Comparison of the success rate of tracheal intubation between stylet and bougie with a hyperangulated videolaryngoscope: a randomised controlled trial

Hyperangulated videolaryngoscopes are known to increase the success rate of tracheal intubation in the setting of difficult airway management when used with a stylet or bougie. However, there is controversy over which adjunct is more useful. This randomised study aimed to compare first attempt tracheal intubation success rate between a stylet and bougie when using a hyperangulated videolaryngoscope. We recruited patients aged > 20 years who were scheduled for elective surgery under general anaesthesia and required tracheal intubation. We only included patients with factors predicting difficult tracheal intubation based on pre-anaesthesia airway evaluation. Tracheal intubation was attempted using a Glidescope® with either a stylet or bougie as an adjunct according to group assignment. Primary outcome was the success rate of the first tracheal intubation attempt, and secondary outcomes were success of second and third attempts; tracheal intubation time; and occurrence of sore throat, dysphagia or hoarseness. A total of 166 patients were included. The success rate of the first tracheal intubation attempt was significantly higher in patients allocated to the bougie group compared with those allocated to the stylet group (81/83 (98%) vs. 73/83 (88%), respectively; p = 0.032). The number of patients who needed two attempts was significantly lower in those allocated to the bougie group compared with those allocated to the stylet group (1/83 (1%) vs. 9/83 (11%), respectively; p = 0.018). Each group had one patient (1%) where tracheal intubation was achieved after a third attempt. There was no significant difference in the occurrence of sore throat, dysphagia and hoarseness between the two groups. When difficult tracheal intubation is anticipated and a hyperangulated videolaryngoscope is used, the success rate of the first attempt is higher when a bougie is used compared with a stylet.

Anti-4-1BB×PD-L1 Bispecific Antibody Reinvigorates Tumor-Specific Exhausted CD8+ T Cells and Enhances the Efficacy of Anti-PD-1 Blockade

PURPOSE

To overcome the limited efficacy of immune checkpoint blockade, there is a need to find novel cancer immunotherapeutic strategies for the optimal treatment of cancer. The novel anti-4-1BB×PD-L1 bispecific antibody-ABL503 (also known as TJ-L14B)-was designed to simultaneously target PD-L1 and 4-1BB, and demonstrated strong antitumor T-cell responses without considerable toxicity. Here, we investigated how the combination of ABL503 and anti-PD-1 blockade affected the reinvigoration of exhausted tumor-infiltrating CD8+ T cells (CD8+ TILs) and anti-tumor efficacy.

EXPERIMENTAL DESIGN

Single cell suspensions of hepatocellular carcinoma and ovarian cancer from treatment-naive patients were used for immunophenotyping of CD8+ TILs and in vitro functional assays. Humanized hPD-1/hPD-L1/h4-1BB triple knock-in mice were used to evaluate the effects of ABL503 and anti-PD-1 blockade in vivo.

RESULTS

We observed that ABL503 successfully restored the functions of 4-1BB+ exhausted CD8+ TILs, which were enriched for tumor-specific T cells but unresponsive to anti-PD-1 blockade. Importantly, compared to anti-PD-1 blockade alone, the combination of ABL503 and anti-PD-1 blockade further enhanced the functional restoration of human CD8+ TILs in vitro. Consistently, the combination of ABL503 with anti-PD-1 in vivo significantly alleviated tumor growth, and induced enhanced infiltration and activation of CD8+ TILs.

CONCLUSIONS

ABL503-a PD-L1 and 4-1BB dual-targeting bispecific antibody-elicits pronounced additive tumor growth inhibition, with increased infiltration and functionality of exhausted CD8+ T cells, which in turn enhances the anti-cancer effects of anti-PD-1 blockade. These promising findings suggest that ABL503 (TJ-L14B) in combination with PD-1 inhibitors will likely further enhance therapeutic benefit in clinical trials.

Geographic information system-based determination of priority monitoring areas for hazardous air pollutants in an industrial city

Industrial cities are hotspots for many hazardous air pollutants (HAPs), which are detrimental to human health. We devised an identification method to determine priority HAP monitoring areas using a comprehensive approach involving monitoring, modeling, and demographics. The methodology to identify the priority HAP monitoring area consists of two parts: (1) mapping the spatial distribution of selected categories relevant to the target pollutant and (2) integrating the distribution maps of various categories and subsequent scoring. The identification method was applied in Ulsan, the largest industrial city in South Korea, to identify priority HAP monitoring areas. Four categories related to HAPs were used in the method: (1) concentrations of HAPs, (2) amount of HAP emissions, (3) the contribution of industrial activities, and (4) population density in the city. This method can be used to select priority HAP monitoring areas for intensive monitoring campaigns, cohort studies, and epidemiological studies.

CRISPR-Cas9 and beyond: identifying target genes for developing disease-resistant plants

Throughout the history of crop domestication, desirable traits have been selected in agricultural products. However, such selection often leads to crops and vegetables with weaker vitality and viability than their wild ancestors when exposed to adverse environmental conditions. Considering the increasing human population and climate change challenges, it is crucial to enhance crop quality and quantity. Accordingly, the identification and utilization of diverse genetic resources are imperative for developing disease-resistant plants that can withstand unexpected epidemics of plant diseases. In this review, we provide a brief overview of recent progress in genome-editing technologies, including zinc-finger nucleases (ZFNs), transcription activator-like effector nucleases (TALENs), and clustered regularly interspaced short palindromic repeats (CRISPR)-associated protein 9 (Cas9) technologies. In particular, we classify disease-resistant mutants of Arabidopsis thaliana and several crop plants based on the roles or functions of the mutated genes in plant immunity and suggest potential target genes for molecular breeding of genome-edited disease-resistant plants. Genome-editing technologies are resilient tools for sustainable development and promising solutions for coping with climate change and population increases.

Assisted reproductive techniques and subsequent risk of asthma and allergic rhinitis in offspring: a nationwide birth cohort study in South Korea

OBJECTIVE

The relationship between assisted reproductive techniques (ART) and the risk of asthma and allergic rhinitis (AR) is controversial. Thus, we aimed to investigate the relationship between ART and the risk of asthma and AR in a nationwide, large-scale birth cohort.

PATIENTS AND METHODS

This study utilized the National Health Insurance Service data in South Korea to conduct a nationwide, large-scale, population-based birth cohort. We included all infants born between 2017 and 2018. AR, asthma, food allergies, and atopic dermatitis were defined using the International Classification of Diseases tenth edition codes. Asthma was classified as allergic or non-allergic based on accompanying allergic diseases (AR, food allergy, or atopic dermatitis). Using 1:10 propensity score matching, we compared infants conceived through ART with those conceived naturally (non-ART). After matching, logistic regression was used to compare the hazard ratio for asthma and AR between the two groups.

RESULTS

We included 543,178 infants [male infants, 280,194 (51.38%)]. After matching, 8,925 and 74,229 infants were selected for the ART and non-ART groups, respectively. The ART group showed a decreased risk of asthma in the offspring [adjusted hazard ratio (aHR), 0.45; 95% confidence interval (CI), 0.41-0.48]. Similarly, for AR, being conceived by ART was associated with a decreased risk of AR (aHR, 0.25; 95% CI, 0.12-0.37). ART offspring showed a decreased risk of asthma and AR in offspring compared to that observed in non-ART offspring.

CONCLUSIONS

Our study offers important insights for clinicians, researchers, and parents regarding the health outcomes of ART-conceived infants and enhances our understanding of ART's impact on respiratory health.

Angiotensin Receptor Blockers and the Risk of Suspected Drug-Induced Liver Injury: A Retrospective Cohort Study Using Electronic Health Record-Based Common Data Model in South Korea

INTRODUCTION

Angiotensin receptor blockers are widely used antihypertensive drugs in South Korea. In 2021, the Korea Ministry of Food and Drug Safety acknowledged the need for national compensation for a drug-induced liver injury (DILI) after azilsartan use. However, little is known regarding the association between angiotensin receptor blockers and DILI.

OBJECTIVE

We conducted a retrospective cohort study in incident users of angiotensin receptor blockers from a common data model database (1 January, 2017-31 December, 2021) to compare the risk of DILI among specific angiotensin receptor blockers against valsartan.

METHODS

Patients were assigned to treatment groups at cohort entry based on prescribed angiotensin receptor blockers. Drug-induced liver injury was operationally defined using the International DILI Expert Working Group criteria. Cox regression analyses were conducted to derive hazard ratios and the inverse probability of treatment weighting method was applied. All analyses were performed using R.

RESULTS

In total, 229,881 angiotensin receptor blocker users from 20 university hospitals were included. Crude DILI incidence ranged from 15.6 to 82.8 per 1000 person-years in treatment groups, most were cholestatic and of mild severity. Overall, the risk of DILI was significantly lower in olmesartan users than in valsartan users (hazard ratio: 0.73 [95% confidence interval 0.55-0.96]). In monotherapy patients, the risk was significantly higher in azilsartan users than in valsartan users (hazard ratio: 6.55 [95% confidence interval 5.28-8.12]).

CONCLUSIONS

We found a significantly higher risk of suspected DILI in patients receiving azilsartan monotherapy compared with valsartan monotherapy. Our findings emphasize the utility of real-world evidence in advancing our understanding of adverse drug reactions in clinical practice.

The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

High-level production and purification of bioactive recombinant human activin A in Chinese hamster ovary cells

Activin A, a member of the TGF-β superfamily, is a homodimer of the inhibin βΑ subunit that plays a diversity of roles in biological processes. Because of its multiple functions, significant efforts have been made to produce activin A, however, unsatisfactory results were obtained due to its low level of expression. In this study, a stable CHO cell line exhibiting high expression of rhActivin A was isolated and production of rhActivin A was achieved using the cell line from 11-day fed-batch cultures in a 7.5 L bioreactor. The production rate was 0.22 g/L, substantially higher than those reported in previous studies. The culture supernatant of the bioreactor was used to purify rhActivin A (purity: >99%, recovery rate: 47%). The purified rhActivin A exhibited biological activity, with an EC50 of 3.893 ng/mL and a specific activity of 1.38 × 103 IU/mg. The control of process-related impurities in the purified rhActivin A was successful and met the USP recommendations for use in cell therapy. Thus, our production and purification methods were appropriate for large-scale GMP-grade rhActivin A production, which can be used for various purposes including cell therapy.

