Optimization of a mouse model of pancreatic cancer to simulate the human phenotypes of metastasis and cachexia

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) presents with a high mortality rate. Two important features of PDAC contribute to this poor outcome. The first is metastasis which occurs in ~ 80% of PDAC patients. The second is cachexia, which compromises treatment tolerance for patients and reduces their quality of life. Although various mouse models of PDAC exist, recapitulating both metastatic and cachectic features have been challenging.

METHODS

Here, we optimize an orthotopic mouse model of PDAC by altering several conditions, including the subcloning of parental murine PDAC cells, implantation site, number of transplanted cells, and age of recipient mice. We perform spatial profiling to compare primary and metastatic immune microenvironments and RNA sequencing to gain insight into the mechanisms of muscle wasting in PDAC-induced cachexia, comparing non-metastatic to metastatic conditions.

RESULTS

These modifications extend the time course of the disease and concurrently increase the rate of metastasis to approximately 70%. Furthermore, reliable cachexia endpoints are achieved in both PDAC mice with and without metastases, which is reminiscent of patients. We also find that cachectic muscles from PDAC mice with metastasis exhibit a similar transcriptional profile to muscles derived from mice and patients without metastasis.

CONCLUSION

Together, this model is likely to be advantageous in both advancing our understanding of the mechanism of PDAC cachexia, as well as in the evaluation of novel therapeutics.

[Clinical phenotypic and genotypic analysis of 5 pediatric patients with β-ketothiolase deficiency]

Objective: To summarize the clinical and genetic characteristics of children with β-ketothiolase deficiency (BKTD). Methods: The clinical characteristics, biochemical, markers detected by tandem mass spectrometry (MS/MS) and gas chromatography-mass spectrometry (GC/MS), as well as the variants in ACAT1 gene among 5 children with BKTD in Children's Hospital of Chongqing Medical University between October 2018 and December 2022 were retrospectively analyzed. Results: The onset age of the disease in 5 patients (4 males and 1 female) ranged from 9.7 to 28.0 months. During the acute phase, severe metabolic acidosis was observed with a pH of 6.9-7.1, as well as hypoglycaemia (2.3-3.4 mmol/L) and positive urinary ketone bodies (+-++++). Blood levels of methylcrotonyl carnitine, methylmalonyl carnitine and malonyl carnitine were 0.03-0.42, 0.34-1.43 and 0.83-3.53 μmol/L respectively and were significantly elevated. Urinary 2-methyl-3-hydroxybutyric acid was 22-202 and 3-hydroxybutyric acid was 4-6 066, both were higher than the normal levels. Methylcrotonylglycine was mild elevated (0-29). The metabolites detected by MS/MS and GC/MS were significantly reduced after treatment. Analysis of ACAT1 gene mutation was performed in 5 children. Most variants were missense (8/9). Four previously unreported variants were identified: c.678G>T (p.Trp226Cys), c.302A>G (p.Gln101Arg), c.627_629dupTGA (p.Asn209_Glu210insAsp) and c.316C>T (p.Gln106Ter), the first 2 variants were predicted to be damaging by SIFT, PolyPhen-2 and Mutation Taster software. c.316C>T (p.Gln106Ter) is a nonsense variant. Conclusions: β-ketothiolase deficiency is relatively rare, lacks specific clinical manifestations, however severe metabolic acidosis, hypoglycemia, and ketosis during the acute onset were consistent findings. Missense mutations in the ACAT1 gene are common genetic causes of β-ketothiolase deficiency.

[Pelvic exenteration for late complications of radiation-induced pelvic injury: a preliminary study]

Objective: To investigate the safety and efficacy of total pelvic exenteration (TPE) for treating late complications of radiation-induced pelvic injury. Methods: This was a descriptive case series study. The inclusion criteria were as follows: (1) confirmed radiation-induced pelvic injury after radiotherapy for pelvic malignancies; (2) late complications of radiation-induced pelvic injury, such as bleeding, perforation, fistula, and obstruction, involving multiple pelvic organs; (3) TPE recommended by a multidisciplinary team; (4) patient in good preoperative condition and considered fit enough to tolerate TPE; and (5) patient extremely willing to undergo the procedure and accept the associated risks. The exclusion criteria were as follows: (1) preoperative or intraoperative diagnosis of tumor recurrence or metastasis; (2) had only undergone diversion or bypass surgery after laparoscopic exploration; and (3) incomplete medical records. Clinical and follow-up data of patients who had undergone TPE for late complications of radiation-induced pelvic injury between March 2020 and September 2022 at the Sixth Affiliated Hospital of Sun Yat-sen University were analyzed. Perioperative recovery, postoperative complications, perioperative deaths, and quality of life 1 year postoperatively were recorded. Results: The study cohort comprised 14 women, nine of whom had recto-vagino-vesical fistulas, two vesicovaginal fistulas, one ileo-vesical fistula and rectal necrosis, one ileo-vesical and rectovaginal fistulas, and one rectal ulcer and bilateral ureteral stenosis. The mean duration of surgery was 592.1±167.6 minutes and the median blood loss 550 (100-6000) mL. Ten patients underwent intestinal reconstruction, and four the Hartmann procedure. Ten patients underwent urinary reconstruction using Bricker's procedure and 7 underwent pelvic floor reconstruction. The mean postoperative hospital stay was 23.6±14.9 days. Seven patients (7/14) had serious postoperative complications (Clavien-Dindo IIIa to IVb), including surgical site infections in eight, abdominopelvic abscesses in five, pulmonary infections in five, intestinal obstruction in four, and urinary leakage in two. Empty pelvis syndrome (EPS) was diagnosed in five patients, none of whom had undergone pelvic floor reconstruction. Five of the seven patients who had not undergone pelvic floor reconstruction developed EPS, compared with none of those who had undergone pelvic floor reconstruction. One patient with EPS underwent reoperation because of a pelvic abscess, pelvic hemorrhage, and intestinal obstruction. There were no perioperative deaths. During 18.9±10.1 months of follow-up, three patients died, two of renal failure, which was a preoperative comorbidity, and one of COVID-19. The remaining patients had gradual and significant relief of symptoms during follow-up. QLQ-C30 assessment of postoperative quality of life showed gradual improvement in all functional domains and general health at 1, 3, and 6 months postoperatively (all P<0.05). Conclusions: TPE is a feasible procedure for treating late complications of radiation-induced pelvic injury combined with complex pelvic fistulas. TPE is effective in alleviating symptoms and improving quality of life. However, the indications for this procedure should be strictly controlled and the surgery carried out only by experienced surgeons.

Efficacy and Safety of High-Dose Vitamin C Combined with Total Neoadjuvant Chemoradiotherapy in Locally Advanced Rectal Cancer (HCCSC R02 Study)

PURPOSE/OBJECTIVE(S)

Forpatients with locally advanced rectal cancer (LARC), the standard treatment is fluoropyrimidine (FU) -based neoadjuvant chemoradiotherapy (NCRT) combined with curative surgery. The CAO/ARO/AIO-04 trial and FORWARC trial reported that the addition of oxaliplatin to FU -based NCRT contributed to improve pathologic complete response (pCR), nevertheless, increased the acute therapeutic toxicity. Some studies showed that vitamin C (VitC) had potential benefits on anti-tumor therapy and anti-inflammatory response. Therefore, we conducted this HCCSC R02 study to explore the efficacy and safety of adding a high-dose intravenous VitC to mFOLFOX6/XELOX -based NCRT in LARC.

MATERIALS/METHODS

HCCSCR02 study was designed as a prospective, single-center phase II trial, which including pts aged 18-75 years with stage II/III rectal adenocarcinoma, distance from anus ≤12cm. The enrollment criteria included: staged with MRI as cT3/cT4 or cN1/2, or mesorectal fascia involvement (MRF+), or difficult to preserve the anus. Patients with glucose-6-phosphate dehydrogenase enzyme(G6PD) deficiency were excluded. Pelvic intensity modulated radiation therapy (IMRT) was given in 45-50.4Gy/25-28 fractions. Concurrently, two cycles of chemotherapy (mFOLFOX6 or XELOX) were administered during IMRT, as well as intravenous VitC (24g) delivered daily after the end of each radiation therapy. Additional 2-3 cycles of mFOLFOX6 / XELOX were adopted between the completion of radiotherapy and surgery. The primary endpoint was pCR rate. The secondary endpoints included radiation-related toxicities, overall survival (OS) and disease-free survival (DFS). This study is still recruiting.

RESULTS

From May 15, 2021 to Feb 8, 2023, 19 pts were recruited and finished all the scheduled NCRT, of which the proportion of cT4, cT3, cN2, cN1 were 31.6%, 63.2%, 52.6%, 36.8%, respectively. In addition, 10 pts (52.6%) were diagnosed as MRF+ initially, and 8 pts (42.1%) had a lower primary tumor(≤5cm) who were considered difficult for anal preservation before NCRT. All subjects enrolled were confirmed to be proficient mismatch repair (pMMR). As a result, 18 pts underwent a total mesorectal excision (TME) all with R0-resection, and 8 pts were evaluated as pCR (44.4%, 8/18, confidence interval: 0.246-0.663), 11 as major pathological response rate (MPR) (61.6%, 11/18), respectively. The anus preservation rate in patients with lower diseases was 87.5% (7/8). One case accepted a watch-and-wait strategy because of clinical complete response (cCR). Overall, grade 3 toxicities were observed in 4 pts, including 3 leucopenia (15.8%, 3/19), 2 neutropenia (10.5%, 2/19) and 1 diarrhea (5.3%, 1/19). No grade 4 adverse event was observed.

