A novel cell source for therapy of knee osteoarthritis using atelocollagen microsphere-adhered adipose-derived stem cells: Impact of synovial fluid exposure on cell activity

Introduction

Administration of adipose-derived stem cells (ADSCs) into the joint cavity has been shown to alleviate the symptoms of knee osteoarthritis (OA) by releasing exosomes and anti-inflammatory cytokines. However, the therapeutic effect of these cells is limited by their rapid disappearance after administration. Thus, it is necessary to prolong cell survival in the joint cavity. This study aimed to investigate the potential application of ADSCs adhered to atelocollagen microspheres (AMSs) for cell therapy of knee OA.

Methods

ADSCs were cultured for 2, 4, and 7 days in AMS suspension or adherent culture dishes. The supernatants were analyzed for IL-10 and exosome secretion via enzyme-linked immunosorbent assay and Nanosight. The effect of AMS was compared with that of adherent-cultured ADSCs (2D-cultured ADSCs) using transcriptome analysis. Moreover, the solubility of AMS and viability of ADSCs were evaluated using synovial fluid (SF) from patients with knee OA.

Results

Compared with 2D-cultured ADSCs, AMS-cultured ADSCs exhibited a significant increase in secretion of exosomes and IL-10, and the expression of several genes involved in extracellular matrix and immune regulation were altered. Furthermore, when AMS-cultured ADSCs were cultured in SF from knee OA patients to mimic the intra-articular environment, the SF dissolved the AMSs and released viable ADSCs. In addition, AMS-cultured ADSCs showed significantly higher long-term cell viability than 2D-cultured ADSCs.

Conclusion

Increased survival of AMS-adhered ADSCs was observed in the intra-articular environment, and AMSs were found to gradually dissipate. These results suggest that AMS-adhered ADSCs are promising source for cell therapy of knee OA.

Long‑term survival prognosis of function‑preserving curative gastrectomy for early gastric cancer

Segmental gastrectomy, mini-distal gastrectomy and local resection of the stomach are function-preserving curative gastrectomies (FPGs), which are used to treat gastric cancer in specialized centers. These surgical options are less invasive and can alleviate postgastrectomy symptoms more than standard gastrectomy; however, their association with prognosis remains to be fully elucidated. The present study aimed to compare the survival prognosis of patients diagnosed as node-negative by sentinel node biopsy (SNB) treated via FPG with reduced lymph node dissection with that of patients who underwent guideline gastrectomy (GL). This retrospective study was conducted between April 1999 and March 2016. The inclusion criteria were a diagnosis of gastric cancer type 0, of ≤5 cm, located in L or M areas, and pT1N0. Patients who underwent distal gastrectomy and pylorus-preserving gastrectomy were included as controls in the GL group. Among the 146 and 300 patients in the FPG and GL groups, respectively, only 1 patient in the GL group experienced recurrence. The overall survival (OS) of the FPG group was 96.6% at 5 years and 92.5% at 10 years, which was significantly higher than that of the GL group (P<0.05). In addition, the cumulative incidence of non-cancer-related deaths, especially pulmonary diseases, was lower in the FPG group than that in the GL group (P<0.05). Notably, the OS and non-cancer death rate in the FPG group remained significantly better after propensity score-matching analysis. In conclusion, for early gastric cancer located in M or L areas, patients treated via FPG guided by SNB have a better prognosis and fewer deaths caused by respiratory disease than those treated via GL. The present clinical trial was registered under the following trial registration numbers: UMIN000010154 (2013/3/4), UMIN000023828 (2016/8/29), jRCTs041180006 (2018/10/9).

Climate-driven variability of the Southern Ocean CO2 sink

The Southern Ocean is a major sink of atmospheric CO2, but the nature and magnitude of its variability remains uncertain and debated. Estimates based on observations suggest substantial variability that is not reproduced by process-based ocean models, with increasingly divergent estimates over the past decade. We examine potential constraints on the nature and magnitude of climate-driven variability of the Southern Ocean CO2 sink from observation-based air-sea O2 fluxes. On interannual time scales, the variability in the air-sea fluxes of CO2 and O2 estimated from observations is consistent across the two species and positively correlated with the variability simulated by ocean models. Our analysis suggests that variations in ocean ventilation related to the Southern Annular Mode are responsible for this interannual variability. On decadal time scales, the existence of significant variability in the air-sea CO2 flux estimated from observations also tends to be supported by observation-based estimates of O2 flux variability. However, the large decadal variability in air-sea CO2 flux is absent from ocean models. Our analysis suggests that issues in representing the balance between the thermal and non-thermal components of the CO2 sink and/or insufficient variability in mode water formation might contribute to the lack of decadal variability in the current generation of ocean models. This article is part of a discussion meeting issue 'Heat and carbon uptake in the Southern Ocean: the state of the art and future priorities'.

Urine osmolality predicts worsening renal function and poor prognosis in acute decompensated heart failure

Background/Purpose

Worsening renal function (WRF) can sometimes occur in the patients with acute decompensated heart failure (ADHF) and increase the risk of morbidity and mortality (1). In a previous study, it was reported that fractional excretion of sodium (FENa) reflects net sodium reabsorption from nephron segments and predicts WRF during treating ADHF (2). On the other hand, recently the new drugs which approach urine concentration mechanism and affect urine osmolality (U-OSM), such as tolvaptan and sodium-glucose cotransporter-2 inhibitor, have begun to be widely used as treatment of heart failure. Thus, we focused on U-OSM, which reflects not only sodium handling but also water excretion controlled by the collecting duct, and evaluated the association between WRF and U-OSM. Moreover, previous studies have demonstrated that FENa, fractional excretion of urea nitrogen and transtubular potassium concentration gradient are markers for long-term prognosis in patients with ADHF (3–5). Therefore, we also studied whether U-OSM can predict prognosis in ADHF.

Methods

A total of 157 patients admitted to our hospital because of a primary diagnosis of ADHF from February 2020 through July 2021 were retrospectively reviewed. U-OSM in the spot urinary samples were examined within 72 hours after admission. U-OSM was calculated based on the following validated formula (6): U-OSM = 1.07 × {2 × [urine sodium (mEq/L)] + [urine urea nitrogen (mg/dL)]/2.8 + [urine creatinine (mg/dl)] × 2/3} + 16.2. The primary outcome was the occurrence of WRF during hospitalization. WRF was defined as increased serum creatinine ≥0.3 mg/dL from baseline (7). The secondary outcome was the occurrence of ADHF readmission and all-cause death within 180 days after discharge.

