C-C Bond Cleavage-Induced C- to N-Acyl Transfer for Synthesis of Amides

A new approach for the preparation of amides was developed using C-C bond cleavage that initiates C- to N-acyl transfer, employing activated ketones as acylation reagents and amine nucleophiles. The reaction was operational under the coupling reagent system that is commonly utilized for peptide bond formations. The method enables practical preparation of amides using linear and cyclic ketone substrates under mild conditions.

Clinical and radiological outcomes of non-window-type bioactive glass-ceramic cage in single-level ACDF versus PEEK cage filled with autologous bone

Bioactive glass-ceramic (BGC) cage is a substitute for polyether ether ketone (PEEK) cages in anterior cervical discectomy and fusion (ACDF). Only a few comparative studies exist using PEEK and non-window-type BGC cages (CaO-SiO2-P2O5-B2O3) in single-level ACDF. This study compared PEEK cages filled with autologous iliac bone grafts and BGC cages regarding clinical safety and effectiveness. A retrospective case series was performed on 40 patients who underwent single-level ACDF between October 2020 and July 2021 by a single orthopedic spine surgeon. The spacers used in each ACDF were a PEEK cage with a void filled with an autologous iliac bone graft and a non-window-type BGC cage in 20 cases. The grafts were compared pre-operatively and post-operatively at 6 weeks and 3, 6, and 12 months. Post-operative complications were investigated in each group. Clinical outcome was measured, including Visual Analog Scale (VAS) scores of neck and arm pains, Japanese Orthopedic Association score (JOA), and Neck Disability Index (NDI). Dynamic lateral radiographs were used to assess the inter-spinous motion (ISM) between the fusion segment and subsidence. The fusion status was evaluated using a computed tomography (CT) scan. Overall, 39 patients (19 and 20 patients in the PEEK and BGC groups, respectively) were recruited. Eighteen (94.7%) and 19 (95.0%) patients in the PEEK and BGC groups, respectively, were fused 12 months post-operatively, as assessed by ISM in dynamic lateral radiograph and bone bridging formation proven in CT scan. The PEEK and BGC groups showed substantial improvement in neck and arm VAS, JOA, and NDI scores. No substantial difference was found in clinical and radiological outcomes between the PEEK and BGC groups. However, the operation time was considerably shorter in the BGC group than in the PEEK group. In conclusion, a non-window-type BCG cage is a feasible substitute for a PEEK cage with an autologous iliac bone graft in single-level ACDF.

TRIAD method to assess ecological risks of contaminated soils in abandoned mine sites

Site-specific soil ecological risk assessment is important for protecting soil ecosystems because it reflects the environmental factors at the site to detect ecological risks and develop risk management measures. This study assessed the ecological risks from chemical pollutants in abandoned mine sites using the TRIAD approach, evaluating its overall applicability, including the tiered system of assessment. A site-specific soil ecological risk assessment was conducted for five abandoned mine sites (Sites 1-4 and R, the reference site); integrated risks (IRs) for each site were calculated. Our results of the Tier 2 assessment showed that IRs at Sites 1-4 were 0.701, 0.758, 0.840, and 0.429, respectively. The IR classification was moderate, high, high, and low risk, in that order for Sites 1-4, the same as that for Tier 1. The IR had more varied analyses, emphasizing the significance of conducting higher tiered analyses under TRIAD while maintaining a balance between soil ecosystem protection and socioeconomic costs. Multiple analyses reduced the uncertainty of IR, thus enabling efficient risk management decision-making to protect soil ecosystems. Our study provides a basis for using the TRIAD for soil assessment and establishing policies for site-specific soil ecological risk assessments.

Carboxylate-Directed Pd-Catalyzed β-C(sp3)-H Arylation of N-Methyl Alanine Derivatives for Diversification of Bioactive Peptides

This study presents a Pd(II)-catalyzed method for the β-C(sp3)-H arylation of N-Cbz- or N-Fmoc-protected N-methyl alanines, providing ready access to building blocks for N-methylated peptide synthesis. For this transformation, the native carboxylate was exploited as the directing group, attributing its success to the use of a monoprotected amino-pyridine ligand. Its synthetic utility was demonstrated by facile generation of nine analogues of the naturally occurring N-methylated cyclic peptide cycloaspeptide A.

Assessing the Potential Distribution of Oxalis latifolia, a Rapidly Spreading Weed, in East Asia under Global Climate Change

Oxalis latifolia, a perennial herbaceous weed, is a highly invasive species that poses a threat to agricultural lands worldwide. East Asia is under a high risk of invasion of O. latifolia under global climate change. To evaluate this risk, we employed maximum entropy modeling considering two shared socio-economic pathways (SSP2-4.5 and SSP5-8.5). Currently, a small portion (8.02%) of East Asia is within the O. latifolia distribution, with the highest coverages in Chinese Taipei, China, and Japan (95.09%, 9.8%, and 0.24%, respectively). However, our projections indicated that this invasive weed will likely be introduced to South Korea and North Korea between 2041 and 2060 and 2081 and 2100, respectively. The species is expected to cover approximately 9.79% and 23.68% (SSP2-4.5) and 11.60% and 27.41% (SSP5-8.5) of the total land surface in East Asia by these time points, respectively. South Korea and Japan will be particularly susceptible, with O. latifolia potentially invading up to 80.73% of their territory by 2081-2100. Mongolia is projected to remain unaffected. This study underscores the urgent need for effective management strategies and careful planning to prevent the introduction and limit the expansion of O. latifolia in East Asian countries.

Global spatial distribution of Chromolaena odorata habitat under climate change: random forest modeling of one of the 100 worst invasive alien species

Anthropogenic activities and global climate change increase the risk of Chromolaena odorata invasion and habitat expansion. To predict its global distribution and habitat suitability under climate change, a random forest (RF) model was employed. The RF model, utilizing default parameters, analyzed species presence data and background information. The model revealed that the current spatial distribution of C. odorata covers 7,892,447 km2. Predictions for 2061- 2080 indicate expansion of suitable habitat (42.59 and 46.30%), reduction of suitable habit (12.92 and 12.20%), and preservation of suitable habitat (87.08 and 87.80%) under the SSP (Shared Socio-economic Pathway) 2-4.5 and SSP5-8.5 scenarios, respectively, in comparison to the present distribution. Currently, C. odorata is predominantly found in South America, with limited presence in other continents. However, the data suggest that climate change will elevate the global invasion risk of C. odorata worldwide, particularly in Oceania, Africa, and Australia. Countries such as Gambia, Guinea-Bissau, and Lesotho, which currently have unsuitable habitats, are predicted to have highly suitable habitats with climate change, supporting the idea that global habitat expansion for C. odorata will occur due to climate change. This study indicates that proper management of C. odorata is crucial during the early invasion phase.

RENEB Inter-Laboratory Comparison 2021: The Dicentric Chromosome Assay

After large-scale radiation accidents where many individuals are suspected to be exposed to ionizing radiation, biological and physical retrospective dosimetry assays are important tools to aid clinical decision making by categorizing individuals into unexposed/minimally, moderately or highly exposed groups. Quality-controlled inter-laboratory comparisons of simulated accident scenarios are regularly performed in the frame of the European legal association RENEB (Running the European Network of Biological and Physical retrospective Dosimetry) to optimize international networking and emergency readiness in case of large-scale radiation events. In total 33 laboratories from 22 countries around the world participated in the current RENEB inter-laboratory comparison 2021 for the dicentric chromosome assay. Blood was irradiated in vitro with X rays (240 kVp, 13 mA, ∼75 keV, 1 Gy/min) to simulate an acute, homogeneous whole-body exposure. Three blood samples (no. 1: 0 Gy, no. 2: 1.2 Gy, no. 3: 3.5 Gy) were sent to each participant and the task was to culture samples, to prepare slides and to assess radiation doses based on the observed dicentric yields from 50 manually or 150 semi-automatically scored metaphases (triage mode scoring). Approximately two-thirds of the participants applied calibration curves from irradiations with γ rays and about 1/3 from irradiations with X rays with varying energies. The categorization of the samples in clinically relevant groups corresponding to individuals that were unexposed/minimally (0-1 Gy), moderately (1-2 Gy) or highly exposed (>2 Gy) was successfully performed by all participants for sample no. 1 and no. 3 and by ≥74% for sample no. 2. However, while most participants estimated a dose of exactly 0 Gy for the sham-irradiated sample, the precise dose estimates of the samples irradiated with doses >0 Gy were systematically higher than the corresponding reference doses and showed a median deviation of 0.5 Gy (sample no. 2) and 0.95 Gy (sample no. 3) for manual scoring. By converting doses estimated based on γ-ray calibration curves to X-ray doses of a comparable mean photon energy as used in this exercise, the median deviation decreased to 0.27 Gy (sample no. 2) and 0.6 Gy (sample no. 3). The main aim of biological dosimetry in the case of a large-scale event is the categorization of individuals into clinically relevant groups, to aid clinical decision making. This task was successfully performed by all participants for the 0 Gy and 3.5 Gy samples and by 74% (manual scoring) and 80% (semi-automatic scoring) for the 1.2 Gy sample. Due to the accuracy of the dicentric chromosome assay and the high number of participating laboratories, a systematic shift of the dose estimates could be revealed. Differences in radiation quality (X ray vs. γ ray) between the test samples and the applied dose effect curves can partly explain the systematic shift. There might be several additional reasons for the observed bias (e.g., donor effects, transport, experimental conditions or the irradiation setup) and the analysis of these reasons provides great opportunities for future research. The participation of laboratories from countries around the world gave the opportunity to compare the results on an international level.

