Effects of meal type on the bioavailability of vutiglabridin, a novel anti-obesity agent, in healthy subjects

Vutiglabridin, which affects the pharmacokinetics (PKs) of food, is currently under clinical development for the treatment of obesity. This study aimed to evaluate the effects of low- and high-fat meals on PKs of vutiglabridin in healthy male subjects. A randomized, open-label, single-dose, three-period, six-sequence crossover study was conducted. The subjects received a single oral dose of vutiglabridin 480 mg in a fasted state, 30 min after the intake of a low-fat meal (total 500-600 kcal, fat content 100-125 kcal) and high-fat meal (total 800-1000 kcal, fat content 500-600 kcal), with a 21-day washout period. Geometric mean ratios (GMRs) and 90% confidence intervals (CIs) for maximum plasma concentration (Cmax ) and area under the plasma concentration-time curve to the last measurable timepoint (AUClast ) were calculated. After intake of low- and high-fat meals, systemic exposure to vutiglabridin was increased, and the time to reach Cmax (Tmax ) was delayed compared to that in the fasted state. The GMRs (90% CIs) of low-fat meal to fasted state for Cmax and AUClast were 2.14 (1.76-2.60) and 2.15 (1.92-2.42), respectively, and those of high-fat meal to fasted state were 3.07 (2.53-3.72) and 3.00 (2.67-3.37), respectively. The median Tmax was delayed by 1.5 h in both fed states compared with that in the fasted state. The study drug was well-tolerated after administration in both the fed and fasted states. Food ingestion substantially increased the extent of oral vutiglabridin absorption in healthy subjects, and this enhancement increased with the fat content of the meal.

Digital Mechanical Metamaterial: Encoding Mechanical Information with Graphical Stiffness Pattern for Adaptive Soft Machines

Inspired by the adaptive features exhibited by biological organisms like the octopus, soft machines that can tune their shape and mechanical properties have shown great potential in applications involving unstructured and continuously changing environments. However, current soft machines are far from achieving the same level of adaptability as their biological counterparts, hampered by limited real-time tunability and severely deficient reprogrammable space of properties and functionalities. As a steppingstone toward fully adaptive soft robots and smart interactive machines, an encodable multifunctional material that uses graphical stiffness patterns is introduced here to in situ program versatile mechanical capabilities without requiring additional infrastructure. Through independently switching the digital binary stiffness states (soft or rigid) of individual constituent units of a simple auxetic structure with elliptical voids, in situ and gradational tunability is demonstrated here in various mechanical qualities such as shape-shifting and -memory, stress-strain response, and Poisson's ratio under compressive load as well as application-oriented functionalities such as tunable and reusable energy absorption and pressure delivery. This digitally programmable material is expected to pave the way toward multienvironment soft robots and interactive machines.

Surgical strategy of the treatment of atypical femoral fractures

The atypical femoral fracture (AFF) has been attracting significant attention because of its increasing incidence; additionally, its treatment is challenging from biological and mechanical aspects. Although surgery is often required to manage complete AFFs, clear guidelines for the surgical treatment of AFFs are currently sparse. We reviewed and described the surgical treatment of AFFs and the surveillance of the contralateral femur. For complete AFFs, cephalomedullary intramedullary nailing spanning the entire length of the femur can be used. Various surgical techniques to overcome the femoral bowing common in AFFs include a lateral entry point, external rotation of the nail, and the use of a nail with a small radius of curvature, or a contralateral nail. In the case of a narrow medullary canal, severe femoral bowing, or pre-existing implants, plate fixation may be considered as an alternative. For incomplete AFFs, prophylactic fixation depends on several risk factors, such as a subtrochanteric location, presence of a radiolucent line, functional pain, and condition of the contralateral femur; the same surgical principles as those in complete AFFs can be applied. Finally, once AFF is diagnosed, clinicians should recognize the increased risk of contralateral AFFs, and close surveillance of the contralateral femur is recommended.

Effect of hemodialysis on the pharmacokinetics and pharmacodynamics of evogliptin

AIM

To investigate the possible effect of hemodialysis (HD) on the pharmacokinetics (PKs) and pharmacodynamics (PDs) of evogliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor.

METHODS

A single-dose, open-label, parallel-group study of eight end-stage renal disease (ESRD) patients and eight matched healthy subjects was conducted. ESRD patients received a single oral dose of evogliptin 5 mg after and before HD with a 2-week washout between each dose, and healthy subjects received a single oral dose of evogliptin 5 mg. Serial blood, dialysate and urine samples were collected to assess the PK and PD profiles of evogliptin. To compare PK parameters before and after HD, geometric mean ratios (GMRs) and 90% confidence intervals (CIs) were calculated.