Results

Primary Outcome. WRF developed in 46% of all patients. In the patients that developed WRF during hospitalization, U-OSM was significantly lower than in the patients without WRF (366±106 mOsm/L versus 430±128 mOsm/L; P&lt;0.001). Receiver operating characteristic curve analysis revealed the optimal cutoff values of U-OSM was 403 mOsm/L (AUC 0.64; 95% CI: 0.56–0.72; P&lt;0.001) to predict the WRF (Figure 1). On multivariable logistic regression analysis, U-OSM (OR, 1.99, 95% CI: 1.27–3.12; p=0.003) and serum creatinine (OR, 1.00, 95% CI: 0.99–1.00; P=0.009) were independent predictors of WRF.

Secondary Outcome. There were 34 patients (22%) readmitted and 9 patients (6%) died within 180 days after discharge. ROC curve analysis revealed the optimal cutoff values of U-OSM as 349 mOsm/L (C-statistic 0.74; 95% CI: 0.65–0.83; P&lt;0.001) to predict ADHF readmission and all-cause death within 180 days (Figure 2A). On Kaplan-Meier analysis, the secondary outcome was significantly higher in patients with U-OSM&lt;349 mOsm/L (u-OSM≥349, 57%, U-OSM&lt;349, 43%; HR, 0.99; 95% CI: 0.99–1.00, P&lt;0.001) (Figure 2B).

Conclusion

U-OSM on admission may be a predictor of WRF and a prognostic marker in ADHF patients.

Funding Acknowledgement

Type of funding sources: None.

Development and initial validation of the Japanese healthy work environment assessment tool for critical care settings

AIM

This study aims to translate the Healthy Work Environment Assessment Tool (HWE-AT) into Japanese and evaluate its validity and reliability.

DESIGN AND METHODS

The authors followed the guidelines for scale translation, adaptation, and validation in cross-cultural healthcare research. After translation and back-translation, a series of pilot studies were conducted to assess comprehensibility. Subsequently, an expert panel established the content validity. Content validity was calculated using the content validity index (CVI). Finally, we verified the construct validity and calculated the test-retest reliability.

RESULTS

The updated HWE-AT achieved sufficient comprehensibility after conducting the two pilot tests. Content validity was calculated using the scale-level CVI/average and all the items were 1.00. The content validity indices CFI and RMSEA were 0.918 and 0.082, respectively. Intraclass correlation coefficients for all dimensions ranged from 0.618 to 0.903, indicating acceptable test-retest reliability. Our findings suggest that the Japanese version of the HWE-AT has good validity and reliability.

Life prognosis of sentinel node navigation surgery for early-stage gastric cancer: Outcome of lymphatic basin dissection

BACKGROUND

Lymphatic basin dissection is a sentinel node biopsy method that is specific for gastric cancer. In this method, the dyed lymphatic system is dissected en bloc, and sentinel nodes are identified at the back table (ex vivo). Even with lymphatic basin dissection, blood flow to the residual stomach can be preserved, and function-preserving curative gastrectomy can be performed. The oncological safety of function-preserving curative gastrectomy combined with lymphatic basin dissection has not yet been fully investigated. We hypothesized that the oncological safety of sentinel node navigation surgery (SNNS) is not inferior to that of the guidelines.

AIM

To investigate the life prognosis of SNNS for gastric cancer in comparison with guidelines surgery.

METHODS

This was a retrospective cohort study. Patients were selected from gastric cancer patients who underwent sentinel node biopsy from April 1999 to March 2016. Patients from April 1999 to August 2008 were from the Department of Surgery II, Kanazawa University Hospital, and patients from August 2009 to March 2016 were from the Department of Surgical Oncology, Kanazawa Medical University Hospital. Patients who were diagnosed with gastric cancer, which was preoperatively diagnosed as superficial type (type 0), 5 cm or less in length, clinical T1-2 and node negative, and underwent various gastrectomies guided by sentinel node navigation were retrospectively collected. The overall survival (OS) and relapse-free survival (RFS) of these patients (SNNS group) were investigated. Patients with gastric cancer of the same stage and who underwent guidelines gastrectomy with standard nodal dissection were also selected as the control group.

RESULTS

A total of 239 patients in the SNNS group and 423 patients in the control group were included. Pathological nodal metastasis was observed in 10.5% and 10.4% of the SNNS and control groups, respectively. The diagnostic abilities of sentinel node biopsy were 84% and 98.6% for sensitivity and accuracy, respectively. In the SNNS group, 81.6% of patients underwent modified gastrectomy or function-preserving curative gastrectomy with lymphatic basin dissection, in which the extent of nodal dissection was further reduced compared to the guidelines. The OS rate in the SNNS group was 96.8% at 5 years and was significantly better than 91.3% in the control group (P = 0.0014). The RFS rates were equal in both groups. After propensity score matching, there were 231 patients in both groups, and the cumulative recurrence rate was 0.43% at 5 years in the SNNS group and 1.30% in the control group, which was not statistically different.

CONCLUSION

The oncological safety of patients who undergo gastrectomy guided by sentinel node navigation is not inferior to that of the guidelines surgery.

Effects of cardiac rehabilitation on the two-year prognosis of patients with heart failure: a multicentre prospective cohort study

Background

Cardiac rehabilitation (CR) is a comprehensive disease management program highly recommended by heart failure (HF) guidelines. However, the prognostic effects of outpatient CR are inconsistent among recent meta-analyses which enrolled mainly younger HF with reduced ejection fraction (HFrEF). With an aging population, an increased importance of CR has been put on patients with HF with preserved ejection fraction (HFpEF).

Purpose

This study aimed to examine the prognostic effects of regularly undergoing CR for 6 months after discharge analysing nationwide cohort data including older population with HFrEF and HFpEF.

Methods

We analysed 2876 patients who hospitalised for acute HF or worsening chronic HF and capable of walking at discharge in the multicentre prospective cohort study. Frequency of outpatient CR participation of each patient was collected using medical records. We assessed CR frequency within 6 months of discharge since most collaborating hospitals conducted final follow-up examinations at 6 months. The CR group was defined as patients who underwent outpatient CR once or more per week for 6 months after discharge. The main study endpoint was a composite of all-cause mortality and HF rehospitalisation during a 2-year follow-up. We performed a propensity score-matched analysis to compare survival rates between the CR and non-CR groups. Propensity scores for each patient were produced by a logistic regression analysis with the CR group as the dependent variable and 33 potential confounders as independent variables. To evaluate events beyond 6 months, we also conducted landmark analyses at 6 months.

