Eosinophilic meningoencephalitis successfully treated with glucocorticoids and intravenous immunoglobulin: a case report

Eosinophilic meningoencephalitis is a rare inflammatory condition of the central nervous system. As a limited number of cases has been reported, debate remains on the optimal treatment. We present a case of idiopathic eosinophilic meningoencephalitis successfully treated with glucocorticoids and intravenous immunoglobulin (IVIG). After extensive evaluation to rule out other possible causes, the patient was treated with intravenous (IV) dexamethasone and showed significant improvement within a few days. However, neurologic impairment persisted, and follow-up lumbar puncture results showed only a mild decrease in pleocytosis. Even after an additional 5 days of IV methylprednisolone, cerebrospinal fluid (CSF) pleocytosis persisted, and brain magnetic resonance imaging (MRI) showed an increase in enhanced lesions, implying persistent neuroinflammation. The patient was maintained on high-dose oral prednisolone for 2 months, and additional immune-modulatory effects were treated with IVIG. Follow-up MRI at 2 months showed a significant decrease in the extent of multiple enhanced lesions and a normalized CSF profile. The patient was maintained on regular maintenance doses of IVIG for an additional 6 months without any neurologic signs or symptoms. Inflammation is the key pathophysiology underlying neurological damage in eosinophilic meningoencephalitis. A literature review revealed that corticosteroid treatment is the only anti-inflammatory treatment used in cases of idiopathic meningoencephalitis, resulting in sufficient response in most patients but only partial response or death in a few cases. This is the first case report of IVIG use in idiopathic eosinophilic meningoencephalitis, suggesting the possibility of a new treatment modality for refractory cases.

Topiramate dosage optimization for effective antiseizure management via population pharmacokinetic modeling

OBJECTIVE

Despite the suggested topiramate serum level of 5-20 mg/L, numerous institutions have observed substantial drug response at lower levels. We aim to investigate the correlation between topiramate serum levels, drug responsiveness, and adverse events to establish a more accurate and tailored therapeutic range.

METHODS

We retrospectively analyzed clinical data collected between January 2017 and January 2022 at Seoul National University Hospital. Drug responses to topiramate were categorized as "insufficient" or "sufficient" by reduction in seizure frequency ≥ 50%. A population pharmacokinetic model estimated serum levels from spot measurements. ROC curve analysis determined the optimal cutoff values.

RESULTS

A total of 389 epilepsy patients were reviewed having a mean dose of 178.4 ± 117.9 mg/day and the serum level, 3.9 ± 2.8 mg/L. Only 5.6% samples exhibited insufficient response, with a mean serum level of 3.6 ± 2.5 mg/L while 94.4% demonstrated sufficient response, with a mean 4.0 ± 2.8 mg/L, having no statistical significance. Among the 69 reported adverse events, logistic regression analysis identified a significant association between ataxia and serum concentration (p = 0.04), with an optimal cutoff value of 6.5 mg/L.

INTERPRETATION

This study proposed an optimal therapeutic concentration for topiramate based on patients' responsiveness to the drug and the incidence of adverse effects. We recommended serum levels below 6.5 mg/L to mitigate the risk of ataxia-related side effects while dose elevation was found unnecessary for suboptimal responders, as the drug's effectiveness plateaus at minimal doses.

Gut microbiome diversity in a febrile seizure mouse model

Purpose

Febrile seizures at a young age can provoke late-onset temporal lobe epilepsy. Since recent evidence has suggested that the gut microbiome affects central nervous system pathology across the blood-brain barrier, we hypothesized that febrile seizures alter the composition of the gut microbiome to provoke epilepsy.

Methods

Third-generation C57BL/6 mice were separated into two groups (n = 5 each), and hot air was applied to only one group to cause febrile seizures. After two weeks of heat challenge, the fecal pellets acquired from each group were analyzed.

Results

The gut microbiota of fecal pellets from each group revealed five taxa at the genus level and eight taxa at the species level that were significantly different in proportion between the groups.

Conclusion

Although there was no significant difference in the overall diversity of the gut microbiota between the two groups, the identified heterogeneity may imply the pathognomonic causative relevance of febrile seizures and the development of epilepsy.

Identification of bacterial pathogens in brain abscesses by metagenomic approach using nanopore 16S amplicon sequencing

Brain abscess is medically challenging. In this study, we applied nanopore sequencing for 16S rRNA analysis and investigated its efficacy and diagnostic value for patients with brain abscesses. Genomic DNA was extracted from the pus samples (n = 27) of brain abscess, and 16S rRNA genes were amplified by PCR. Sequencing libraries were generated using a rapid barcoding kit, and the generated reads were analyzed using the EPI2ME16S workflow. A conventional culture study was performed. More sensitive identification of pathogens was made by 16S sequencing, faster than the culture study. The proportion of anaerobic bacteria identified by 16S sequencing was higher (75%) than that obtained by culturing (32%). Polymicrobial infections were identified in 10 cases (40%) by 16S sequencing, while the culture study identified multiple bacteria in only 2 cases (8%). 16S sequencing was useful for identifying the composition of polymicrobial infections, including rare pathogens, and for the initial diagnosis of space-occupying lesions.

Search for Boosted Dark Matter in COSINE-100

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

Cognitive function improvement effects of gintonin-enriched fraction in subjective memory impairment: An assessor- and participant-blinded placebo-controlled study

Background

Gintonin is a new material of ginseng that acts through the ginseng-derived lysophosphatidic acid (LPA) receptor ligand. The gintonin-enriched fraction (GEF) inhibits amyloid plaque accumulation in the cortex and hippocampus, improves cognitive dysfunction by increasing acetylcholine levels, and promoted hippocampal neurogenesis in an animal model of Alzheimer's disease. We evaluated the effect of the GEF on the cognitive performance of subjects with subjective memory impairment (SMI).

Methods

In this eight-week, randomized, assessor- and participant-blinded, placebo-controlled study, participants with SMI were assigned to three groups receiving placebo, GEF 300 mg/day or GEF 600 mg/day. The Korean versions of the Alzheimer's Disease Assessment Scale (K-ADAS), Mini-Mental State Examination (K-MMSE), and Stroop color-word test (K-SCWT) were also evaluated along with the safety profiles.

Results

One hundred thirty-six participants completed the study. After eight weeks, we analyzed intergroup differences in primary or secondary outcome score changes. When we compared the GEF group with the placebo group, we observed significant improvements in the K-ADAS and K-SCWT scores. The GEF group did not show a significant improvement in K-MMSE and BDI scores compared to the placebo group. No adverse events were observed in the gintonin and placebo groups for eight weeks.

Conclusion

The GEF is safe and effective in improving subjective cognitive impairment related to both the K-ADAS and K-SCWT in this study. However, further large-scale and randomized controlled studies are warranted to secure other cognitive function tests besides the K-ADAS and K-SCWT, and to confirm the findings of the current study.

A randomised controlled trial of the analgesia nociception index for intra-operative remifentanil dose and pain after gynaecological laparotomy

We aimed to investigate the effect of the analgesia nociception index on postoperative pain. We randomly allocated 170 women scheduled for gynaecological laparotomy and analysed results from 159: in 80 women, remifentanil was infused to maintain analgesia nociception indices 50-70; and in 79 women, remifentanil was infused to maintain systolic blood pressure < 120% of baseline values. The primary outcome was the proportion of women with pain scores ≥ 5 (scale 0-10) within 40 min of admission to recovery. The proportion of women with pain scores ≥ 5 was 62/80 (78%) vs. 64/79 (81%), p = 0.73. Mean (SD) doses of fentanyl in recovery were 53.6 (26.9) μg vs. 54.8 (20.8) μg, p = 0.74. Intra-operative remifentanil doses were 0.124 (0.050) μg.kg-1 .min-1 vs. 0.129 (0.044) μg.kg-1 .min-1 , p = 0.55.