Association of Balance Impairment with Risk of Incident Dementia among Older Adults

BACKGROUND

A growing body of data suggests that balance impairment may be linked to the onset of dementia.

OBJECTIVES

However, a large-scale epidemiologic investigation is needed to clarify its association in older adults.

DESIGN

A retrospective-prospective hybrid database.

SETTING

Cox proportional hazards regression model was used to assess the relationship between balance impairment and the risk of incident dementia, and the results were provided as adjusted hazard ratios (aHR) with 95% confidence intervals (CI). All participants were tracked until the date of incident dementia, death, or 31 December 2019 whichever came first.

PARTICIPANTS

We analyzed 143,788 older adults who had at least one health screening between 2009 and 2019 from the Korea National Health Insurance Service-Senior Cohort.

MEASUREMENTS

A total of 3,774 cases of dementia were discovered throughout 850,425 person-years of follow-up investigation. Balance impairment was associated with a risk of dementia compared to those without balance impairment (adjusted hazard ratio [aHR] 1.83; 95% CI, 1.69-2.00; P value <0.001).

RESULTS

Risks of the Alzheimer's disease (aHR, 1.80; 95% CI, 1.65-1.96; P for trend <0.001) and the vascular dementia (aHR, 2.94; 95% CI, 1.89-4.58; P for trend <0.001) showed comparable trends and findings.

CONCLUSIONS

Balance impairment was found to be independently associated with an increased risk of dementia in older adults.

Effects of vitamin E and selenium administration on transportation stress in pregnant dairy heifers

We investigated the effects of road transportation and administration of the vitamin E and selenium (ESe) on circulating cortisol, haptoglobin, blood metabolites, oxidative biomarkers, white blood cell profiles, and behaviors in pregnant dairy heifers. Forty pregnant Holstein heifers were randomly assigned to one of 4 treatments: no transportation and no ESe administration, no transportation and ESe administration, transportation and no administration, and transportation and ESe administration. The ESe (70 IU/kg dry matter feed of dl-α-tocopheryl acetate and 0.3 mg/kg dry matter feed of sodium selenite) was orally delivered once a day from 7 d before transportation to 3 d after transportation. The heifers were transported in trucks designed for cattle transportation. Blood was collected 1 h before transportation, immediately after transportation (IAT), and at 6, 24, and 48 h after transportation. Behaviors were recorded using a video camera for 2 consecutive days after transportation. Transported/non-ESe-administered heifers had greater cortisol at IAT, haptoglobin at 6 and 24 h after transportation, total oxidative status at 6 h after transportation, and nonesterified fatty acid levels, white blood cell numbers, and neutrophil percentages at IAT and 6 h after transportation in the blood than nontransported heifers. Transported/non-ESe-administered heifers had lower total antioxidative status levels at 48 h after transportation and lymphocyte percentages at IAT and 6 h after transportation than nontransported heifers. Lying time was shorter in transported heifers than nontransported/non-ESe-administered heifers. Transported/ESe-administered heifers had lower cortisol, total oxidative status, nonesterified fatty acid levels at IAT, and haptoglobin concentrations at 6 and 24 h after transportation than transported/non-ESe-administered heifers. Transported/ESe-administered heifers had greater total antioxidative status levels at 48 h after transportation than transported/non-ESe-administered heifers. No ESe administration effects were observed for white blood cell number and neutrophil and lymphocyte percentages and lying time. In conclusion, road transportation caused temporary oxidative stress. Administrating ESe partially alleviated the stress, suggesting that ESe administration could be a viable strategy to reduce stress in transported pregnant heifers, providing a novel role of vitamin E and selenium for improving animal welfare.

National trends in the prevalence of hepatitis B and C in South Korea, before and during the COVID-19 pandemic (2007-2021) - a nationwide representative study

OBJECTIVE

Due to the various changes caused by the COVID-19 pandemic, some infectious diseases showed different epidemiology and prevalence during the pandemic. However, there is a lack of comprehensive studies on trends in the prevalence of hepatitis B and C related to the pandemic. Thus, we compared the prevalence of hepatitis B and C before and during the COVID-19 pandemic in South Korea.

SUBJECTS AND METHODS

We conducted a comprehensive trend analysis with a nationwide serial cross-sectional survey from 2007 to 2021 (n=86,931) using the Korea National Health and Nutrition Examination Survey (KNHANES). The changes in the prevalence of hepatitis B and C were evaluated using a weighted regression model to assess the impact of the COVID-19 pandemic.

RESULTS

From 2007 to 2021, 86,931 Korean adults aged 19 or older were included in the KNHANES data. The prevalence of hepatitis B showed a declining trend until the onset of the pandemic (1.80% in 2007-2009; 1.08% in 2016-2019; and 1.01% in 2020), at which point this trend reversed (1.39% in 2021). The prevalence of hepatitis C remained stable (0.14% in 2007-2009 and 0.18% in 2016-2019), with no particular surge related to the COVID-19 pandemic (βdiff, -0.002; 95% CI, -0.761 to 0.756). For hepatitis B, old age was identified as a pandemic-related vulnerable factor (ratio of odds ratio, 1.68; 95% CI, 1.05-2.70).

CONCLUSIONS

In this study, unlike other infectious diseases, hepatitis B and C did not show a decreasing trend during the pandemic. In particular, hepatitis B showed a rebound trend during the pandemic, which was noticeable in those aged 60 or older. Further studies are needed to support these findings.

Search for Boosted Dark Matter in COSINE-100

We search for energetic electron recoil signals induced by boosted dark matter (BDM) from the galactic center using the COSINE-100 array of NaI(Tl) crystal detectors at the Yangyang Underground Laboratory. The signal would be an excess of events with energies above 4 MeV over the well-understood background. Because no excess of events are observed in a 97.7  kg·yr exposure, we set limits on BDM interactions under a variety of hypotheses. Notably, we explored the dark photon parameter space, leading to competitive limits compared to direct dark photon search experiments, particularly for dark photon masses below 4 MeV and considering the invisible decay mode. Furthermore, by comparing our results with a previous BDM search conducted by the Super-Kamionkande experiment, we found that the COSINE-100 detector has advantages in searching for low-mass dark matter. This analysis demonstrates the potential of the COSINE-100 detector to search for MeV electron recoil signals produced by the dark sector particle interactions.

A Low-Voltage, High-Force Capacity Electroadhesive Clutch Based on Ionoelastomer Heterojunctions

Electroadhesive devices with dielectric films can electrically program changes in stiffness and adhesion, but require hundreds of volts and are subject to failure by dielectric breakdown. Recent work on ionoelastomer heterojunctions has enabled reversible electroadhesion with low voltages, but these materials exhibit limited force capacities and high detachment forces. It is a grand challenge to engineer electroadhesives with large force capacities and programmable detachment at low voltages (<10 V). In this work, tough ionoelastomer/metal mesh composites with low surface energies are synthesized and surface roughness is controlled to realize sub-ten-volt clutches that are small, strong, and easily detachable. Models based on fracture and contact mechanics explain how clutch compliance and surface texture affect force capacity and contact area, which is validated over different geometries and voltages. These ionoelastomer clutches outperform the best existing electroadhesive clutches by fivefold in force capacity per unit area (102 N cm-2 ), with a 40-fold reduction in operating voltage (± 7.5 V). Finally, the ability of the ionoelastomer clutches to resist bending moments in a finger wearable and as a reversible adhesive in an adjustable phone mount is demonstrated.

Robotic abdominoperineal resection for T4b rectal cancer using the da Vinci SP platform

PURPOSE

The aim of the present report wasto describe a novel technique of robotic abdominoperineal resection (APR) for the treatment of T4b low rectal cancer using the da Vinci® Single-Port (SP) system (Intuitive Surgical, Sunnyvale, CA, USA).

METHODS

A 3-cm transverse incision was made in the left lower quadrant of the abdomen, in the area designated for permanent colostomy. A Uniport® (Dalim Medical, Seoul, Korea) was introduced and a 25 mm multichannel SP trocar was inserted into the Uniport. A 5-mm laparoscopic assistant port was introduced on the upper midline. A video showing each step of the technique is attached.

RESULTS

Two consecutive female patients (70 and 74 years old) underwent SP robotic APR with partial resection of the vagina 8 weeks after preoperative chemoradiotherapy. In both cases, rectal cancer was located 1 cm above the anal verge and invaded the vagina (initial stage and ymrT stage T4b). Operative time was 150 and 180 min, respectively. Estimated blood loss was 10 and 25 ml, respectively. No postoperative complications occurred. The length of postoperative hospital stay was 5 days in both cases. The final pathological stage was ypT4bN0 and ypT3N0 respectively.

CONCLUSIONS

In this first experience, SP robotic APR appears to be a safe and feasible procedure for locally advanced low rectal cancer. In addition, the invasiveness of the procedure is reduced by means of the SP system, which only requires a single incision in the area designated for colostomy. Prospective studies on a larger number of patients are necessary to confirm the outcomes of this technique compared to other minimally invasive approaches.

Lymphatic muscle cells are the innate pacemaker cells regulating mouse lymphatic collecting vessel contractions

Collecting lymphatic vessels (cLVs) exhibit spontaneous contractions with a pressure-dependent frequency, but the identity of the lymphatic pacemaker cell is still debated. By analogy to pacemakers in the GI and lower urinary tracts, proposed cLV pacemaker cells include interstitial cells of Cajal like cells (ICLC), pericytes, as well as the lymphatic muscle (LMCs) cells themselves. Here we tested the extent to which these cell types are invested into the mouse cLV wall and if any cell type exhibited morphological and functional processes characteristic of pacemaker cells: a contiguous network; spontaneous Ca2+ transients; and depolarization-induced propagated contractions. We employed inducible Cre (iCre) mouse models routinely used to target these specific cell populations including: c-kitCreERT2 to target ICLC; PdgfrβCreERT2 to target pericytes; PdgfrαCreER™ to target CD34+ adventitial fibroblast-like cells or ICLC; and Myh11CreERT2 to target LMCs. These specific inducible Cre lines were crossed to the fluorescent reporter ROSA26mT/mG, the genetically encoded Ca2+ sensor GCaMP6f, and the light-activated cation channel rhodopsin2 (ChR2). c-KitCreERT2 labeled both a sparse population of LECs and round adventitial cells that responded to the mast cell activator compound 48-80. PdgfrβCreERT2 drove recombination in both adventitial cells and LMCs, limiting its power to discriminate a pericyte specific population. PdgfrαCreER™ labeled a large population of interconnected, oak leaf-shaped cells primarily along the adventitial surface of the vessel. Titrated induction of the smooth muscle-specific Myh11CreERT2 revealed a LMC population with heterogeneous morphology. Only LMCs consistently, but heterogeneously, displayed spontaneous Ca2+ events during the diastolic period of the contraction cycle, and whose frequency was modulated in a pressure-dependent manner. Optogenetic depolarization through the expression of ChR2 by Myh11CreERT2, but not PdgfrαCreER™ or c-KitCreERT2, resulted in a propagated contraction. These findings support the conclusion that LMCs, or a subset of LMCs, are responsible for mouse cLV pacemaking.