Results

Of the 2876 enrolled patients, 313 underwent CR for 6 months. After propensity score matching using confounding factors, 626 patients (313 pairs) were included in the survival analysis (median age: 74 years, men: 59.6%, median left ventricular ejection fraction [LVEF]: 42%). During 1006.1 person-years of follow-up, 137 patients were rehospitalised due to HF exacerbation, and 50 patients died in the matched cohort. In Cox proportional hazards model (Figure 1), CR was associated with a reduced risk of composite outcomes (hazard ratio [HR] 0.66; 95% confidence interval [CI] 0.48–0.91), all-cause mortality (HR 0.53; 95% CI 0.30–0.95), and HF rehospitalisation (HR 0.66; 95% CI 0.47–0.92). A subgroup analysis showed similar CR effects in patients with HFpEF (LVEF ≥50%) and HFrEF (LVEF &lt;40%). However, in a landmark analysis, CR did not reduce the adverse outcomes beyond 6 months after discharge (Figure 2).

Conclusions

The findings of this study demonstrate the needs that CR should become a standard treatment for HF regardless of HF type and the necessity of periodical follow-up after completing CR program to maintain its prognostic effects.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant-in-Aid for Scientific Research (A) from the Japan Society for the Promotion of Science Figure 1. Prognostic effects of CRFigure 2. Landmark analysis

Association between lowering heart rate during IMPELLA support and favorable short-term outcome in patients with cardiogenic shock

Background

Impella has been increasingly used in patients with cardiogenic shock (CGS). Target values for clinical indices for appropriate management of Impella have not yet been established.

Purpose

We aimed to elucidate the association between heat rate (HR) during Impella treatment in patients with CGS and clinical outcomes.

Methods and results

We retrospectively evaluated 62 patients (68±14 years; male 77%) with CGS receiving temporary circulatory support with the Impella between February 1, 2019, and February 31, 2021. The primary end point was 30-day mortality. Clinical characteristics, laboratory and hemodynamic markers at implantation of Impella (baseline), 12, 24 hr after implantation, and removal of Impella were assessed. There were 28 patients with concomitant use of extracorporeal membrane oxygenation (ECMO). Treatment periods using Impella were 8±6 days. After excluding 11 patients who died during Impella support, the relationship between clinical indicators at each time points and 30-day mortality was evaluated. There were 22 patients (43%) with 30-day mortality. Factors associated with 30-day mortality were: female, ECMO, higher 24-hr lactate level, lower 24-hr cardiac power output, and higher HR at removal. Lower HR of ≤81 bpm at removal was found to most accurately predict lower 30-day mortality (Figure 1). Higher increases in dose of beta-blockers during Impella support and lower absolute doses of norepinephrine at removal were correlated with decreases in HR during Impella support.

Conclusions

In patients with CGS treated with Impella, lower HR at removal was associated with lower incidence of 30-day mortality. Lowering HR during Impella treatment was recognized as a simple indicator for favorable clinical outcomes in patients with CGS. It was suggested that chronotropic interventions during Impella treatment may be novel therapeutic options in patients with CGS.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Angioscopic evaluation of vascular healing at 1 and 12 months after drug-coated stent implantation

Background

Polymer- and carrier-free Biolimus-A9-coated stent (DCS) is expected better vascular healing compared with conventional durable polymer drug-eluting stents (DES). Moreover, DCS had been demonstrated in clinical trials to allow one-month short dual antiplatelet therapy, which might achieve sufficient healing at only 1 month after implantation. However, the process of vascular healing after DCS implantation has not been elucidated by angioscopic observation.

Purpose

To evaluate the process of vascular healing at 1 month and 12 months after DCS implantation.

Methods

This study included 57 patients treated with DCS or durable polymer everolimus-eluting stents (EES) in our hospital from April 2017 to April 2019. Firstly, the angioscopic findings of DCS at 1 month (n=16) and 12 months (n=14) after implantation were respectively compared with EES at 12 months after implantation (EES-12, n=35) as a standard healing status of DES. Secondary, angioscopic findings of DCS at 1 month and 12 months after implantation were compared among the serially observed eight patients. Neointimal coverage (NIC) grade, yellow colour grade, and the presence of thrombus were evaluated. NIC grade was classified as grade 0 (no neointimal coverage), grade 1 (struts were bulged into lumen but covered), grade 2 (struts were embedded in the neointima but visible), or grade 3 (struts were fully embedded and invisible). Yellow colour grade was classified as grade 0 (white), grade 1 (light yellow), grade 2 (yellow), or grade 3 (intensive yellow).

Results

At 1 month after DCS implantation, dominant NIC grade was lower (0.3±0.5 vs. 1.5±0.7, p&lt;0.001) and the frequency of thrombus was higher (38% vs. 6%, p=0.008) than EES-12. On the other hands, at 12 months after DCS implantation, dominant NIC grade was higher (2.1±0.6 vs. 1.5±0.7, p=0.013) and the frequency of thrombus was not different (7% vs. 6%, p=1.000) in comparison with EES-12. By serial observation of DCS, dominant NIC grade was higher at 12 months than at 1 month (2.3±0.5 vs. 0.4±0.5, p&lt;0.001), while yellow colour grade (1.0±0.5 vs. 1.5±1.2, p=0.227) and the frequency of thrombus adhesion (0% vs. 38%, p=0.200) were not different.

Conclusion

Compared with EES-12, vascular healing of DCS was inferior at 1 month but superior at 12 months.

Figure 1

Funding Acknowledgement

Type of funding source: None

Weight loss early after discharge predicts the risk of rehospitalization in non-obese patients with heart failure preserved ejection fraction

Background

Weight loss (WL) has been considered as a prognostic factor in heart failure with reduced ejection fraction (HFrEF). However, the prognosis and associated factors of WL in heart failure with preserved ejection fraction (HFpEF) have remained unclear.

Purpose

This study aimed to examine the prevalence, prognosis, and clinical characteristics of worse prognosis based on the identified WL after discharge in HFpEF.