The rocky road to freedom: number of countries transited during defection and risk of metabolic syndrome among North Korean Refugees in South Korea

OBJECTIVES

North Korean Refugees (NKRs) undergo defection, and this has been shown to impact their current health status in South Korea. However, little is understood about how the defection process is related to metabolic syndrome (MetS). This study regarded the defection process to be a quasi-measurement of traumatic experience and investigated whether defection was a risk factor for MetS among NKRs living in South Korea.

STUDY DESIGN

This cross-sectional study obtained data from the Korea University Anam Hospital in Seoul. NKRs (N = 847) voluntarily completed questionnaires and underwent at least one medical examination between October 2008 and July 2021.

METHODS

Multivariable logistic regression models were used to evaluate whether the number of countries transited by NKRs was associated with MetS by controlling for covariates.

RESULTS

The prevalence of MetS among male and female NKRs in South Korea was 12.3% and 13.3%, respectively. The highest prevalence of MetS (33.4%) was among NKRs who had transited two countries. The number of months in transit countries (mean: 49.9 ± 51.7) and period of residence in South Korea (mean: 40.9 ± 40.9 months) were also considered. NKRs who transited three countries had a higher probability of MetS (odds ratio [OR] 2.660, 95% confidence interval [CI] 1.161-6.097) than those who travelled directly to South Korea. NKRs who transited three countries and had only resided in South Korea for a short period had a higher probability of MetS (OR 3.424, 95% CI 1.149-10.208) than those who have lived in South Korea for a longer period.

CONCLUSIONS

Considering the social vulnerability of NKRs and consequential health problems, there is an urgent need for appropriate support from the government and society.

Anti-seizure medication prescription in epilepsy patients in South Korea: A seven-year population-based retrospective cohort study

BACKGROUND AND OBJECTIVES

This study aimed to explore the natural history of patients with epilepsy using overall antiseizure-medication (ASM) treatment patterns on a nationwide scale in South Korea.

METHODS

We investigated a retrospective longitudinal cohort of patients with epilepsy in South Korea using nationwide data from the Korean National Health Information Database of the Health Insurance and Review Assessment Service between January 1st, 2009, and December 31st, 2018. Histories of each patient's ASM prescription were followed for up to 7 years from the index date, the first observed date of ICD-10 epilepsy diagnosis codes with at least one ASM prescription.

RESULTS

Of 82,390 incident patients analyzed, ten thousand and fifty-nine were followed up to seven years, and nearly 60% of them discontinued the ASM(s). The proportion of patients with possible drug-resistant epilepsy (DRE), who experience three or more types of ASMs, gradually increased, reaching approximately 8.8% of the total number of patients in the seventh year (6.45% for adults, 21.8% for children). The duration of progression for half of the patients with possible DRE was 1.29 years for children, 1.79 years for adults, and 1.62 years for mixed-age patients. However, even in the sixth year, 72 cases progressed to possible DRE, and 6 cases with possible DRE discontinued ASMs in the next year, showing a dynamic process.

DISCUSSION

Our population-based study showed the dynamic changes of anti-seizure medication prescription in epilepsy patients with real-world data, which slowly stabilizes over years after the first diagnosis of epilepsy.

Three-Dimensional Analysis of the Trapezium Subchondral Bone and its Association with Trapeziometacarpal Joint Osteoarthritis

Subchondral bone properties are associated with the pathogenesis of osteoarthritis (OA), but this relationship has not been confirmed in the trapeziometacarpal joint (TMCJ). We aimed to evaluate the thickness (SBT) and density (SBD) of three-dimensional (3D) trapezium subchondral bone models derived from computed tomography (CT) images, and their relationships with early-stage TMCJ OA. We reviewed patients with a distal radius fracture who underwent conventional CT scans and such osteoporosis evaluations as bone mineral density (BMD) and bone turnover markers (BTMs). From 3D trapezium subchondral bone models, we measured SBT and SBD according to the OA stage and performed multivariate analyses to evaluate their associations with age, sex, body mass index, BMD, and BTMs. As results, a total of 156 patients (78 men and 78 age-matched women; mean age, 67 ± 10 years) were analyzed. There were 30 (19%) with grade 0, 71 (45%) with grade 1, 13 (8%) with grade 2, and 42 (27%) with grade 3 TMCJ OA. SBT was significantly lower in patients with grade 1 OA than those with grade 0 or grade 3 OA, but SBD generally increased according to the OA severity. Low SBT was associated with low BMD, and low SBD with low BMD, high osteocalcin levels, and severe OA grades. In conclusion, patients with early-stage radiographic TMCJ OA have a lower SBT at the trapezium, which may support the potential role of subchondral bone in OA pathogenesis. This study also shows that subchondral bone properties are associated with BMD and osteocalcin levels.

Clinicoradiologic data of familial cerebral cavernous malformation with age-related disease burden

OBJECTIVE

Familial cerebral cavernous malformation (FCCM) is an autosomal dominant disease induced by loss-of-function mutations in three CCM genes, KRIT1, CCM2, and PDCD10. However, previous studies paid little attention to analyzing the radiologic features and age-related disease burden according to the genes. Therefore, we retrospectively reviewed the genetic tests of our center's clinical FCCM patients.

METHOD

This study investigated clinical FCCM patients with multiple lesions or a family history of CCMs who underwent the FCCM gene (KRTI1, CCM2, and PDCD10) panel test. The clinical, genetic, and radiologic features were analyzed.

RESULT

Among the patients (n = 34) undergoing the FCCM gene test, twenty-seven patients had CCM confirmed by brain MRI, and twenty-one patients were considered to have FCCM (cohort 1). In cohort 1, thirteen patients had mutations in the FCCM gene, but eight did not. Cohort 2 comprised cohort 1 and four family members with the same mutation as the probands. Six novel variants in CCM genes were detected (KRIT1 c.22_26del, c.815dup, c.1094_1098del, c.1147-2A>G, c.2124dup, and PDCD10 c.150 + 1dup). Cohort 1 demonstrated that brainstem lesions were mostly associated with the mutation detection in CCM genes (brainstem, lateral temporal, and parietal lesions vs. lateral temporal and parietal lesions, AUC 0.928 vs. 0.779, P = 0.0389). The radiologic severity worsened according to age in the KRIT1 group compared with the Mutation not detected group (correlation coefficient 0.75 (P < 0.001) versus 0.53 (P = 0.004)).

CONCLUSION

The brainstem lesion could be the radiologic marker for FCCM with the mutation detected. The age-related disease burden regarding FCCM according to genetic information was demonstrated.

Autoimmune limbic encephalitis combined with leptomeningeal metastases of non-small cell lung cancer: treatment response to osimertinib, immunoglobulin, rituximab, and tocilizumab

When a patient with encephalopathy has an organic brain lesion, his symptom is easily and often mistakenly attributed to that brain lesion. However, a combination of different conditions is also possible. We present a case of autoimmune limbic encephalitis combined with leptomeningeal carcinomatosis. A 57-year-old female patient was transferred to our institute with a 1-month history of seizure and aggressive behavior. Subacute onset of psychosis with multifocal T2 high signal lesions suggested autoimmune encephalitis, and high-dose steroid pulse and immunoglobulin therapy were started. However, a cerebrospinal fluid study revealed metastatic adenocarcinoma of non-small cell lung cancer, of which she was in complete remission state. Osimertinib, a third-generation epidermal growth factor receptor tyrosine kinase inhibitor, was started targeting leptomeningeal metastases while maintaining immunotherapy of rituximab and tocilizumab. Her neurological symptoms showed improvement in response to immunotherapy which lasted approximately 1 month and then deteriorated again. We concluded that her symptoms were more attributable to autoimmune encephalitis than leptomeningeal carcinomatosis, and discontinued osimertinib.

