported with respect to schwannoma of case report in Japan.

Potential anti-tumor-promoting activity of 3alpha-hydroxy-D:A-friedooleanan-2-one from the stem bark of Mallotus philippensis

Four known friedelane-type triterpenoids, friedelin ( 1), 3-hydroxy-D:A-friedoolean-3-en-2-one ( 2), 2beta-hydroxy-D:A-friedooleanan-3-one ( 3), and 3alpha-hydroxy-D:A-friedooleanan-2-one ( 4), and two known lupane-type triterpenoids, lupeol ( 5) and betulin ( 6), were isolated from the stem bark of Mallotus philippensis. Isolates 1 - 4 and their synthetic analogues, 3-acetoxy-D:A-friedoolean-3-en-2-one ( 2A) and 3alpha-acetoxy-D:A-friedooleanan-2-one ( 4A), were tested for their inhibitory effects on Epstein-Barr virus early antigen (EBV-EA) activation induced by 12- O-tetradecanoylphorbol 13-acetate (TPA). The inhibitory effect of compounds 2 (IC (50) = 292 mol ratio/32 pmol/TPA) and 4 (IC (50) = 288) was stronger than those of the other compounds tested and the positive control, curcumin (IC (50) = 343). Compound 4 strongly inhibited mouse skin tumor promotion in an IN VIVO two-stage carcinogenesis model. Studies have been conducted to identify the biologically active compounds extracted from the leaves, bark, and cones of trees that currently have no specific commercial use and are therefore treated as waste in the forestry industry.

F-19848 A, a novel inhibitor of hyaluronic acid binding to cellular receptor CD44

In the course of our screening for inhibitors of hyaluronic acid (HA) binding to cellular receptor CD44, a novel inhibitor, F-19848 A, was isolated from the cultured broth of the fungus strain Dacrymyces sp. SANK 20204. This compound inhibited the binding of CD44 and HA with an IC50 value of 23.5 microM and CD44-dependent HA degradation was inhibited with an IC50 value of 98.6 microM in a cell-based assay. The structure was elucidated by physico-chemical properties, analysis of spectral data, and decomposition experiments.

F-16438s, Novel Binding Inhibitors of CD44 and Hyaluronic Acid

In an attempt to obtain inhibitors of hyaluronic acid (HA) binding to its receptor, CD44, we established an efficient assay method to detect and quantify binding using fluorescein-labeled HA and HEK293 cells stably expressing CD44. As a result of the screening of culture broths of microorganisms, we found fungus strain Gloeoporus dichrous SANK 30502 produced inhibitory activity in this new assay. Five compounds, F-16438 A, B, E, F and G, were isolated from the fermentation broths, and their IC50 values were determined to be 10.3, 13.5, 27.3, 12.0 and 13.0 microM, respectively. F-16438 A, B, E, F and G are the first reported inhibitors of binding HA to CD44. F-16438 A, B, E and F have novel structures.

F-16438s, Novel Binding Inhibitors of CD44 and Hyaluronic Acid

In the course of our screening for binding inhibitors of CD44 and hyaluronic acid, five active compounds, F-16438 A, B, E, F and G were found and isolated from the cultured broth of a fungal strain, Gloeoporus dichrous SANK 30502. The structures of these compounds except for F-16438 G were elucidated by physico-chemical and spectral data to be new compounds related to caloporoside; F-16438 G was identified to be the 6'-malonylated derivative of caloporoside.

Structure determination of inonotsuoxides A and B and in vivo anti-tumor promoting activity of inotodiol from the sclerotia of Inonotus obliquus

Two new lanostane-type triterpenoids, inonotsuoxides A (1) and B (2) along with three known lanostane-type triterpenoids, inotodiol (3), trametenolic acid (4), and lanosterol (5), were isolated from the sclerotia of Inonotus obliquus (Pers.: Fr.) (Japanese name: Kabanoanakake) (Russian name: Chaga). Their structures were determined to be 22R,25-epoxylanost-8-ene-3beta,24S-diol (1) and 22S,25-epoxylanost-8-ene-3beta,24S-diol (2) on the basis of spectral data including single crystal X-ray analysis. These compounds except for 2 were tested for their inhibitory effects on Epstein-Barr virus early antigen (EBV-EA) activation induced by 12-O-tetradecanoylphorbol-13-acetate (TPA), as a test for potential cancer chemopreventive agents. The most abundant triterpene, inotodiol (3), was investigated for the inhibitory effect in a two-stage carcinogenesis test on mouse skin using 7,12-dimethylbenz[a]anthracene (DMBA) as an initiator and TPA as a promoter. Compound 3 was found to exhibit the potent anti-tumor promoting activity in the in vivo carcinogenesis test.