Methods

The study was conducted as a part of a multicenter cohort study (Flagship). The cohort study enrolled ambulatory HF who hospitalized due to acute HF or exacerbation of chronic HF. Patients with severe cognitive, psychological disorders or readmitted within 6-month after discharge were excluded in the study. WL was defined as ≥5% weight loss in 6-month after discharge and HFpEF was defined as left ventricular ejection fraction (LVEF) ≥50% at discharge. Age, gender, etiology, prior HF hospitalization, New York Heart Association (NYHA) class, brain natriuretic peptide (BNP) or N-terminal-proBNP (NT-proBNP), anemia (hemoglobin; male &lt;13g/dL, female &lt;12g/dL), serum albumin, Geriatric Depression Scale, hand grip strength and comorbidities were collected at discharge. Patients were stratified according to their body mass index (BMI) at discharge as non-obese (BMI &lt;25) or obese (BMI ≥25). We analyzed the association between WL and HF rehospitalization from 6 month to 2 years after discharge using Kaplan-Meier curve analysis and Cox regression analysis adjusted for age and gender, and clinical characteristics associated to worse prognosis in WL using logistic regression analysis adjusted for potential confounders in HFpEF.

Results

A total of 619 patients with HFpEF were included in the analysis. The prevalence of WL was 12.9% in 482 non-obese and 15.3% in 137 obese patients. During 2 years, 72 patients were readmitted for HF (non-obese: 48, obese: 24). WL in non-obese independently associated with poor prognosis (hazard ratio: 2.2: 95% confidence interval: 1.13–4.25) after adjustment for age and sex, while WL in obese patients did not. Logistic regression analysis chose age (odds ratio 1.02 per 1 year; 1.00–1.05), anemia (2.14; 1.32–3.48), and BNP ≥200pg/mL or NT-proBNP ≥900pg/mL (1.83; 1.18–2.86) as independent associated factors for worse prognosis of WL in non-obese patients.

Conclusion

In HFpEF, WL in early after discharge in non-obese elderly patients may be a prognostic indicator for HF rehospitalization. HF management including WL prevention along with controlling anemia is likely to improve prognosis in this population.

Kaplan Meier survival curves

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): A Grant-in-Aid for Scientific Research (A) from the Japan Society for the Promotion of Science

Severity of postgastrectomy syndrome and quality of life after advanced gastric cancer radical gastrectomy

It has previously been suggested that postgastrectomy syndrome (PGS) is more severe in patients after surgery for advanced gastric cancer than in patients with early gastric cancer. Using the postgastrectomy syndrome assessment scale-45 (PGSAS-45), the present study aimed to determine whether PGS for postgastrectomy patients, in Kanazawa Medical University Hospital, with advanced gastric cancer was more severe than for patients with early gastric cancer. A questionnaire survey was conducted using PGSAS-45 for curative gastric cancer gastrectomy cases at Kanazawa Medical University Hospital. The questionnaire data were combined with patient background data, anonymized and moved to an unlinked file for patient privacy. Using this dataset, non-recurrent cases of distal partial gastrectomy were extracted and divided into two groups, stage IA or IB patients (group E), and stage IIA or higher (group A). The main outcome measures (MOMs) of PGSAS-45 were compared between the two groups. The participants in the present study included 35 cases in group E and 22 cases in group A. The results of a univariate analysis to compare the MOMs between the two groups showed that only the dumping subscale was significantly different in group A and was judged to be caused by the underlying bias of the background factor. There were no MOMs with significant differences in the pathological stage based on multiple regression analyses. In cases of distal partial gastrectomy, the PGS and quality of life (QoL) of patients following advanced gastric cancer surgery were similar to those of patients with early gastric cancer. The standardized treatment for advanced gastric cancer did not induce notable postoperative failures, and QoL was not impaired. In contrast, for early-stage gastric cancer cases, the present study suggests that it is necessary to distinguish metastasis-negative cases to indicate an appropriate, function-preserving curative gastrectomy.

Comparison of the pain-reducing effects of EMLA cream and of lidocaine tape during arteriovenous fistula puncture in patients undergoing hemodialysis: A multi-center, open-label, randomized crossover trial

Arteriovenous fistula puncture pain is a serious problem for patients undergoing dialysis and a good indication for topical anesthetics. No previous study has compared lidocaine/prilocaine cream (EMLA) with lidocaine tape for pain relief during arteriovenous fistula puncture in patients undergoing maintenance hemodialysis. To this end, we conducted a multicenter randomized crossover study including 66 patients (mean age, 65.8 years; males, 57.6%) undergoing maintenance hemodialysis thrice/week. Subjects were assigned to Sequence EL (EMLA administration followed by lidocaine, with 1-week wash-out) or Sequence LE (reverse administration, first lidocaine then EMLA). All subjects completed the study. At each puncture site, 1 g EMLA (25 mg lidocaine + 25 mg prilocaine) or one sheet of lidocaine tape (18 mg lidocaine) was applied 1 h or 30 min prior to arteriovenous fistula puncture, respectively. The primary endpoint was puncture pain relief, which was measured using a 100-mm visual analog scale. The secondary endpoints included quality of life, which was measured by SF-36, and safety. EMLA produced a 10.1-mm greater visual analog scale improvement than lidocaine tape (P = 0.00001). However, there was no statistically significant difference in the quality of life between the two groups, and no significant carryover/period effect was observed in any analysis. Further, no drug-related adverse events were observed. Taken together, these results suggest that EMLA cream is superior to lidocaine tape for the relief of arteriovenous fistula puncture pain in patients undergoing maintenance hemodialysis. Trial registration: University Hospital Medical Information Network Clinical Trials Registry (UMIN000027885).

P92 A novel method of correcting the left ventricular stroke volume by Doppler echocardiography: comparison with multidetector computed tomography

Background

Although transthoracic Doppler echocardiography is widely used for estimating left ventricular stroke volume (SV), accelerated blood flow in the left ventricular (LV) outflow tract may lead to overestimation. SV can be calculated accurately from left ventricular end-systolic and end-diastolic volume determined by multi-detector computed tomography (MDCT). However, radiation exposure as well as the use of contrast medium hampers its routine use.

Purpose

The purpose of this study was to examine whether the correction of SV measured by pulsed wave Doppler echocardiography (SVdop) can accurately predicts SV obtained by MDCT (SVct).