Association of Nucleus Basalis of Meynert Functional Connectivity and Cognition in Idiopathic Rapid-Eye-Movement Sleep Behavior Disorder

Background and Purpose

Cognitive impairments are common in isolated rapid-eye-movement sleep behavior disorder (iRBD), in which the cholinergic system may play an important role. This study aimed to characterize the cortical cholinergic activity using resting-state functional connectivity (FC) of the nucleus basalis of Meynert (NBM) according to the cognitive status of iRBD patients.

Methods

In this cross-sectional study, 33 patients with polysomnography-confirmed iRBD and 20 controls underwent neuropsychological evaluations and resting-state functional magnetic resonance imaging. Thirteen of the iRBD patients had mild cognitive impairment (iRBD-MCI), and the others were age-matched patients with normal cognition (iRBD-NC). The seed-to-voxel NBM–cortical FC was compared among the patients with iRBD-MCI, patients with iRBD-NC, and controls. Correlations between average values of significant clusters and cognitive function scores were calculated in the patients with iRBD.

Results

There were group differences in the FC of the NBM with the left lateral occipital cortex and lingual gyrus (adjusted for age, sex, and education level). The strength of FC was lower in the iRBD-MCI group than in the iRBD-NC and control groups (each post-hoc p<0.001). The average NBM–lateral occipital cortex FC was positively correlated with the memory-domain score in iRBD patients.

Conclusions

The results obtained in this study support that cortical cholinergic activity is impaired in iRBD patients with MCI. FC between NBM and posterior regions may play a central role in the cognitive function of these patients.

Correlations between skeletal maturity and dental calcification stages in Korean children

AIM

To evaluate the relationship between dental calcification and skeletal maturity and to identify the tooth with the highest correlation with skeletal maturity index in Korean children.

MATERIALS

For 447 children (205 boys and 242 girls) aged between 5 and 13 years, hand-wrist and lateral cephalometric radiographs were taken to assess skeletal maturity by Fishman's skeletal maturity indicators (SMI) and Baccetti's cervical vertebrae maturation (CVM) stages. Dental panoramic radiographs were taken to assess dental maturity of the permanent mandibular canine, first and second premolar, and second molar using the method devised by Dermirjian.

CONCLUSION

Dental calcification stages determined by panoramic radiographs can be clinically used as useful indices to predict skeletal maturity in Korean children.

Long-term outcomes of ruptured hepatocellular carcinoma: An international multicentric propensity score-matched study

Objective

Long-term outcomes of patients with ruptured hepatocellular carcinoma (rHCC) remain scant. This study aimed to assess disease-free survival (DFS) and overall survival (OS) after surgical resection of rHCC compared to non-ruptured HCC (nrHCC).

Methods

Patients with rHCC and nrHCC were collected from 8 centers in Europe, Asia, and North America. Resected rHCC patients were matched 1:1 to patients undergoing surgery for nrHCC using propensity score and nearest-neighbor method (matching criteria: age, tumor size, cirrhosis, Child-Pugh score, Barcelona Clinic Liver Cancer stage, resection status, grade, and microvascular invasion). Survival rates were calculated using Kaplan-Meier method.

Results

A total of 2033 patients were included: 226 rHCC patients (172 operated: 68 with upfront surgery and 104 after embolization) and 1807 nrHCC patients. Median DFS and OS of rHCC patients (all treatments confounded) were 10 months (95% CI 7–13) and 22 months (95% CI 13–31). Prognostic factors for worse OS among rHCC patients were absence of preoperative arterial embolization (HR 2.3, 95% CI 1.2–4.6, p=0.016), cirrhosis Child B/C (HR 2.4, 95% CI 1.1–5.4, p=0.040), and R1/R2 margins (HR 2, 95% CI 1–5, p=0.049). Survivals were similar between Western and Eastern rHCC patients.

After propensity score matching, 106 rHCC patients and 106 nrHCC patients displayed similar characteristics. Patients with rHCC had shorter median DFS (12 months, 95% CI 7–17 vs. 22 months, 95% CI 12–32, p=0.011), but similar median OS compared to nrHCC patients (43 months, 95% CI 21–65 vs. 63 months, 95% CI 21–105, p=0.060).

Conclusion

In this large dataset including Eastern and Western patients, rHCC was associated with shorter DFS compared to nrHCC, while OS was similar.

Neuropsychiatric symptoms and seizure related with serum cytokine in epilepsy patients

Neuroinflammation contributes to epileptogenesis and ictogenesis. Various signals of neuroinflammation lead to neuronal hyper-excitability. Since an interplay between epilepsy, psychiatric comorbidities and neuroinflammation has been suggested, we explored psychiatric symptoms in epilepsy patients, and the relationship with neuroinflammation. We screened epilepsy patients who were admitted for video-EEG monitoring between July 2019 and December 2020. Enrolled patients were asked to respond to neuropsychiatric questionnaires (Hospital Anxiety and Depression Scale (HADS) and Neuropsychiatric Inventory-Questionnaire (NPI-Q)) on admission. Serum cytokines (IL-1β, IL-2, IL-6, IFN-γ, CCL2, and CCL5) were measured by ELISA on admission, and within 6 h after a seizure. We enrolled 134 patients, and 32 patients (23.9%) had seizures during monitoring. Cytokine levels did not change after seizures, but IL-2 and IL-6 increased in cases of generalized tonic–clonic seizures. The HADS-A score was lower in Q4 of CCL5 (p-value = 0.016) and anxiety was also less common in Q4 of CCL5 (p-value = 0.042). NPI-Q question 4 (depression) severity was higher in CCL2 (p-value = 0.024). This suggested that psychiatric symptoms may also be related to inflammatory processes in epilepsy patients. Further large, standardized studies are necessary to underpin the inflammatory mechanisms in epilepsy and psychiatric symptoms.

High-precision measurement of the W boson mass with the CDF II detector

The mass of the W boson, a mediator of the weak force between elementary particles, is tightly constrained by the symmetries of the standard model of particle physics. The Higgs boson was the last missing component of the model. After observation of the Higgs boson, a measurement of the W boson mass provides a stringent test of the model. We measure the W boson mass, M_W, using data corresponding to 8.8 inverse femtobarns of integrated luminosity collected in proton-antiproton collisions at a 1.96 tera-electron volt center-of-mass energy with the CDF II detector at the Fermilab Tevatron collider. A sample of approximately 4 million W boson candidates is used to obtain [Formula: see text], the precision of which exceeds that of all previous measurements combined (stat, statistical uncertainty; syst, systematic uncertainty; MeV, mega-electron volts; c, speed of light in a vacuum). This measurement is in significant tension with the standard model expectation.

The safety and efficacy of intravenous immunoglobulin in autoimmune encephalitis

OBJECTIVE

Although intravenous immunoglobulin (IVIG) is the first-line immunotherapy in autoimmune encephalitis, all supporting evidence comes from retrospective case series. Here, we performed a prospective clinical trial of IVIG for functional recovery in autoimmune encephalitis.

METHODS

This single-arm, open-label study assessed the efficacy and safety of 10% intravenous IVIG treatment in newly diagnosed patients with possible autoimmune encephalitis. Patients received IVIG (0.4 g/kg/day) for 5 days. Rescue immunotherapy was permitted when the patient deteriorated before day 8 or showed no improvement at day 8. The primary outcome was the change in the modified Rankin Scale (mRS) score at day 8 and 29. The secondary outcomes were the mRS score improvement and the score changes and improvements on four other clinical scales.

RESULTS

Overall, 23 patients received IVIG (intension-to-treat, ITT), and 18 patients completed the study according to the protocol (per-protocol, PP). mRS improved significantly at days 8 and 29 compared to baseline in both the ITT and PP populations. Other secondary outcomes also improved significantly at day 8, 15, and 29 versus baseline. In the PP population, 6/18 patients achieved favorable outcomes with IVIG alone (mRS = 0~2 at day 8), and 12/18 patients received rescue immunotherapy. Five adverse events were reported in relation to IVIG, all of which were mild.