CONCLUSION

The addition of high-dose VitC to the mFOLFOX6/XELOX-based NCRT in LARC showed a promising pCR, well tolerance, particularly low rate of diarrhea, thus warrants further investigation.

CLINICAL TRIAL INFORMATION

NCT04801511.

[BCS1Neonatal growth retardation and lactic acidosis initiated by novel mutation sites in L gene]

This study aims to analyze the clinical characteristics and genetic variations of two cases with developmental delay and lactic acidosis in a family, and to explore the relationship between genetic variations and clinical features. A retrospective analysis was conducted on the clinical characteristics of two siblings with developmental delay and lactic acidosis who were treated at the Neonatal Department of Children's Hospital of Chongqing Medical University in May 2019 and December 2021, respectively. Whole-exome sequencing was used to detect genetic variations in the affected children. Homology modeling of the BCS1L protein was performed to analyze the structural and functional changes of the protein. The correlation between genetic variations and clinical phenotypes was analyzed. The results showed that the main clinical features of the two affected children in this family were manifestations of mitochondrial respiratory chain complex Ⅲ deficiency, including prematurity, developmental delay, respiratory failure, lactic acidosis, cholestasis, liver dysfunction, renal tubular lesions, coagulation dysfunction, anemia, hypoglycemia, hypotonia, and early death. Whole-exome sequencing revealed a novel deletion mutation c.486_488delGGA (p.E163del) and a novel missense mutation c.992C>T (p.T331I) in the BCS1L gene. Structural analysis of the homology modeling showed that the compound heterozygous mutation had a significant impact on protein function. In conclusion, the novel mutation site c.992C>T (p.T331I) in the BCS1L gene is a "likely pathogenic" mutation, and the compound heterozygous mutation is closely related to the phenotype of mitochondrial respiratory chain complex Ⅲ deficiency.

Targeting protein tyrosine phosphatases for CDK6-induced immunotherapy resistance

Elucidating the mechanisms of resistance to immunotherapy and developing strategies to improve its efficacy are challenging goals. Bioinformatics analysis demonstrates that high CDK6 expression in melanoma is associated with poor progression-free survival of patients receiving single-agent immunotherapy. Depletion of CDK6 or cyclin D3 (but not of CDK4, cyclin D1, or D2) in cells of the tumor microenvironment inhibits tumor growth. CDK6 depletion reshapes the tumor immune microenvironment, and the host anti-tumor effect depends on cyclin D3/CDK6-expressing CD8+ and CD4+ T cells. This occurs by CDK6 phosphorylating and increasing the activities of PTP1B and T cell protein tyrosine phosphatase (TCPTP), which, in turn, decreases tyrosine phosphorylation of CD3ζ, reducing the signal transduction for T cell activation. Administration of a PTP1B and TCPTP inhibitor prove more efficacious than using a CDK6 degrader in enhancing T cell-mediated immunotherapy. Targeting protein tyrosine phosphatases (PTPs) might be an effective strategy for cancer patients who resist immunotherapy treatment.

[Prognostic value of perioperative change of neutrophil elastase and myeloperoxidase in coronary circulation on perioperative myocardial injury and clinical outcome of patients underwent surgical valve replacement]

Objective: To investigate the clinical value of observing perioperative changes of myeloperoxidase (MPO) and neutrophil elastase (NE) in coronary artery circulation in patients underwent valve replacement surgery. Methods: This perspective cohort study was performed in patients who underwent valvular surgery in Nanjing Drum Tower Hospital and Fuwai Hospital from June 2021 to June 2022. Patients were divided into perioperative myocardial injury group and age-, sex- and type of cardiac procedure-matched non-perioperative myocardial injury control group in the ratio of 1∶1. Perioperative myocardial injury was defined as cardiac troponin T (cTnT)>0.8 μg/L on the first postoperative day (POD), and the cTnT level on the second POD increased by more than 10% compared with the cTnT level on the first POD. During the operation, blood samples were collected from the coronary sinus before clamping ascending aorta, and within 5 minutes after de-clamping ascending aorta. Then, the levels of MPO and NE on coronary sinus were continuously measured. The death, severe ventricular arrhythmia, pneumonia, re-intubation, repeat cardiac surgery, extracorporeal membrane oxygenation (ECMO), intra-aortic balloon pump (IABP), continuous renal replacement therapy (CRRT), mechanical ventilation time and the duration of intensive care unit (ICU) were recorded. The levels of MPO and NE and the incidence of clinical outcomes were compared between the myocardial injury group and the control group. The independent risk factors of myocardial injury were analyzed by multivariate logistic regression. Results: A total of 130 patients were enrolled, aged (60.6±7.6) years old, with 59 males (45.4%). There were 65 patients in the myocardial injury group and 65 patients in the control group. During hospitalization, there was no death, ECMO, IABP and CRRT cases in both groups. Compared with the control group, the incidence of severe ventricular arrhythmia (13.8%(9/65) vs. 3.1%(2/65), P=0.03), pneumonia (20.0%(13/65) vs. 3.1%(2/65), P=0.03), re-intubation (6.2%(4/65) vs. 0, P=0.04) was significantly higher in myocardial injury group. The mechanical ventilation time (16.8(10.7, 101.7) h vs. 7.5(4.7, 15.1) h, P<0.01), and the duration of ICU (3.7(2.7, 18.9) vs. 2.7(1.8, 6.9)d, P<0.01) were significantly longer in myocardial injury group compared with the control group. There was no significant difference in the levels of MPO and NE in coronary sinus blood between the two groups before aortic clamping (all P>0.05). However, MPO ((551.3±124.2) μg/L vs. (447.2±135.9) μg/L, P<0.01) and NE ((417.0±83.1)μg/L vs. (341.0±68.3)μg/L, P<0.01) after 5 min aortic de-clamping were significantly higher in myocardial injury group than in the control group. Multivariate logistic regression analysis showed that the levels of NE (OR=1.02, 95%CI: 1.01-1.02, P<0.01), MPO (OR=1.00, 95%CI: 1.00-1.01, P=0.02) and mechanical ventilation time (OR=1.03, 95%CI: 1.01-1.06, P=0.02) were independent risk factors of myocardial injury in patients after surgical valvular replacement. Conclusion: Perioperative myocardial injury is related poor clinical outcomes, perioperative NE and MPO in coronary artery circulation are independent risk factors of perioperative myocardial injury in patients undergoing valve replacement surgery.

[Observational study on perioperative outcomes of pelvic exenteration]

Objective: To investigate the surgical indications and perioperative clinical outcomes of pelvic exenteration (PE) for locally advanced, recurrent pelvic malignancies and complex pelvic fistulas. Methods: This was a descriptive study.The indications for performing PE were: (1) locally advanced, recurrent pelvic malignancy or complex pelvic fistula diagnosed preoperatively by imaging and pathological examination of a biopsy; (2)preoperative agreement by a multi-disciplinary team that non-surgical and conventional surgical treatment had failed and PE was required; and (3) findings on intraoperative exploration confirming this conclusion.Contraindications to this surgical procedure comprised cardiac and respiratory dysfunction, poor nutritional status,and mental state too poor to tolerate the procedure.Clinical data of 141 patients who met the above criteria, had undergone PE in the Sixth Affiliated Hospital of Sun Yat-sen University from January 2018 to September 2022, had complete perioperative clinical data, and had given written informed consent to the procedure were collected,and the operation,relevant perioperative variables, postoperative pathological findings (curative resection), and early postoperative complications were analyzed. Results: Of the 141 included patients, 43 (30.5%) had primary malignancies, 61 (43.3%) recurrent malignancies, 28 (19.9%) complex fistulas after radical resection of malignancies,and nine (6.4%)complex fistulas caused by benign disease. There were 79 cases (56.0%) of gastrointestinal tumors, 30 cases (21.3%) of reproductive tumors, 16 cases (11.3%) of urinary tumors, and 7 cases (5.0%) of other tumors such mesenchymal tissue tumors. Among the 104 patients with primary and recurrent malignancies, 15 patients with severe complications of pelvic perineum of advanced tumors were planned to undergo palliative PE surgery for symptom relief after preoperative assessment of multidisciplinary team; the other 89 patients were evaluated for radical PE surgery. All surgeries were successfully completed. Total PE was performed on 73 patients (51.8%),anterior PE on 22 (15.6%),and posterior PE in 46 (32.6%). The median operative time was 576 (453,679) minutes, median intraoperative blood loss 500 (200, 1 200) ml, and median hospital stay 17 (13.0,30.5)days.There were no intraoperative deaths. Of the 89 patients evaluated for radical PE surgery, the radical R0 resection was achieved in 64 (71.9%) of them, R1 resection in 23 (25.8%), and R2 resection in two (2.2%). One or more postoperative complications occurred in 85 cases (60.3%), 32 (22.7%)of which were Clavien-Dindo grade III and above.One patient (0.7%)died during the perioperative period. Conclusion: PE is a valid option for treating locally advanced or recurrent pelvic malignancies and complex pelvic fistulas.

Cancer cachexia: involvement of an expanding macroenvironment

Advanced cancers often present with the cachexia syndrome that impacts peripheral tissues, leading to involuntary weight loss and reduced prognosis. The central tissues undergoing depletion are skeletal muscle and adipose, but recent findings reveal an expanding tumor macroenvironment involving organ crosstalks that underlie the cachectic state.