Methods： We enrolled consecutive 61 patients who underwent both MDCT and transthoracic echocardiography. Patients with moderate or severe valvular diseases and valve replacement surgery were excluded. Correction of SV was explored with SVct as a reference.

Results： Univariate analysis showed that SVdop (r = 0.42, P = 0.0007) and patient age (r=-0.50, P &lt; 0.0001) were significantly correlated with SVct. On the other hand, left ventricular ejection fraction calculated by Teicholz method (EFteich) (r = 0.19, P = 0.14), systolic blood pressure (r = 0.07, P = NS), and LV mass index (r=-0.02, P = NS) were not correlated with SVct. Multivariate analysis showed that SVdop, patient age and EFteich were the independent predictive factors for SVct (R2 = 0.49, P &lt; 0.0001). Based on these correlations, we postulated SV as: corrected SV = SVdop × 0.40 + EFteich × 0.46 – age × 0.67 + 44.77. As expected, the correlation between corrected SV and SVct significantly improved (r = 0.70, P &lt; 0.0001). Bland-Altman plot analysis showed that corrected SV significantly reduced the variation between SVdop and SVct, and diminished the overestimation of SVdop (Figure).

Conclusion： The new correction formula of SVdop may correct the overestimation of SV obtained by pulsed wave Doppler echocardiography, although the formula remains to be validated in a separate cohort of patients.

Abstract P92 Figure

Leukemia inhibitory factor induces corticotropin-releasing hormone in mouse trophoblast stem cells

Previous studies have shown that some inflammatory cytokines promote the expression of corticotropin-releasing hormone (CRH) in trophoblasts during pregnancy and that placental CRH could induce the production of adrenocorticotropic hormone (ACTH) in humans. However, whether the same is true in rodent placenta remains unclear. In this study, we examined the effect of pro-inflammatory cytokine LIF on the induction of CRH in mouse trophoblast stem cells (mTSCs). During differentiation, the CRH levels in mTSCs gradually increased. On days 3 and 5 after LIF supplementation, Crh expression in the differentiated mTSCs was significantly increased with LIF treatment than those without LIF treatment. Moreover, the CRH concentration in the culture media increased. Thereafter, we examined the contribution of the downstream pathways of LIF to CRH induction in differentiated mTSCs. The LIF-induced upregulation of CRH was attenuated by inhibition of PI3K/AKT and MAPK phosphorylation but not by inhibition of JAK/STAT3. Therefore, in mTSCs, LIF increased Crh expression through activation of the PI3K/AKT and MAPK pathways but not by the JAK/STAT3 pathway. The present study suggests that mTSC is an ideal in vitro model for studying regulation and function of placental CRH.

P6322Trajectories of functional limitations during 14 months after discharge among patients with heart failure: a multicenter cohort study

Background

Severity of functional limitations (FLs) has been considered as a prognostic factor in patients with heart failure (HF). However, trajectory patterns of FLs after discharge and their associated factors have remained unclear.

Purpose

This study aimed to explore trajectories of FLs after discharge and to examine clinical characteristics based on the identified trajectories.

Methods

This study was performed as a part of a multicenter cohort study. The cohort study enrolled hospitalized patients due to acute HF or exacerbation of chronic HF and who were able to walk at discharge. Patients with severe cognitive or psychological disorders or less than 6-month life expectancy were excluded. FLs were assessed using Performance Measure for Activities of Daily Living-8 (PMADL-8; higher scores indicate worse FLs) at discharge and 1-, 6-, 10- and 14-month after discharge. To identify FLs trajectories getting worse after discharge, we excluded patients already having severe FLs at discharge (PMADL-8 ≥21, a cut off value for predicting poor prognosis). Group-based trajectory modeling (GBTM) was conducted to identify distinct PMADL-8 trajectories. Then, associated factors of trajectory group that showed increasing FLs after discharge were examined using logistic regression analysis adjusted for potential confounders.

Results

A total of 953 patients were included in the analysis (age: 70.6±11.8 years, men: 70.9%, left ventricular ejection fraction <40%: 41.3%). GBTM identified four PMADL-8 trajectories: two separate trajectories where PMADL-8 remained low (T1: 14.1%, T2: 31.3%), mildly increasing PMADL-8 trajectory (T3: 41.0%) and rapidly increasing PMADL-8 trajectory (T4: 13.6%) (Figure). Logistic regression analysis showed that age (odds ratio 1.05, per 1 year; 95% confidence interval 1.02–1.07), women (2.12; 1.31–3.45), brain natriuretic peptide ≥200 pg/mL (1.88; 1.10–3.21), estimated glomerular filtration rate <30 mL/min/1.73m2 (2.50; 1.41–4.41), depression (2.34; 1.44–3.80), and re-hospitalization due to HF during 1-year follow-up (2.85; 1.56–5.21) were independent associated factors of T4 group.

Figure 1. Trajectories of PMADL-8

Conclusions

The high-risk population for increasing FLs after discharge was identified by GBTM. The findings of this study suggest the importance of long-term HF management for preventing FLs after discharge especially among those with older age, female gender and depression.

Acknowledgement/Funding

This work was supported by a Grant-in-Aid for Scientific Research (A) from the Japan Society for the Promotion of Science [16H01862].

296Clinical benefit of assessing cognitive function in frail patients with heart failure: a multicenter prospective cohort study

Background

Cognitive decline is highly prevalent in patients with heart failure (HF) and increases the risk of hospital readmission or mortality due to poor self-care ability. Although cognitive decline often coexists with physical frailty (PF) in HF, the clinical utility of combined assessment of both cognitive function and PF remains unclear.

Purpose

The aim of this study was to examine the prognostic value of assessing cognitive function and PF in patients with HF.