INTERPRETATION

IVIG improved neurological functional outcomes, and the improvement was evident by day 8. Adverse effects were tolerable. These data provide the prospective evidence regarding the efficacy of IVIG in improving the functional outcomes of autoimmune encephalitis.

Anakinra treatment for refractory cerebral autoinflammatory responses

Refractory cerebral autoinflammatory–autoimmune diseases are often associated with dysregulated innate immunity and are targeted by anakinra, an interleukin‐1 receptor antagonist. We analyzed the therapeutic effect of anakinra in refractory cerebral autoinflammatory response (CAIR) at a single institution from January 2017 to May 2021. In total, 12 patients with various etiologies were sympathetically treated with anakinra (100 mg/day subcutaneously). Four patients showed good responses, and among these patients, three patients had pathologically demonstrated CAIR. The other eight patients were nonresponsive. No patient had a serious adverse effect. Thus, anakinra may be a therapeutic option for refractory cerebral autoinflammatory diseases.

Direct brain involvement of Takayasu arteritis treated with rituximab and infliximab: a case report

Takayasu arteritis (TAK) is a systemic vasculitis involving large arteries. Reports of direct central nervous system (CNS) involvement in TAK are extremely rare in the literature. In addition, treatment for direct involvement has not been reported. Herein, we describe a case of encephalitis in a TAK patient who presented with fever and headache at the first attack, then cognitive impairment at the second attack. The patient improved with rituximab and especially infliximab. These findings indicate the usefulness of rituximab and infliximab to treat the direct CNS manifestations in TAK.

Successful treatment with rituximab for central nervous system vasculitis caused by Epstein-Barr virus-associated lymphoproliferative disorder with immunoglobulin M gammopathy

Monoclonal gammopathy of undetermined significance (MGUS) is associated with several autoimmune conditions, including central nervous system (CNS) vasculitis. Epstein-Barr virus (EBV) is a pathogen capable of triggering a systemic immune response and is involved in the occurrence of a wide range of B-cell lymphoproliferative disorders. In systemic autoimmune diseases, EBV infection is suspected to play a central role in pathogenesis. Here, we present a case that was thought to be a systemic autoimmune disease and CNS vasculitis that developed after EBV infection, demonstrating that rituximab is effective for the treatment.

Meniscal and Cartilage Changes on Serial MRI After Medial Opening-Wedge High Tibial Osteotomy

Background:

Assessments of the effects of realignment using opening-wedge high tibial osteotomy (OWHTO) on the medial, lateral, and patellofemoral compartments have been limited to cartilage evaluations.

Purpose/Hypothesis:

The purpose was to evaluate the effects of OWHTO on the meniscus and cartilage of each compartment as a cooperative unit (meniscochondral unit) using serial magnetic resonance imaging (MRI). It was hypothesized that (1) favorable changes in the meniscochondral unit would occur in the medial compartment and (2) that changes in the patellofemoral and lateral compartments would be negligible.

Study Design:

Case series; Level of evidence, 4.

Methods:

Included were 36 knees that underwent OWHTO from March 2014 to February 2016 and had postoperative serial MRI. The MRI was performed at 19.9 ± 7.4 and 52.3 ± 8.3 months postoperatively, and the cartilage and meniscal changes were evaluated by highlighting the regions of interest. We evaluated the T2 relaxation times of each cartilage and meniscal area, the cross-sectional area of the menisci, and the extrusion of the medial meniscus (MM). The meniscochondral unit was assessed using subgroup analyses according to the status of the MM.

Results:

Significant decreases were seen in T2 relaxation times in the medial femoral condyle (MFC) (P < .001) and medial tibial plateau (MTP) (P = .050), and significant increases were seen in the lateral femoral condyle (LFC) (P = .036). The change was more prominent in the MFC compared with the MTP and LFC (P = .003). No significant changes were observed in the lateral tibial plateau, patella, or trochlear groove. The area of the lateral meniscus (body and posterior horn) was decreased compared with preoperative MRI (P < .001 for both). The extent of MM extrusion decreased between the preoperative, first follow-up, and second follow-up MRIs (P < .001).

Conclusion:

OWHTO affected the medial compartment positively, the lateral compartment negatively, and the patellofemoral compartment negligibly. The effects were more prominent and consistent in the medial than in the lateral compartment.

Odderon Exchange from Elastic Scattering Differences between pp and pp[over ¯] Data at 1.96 TeV and from pp Forward Scattering Measurements

We describe an analysis comparing the pp[over ¯] elastic cross section as measured by the D0 Collaboration at a center-of-mass energy of 1.96 TeV to that in pp collisions as measured by the TOTEM Collaboration at 2.76, 7, 8, and 13 TeV using a model-independent approach. The TOTEM cross sections, extrapolated to a center-of-mass energy of sqrt[s]=1.96  TeV, are compared with the D0 measurement in the region of the diffractive minimum and the second maximum of the pp cross section. The two data sets disagree at the 3.4σ level and thus provide evidence for the t-channel exchange of a colorless, C-odd gluonic compound, also known as the odderon. We combine these results with a TOTEM analysis of the same C-odd exchange based on the total cross section and the ratio of the real to imaginary parts of the forward elastic strong interaction scattering amplitude in pp scattering for which the significance is between 3.4σ and 4.6σ. The combined significance is larger than 5σ and is interpreted as the first observation of the exchange of a colorless, C-odd gluonic compound.

Serum neurofilament light chain as a severity marker for spinocerebellar ataxia

Since the serum neurofilament light (NfL) chain is known as a promising biomarker in neurodegenerative diseases, we aimed to evaluate serum NfL as a biomarker indicating neuronal damage in autosomal-dominant (AD) spinocerebellar ataxia (SCA). We reviewed patients diagnosed with AD SCA in the outpatient clinic of Seoul National University Hospital's (SNUH) Department of Neurology between May and August of 2019. We reviewed the demographic data, clinical characteristics, Scale for the Assessment and Rating of Ataxia (SARA) score, and brain magnetic resonance imaging (MRI) scans. The serum NfL was measured by electrochemiluminescence (ECL) immunoassay. Forty-nine patients with AD SCA were reviewed and their serum NfL level was determined. The median serum NfL level (109.5 pg/mL) was higher than control (41.1 pg/mL) (p-value < 0.001). Among the AD SCA patients, there was a positive correlation between the serum NfL level and the trinucleotide repeat number (r = 0.47, p-value = 0.001), disease duration (r = 0.35, p-value = 0.019), disease duration/age × trinucleotide repeat number (r = 0.330, p-value = 0.021), and SARA score (n = 33; r = 0.37, p-value = 0.033). This study shows that serum NfL is elevated in AD SCA patients and correlates with clinical severity.

Nanopore 16S Amplicon Sequencing Enhances the Understanding of Pathogens in Medically Intractable Diabetic Foot Infections

Diabetic foot infections (DFIs) cause substantial morbidity and mortality. The mainstay of the treatment is empiric antibiotics and surgical debridement in severe cases. In this study, we performed nanopore 16S rDNA sequencing from the debridement specimens of DFIs. Fifty-four surgical debridement specimens obtained from 45 patients with medically intractable DFI were included. The 16S rDNA PCR was performed on each specimen, and Nanopore sequencing was performed for up to 3 h. The reads were aligned to the BLAST database, and the results were compared with conventional culture studies. The 16S sequencing results revealed that the majority of the DFIs (44 of 54, 81.5%) were polymicrobial infections. All bacteria isolated by conventional culture studies were detected by 16S sequencing. Several anaerobes (Prevotella, Finegoldia, Anaerococcus, Bacteroides) were commonly identified by 16S sequencing but were frequently missed by culture studies. In many cases, certain bacteria only revealed by the 16S sequencing were more abundant than the bacteria isolated by the culture studies. In conclusion, nanopore 16S sequencing was capable of pathogen identification in DFIs and has many advantages over conventional culture studies. Nanopore 16S sequencing enables a comprehensive understanding of the bacteria involved in DFIs.