Pattern of pericardial calcification determines the mid-term postoperative outcome after pericardiectomy in chronic constrictive pericarditis

Background/Introduction

Although pericardiectomy is an effective treatment of constrictive pericarditis (CP), clinical outcome is not always successful. Pericardial calcification is a unique finding in CP. However, the amount and localization of calcification vary. Computer tomography (CT) can visualize the pericardial calcification with high sensitivity and provide the anatomical assessment.

Purpose

We investigated that how the pattern and amount of pericardial calcification affect the mid-term postoperative outcome after pericardiectomy in CP.

Methods

All of the patients who underwent total pericardiectomy in our hospital from 2010 to 2020 were derived from electrical medical records (n=105). Among them, preoperative CT scans (non-gated non-contrast) of 98 patients were available and, thus, 98 consecutive patients were finally analyzed. Medical records were reviewed in a retrospective manner. Cardiovascular event is defined as cardiovascular death or hospitalization associated with a heart failure symptom and all cause event is defined as all events that require admission. CT scan was analyzed by Aquarius Workstation, and the volume and localization pattern of pericalcification were derived. Pericardium calcium score was given as an Agatston score.

Results

Of 98 patients, 25 (25.5%) patients were hospitalized with heart failure symptom after pericardiectomy. Median follow up duration of patients is 172 weeks. A group with cardiovascular event had higher NYHA grade (P<0.001), lower calcium volume (P=0.004), and lower calcium score (P=0.01). Multivariate cox proportional analysis showed that high ln(calcium score) before pericardiectomy was dependent predictor of cardiovascular event (hazard ratio, 0.90; P=0.04) and all cause event (hazard ratio, 0.91, P=0.04) after pericardiectomy. When we set the cut off value at 7.22, based on ROC curve, there was a significant difference in cardiovascular event between the groups divided by this cutoff value in Kaplan-Meier curve (P=0.002) and multivariate cox proportional analysis (P=0.04). In the subgroup analysis, myocardium invasion and circumferential calcification were more common in the high calcium score group. Idiopathic & tuberculosis pericarditis were more associated with high calcium score group and post-operative pericarditis, other reasons (infection, radiation, etc) were more associated with low calcium group.

Conclusion

Low burden of pericardial calcification was associated high rate of mid-term clinical event after pericardiectomy CP. Preoperative evaluation of pericardial calcification pattern can be used as predictor of postoperative outcomes.

Funding Acknowledgement

Type of funding sources: None.

Climate change-induced invasion risk of ecosystem disturbing alien plant species: An evaluation using species distribution modeling

Species distribution modeling is widely used for evaluating invasion risk, and for prioritizing areas for the control and management of invasive species. However, selecting a modeling tool that accurately predicts species invasion risk requires a systematic approach. In this study, five species distribution models (SDMs), namely, artificial neural network (ANN), generalized linear model (GLM), multivariate adaptive regression splines (MARS), maximum entropy (MaxEnt), and random forest (RF), were performed and evaluated their model performance using the mean value of area under the curve (AUC), true skill statistics (TSS), and Kappa scores of 12 ecosystem disturbing alien plant species (EDAPS). The mean evaluation metric scores were highest in RF (AUC = 0.924 ± 0.058, TSS = 0.789 ± 0.109, Kappa = 0.671 ± 0.096, n = 12) and lowest in ANN. The ANOVA of AUC, TSS, and Kappa metrics revealed the RF model was significantly different from other SDMs and was therefore selected as the relatively best model. The potential distribution area and invasion risk for each EDAPS were quantified. Under the current climate conditions of South Korea, the average potential distribution area of EDAPS was estimated to be 13,062 km2. However, in future climate change scenarios, the average percentage change of EDAPS distribution relative to the current climate was predicted to be increased over 219.93%. Furthermore, under the current climate, 0.16% of the area of the country was estimated to be under a very high risk of invasion, but this would increase to 60.43% by 2070. Invasion risk under the current climate conditions was highest in the northwestern, southern, and southeastern regions, and in densely populated cities, such as Seoul, Busan, and Daegu. By 2070, invasion risk was predicted to expand across the whole country except in the northeastern region. These results suggested that climate change induced the risk of EDAPS invasiveness, and SDMs could be valuable tools for alien and invasive plant species risk assessment.

Heat exposure and workers' health: a systematic review

OBJECTIVES

Several studies on the health effects of heat exposure on workers have been reported; however, only few studies have summarized the overall and systematic health effects of heat exposure on workers. This study aims to review the scientific reports on the health status of workers exposed to high temperatures in the workplace.

METHODS

We reviewed literature from databases such as PubMed and Google Scholar, using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines to identify studies that address health effects of heat exposure among workers.

RESULTS

In total, 459 articles were identified, and finally, 47 articles were selected. Various health effects of heat exposure on workers have been reported, such as heat-related diseases, deaths, accidents or injuries, effects on the urinary system, reproductive system, and on the psychological system.

CONCLUSIONS

Our review suggests that many workers are vulnerable to heat exposure, and this has a health effect on workers.

Gasserian ganglion radiofrequency thermoablation in a patient with aneurysm of the anterior communicating artery -A case report

Background

Gasserian ganglion radiofrequency thermoablation is a good treatment option for the management of pain in trigeminal neuralgia. We report a case in which the patient of trigeminal neuralgia combined with anterior cerebral artery aneurysm was treated successfully by gasserian ganglion thermoablation without any complication.

Case

An 85-year-old female presenting with electric shock like sensation in the gum and molar teeth was diagnosed as trigeminal neuralgia. Carbamazepine medication and trigeminal nerve blockade relieved her pain partially, but severe side effects of carbamazepine occurred. Magnetic resonance angiography of the brain showed saccular aneurysm in inferior aspect of the anterior communicating artery. Gasserian ganglion thermoablation under sedation anesthesia using nicardipine was performed carefully without any rupture of the cerebral aneurysm.

Conclusions

Gasserian ganglion thermoablation could be performed safely in a patient with cerebral aneurysm without any inadvertent event.

A phase transition-induced photocathodic p-CuFeO2 nanocolumnar film by reactive ballistic deposition

Vertical nanocolumnar Cu–Fe–O electrodes synthesized by the reactive ballistic deposition technique followed by heat treatment in an Ar atmosphere undergo a switch for conductivity at elevated temperatures.

Greater occipital nerve blockade using ultrasound guidance for the headache of spontaneous intracranial hypotension - A case report

Background

Spontaneous intracranial hypotension occurs due to cerebrospinal fluid leakage from the spinal column, and orthostatic headache is the most common clinical presentation. Recent studies showed that bilateral greater occipital nerve blockade demonstrated clinical efficacy in relieving post-dural puncture headache after caesarean section.

Case

A 40-year-old male who presented severe orthostatic headache was consulted to our pain clinic from neurology department. He initially felt a dull nature pain over the whole occipital area which then spread over the frontal and parietal areas. His headache was combined with nausea and vomiting. An epidural blood patch was delayed until final cisternography, and bilateral greater occipital nerve blockade using ultrasound guidance was performed instead. After the blockade, the previously existing headache around the occipital and parietal areas disappeared completely, but mild headache persisted around the frontal area.

Conclusions

Greater occipital nerve blockade could be a good therapeutic alternative to improve headache resulting from spontaneous intracranial hypotension.

Anti-diabetic effects of Protaetia brevitarsis in pancreatic islets and a murine diabetic model

OBJECTIVE

In this study, the antidiabetic efficacy of Protaetia brevitarsis in alloxan-treated pancreatic islets and db/db mice was investigated. P. brevitarsis was tested for alloxan-mediated cytotoxicity and nitric oxide production in mice pancreatic islets.

MATERIALS AND METHODS

The anti-diabetic effect of P. brevitarsis was also evaluated in db/db mice after 4 weeks of administration. Biochemical analysis, oral glucose tolerance test (OGTT), and pancreatic histological analysis were performed.

RESULTS

P. brevitarsis displayed hypoglycemic activity in alloxan-treated mice pancreatic islets. Our results showed that P. brevitarsis protects pancreatic islets from cytotoxicity. Moreover, daily oral supplementation with P. brevitarsis for 4 weeks reduced plasma glucose levels without affecting body weight and food intake, elevated glucose tolerance in OGTT, improved blood lipid parameters, inhibited fat accumulation, and restored islet structure of db/db mice.