RESULTS

The GMRs and its 90% CIs for the maximum concentration (C_max ) and area under the concentration-time curve from time 0 to the last measurable timepoint (AUC_last ) of evogliptin when administered before HD compared to after HD were 0.7293 (0.6171-0.8620) and 0.9480 (0.8162-1.1010), respectively. The maximum DPP-4 inhibitory effect (E_max ), area under the DPP-4 inhibitory effect-time curve (AUEC_last ), and time duration of more than 80% DPP-4 inhibition (Fi80) were comparable when evogliptin was administered before and after HD. Compared to healthy subjects, the mean AUC_last of evogliptin was approximately 1.4-fold greater in ESRD patients, but the difference is unlikely to affect the safety and efficacy of evogliptin.

CONCLUSION

The effect of HD on the PKs and PDs of evogliptin was not clinically significant; therefore, dose adjustment according to HD status is not necessary. This article is protected by copyright. All rights reserved.

Perioperative risk and benefit of antiplatelet therapy in patients undergoing non-cardiac surgery within 1 year after percutaneous coronary intervention with second-generation drug-eluting stents

Background

Antiplatelet therapy (APT) in patients undergoing non-cardiac surgery (NCS) after percutaneous coronary intervention (PCI) is still on debate due to its opposite effects which are to prevent from cardiovascular events and to cause bleeding. There is no apparent consensus on how to determine perioperative APT strategy within 1 year after PCI. Therefore, we investigated the risk and benefit of APT in NCS within 1 year after PCI.

Methods

Patients undergoing NCS after PCI with second-generation drug-eluting stents are retrospectively included from multicenter cohort of 8 medical centers in Korea. Perioperative clinical event within 30 days after NCS was recorded. Net adverse clinical event (NACE) including all cause death, major adverse cardiac event (MACE, a composite of cardiac death, myocardial infarction, and stent thrombosis) and major bleeding were evaluated. To overcome bias, propensity score covariate adjustment was performed using logistic regression analysis to generate propensity scores for patients of both APT strategies.

Results

Total 1130 patients (median age 69 years, female 30.5%) undergoing NCS within 1 year after PCI were eligible in the cohort. Study population included 55.1% patients suffered from ACS and 22.5% underwent complex PCI. NCS included 45.8% intermediate-to-high risk surgery and 10.7% urgent or emergent surgery. APT was continued during NCS in 62.7% of the patients. More patients continued DAPT (48% vs. 32%, p<0.001) among the patients who underwent NCS within 6 months after PCI than those who underwent NCS after 6 months. There were 49 NACE (4.3%), 16 MACE (1.4%) and 23 major bleeding events (2.0%), respectively. Continuing APT was associated with a lower risk of NACE (Adjusted hazard ratio [HR], 0.49; 95% confidence interval [CI], 0.27–0.89; p=0.020)) and MACE (Adjusted HR, 0.35; 95 CI, 0.12–0.96; p=0.042). Subgroup analysis showed a tendency that continuing APT might be favorable than discontinuing APT in terms of MACE in patients who were diagnosed with ACS, underwent complex PCI, or underwent NCS within 6 months after PCI.

Conclusions

About two thirds of the patients were continuing APT during NCS. Our findings may support a careful consideration of APT continuation for some of the patients who are undergoing NCS within 1 year after PCI.

Funding Acknowledgement

Type of funding sources: None.

Synthetic amyloid beta does not induce a robust transcriptional response in innate immune cell culture systems

BACKGROUND

Alzheimer's disease (AD) is a progressive neurodegenerative disease that impacts nearly 400 million people worldwide. The accumulation of amyloid beta (Aβ) in the brain has historically been associated with AD, and recent evidence suggests that neuroinflammation plays a central role in its origin and progression. These observations have given rise to the theory that Aβ is the primary trigger of AD, and induces proinflammatory activation of immune brain cells (i.e., microglia), which culminates in neuronal damage and cognitive decline. To test this hypothesis, many in vitro systems have been established to study Aβ-mediated activation of innate immune cells. Nevertheless, the transcriptional resemblance of these models to the microglia in the AD brain has never been comprehensively studied on a genome-wide scale.

METHODS

We used bulk RNA-seq to assess the transcriptional differences between in vitro cell types used to model neuroinflammation in AD, including several established, primary and iPSC-derived immune cell lines (macrophages, microglia and astrocytes) and their similarities to primary cells in the AD brain. We then analyzed the transcriptional response of these innate immune cells to synthetic Aβ or LPS and INFγ.