Probing the Symmetry Energy with the Spectral Pion Ratio

Many neutron star properties, such as the proton fraction, reflect the symmetry energy contributions to the equation of state that dominate when neutron and proton densities differ strongly. To constrain these contributions at suprasaturation densities, we measure the spectra of charged pions produced by colliding rare isotope tin (Sn) beams with isotopically enriched Sn targets. Using ratios of the charged pion spectra measured at high transverse momenta, we deduce the slope of the symmetry energy to be 42<L<117  MeV. This value is slightly lower but consistent with the L values deduced from a recent measurement of the neutron skin thickness of ^{208}Pb.

A hospital-based study on etiology and prognosis of bacterial meningitis in adults

Bacterial meningitis is a neurological emergency with high morbidity and mortality. We herein investigated clinical features, etiology, antimicrobial susceptibility profiles, and prognosis of bacterial meningitis in adults from a single tertiary center. We retrospectively reviewed medical records of patients with laboratory-confirmed bacterial meningitis from 2007 to 2016. Patients with recent neurosurgery, head trauma, or indwelling neurosurgical devices were classified as having healthcare-related meningitis. Causative microorganisms were identified by analyzing cerebrospinal fluid (CSF) and blood cultures, and antimicrobial susceptibility profiles were evaluated. We performed multiple logistic regression analysis to identify factors associated with unfavorable outcomes. We identified 161 cases (age, 55.9 ± 15.5 years; male, 50.9%), of which 43 had community-acquired and 118 had healthcare-related meningitis. CSF and blood culture positivity rates were 91.3% and 30.4%, respectively. In community-acquired meningitis patients, Klebsiella pneumoniae (25.6%) was the most common isolate, followed by Streptococcus pneumoniae (18.6%) and Listeria monocytogenes (11.6%). The susceptibility rates of K. pneumoniae to ceftriaxone, cefepime, and meropenem were 85.7%, 81.3%, and 100%, respectively. Among healthcare-related meningitis patients, the most common bacterial isolates were coagulase-negative staphylococci (28.0%), followed by Staphylococcus aureus (16.1%) and Enterobacter spp. (13.6%). Neurological complications occurred in 39.1% of the patients and the 3-month mortality rate was 14.8%. After adjusting for covariates, unfavorable outcome was significantly associated with old age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.00–1.06), neurological complications (OR 4.53, 95% CI 1.57–13.05), and initial Glasgow coma scale ≤ 8 (OR 19.71, 95% CI 4.35–89.40). Understanding bacterial pathogens and their antibiotic susceptibility may help optimize antimicrobial therapy in adult bacterial meningitis.

Tofacitinib treatment for refractory autoimmune encephalitis

To treat intractable cases of autoimmune encephalitis, the need for novel immunotherapy that penetrates the blood-brain barrier (BBB) is increasing. Tofacitinib is a Janus kinase (JAK) inhibitor used to treat refractory immune-mediated diseases that effectively penetrates the BBB. Accordingly, tofacitinib could be a new option for patients with refractory autoimmune encephalitis. Patients treated with tofacitinib were selected from Seoul National University Hospital cohort for autoimmune encephalitis from April 2019 until July 2020. We retrospectively analyzed the efficacy of tofacitinib in patients with autoimmune encephalitis who showed insufficient responses to multimodal conventional immunotherapies. Tofacitinib was administered orally at a dose of 5 mg twice daily. A total of eight patients were treated with tofacitinib; two had good responses (clinical global impression-improvement score [CGI-I] = 1 or 2), three had partial responses (CGI-I = 3), and three showed no significant improvements (CGI-I = 4) in response to tofacitinib. The two good responders showed the improvement of chronic autoimmune meningoencephalitis and the cessation of the new-onset refractory status epilepticus in anti-myelin oligodendrocyte glycoprotein (MOG)-associated disorder, which was previously intractable to anesthetics and the other immunotherapies. No patients had serious side effects. Our findings suggest the potential of tofacitinib as a therapeutic option for central nervous system autoimmune diseases.

Altered insular functional connectivity in isolated REM sleep behavior disorder: a data-driven functional MRI study

OBJECTIVE

Functional connectivity (FC) changes can occur prior to structural changes. This study aimed to evaluate data-driven whole-brain FC associated with isolated rapid eye movement sleep behavior disorder (iRBD) using multivariate pattern analysis (MVPA).

METHODS

This was a cross-sectional study of 50 polysomnography-confirmed iRBD patients and 20 age- and sex-matched controls. We used MVPA implemented in the connectome-MVPA CONN toolbox to identify data-driven seed regions for post hoc seed-to-voxel connectivity analysis. The association between FC changes and clinical characteristics, including cognition, depression, autonomic function, and daytime sleepiness, was evaluated.

RESULTS

MVPA revealed one significant cluster located in the left posterior insular cortex. Seed-to-voxel FC analysis using the cluster as a seed showed significantly reduced FC with two clusters located in the precuneus in iRBD patients compared to the controls. The degree of FC was associated with the Montreal Cognitive Assessment-Korean version scores (r = 0.317, p = 0.025).

CONCLUSION

This study emphasizes the insula as an important neural correlate associated with iRBD that was associated with cognitive function.

Teratoma Removal, Steroid, IVIG, Rituximab and Tocilizumab (T-SIRT) in Anti-NMDAR Encephalitis

In anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis, we analysed the efficacy of a combined immunotherapy protocol consisting of teratoma removal, steroid, intravenous immunoglobulin (IVIG), rituximab and tocilizumab (T-SIRT). This cohort study included seventy-eight consecutive patients treated for anti-NMDAR encephalitis between Jan 2014 and Oct 2019 in a national referral hospital. Detailed 2-year disease time course was analysed using Clinical Assessment Scale for Autoimmune Encephalitis (CASE) scores at every 2 weeks for 12 weeks from baseline, every month for the next 3 months and then every 3 months. Treatment regimens at each time point were categorized as SI, SIR, or SIRT with/without teratoma removal (T). Adverse events were classified according to the Common Terminology Criteria for Adverse-Events (CTCAE v5.0), where a severe adverse event was defined as an adverse event with CATAE grade 4. In a linear mixed model analysis, using the SIRT regimen was more effective than SIR or SI regimens in lowering CASE scores (P < 0.001 and P = 0.001, respectively). The presence of teratoma (P = 0.001), refractory status epilepticus (P < 0.001) and a higher CASE score at baseline (P < 0.001) predicted a higher CASE score at each time point. Completion of the (T)-SIRT regimen within 1 month of onset resulted in better 1-year improvements in CASE score (P < 0.001) and modified Rankin scale scores (P = 0.001), compared to those of using other regimens within 1 month or delaying teratoma removal for more than 1 month. Pneumonia was a frequent adverse event (52/78, 66.7%) in the whole study population and neutropenia was frequent during SIRT (11/52, 21.2%), but the regimen was well tolerated in most patients. We concluded that the early application of combined immunotherapy consisting of T-SIRT had better efficacy than was found for delayed or partial application of this combination in anti-NMDAR encephalitis.

Soft implantable drug delivery device integrated wirelessly with wearable devices to treat fatal seizures

Personalized biomedical devices have enormous potential to solve clinical challenges in urgent medical situations. Despite this potential, a device for in situ treatment of fatal seizures using pharmaceutical methods has not been developed yet. Here, we present a novel treatment system for neurological medical emergencies, such as status epilepticus, a fatal epileptic condition that requires immediate treatment, using a soft implantable drug delivery device (SID). The SID is integrated wirelessly with wearable devices for monitoring electroencephalography signals and triggering subcutaneous drug release through wireless voltage induction. Because of the wireless integration, bulky rigid components such as sensors, batteries, and electronic circuits can be moved from the SID to wearables, and thus, the mechanical softness and miniaturization of the SID are achieved. The efficacy of the prompt treatment could be demonstrated with animal experiments in vivo, in which brain damages were reduced and survival rates were increased.