CONCLUSIONS

The present study provided evidence for the anti‑diabetic effect of P. brevitarsis in alloxan-treated pancreatic islets and db/db mice. These results suggest that P. brevitarsis may be used as an adjunctive anti-diabetic agent or as a functional food.

Multigeneration toxicity of Geunsami® (a glyphosate-based herbicide) to Allonychiurus kimi (Lee) (Collembola) from sub-individual to population levels

Glyphosate-based herbicide (GBH) is the most widely used herbicide worldwide and has long been considered to have significantly low toxicity to non-target soil invertebrates based on short-term toxicity tests (<56 d). However, long-term GBH toxicity assessment is necessary as GBH is repeatedly applied in the same field annually because of the advent of glyphosate-resistant crops. In this study, a multigeneration test was conducted where Allonychiurus kimi (Collembola) was exposed to GBH for three generations (referred to as F0, F1, and F2) to evaluate the long-term toxic effect. The endpoints used were adult survival and juvenile production for the individual level toxicity assessment. Phospholipid profile and population age structure were the endpoints used for sub-individual and population levels, respectively. GBH was observed to have no negative effects on adult survivals of all generations, but juvenile production was found to decrease in a concentration-dependent manner, with EC50s being estimated as 572.5, 274.8, and 59.8 mg a.i. kg-1 in the F0, F1, and F2 generations, respectively. The age structure of A. kimi population produced in the test of all generations was altered by GBH exposure, mainly because of the decrease in the number of young juveniles. Further, differences between the phospholipid profiles of the control and GBH treatments became apparent over generations, with PA 16:0, PA 12:0, and PS 42:0 lipids not being detected at the highest concentration of 741 mg kg-1 in F2. Considering all our findings from sub-individual to population levels, repeated and long-term use of GBH could have significantly higher negative impacts on non-target soil organisms than expected.

Comparison of Efficacy of an Epidural Blood Patch in Patients with Spinal Leakage of Cerebrospinal Fluid

BACKGROUND

The leakage of cerebrospinal fluid (CSF) can be encountered spontaneously or after procedures such as epidural or spinal anesthesia, intrathecal chemotherapy, CSF tapping, or other various spinal procedures. The leakage of CSF can lead to intracranial hypotension, which is associated with an orthostatic headache. For such patients with this type of headache, an epidural blood patch is the treatment of choice.

OBJECTIVE

The purpose of this study is to compare the clinical features and efficacy of an epidural blood patch for patients with spinal leakage of CSF.

STUDY DESIGN

Retrospective study.

SETTING

University hospital inpatients referred for consultation to the pain clinic.

METHODS

Identification of patients with orthostatic headache was performed using the program Clinical Data Warehouse (CDW) v 2.5. Search word in CDW for analysis was "epidural blood patch." We carefully evaluated the demographics, etiology, clinical features of headache, associated phenomena other than headache, level and types of CSF leakage, and frequencies and outcomes of epidural blood patches. We allocated patients into 2 groups according to the cause of headache: spontaneous intracranial hypotension (group SIH) and post-dural puncture headache (group PDPH).

RESULTS

The number of patients needing repeated epidural blood patches was significantly higher in the SIH group SIH in the PDPH group (P = 0.007). In the PDPH group, a targeted epidural blood patch was possible in 100% of the cases, whereas it was possible in only 66.7% of the patients in the SIH group, indicated by previous examination (P < 0.001). Forty patients (90.9%) and 17 patients (70.8%) achieved complete recovery from headache after a single epidural blood patch in the PDPH group and SIH group, respectively (P < 0.001).

LIMITATION

The number of patients allocated to each group was not balanced because of the retrospective design.

CONCLUSION

Most patients in the PDPH group required a single epidural blood patch to achieve complete recovery from headache. However, patients in the SIH group required repeated epidural blood patches for complete pain relief.

The Effect of Normal Saline Injection Volumes on the Optic Nerve Sheath Diameter during Thoracic Epidural Analgesia

BACKGROUND

Saline or local anesthetic injection into the epidural space increases intracranial pressure (ICP), at least transiently. Measurement of the optic nerve sheath diameter (ONSD) using ocular ultrasonography is one of the noninvasive methods for ICP assessment.

OBJECTIVES

The purpose of this study is to investigate the effects of the different volume on the ONSD and cerebral oxygen saturation (rSO2) during thoracic epidural saline injection under awake conditions.

STUDY DESIGN

Prospective randomized, controlled trial.

SETTING

An interventional pain management practice in South Korea.

METHODS

This study included 71 patients receiving thoracic epidural catheterization for pain management, following upper abdominal or thoracic surgery. Following successful epidural space confirmation, patients were randomly allocated to receive 5 mL (5 mL group), 10 mL (10 mL group), and 20 mL (20 mL group) of epidural normal saline. Transorbital sonography was performed to measure the ONSD. This was measured at 3 mm posterior to the optic nerve head. An rSO2 was measured using cerebral oximeter sensors.

RESULTS

All 3 groups showed significant increases of ONSD from 10 minutes to 40 minutes as compared to baseline (before procedure). Among the 3 groups, the 20 mL group demonstrated the most significantly increased ONSD, as compared to the 5 mL and 10 mL groups. At the 20 minute and 40 minute time points, the ONSD showed a volume-dependent increase (P = 0.0005, P = 0.014). All 3 groups showed the rSO2 to be distributed between 60~70% without any statistical difference.

LIMITATIONS

We could not determine the returning point of the normalized ONSD value.

CONCLUSION

Twenty milliliters of normal saline epidural injection resulted in a significant increase of ONSD, as compared to the 5 mL and 10 mL groups. Our results also indicate that an increase of ONSD occurs in accordance with the injected volume of normal saline.

Comparison of Intravascular Injection Incidences and Technical Easiness Between Anteroposterior and Oblique Approaches During S1 Transforaminal Epidural Injection

BACKGROUND

Transforaminal epidural injection (TFEI) is a useful intervention for radicular leg pain. Compared to TFEI in lumbar level, S1 TFEI is reported to have higher incidence rates of intravascular injection as well as technical difficulties.

OBJECTIVE

The purpose of this study is to compare the incidence rates of intravascular injection and foramen passage time between anteroposterior (AP) and oblique (OB) approaches.

STUDY DESIGN

Prospective randomized trial.

SETTING

An interventional pain management practice in South Korea.

METHODS

One hundred forty-seven patients receiving S1 TFEI for radicular leg pain were randomly assigned to one of 2 approach methods (AP view vs OB view). For S1 TFEI in the OB view group, lineup of the L5-S1 endplate was performed by adjusting the cephalad-caudad tilt. Then C-arm was rotated at an ipsilateral oblique angle, approximately 10° to 15°. After final confirmation of intravascular injection with real time fluoroscopy, the foramen passage time and amount of radiation exposure during S1 TFEI were measured.

RESULTS

The incidence rate of intravascular injection in the AP view group was 24.2% (24/99), whereas that of intravascular injection in the OB view group was 10.1% (17/99, P = 0.008). The radiation dose required to pass the S1 foramen was significantly higher in the AP view group than in the OB view group (51.3 ± 27.2 cGy/cm2 vs 41.0 ± 17.0 cGy/cm2, P = 0.002). The foramen passage time during S1 TFEI was significantly higher in the AP view group than in the OB view group (103.5 ± 44.1 second vs 84.9 ± 21.0 second, P = 0.001). The failure rate of S1 TFEI was significantly higher in the AP view group than in the OB view group (13% vs 4%, P = 0.022).

LIMITATION

The physicians involved in the present study were not blinded to the type of approach method (AP view vs OB view) by fluoroscopy.

CONCLUSION

Our study demonstrated reduced incidence rates of intravascular injection and reduced foramen passage time and radiation dosage with the use of OB view method during S1 TFEI.

Catalytic Carbochlorocarbonylation of Unsaturated Hydrocarbons via C-COCl Bond Cleavage*

Here we report a palladium‐catalysed difunctionalisation of unsaturated C−C bonds with acid chlorides. Formally, the C−COCl bond of an acid chloride is cleaved and added, with complete atom economy, across either strained alkenes or a tethered alkyne to generate new acid chlorides. The transformation does not require exogenous carbon monoxide, operates under mild conditions, shows a good functional group tolerance, and gives the isolated products with excellent stereoselectivity. The intermolecular reaction tolerates both aryl‐ and alkenyl‐substituted acid chlorides and is successful when carboxylic acids are transformed to the acid chloride in situ. The reaction also shows an example of temperature‐dependent stereodivergence which, together with plausible mechanistic pathways, is investigated by DFT calculations. Moreover, we show that benzofurans can be formed in an intramolecular variant of the reaction. Finally, derivatisation of the products from the intermolecular reaction provides a highly stereoselective approach for the synthesis of tetrasubstituted cyclopentanes.

Low-dose rivaroxaban associated with lower incidence of all-cause mortality and bleeding complications in older patients with non-valvular atrial fibrillation

Background

Low-dose rivaroxaban 10mg daily was used in the J-ROCKET AF trial, and it demonstrated the safety in Asian population. It remains unclear whether low-dose rivaroxaban vs. standard dose 20mg daily is associated with efficacy, safety, and net-clinical outcomes in older Asian patients with non-valvular atrial fibrillation.