Definitive Radiotherapy in Patients with Clinical T1N0M0 Esophageal Squamous Cell Carcinoma: A Multicenter Retrospective Study

PURPOSE/OBJECTIVE(S)

In this study, we aimed to assess the failure pattern and survival outcomes and to analyze the optimal treatment field of definitive RT for T1N0M0 esophageal squamous cell carcinoma (ESCC).

MATERIALS/METHODS

We performed a retrospective analysis in a multi-institutional cohort of patients with histologically confirmed T1N0M0 ESCC. We included patients who underwent RT with definitive aim from 2010 to 2019. Patterns of failure were demonstrated as in-field locoregional, out-field locoregional and distant metastasis. In the survival analysis, freedom from locoregional recurrence and their association with clinicopathologic risk factors were analyzed. We performed a propensity score matching in the cT1b patients to adjust for the heterogeneity of radiation technique, radiation dose and the use of concurrent chemotherapy.

RESULTS

A total of 168 patients were included with a median follow-up of 34.0 months, and there were 20 cT1a, 94 cT1b and 24 cT1x, (cT1, not otherwise specified) patients. The rates of all and locoregional failure were 26.9% and 23.1% for cT1a and 25.0% and 22.4% for cT1b patients. 10 (10.6%) patients experienced grade ≥ 3 adverse events. Among 116 cT1b patients, 69 patients received elective nodal irradiation (ENI) and 47 patients received involved field irradiation (IFI). After propensity score matching, the 3-year FFLRR rate was 84.5% (95% Confidence Interval, 71.0 - 92.1%). There was no significant difference between the ENI and IFI patients in FFLRR (Log-rank P = 0.831). In the multivariate analysis, the use of concurrent chemotherapy was the only factor marginally associated with FFLRR (Hazard ratio, 0.17; 95% CI, 0.02 - 1.13; P = 0.067).

CONCLUSION

cT1a patients who cannot receive endoscopic resection, showed similar rates of failure compared with cT1b patients, which questioned the accuracy of the staging and raised the need for through treatment such as chemoradiotherapy. In cT1b patients, IFI using dose of 50 to 60 Gy with concurrent chemotherapy could be a reasonable treatment option.

Treatment Outcomes of Stereotactic Body Radiation Therapy for Pulmonary Metastasis from Sarcoma: A Multicenter, Retrospective Study

PURPOSE/OBJECTIVE(S)

The aim of this study was to evaluate the treatment outcomes and potential dose-response relationship of stereotactic body radiation therapy (SBRT) for pulmonary metastasis of sarcoma.

MATERIALS/METHODS

A retrospective review of 39 patients and 71 lesions treated with SBRT from two institutions was performed. The patients had oligometastatic or oligoprogressive disease, or were receiving palliation. Doses of 20-60 Gy were delivered in 1-5 fractions. The local control per tumor (LCpT) was evaluated according to the biologically effective dose with an α/β ratio of 10 (BED10) of the prescribed dose (BED10 ≥ 100 Gy vs. BED10 < 100 Gy). Clinical outcomes per patient, including local control per patient (LCpP), pulmonary progression-free rate (PPFR), any progression-free rate (APFR), and overall survival (OS) were investigated.

RESULTS

The median follow-up period was 27.2 months. The 1-, 2-, and 3-year LCpT rates for the entire cohort were 100.0%, 88.3%, and 73.6%, respectively. There was no observed difference in LCpT between the two BED10 groups (p = 0.180). The 3-year LCpP, PPFR, APFR, and OS rates were 78.1%, 22.7%, 12.9%, and 83.7%, respectively. Five (12.8%) patients with oligometastasis had long-term disease-free intervals, with a median survival period of 40.7 months. Factors that were associated with a worse prognosis were oligoprogression (vs. oligometastasis), multiple pulmonary metastases, and simultaneous extrathoracic metastasis.

CONCLUSION

SBRT for pulmonary metastasis of sarcoma is effective. Some selected patients may achieve durable response. Considerations of SBRT indication and disease extent may be needed as they may influence the prognosis.

The Early and Late Effects of High-Dose Irradiation on Cardiac Injury in a Rat Model

PURPOSE/OBJECTIVE(S)

Radiation-induced heart disease is a critical concern after radiotherapy (RT) for thoracic and chest wall tumors; however, the biological effects and mechanisms are still unknown. In this study, we investigated dose-responsive functional and pathological changes in rat hearts at 1, 3, and 5 months after high-dose irradiation. Then, we sought to elucidate the underlying mechanisms of myocardial changes induced by high-dose irradiation.

MATERIALS/METHODS

Whole hearts of rats (N = 72) were irradiated with a single fraction of 0 (control), 10, 20, or 30 Gy and allocated into three groups according to the follow-up period after RT: baseline, one, three, and five months. During follow-up periods, rats underwent functional evaluation by electrocardiogram and echocardiography at 4-week intervals. If a rat's body weight decreased by 20% or more, it was considered premature death, and the heart was explanted immediately. Otherwise, all hearts were explanted when each group's follow-up period was completed. Pathological changes of cardiac structures were evaluated using a light microscope after staining with hematoxylin-eosin, Masson's trichrome, α-smooth muscle actin, desmin, and connexin-43.

RESULTS

All rats irradiated with 0 or 10 Gy completed their follow-up periods with continuously increasing body weight. However, among rats irradiated with 20 or 30 Gy, half of the rats died prematurely at 8-10 weeks after RT, and the remainder survived until 20 weeks. In echocardiography, increased wall thickness and E/E' ratio, and decreased end-diastolic volume were observed in 20-30 Gy groups compared to 0-10 Gy groups from 8 weeks after RT. Ejection fraction was preserved in all groups. In pathological review, 20-30 Gy groups demonstrated diffuse inflammation and vacuolization at 4 weeks. Then, at 8 weeks, prominent fibrotic changes and intercalated disc disruptions were observed. Notably, fibrotic changes were somewhat resolved at 20 weeks, but intercalated disc disruptions were not repaired until 20 weeks. The 0 and 10 Gy groups showed no significant changes in both functional and pathological analyses.

CONCLUSION

Rats irradiated with 20 or 30 Gy showed diastolic dysfunction in functional analysis and time-dependent myocardial changes in pathological analysis. Radiation-induced fibrosis might be a "reactive" fibrosis, which could proceed to either a profibrotic course (progressive fibrosis) or an anti-fibrotic course (recovery phase). Further studies are needed to identify whether high-dose irradiation-induced cardiac fibrosis could be reversible.

Particulate matter concentration effects on attention to environmental issues: a cross-sectional study among residents in Korea's Pohang Industrial Complex

Background

With modernization, air pollution has become increasingly serious, and its effects on health have been revealed. As a result, public interest in environmental pollution has become critical for regulating air pollution. In our study, we aim to evaluate the impact of air pollution levels on public attention to environmental issues and examine whether awareness of the residential environment's impact on health acts as a mediator in this relationship.

Methods

We conducted an analysis on 400 individuals surveyed in the preliminary feasibility study on adverse health effects in the Pohang Industrial Complex, to examine the relationship between particulate matter 2.5 (PM2.5) and attention to environmental issues. Logistic regression analysis was performed, and mediation analysis was used to determine whether awareness of the residential environment's impact on health mediated the relationship.

Results

The logistic regression analysis results showed that PM2.5 levels were associated with attention to environmental issues (adjusted odds ratio [AOR]: 2.1; 95% confidence interval [CI]: 1.3-3.5; p = 0.003) and awareness of health impacts (AOR: 3.4; 95% CI: 1.6-7.1; p = 0.001). The PM2.5 levels showed 9.9% (95% CI: 5.4-14.0) increase in the prevalence of high attention to environmental issues, of which, only 1.0% (95% CI: 0.2-2.3) were mediated by health impact awareness. In the overall analysis, 10% of the total effect of PM2.5 on attention to environmental issues was mediated by health impact awareness.

Conclusions

According to this study's results, there was a correlation between air pollution levels and attention to environmental issues. Awareness of the health impacts of air pollution partially mediated the effect of air pollution levels on attention to environmental issues. In future studies, it is recommended to identify other mediators to further understand this structure.

Associations of chronotype and insomnia with menstrual problems in newly employed nurses at university hospitals in the Republic of Korea

Background

Dysmenorrhea and menstrual cycle changes occur in women working shifts. Circadian rhythm disruption and sleep disturbances associated with shift work leads to health problems. We identified chronotypes and the occurrence of insomnia among newly employed university hospital nurses and investigated the association of these factors with menstrual problems.

Methods

We conducted pre-placement health examinations for shift workers using self-reported questionnaires between 2018 and 2020. A total of 463 nurses were included in the study. Sociodemographic data, shift work experience, and information on insomnia were collected from health examination data. In addition, details regarding chronotype, dysmenorrhea, irregular and abnormal menstrual cycles, amenorrhea, and contraceptive use were obtained from the questionnaire. Multiple logistic regression analysis was performed to study the association between chronotype, insomnia, and menstrual problems after controlling for age, body mass index, contraceptive use, amenorrhea, and prior shift work.

Results

The prevalence rates of dysmenorrhea, irregular menstrual cycles, and longer menstrual cycles were 23.8%, 14.9%, and 4.1%, respectively. The risk of dysmenorrhea increased in the evening-type (odds ratio [OR]: 3.209; 95% confidence interval [CI]: 1.685-6.113) and those with insomnia (OR: 1.871; 95% CI: 1.074-3.261). Additionally, the risk of an irregular menstrual cycle (OR: 2.698; 95% CI: 1.167-6.237) increased in the evening-type, and the risk of a longer menstrual cycle (OR: 4.008; 95% CI: 1.354-11.864) increased in individuals with insomnia.