A simple and efficient method of generating HCMV pp65-specific T cells using overlapping peptides

The methods for expansion of human cytomegalovirus (HCMV)-specific T lymphocytes are limited due to the complex culture process, long culture duration, and human leukocyte antigen (HLA) restriction. Here, we report that in vitro stimulation with pp65 kDa phosphoprotein (pp65)-derived overlapping synthetic peptides rapidly generates large numbers of HCMV-specific cytotoxic T lymphocytes from peripheral blood mononuclear cells (PBMCs) regardless of HLA type. Treatment of PBMCs from healthy volunteers expressing HLA-A*02:01 or HLA-A*24:02 with 138 pp65 overlapping peptides (OLP) resulted in an expansion of HCMV pp65 NLVPMVATV (NLV) pentamer-specific CD8+ T lymphocytes that expressed interferon (IFN)-γ, but the pp65 NLV peptide did not generate HCMV-specific CD8+ T lymphocytes in PBMCs obtained from an HLA-A*24:02 donor due to HLA restriction. The OLP-induced T lymphocytes specific for HCMV derived from PBMCs of HLA-A*02:01- and HLA-A*24:02-expressing donors showed effective cytolytic responses against target cells loaded with OLP or the NLV epitope, but pp65 NLV peptide-induced T lymphocytes did not. Phenotypic analyses demonstrated that OLP increased the frequency of CD3+ CD8+ cells, but not CD3+ CD4+, CD14+, or CD56+ cells, in donor PBMCs. Thus, this study provides evidence that in vitro stimulation with OLP efficiently generates sufficient numbers of HCMV pp65-specific cytotoxic T lymphocytes for adoptive cell therapy. Keywords: human cytomegalovirus; cytotoxic T lymphocyte; overlapping peptides; pp65; cytotoxicity.

Association between body mass index and stroke severity in acute ischaemic stroke with non-valvular atrial fibrillation

BACKGROUND AND PURPOSE

The objective of this study was to investigate the association between body mass index (BMI) and both initial stroke severity at presentation and functional outcomes after acute ischaemic stroke (AIS) in patients with non-valvular atrial fibrillation (NVAF).

METHODS

Patients were categorized on the basis of their BMI into underweight (BMI <18.5, n = 111), normal (18.5 ≤ BMI <25, n = 1036) and overweight to obese (BMI ≥25, n = 472) groups. Initial stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) score and functional outcomes were assessed using the modified Rankin Scale score at discharge. The differences in stroke severity and functional outcomes were compared between groups using robust log-linear regression with a Poisson distribution and binary logistic regression analysis.

RESULTS

A total of 1619 AIS patients with NVAF from six hospitals were included. Compared with the NIHSS scores [median 5, interquartile range (IQR) 2-14] of normal-weight patients, the NIHSS scores (median 9, IQR 4-19) of underweight patients were more likely to be higher, whereas those of overweight to obese patients were lower (median 4, IQR 1-12) (P < 0.001). In terms of functional outcomes after stroke, underweight patients had a higher risk of poor functional outcomes (odds ratio 1.78, 95% confidence interval 1.09-2.56, P = 0.01) but overweight to obese patients had no significant difference in functional outcomes compared with normal-weight patients.

CONCLUSION

An inverse association was found between BMI and stroke severity in AIS patients with NVAF. This suggests the presence of an obesity paradox for short-term outcomes in patients with NVAF.

Suspected Metallic Embolization Distal to Coiled Intracranial Aneurysms Detectable by Susceptibility-Weighted MR Imaging

BACKGROUND AND PURPOSE

After endovascular coiling of intracranial aneurysms, round dark parenchymal lesions believed to be particulate metal are sometimes encountered in MR imaging studies of the brain. We used SWI to assess the frequency of such occurrences, in addition to exploring likely causes and clinical implications.

MATERIALS AND METHODS

We reviewed 700 MR imaging studies performed between September 2018 and March 2019 at our institution as follow-up monitoring of coiled intracranial aneurysms. Any sizeable (>5 mm) rounded dark-signal lesions encountered were presumed to be metallic. The magnitudes and locations of such lesions were recorded. In patients with these lesions, pertinent procedural documentation was screened for devices used, including coils, microcatheters, microguidewires, and stents. Medical records were also examined to determine whether any related symptoms ensued.

RESULTS

Twenty patients (2.8%) exhibited a total of 25 lesions on SWI. Diameters ranged from 5 to 11 mm (median, 8 mm). All except 2 lesions were located in brain regions downstream from aneurysms, but all lesions occupied vascular territories of vessels used to place guiding catheters. Other than the Synchro 14, which was routinely deployed, no device was regularly used in patients with SWI-detectable lesions; and none of the affected patients developed focal neurologic symptoms as a consequence.

CONCLUSIONS

Although the origins remain unclear, distal embolization of particulate metal distal to coiled cerebral aneurysms is occasionally observed on follow-up MR imaging studies. Such lesions, however, seem to have no apparent clinical impact.

Lung function as a predictor of incident type 2 diabetes in community-dwelling adults: A longitudinal finding over 12 years from the Korean Genome and Epidemiology Study

AIM

Reduced lung function is associated with type 2 diabetes (T2D), but there are limited data in East Asian populations on the relationship between them. For this reason, this study investigated the longitudinal relationship of lung function with incident T2D in Korean adults.

METHODS

The study included 7583 non-diabetic adults aged 40-69 years from the Korean Genome and Epidemiology Study. Participants were divided into four groups according to gender-specific quartiles (Q1-Q4) of %PFVC and %PFEV₁. Also, HRs with 95% CIs for incident T2D were prospectively analyzed as per American Diabetes Association criteria using multivariate Cox proportional-hazards regression models.

RESULTS

During a 12-year follow-up, 1403 (18.5%) participants presented with newly developed T2D. HRs (95% CIs) of incident T2D in Q1 vs. Q4 (reference) of %PFVC were 1.67 (1.35-2.07) for men and 1.77 (1.39-2.24) for women and, of %PFEV₁, 1.58 (1.28-1.95) for men and 1.61 (1.27-2.03) for women, after adjusting for age, waist circumference, smoking status, alcohol intake, regular exercise, education levels, monthly household income, family history of diabetes, HOMA-IR, triglycerides, HDL cholesterol and high-sensitivity C-reactive protein levels.

CONCLUSION

Reduced lung function precedes and significantly predicts the future development of T2D independently of obesity, smoking and inflammation in community-dwelling middle-aged and elderly people.

The effect of low body mass index on the development of chronic obstructive pulmonary disease and mortality

BACKGROUND

Sarcopenia may worsen disease progression and lead to poor outcomes in chronic obstructive pulmonary disease (COPD).

OBJECTIVES

We aimed to determine the effect of BMI on the development of COPD and mortality.

METHODS

We enrolled 437 584 participants registered in the physical health check-up cohort database of the Korean National Health Interview Survey from 2002 to 2003, and we defined COPD diagnosis based on the ICD-10 code and prescribed medication. BMI (kg m^-2 ) classified them to five groups (low BMI < 18.5, normal BMI 18.5-23, overweight 23-25, obesity 25-30, severe obesity ≥30) at baseline.

RESULTS

Participants in the low BMI group had a significantly higher rate of COPD development for 13 years (7.6%) than those in other groups (3.4-4.1%, P < 0.0001). Amongst never or light smokers, COPD development in the low BMI group (5.6-6.7%) was significantly higher than that in other groups (2.8-4.7%). Similarly, amongst participants with a smoking history of ≥30 years, COPD development in the low BMI group (20.1%) was higher than those in other groups (8.4-12.4%). On multivariable analysis, normal or higher than normal body weight was significantly protective against the development of COPD (hazard ratio [HR], 0.609-0.739,) compared to low BMI. COPD-free-survival (HR, 0.491-0.622) and overall survival (HR, 0.440-0.585) were also better in them compared to those with low BMI (all P < 0.0001).