[Correlation between cerebral oxygen saturation monitored by near-infrared spectroscopy during operation and risk of stroke after acute type A aortic dissection surgery]

Objective: Near-infrared spectroscopy (NIRS) is widely used for intraoperative cerebral oxygen saturation monitoring in patients with acute type A aortic dissection. This study aimed to investigate the correlation between NIRS-derived oxygen saturation and risk of postoperative stroke. Methods: This study included 193 patients with acute type A aortic dissection undergoing emergency surgery and elective unilateral cerebral perfusion via the right axillary artery at the Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Nanjing, China, from 2018 to 2020. NIRS was used for intraoperative cerebral oxygen saturation monitoring, and the basal values and the lowest values of cerebral oxygen saturation during deep hypothermic circulatory arrest (DHCA) were recorded. The patients were divided into no-stroke group (n=178, 92.2%) and stroke group (n=15, 7.8%) according to the absence or presence of postoperative stroke. The differences in preoperative, operative and postoperative clinical differences between the two groups were compared, and the relationship between the lowest cerebral oxygen saturation value and the change in cerebral oxygen saturation value ((base-lowest)/basal) and postoperative stroke were analyzed. Results: The proportion of preoperative atrial fibrillation (6.7% vs. 0.6%, P=0.026), and the proportion of preoperative hypotension (26.7% vs. 9.0%, P=0.031) were significantly higher in the stroke group than no-stroke group. There were no differences in the surgical approach between the two groups. Cardiopulmonary bypass (CPB) time ((256.1±84.8) h vs.(217.8±58.4) h, P=0.020), postoperative mechanical ventilation time ((139.3±172.8) h vs. (35.6±45.6) h, P<0.001) were significantly longer in stroke group as compared to no-stroke group. Incidence of postoperative tracheotomy (20.0% vs. 1.1%, P<0.001), acute kidney injury (73.3% vs. 30.3%, P=0.001) and continuous renal replacement therapy (46.7% vs. 11.8%, P<0.001) as well as mortality (20.0% vs. 5.1%, P=0.022) were significantly higher in the stroke group than in non-stroke group. There was no significant difference in the basal NIRS value and the lowest NIRS value during DHCA between the two groups. Patients in the stroke group had a significantly greater intraoperative change rate of right NIRS as compared to no-stroke group (15.2%±15.7% vs. 9.2%±7.0%, P=0.006). Conclusions: NIRS is valuable for monitoring cerebral oxygen saturation during acute type A aortic dissection surgery, and the rate change of NIRS during operation correlates significantly with postoperative stroke.

The effectiveness and safety of liraglutide in treating overweight/obese patients with polycystic ovary syndrome: a meta-analysis

PURPOSE

The purpose of this study is to evaluate the effectiveness and safety of liraglutide/liraglutide + metformin in overweight/obese women with polycystic ovary syndrome (PCOS).

METHODS

The related literatures published until April 2021 were searched in PubMed, Cochrane Library, MEDLINE and EmBase.

RESULTS

Six randomized controlled trials of 127 related articles were obtained through searching. Three articles compared liraglutide with metformin, and four articles compared liraglutide combined with metformin with metformin. Our meta-analysis suggests that liraglutide was superior to metformin only in weight loss [MD = - 2.74, 95% CI (- 4.29, - 1.18), P = 0.0006]. Compared with metformin group, the combination group had significant advantages in weight loss [MD = - 3.81, 95% CI (- 5.16, - 2.46), P < 0.001], BMI [MD = - 2.59, 95% CI (- 3.12, - 2.07), P < 0.001], waist circumference [MD = - 6.26, 95% CI (- 7.79, - 4.72), P < 0.001], fasting blood glucose [MD = - 0.59, 95% CI (- 0.74, - 0.44), P < 0.001] and fasting insulin [MD = - 1.52, 95% CI (- 2.69, - 0.35), P = 0.01], while the incidence of adverse reactions was relatively high [RR = 2.91, 95% CI (1.55, 5.46), P = 0.00009].

CONCLUSION

The present results indicate that liraglutide and metformin have the similar effects in the treatment of overweight/obese PCOS patients. Liraglutide combined with metformin is more effective than metformin in improving PCOS, but it is necessary to master the correct medication method to reduce the occurrence of adverse reactions.

Impact of intraoperative methadone use on postoperative opioid requirements after cardiac surgery

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

Inadequate pain control after cardiac surgery increases postoperative morbidity. Increasing evidence suggests that perioperative intravenous (IV) methadone results in improved analgesia. This study evaluated the effect of intraoperative IV methadone on postoperative opioid requirements and surgical recovery.

METHODS

A retrospective review of patients undergoing coronary artery bypass graft (CABG), valvular surgery or both between April 2017 and August 2018 was conducted. Patients were separated into a usual care cohort of those who received short-acting opioids (ie, IV fentanyl, hydromorphone, or morphine) alone or a methadone cohort of those who received IV methadone plus short-acting opioids. Opioid requirements were assessed within the first 24 hours of surgery (postoperative day [POD] 0) and 25 to 48 hours after surgery (POD 1) as oral morphine milligram equivalents (MME). Postoperative pain scores, adjunctive analgesia, time to extubation, use of noninvasive respiratory support (continuous positive airway pressure [CPAP] or bilevel positive airway pressure [BiPAP]), and intensive care unit (ICU) and hospital length of stay (LOS) were also evaluated.

RESULTS

A total of 117 patients were evaluated (methadone cohort, n = 52; usual care cohort, n = 65). Median cumulative intraoperative opioid consumption was less in the methadone cohort (150 MME vs 314.1 MME; P < 0.0001). The methadone cohort required 44% fewer MME than the usual care cohort on POD 0 (median MME, 15.8 vs 36; P = 0.025), with low and not significantly different opioid use in both cohorts on POD 1 (15.5 MME vs 7.5 MME; P = 0.47). Weight-based methadone dosing ranged from 0.1 to 0.4 mg/kg (mean, 0.22 mg/kg). There were no significant differences in pain scores, time to extubation, use of CPAP or BiPAP, or ICU and hospital LOS.

CONCLUSION

Intraoperative IV methadone in cardiac surgery patients was safe and significantly reduced intraoperative and postoperative opioid requirements on POD 0.

[Ultrastructural features of the corneal epithelium with micromolecular compound J2 in the corneal allograft of rats using atomic force microscopy]

Objective: To study the ultrastructural features of the corneal epithelium in the corneal allograft of rats with micromolecular compound J2. Methods: An experimental study. Primarily cultured corneal epithelial cells of rats were used. Mononuclear cells (MNCs) by density gradient centrifugation were assigned into the experimental group [MNCs (2 ml)+corneal epithelial cells+J2], control group [MNCs (2 ml)+corneal epithelial cells] and blank group (corneal epithelial cells). Quantity of CD80 expression was obtained by flow cytometry after coculture. Amplitude and height images were obtained by tapping mode atomic force microscopy (AFM) with a scan rate of 2 Hz and an integral gain of 0.3 to 0.5. Statistical analysis of Ra, Rq, Rvm and Rt was performed using the single-factor analysis of variance, and P value was calculated. Results: There were obvious differences in the ultrastructure measured by AFM among groups. Ra was 86.75±12.60 in the experimental group, 120.23±12.11 in the control group, and 61.94±10.62 in the blank group (F=306.92, P<0.01). Rq was 102.53±9.45, 138.30±10.13, and 91.96±7.25, respectively, in the three groups (F=361.85, P<0.01). Rvm was -42.21±14.22, -67.36±10.89, and -32.18±19.01, respectively (F=72.22, P<0.01). Rt was 437.32±15.66, 495.32±13.96, and 339.92±11.22, respectively (F=1634.26, P<0.01). The one way analysis of variance showed significant differences in these parameters among groups. Conclusions: Corneal epithelial cells of rats activated by MNCs had higher CD80 expression, but the expression became decreased with micromolecular compound J2. The ultrastructure of the corneal epithelium became coarser after MNCs activation, and the number of protrusions increased significantly. The ultrastructural changes were alleviated by J2.(Chin J Ophthalmol, 2021, 57: 608-613).

[The incidence and related factors of coronary events among 40-49 years old patients undergoing cardiac thoracotomy without preoperative CAG]

Objective: To investigate the long-term incidence of coronary events and related factors in patients undergoing cardiac thoracotomy without preoperative coronary angiography (CAG). Methods: This was a retrospective study. The clinical data of patients, aged between 40 and 49 years old, who underwent cardiothoracic surgery, including heart valve surgery, congenital heart disease surgery, cardio great vessels surgery and other non-coronary artery disease (CAD) surgery, in Nanjing Drum Tower Hospital from December 2009 to May 2017, were enrolled. Patients with suspected CAD, or patients with coronary CTA defined calcified coronary arteries received CAG examination prior operation, and the rest patients did not receive routine CAG examinations. The patients who did not receive routine CAG examinations were followed up by telephone. The primary endpoints include death related to coronary arteries, coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI). The secondary endpoints include the new onset angina, clinically diagnosed CAD or receiving the first and second prevention for CAD. The other outcome events included cardiac death and all-cause mortality. The primary and secondary endpoints were all regarded as coronary events. The patients without preoperative CAG were divided into two groups: the positive group and the negative group, according to the incidence of coronary events during follow-up. Clinical data were compared between the two groups. Results: A total of 952 patients were included. The age was (45.2±2.7) years old, 406(42.65%) patients were male. Preoperative CAG was performed in 73 patients, among whom 9 (12.32%) patients underwent simultaneous CABG. Among the 879 cases who did not undergo coronary angiography before the operation, 18(2.05%) died during perioperative period (hospitalization and within 30 days after discharge). The patients were followed up for (61.6±25.8) months, and 28(3.25%) patients were lost to follow up. During long-term follow up, there were no fatal cases due to severe coronary events and no cases of CABG or PCI. Only 4.41% (38/861) patients had the secondary endpoints, namely the occasional onset of atypical angina. The incidence rate of the long-term coronary events, all-cause mortality and cardiac death were 4.41% (38/861), 1.16% (10/861), 0.46% (4/861) during long-term follow-up. The prevalence of hypertension was significantly higher in positive group than negative group (34.21% (13/38) vs. 20.89% (164/785), P=0.045). Conclusions: It is feasible not to perform preoperative CAG examination for non-CAD patients aged 40-49 years who will undergo cardiac thoracotomy. However, we need to be aware the risk of coronary events in the patients complicating with risk factors of CAD, such as hypertension.