Purpose

To evaluate the effects of low-dose rivaroxaban on efficacies and safeties in the old patients age more than 85 years.

Methods

We retrospectively enrolled the patients from medical records between Oct 2012 and Nov 2016. We used 2x2 factorial design by age of 85 years and use of low-dose rivaroxaban. The study outcomes were one-year all-cause mortality and bleeding complications.

Results

The study cohort consisted of 2,386 patients with the mean age 76.6 years (SD 10.5), 51.8% male, CHA2DS2Vsc 4.4 (SD 1.7) and HASBLED 1.6 (SD 1.0). In the age ≥85 group (n=593), low vs. standard dose rivaroxaban had a lower incidence of all-cause mortality (5.3% vs. 10.6%, P=0.021), whereas the incidence of all-cause mortality was greater in the low dose rivaroxaban compared with the standard dose in the age &lt;85 group (3.7% vs. 1.8%, P=0.012). No significant differences of bleeding complication rates were found between the low- and standard-dose rivaroxaban regarding age &lt;85 or ≥85 years. After adjusting for potential confounders, low dose rivaroxaban was associated with a decreased risk of all-cause mortality in the age ≥85 group (adjusted HR: 0.400 95% CI: 0.215–0.743, P=0.004), but the significant association was not found in the age &lt;85 group (adjusted HR: 1.101 95% CI: 0.557–2.174, P=0.782).

Conclusion

Low dose rivaroxaban was associated with a decreased risk of all-cause mortality in the patients with non-valvular atrial fibrillation and age ≥85 years.

Funding Acknowledgement

Type of funding sources: None.

Predicting Impacts of Climate Change on Northward Range Expansion of Invasive Weeds in South Korea

Predicting the distribution of invasive weeds under climate change is important for the early identification of areas that are susceptible to invasion and for the adoption of the best preventive measures. Here, we predicted the habitat suitability of 16 invasive weeds in response to climate change and land cover changes in South Korea using a maximum entropy modeling approach. Based on the predictions of the model, climate change is likely to increase habitat suitability. Currently, the area of moderately suitable and highly suitable habitats is estimated to be 8877.46 km², and 990.29 km², respectively, and these areas are expected to increase up to 496.52% by 2050 and 1439.65% by 2070 under the representative concentration pathways 4.5 scenario across the country. Although habitat suitability was estimated to be highest in the southern regions (<36° latitude), the central and northern regions are also predicted to have substantial increases in suitable habitat areas. Our study revealed that climate change would exacerbate the threat of northward weed invasions by shifting the climatic barriers of invasive weeds from the southern region. Thus, it is essential to initiate control and management strategies in the southern region to prevent further invasions into new areas.

Palladium-Catalyzed Decarbonylative Iodination of Aryl Carboxylic Acids Enabled by Ligand-Assisted Halide Exchange

We report an efficient and broadly applicable palladium-catalyzed iodination of inexpensive and abundant aryl and vinyl carboxylic acids via in situ activation to the acid chloride and formation of a phosphonium salt. The use of 1-iodobutane as iodide source in combination with a base and a deoxychlorinating reagent gives access to a wide range of aryl and vinyl iodides under Pd/Xantphos catalysis, including complex drug-like scaffolds. Stoichiometric experiments and kinetic analysis suggest a unique mechanism involving C-P reductive elimination to form the Xantphos phosphonium chloride, which subsequently initiates an unusual halogen exchange by outer sphere nucleophilic substitution.

Intrathecal drug delivery to treat intractable neuropathic pain following Sjögren's syndrome-induced transverse myelitis: A case report

RATIONALE

Transverse myelitis (TM) is a spinal cord inflammatory myelopathy that causes motor/sensory loss and urinary retention below the level of the affected spinal cord. Although a few case reports have described the control of neuropathic pain in patients with TM via spinal cord stimulation, no documented case regarding the control of severe allodynia following TM via intrathecal pump has been described.

PATIENT CONCERNS

A 37-year-old woman was referred to a pain clinic for severe intractable pain below the T5 level followed by Sjögren's syndrome-induced TM.

DIAGNOSES

A neurological examination revealed paresthesia and allodynia below the T5 level. The sensory evaluation was limited by extreme pain and jerking movements. The muscle strength of both lower limbs was grade 3.

INTERVENTIONS

Intrathecal pump was inserted into the left lower abdomen. Catheter tip was placed at the midline of the T8 level.

OUTCOMES

The numeric rating scale (NRS) for pain score decreased from 10 to 5. Functional Independence Measure score increased from 67 before implantation to 92 at the time of discharge, while the patient's Barthel score increased from 31 to 46.

LESSONS

Neuropathic pain due to Sjögren's syndrome-related TM could be controlled effectively using the intrathecal morphine pump.

The proliferative phase endometrium in IVF/ICSI: an in-cycle molecular analysis predictive of the outcome following fresh embryo transfer

STUDY QUESTION

Does an early proliferative phase endometrial biopsy harvested during ovarian stimulation harbour information predictive of the outcome following fresh embryo transfer (ET) in that same cycle?

SUMMARY ANSWER

Transcriptome analysis of the whole-tissue endometrium did not reveal significant differential gene expression (DGE) in relation to the outcome; however, the secretome profile of isolated, cultured and in vitro decidualized endometrial stromal cells (EnSCs) varied significantly between patients who had a live birth compared to those with an implantation failure following fresh ET in the same cycle as the biopsy.

WHAT IS KNOWN ALREADY

In the majority of endometrial receptivity research protocols, biopsies are harvested during the window of implantation (WOI). This, however, precludes ET in that same cycle, which is preferable as the endometrium has been shown to adapt over time. Endometrial biopsies taken during ovarian stimulation have been reported not to harm the chances of implantation, and in such biopsies DGE has been observed between women who achieve pregnancy versus those who do not. The impact of the endometrial proliferative phase on human embryo implantation remains unclear, but deserves further attention, especially since in luteal phase endometrial biopsies, a transcriptional signature predictive for repeated implantation failure has been associated with reduced cell proliferation, possibly indicating proliferative phase involvement. Isolation, culture and in vitro decidualization (IVD) of EnSCs is a frequently applied basic research technique to assess endometrial functioning, and a disordered EnSC secretome has previously been linked with failed implantation.

STUDY DESIGN, SIZE, DURATION

This study was nested in a randomized controlled trial (RCT) investigating the effect of endometrial scratching during the early follicular phase of ovarian stimulation on clinical pregnancy rates after IVF/ICSI. Of the 96 endometrial biopsies available, after eliminating those without fresh ET and after extensive matching in order to minimize the risk of potential confounding, 18 samples were retained to study two clinical groups: nine biopsies of patients with a live birth versus nine biopsies of patients with an implantation failure, both following fresh ET performed in the same cycle as the biopsy. We studied the proliferative endometrium by analysing its transcriptome and by isolating, culturing and decidualizing EnSCs in vitro. We applied this latter technique for the first time on proliferative endometrial biopsies obtained during ovarian stimulation for in-cycle outcome prediction, in an attempt to overcome inter-cycle variability.

PARTICIPANTS/MATERIALS, SETTING, METHODS

RNA-sequencing was performed for 18 individual whole-tissue endometrial biopsies on an Illumina HiSeq1500 machine. DGE was analysed three times using different approaches (DESeq2, EdgeR and the Wilcoxon rank-sum test, all in R). EnSC isolation and IVD was performed (for 2 and 4 days) for a subset of nine samples, after which media from undifferentiated and decidualized cultures were harvested, stored at -80°C and later assayed for 45 cytokines using a multiplex suspension bead immunoassay. The analysis was performed by partial least squares regression modelling.

MAIN RESULTS AND THE ROLE OF CHANCE

After correction for multiple hypothesis testing, DGE analysis revealed no significant differences between endometrial samples from patients who had a live birth and those with an implantation failure following fresh ET. However secretome analysis after EnSC isolation and culture, showed two distinct clusters that clearly corresponded to the two clinical groups. Upon IVD, the secretome profiles shifted from that of undifferentiated cells but the difference between the two clinical groups remained yet were muted, suggesting convergence of cytokine profiles after decidualization.

LIMITATIONS, REASONS FOR CAUTION

Caution is warranted due to the limited sample size of the study and the in vitro nature of the EnSC experiment. Validation on a larger scale is necessary, however, hard to fulfil given the very limited availability of in-cycle proliferative endometrial biopsies outside a RCT setting.

WIDER IMPLICATIONS OF THE FINDINGS

These data support the hypothesis that the endometrium should be assessed not only during the WOI and that certain endometrial dysfunctionalities can probably be detected early in a cycle by making use of the proliferative phase. This insight opens new horizons for the development of endometrial tests, whether diagnostic or predictive of IVF/ICSI treatment outcome.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by Fonds Wetenschappelijk Onderzoek (FWO, Flanders, Belgium, 11M9415N, 1 524 417N), Wetenschappelijk Fonds Willy Gepts (WFWG G160, Universitair Ziekenhuis Brussel, Belgium) and the National Medicine Research Council (NMRC/CG/M003/2017, Singapore). There are no conflicts of interests.