CONCLUSIONS

Low BMI is an important risk factor for COPD development and mortality. Maintaining adequate body weight may reduce the risk for COPD development and mortality.

Inhibitory effects of herbal decoction Ojeoksan on proliferation and migration in vascular smooth muscle cells

The proliferation of vascular smooth muscle cells plays a crucial role in pathogenesis of cardiovascular disease. The principal objective of this study was to determine the effects of Ojeoksan (OJS) on human aortic smooth muscle cell (HASMC) proliferation induced by tumor necrosis factor α (TNF-aα). Thymidine incorporation after TNF-α treatment was increased and this effect was inhibited significantly by OJS treatment. HASMC proliferation and migration by kinetic live cell imaging were also reduced by treatment with OJS. TNF-α induced the expression of cyclins/cyclin-dependent kinases (CDKs) and reduced the expression of p21^waf1/cip1/p27^kip1. However, OJS also attenuated the expression of TNF-α-induced cell-cycle regulatory proteins. The results of Western blot analysis demonstrated that the TNF-α treated HASMC secreted gelatinases, probably including MMP-2/-9, which may be involved in the invasion and migration of HASMC. Additionally, OJS suppressed the mRNA expression levels of matrix metalloproteinase-2/-9 (MMP-2/-9) in a dose-dependent manner. OJS inhibited the production of TNF-α-induced hydrogen peroxide (H₂O₂) and the formation of DCF-sensitive intracellular reactive oxygen species (ROS). Further, OJS suppressed the nuclear translocation and phosphorylation of inhibitor of kappa B-α (IκB-α) of nuclear factor κB (NF-κB) under TNF-α conditions. Our results demonstrate that OJS exerts inhibitory effects on TNF-α-induced HASMC proliferation and migration, suggesting the involvement of the inhibition of both MMP-2 and MMP-9 expressions, and the downregulation of ROS/NF-κB signaling. Thus, herbal decoction OJS may be a possible therapeutic approach to the inhibition of cardiovascular disease including atherosclerosis.

Search for a Dark Matter-Induced Annual Modulation Signal in NaI(Tl) with the COSINE-100 Experiment

We present new constraints on the dark matter-induced annual modulation signal using 1.7 years of COSINE-100 data with a total exposure of 97.7 kg yr. The COSINE-100 experiment, consisting of 106 kg of NaI(Tl) target material, is designed to carry out a model-independent test of DAMA/LIBRA's claim of WIMP discovery by searching for the same annual modulation signal using the same NaI(Tl) target. The crystal data show a 2.7  cpd/kg/keV background rate on average in the 2-6 keV energy region of interest. Using a χ-squared minimization method we observe best fit values for modulation amplitude and phase of 0.0092±0.0067  cpd/kg/keV and 127.2±45.9  d, respectively.

Increasing prevalence of antimicrobial resistance in urinary tract infections of neurological patients, Seoul, South Korea, 2007-2016

OBJECTIVES

Urinary tract infection (UTI) is a common medical complication experienced by patients with neurologic diseases. In this study, we established the microbial etiologies of UTI, and resistances to antibiotics in UTI as well as determining which appropriate empirical antibiotics should be used to treat UTI in neurological patients.

DESIGNS AND METHODS

We retrospectively reviewed microbial etiologies and antimicrobial resistance among patients experiencing UTI events in the neurology ward of Seoul National University Hospital from 2007 to 2016.

RESULTS

The total number of UTI events observed was 301, and Klebsiella pneumoniae was the most common pathogen observed in UTIs. But in catheter-associated UTI (CAUTI), Enterococcus species were the most prevalent pathogens. Susceptibility to commonly-prescribed antibiotics decreased over 10 years, indicating increased antibiotic resistance in pathogens associated with UTI. ESBL-producing K. pneumoniae increased significantly, while increases of MDR K. pneumoniae, ESBL-producing E. coli, and VRE were not observed.

CONCLUSIONS

The worldwide trend of increasing drug-resistant pathogens should be considered, and further studies on antibiotics resistance in UTI are needed. These data will greatly assist physicians when they select antibiotics to treat UTIs in neurological patients.

Effects of α-lipoic acid on chronic cerebrovascular hypoperfusion in an animal model of vascular dementia

OBJECTIVE

Given the aging population, the treatment of vascular dementia (VaD) is becoming increasingly important. The antioxidant α-lipoic acid (α-LA) protects against neurodegeneration in VaD, but the underlying mechanisms remain unclear. Hence, we aimed to identify the effects of α-LA on cognitive function following chronic cerebrovascular hypoperfusion in a VaD animal model.

MATERIALS AND METHODS

Mice were categorized into the sham, bilateral common carotid artery stenosis (BCAS), or BCAS + α-LA group. The BCAS + α-LA group was intraperitoneally injected (100 mg/kg) once daily with α-LA for 4 weeks after BCAS surgery, while the BCAS and sham groups were injected with saline. After the last injection, we examined cognitive function and exploration behavior using the Morris water maze. Mice brains were then harvested for Western blot analyses.

RESULTS

The BCAS group, but not the BCAS + α-LA group, showed cognitive dysfunction in the Morris water maze. Apoptosis pathways involving poly (ADP-ribose) polymerase (PARP) cleavage, phosphorylated-mammalian target of rapamycin (p-mTOR), phosphorylated-3-phosphoinositide-dependent protein kinase-1, and phosphorylated-protein kinase B (p-AKT) were enhanced in the BCAS group than the α-LA group. The BCAS + α-LA group demonstrated less PARP cleavage and p-mTOR function than did the BCAS group. The activity of autophagy pathways involving LC3B was higher in the BCAS and BCAS + α-LA groups than the sham group, but there were no significant differences between the BCAS and BCAS + α-LA groups.

CONCLUSIONS

In the BCAS rodent model, cognitive dysfunction and apoptosis mediated by the phosphatase and tensin homolog/AKT/mTOR pathway were observed in the hippocampus. However, acting on the mTOR pathway, α-LA improved cognitive function and led to hippocampal cell survival. Thus, α-LA may be useful for treating VaD.

First Direct Search for Inelastic Boosted Dark Matter with COSINE-100

A search for inelastic boosted dark matter (IBDM) using the COSINE-100 detector with 59.5 days of data is presented. This relativistic dark matter is theorized to interact with the target material through inelastic scattering with electrons, creating a heavier state that subsequently produces standard model particles, such as an electron-positron pair. In this study, we search for this electron-positron pair in coincidence with the initially scattered electron as a signature for an IBDM interaction. No excess over the predicted background event rate is observed. Therefore, we present limits on IBDM interactions under various hypotheses, one of which allows us to explore an area of the dark photon parameter space that has not yet been covered by other experiments. This is the first experimental search for IBDM using a terrestrial detector.

Prevalence of elevated body mass index condition and its associated demographic variables among adults in urban areas in Johor, Malaysia

INTRODUCTION

The prevalence of overweight and obesity is increasing at an alarming rate. It is a major factor for many other metabolic disorders. This study aimed to determine the prevalence of increase body mass index (BMI) and obesity and their associated demographic characteristics among adults in an urban area.

METHODS

A retrospective study was conducted where data was extracted from the Health Status Screening Form (BSSK) at health clinics in Johor Bahru. Using the World Health Organization (WHO), criteria for obesity, BMI≥30.0 kg/m2 was specified as obese and combination of both BMI ranges for overweight (25.0-30.0kg/m2) and obesity (≥30.0kg/m2) as elevated BMI.