RESULTS

We found that human induced pluripotent stem cell (hIPSC)-derived microglia (IMGL) are the in vitro cell model that best resembles primary microglia. Surprisingly, synthetic Aβ does not trigger a robust transcriptional response in any of the cellular models analyzed, despite testing a wide variety of Aβ formulations, concentrations, and treatment conditions. Finally, we found that bacterial LPS and INFγ activate microglia and induce transcriptional changes that resemble many, but not all, aspects of the transcriptomic profiles of disease associated microglia (DAM) present in the AD brain.

CONCLUSIONS

These results suggest that synthetic Aβ treatment of innate immune cell cultures does not recapitulate transcriptional profiles observed in microglia from AD brains. In contrast, treating IMGL with LPS and INFγ induces transcriptional changes similar to those observed in microglia detected in AD brains.

Abnormal Lipid Profiles in Nontraumatic Osteonecrosis of the Femoral Head: A Comparison with Osteoarthritis Using Propensity Score Matching

BACKGROUND

Abnormal lipid metabolism may play an important role in the development of nontraumatic osteonecrosis of the femoral head (ON). By comparing lipid biomarkers in patients with ON and osteoarthritis (OA) after propensity score matching, we sought to reveal (1) common lipid biomarkers that are abnormal in ON regardless of the etiology and (2) specific lipid biomarkers associated with ON according to the etiology.

METHODS

Among 2,268 patients who underwent primary THA, 1,021 patients were eligible for this study. According to the Association Research Circulation Osseous criteria, ON was classified as either idiopathic (n = 230), alcohol-associated (n = 293), or glucocorticoid-associated ON (n = 132). Most common cause of OA was hip dysplasia in 106 patients (47%). We investigated patient lipid profiles by assessing total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides (TGs), apolipoprotein (Apo) A1 and B, lipoprotein (a) levels and ApoB/A1 ratio. Since age and body mass index affect the lipid profile, we performed propensity score matching to select 304 patients for final analysis and compared lipid profiles between the ON and OA groups. We also compared biomarkers between the ON subgroups and the OA group.

RESULTS

Overall, the ON group showed lower HDL-C (p < 0.001), higher TGs (p = 0.001) levels and higher ApoB/A1 ratio (p = 0.003). Idiopathic ON patients demonstrated lower HDL-C (p = 0.032), higher TGs (p = 0.016), ApoB (p = 0.024) levels and ApoB/A1 ratio (p = 0.008). The alcohol-associated ON subgroup showed lower HDL-C (p < 0.001), higher TGs (p = 0.010) levels and ApoB/A1 ratio (p = 0.030). Finally, the steroid-associated ON subgroup demonstrated lower HDL-C (p = 0.003), higher TGs (p = 0.039), lower TC (p = 0.022), LDL-C (p = 0.021), and ApoA1 (p = 0.004) levels.

CONCLUSIONS

Higher TGs and lower HDL-C levels were associated with nontraumatic ON regardless of the etiology. Additionally, idiopathic ON was associated with higher ApoB levels and ApoB/A1 ratio. Alcohol-associated ON was related to higher ApoB/A1 ratio, and steroid-associated ON paired with decreased TC, LDL-C, and ApoA1 levels. Our findings may support future efforts for prevention and management of nontraumatic ON.

LEVEL OF EVIDENCE

Diagnostic Level III.

Average 22-Year Results of Total Hip Arthroplasty Using Harris-Galante Prosthesis in Patients under 50 Years

Background

The Harris-Galante (HG) prosthesis is a first-generation, cementless total hip arthroplasty (THA) prosthesis. Considering the recent increase in the demand for THA in young patients and their life expectancy, a study with a follow-up duration of longer than 20 years in a young population is needed. Therefore, we evaluated the long-term clinical and radiographic results after cementless THA using the HG prosthesis in patients younger than 50 years.

Methods

A total of 61 THAs performed using the HG with a minimum follow-up of 10 years were included. There were 38 men and 11 women with an average age of 46 years and the mean follow-up duration was 22 years. Clinical evaluation included modified Harris Hip Score (HHS) and radiographic analysis consisted of cup inclination, anteversion angle, component stability, osteolysis, liner wear rate, wear-through, liner dissociation, and heterotopic ossification. Complications included recurrent dislocation, periprosthetic femoral fracture, and periprosthetic joint infection. Survivorship analysis included cup and stem revision for aseptic loosening, as well as any revision.