Conclusions

Our findings suggest that dysmenorrhea is promoted in the evening-type and insomnia individuals. There may be an increased risk of irregular menstrual cycles among evening-type nurses and an increased risk of longer menstrual cycles among those with insomnia. Therefore, factors such as evening-type and insomnia should be considered for the prevention of menstrual problems in women performing shift work.

The impacts of working time flexibilization on occupational safety and health: an expert survey

The policy proposal by the current Korean government that proposes flexible overtime rules is causing social controversy. This study has explored the 612 experts' opinions on the occupational safety and health impacts of the policy using an online self-report survey. They expected short-term overwork (87.25%), overwork inequality (86.44%), irregular working hours (84.31%), chronic overwork (84.15%), long working hours (83.66%), and unpredictability of working hours (81.86%) as a result of the policy change. They also responded that the policy change would increase industrial accident deaths (87.25%), mental illnesses (87.09%), deaths due to overwork or cardiovascular diseases (83.84%), and accidents (83.33%). They disagreed that the government's flexibilization policy, while agreeing that the necessity of policies on regulating night work (94.77%), guaranteeing wages to eliminate overtime (90.36%), establishing working time regulations for the bogus self-employed (82.84%), and applying the 52-hour workweek system to all workplaces (76.47%). These expert opinions are consistent with previous research on the health effects of working hours.

A162 RARE PRESENTATION OF EXTRANODAL NK/T-CELL LYMPHOMA INVOLVING STOMACH AND EYE: CASE REPORT AND LITERATURE REVIEW

Background

Extranodal NK/T-cell lymphoma (ENKTL) is a rare and aggressive form of non-Hodgkin lymphoma. ENKTL are predominantly localized to nasal and upper aerodigestive sites, but extranasal involvement including gastrointestinal tract are rarely seen. Small and large intestines are primary sites of gastrointestinal ENKTL. Gastric involvements are exceedingly rare accounting for less than 5% of all gastrointestinal ENKTL.

Purpose

We present a literature review on gastrointestinal ENKTL and a case report of gastrointestinal bleed secondary to ENKTL involving stomach and left orbit.

Method

Case report and literature review.

Result(s)

33-year-old female was admitted to a tertiary hospital with 3-week history of epigastric pain and left periorbital swelling. Abdominal CT showed edema and thickening of gastric folds. Head CT showed grossly enlarged left lateral rectus muscle and periorbital soft tissue swelling suggestive of left orbital pseudotumor. Esophagogastroduodenoscopy revealed multifocal Forrest classification II-C ulcerations throughout her stomach and duodenum. Biopsies from stomach showed gastric mucosa with extensive infiltration by an atypical lymphoid cell population. Immunohistochemistry demonstrated high grade lymphoid cells with uniform expression of CD2, CD3, CD30, CD56, TIA1, perforin and granzyme B. EBV-encoded small RNA in-situ hybridization (EBER ISH) was strongly positive. Findings were consistent with gastric ENKTL. Left orbital biopsy revealed similar morphology and phenotypic features consistent with concurrent ENKTL involvement of her orbit. Patient was initiated on intravenous corticosteroids, but unfortunately developed hemorrhagic shock secondary to gastrointestinal bleeding from gastric ulcer and passed away.

Gastrointestinal ENKTL is a rare presentation of a rare disease. Gastric involvement is especially rare and described only in few case reports. Gastrointestinal ENKTL are often initially asymptomatic but can progress to abdominal pain, bleeding and even bowel perforation. Due its nonspecific clinical features and rarity, diagnosis can be difficult and requires careful examination by an experienced pathologist. This aggressive lymphoma is characterized by positive CD2, CD3, CD30, CD56, TIA, granzyme B, perforin and EBER ISH. Optimal treatment approach remains unclear due to lack of prospective clinical studies. Currently, treatment modalities used for other lymphomas including radiotherapy and non-anthracycline-based chemotherapy are used. Despite treatment, prognosis is grim with median overall survival period of 7-8 months.

Image

Conclusion(s)

We present a case of gastric and orbital ENKTL with gastric ulcer bleeding. Gastric ENKTL disease is a rare presentation of a rare disease. Due to non-specific clinical features, diagnosis is often difficult and relies on careful pathology examination by experienced pathologist. Prognosis is poor without optimal treatment approach due to rarity of disease and lack of validated data.

Please acknowledge all funding agencies by checking the applicable boxes below

None

Disclosure of Interest

None Declared

INFLAMMATORY BOWEL DISEASES

MECHANISMS AND TREATMENTS

A135 ENDOSCOPIC SUBMUCOSAL DISSECTION OF GASTRIC ADENOMAS AND EARLY CARCINOMAS

Background

Management of gastric adenoma and early gastric cancer requires endoscopic resection. This can often be achieved with endoscopic mucosal resection (EMR), which has been shown to be effective with a good safety profile. One disadvantage of EMR is that it is often completed piecemeal, leading to indeterminant margins and higher rates of recurrences that require additional intervention. Endoscopic submucosal dissection (ESD) is a more advanced endoscopic resection technique that has been shown to be more effective than EMR at en-bloc resection. ESD requires high technical proficiency but it is becoming more widely available in western countries.

Purpose

The purpose of this study is to report on the outcomes and rates of complications of gastric ESD completed in a tertiary centre in British Columbia.

Method

All gastric ESD was completed by a senior therapeutic endoscopist who has previously received training in Japan. Retrospective data were collected on all gastric ESD procedures done in St. Paul’s Hospital from May 7th, 2015, when the procedure first became available, to Aug 30th, 2022. Inclusion criteria were all adults who have undergone ESD for resection of a gastric lesion. Exclusion criteria were patients younger than 18. Data collected included demographic variables, polyp characteristics, procedural outcomes, and complications.

Result(s)

A total of 49 ESD procedures were completed. The mean size of the resected lesions was 25.3 mm (range: 5 – 100 mm). Technical success, defined as successful resection of all polypoid tissue, was achieved in 48/49 procedures (98.0%). En bloc resection was achieved in 42/48 (87.5%) completed ESD. The rate of R0 resection was also 42/48 (87.5%). Curative resection, defined as technically successful ESD with an R0 margin and no lymphovascular invasion, was achieved in 41/49 (83.7%) of the cases. In our cohort, 8 patients had adenocarcinoma, 5 of which had a curative resection with no evidence of recurrence. None of the ESD resulted in any intra-procedural or delayed perforation. 5/49 (10.2%) patients had clinically significant post-endoscopic resection bleeding. Out of 37 patients that completed follow-up, 3 (8.1%) had recurrence, and all of them were managed endoscopically. 4/49 (8.2%) of patients required surgery post-ESD.

Conclusion(s)

In our cohort, ESD is an effective endoscopic resection modality for gastric lesions with a high rate of technical success and curative resection. Despite a deeper plane of resection versus other endoscopic resection modalities, its complication rate remains low. Although ESD requires high technical proficiency, its favorable outcomes along with low rates of complication make ESD highly feasible for the resection of gastric lesions. Further research will be needed to study the implementation and outcomes of

ESD in a western setting.

Please acknowledge all funding agencies by checking the applicable boxes below

None

Disclosure of Interest

None Declared

A131 ENDOSCOPIC SUBMUCOSAL DISSECTION OF COLORECTAL ADENOMAS AND EARLY ADENOCARCINOMAS: OUTCOMES FROM BRITISH COLUMBIA

Background

Endoscopic resection is the standard of care for the management of colorectal polyps. Larger and more complex polyps require endoscopic mucosal resection (EMR). While complications have been low, EMR is often piecemeal, resulting in indeterminant margins and often a higher recurrence rate. Endoscopic submucosal dissection (ESD) is an advanced endoscopic resection technique with a higher rate of en bloc resection. While more data exist for the resection of gastric lesions with ESD, ESD is becoming more widely used in western countries for the resection of colorectal lesions.

Purpose

The purpose of this study is to report on the outcomes and rates of complications for colorectal ESD completed in a tertiary centre in British Columbia.

Method

All colorectal ESD was completed by a senior therapeutic endoscopist who has previously received training in Japan. Retrospective data were collected on all colorectal ESD procedures done in St. Paul’s Hospital from July 11th, 2016, when the procedure first became available, to Aug 30th, 2022. Inclusion criteria were all adults who have undergone ESD for resection of a colorectal lesion. Exclusion criteria were patients younger than 18. Data collected included demographic variables, polyp characteristics, procedural outcomes, and complications.

Result(s)

A total of 39 ESD procedures were completed. The mean size of the resected lesion was 30.4 mm (range: 5 – 60 mm). Technical success, defined as successful resection of all polypoid tissue, was achieved in 35/39 procedures (89.7%). En-bloc resection was achieved in 27/35 (77.1%) of the completed ESD. The rate of R0 resection was 22/35 (62.9%). Curative resection, defined as technically successful ESD with R0 margin and no lymphovascular invasion, was achieved in 23/39 (59.0%) of the cases and the majority of the patients with non-curative resection that underwent endoscopic surveillance had no recurrence on follow-up. In our cohort, 3/39 (7.7%) patients had adenocarcinoma. None of the ESD resulted in any intra-procedural or delayed perforation. 3/39 (7.7%) patients had clinically significant post-endoscopic resection bleeding. Out of 24 patients that completed follow-up, 4 (16.7%) had recurrence at the resection site that was managed endoscopically. 4/39 (10.3%) of patients required surgery post-ESD.

Conclusion(s)

In our cohort, ESD is an effective endoscopic resection modality for the management of colorectal adenomas and early adenocarcinoma with a high rate of technical success and low rates of complications. Although the rate of curative resection was low, most were the result of R1 or Rx resection and a majority of the follow-ups in this subgroup demonstrated no further recurrence. The rate of en bloc resection is high, especially given the average size of adenomas in this cohort. Although ESD requires high technical proficiency, its favorable outcomes and low complication rates make ESD highly feasible for the resection of colorectal lesions.

Please acknowledge all funding agencies by checking the applicable boxes below

None

Disclosure of Interest

None Declared

Risk factors for delirium among patients with advanced cancer in palliative care: a multicenter, patient-based registry cohort in South Korea

OBJECTIVE

Previous studies have comprehensively investigated the prevalence and various potential risk factors for delirium among patients with advanced cancer admitted to the acute palliative care unit (APCU). Our objective was to evaluate the comprehensive association between delirium and various risk factors among patients with advanced cancer in an acute palliative care setting using a patient-based multicenter registry cohort.