RESULTS

The overall prevalence of elevated BMI and obesity was 54.6% and 20.1% respectively. Men had a higher prevalence of elevated BMI (57.4%) with odds of 1.28 higher (95%CI: 1.04-1.58). High prevalence of elevated BMI and obesity were seen among the Indians (elevated BMI - 60.2%, obesity - 19.4%) followed by Malays (elevated BMI -57.8%, obesity - 23.1%) and Chinese showed the lowest (elevated BMI - 39.0%, obesity - 8.8%). The odds of elevated BMI and obesity were lower among younger adults as compared to older adults (≥30 years old).

CONCLUSION

Using WHO criteria, about one in two adults had elevated BMI while one in five were obese. Elevated BMI and obesity disparities were evident in age and ethnicity, but sex differences were encountered in elevated BMI group.

Correction to: Mite color alteration and acaricidal activity of 3,7-dimethyl-2,6-octadienal and its structural analogues against the stored food pest mite Tyrophagus putrescentiae

Due to an unfortunate turn of events, an incorrect funding note was provided in the original publication as it should have read.

Abstract PD4-07: PET imaging of PARP-1 expression in breast cancer

18F-FluorThanatrace ([18F]-FTT) is a novel radiotracer shown to quantify Poly [ADP-ribose] polymerase 1 (PARP-1) expression in vitro and in vivo through a receptor-ligand interaction. A recent study at the University of Pennsylvania in women with ovarian cancer demonstrated in vivo visualization of PARP-1 expression in tumors using this radiotracer that closely correlated with an in vitro assay of PARP-1 in tumor tissue (Makvandi, M. J. Clin. Invest. 128:2116, 2018). A radioligand with PARP-1 specificity, [125I]-KX1, was also developed as a companion tool for ex vivo evaluation of PARP-1 expression and PARP inhibitor (PARPi) drug occupancy by radioligand binding assay (Makvandi, M. Cancer Res. 76:4516, 2016). As the first step in validating this biomarker in breast cancer, we performed a prospective clinical trial comparing in vivo [18F]-FTTuptake and ex vivo PARP-1 expression in women with primary breast cancer.

Methods: 24 patients with Stage I-IV primary breast cancer were imaged with [18F]-FTT prior to any therapy including surgery. We correlated in vivo uptake with ex vivo immunohistochemistry (IHC) for PARP-1 and [125I]-KX1 autoradiography in untreated surgical specimens. Tumors were analyzed for alterations in DNA repair genes, copy number-based as well as mutational signatures indicative of homologous recombination deficiency (HRD) and mutational burden, using our established protocol (Maxwell, KN, Nature Commun. 8:319, 2017).

Results: [18F]-FTT uptake was visualized above background in all primary breast tumors and known metastases. Two areas of unexpected uptake revealed an unknown contralateral breast cancer and an ovarian carcinoid, respectively. We expected that uptake might be highest in triple negative breast cancer (TNBC), where PARPi have been most heavily studied. However, a range of tracer uptake was observed in tumors independent of breast cancer subtype (hormone receptor positive/HER2 negative, TNBC, HER2+) and BRCA status. Uptake ratios (SUVmax tumor/SUV max opposite breast) ranged from 1.2-10.5 with a median 4.0. Ex vivo[125I]-KX1 autoradiography was performed on a subset of untreated primary tumors (n=5) and compared with IHC staining for PARP-1 on sequential sections. This revealed a close spatial correspondence between elevated PARP-1 expression by IHC and regions of elevated [125I]-KX1 binding radiographically. There was also a strong positive correlation between in vivo [18F]-FTT uptake and ex vivo quantitative [125I]-KX1 autoradiography (r=0.78). Genomic analysis of HRD in all tumors is pending and will be reported.

Conclusion: Initial analyses support the ability of [18F]-FTT to visualize and measure PARP-1 expression in breast cancer. This is the first step toward developing an imaging companion diagnostic to help guide PARP inhibitor treatment in breast cancer. Ongoing studies are expanding upon these results, testing the extent to which expression of PARP-1 by [18F]-FTT can predict response to PARP inhibitors and measure target engagement during therapy.

Citation Format: McDonald ES, Carlin S, Maxwell KN, Nayak A, Doot RK, Pantel AR, Farwell MD, Pryma DA, Clark AS, Shah P, DeMichele AM, Ziober A, Schubert EK, Palmer K, Lee HS, Matro J, de la Cruz L, Tchou J, Anderson DN, Feldman MD, Sheffer RE, Knollman H, Schnall MD, Makvandi M, Domchek S, Hubbard RA, Mach RH, Mankoff DA. PET imaging of PARP-1 expression in breast cancer [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 PD4-07.

Abstract P1-02-04: Is asymptomatic surveillance after standard treatment beneficial? : A 10yr-survival analysis of recurrent breast cancer patients by detection method of recurrence

Surveillance of recurrence after standard treatment of breast cancer (BC) for early detection and it's impact on overall survival are known to differ depending on recurrent site. Current guideline recommends asymptomatic surveillance to only detect loco-regional recurrences. As the evidences depend on historical randomized clinical trials we aimed to address questions whether earlier detection might have impact on survival now that plenty of new treatment strategies can be offered. Also to give answers to heterogeneous surveillance strategy in real-world practice we performed a retrospective 10yr-survival analysis of a large cohort of recurrent BC patients according to their detection method.

From 4188 operable breast cancer patients who completed standard treatment Asan Medical Center from 2006 to 2008 469 patients with recurrent BC were analyzed. Median disease free interval was 35.3 months (range 2.8-97.6) and overall survival (OS) was analyzed as time from initial diagnosis/surgery to death. Among 469 patients who developed recurrence 23.7% were local (ipsilateral breast skin chest wall) 22.6% were regional (ipsilateral axillary internal mammary lymph nodes) and 53.7% developed distant metastasis. 10yr-overall survival was analyzed according to recurrent site and it's detection method.

Detection of recurrence were categorized as 'asymptomatic surveillance (N=162, 34.5%)' and 'symptom-guided (N=307, 65.5%)'. Asymptomatic screening method included mammography breast-ultrasound serum tumor marker (CA15-3) and systemic images (eg. chest X-ray bone scan PET scans). Symptom-guided detection rate for local regional and distant metastasis was 14.9%, 5.5% and 15.1% respectively. Overall asymptomatic vs symptomatic 10yr-OS did not differ (81.3 vs 78.8 months, p=0.778). Among patients with distant metastasis 10ys-OS was not significantly different (70.3 vs 66.7 months p=0.846) and was similar according to stage/subtype. Among patients with local recurrence only 10yr-OS was 95.1 months ('symptomatic' vs 'aymptomatic 94.4 vs 94.5, p=0.809) which may be insufficient number of events to show significant difference. Among regional recurrent BCs, longer OS was observed in asymptomatically detected patients than symptom-guided group (86.1 vs 63.4, p=0.004). In Cox regression analyses asymptomatic detection showed significant better survival (HR=3.9, 95%CI:1.6-9.5) and this observation was more evident in patients with hormone receptor(HR) negative primary BCs (69.9 vs 47.9, p=0.029). Intriguingly, only 8.6% (7/80) of regional recurrence were diagnosed by mammography.

We observed survival benefit with asymptomatic screening in detecting regional recurrence especially in HR-negative primary BC patients. And role of systemic radiology even in advanced high risk breast cancer patients were limited. Although with limitation that surveillance method varied widely we emphasize the role of aymptomatic surveillance of regional nodal evaluation including breast-ultrasound. These findings are to be validated from a prospective clinical study along with using cutting edge modalities other than radiology which enable detection of micro-metastasis.

Citation Format: Lee Y, Lee HS, Ahn SH, Son BH, Kim J, Lee SB. Is asymptomatic surveillance after standard treatment beneficial? : A 10yr-survival analysis of recurrent breast cancer patients by detection method of recurrence [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 P1-02-04.