Methods

This prospective study was performed as a multicenter cohort study in Japan (FLAGSHIP). We enrolled 1611 patients admitted for acute HF or exacerbation of chronic HF and who were able to walk at discharge. Patients with severe dementia [Mini-Mental State Examination (MMSE) scores <18], severe psychological disorders or less than 6-month life expectancy were excluded. From data at discharge, we collected data on cognitive function, PF, age, gender, New York Heart Association class, left ventricular ejection fraction, brain natriuretic peptide, estimate glomerular filtration rate, hemoglobin, depression (5-item geriatric depression scale ≥2) and comorbidities, including atrial fibrillation, diabetes mellitus, stroke, and hyponatremia. PF was defined as ≥2 of the followings based on our previous publication: usual walking speed <0.8 m/s; grip strength <26 kg (men) or <17 kg (women); Performance Measure of Activity in Daily Living-8 ≥21; body mass index <20 kg/m2. Cognitive function was assessed by MMSE. We selected the optimal cutoff point of MMSE that predict a worse outcome by the receiver operating characteristic (ROC) curve analysis. Study outcome was a composite outcome of rehospitalization for worsening HF or all-cause mortality within 2 years after discharge. We used Cox proportional-hazard models to examine the association between the presence of cognitive decline and PF and 2-years prognosis, controlling for potential confound factors.

Results

A total of 507 events (31.5%) were observed (400 HF rehospitalization, 27 cardiac death, 80 non-cardiac death). The optimal cutoff point of MMSE was 28 (the area under the ROC curve: 0.58, p<0.01, sensitivity: 71.0%, specificity: 41.0%). There was a significant difference in event-free survival across the groups stratified by cognitive decline (MMSE <28) and PF (Figure). After adjusting for all variables, coexistence of both cognitive decline and PF was independently associated with 2-years prognosis (hazard ratio: 1.52, 95% confidence interval: 1.19–1.94).

Conclusion

Our data shows that even a slight decline in cognitive function leads to an increased risk of death or HF rehospitalization in frail patients with HF. Combined assessment both cognitive function and PF improves risk stratification for readmission and mortality in patients with HF.

Acknowledgement/Funding

This work was supported by a Grant-in-Aid for Scientific Research (A) from the Japan Society for the Promotion of Science [16H01862].

The neutrophil/lymphocyte ratio as a predictor of peritoneal metastasis during staging laparoscopy for advanced gastric cancer: a retrospective cohort analysis

BACKGROUND

The use of staging laparoscopy (SL) has become widespread in patients with advanced gastric cancer (GC). This study aimed to evaluate the predictive value of the neutrophil/lymphocyte ratio (NLR) for the presence of peritoneal metastasis during staging laparoscopy in patients with advanced GC.

METHODS

This retrospective analysis was performed in 35 patients with advanced GC who underwent SL at Kanazawa Medical University Hospital between January 2009 and December 2017. Clinicopathological characteristics were examined and multivariate analyses were performed to identify preoperative laboratory parameters that were independently associated with the presence of peritoneal metastasis or cytological malignancy (P/CY positive) during SL.

RESULTS

A P/CY-positive result was confirmed during SL in 16 patients (45.7%). Patients with type 4 or diffuse type 3 tumors showed a significantly higher P/CY-positive rate than those with other tumor types (58.3% vs. 18.2%, P = 0.02). In the univariate analysis for preoperative laboratory parameters, NLR (P < 0.0001) and total protein (P = 0.03) and albumin (P = 0.04) levels were significantly correlated with a P/CY-positive result. On multivariate analysis, NLR was significantly correlated with a P/CY-positive result (P = 0.0002). In patients with type 4 or diffuse type 3 tumors, a high NLR (> 3.5) was associated with a significantly higher P/CY-positive rate than a low NLR (≤ 3.5) (83.3% vs. 33.3%, P = 0.01). Moreover, in patients without type 4 or diffuse type 3 tumors, the P/CY-positive rates were 100% and 0% in patients with NLR > 3.5 and NLR ≤ 3.5, respectively.

CONCLUSIONS

The preoperative NLR was a significant independent predictor of the presence of peritoneal metastasis during SL. Regardless of tumor type, patients with a high NLR could be reasonable candidates for SL. On the other hand, non-diffuse type tumor accompanied by a low NLR may not need to undergo SL.

Modified Gant-Miwa-Thiersch procedure (mucosal plication with anal encircling) for rectal prolapse

AIM

Rectal prolapse (RP) is usually associated with elderly women and is well recognized as having a detrimental effect on quality of life. A number of surgical procedures for RP are available, but morbidity and mortality are substantial. The Gant-Miwa-Thiersch procedure (GMT) has been frequently used for RP in Japan. However, as GMT has a high recurrence rate it is not widely used elsewhere. The aim of this study was to evaluate a modified version of GMT (mGMT) in comparison with other procedures.

METHOD

mGMT was performed under spinal or local anaesthesia in 187 patients with RP. No normal mucosa was left between the tags and lateral wounds were created in the Thiersch procedure. Morbidity, mortality and recurrence rates were recorded.

RESULTS

No serious postoperative complications and no operative deaths occurred after mGMT. Eight per cent of patients suffered from infection of the strings. The overall recurrence rate after mGMT was 7.5% with a median follow-up period of 13.8 years.

CONCLUSION

On the basis of these results, we consider that mGMT has a number of advantages: it is minimally invasive, does not require general anaesthesia, is technically simple to perform and is associated with satisfactory outcomes and low morbidity. mGMT should be considered an option for the treatment of RP in elderly patients.

Effect of switching to teneligliptin from other dipeptidyl peptidase-4 inhibitors on glucose control and renoprotection in type 2 diabetes patients with diabetic kidney disease

AIMS/INTRODUCTION

The objective of the present study was to elucidate the effect of switching to teneligliptin from other dipeptidyl peptidase-4 (DPP-4) inhibitors on glucose control and renoprotection in type 2 diabetes mellitus patients with diabetic kidney disease.

MATERIALS AND METHODS

The present study was a single-arm, open-label, observational study. A total of 23 patients, who had urinary albumin/creatinine ratios (UACR) ≥30 mg/gCr in their first urine in the early morning, and received other DPP-4 inhibitors and renin-angiotensin system inhibitors, switched to teneligliptin 20 mg/day. After switching to teneligliptin for 24 weeks, we evaluated changes in glycated hemoglobin (HbA1c), fasting plasma glucose levels, plasma DPP-4 activity and UACR.

RESULTS

HbA1c, fasting plasma glucose and UACR values showed no significant change after 24 weeks compared with baseline. However, plasma DPP-4 activity was significantly reduced after 24 weeks (0.57 ± 0.26 nmol/min/mL, P = 0.012, vs baseline), compared with baseline (1.49 ± 1.73 nmol/min/mL), and there was a positive relationship between the change rate of plasma DPP-4 activity (Δ%DPP-4) for 24 weeks and the levels of plasma DPP-4 activity (r = -0.5997, P = 0.0025) and fasting plasma glucose (r = -0.4235, P = 0.0440) at baseline. Additionally, the Δ%DPP-4 for 24 weeks was significantly correlated to the change rate of UACR (r = 0.556, P = 0.0059). However, there was no relationship between Δ%DPP-4 and ΔHbA1c (amount of HbA1c change).