PATIENTS AND METHODS

We performed a multicenter, patient-based registry cohort study collected in South Korea between January 1, 2019, and December 31, 2020. Delirium was identified using a medical record review based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

RESULTS

In total, 2,124 eligible patients with advanced cancer in the APCU met the inclusion criteria. There were 127 out of 2,124 patients (prevalence, 6.0%; 95% CI, 5.0 to 7.1) with delirium during admission. Delirium in patients with advanced cancer was associated with age >70 years (OR, 1.793; 95% CI, 1.246 to 2.581), male sex (OR, 1.675; 95% CI, 1.131 to 2.479), no chemotherapy during hospitalization (OR, 2.019; 95% CI, 1.236 to 3.298), hearing impairment (OR, 3.566; 95% CI, 1.176 to 10.810), underweight (OR, 1.826; 95% CI, 1.067 to 3.124), current use of opioid medication (OR, 1.942; 95% CI, 1.264 to 2.982), previous history of delirium (OR, 12.497; 95% CI, 6.920 to 22.568), and mental illness (OR, 2.333; 95% CI, 1.251 to 4.352).

CONCLUSIONS

In a large-scale multicenter patient-based registry cohort, delirium was associated with old age, male sex, no chemotherapy during hospitalization, hearing impairment, underweight, current use of opioid medication, and a history of delirium and mental illness. Our findings suggest physicians should pay attention to delirium in patients with advanced cancer admitted to the APCU with the above risk factors.

A novel cardiac arrest severity score for the early prediction of hypoxic-ischemic brain injury and in-hospital death

Funding Acknowledgements

Type of funding sources: None.

Background

Out-of-hospital cardiac arrest (OHCA) outcomes are unsatisfactory despite postcardiac arrest care. Early prediction of prognoses might help stratify patients and provide tailored therapy.

Purpose

In this study, we derived and validated a novel scoring system to predict hypoxic-ischaemic brain injury (HIBI) and in-hospital death (IHD).

Methods

We retrospectively analysed Korean Hypothermia Network prospective registry data collected from in Korea between 2015 and 2018. Patients without neuroprognostication data were excluded, and the remaining patients were randomly divided into derivation and validation cohorts. HIBI was defined when at least one prognostication predicted a poor outcome. IHD meant all deaths regardless of cause. In the derivation cohort, stepwise multivariate logistic regression was conducted for HIBI and IHD scores, and model performance was assessed. We then classified patients into four categories and analysed associations between the categories and cerebral performance categories (CPCs) at hospital discharge. Finally, we validated our models in the internal validation cohort.

Results

Among 1373 patients, 240 were excluded, and 1133 were randomised into derivation (n=754) and validation cohorts (n=379). In the derivation cohort, 7 and 8 predictors were selected for HIBI (0–8) and IHD scores (0–11), respectively, and the area under the curve (AUC) was 0.85 (95% CI 0.82–0.87) and 0.80 (95% CI 0.77–0.82), respectively. Applying optimum cutoff values of ≥6 points for HIBI and ≥7 points for IHD, patients were classified as follows: HIBI (-)/IHD (-), Category 1 (n=424); HIBI (-)/IHD (+), Category 2 (n=100); HIBI (+)/IHD (-), Category 3 (n=21); and HIBI (+)/IHD (+), Category 4 (n=209). CPCs at discharge were significantly different in each category (p&lt;0.001). In the validation cohort, the model showed moderate discrimination (AUC 0.83, 95% CI 0.79–0.87 for HIBI and AUC 0.77, 95% CI 0.72–0.81 for IHD) with good calibration. Each category of the validation cohort showed a significant difference in discharge outcomes (p&lt;0.001) and a similar trend to the derivation cohort.

Conclusions

We presented a novel approach for assessing illness severity after OHCA. Although external prospective studies are warranted, risk stratification for HIBI and IHD could help provide OHCA patients with appropriate treatment.

Association between Fiber Intake and Risk of Incident Chronic Kidney Disease: The UK Biobank Study

OBJECTIVES

Dietary fiber intake is associated with a lower risk of diabetes, cardiovascular disease, and cancer. However, it is unknown whether dietary fiber has a beneficial effect on preventing the development of chronic kidney disease (CKD).

DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS

Using the UK Biobank prospective cohort, 110,412 participants who completed at least one dietary questionnaire and had an estimated glomerular filtration rate ≥60 mL/min/1.73 m2, urinary albumin-to-creatinine ratio <30 mg/g, and no history of CKD were included. The primary exposure was total dietary fiber density, calculated by dividing the absolute amount of daily total fiber intake by total energy intake (g/1,000 kcal). We separately examined soluble and insoluble fiber densities as additional predictors. The primary outcome was incident CKD based on diagnosis codes.

RESULTS

A total of 3,507 (3.2%) participants developed incident CKD during a median follow-up of 9.9 years. In a multivariable cause-specific model, the adjusted hazard ratios (aHRs; 95% confidence intervals [CIs]) for incident CKD were 0.85 (0.77-0.94), 0.78 (0.70-0.86), and 0.76 (0.68-0.86), respectively, for the second, third, and highest quartiles of dietary fiber density (reference: lowest quartile). In a continuous model, the aHR for each +∆1.0g/1,000 kcal increase in dietary fiber density was 0.97 (95% CI, 0.95-0.99). This pattern of associations was similar for both soluble and insoluble fiber densities and did not differ across subgroups of sex, age, body mass index, hypertension, diabetes, smoking, and inflammation.

CONCLUSION

Increased fiber intake was associated with a lower risk of CKD in this large well-characterized cohort.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

Grabody B, an IGF1 receptor-based shuttle, mediates efficient delivery of biologics across the blood-brain barrier

Effective delivery of therapeutics to the brain is challenging. Molecular shuttles use receptors expressed on brain endothelial cells to deliver therapeutics. Antibodies targeting transferrin receptor (TfR) have been widely developed as molecular shuttles. However, the TfR-based approach raises concerns about safety and developmental burden. Here, we report insulin-like growth factor 1 receptor (IGF1R) as an ideal target for the molecular shuttle. We also describe Grabody B, an antibody against IGF1R, as a molecular shuttle. Grabody B has broad cross-species reactivity and does not interfere with IGF1R-mediated signaling. We demonstrate that administration of Grabody B-fused anti-alpha-synuclein (α-Syn) antibody induces better improvement in neuropathology and behavior in a Parkinson's disease animal model than the therapeutic antibody alone due to its superior serum pharmacokinetics and enhanced brain exposure. The results indicate that IGF1R is an ideal shuttle target and Grabody B is a safe and efficient molecular shuttle.

Association between Menopausal Hormone Therapy and Frailty: Cross-Sectional Study Using National Survey Data in Korea

Frailty is a multidimensional clinical syndrome that increases the risk of adverse health outcomes. Previous studies have reported a close link between menopause and frailty. Combined estrogen−progestin therapy (or estrogen-only therapy in women who have undergone a hysterectomy) is currently approved as a menopausal hormone therapy (MHT) to treat menopausal symptoms. Despite increasing evidence of the importance of sex hormones in the development of frailty, very few studies have investigated the association between MHT and frailty. A cross-sectional evaluation was conducted using population-based survey data known as the Korea National Health and Nutrition Examination Survey (KNHANES IV-V, 2008−2012). The KNHANES data provided variables that were used to construct a 51-item frailty index (FI). The number of study population, only including postmenopausal women, was 7823 women, and their mean age was 62.51 years (range 32−80 years). Approximately 40% of them had graduated from middle school or higher, 45% lived in metropolitan statistical areas, and 5% were recipients of the national Medical Aid. The mean age at menopause was 48.66 years (range 30−62 years). Overall, the mean FI value was 0.15, and the prevalence of MHT was 13.23%. Findings from multiple regression analysis using the inverse probability of treatment weighting showed that a treatment duration of more than 2 years and up to 5 years, age at first treatment between 50 and 59 years, and MHT initiation 3 to 6 years after menopause were all negatively associated with frailty (p < 0.05). Further studies are needed to confirm these findings using prospective data.

Prognostic impact of plasma glucose on cardiogenic shock patients with or without diabetes ellitus: smart rescue trial

Background

Even though the presence of hyperglycemia has shown to affect the clinical outcome of cardiogenic shock patients, the extent of hyperglycemia and its association with prognosis have not been fully addressed in large population

Purpose

Investigate the clinical relationship between hyperglycemic status and in-hospital mortality in cardiogenic shock patients

Method

A total of 1,177 consecutive cardiogenic shock patients were enrolled from January 2014 to December of 2018 at 12 hospitals in South Korea. The primary outcome was in-hospital mortality. Patients were divided into four groups according to their initial plasma glucose level in each of diabetes patients (n=752) and non-diabetes patients (n=425); group 1 (≤8 mmol/L), group 2 (8–12 mmol/L), group 3 (12–16 mmol/L) and group 4 (≥16 mmol/L).

Results

The groups with higher admission plasma glucose were associated with lower systolic blood pressure and higher lactic acid level in both diabetic and non-diabetic patients. In-hospital mortality increased in groups with higher admission plasma glucose level in non-diabetic patients (group-1:24.2%, group-2: 28.6%, group-3: 38.1%, group-4: 49.0%, p&lt;0.01) whereas in diabetic patients, mortality and admission plasma glucose level showed no significant association (group-1: 45%, group-2: 35.4%, group-3: 33.3%, group-4: 43.1%, p=0.26). Even after Multivariate analysis, high plasma glucose was an independent predictor of in-hospital mortality in non-diabetic patients

Conclusion

In cardiogenic shock patients, plasma glucose obtained at admission was associated with in-hospital mortality in non-diabetic patients

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): Inha University hospital

Impact of obesity paradox between genders on in-hospital mortality in cardiogenic shock: a retrospective cohort study

Background

In a few studies, obesity was associated with better outcomes in patients with cardiogenic shock (CS). Although this phenomenon, the “obesity paradox”, reportedly manifests differently based on sex in other disease entities, it has not yet been investigated in CS patients.