Abstract IA-17: Mechanisms of pancreatic cancer-induced cachexia

Cachexia is a debilitating syndrome that results in severe, involuntary weight loss due to the depletion of skeletal muscle mass. Currently, no effective therapy exists to combat this malignant disorder. For pancreatic cancer, 85% of patients lose on average 14% of their pre-illness weight, and cachexia dramatically limits their ability to tolerate surgery, chemo- or radiotherapy. New therapies will likely evolve from an enhanced understanding of the mechanisms leading to muscle wasting and tumor development. Our laboratory has been examining the role of the NF-κB signaling pathway in tumorigenesis for several decades and that interest led us to discover the connection between NF-κB and muscle wasting in cancer cachexia and more recently in pancreatic cancer. We view the pathway as playing two separate functions in pancreatic cancer-induced cachexia. The first occurs at the level of skeletal muscle, or more preciously in skeletal muscle stem cells. We have found that during cancer progression, skeletal muscle undergoes a type of injury response leading to the activation of resident stem cells to engage in a regeneration program. NF-κB is activated in these stem cells and functions to inhibit regeneration, which contributes to the overall wasting process in cachexia. New data reveal that NF-κB activity in progenitor cells also regulates a local muscle inflammatory environment that might also contribute to skeletal muscle catabolism. The mechanism of this regulation will be discussed in more details. The second function of NF-κB signaling that we are pursuing focuses in the tumor microenvironment of pancreatic cancer. Using orthotopic mouse models of pancreatic cancer, we showed that NF-κB plays a critical role in protecting tumor cells from the surveillance property of anti-tumor macrophages. This occurs through the direct transcriptional regulation of the immunosuppressive cytokine, GDF15. Interestingly, circulating levels of GDF15 are elevated in cachectic patients and recent studies indicate that this cytokine might be an attractive therapeutic target in cancer cachexia. Together, we speculate that NF-κB functions in cancer cachexia by acting in muscle stem cells to block muscle repair, as well as promoting pancreatic cancer through the production of immunosuppressive genes such as GDF15.

Citation Format: Benjamin Pryce, Nivedita Ratnam, Erin E. Talbert, Mary Dilhoff, Carl R. Schmidt, David J. Wang, Denis C. Guttridge. Mechanisms of pancreatic cancer-induced cachexia [abstract]. In: Proceedings of the AACR Virtual Special Conference on Pancreatic Cancer; 2020 Sep 29-30. Philadelphia (PA): AACR; Cancer Res 2020;80(22 Suppl):Abstract nr IA-17.

Prevalence and factors associated with motoric cognitive risk syndrome in community-dwelling older Chinese: a cross-sectional study

BACKGROUND AND PURPOSE

A recently proposed pre-dementia syndrome, motoric cognitive risk (MCR) syndrome, is characterized by cognitive complaints and slow gait, and increases the risk of dementia and mortality. The aim of the present study was to explore the prevalence of and factors associated with MCR syndrome in elderly community-dwelling Chinese subjects.

METHODS

The Ningbo Community Study on Aging recruited 953 Chinese community-dwelling participants aged ≥ 65 years from November 2016 to March 2017. Handgrip, Five-Times-Sit-to-Stand (FTSS) test time and body composition, as well as comprehensive geriatric evaluation, were measured as potentially independent factors associated with MCR syndrome.

RESULTS

The prevalence of MCR syndrome was 12.8% in men and 12.6% in women, and high prevalence of MCR syndrome was not associated with age or sex. Multiple logistic regression analysis by sex showed that a 1-SD increase in FTSS test time in males and females was associated with 45% (95% confidence intervals, 19-76; P < 0.01) and 20% (95% confidence intervals, 9-33; P < 0.01) higher risk of having MCR syndrome, respectively, whereas handgrip strength was inversely correlated with MCR syndrome in males [odds ratio (OR), 0.91; P = 0.02] but not females (P = 0.06). Moreover, the relationship of arm fat mass and MCR syndrome was statistically significant in both sexes (OR, 1.69-1.77), but leg fat mass was only associated with MCR syndrome (OR, 1.56; P = 0.02) in men.

CONCLUSIONS

Handgrip, FTSS test time and body composition were associated in a sex-specific manner with MCR syndrome in elderly community-dwelling Chinese subjects. Our results on MCR syndrome are novel and should be considered as important information in future studies.

[Nursing care of one case of incontinent dermatitis complicated with sacrococcygeal pressure ulcer]

A 67-year-old female patient with incontinent dermatitis complicated with sacrococcygeal pressure ulcer was admitted to our unit in November 2017. The wound was treated with a new dressing based on the concept of wet healing, management of exudation, prevention of infection to promote wound healing. Meanwhile, the fecal incontinence was properly treated with colostomy bag combined with disposable negative pressure drainage device to avoid fecal contamination and aggravation of pressure ulcer. Incontinent dermatitis was treated with wound protective powder and wound protective film. After 14 days of treatment, the wound of pressure ulcer was reduced and the incontinent dermatitis was cured.

The Interpeduncular Angle: A Practical and Objective Marker for the Detection and Diagnosis of Intracranial Hypotension on Brain MRI

BACKGROUND AND PURPOSE

Classic findings of intracranial hypotension on MR imaging, such as brain stem slumping, can be variably present and, at times, subjective, potentially making the diagnosis difficult. We hypothesize that the angle between the cerebral peduncles correlates with the volume of interpeduncular cistern fluid and is decreased in cases of intracranial hypotension. We aimed to investigate its use as an objective assessment for intracranial hypotension.

MATERIALS AND METHODS

Brain MRIs of 30 patients with intracranial hypotension and 30 age-matched controls were evaluated by 2 fellowship-trained neuroradiologists for classic findings of intracranial hypotension and the interpeduncular angle. Group analysis was performed with a Student t test, and receiver operating characteristic analysis was used to identify an ideal angle threshold to maximize sensitivity and specificity. Interobserver reliability was assessed for classic findings of intracranial hypotension using the Cohen κ value, and the interpeduncular angle, using the intraclass correlation.

RESULTS

The interpeduncular angle had excellent interobserver reliability (intraclass correlation coefficient value = 0.833) and was significantly lower in the intracranial hypotension group compared with the control group (25.3° versus 56.3°; P < .001). There was significant correlation between the interpeduncular angle and the presence of brain stem slumping (P < .001) and in cases with ≥3 classic features of intracranial hypotension (P = .01). With a threshold of 40.5°, sensitivity and specificity were 80% and 96.7%, respectively.

CONCLUSIONS

The interpeduncular angle is a sensitive and specific measure of intracranial hypotension and is a reliably reproducible parameter on routine clinical MR imaging.

Full Sibling Testing Based on NGS-SNP Genotyping Method and IBS Strategy

Abstract

Objective To evaluate the effectiveness of single nucleotide polymorphism （SNP） genoty-ping in combination with identity by state （IBS） strategy in full sibling testing. Methods Thirty-five blood samples were collected from a four-generation family. Ninety autosomal SNPs were genotyped using Precision ID Identity Panel. The distribution of IBS scores for full siblings and other relationships were calculated and compared. The relationships were determined using Fisher discriminant function and threshold method, respectively. Results Based on family members and previous research, 44, 30, 111, 71 and 1 000 pairs of full siblings （FS）, grandparent-grandchild （GG）, uncle/aunt-nephew/niece （UN）, first cousins （FC） and unrelated individuals （UI） were obtained, respectively. The average IBS scores were 148, 130, 132, 124 and 120, respectively. Except for the GG and UN pairs, the distribution differences among the other relationships had statistical significance （P<0.05）. The false rates of Fisher discriminant function to determine relationships were 1.3%, 22.3%, 17.0% and 38.7% for FS, GG, UN and FC, respectively. Based on the simulation data, the thresholds t₁=128 and t₂=141 were recommended to determine full sibling relationships （the false rate ≤0.05%）. Conclusion The 90 SNP genetic markers included in the Precision ID Identity Panel meet the testing requirements for full sibling relationships. The threshold method based on IBS has a relatively lower false rate and is more flexible.

[Treatment experience of cardiac rupture in patients with acute myocardial infarction]

Objective: To analyze the treatment results of cardiac rupture in patients with acute myocardial infarction (AMI) . Method: Clinical data of 6 with cardiac rupture after AMI, who were hospitalized in our hospital from June 2015 to June 2017, were retrospectively analyzed,and the clinical manifestations, methods of treatment and outcomes were investigated. Results: Cardiac function classification was Killip class Ⅱin all patients. There were 3 massive anterior wall myocardial infarction, 2 anterior wall myocardial infarction,and 1 inferior myocardial infarction. There were 4 patients with ventricular septal defect, 1 patient with rupture of papillary muscle,and 1 patient with left ventricular free wall rupture.All patients received continuous infusion of vasoactive medicines and treated with intra-aortic balloon pump(IABP), 2 patients (1 patient accepted operative treatment,and 1 patient received conservative treatment) were treated with extracorporeal membrane oxygenation (ECMO), mechanical ventilation,and continuous renal replacement therapy(CRRT).Three patients received surgical repair,1 case was supported by IABP, 1 case supported by ECMO,CRRT,and IABP,and 1 case did not use IABP or ECMO post operation. All 3 surgically treated patients recovered successfully and were discharged from hospital.Meanwhile, in the other 3 patients treated conservatively, 2 patients died in the hospital and 1 patient was discharged according to own will. Conclusion: On the basis of vasoactive medicines and IABP, surgery repair is a feasible option for cardiac rupture patients secondary to AMI,and ECMO may improve the perioperative state in these patients.