TRIAL REGISTRATION NUMBER

NCT02061228.

Timing and clinical outcomes of tracheostomy in patients with COVID-19

In this retrospective multicentre cohort study that included 27 COVID-19 patients who underwent tracheostomy, the mean time between intubation and tracheostomy was 15.8 days and the negative conversion time of COVID-19 was 43.1 days. Eleven patients (40.7%) died of COVID-19 and the use of percutaneous dilatation tracheostomy was significantly associated with in-hospital death. Timely tracheostomy could be performed in COVID-19 patients, regardless of duration of intubation or positivity of COVID-19 test, with an open surgical tracheostomy as a preferable technique.

Factors Predicting the Success of Adhesiolysis Using a Steerable Catheter in Lumbar Failed Back Surgery Syndrome: A Retrospective Study

Failed back surgery syndrome (FBSS) is a commonly encountered disease after lumbar surgery. There are many cases where it is difficult to choose a treatment because no specific cause can be found. Nevertheless, according to recent reports, adhesiolysis has shown reasonable evidence. However, considering its poor cost-effectiveness, adhesiolysis cannot be used as the first line of treatment. FBSS patients often suffer from chronic pain; accordingly, they become frustrated when this treatment produces a poor response. Therefore, before the procedure, the target group must be selected carefully. We sought to identify the pre-procedure factors predicting the effect of adhesiolysis in FBSS. A total of 150 patients were evaluated and analyzed retrospectively. Of these 150 patients, 69 were classified as responders three months after the procedure (46%). The outer diameter of the catheter during the procedure and grade of foraminal stenosis were correlated with the procedure effect. In conclusion, of the 2.1 mm diameter of the catheter, 1.7 mm of it was used during the procedure, and the milder the foraminal stenosis, the greater the pain reduction effect was three months after the procedure.

Palladium-catalysed carboformylation of alkynes using acid chlorides as a dual carbon monoxide and carbon source

Hydroformylation, a reaction that installs both a C-H bond and an aldehyde group across an unsaturated substrate, is one of the most important catalytic reactions in both industry and academia. Given the synthetic importance of creating new C-C bonds, the development of carboformylation reactions, wherein a new C-C bond is formed instead of a C-H bond, would bear enormous synthetic potential to rapidly increase molecular complexity in the synthesis of valuable aldehydes. However, the demanding complexity inherent in a four-component reaction, utilizing an exogenous CO source, has made the development of a direct carboformylation reaction a formidable challenge. Here, we describe a palladium-catalysed strategy that uses readily available aroyl chlorides as a carbon electrophile and CO source, in tandem with a sterically congested hydrosilane, to perform a stereoselective carboformylation of alkynes. An extension of this protocol to four chemodivergent carbonylations further highlights the creative opportunity offered by this strategy in carbonylation chemistry.

Anifrolumab for the treatment of active systemic lupus erythematosus: a meta-analysis of randomized controlled trials

We surveyed randomized controlled trials (RCTs) examining the efficacy and safety of anifrolumab 300 mg in patients with active systemic lupus erythematosus (SLE) despite receiving standard therapy, using MEDLINE, EMBASE, the Cochrane Controlled Trials Register, and manual searches. Meta-analysis performed to determine treatment efficacy and safety outcomes of three RCTs (459 patients and 468 controls) revealed that the BICLA responses were significantly higher in the anifrolumab group than in the placebo group (OR = 2.071, 95%CI 1.575-2.725, p < 0.001). Steroid reduction and CLASI reduction were also significantly higher in the anifrolumab group than in the placebo group (OR = 1.811, 95%CI = 1.308-2.506, p < 0.001; OR = 2.245, 95%CI = 1.437-3.506, p < 0.001). Compared with placebo, anifrolumab significantly increased the SRI7 and SRI8 responses in SLE patients (OR = 1.866, 95%CI = 1.372-2.536, p < 0.001; OR = 1.925, 95%CI = 1.387-2.672, p < 0.001). The SRI4, 5, and 6 responses also tended to be higher in the anifrolumab group than in the placebo group. Adverse event incidence was significantly higher in the anifrolumab group than in the placebo group (OR = 1.815, 95%CI = 1.262-2.611, p = 0.001); serious adverse events were significantly lower in the anifrolumab group than in the placebo group (OR = 0.679, 95%CI = 0.468-0.986, p = 0.042). Herpes zoster infection was significantly higher in the anifrolumab group than in the placebo group (OR = 4.089, 95%CI = 1.750-9.522, p = 0.001). Anifrolumab is effective for treating active SLE. However, anifrolumab increased the incidence of herpes zoster infection compared with placebo.

Comparative study of the efficacy and safety of tofacitinib, baricitinib, upadacitinib, and filgotinib versus methotrexate for disease-modifying antirheumatic drug-naïve patients with rheumatoid arthritis

An assessment of the relative efficacy and tolerability of tofacitinib, baricitinib, upadacitinib, and filgotinib compared to those of methotrexate (MTX) was performed in disease-modifying antirheumatic drug (DMARD)-naive patients with rheumatoid arthritis (RA). We performed a Bayesian network meta-analysis to combine direct and indirect evidence from randomized controlled trials (RCTs) so as to examine the efficacy and safety of tofacitinib, baricitinib, upadacitinib, filgotinib, and MTX in DMARD-naïve RA patients. Four RCTs comprising 2185 patients met the inclusion criteria. The ranking probability based on the surface under the cumulative ranking curve (SUCRA) indicated that upadacitinib 15 mg had the highest probability of achieving the American College of Rheumatology 20% (ACR20) response rate, followed by baricitinib 4 mg, tofacitinib 5 mg, filgotinib 200 mg, and MTX. Tofacitinib, baricitinib, upadacitinib, and filgotinib treatments achieved significantly higher ACR50 and ACR70 responses compared to MTX. Tofacitinib 5 mg had the highest probability of achieving the ACR50 and ACR70 response rates, followed by upadacitinib 15 mg, baricitinib 4 mg, filgotinib 200 mg, and MTX. The safety analysis based on serious adverse events, adverse events (AEs), and withdrawals due to AEs revealed no statistically significant differences between the respective intervention groups. In conclusion, tofacitinib, baricitinib, upadacitinib, and filgotinib were effective treatment options for DMARD-naïve RA patients, suggesting a difference in efficacy and safety among the different JAK inhibitors.

Association between plasminogen activator inhibitor‑1 (PAI-1) 4G/5G polymorphism and circulating PAI-1 level in systemic lupus erythematosus and rheumatoid arthritis : A meta-analysis

OBJECTIVE

This study systemically reviewed the evidence regarding the association between plasminogen activator inhibitor‑1 (PAI‑1) 4G/5G polymorphism and susceptibility to systemic lupus erythematous (SLE)/lupus nephritis (LN) and rheumatoid arthritis (RA) and the relationship between circulating PAI‑1 levels and SLE/LN and RA.

METHODS

We conducted a meta-analysis on the association between the PAI‑1 4G/5G polymorphism and SLE/LN or RA risk and serum/plasma PAI‑1 levels in patients with SLE/LN and RA and healthy controls.

RESULTS

Nine articles including 657 patients with SLE and 668 controls and 567 patients with RA and 772 controls were included. No association was revealed between SLE and PAI‑1 4G allele in all study subjects (odds ratio [OR] = 0.944, 95% confidence interval [CI] = 0.808-1.102, p = 0.463). Ethnicity-based stratification showed no association between the PAI‑1 4G allele and SLE among Europeans and Asians. No association was detected between LN and RA and the PAI‑1 4G allele (OR = 0.886, 95% CI = 0.713-1.102, p = 0.278; OR = 0.8736, 95% CI = 0.747-1.020, p = 0.088, respectively) or between SLE/LN and RA and the PAI‑1 4G/5G polymorphism using the recessive and dominant models and homozygote contrast. The circulating PAI‑1 level was significantly higher in the SLE group than in the control group (standardized mean difference [SMD] = 0.337, 95% CI = 0.057-0.619, p = 0.019). However, serum/plasma PAI‑1 level showed no significant difference between RA and control group (SMD = 0.333, 95% CI = -0.6989-1.35, p = 0.527).

CONCLUSIONS

There was no association between the PAI‑1 4G/5G polymorphism and SLE/LN and RA development and significantly higher levels of circulating PAI‑1 were observed in patients with SLE but not in those with RA.