Methods and results

1,227 patients with CS from The REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy of left ventricular assist device for Korean patients with cardiogenic shock (RESCUE) registry in Korea were analyzed. The study population was classified into obese and non-obese groups according to Asian-Pacific criteria (BMI &gt;25.0 kg/m2 for obese). Clinical impact of obesity on in-hospital mortality according to sex was analyzed using logistic regression analysis and restricted cubic spline curves. In-hospital mortality rate was significantly lower in obese men than non-obese men (34.2% vs. 24.1%, p=0.004) while the difference was not significant in women (37.3% vs. 35.8%, p=0.884). As a continuous variable, higher BMI showed a protective effect in men conversely, BMI was not associated with clinical outcomes in women. Comparing to normal-weight patients, obesity was associated with a decreased risk of in-hospital death in men (multivariable-adjusted OR 0.63, CI 0.43–0.92, p=0.016), not in women (multivariable-adjusted OR 0.94, 95% CI 0.55–1.61, p=0.828). Interaction P value for the association between BMI and sex was 0.023.

Conclusions

Obesity paradox exists and apparently occurs in men among CS patients. The differential effect of BMI on in-hospital mortality was observed according to sex.

Funding Acknowledgement

Type of funding sources: None.

Public View of Public Health Emergencies Based on Artificial Intelligence Data

In the current environment where the network and the real society are intertwined, the network public view of public emergencies has involved in reality and altered the ecology of communal public views in China. A new online court of influence has been created, and it affected the trend of events. As the main type of public emergencies, public health emergencies are directly related to people's health and life insurance. Therefore, the public often pays special attention. At present, correct media guidance plays an irreplaceable and important role in calming people's hearts and stabilizing social order. If news and public view are left unchecked, it is likely to cause panic among the people. However, in reality, public view research has always been a research object that is difficult to intelligentize and quantify. Based on such a realistic background, the article conducts a research on public view of public health emergencies based on artificial intelligence data analysis. This study designs an expert system for network public view and optimizes the algorithm for the key problem: SFC deployment. Finally, the system was put into real news and public opinion research on new coronavirus epidemic prevention, and experimental tests were carried out. The experimental results have shown that in the new coronavirus incident, the nuclear leakage incident, and the epidemic prevention policy, the data obtained by the public through the Internet are 50%, 68.06%, and 64.35%, respectively. For the system function in this study, both ICSO and IPSO are far better than the optimization results of CSO and PSO. For most of the test functions, IPSO is better than ICSO's optimization results, which better fulfills the needs of the research content. This study will make an in-depth analysis of the evolution process of online public opinion on public emergencies from the macro-, meso-, and micro-perspectives, in order to analyze the dissemination methods and internal evolution mechanism of various public emergencies of online public opinion, which provides countermeasures and suggestions for the government to guide and manage network public opinion.

Artificial intelligence-powered pathology image analysis merged with spatial transcriptomics reveals distinct TIGIT expression in the immune-excluded tumor-infiltrating lymphocytes

2570

Background: TIGIT is a promising emerging immunotherapeutic target. However, the specific sources of TIGIT expression within the tumor microenvironment are largely unknown. Here, we present an AI-powered spatial tumor-infiltrating lymphocyte (TIL) analyzer, Lunit SCOPE IO, to integrate image analysis from whole slide images with single-cell molecular profiling. Methods: We used The Cancer Genome Atlas (TCGA) RNA expression data across 23 cancer types (n=6,930). Lunit SCOPE IO was developed, trained, and validated based on >17k H&E whole-slide images, to segment cancer area (CA) and cancer-associated stroma (CS) and to detect tumor cells and TILs. The intra-tumoral TIL, stromal TIL, and tumor cell purity (TCP) in the CA+CS area were calculated. The public spatial transcriptomics (ST) dataset for breast cancer was downloaded from the 10X Visium web page. Lunit SCOPE IO was applied to the associated H&E WSIs to match distinct TIGIT expression to single cells identified in the WSIs. Results: TIGIT was highly expressed in TGCT (3.45±0.11; median±SEM), LUAD (3.07±0.05), and HNSC (2.89±0.06), and was highly enriched in samples with microsatellite instability-high or tumor mutational burden-high (≥ 10/Mb) compared to those without them (fold change = 1.30, p < 0.001). At a macroscopic, bulk-level in the TCGA dataset, TIGIT expression was positively correlated with intra-tumoral TIL density (R=0.37, p<0.001) and stromal TIL density (R=0.42, p<0.001), but it was negatively correlated with TCP (R=-0.27, p<0.001). Lunit SCOPE IO analyzed the images from ST analysis and calculated intra-tumoral TIL, stromal TIL, and TCP of each region of interest, containing 2 (IQR 0-7) cells. Interestingly, at a microscopic, cell-level, TIGIT expression was still higher in areas of enriched stromal TIL (P < 0.001) and lower in tumor cell-dense areas, but it was not significantly correlated with enriched intra-tumoral TIL areas, meaning that TIGIT expression is likely derived from the excluded TILs in the CS area. Conclusions: Interactive analysis of spatial transcriptomics with AI-powered pathology image analysis revealed that TIGIT expression in the tumor microenvironment is exclusive to confined areas with stromal TIL enrichment, reflecting the exclusion of TIL from the tumor nest. [Table: see text]

AK2 is an AMP-sensing negative regulator of BRAF in tumorigenesis

The RAS-BRAF signaling is a major pathway of cell proliferation and their mutations are frequently found in human cancers. Adenylate kinase 2 (AK2), which modulates balance of adenine nucleotide pool, has been implicated in cell death and cell proliferation independently of its enzyme activity. Recently, the role of AK2 in tumorigenesis was in part elucidated in some cancer types including lung adenocarcinoma and breast cancer, but the underlying mechanism is not clear. Here, we show that AK2 is a BRAF-suppressor. In in vitro assays and cell model, AK2 interacted with BRAF and inhibited BRAF activity and downstream ERK phosphorylation. Energy-deprived conditions in cell model and the addition of AMP to cell lysates strengthened the AK2-BRAF interaction, suggesting that AK2 is involved in the regulation of BRAF activity in response to cell metabolic state. AMP facilitated the AK2-BRAF complex formation through binding to AK2. In a panel of HCC cell lines, AK2 expression was inversely correlated with ERK/MAPK activation, and AK2-knockdown or -knockout increased BRAF activity and promoted cell proliferation. Tumors from HCC patients showed low-AK2 protein expression and increased ERK activation compared to non-tumor tissues and the downregulation of AK2 was also verified by two microarray datasets (TCGA-LIHC and GSE14520). Moreover, AK2/BRAF interaction was abrogated by RAS activation in in vitro assay and cell model and in a mouse model of HRAS^G12V-driven HCC, and AK2 ablation promoted tumor growth and BRAF activity. AK2 also bound to BRAF inhibitor-insensitive BRAF mutants and attenuated their activities. These findings indicate that AK2 monitoring cellular AMP levels is indeed a negative regulator of BRAF, linking the metabolic status to tumor growth.

LAG-3xPD-L1 bispecific antibody potentiates antitumor responses of T cells through dendritic cell activation

Several preclinical studies demonstrate that antitumor efficacy of PD-1/PD-L1 blockade can be improved by combination with other checkpoint inhibitors. Lymphocyte-activation gene 3 (LAG-3) is an inhibitory checkpoint receptor involved in T cell exhaustion and tumor immune escape. Here, we describe ABL501, a bispecific antibody targeting LAG-3 and PD-L1 in modulating immune cell responses against tumors. ABL501 that efficiently inhibits both LAG-3 and PD-L1 pathways enhances the activation of effector CD4⁺ and CD8⁺ T cells with a higher degree than a combination of single anti-LAG-3 and anti-PD-L1. The augmented effector T cell responses by ABL501 resulted in mitigating regulatory T cell-mediated immunosuppression. Mechanistically, the simultaneous binding of ABL501 to LAG-3 and PD-L1 promotes DC activation and tumor cell conjugation with T cells that subsequently mounts effective CD8⁺T cell responses. ABL501 demonstrates its potent in vivo antitumor efficacy in a humanized xenograft model and with knock-in mice expressing human orthologs. The immune profiling analysis of peripheral blood reveals an increased abundance of LAG-3^hiPD-1^hi memory CD4⁺T cell subset in relapsed cholangiocarcinoma patients after gemcitabine plus cisplatin therapy, which are more responsive to ABL501. This study supports the clinical evaluation of ABL501 as a novel cancer immunotherapeutic, and a first-in-human trial has started (NCT05101109).

Association between oral health and frailty: results from the Korea National Health and Nutrition Examination Survey

Background

Previous research has suggested that poor oral health is positively associated with frailty. The objective of this study was to explore associations of key oral diseases (periodontal disease, tooth loss), and oral hygiene and management behaviors with the level of frailty in community-dwelling older Korean adults using national representative survey data.

Methods

This study used cross-sectional, 6th and 7th Korea National Health and Nutrition Examination Survey (KNHANES VI, VII) data. Adults aged 50+ years were included. Frailty was measured using frailty phenotype (FP) and frailty index (FI). FP was determined using five frailty criteria, i.e., weight loss, weakness, exhaustion, slowness, or low physical activity, and the level of frailty was classified with the number of criteria present (robust, none; pre-frail, 1–2; frail, 3+). FI was determined using a 44-item FI constructed according to a standard protocol, and the level of frailty was classified as robust (FI: ≤ 0.08), pre-frail (FI: 0.08–0.25), and frail (FI: ≥ 0.25). Multiple ordinal regression analyses were conducted with each type of frailty as the outcome variable. Independent variables of interest were the periodontal status, number of teeth, and practices on oral hygiene and management. Analyses were additionally adjusted for participants’ socioeconomic, diet, and behavioral characteristics.

Results

The prevalence of frailty was 4.38% according to the FP classification (n = 4156), 10.74% according to the FI classification (n = 15,073). In the final adjusted model, having more teeth and brushing after all three meals were significantly associated with lower odds of being more frail (in both frailty models); no significant association was observed between periodontal disease and frailty.

Conclusions

Findings from this study show having more teeth and practicing adequate brushing are significantly associated with frailty. Due to limitations of the study design, well-designed longitudinal studies are needed to confirm these findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02968-x.