CONCLUSIONS

Switching to teneligliptin from other DPP-4 inhibitors for 24 weeks reduces plasma DPP-4 activity, which is associated with a reduction in albuminuria, independent of the change in glucose levels, in type 2 diabetes mellitus patients with diabetic kidney disease.

Abstract P4-06-28: Doxorubicin induces cellular senescence in human breast cancer cells and sensitizes them to cytotoxic T-lymphocytes

[Background]“Cellular senescence” is a state in which cells undergo irreversible cell cycle arrest in response to various cellular stresses. Senescence is induced in not only normal cells but also cancer cells when anti-cancer agents trigger DNA damage. Recent studies have revealed additional feature of senescent cells: increased secretion of various secretory proteins, such as inflammatory cytokines, chemokines, growth factors, and MMPs. This newly recognized senescent phenotype, termed senescence-associated secretory phenotype (SASP), reportedly contribute to tumor recurrence and promotion. Alternatively, senescent cancer cells could be good targets in anti-cancer immunotherapy because they are cell cycle-arrested.

[Objective]In this study, we determined whether ”cellular senescence” could be induced by a chemotherapeutic drug doxorubicin (DXR) and whether senescent cancer cells might increase their susceptibility to cytotoxic T-lymphocytes using human breast cancer cells.

[Methods and Results]A triple-negative (negative for ER, PR, and HER2) human breast cancer cell line (MDA-MB-231) was used. This cell line was treated with DXR for 2 days and examined for their appearance microscopically. The DXR treatment (500 nM) decreased their proliferating ability and increased their cell size. Colony formation assay revealed that cancer cells significantly decreased the number of colonies even with lower doses (3 nM) of DXR. In immunoblot assay, the DXR treatment increased the protein expression of p21, which inhibits cell cycle. In a flow cytometric assay after staining with SPIDER-β-gal, the DXR treatment (500 nM) increased the expression of β-gal in MDA-MB-231 cells. The induction of SA-β-gal in DXR-treated cancer cells were also confirmed by confocal imaging. In addition, the DXR treatment (500 nM) for 2 days beforehand increased their subsequent ability to produce IL-6 and IL-8. Although the DXR treatment (500 nM) decreased the expression of epidermal growth factor receptor (EGFR) on cancer cells, this treatment sensitized them to anti-EGFR chimeric antigen receptor (CAR) T-lymphocytes in apoptosis assay.

[Conclusion]These results suggest that a chemotherapeutic drug DXR can render MDA-MB-231 cells to be senescent and increase their sensitivity to antigen-specific cytotoxic T-lymphocytes. These findings may provide a rationale of combination of chemotherapy and T cell-based anti-cancer immunotherapy.

Citation Format: Inao T, Iida Y, Kotani H, Harada M. Doxorubicin induces cellular senescence in human breast cancer cells and sensitizes them to cytotoxic T-lymphocytes [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-06-28.

Change in Impulse Response of Heart Rate to Instantaneous Lung Volume

A method is presented that relates the heart rate variability (HRV) to the change in instantaneous lung volume (ILV) under non-stationary conditions. Methods utilizing a recursive least squares (RLS) algorithm and a modified Widrow LMS algorithm are proposed to keep track of changes in impulse response of HRV to ILV. Results are presented of real data analysis and a dedicated system is proposed utilizing DSP chips for the real time data processing.

Ultrasonic cavitation induced water in vegetable oil emulsion droplets--a simple and easy technique to synthesize manganese zinc ferrite nanocrystals with improved magnetization

In the present investigation, synthesis of manganese zinc ferrite (Mn(0.5)Zn(0.5)Fe(2)O(4)) nanoparticles with narrow size distribution have been prepared using ultrasound assisted emulsion (consisting of rapeseed oil as an oil phase and aqueous solution of Mn(2+), Zn(2+) and Fe(2+) acetates) and evaporation processes. The as-prepared ferrite was nanocrystalline. In order to remove the small amount of oil present on the surface of the ferrite, it was subjected to heat treatment at 300 °C for 3h. Both the as-prepared and heat treated ferrites have been characterized by X-ray diffraction (XRD), infrared spectroscopy (IR), TGA/DTA, transmission electron microscopy (TEM) and energy dispersion X-ray spectroscopy (EDS) techniques. As-prepared ferrite is of 20 nm, whereas the heat treated ferrite shows the size of 33 nm. In addition, magnetic properties of the as-prepared as well as the heat treated ferrites have also been carried out and the results of which show that the spontaneous magnetization (σ(s)) of the heat treated sample (24.1 emu/g) is significantly higher than that of the as-synthesized sample (1.81 emu/g). The key features of this method are avoiding (a) the cumbersome conditions that exist in the conventional methods; (b) usage of necessary additive components (stabilizers or surfactants, precipitants) and (c) calcination requirements. In addition, rapeseed oil as an oil phase has been used for the first time, replacing the toxic and troublesome organic nonpolar solvents. As a whole, this simple straightforward sonochemical approach results in more phase pure system with improved magnetization.

Development and optimization of acoustic bubble structures at high frequencies

At high ultrasound frequencies, active bubble structures are difficult to capture due to the decrease in timescale per acoustic cycle and size of bubbles with increasing frequencies. However the current study demonstrates an association between the spatial distribution of visible bubbles and that of the active bubble structure established in the path of the propagating acoustic wave. By monitoring the occurrence of these visible bubbles, the development of active bubbles can be inferred for high frequencies. A series of still images depicting the formation of visible bubble structures suggest that a strong standing wave field exists at early stages of wave propagation and weakens by the increase in the attenuation of the acoustic wave, caused by the formation of large coalesced bubbles. This attenuation is clearly demonstrated by the occurrence of a force which causes bubbles to be driven toward the liquid surface and limit standing wave fields to near the surface. This force is explained in terms of the acoustic streaming and traveling wave force. It is found that a strong standing wave field is established at 168 kHz. At 448 kHz, large coalesced bubbles can significantly attenuate the acoustic pressure amplitude and weaken the standing wave field. When the frequency is increased to 726 kHz, acoustic streaming becomes significant and is the dominant force behind the disruption of the standing wave structure. The disruption of the standing wave structure can be minimized under certain pulse ON and OFF ratios.