[Melatonin Induces Apoptotic Cell Death in 3T3-L1 Preadipocytes]

Obesity is a major disease that causes significant complications. Inhibition of preadipocyte proliferation has the potential to prevent obesity and metabolic diseases. Melatonin is a pineal gland hormone that has various effects on cells and tissues. In this research, we investigated whether melatonin induces apoptosis in 3T3-L1 preadipocytes. 3T3-L1 preadipocytes were cultured until confluence and then treated with 0, 10, 100, and 1000 μM melatonin for 1, 3, and 5 days. A cell viability assay kit was used for determining cell viability. Cell death marker proteins were assessed by Western blot analysis using GAPDH for control. Apoptotic morphological changes with nuclei fragmentation were observed using DAPI staining. Melatonin treatment decreased the phosphorylated extracellular signal-regulated kinases (p-ERK) activation while increasing the activation of caspase-3, 8, and 9. Furthermore, melatonin not only increased Bcl-2-associated X protein (Bax) but decreased B-cell lymphoma 2 (Bcl-2) expression as dose increases from 0 to 1000 μM. The melatonin treatment also suppressed the growth of preadipocytes with increasing concentration. These effects were attenuated by luzindole, a melatonin receptor antagonist and U0126, an inhibitor of p-ERK activation. In conclusion, melatonin can induce apoptosis of 3T3-L1 preadipocytes via p-ERK decrease.

Comparative efficacy and safety of secukinumab and ixekizumab in patients with active ankylosing spondylitis

OBJECTIVE

Evaluation of the effectiveness and safety of secukinumab and ixekizumab in active ankylosing spondylitis (AS) patients.

METHODS

A Bayesian network meta-analysis was conducted using direct and indirect data from five randomized controlled trials that examined the efficacy and safety of secukinumab 150 mg every 4 weeks and ixekizumab 80 mg every 2 weeks (IXEQ2W) or every 4 weeks (IXEQ4W) in active AS patients.

RESULTS

Data from 1433 patients were analyzed. The Assessment of Spondyloarthritis International Society evaluation 20% response rates (ASAS20) were significantly higher with secukinumab 150 mg, IXEQ2W, IXEQ2W, and adalimumab 40 mg (odds ratio [OR] 2.75, 95% Bayesian credible interval [CrI] 2.04-3.69; OR 2.59, 95% CrI 1.69-3.98; OR 2.45, 95% CrI 1.60-3.75; and OR 1.94, 95% CrI 1.13-3.37, respectively) compared to the placebo group. Efficacies of secukinumab and ixekizumab were numerically higher compared to adalimumab 40 mg, although there was no significant difference in the ASAS20 response rates. The ASAS40 response rate showed a pattern of distribution similar to the ASAS20 response rate, with the exception of the ixekizumab group, which was associated with the most favorable surface under the cumulative ranking curve (SUCRA) for the ASAS40 response rate. Based on the SUCRA rating, secukinumab 150 mg had the highest probability of being the best ASAS20 response rate therapy, followed by IXEQ2W, IXEQ4W, adalimumab 40 mg, and placebo. There was no significant difference between the treatments regarding the number of serious adverse events (SAEs).

CONCLUSION

Secukinumab and ixekizumab were effective in active AS treatment, without the risk of SAEs.

Sex-specific association of urate and levodopa-induced dyskinesia in Parkinson's disease

BACKGROUND AND PURPOSE

As a major antioxidant, uric acid (UA) is known to be associated with the clinical progression of Parkinson's disease (PD). This study investigated whether baseline UA levels are associated with the risk for levodopa-induced dyskinesia (LID) in PD in a sex-dependent manner.

METHODS

In all, 152 patients with de novo PD (78 males and 74 females) who were followed up for >2 years were enrolled. The effect of baseline serum UA levels on LID-free survival was assessed by Cox regression, separately for sex, whilst being adjusted for potential confounding factors. The optimal UA level cut-off value to determine the high-risk group for LID was set using Contal and O'Quigley's method.

RESULTS

Levodopa-induced dyskinesia developed in 23 (29.5%) male patients and 30 (40.5%) female patients. Cox regression showed a significant interaction between UA level and sex. Higher UA levels were associated with a higher risk for LID in male PD patients (hazard ratio 1.380; 95% confidence interval 1.038-1.835; P = 0.027), although this relationship was not observed in female PD patients. The optimal UA level cut-off for LID in male PD was 7.2 mg/dl, and the high UA group had a 5.7-fold higher risk of developing LID than the low UA group.

CONCLUSIONS

Contrary to a presumptive beneficial role of UA, the present study demonstrated that higher UA levels are associated with increased risk of LID occurrence in male patients with PD, suggesting a sex-dependent role of UA in LID.

75Safety and efficacy of rivaroxaban in combination with anti-arrhythmic drugs in patients with non-permanent atrial fibrillation

Background

Rivaroxaban is useful for stroke prevention in atrial fibrillation (AF) patients. Most patients with non-permanent AF also treated with anti-arrhythmic drugs (AADs) to prevent the recurrence of arrhythmia. But there are limited data regarding drug-drug interactions between rivaroxaban and AADs despite its high clinical relevance.

Purpose

To compare the bleeding risks and ischemic events between the use of rivaroxaban alone and the concomitant use of AADs.

Methods

This is a multicenter retrospective study, which identified patients with a diagnosis of non-permanent AF who received rivaroxaban more than 1 month between December 1, 2011 and November 30, 2016. The study divided patients into 4 groups : rivaroxaban alone, combined with amiodarone, dronedarone and propafenone. We compared the clinical events and cumulative incidences to compare the endpoints including efficacy endpoint (new ischemic stroke, intracranial hemorrhage, or new

embolism), safety endpoints (Hb fall more than 2g/dL or transfusion more than 2U PRBC, critical site bleeding, or fatal bleeding.) and major adverse cardiovascular events (MACE), including cardiovascular death, myocardial infarction, new ischemic stroke, new embolism, or intracranial hemorrhage.

Results

Of 1777 enrolled patients, the rivaroxaban alone was 1205 cases, 177 in amiodarone group, 231 in dronedarone group and 164 in propafenone group. There was no statistically significant difference on efficacy endpoints, safety endpoints and MACE between the 4 groups. The average dosage of rivaroxaban was insignificantly the lowest in the group combined with dronedarone (12.3mg, p = 0.146). The rate of new embolism (0%, p = 0.029), recurrent heart failure admission rate (3.9%, p &lt; 0.001), and all-cause mortality (3.0%, p = 0.013) in dronedarone group showed a significant lower occurrence rate. The occurrence rate of new ischemic stroke (0.9%, p = 0.549), new hemorrhagic stroke (0.4%, p = 0.546), efficacy endpoints (1.7%, p = 0.369) and MACE (3.9%, p = 0.72) in dronedarone droup were the lowest but insignificant. The cumulative incidences of efficacy endpoints, safety endpoints and MACE during follow-up period were also similar in these four groups.(Picture 1)

Conclusions

In patients with non-permanent atrial fibrillation, this real-world study showed that there were no significant differences between using rivaroxaban alone or concomitant with an AAD (dronedarone/amiodarone/propafenone) on events such as new ischemic stroke, intracranial hemorrhage, GI bleeding and MACEs. The happening of new embolism was lower especially in the group combined with dronedarone. The safety and efficacy between rivaroxaban alone and combined with rhythm control using AADs proved to be the same.  Relative low dose rivaroxaban combined with dronedarone did not increase the bleeding risk, and may decrease the probability of thromboembolism.

Abstract Figure. Picture 1

P1064Using Data Mining to Predict Bleeding Events caused by Novel Oral Anticoagulants

Background

Novel oral anticoagulants (NOAC) is important in preventing thromboembolism in atrial fibrillation (AF) patients. Bleeding risk was evaluated by HAS-BLED score traditionally. Data mining is a relatively new discipline that has sprung up at the confluence of several other disciplines, driven primarily by the growth of large databases. 

Purpose

This study aimed to find a useful predictive model by data mining to assess the risk of rivaroxaban, an antithrombotic drug that causes bleeding in AF patients. The seven parameters of the HAS-BLED score were used to predict the effect of rivaroxaban on bleeding tendency in AF patients and may provide clinicians with appropriate treatments to avoid complications from bleeding events and reduce the incidence of health damage.

Methods

Through conducting a multicenter retrospective study, we identified patients with AF who were treated with rivaroxaban for more than 1 month between December 1, 2011 and November 30, 2016. After preprocessing, the established data were used for training and testing of data mining models. This study evaluated four models, including association rules, neural networks, Bayesian classification, and decision trees.

Result

Of the 872 enrolled cases, 432 were in any of the bleeding groups and 432 were in the non-bleeding randomized control group. After comparing the overall classification accuracy, omission error and over-prediction error, the decision tree proved to be the most accurate model for bleeding prediction. The overall classification accuracy is 77%, the omission error is 15%, the over-prediction error is 21.9%, and the AUC score is 0.84. The results show that the model has good discriminative ability and visibility of decision rules.

Conclusion

Among several data mining models, decision tree proved to be the most accurate model for bleeding prediction. The conclusion of this study can be used as a reference for supporting decision making before anticoagulation treatment and suggest future research to compare efficacy of bleeding prediction between HAS-BLED score and decision tree.