Development of a Customized Endoscopic Dual-Diffusing Optical Fiber Probe for Pancreatic Cancer Therapy: Toward Clinical Use

Objective: We developed a dual-diffusing optical fiber probe (DDOFP), capable of uniformly illuminating the anatomical structure of pancreatic duct for photodynamic therapy (PDT) of pancreatic cancer in clinical settings. Background: Optical fiber presents a unique route for pancreatic PDT by enabling access to the pancreatic duct. For effective pancreatic PDT, the optical fiber should produce a uniform illumination covering of the pancreatic duct, while maintaining its transmission property under thermomechanical stresses in surgical environments. Methods: The transmission profiles of DDOFP were measured using a charge-coupled device (CCD) camera at two directions: front-spherical and side-cylindrical areas of the optical fiber. We simulated the change in transmission property by curved tube structures using optically transparent phantom. DDOFP was integrated with 19-gauge needle catheter that is commercially used as an optical guide to treat pancreatic cancer. The temperature of DDOFP was measured at the end face using a thermistor probe in the bovine tissue, while delivering laser energy of over 200 and 500 J. Results: DDOFP was customized to secure the inner diameter of the 19-gauge needle catheter of 686 μm to be integrated as a clinical device. The round ball lens fiber tip minimized the back-burn effect caused by blood carbonization during surgery and induced front-spherical diffusion. DDOFP produced uniform light illumination with intensity difference of <10%. When DDOFP was bent with a small curvature <15 mm, the transmission intensity was consistent. Under high-power laser transmission, DDOFP was found to be robust to cracking or deformation. Conclusions: DDOFP was customized for pancreatic PDT with superior thermomechanical property and uniform light illumination at both the front-spherical and side-cylindrical areas. This is the smallest clinically available optical fiber per our knowledge and officially approved by the Korea Food and Drug Administration (item approval number: 17-516). DDOFP can contribute immensely toward the efficient delivery of pancreatic PDT and photothermal therapy.

Factors associated with treatment escalation among MS specialists and general neurologists: Results from an International cojoint study

BACKGROUND

Previous studies in multiple sclerosis (MS) showed that therapeutic inertia (TI) affects 60-90% of neurologists and up to 25% of daily treatment decisions. The objective of this study was to determine the most common factors and attribute levels associated with decisions to treatment escalation in an international study in MS care.

METHODS

300 neurologists with MS expertise from 20 countries were invited to participate. Participants were presented with 12 pairs of simulated MS patient profiles described by 13 clinically relevant factors. We used disaggregated discrete choice experiments to estimate the weight of factors and attributes affecting physicians' decisions when considering treatment selection. Participants were asked to select the ideal candidate for treatment escalation from modest to higher-efficacy therapies.

RESULTS

Overall, 229 neurologists completed the study (completion rate: 76.3%). The top 3 weighted factors associated with treatment escalation were: previous relapses (20%), baseline expanded disability status scale [EDSS] (18%), and MRI activity (13%). Patient demographics and desire for pregnancy had a modest influence (≤ 3%). We observed differences in the weight of factors associated with treatment escalation between MS specialists and non-MS specialists.

CONCLUSIONS

Our results provide critical information on factors influencing neurologists' treatment decisions and should be applied to continuing medical education strategies.

Primary Colonic Epithelioid Angiosarcoma with Hepatic Metastasis: A Case Report

Colonic angiosarcoma is an extremely rare and aggressive malignant tumor with poor prognosis. We report a case of colonic epithelioid angiosarcoma with colonic obstruction and rapidly progressive hepatic metastasis in a 44-year-old female. Abdominal CT revealed a heterogeneously enhancing irregular mass in the ascending colon, causing proximal bowel distension. The patient underwent surgery, and histopathological examination revealed a poorly differentiated carcinoma. A follow-up liver dynamic MRI after 4 months revealed newly developed diffusely scattered numerous small nodules in both hepatic lobes with peripheral and nodular marked arterial hyperenhancement, raising the suspicion of hepatic angiosarcoma. A pathologic second opinion was obtained, and additional immunohistochemistry revealed colonic epithelioid angiosarcoma. The patient showed progressive hepatic metastasis on follow-up abdominal CT after 6 months and died 8 months after initial diagnosis. We describe an educational case of colonic angiosarcoma, a rare malignant tumor, with rapidly progressive hepatic metastasis that showed radiologic findings suggestive of angiosarcoma and enabled a re-diagnosis for proper treatment and prognosis prediction.

Construction of a tunable promoter library to optimize gene expression in Methylomonas sp. DH-1, a methanotroph, and its application to cadaverine production

BACKGROUND

As methane is 84 times more potent than carbon dioxide in exacerbating the greenhouse effect, there is an increasing interest in the utilization of methanotrophic bacteria that can convert harmful methane into various value-added compounds. A recently isolated methanotroph, Methylomonas sp. DH-1, is a promising biofactory platform because of its relatively fast growth. However, the lack of genetic engineering tools hampers its wide use in the bioindustry.

RESULTS

Through three different approaches, we constructed a tunable promoter library comprising 33 promoters that can be used for the metabolic engineering of Methylomonas sp. DH-1. The library had an expression level of 0.24-410% when compared with the strength of the lac promoter. For practical application of the promoter library, we fine-tuned the expressions of cadA and cadB genes, required for cadaverine synthesis and export, respectively. The strain with P_rpmB-cadA and P_DnaA-cadB produced the highest cadaverine titre (18.12 ± 1.06 mg/L) in Methylomonas sp. DH-1, which was up to 2.8-fold higher than that obtained from a non-optimized strain. In addition, cell growth and lysine (a precursor of cadaverine) production assays suggested that gene expression optimization through transcription tuning can afford a balance between the growth and precursor supply.

CONCLUSIONS

The tunable promoter library provides standard and tunable components for gene expression, thereby facilitating the use of methanotrophs, specifically Methylomonas sp. DH-1, as a sustainable cell factory.

CT findings after left renal vein division during abdominal aortic surgery

BACKGROUND

The rationale behind left renal vein division (LRVD) is the assumption that adequate collateral draining channels will develop.

PURPOSE

To describe computed tomography (CT) findings after LRVD during aortic surgery.

MATERIAL AND METHODS

Among 61 consecutive patients who underwent LRVD during aneurysm repair or revascularization for aortic occlusive disease between January 2003 and December 2017, 51 patients (40 men, mean age 71.4 ± 8.4 years) were enrolled. Contrast-enhanced CT images were analyzed to evaluate collateral drainage, patency, left renal vein diameter, and left renal parenchymal thickness. A total of 115 radiologic reports were reviewed to check whether these findings were accurately mentioned.

RESULTS

The median time period of the first postoperative follow-up CT was 36 days (range 7-1351 days). The gonadal vein (n = 47) was the most common collateral draining channel, followed by the retroperitoneal veins (n = 42) and adrenal vein (n = 33). Thrombosis occurred in five patients between postoperative days 7 and 17 in the remnant renal vein (n = 3), remnant renal vein plus gonadal and adrenal veins (n = 1), and gonadal vein (n = 1). There was a significant decrease in renal vein diameter (-0.48 ± 2.12 mm, P = 0.006). There was no significant difference in parenchymal thickness (-0.25 ± 1.27 mm, P = 0.193). Neither LRVD nor any associated findings were correctly stated on radiologic reports.

CONCLUSION

Postoperative contrast-enhanced CT can delineate collateral draining channels and complications following LRVD. However, these findings tend to be either missed or misinterpreted.

892 ABL503 (TJ-L14B), PD-L1x4–1BB bispecific antibody induces superior anti-tumor activity by PD-L1-dependent 4–1BB activation with the increase of 4–1BB+CD8+ T cells in tumor microenvironment

Background

PD-(L)1 inhibitor has revolutionized cancer treatment, but there are unmet clinical needs for PD-(L)1 inhibitor-resistant/refractory patients. Activation of T cells in tumor microenvironment by 4-1BB agonist antibodies is one of the promising approaches to complement the current limitation of PD-(L)1 inhibitors. Although 4-1BB is a promising target for immunotherapy, clinical studies using 4-1BB agonist antibodies showed systemic immune cell activation resulting in dose-limiting hepatotoxicity. We generated ABL503 (TJ-L14B), a bispecific antibody that combines PD-(L)1 blockade and PD-L1-dependent 4-1BB agonistic activity by binding both PD-L1 and 4-1BB to limit unwanted toxicities while exerting a potent anti-tumor efficacy. Here, we reported the pre-clinical properties of ABL503 (TJ-L14B) in various studies.

Methods

The activity of ABL503 (TJ-L14B) was characterized and evaluated in 1) PD-1 and 4-1BB signaling reporter cells cocultured with various tumor cells and PBMCs, 2) hPD-L1/h4-1BB knock-in mice implanted with MC38 tumor expressing different level of hPD-L1, 3) patient-derived lung cancer organoids cocultured with autologous PBMCs, and 4) PBMCs from healthy donors to measure cytokine release.

Results

Functional evaluation of ABL503 (TJ-L14B) indicates the activation of 4-1BB signaling was solely dependent on engagement of hPD-L1 expressed on immune cells as well as on tumor cells, pointing to pivotal roles of PD-L1 on both immune cells and tumor cells for the activity of ABL503 (TJ-L14B). In vivo anti-tumor activity of ABL503 (TJ-L14B) across different hPD-L1 levels showed prominent anti-tumor effect with significantly increased number of CD8+ cells and 4-1BB+ cells in the tumor. This anti-tumor activity was correlated with the proliferation (Ki-67+) of CD8+ T cells in the tumor microenvironment. Ex vivo assays utilizing patient-derived lung cancer organoids revealed that ABL503 (TJ-L14B) exhibits superior tumor-killing activity than that by benchmark PD-L1 antibody, Atezolizumab. In addition, cytokine release assay demonstrated that ABL503 (TJ-L14B) did not induce non-specific pro-inflammatory cytokine release by human PBMCs.

Conclusions

Our data indicate that PD-L1 and 4-1BB dual targeting bispecific antibody, ABL503 (TJ-L14B), shows potent 4-1BB agonistic activity and anti-tumor effect in a PD-L1-dependent fashion concomitant with 4-1BB+/CD8+ T cell activation and proliferation to overcome limitations of PD-(L)1-targeted therapy while minimizing the risk of peripheral toxicity. The phase 1 clinical trial in the U.S. is currently ongoing in patients with locally advanced or metastatic solid tumors (NCT04762641).