Disruption of stromal hedgehog signaling initiates RNF5-mediated proteasomal degradation of PTEN and accelerates pancreatic tumor growth

Disrupting paracrine Hedgehog signaling in pancreatic cancer stroma through genetic deletion of fibroblast Smoothened leads to proteasomal degradation of fibroblast PTEN and accelerates tumor growth.

The contribution of the tumor microenvironment to pancreatic ductal adenocarcinoma (PDAC) development is currently unclear. We therefore examined the consequences of disrupting paracrine Hedgehog (HH) signaling in PDAC stroma. Herein, we show that ablation of the key HH signaling gene Smoothened (Smo) in stromal fibroblasts led to increased proliferation of pancreatic tumor cells. Furthermore, Smo deletion resulted in proteasomal degradation of the tumor suppressor PTEN and activation of oncogenic protein kinase B (AKT) in fibroblasts. An unbiased proteomic screen identified RNF5 as a novel E3 ubiquitin ligase responsible for degradation of phosphatase and tensin homolog (PTEN) in Smo-null fibroblasts. Ring Finger Protein 5 (Rnf5) knockdown or pharmacological inhibition of glycogen synthase kinase 3β (GSKβ), the kinase that marks PTEN for ubiquitination, rescued PTEN levels and reversed the oncogenic phenotype, identifying a new node of PTEN regulation. In PDAC patients, low stromal PTEN correlated with reduced overall survival. Mechanistically, PTEN loss decreased hydraulic permeability of the extracellular matrix, which was reversed by hyaluronidase treatment. These results define non-cell autonomous tumor-promoting mechanisms activated by disruption of the HH/PTEN axis and identifies new targets for restoring stromal tumor-suppressive functions.

NF-κB inhibition rescues cardiac function by remodeling calcium genes in a Duchenne muscular dystrophy model

Duchenne muscular dystrophy (DMD) is a neuromuscular disorder causing progressive muscle degeneration. Although cardiomyopathy is a leading mortality cause in DMD patients, the mechanisms underlying heart failure are not well understood. Previously, we showed that NF-κB exacerbates DMD skeletal muscle pathology by promoting inflammation and impairing new muscle growth. Here, we show that NF-κB is activated in murine dystrophic (mdx) hearts, and that cardiomyocyte ablation of NF-κB rescues cardiac function. This physiological improvement is associated with a signature of upregulated calcium genes, coinciding with global enrichment of permissive H3K27 acetylation chromatin marks and depletion of the transcriptional repressors CCCTC-binding factor, SIN3 transcription regulator family member A, and histone deacetylase 1. In this respect, in DMD hearts, NF-κB acts differently from its established role as a transcriptional activator, instead promoting global changes in the chromatin landscape to regulate calcium genes and cardiac function.

NF-κB regulates GDF-15 to suppress macrophage surveillance during early tumor development

Macrophages are attracted to developing tumors and can participate in immune surveillance to eliminate neoplastic cells. In response, neoplastic cells utilize NF-κB to suppress this killing activity, but the mechanisms underlying their self-protection remain unclear. Here, we report that this dynamic interaction between tumor cells and macrophages is integrally linked by a soluble factor identified as growth and differentiation factor 15 (GDF-15). In vitro, tumor-derived GDF-15 signals in macrophages to suppress their proapoptotic activity by inhibiting TNF and nitric oxide (NO) production. In vivo, depletion of GDF-15 in Ras-driven tumor xenografts and in an orthotopic model of pancreatic cancer delayed tumor development. This delay correlated with increased infiltrating antitumor macrophages. Further, production of GDF-15 is directly regulated by NF-κB, and the colocalization of activated NF-κB and GDF-15 in epithelial ducts of human pancreatic adenocarcinoma supports the importance of this observation. Mechanistically, we found that GDF-15 suppresses macrophage activity by inhibiting TGF-β-activated kinase (TAK1) signaling to NF-κB, thereby blocking synthesis of TNF and NO. Based on these results, we propose that the NF-κB/GDF-15 regulatory axis is important for tumor cells in evading macrophage immune surveillance during the early stages of tumorigenesis.

[Expression profiles and clinical implication of plasma chemokines in patients with Stanford type A aortic dissection]

Objective: To explore the plasma chemokines expressions and related clinical implication in patients with Stanford type A aortic dissection (AD). Methods: We retrospectively analyzed the data of 65 patients with Stanford type A aortic dissection, hypertensive patients and 11 healthy subjects admitted in our department from October 2013 to December 2014, they were divided into four groups: NH-CON group (11 healthy subjects), H-AD group (29 AD patients with hypertension), NH-AD group (21 AD patients without hypertension), and H-CON group (14 hypertension patients). Four plasma samples from AD patients and 4 plasma samples from healthy subjects were collected randomly with random numbers table, and the levels of different chemokines were examined by protein array analysis. Then, plasma levels of chemokines including macrophage inflammatory protein 1β(MIP-1β), epithelial neutrophil activating peptide 78(ENA-78), interleukin 16(IL-16), interferon inducible protein 10(IP-10) and FMS-like tyrosine kinase 3(Flt-3) ligand were analyzed by luminex. Pearson analysis was used to determine the correlations between the chemokines and serum C reactive protein (CRP) levels. Results: Plasma levels of MIP-1β(34.0(29.3, 47.2) ng/L vs. 51.0(28.2, 80.7) ng/L, P<0.05) and ENA-78(110.5(59.1, 161.4) ng/L vs. 475.7(299.3, 837.3) ng/L, P<0.05) were significantly lower in H-AD group, while plasma IL-16 level was significantly higher in H-AD group(54.7(16.3, 187.8) ng/L vs. 17.5(11.9, 20.8) ng/L, P<0.05) than in H-CON group. Plasma levels of MIP-1β(48.3(26.4, 62.1) ng/L, P<0.05) were significantly lower in H-AD patients than in NH-AD patients. Plasma level of ENA-78 was significantly lower in NH-AD group than in NH-CON group (95.0(58.0, 155.0) ng/L vs. 257.7(85.2, 397.8) ng/L, P<0.05). The levels of IP-10 and Flt-3 ligand were similar among the 4 groups (all P>0.05). Pearson analysis showed that there were no correlation between MIP-1β(r(2)=0.01, P>0.05), ENA-78(r(2)=0.02, P>0.05), IL-16(r(2)=0.02, P>0.05), IP-10(r(2)=0.00, P>0.05), Flt-3 ligand(r(2)=0.02, P>0.05) and CRP levels in patients with Stanford type A aortic dissection. Conclusions: Lower plasma levels of MIP-1β and ENA-78 and higher plasma levels of IL-16 may associate with the occurrence and development of type A aortic dissection, but their concentrations are not correlated with serum CRP levels. There is no significant change on plasma levels of IP-10 and Flt-3 in the Stanford type A aortic dissection patients.

[The multicenter study on the registration and follow-up of low anticoagulation therapy for the heart valve operation in China]

OBJECTIVE

To investigate the optimal anticoagulation methods and monitoring strategy for Chinese patients undergoing heart valve replacement, which is potentially quite different from western populations.

METHODS

In this multicenter prospective cohort study, the anticoagulation and monitoring strategy data was acquired from 25 773 in-hospital patients in 35 medical centers and 20 519 patients in outpatient clinic in 11 medical centers from January 1st, 2011 to December 31th, 2015.

RESULTS

As for in-hospital patients, mean age of study population was (48.6±11.2) years old; main etiology of valve pathology was rheumatic (87.5%) origin among study cohort; 94.8% of study population received mechanical valve implantation; international normalized ratio (INR) monitoring (in all the study centers) and low-intensity anticoagulation strategy (31 hospitals chose target INR range of 1.5-2.5, and actual values of INR among 89.2% of 100 069 in-hospital monitoring samples were 1.5-2.5), with mean actual INR values of 1.84±0.53, and warfarin dosage of (2.82±0.93) mg/d were widely adopted among the study centers; strategies of in-hospital warfarin administration were similar in all the study centers; complication rates of low-intensity anticoagulation strategy were low in severe hemorrhage (0.02%), thrombosis (0.05%), and thromboembolism (0.05%) events, without anticoagulation-related death.As for 18 974 outpatient clinic patients, the follow-up rate was 92.47%, with a total of 30 012 patient-years (Pty). Anticoagulation-related morbidity and mortality rates were 0.67% and 0.15% Pty; major hemorrhage morbidity and mortality rates were 0.25% and 0.13% Pty; thromboembolism morbidity and mortality rates were 0.45% and 0.03% Pty.The mean dosage of warfarin daily dosage was (2.85±1.23) mg/d and INR value was 1.82±0.57.No significant regional difference in the intensity of anticoagulation therapy was noted during the study.

CONCLUSIONS

INR can be used as a normalized indicator for intensity of anticoagulation therapy in China.The optimal anticoagulation intensity with INR range from 1.5 to 2.5 is safe and effective for Chinese patients with heart valve replacement, and there is no significant regional difference in the intensity of anticoagulation therapy.