Data mining comparison Model Omission error Commission error Overall accuracy AUC score Ranking Decision tree 15.0% 21.90% 77.00% 0.84 1 Association rules 16.8% 27.20% 76.50% 0.81 2 Neural networks 12.0% 26.40% 78.20% 0.83 3 Bayesian classification 16.1% 27.50% 76.50% 0.83 4

Non-Alcoholic Fatty Liver Disease in Patients with Type 2 Diabetes Mellitus: A Position Statement of the Fatty Liver Research Group of the Korean Diabetes Association

This clinical practice position statement, a product of the Fatty Liver Research Group of the Korean Diabetes Association, proposes recommendations for the diagnosis, progression and/or severity assessment, management, and follow-up of non-alcoholic fatty liver disease (NAFLD) in patients with type 2 diabetes mellitus (T2DM). Patients with both T2DM and NAFLD have an increased risk of non-alcoholic steatohepatitis (NASH) and fibrosis and a higher risk of cardiovascular diseases and diabetic complications compared to those without NAFLD. With regards to the evaluation of patients with T2DM and NAFLD, ultrasonography-based stepwise approaches using noninvasive biomarker models such as fibrosis-4 or the NAFLD fibrosis score as well as imaging studies such as vibration-controlled transient elastography with controlled attenuation parameter or magnetic resonance imaging-proton density fat fraction are recommended. After the diagnosis of NAFLD, the stage of fibrosis needs to be assessed appropriately. For management, weight reduction achieved by lifestyle modification has proven beneficial and is recommended in combination with antidiabetic agent(s). Evidence that some antidiabetic agents improve NAFLD/NASH with fibrosis in patients with T2DM is emerging. However, there are currently no definite pharmacologic treatments for NAFLD in patients with T2DM. For specific cases, bariatric surgery may be an option if indicated.

Circulating interleukin-23 levels in ankylosing spondylitis and their correlation with disease activity : A meta-analysis

OBJECTIVE

To systematically investigate the relationship between circulating interleukin-23 (IL‑23) levels and ankylosing spondylitis (AS) and establish a correlation between these hematological indices and AS activity/severity.

METHODS

We searched the Medline, Embase, and Cochrane databases; performed a meta-analysis comparing serum/plasma IL‑23 levels in patients with AS to those of controls; and examined the correlation coefficients between serum/plasma IL‑23 levels and AS activity.

RESULTS

Ten studies including 1724 patients with AS and 1589 controls were included in this meta-analysis. This meta-analysis showed that circulating IL‑23 levels were significantly higher in the AS than in the control group (standardized mean difference [SMD] 1.479; 95% confidence interval [CI] 0.308-2.650; p = 0.013). Stratification by ethnicity showed a significantly increased IL‑23 level in the AS group in an Asian population (SMD 1.551; 95% CI 0.543-2.558; p = 0.003). Stratification by adjustment for age and sex revealed significantly higher IL‑23 levels in the AS adjustment group. Subgroup analysis of sample size showed a significantly higher IL‑23 level for a small (n < 150) sample number in the AS group. Meta-analysis of correlation coefficients revealed that the IL‑23 level was positively associated with the Bath Ankylosing Spondylitis Metrology Index (BASMI; correlation coefficient 0.464; 95% CI 0.027-0.752; p = 0.038), erythrocyte sedimentation rate (ESR; correlation coefficient 0.258; 95% CI 0.076-0.422; p = 0.006), and C‑reactive protein (CRP; correlation coefficient 0.291; 95% CI 0.053-0.498; p = 0.017).

CONCLUSION

This meta-analysis demonstrated that the circulating IL‑23 level is significantly higher in patients with AS, and a significant positive correlation exists between the circulating IL‑23 level and BASMI, ESR, and CRP.

Association between Non-Alcoholic Steatohepatitis and Left Ventricular Diastolic Dysfunction in Type 2 Diabetes Mellitus

BACKGROUND

Impaired diastolic heart function has been observed in persons with non-alcoholic fatty liver disease (NAFLD) and/or with type 2 diabetes mellitus (T2DM). However, it is unclear whether NAFLD fibrotic progression, i.e., non-alcoholic steatohepatitis, poses an independent risk for diastolic dysfunction in T2DM. We investigated the association between liver fibrosis and left ventricular (LV) diastolic dysfunction in T2DM.

METHODS

We analyzed 606 patients with T2DM, aged ≥50 years, who had undergone liver ultrasonography and pulsed-wave Doppler echocardiography. Insulin sensitivity was measured by short insulin tolerance test. Presence of NAFLD and/or advanced liver fibrosis was determined by abdominal ultrasonography and NAFLD fibrosis score (NFS). LV diastolic dysfunction was defined according to transmitral peak early to late ventricular filling (E/A) ratio and deceleration time, using echocardiography.

RESULTS

LV diastolic dysfunction was significantly more prevalent in the NAFLD versus non-NAFLD group (59.7% vs. 49.0%, P=0.011). When NAFLD was stratified by NFS, subjects with advanced liver fibrosis exhibited a higher prevalence of diastolic dysfunction (49.0%, 50.7%, 61.8%; none, simple steatosis, advanced fibrosis, respectively; P for trend=0.003). In multivariable logistic regression, liver fibrosis was independently associated with diastolic dysfunction (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.07 to 2.34; P=0.022) after adjusting for insulin resistance and cardiometabolic risk factors. This association remained significant in patients without insulin resistance (OR, 4.32; 95% CI, 1.73 to 11.51; P=0.002).

CONCLUSIONS

Liver fibrosis was associated with LV diastolic dysfunction in patients with T2DM and may be an independent risk factor for diastolic dysfunction, especially in patients without systemic insulin resistance.

Cognitive anosognosia is associated with frontal dysfunction and lower depression in Parkinson's disease

BACKGROUND AND PURPOSE

Anosognosia refers to a deficit of self-awareness or impaired insight for cognitive and behavioral problems. Cognitive anosognosia was explored in de novo patients with Parkinson's disease (PD) and its relationship to cognitive function and neuropsychiatric symptoms was investigated.

METHODS

The cross-sectional study enrolled 340 drug-naïve patients with PD. According to the presence of mild cognitive impairment (MCI) and subjective cognitive complaint, patients were classified as patients with cognitive anosognosia (PD-CA, n = 74), with normal cognitive recognition (PD-NR, n = 184) or with cognitive underestimation (PD-CU, n = 82). After controlling for covariates, cognitive performance and neuropsychiatric symptoms were compared between the PD groups.

RESULTS

Cognitive anosognosia was found in 21.8% of patients with de novo PD. The PD-CA group showed poorer performance in all cognitive domains except for attention. Amongst PD patients with MCI, those with cognitive anosognosia showed lower composite z-scores in the Stroop color reading test than those without. The Beck Depression Inventory score in the PD-NR group was lower than that in the PD-CU group and higher than that in the PD-CA group. The Cognitive Complaints Interview score mediated the association between cognitive anosognosia and Beck Depression Inventory score.

CONCLUSIONS

Cognitive anosognosia in PD was associated with greater frontal dysfunction and lower depression. Since cognitive anosognosia has a harmful impact on PD patients and their caregivers due to overestimation of their abilities in everyday life, early identification of cognitive anosognosia in PD is important in management and prognosis.

Anti-Inflammatory Effect for Atherosclerosis Progression by Sodium-Glucose Cotransporter 2 (SGLT-2) Inhibitor in a Normoglycemic Rabbit Model

Background and Objectives

We sought to investigate an anti-atherosclerotic and anti-inflammatory effect of sodium-glucose cotransporter-2 (SGLT-2) inhibitors in normoglycemic atherosclerotic rabbit model.

Methods

Male New Zealand white rabbits (n=26) were fed with a 1% high-cholesterol diet for 7 weeks followed by normal diet for 2 weeks. After balloon catheter injury, the rabbits were administered with the Dapagliflozin (1mg/kg/day) or control-medium for 8 weeks (n=13 for each group). All lesions were assessed with angiography, optical coherence tomography (OCT), and histological assessment.

Results

Atheroma burden (38.51±3.16% vs. 21.91±1.22%, p<0.01) and lipid accumulation (18.90±3.63% vs. 10.20±2.03%, p=0.047) was significantly decreased by SGLT-2 inhibitor treatment. The SGLT-2 inhibitor group showed lower macrophage infiltration (20.23±1.89% vs. 12.72±1.95%, p=0.01) as well as tumor necrosis factor (TNF)-α expression (31.17±4.40% vs. 19.47±2.10%, p=0.025). Relative area of inducible nitric oxide synthase⁺ macrophages was tended to be lower in the SGLT-2 inhibitor-treated group (1.00±0.16% vs. 0.71±0.10%, p=0.13), while relative proportion of Arg1⁺ macrophage was markedly increased (1.00±0.27% vs. 2.43±0.64%, p=0.04). As a result, progression of atherosclerosis was markedly attenuated in SGLT-2 inhibitor treated group (OCT area stenosis, 32.13±1.20% vs. 22.77±0.88%, p<0.01). Mechanistically, SGLT-2 treatment mitigated the inflammatory responses in macrophage. Especially, Toll-like receptor 4/nuclear factor-kappa B signaling pathway, and their downstream effectors such as interleukin-6 and TNF-α were markedly suppressed by SGLT-2 inhibitor treatment.