Inhibition of alpha-synuclein aggregation by AM17, a synthetic resveratrol derivative

Parkinson's disease (PD) is linked to the aberrant self-assembly of the amyloid protein, α-synuclein (αS), where αS monomers aggregate to form oligomers and fibrils. Out of the three conformers, αS oligomers are the major toxic agents in PD, while αS fibrils may work as a reservoir for toxic oligomeric conformers. Thus, compounds that inhibit aggregation of αS monomers and disaggregate αS oligomers and fibrils may serve as therapeutic agents against PD. In this regard, resveratrol and its synthetic derivatives (e.g., AM17, which contains a copper ion-selective ionophoric motif) have previously been examined for their inhibitory effects on aggregation of amyloid proteins, such as the β-amyloid peptide implicated in Alzheimer's disease. In the current study, we employed an array of experimental tools, such as Thioflavin T fluorescence, transmission electron microscopy, immuno-dot blot assays, SDS- and native-PAGE, and circular dichroism, to determine the impact of AM17 and resveratrol on αS aggregation. To the best of our knowledge, we show for the first time that AM17 not only inhibits aggregation of αS monomers but also disaggregates αS oligomers and fibrils, independent of the copper ions. Similar αS aggregation inhibitory effects were observed with resveratrol only in the presence of the copper ion. The present study supports the high promise of applicability of AM17 as an effective amyloid aggregation inhibitor for various conformers and protein sequences.

Associations between changing patterns of ST-T waves morphologies in rest electrocardiography and cardiovascular risk in an asymptomatic low risk population: a report from Ansan-Ansung cohort study

Background

While clinical significance of ST-T wave abnormalities (STA) in rest electrocardiography (ECG) on long-term cardiovascular outcomes has been on debate, few studies have been reported on the association between the changes in ST-T waves in rest ECG and cardiovascular outcomes in low risk populations. We investigate the changing patterns of STA in rest ECG and the predictive value of the changes in ST-T wave in rest ECG for cardiovascular events in an asymptomatic general population.

Methods

A longitudinal community-based cohort study was conducted for 12 years. Koreans aged 40–69 years were followed biennially through scheduled revisit for comprehensive assessments. Among 10,030 participants, 6,648 participants who did not have any cardiovascular diseases, angina-related symptoms or pathologic Q waves in rest ECG at baseline were included for analysis. Changes in STAs were defined using the changes between ECG at baseline and that at the first revisit. A major adverse cardiovascular events was defined as a composite of cardiac death, myocardial infarction, clinical diagnosis of coronary artery disease and stroke.

Results

Among 5,924 participants without STA at baseline, only 187 participants (3.2%) developed new STA. Among 724 patients (10.9%) with STA at baseline, 274 patients (37.8%) persistently showed STA at the first revisit. MACEs occurred more frequently in the participants persistently with STA and those with newly-developed STA than in the participants persistently without STA (Figure 1). Multivariate Cox-proportional hazard models showed that a higher risk of MACE was only associated with the persisted STA (HR 1.69; 95% CI 1.10–2.63). In participants with baseline STA, persisted T-wave flattening was associated with a higher risk of MACE, whereas T-wave inversion, either persisted or fluctuated was not associated with a higher risk of MACE, compared with persistent absence of STA (Figure 2). In the participants without baseline STAs, multivariate Cox-proportional hazard model showed that newly-developed T-wave flattening (HR 1.85; 95% CI 0.20–2.84), not T-wave inversion (HR 1.50; 95% CI 0.85–2.65) was associated with a higher risk of MACE. Survival receiver operating curve analysis showed that the changes in STAs had a C-index of 0.538 (95% CI 0.511–0.558), a sensitivity of 13.0% and a specificity of 92.5% and add only a small value to the predictive power of 10-year atherosclerotic cardiovascular diseases risk estimator (C-index without STA changes 0.708 [0.681–0.736] vs. C-index with STA changes 0.721 [0.694–0.748]).

Conclusions

STAs uncommonly developed while frequently disappeared spontaneously in the asymptomatic general population. Persisted STA and newly developed STA in rest ECG were predictive of future cardiovascular events in the asymptomatic general population. However, the changes in STAs did not significantly improve the predictive value of the conventional risk estimator, when added.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Research Foundation of Korea Figure 1Figure 2

Simulation and validation for count-based binary decision of target blood pressure achievement in home blood pressure monitoring data analysis for clinical practice

Introduction

Home blood pressure monitoring (HBPM) is a useful tool to identify hypertension and to decide whether a patient's blood pressure (BP) is controlled. The use of automatized oscillometric BP measurement devices has become increasingly popular with help of information technology and internet of things to the devices. However, applying HBPM to daily clinical practices is still challenging, because most patients with hypertension are in age groups not familiar to digital devices and internet and high BP criteria using average home BP values are often useless in outpatient clinics without easily accessible average BP calculation tools. Therefore, we developed a simple and straightforward method to interpret HBPM through counts of BP ≥135/85 mmHg.

Methods

We simulated 400 cases of HBPM using a random number generator function in statistical software. The simulated average home systolic BP (SBP) and its standard deviation (SD) were 125±15 mmHg and 12±5 mmHg and the number of HBP readings was 24 times. The simulated diastolic BP (DBP) was randomly selected to 50–75% of the SBP. The validation of the binary interpretation method was conducted using actual HBPM data from 386 subjects in a rural area of South Korea. Receiver operating characteristics curve analysis was conducted, and linear regression and logarithmic models were fitted between the numbers of home BP ≥135/85 mmHg and mean BP. Hypertension was defined with average home BP ≥135/85 mmHg.

Results

In the simulated cohort, hypertension was presented in 197 cases (49.3%). The C-index of the numbers of BP readings ≥135/85 mmHg was 0.994 (95% confidence interval [CI] 0.990–0.998), and ≥12 of 24 BP readings ≥135/85 mmHg showed a sensitivity of 95.4%, a specificity of 95.1% and an accuracy of 95.3% for the diagnosis of hypertension. In validation cohort, the numbers of home BP measurements varied from 8 to 81 times. The validation cohort similarly showed that the C-index of the ratio between the number of high BP readings (≥135/85 mmHg) to the number of BP measurements (R-NHBP/NBP) was 0.985 (95% CI, 0.976–0.994) and the best accuracy was shown at R-NHBP/NBP of ≥0.45. R-NHBP/NBP of ≥0.5 showed a sensitivity of 0.957, a specificity of 0.907 and an accuracy of 0.927. The accuracy of the R-NHBP/NBP of ≥0.5 decreased as SD and the range of SBP increased, whereas it did not change with the number of measurements (Figure 1). R-NHBP/NBP &lt;0.2 predicted normotension and R-NHBP/NBP &gt;0.8 predicted hypertension in 95% confidence. Mean widths of the 95 prediction intervals for the average SBP and DBP were 18.2 mmHg and 12.6 mmHg, respectively (Figure 2).

Conclusion

Counting the number of BP ≥135/85 mmHg can provide accurate assessments for the BP levels. R-NHBP/NBP of ≥0.5 is a simple and accurate marker of high BP in HBPM, and R-NHBP/NBP could be a useful tool to assess BP levels in patients practicing HBPM.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Novel anti-4-1BB×PD-L1 bispecific antibody augments anti-tumor immunity through tumor-directed T-cell activation and checkpoint blockade

Background

Stimulation of 4-1BB with agonistic antibodies is a promising strategy for improving the therapeutic efficacy of immune checkpoint inhibitors (ICIs) or for overcoming resistance to ICIs. However, dose-dependent hepatotoxicity was observed in clinical trials with monoclonal anti-4-1BB agonistic antibodies due to the activation of 4-1BB signaling in liver resident Kupffer cells.

Methods

To avoid this on-target liver toxicity, we developed a novel bispecific antibody (4-1BB×PD-L1 bispecific antibody, termed “ABL503”) uniquely designed to activate 4-1BB signaling only in the context of PD-L1, while also blocking PD-1/PD-L1 signaling.

Results

Functional evaluation using effector cells expressing both 4-1BB and PD-1 revealed superior biological activity of ABL503 compared with the combination of each monoclonal antibody. ABL503 also augmented T-cell activation in in vitro assays and further enhanced the anti-PD-L1-mediated reinvigoration of tumor-infiltrating CD8⁺ T cells from patients with cancer. Furthermore, in humanized PD-L1/4-1BB transgenic mice challenged with huPD-L1-expressing tumor cells, ABL503 induced superior anti-tumor activity and maintained an anti-tumor response against tumor rechallenge. ABL503 was well tolerated, with normal liver function in monkeys.

Conclusion

The novel anti-4-1BB×PD-L1 bispecific antibody may exert a strong anti-tumor therapeutic efficacy with a low risk of liver toxicity through the restriction of 4-1BB stimulation in tumors.

MRI-Visible Perivascular Spaces in the Centrum Semiovale Are Associated with Brain Amyloid Deposition in Patients with Alzheimer Disease-Related Cognitive Impairment

BACKGROUND AND PURPOSE

The association of perivascular spaces in the centrum semiovale with amyloid accumulation among patients with Alzheimer disease-related cognitive impairment is unknown. We evaluated this association in patients with Alzheimer disease-related cognitive impairment and β-amyloid deposition, assessed with [¹⁸F] florbetaben PET/CT.

MATERIALS AND METHODS

MR imaging and [¹⁸F] florbetaben PET/CT images of 144 patients with Alzheimer disease-related cognitive impairment were retrospectively evaluated. MR imaging-visible perivascular spaces were rated on a 4-point visual scale: a score of ≥3 or <3 indicated a high or low degree of MR imaging-visible perivascular spaces, respectively. Amyloid deposition was evaluated using the brain β-amyloid plaque load scoring system.

RESULTS

Compared with patients negative for β-amyloid, those positive for it were older and more likely to have lower cognitive function, a diagnosis of Alzheimer disease, white matter hyperintensity, the Apolipoprotein E ε4 allele, and a high degree of MR imaging-visible perivascular spaces in the centrum semiovale. Multivariable analysis, adjusted for age and Apolipoprotein E status, revealed that a high degree of MR imaging-visible perivascular spaces in the centrum semiovale was independently associated with β-amyloid positivity (odds ratio, 2.307; 95% CI, 1.036-5.136; P = .041).

CONCLUSIONS

A high degree of MR imaging-visible perivascular spaces in the centrum semiovale independently predicted β-amyloid positivity in patients with Alzheimer disease-related cognitive impairment. Thus, MR imaging-visible perivascular spaces in the centrum semiovale are associated with amyloid pathology of the brain and could be an indirect imaging marker of amyloid burden in patients with Alzheimer disease-related cognitive impairment.