Enhancing the Cell Permeability and Metabolic Stability of Peptidyl Drugs by Reversible Bicyclization

Therapeutic applications of peptides are currently limited by their proteolytic instability and impermeability to the cell membrane. A general, reversible bicyclization strategy is now reported to increase both the proteolytic stability and cell permeability of peptidyl drugs. A peptide drug is fused with a short cell-penetrating motif and converted into a conformationally constrained bicyclic structure through the formation of a pair of disulfide bonds. The resulting bicyclic peptide has greatly enhanced proteolytic stability as well as cell-permeability. Once inside the cell, the disulfide bonds are reduced to produce a linear, biologically active peptide. This strategy was applied to generate a cell-permeable bicyclic peptidyl inhibitor against the NEMO-IKK interaction.

A novel approach to symptomatic lumbar facet joint synovial cyst injection and rupture using iGuide navigational software: A case report and review

Spinal synovial cysts are benign protrusions of facet joint capsules caused by degenerative spondylosis, most frequently involving the L4-5 level, and commonly lead to symptoms of back pain, radiculopathy and neurogenic claudication. Although percutaneous treatment via facet joint steroid injection with cyst rupture can provide significant symptom relief, cyst rupture is not always achievable via an indirect trans-facet approach due to limited access from severe degenerative changes. In this case, we describe a successful approach to direct cyst access using a laser-guided navigational software in a patient with severe facet joint osteophytosis. We provide a brief review of literature.

Mutational analysis of podocyte genes in children with sporadic steroid-resistant nephrotic syndrome

Recent studies have demonstrated that mutations in 4 podocyte genes, NPHS1, NPHS2, CD2AP, and WT1, are associated with the pathogenesis of steroid-resistant nephrotic syndrome (SRNS). Systematic investigation of all 4 genes for sporadic SRNS in China has not been performed. We examined 10 Chinese children with sporadic SRNS who showed no response to immunosuppressive agents and 20 SRNS controls who exhibited a response to prolonged steroid or immunosuppressive treatment and achieved complete remission. We analyzed mutations in the 4 podocyte genes, NPHS1, NPHS2, CD2AP, and WT1. Mutational analysis was performed using polymerase chain reaction and direct sequencing. Of the 10 SRNS children who showed no response to immunosuppressive agents, the compound heterozygous NPHS1 mutations 2677A>G (T893A) and *142T>C were identified in 1 patient, while a heterozygous mutation in WT1, 1180C>T (R394W), was found in another patient. Of the 20 SRNS children showing complete remission who responded to prolonged steroid therapy or immunosuppressive agents, 4 heterozygous NPHS1 mutations, 928G>A, IVS8+30C>T, IVS21+14G>A, and IVS25-23C>T, were identified in 4 patients and a heterozygous CD2AP mutation, IVS7-135G>A, was identified in 1 patient. Our results indicate the necessity of genetic examination for mutations in podocyte genes in Chinese SRNS children who show no response to immunosuppressive agents.

NF-κB functions in tumor initiation by suppressing the surveillance of both innate and adaptive immune cells

NF-κB is considered a major contributor to tumor development, but how this factor functions in the initial stages of oncogenesis is not clear. In a model of Ras-induced transformation, we probed NF-κB function as preneoplastic cells formed tumors in mice. As previously shown, the p65 subunit of NF-κB acts as a tumor suppressor in normal cells by sustaining senescence following DNA damage. Our current data reveal that, following immortalization, p65 switches to an oncogene by counteracting the surveillance properties of immune cells. NF-κB exerts this effect by protecting transformed cells against macrophage-derived proapoptotic factors, tumor necrosis factor, and nitric oxide. Additionally, NF-κB acts through transforming growth factor beta (TGF-β) to mitigate T cell cytotoxicity and other factors to expand myeloid-derived suppressor cells. Together, these data suggest that NF-κB functions in the early stages of transformation by suppressing immune surveillance of both innate and adaptive immune cells, information that may be useful for targeted immunotherapies.

Highly efficient beamline and spectrometer for inelastic soft X-ray scattering at high resolution

The design, construction and commissioning of a beamline and spectrometer for inelastic soft X-ray scattering at high resolution in a highly efficient system are presented. Based on the energy-compensation principle of grating dispersion, the design of the monochromator-spectrometer system greatly enhances the efficiency of measurement of inelastic soft X-rays scattering. Comprising two bendable gratings, the set-up effectively diminishes the defocus and coma aberrations. At commissioning, this system showed results of spin-flip, d-d and charge-transfer excitations of NiO. These results are consistent with published results but exhibit improved spectral resolution and increased efficiency of measurement. The best energy resolution of the set-up in terms of full width at half-maximum is 108 meV at an incident photon energy tuned about the Ni L3-edge.

Association study of vascular endothelial growth factor gene polymorphisms with ectopic pregnancy in Chinese women

OBJECTIVE

The purpose of this study is to evaluate potential associations between vascular endothelial growth factor (VEGF) gene polymorphisms and ectopic pregnancy (EP) in Chinese women.

MATERIALS AND METHODS

This was a case-control study wherein 192 women with a history of EP were compared to 210 post-menopausal controls with two pregnancies and no EP for the genotyping of VEGF polymorphisms. Genotyping of the VEGF gene polymorphisms at -460C/T, -1 154G/A, -2578C/A and +936C/T were performed by polymerase chain reaction-restriction fragment length polymorphism.

RESULTS

No significant differences were found in genotype and allele distributions of the -460C/T, +936C/T polymorphisms between cases and controls. Compared with the -1154G/G genotype, the -1154(A/A+G/A) genotype could significantly reduce the risk of developing EP. For the -2578C/A polymorphism, the A/A+C/A geno- type could significantly decrease the risk of developing EP, compared with the C/C genotype. The haplotype analysis suggested that the TAA (VEGF -460/-1154/-2578) and CAA haplotypes could significantly decrease the risk of developing EP compared with the haplotype of TGC.

CONCLUSION

The -1154A or -2578A alleles of VEGF gene could significantly decrease the risk of EP and might be po- tentially protective factors for EP development in Chinese women.

Child implant users' imitation of happy- and sad-sounding speech

Cochlear implants have enabled many congenitally or prelingually deaf children to acquire their native language and communicate successfully on the basis of electrical rather than acoustic input. Nevertheless, degraded spectral input provided by the device reduces the ability to perceive emotion in speech. We compared the vocal imitations of 5- to 7-year-old deaf children who were highly successful bilateral implant users with those of a control sample of children who had normal hearing. First, the children imitated several happy and sad sentences produced by a child model. When adults in Experiment 1 rated the similarity of imitated to model utterances, ratings were significantly higher for the hearing children. Both hearing and deaf children produced poorer imitations of happy than sad utterances because of difficulty matching the greater pitch modulation of the happy versions. When adults in Experiment 2 rated electronically filtered versions of the utterances, which obscured the verbal content, ratings of happy and sad utterances were significantly differentiated for deaf as well as hearing children. The ratings of deaf children, however, were significantly less differentiated. Although deaf children's utterances exhibited culturally typical pitch modulation, their pitch modulation was reduced relative to that of hearing children. One practical implication is that therapeutic interventions for deaf children could expand their focus on suprasegmental aspects of speech perception and production, especially intonation patterns.

GABA estimation in the brains of children on the autism spectrum: measurement precision and regional cortical variation

(1)H magnetic resonance spectroscopy ((1)H MRS) and spectral editing methods, such as MEGA-PRESS, allow researchers to investigate metabolite and neurotransmitter concentrations in-vivo. Here we address the utilization of (1)H MRS for the investigation of GABA concentrations in the ASD brain, in three locations; motor, visual and auditory areas. An initial repeatability study (5 subjects, 5 repeated measures separated by ~5days on average) indicated no significant effect of reference metabolite choice on GABA quantitation (p>0.6). Coefficients of variation for GABA+/NAA, GABA+/Cr and GABA+/Glx were all of the order of 9-11%. Based on these findings, we investigated creatine-normalized GABA+ ratios (GABA+/Cr) in a group of (N=17) children with autism spectrum disorder (ASD) and (N=17) typically developing children (TD) for Motor, Auditory and Visual regions of interest (ROIs). Linear regression analysis of gray matter (GM) volume changes (known to occur with development) revealed a significant decrease of GM volume with Age for Motor (F(1,30)=17.92; p<0.001) and Visual F(1,16)=14.41; p<0.005 but not the Auditory ROI (p=0.55). Inspection of GABA+/Cr changes with Age revealed a marginally significant change for the Motor ROI only (F(1,30)=4.11; p=0.054). Subsequent analyses were thus conducted for each ROI separately using Age and GM volume as covariates. No group differences in GABA+/Cr were observed for the Visual ROI between TD vs. ASD children. However, the Motor and Auditory ROI showed significantly reduced GABA+/Cr in ASD (Motor p<0.05; Auditory p<0.01). The mean deficiency in GABA+/Cr from the Motor ROI was approximately 11% and Auditory ROI was approximately 22%. Our novel findings support the model of regional differences in GABA+/Cr in the ASD brain, primarily in Auditory and to a lesser extent Motor but not Visual areas.