Refined human artificial chromosome vectors for gene therapy and animal transgenesis

Human artificial chromosomes (HACs) have several advantages as gene therapy vectors, including stable episomal maintenance, and the ability to carry large gene inserts. We previously developed HAC vectors from the normal human chromosomes using a chromosome engineering technique. However, endogenous genes were remained in these HACs, limiting their therapeutic applications. In this study, we refined a HAC vector without endogenous genes from human chromosome 21 in homologous recombination-proficient chicken DT40 cells. The HAC was physically characterized using a transformation-associated recombination (TAR) cloning strategy followed by sequencing of TAR-bacterial artificial chromosome clones. No endogenous genes were remained in the HAC. We demonstrated that any desired gene can be cloned into the HAC using the Cre-loxP system in Chinese hamster ovary cells, or a homologous recombination system in DT40 cells. The HAC can be efficiently transferred to other type of cells including mouse ES cells via microcell-mediated chromosome transfer. The transferred HAC was stably maintained in vitro and in vivo. Furthermore, tumor cells containing a HAC carrying the suicide gene, herpes simplex virus thymidine kinase (HSV-TK), were selectively killed by ganciclovir in vitro and in vivo. Thus, this novel HAC vector may be useful not only for gene and cell therapy, but also for animal transgenesis.

Application of optical emission spectroscopy for He I considering the spatial structure of radiation trapping in MAP-II divertor simulator

The He I optical emission spectroscopy that considers the spatial structure of radiation trapping was proposed by us and was applied to a MAP-II divertor simulator. The spatial distribution of the optical escape factor was calculated from the n  (1)P (n≥3) state profiles measured by visible spectroscopy. The profile of 2  (1)P, which is immeasurable by visible spectroscopy, needs to be broader than that of the 3  (1)P state. The sensitivity of the 2  (1)P profile to the T(e) value estimated by He I spectroscopy is investigated.

Spatial distribution of acoustic cavitation bubbles at different ultrasound frequencies

Images of sonoluminescence, sonophotoluminescence and sonochemiluminescence are recorded in order to semi-quantitatively compare the spatial distribution of the cavitation activity at three different ultrasound frequencies (170 kHz, 440 kHz and 700 kHz) and at various acoustic amplitudes. At all ultrasound frequencies investigated, the sonochemically active cavitation zones are much larger than the cavitation zones where sonoluminescence is observed. Also, the sonochemically active bubbles are observed at relatively lower acoustic amplitudes than that required for sonoluminescence bubbles to appear. The acoustic power required for the observation of the initial cavitation bubbles increases with an increase in the ultrasound frequency. The cavitation bubbles are observed relatively uniformly throughout the reactor at 170 kHz whereas they are located away from the transducer at the higher frequencies used in this study. While these observations highlight the complexities involved in acoustic cavitation, possible reasons for the observed results are discussed.

Dependence of sonochemical parameters on the platinization of rutile titania - an observation of a pronounced increase in photocatalytic efficiencies

Using a standing wave sonochemical reactor (SWSR), the influences of parameters of ultrasonic power input, sonication time, sonication temperature and the amount of propanol (which generates the reducing radicals) were systemically investigated to ascertain and optimize the best conditions for the sonochemical reduction of Pt from its precursor hexachloroplatinic acid and then its deposition on rutile TiO(2) (platinization of rutile titania) catalysts. Catalytic activity of the prepared platinized catalysts was tested in the reaction of methyl orange degradation. The results of photocatalytic activity study in the degradation of methyl orange further demonstrate that sonochemically as-prepared Pt/TiO(2) catalysts show a pronounced increase ( approximately 2 times) in photodegradation, even with a deposition of small amounts of platinum (1.4wt.%), as compared to the unsupported or naked rutile titania. Although there are various parameters that influence the sonochemical platinization of rutile titania, the present optimization results clearly indicate that the best photocatalytic degradation of methyl orange can be obtained when the experimental conditions of the preparation were with an input power of 50W, an initial hexachloroplatinic acid volume of 70ml (which results into 1.4wt.% Pt on TiO(2)), sonication time of 90min, 0.18g of propanol and a temperature of 10 degrees C were adopted. The method of ultrasound application to prepare metal supported semiconductors has many advantages such as convenience, safety and high efficiency. Furthermore, it is hopeful that this optimization study can also be extended to the generation of similar metal supported semiconductors.

Nicotinic acetylcholine receptors expressed in the ventralposterolateral thalamic nucleus play an important role in anti-allodynic effects

BACKGROUND AND PURPOSE

Much interest is currently being focused on the anti-nociceptive effects mediated by nicotinic acetylcholine (nACh) receptors, including their location and mechanism of action. The purpose of this study was to elucidate these issues using 5-iodo-3-(2(S)-azetidinylmethoxy)pyridine (5IA), a nACh receptor agonist, and [(125)I]5IA.

EXPERIMENTAL APPROACH

We partially ligated the sciatic nerve of Sprague-Dawley rat to induce neuropathic pain [Seltzer's partial sciatic nerve ligation (PSL) model]. We then examined the changes in nACh receptor density in the CNS using [(125)I]5IA autoradiography and the involvement of nACh receptors in anti-nociceptive effects in the region where changes occurred.

KEY RESULTS

Autoradiographic studies showed that the accumulation of [(125)I]5IA and the number of nACh receptors in the thalamus of PSL rats were increased about twofold compared with those in the sham-operated rats. No change was observed in other brain regions. Rats injected in the ventral posterolateral thalamic nucleus (VPL) with 5IA demonstrated a significant and dose-dependent anti-allodynic effect and this effect was completely antagonized by mecamylamine, injected with 5IA, into the VPL. The blockade of nACh receptors in the VPL by mecamylamine decreased by 70% the anti-allodynic effect of 5IA, given i.c.v. Moreover, mecamylamine given intra-VPL by itself, induced significant hyperalgesia.

CONCLUSIONS AND IMPLICATIONS

Our findings suggest that the nACh receptors expressed in the VPL play an important role in the anti-allodynic effects produced by exogenous and endogenous agonists.