Conclusions

These results together suggest that SGLT-2 inhibitor exerts an anti-atherosclerotic effect through favorable modulation of inflammatory response as well as macrophage characteristics in non-diabetic situation.

Direct and Indirect Effects of Fibroblast Growth Factor (FGF) 15 and FGF19 on Liver Fibrosis Development

Farnesoid X receptor (FXR) induces fibroblast growth factor 15 (FGF15; human ortholog FGF19) in the gut to potently inhibit bile acid (BA) synthesis in the liver. FXR activation in hepatic stellate cells (HSCs) reduces liver fibrosis (LF). Fgf15^-/- mice develop attenuated LF, but the underlying mechanisms for this protection are unclear. We hypothesized that FGF15/19 functions as a profibrotic mediator or mitogen to HSCs and increased BAs in Fgf15^-/- mice leads to enhanced FXR activation in HSCs, subsequently reducing fibrogenesis. In this study, complimentary in vivo and in vitro approaches were used: (1) CCl₄ -induced LF model in wild type (WT), Fgf15^-/- , and Fgf15 transgenic (TG) mice with BA levels modulated by feeding cholestyramine- or cholic acid-containing diets; (2) analysis of primary HSCs isolated from WT and Fgf15^-/- mice; and (3) treatment of a human HSC line, LX-2, with FXR activators and/or recombinant FGF19 protein. The results showed that Fgf15^-/- mice had lower basal collagen expression, which was increased by BA sequestration. CCl₄ induced fibrosis with similar severity in all genotypes; however, cholestyramine increased fibrosis severity only in Fgf15^-/- mice. HSCs from Fgf15^-/- mice showed increased FXR activity and reduced expression of profibrotic mediators. In LX-2 cells, FXR activation increased peroxisome proliferator-activated receptor gamma activity and reduced proliferation. FGF19 activated both signal transducer and activator of transcription 3 and c-Jun N-terminal kinase pathways and reduced nuclear factor kappa-light-chain-enhancer of activated B cells signaling without increasing fibrogenic gene expression or cell proliferation. Conclusion: FGF15/19 does not act as a direct profibrotic mediator or mitogen to HSCs in our models, and the protection against fibrosis by FGF15 deficiency may be mediated through increased BA activation of FXR in HSCs.

Efficacy and Safety of Omega-3 Fatty Acids in Patients Treated with Statins for Residual Hypertriglyceridemia: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial

BACKGROUND

Cardiovascular risk remains increased despite optimal low density lipoprotein cholesterol (LDL-C) level induced by intensive statin therapy. Therefore, recent guidelines recommend non-high density lipoprotein cholesterol (non-HDL-C) as a secondary target for preventing cardiovascular events. The aim of this study was to assess the efficacy and tolerability of omega-3 fatty acids (OM3-FAs) in combination with atorvastatin compared to atorvastatin alone in patients with mixed dyslipidemia.

METHODS

This randomized, double-blind, placebo-controlled, parallel-group, and phase III multicenter study included adults with fasting triglyceride (TG) levels ≥200 and <500 mg/dL and LDL-C levels <110 mg/dL. Eligible subjects were randomized to ATOMEGA (OM3-FAs 4,000 mg plus atorvastatin calcium 20 mg) or atorvastatin 20 mg plus placebo groups. The primary efficacy endpoints were the percent changes in TG and non-HDL-C levels from baseline at the end of treatment.

RESULTS

After 8 weeks of treatment, the percent changes from baseline in TG (-29.8% vs. 3.6%, P<0.001) and non-HDL-C (-10.1% vs. 4.9%, P<0.001) levels were significantly greater in the ATOMEGA group (n=97) than in the atorvastatin group (n=103). Moreover, the proportion of total subjects reaching TG target of <200 mg/dL in the ATOMEGA group was significantly higher than that in the atorvastatin group (62.9% vs. 22.3%, P<0.001). The incidence of adverse events did not differ between the two groups.

CONCLUSION

The addition of OM3-FAs to atorvastatin improved TG and non-HDL-C levels to a significant extent compared to atorvastatin alone in subjects with residual hypertriglyceridemia.

Effects of hydrochlorothiazide on drainage volume and seroma formation in deep inferior epigastric perforator flap breast reconstruction: Randomized controlled trial

BACKGROUND

Seroma is a recognized complication encountered at the reconstructed breast and donor site after abdominal-based breast reconstruction. Seroma is caused by lymphatic channel disruption and the formation of a large space between the deep fascia during flap elevation. Surgical techniques to preserve the lymphatics and secure the closure of the donor site can reduce seroma formation. This study investigated the safety and effectiveness of the diuretic hydrochlorothiazide at reducing interstitial fluid accumulation and seroma formation during deep inferior epigastric perforator (DIEP) flap breast reconstruction.

METHODS

Sixty patients with breast cancer who underwent skin- or nipple-sparing mastectomy and DIEP flap reconstruction were enrolled between August 2016 and June 2017. The patients were randomly assigned to receive either 25 mg per day of hydrochlorothiazide from the second to the twentieth day after surgery (treatment) or no diuretic (control). The clinicopathological characteristics, drainage time, and drainage volume were statistically compared between the two groups.

RESULTS

The average total drainage volume at the donor site was 291 mL in the treatment group and 434 mL in the control group (p = 0.003). The differences in body mass index and flap weight between the two groups were not statistically significant (p = 0.879 and p = 0.963, respectively). No hypotension or electrolyte imbalance was noted during the follow-up.

CONCLUSIONS

Intake of 25 mg per day of hydrochlorothiazide tablets effectively reduced the total abdominal drainage volume and removal time of indwelling drains. However, the adverse effects should be further investigated in a large population and multiracial cohort before using hydrochlorothiazide for seroma prevention.

Associations between paraoxonase-1 and systemic lupus erythematosus

Objective

The objective of this analysis was to explore associations between paraoxonase-1 levels, gene polymorphisms and systemic lupus erythematosus.

Methods

Meta-analyses of paraoxonase-1 levels and Q192R and L55M and polymorphisms in systemic lupus erythematosus were conducted.

Results

Nine articles were incorporated in our meta-analysis, which uncovered that the paraoxonase-1 level was decreased in systemic lupus erythematosus compared to control (standard mean difference = −1.626, 95% confidence interval = −2.829–−0.424, p = 0.008). Ethnicity-specific meta-analysis demonstrated a relation tendency between decreased paraoxonase-1 activity and lupus in Europeans (standard mean difference = −1.236, 95% confidence interval = −2.634–0.163, p = 0.083). Paraoxonase-1 activity was reduced in systemic lupus erythematosus in a single Arab and African population. Decreased paraoxonase-1 activity was found in a small sample of systemic lupus erythematosus patients (standard mean difference = −1.642, 95% confidence interval = −3.076–−0.247, p = 0.021). Ethnicity-specific analysis indicated a relationship between the paraoxonase-1 55 M allele in the Arab systemic lupus erythematosus population. However, a lack of association with systemic lupus erythematosus and the paraoxonase-1 192 R allele was observed.

Conclusions

Meta-analyses revealed reduced paraoxonase-1 activity in patients with systemic lupus erythematosus and found possible associations between systemic lupus erythematosus and paraoxonase-1 L55M polymorphism in a specific ethnic group.

Effects of Alzheimer's disease and Lewy body disease on subcortical atrophy

BACKGROUND AND PURPOSE

Subcortical structures are affected by neurodegeneration in Alzheimer's disease (AD) and Lewy body disease (LBD). Although the co-occurrence of AD and LBD pathologies and their possible interaction have been reported, the effect of AD and LBD on subcortical structures remains unknown. The effects of AD and LBD on subcortical atrophy and their relationship with cognitive dysfunction were investigated.

METHODS

The cross-sectional study recruited 42 patients with pure AD related cognitive impairment (ADCI), 30 patients with pure LBD related cognitive impairment (LBCI), 58 patients with mixed ADCI and LBCI, and 29 normal subjects. A general linear model was used to compare subcortical volume and shape amongst the groups, to investigate the independent and interaction effects of ADCI and LBCI on subcortical shape and volume, and to analyze the relationship between subcortical volume and cognitive dysfunction in each group.

RESULTS

Alzheimer's disease related cognitive impairment and LBCI were independently associated with subcortical atrophies in the hippocampus and amygdala and in the hippocampus and putamen respectively, but their interaction effect was not significant. Compared to the control group, the pure LBCI group exhibited additional local atrophies in the amygdala, caudate and thalamus. Subcortical atrophies correlated differently with cognitive dysfunction according to the underlying causes of cognitive dysfunction.

CONCLUSIONS

The patterns of subcortical atrophies and their correlation with cognitive dysfunction differ according to the underlying AD, LBD or concomitant AD and LBD.