Quiescent fibroblasts are protected from proteasome inhibition-mediated toxicity

Proteasome inhibition is used as a treatment strategy for multiple types of cancers. Although proteasome inhibition can induce apoptotic cell death in actively proliferating cells, it is less effective in quiescent cells. In this study, we used primary human fibroblasts as a model system to explore the link between the proliferative state of a cell and proteasome inhibition-mediated cell death. We found that proliferating and quiescent fibroblasts have strikingly different responses to MG132, a proteasome inhibitor; proliferating cells rapidly apoptosed, whereas quiescent cells maintained viability. Moreover, MG132 treatment of proliferating fibroblasts led to increased superoxide anion levels, juxtanuclear accumulation of ubiquitin- and p62/SQSTM1-positive protein aggregates, and apoptotic cell death, whereas MG132-treated quiescent cells displayed fewer juxtanuclear protein aggregates, less apoptosis, and higher levels of mitochondrial superoxide dismutase. In both cell states, reducing reactive oxygen species with N-acetylcysteine lessened protein aggregation and decreased apoptosis, suggesting that protein aggregation promotes apoptosis. In contrast, increasing cellular superoxide levels with 2-methoxyestradiol treatment or inhibition of autophagy/lysosomal pathways with bafilomycin A1 sensitized serum-starved quiescent cells to MG132-induced apoptosis. Thus, antioxidant defenses and the autophagy/lysosomal pathway protect serum-starved quiescent fibroblasts from proteasome inhibition-induced cytotoxicity.

Abstract 2033: Protection of quiescent fibroblasts from proteasome inhibition-mediated proteotoxicity

Objectives: The aim of this study is to investigate quiescence-related resistance to proteasome-inhibition mediated proteotoxicity, and its regulatory mechanisms. Introduction: Quiescence, the reversible arrest of cellular proliferation, is critical for normal cellular development and tissue maintenance. Moreover, while proteasome inhibitors (PIs) are used to treat specific cancers, it has been shown that subsets of cells within a tumor, through quiescence, avoid PI-induced apoptosis and survive. Thus, deciphering the mechanisms through which quiescent cells resist proteasome inhibition is of basic and clinical relevance. Methods: Proliferating and quiescent primary human fibroblasts were used as a model system to study the effects of PIs (MG132, epoxomycin and Bortezomib). Flow cytometry, Western blots, microscopy and microarrays were used to identify specific pathways activated by proliferating and quiescent fibroblasts in response to proteasome inhibition. Results: We found that the proteasome-inhibited quiescent fibroblasts maintain viability while proliferating fibroblasts rapidly undergo apoptosis. We further found that proteasome-inhibited proliferating and quiescent fibroblasts up-regulate multiple protective pathways, including authophagy, chaperones and antioxidants, and evidence no observable difference in proteasome-mediated degradation pathway activity. However, we found that in proliferating fibroblasts, proteasome inhibition leads to increased reactive oxygen species (ROS), peri-nuclear protein aggresomes, and apoptotic cell death. By comparison, proteasome-inhibited quiescent cells display selective up-regulation of MnSOD (a ROS detoxifying enzyme), dispersed protein aggregates, and less apoptotic cell death. Knockdown of p62/SQSTM1 (a protein important for aggresome formation) or treatment with an antioxidant N-acetylcysteine results in reduced aggresome formation and decreased apoptosis in response to proteasome inhibition. Moreover, inhibition of autophagy sensitizes serum-starved quiescent cells to proteasome inhibition induced apoptosis. This suggests that multiple mechanisms, including autophagy, ROS detoxification and differential subcellular trafficking of ubiquitinated proteins are implicated in quiescence-related resistance to PI-induced apoptosis. These results point to possible strategies for improving the effectiveness of PIs in cancer treatment.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 2033. doi:1538-7445.AM2012-2033

Regulation of the let-7a-3 promoter by NF-κB

Changes in microRNA expression have been linked to a wide array of pathological states. However, little is known about the regulation of microRNA expression. The let-7 microRNA is a tumor suppressor that inhibits cellular proliferation and promotes differentiation, and is frequently lost in tumors. We investigated the transcriptional regulation of two let-7 family members, let-7a-3 and let-7b, which form a microRNA cluster and are located 864 bp apart on chromosome 22q13.31. Previous reports present conflicting data on the role of the NF-κB transcription factor in regulating let-7. We cloned three fragments upstream of the let-7a-3/let-7b miRNA genomic region into a plasmid containing a luciferase reporter gene. Ectopic expression of subunits of NF-κB (p50 or p65/RelA) significantly increased luciferase activity in HeLa, 293, 293T and 3T3 cells, indicating that the let-7a-3/let-7b promoter is highly responsive to NF-κB. Mutation of a putative NF-κB binding site at bp -833 reduced basal promoter activity and decreased promoter activity in the presence of p50 or p65 overexpression. Mutation of a second putative binding site, at bp -947 also decreased promoter activity basally and in response to p65 induction, indicating that both sites contribute to NF-κB responsiveness. While the levels of the endogenous primary let-7a and let-7b transcript were induced in response to NF-κB overexpression in 293T cells, the levels of fully processed, mature let-7a and let-7b miRNAs did not increase. Instead, levels of Lin-28B, a protein that blocks let-7 maturation, were induced by NF-κB. Increased Lin-28B levels could contribute to the lack of an increase in mature let-7a and let-7b. Our results suggest that the final biological outcome of NF-κB activation on let-7 expression may vary depending upon the cellular context. We discuss our results in the context of NF-κB activity in repressing self-renewal and promoting differentiation.

No evidence of a link between influenza vaccines and Guillain-Barre syndrome-associated antiganglioside antibodies

Please cite this paper as: Wang et al. (2011) No evidence of a link between influenza vaccines and Guillain–Barre syndrome–associated antiganglioside antibodies. Influenza and Other Respiratory Viruses 6(3), 159–166.

Background  Guillain–Barre syndrome (GBS) is a rare autoimmune disease characterized by acute, progressive peripheral neuropathy and is commonly associated with the presence of antiganglioside antibodies. Previously, influenza vaccination was linked with the increased incidence of GBS; however, whether antiganglioside antibodies are subsequently induced remains unresolved.

Methods  Sera from human subjects vaccinated with seasonal influenza vaccines from the 2007–2008, 2008–2009, or 1976–1977 influenza seasons were screened for the induction of immunity to influenza and the presence of antiganglioside antibodies pre‐ and post‐vaccination. Likewise, sera from mice vaccinated with seasonal influenza vaccines (1988–1989, 2007–2008) or “swine flu” pandemic vaccines (1976, 2009) were assessed in the same manner. Viruses were also screened for cross‐reacting ganglioside epitopes.

Results  Antiganglioside antibodies were found to recognize influenza viruses; this reactivity correlated with virus glycosylation. Antibodies to influenza viruses were detected in human and mouse sera, but the prevalence of antiganglioside antibodies was extremely low.

Conclusions  Although the correlation between antiganglioside antibody cross‐reactivity and glycosylation of viruses suggests the role of shared carbohydrate epitopes, no correlation was observed between hemagglutinin‐inhibition titers and the induction of antiganglioside antibodies after influenza vaccination.

Relating MEG measured motor cortical oscillations to resting γ-aminobutyric acid (GABA) concentration

The human motor cortex exhibits characteristic beta (15-30 Hz) and gamma oscillations (60-90 Hz), typically observed in the context of transient finger movement tasks. The functional significance of these oscillations, such as post-movement beta rebound (PMBR) and movement-related gamma synchrony (MRGS) remains unclear. Considerable animal and human non-invasive studies, however, suggest that the networks supporting these motor cortex oscillations depend critically on the inhibitory neurotransmitter γ-Aminobutyric acid (GABA). Despite such speculation, a direct relation between MEG measured motor cortex oscillatory power and frequency with resting GABA concentrations has not been demonstrated. In the present study, motor cortical responses were measured from 9 healthy adults while they performed a cued button-press task using their right index finger. In each participant, PMBR and MRGS measures were obtained from time-frequency plots obtained from primary motor (MI) sources, localized using beamformer differential source localization. For each participant, complimentary magnetic resonance spectroscopy (MRS) GABA measures aligned to the motor hand knob of the left central sulcus were also obtained. GABA concentration was estimated as the ratio of the motor cortex GABA integral to a cortical reference NAA resonance at 2 ppm. A significant linear relation was observed between MI GABA concentration and MRGS frequency (R(2)=0.46, p<0.05), with no association observed between GABA concentration and MRGS power. Conversely, a significant linear relation was observed between MI GABA concentration and PMBR power (R(2)=0.34, p<0.05), with no relation observed for GABA concentration and PMBR frequency. Finally, a significant negative linear relation between the participant's age and MI gamma frequency was observed, such that older participants had a lower gamma frequency (R(2)=0.40, p<0.05). Present findings support a role for GABA in the generation and modulation of endogenous motor cortex rhythmic beta and gamma activity.

Computed tomography-guided aspiration versus key-hole craniotomy for spontaneous putaminal haemorrhage: a prospective comparison of minimally invasive procedures

OBJECTIVES

To compare the effectiveness of two minimally invasive procedures, namely computed tomography-guided aspiration and the key-hole approach, in the neurosurgical management for spontaneous putaminal haemorrhage, and to explore the indications for the two approaches.

DESIGN

A multicentre, single-blinded controlled trial.

SETTING

Hospitals taking part in this trial and the sources for patients were from China. Among others, the hospitals involved in the interventions included: the Beijing Tiantan Hospital (of the Capital University of Medical Sciences), the General Hospital of People's Liberation Army, the Peking Union Hospital, and the Shanghai Huashan Hospital (of the Fudan University medical school).

PATIENTS

From September 2001 to November 2003, data were available for analysis from a total of 841 patients with spontaneous putaminal haemorrhage from 135 hospitals all over China (except Tibet, Hong Kong, Taiwan, and Macao). All follow-up data were for at least 3 months.

MAIN OUTCOME MEASURES

Mortality, Glasgow Coma Scale score, postoperative complications, Kanofsky Performance Scale score, and Barthel Index.

RESULTS

There were 563 patients who underwent computed tomography-guided aspiration, and 165 were treated by the key-hole approach. Respective mortality rates 1 month after the operation were 17.9% and 18.3%; at 3 months they were 19.4% and 19.4%. In those undergoing computed tomography-guided aspiration, mortality rates at 3 months after the operation were 28.2% in patients with Glasgow Coma Scale scores of 8 or below, as opposed to 8.2% in those with higher scores. This amounted to a 3.4-fold difference. In those treated by the key-hole approach, the corresponding rates were 30.2% and 7.6%, which amounted to a 4-fold difference. The corresponding mortality at 3 months in patients with complications was 3.9 times as great as in those without complications. In those with haematoma volumes of 70 mL or greater, it was 2.7 times as much as in those in whom the volumes below 30 mL. The postoperative complication rate of computed tomography-guided aspiration (23.7%) did not differ significantly from that in those having the key-hole approach (25.7%) [P=0.420].

CONCLUSIONS

Computed tomography-guided aspiration is not superior to the key-hole approach for treating spontaneous putaminal haemorrhage in terms of favourable outcomes, mortality, and morbidity. However, it could be the first-choice approach for those with bleeds of 50 mL or less, while the key-hole approach may be more suitable for those with larger haematomas.

Mesenchymal Stem Cells Genetically Modified with the Angiopoietin-1 Gene Enhanced Arteriogenesis in a Porcine Model of Chronic Myocardial Ischaemia

The direct injection by thoracoscope of mesenchymal stem cells (MSCs) that had been genetically modified to express angiopoietin-1 was investigated in a porcine model to determine their effect on arteriogenesis and the effectiveness of this technique. Chronic myocardial ischaemia was established using a thoracoscope to insert an ameroid constrictor around the left circumflex coronary artery. Six weeks after establishing the ischaemia, 20 pigs were randomly divided into three groups to receive injections by thoracoscope of either genetically-modified MSCs, unmodified MSCs or phosphate-buffered saline into the ischaemic border area. The injections were repeated 1 month later. The genetically modified MSCs were found to restore blood flow significantly more than the other observed treatments and immunohistochemical evaluation of arteriogenesis supported this finding. In conclusion, the injection of MSCs that had been genetically modified to express angiopoietin-1 improved arteriogenesis and increased collateral blood flow in the myocardial ischaemic area. Thoracoscope delivery of the injection was safe and minimally invasive.

A novel platform for biologically active recombinant human interleukin-13 production

Interleukin-13 (IL-13) is a pleiotropic regulatory cytokine with the potential for treating several human diseases, including type-1 diabetes. Thus far, conventional expression systems for recombinant IL-13 production have proven difficult and are limited by efficiency. In this study, transgenic plants were used as a novel expression platform for the production of human IL-13 (hIL-13). DNA constructs containing hIL-13 cDNA were introduced into tobacco plants. Transcriptional expression of the hIL-13 gene in transgenic plants was confirmed by reverse transcriptase-polymerase chain reaction and Northern blotting. Western blot analysis showed that the hIL-13 protein was efficiently accumulated in transgenic plants and present in multiple molecular forms, with an expression level as high as 0.15% of total soluble protein in leaves. The multiple forms of plant-derived recombinant hIL-13 (rhIL-13) are a result of differential N-linked glycosylation, as revealed by enzymatic and chemical deglycosylation, but not of disulphide-linked oligomerization. In vitro trypsin digestion indicated that plant rhIL-13 was more resistant than unglycosylated control rhIL-13 to proteolysis. The stability of plant rhIL-13 to digestion was further supported with simulated gastric and intestinal fluid digestion. In vitro bioassays using a factor-dependent human erythroleukaemic cell line (TF-1 cells) showed that plant rhIL-13 retained the biological functions of the authentic hIL-13 protein. These results demonstrate that transgenic plants are superior to conventional cell-based expression systems for the production of rhIL-13. Moreover, transgenic plants synthesizing high levels of rhIL-13 may prove to be an attractive delivery system for direct oral administration of IL-13 in the treatment of clinical diseases such as type-1 diabetes.

The characteristics and prognostic importance of NT-ProBNP concentrations in critically ill patients

BACKGROUND

There are limited data for prognostic and diagnostic use of natriuretic peptides in intensive care unit (ICU) patients. We evaluate amino-terminal brain natriuretic peptide (NT-proBNP) in the medical ICU, specifically its correlation with noncardiac admission diagnosis and prognosis of critically ill patients.

METHODS

NT-proBNP (pg/mL) was measured in 179 ICU patients without acute decompensated heart failure or acute coronary syndrome. Death during hospitalization (mortality), APACHE II score, laboratory data, echocardiograms, medical history, and demographics were assessed. NT-proBNP concentrations were compared with established cutoffs for congestive heart failure (>450 pg/mL for patients <50 years of age, >900 pg/mL for patients 50-70 years of age, and >1800 pg/mL for patients >70 years of age). Predictors of mortality and of NT-proBNP were analyzed by regression analysis. Tertiles were compared by analysis of variance and chi-squared test.

RESULTS

NT-proBNP was elevated in these ICU patients (median 2139 pg/mL, 25th percentile 540 pg/mL, 75% percentile 7389 pg/mL). Severity of illness and renal dysfunction (APACHE II score and serum creatinine) increased with rising NT-proBNP. The incidence of acute respiratory distress syndrome, sepsis, death, history of coronary artery disease (CAD) or congestive heart failure (all P <.05) increased with each tertile. Independent predictors of increased NT-proBNP were creatinine (P <.001), CAD (P <.001), APACHE II score (P <.05), and sepsis (P < or =.001). Overall hospital mortality was 26%, and log NT-proBNP (P <.05), APACHE II (P < or =.001), and CAD (P <.05) were independent predictors of mortality.

CONCLUSIONS

For patients admitted to the ICU without decompensated heart failure or acute coronary syndrome, NT-proBNP concentrations are markedly elevated, especially in patients with sepsis. NT-proBNP strongly and independently predicts mortality. However, NT-proBNP should not be used to direct volume management in critically ill patients.

Impedance cardiography: More questions than answers

Thoracic electrical bioimpedance, also known as impedance cardiography (ICG), is a noninvasive method to obtain hemodynamic measurements, including cardiac output. Recently, there has been a flurry of reports on the clinical use of ICG. Authors have suggested that ICG measurements are useful for a myriad of situations, including diagnosis of heart failure, monitoring of a patient's clinical status, and assisting in medicine titration decisions. However, data continue to suggest poor correlation between current generation ICG devices and invasive measurements of cardiac output, especially in heart failure patients. ICG is also not able to accurately measure left ventricular filling pressures. There are limited data demonstrating any improved outcomes using ICG in the clinical setting. Given the available data, ICG use should be limited to the research setting.

Natural history of Canavan disease revealed by proton magnetic resonance spectroscopy (1H-MRS) and diffusion-weighted MRI

Canavan disease is a childhood leukodystrophy caused by mutations in the gene for human aspartoacylase ( ASPA), which leads to an abnormal accumulation of the substrate molecule N-acetyl-aspartate (NAA) in the brain. This study was designed to model the natural history of Canavan disease using MRI and proton magnetic resonance spectroscopy ( (1)H-MRS). NAA and various indices of brain structure (morphology, quantitative T1, fractional anisotropy, apparent diffusion coefficient) were measured in white and gray matter regions during the progression of Canavan disease. A mixed-effects statistical model was used to fit all outcome measures. Longitudinal data from 28 Canavan patients were directly compared in each brain region with reference data obtained from normal, age-matched pediatric subjects. The resultant model can be used to non-invasively monitor the natural history of Canavan disease or related leukodystrophies in future studies involving drug, gene therapy, or stem cell treatments.

Impedance cardiography: More questions than answers

Thoracic electrical bioimpedance, also known as impedance cardiography (ICG), is a noninvasive method to obtain hemodynamic measurements, including cardiac output. Recently, there has been a flurry of reports on the clinical use of ICG. Authors have suggested that ICG measurements are useful for a myriad of situations, including diagnosis of heart failure, monitoring of a patient's clinical status, and assisting in medicine titration decisions. However, data continue to suggest poor correlation between current generation ICG devices and invasive measurements of cardiac output, especially in heart failure patients. ICG is also not able to accurately measure left ventricular filling pressures. There are limited data demonstrating any improved outcomes using ICG in the clinical setting. Given the available data, ICG use should be limited to the research setting.

Mild-onset presentation of Canavan's disease associated with novel G212A point mutation in aspartoacylase gene

We describe two sisters with a mild-onset variant of Canavan's disease who presented at age 50 and 19 months with developmental delay but without macrocephaly, hypotonia, spasticity, or seizures. Remarkably, both patients had age-appropriate head control, gross motor development, and muscle tone. There were very mild deficits in fine motor skills, coordination, and gait. Both sisters had a history of strabismus, but otherwise vision was normal. The older child showed evidence of mild cognitive and social impairment, whereas language and behavior were normal for age in the infant. Both patients were found to be compound heterozygotes for C914A (A305E) and G212A (R71H) mutations in ASPA. Like all other known ASPA mutations, this previously unknown G212A mutation appears to have low absolute enzyme activity. Nevertheless, it is associated in these patients with an extremely benign phenotype that is highly atypical of Canavan's disease. Biochemical and clinical data were evaluated using a generalized linear mixed model generated from 25 other subjects with Canavan's disease. There were statistically significant differences in brain chemistry and clinical evaluations, supporting a distinct variant of Canavan's disease. Future studies of ASPA enzyme structure and gene regulation in these subjects could lead to a better understanding of Canavan's pathophysiology and improvements in ASPA gene therapy.