Results

The HHS improved from 46.5 preoperatively to 81.8 postoperatively (p < 0.001). The average linear wear rate was 0.36 mm/yr. A total of 34 hips (56%) were revised: stem revision in 10 (16.4%), cup revision in 9 (14.8%), exchange limited to bearing surface in 8 (13.1%), and revision of all components in 7 (11.5%). Estimated survivorship at 34 years postoperatively was 90.9% for cup revision for aseptic loosening, 80.5% for stem revision for aseptic loosening, and 22.1% for any revision.

Conclusions

THA using the HG prosthesis showed satisfactory estimated survivorship of the acetabular and femoral components at 34 years postoperatively with good clinical outcomes. Bearing-related problems, such as osteolysis and liner dissociation, accounted for 56% of revision operations and were concerns in patients younger than 50 years.

Precontoured Plate Fixation for Incomplete Atypical Diaphyseal Fracture of Femur using Three-Dimensional Printing Rapid Prototyping: Two Cases Reports

Background

Reconstruction intramedullary nail spanning the whole length of the femur has been the gold standard treatment for complete atypical diaphyseal fractures of the femur (ADF). However, in cases of incomplete ADF combined with severe bowing, this approach might have complications and lead to iatrogenic complete fracture. We report two cases of incomplete ADF with severe bowing using a precontoured plate (PCP) after rapid prototyping (RP) of the deformed femurs with three‐dimensional printing (3DP) technology.

Case presentation

Two patients presented with gradually worsening thigh pain, especially during walking. The patients had been using bisphosphonates for 4 and 10 years, respectively. Radiography showed an incomplete fracture in the lateral cortex of the right femur shaft. The lateral bowing angles measured in the affected femurs were 15° and 14°, and the anterior bowing angles were 20° and 16°, respectively. In bone scans, both patients showed hot uptake in the right mid‐shaft of the femur. Preoperatively, the affected femur of the patient was reconstructed by 3DP RP using CT, and the plate was bent to the shape of the bone model. The ADF was fixed with a PCP using the minimally invasive plate osteosynthesis technique. Both patients were encouraged to start full weight‐bearing and return to their preinjury activity level in daily life immediately after surgery. At 2 years postoperatively, radiography showed healing of the fracture site without recurrence of thigh pain and implant‐related problems.

Conclusion

Although intramedullary nailing is the standard surgical treatment for complete ADF, PCP using 3DP RP could be an effective treatment option for incomplete ADF with severely curved femur.

Does proximal femoral nail antirotation achieve better outcome than previous-generation proximal femoral nail?

BACKGROUND

There are few studies in the literature comparing the clinical outcomes and radiographic results of proximal femoral nail (PFN) and proximal femoral nail antirotation (PFNA) for pertrochanteric femoral fracture (PFF) in elderly patients.

AIM

To evaluate both clinical and radiographic outcomes after fixation with PFN and PFNA in an elderly patient population.

METHODS

One hundred fifty-eight patients older than 65 years with PFF who underwent fixation with either PFN or PFNA were included. Seventy-three patients underwent fixation with PFN, whereas 85 were fixed with PFNA. The mean follow-up was 2.4 years (range, 1-7 years). Clinical outcome was measured in terms of operation time, postoperative function at each follow-up visit, and mortality within one year. Radiographic evaluation included reduction quality after surgery, Cleveland Index, tip-apex distance (TAD), union rate, time to union, and sliding distance of the screw or blade. Complications including nonunion, screw cutout, infection, osteonecrosis of the femoral head, and implant breakage were also investigated.

RESULTS

Postoperative function was more satisfactory in patients who underwent PFNA than in those who underwent PFN (P = 0.033). Radiologically, the sliding difference was greater in PFN than in PFNA patients (6.1 and 3.2 mm, respectively, P = 0.036). The rate of screw cutout was higher in the PFN group; eight for PFN (11.0%) and two for PFNA patients (2.4%, P = 0.027). There were no differences between the two groups in terms of operation time, mortality rate at one year after the operation, adequacy of reduction, Cleveland Index, TAD, union rate, time to union, nonunion, infection, osteonecrosis, or implant breakage.

CONCLUSION

Elderly patients with PFF who underwent PFNA using a helical blade demonstrated better clinical and radiographic outcomes as measured by clinical score and sliding distance compared with patients who underwent PFN.

Arthroscopic treatment of iliopsoas tendinitis after total hip arthroplasty with acetabular cup malposition: Two case reports

BACKGROUND

Optimal treatment for iliopsoas tendinitis after total hip arthroplasty (THA) with cup malposition, iliopsoas release alone or with cup revision, is controversial, particularly in young, active patients. Moreover, arthroscopic iliopsoas tendon (IPT) release in these patients has been rarely described, and midterm effects of this procedure on THA longevity and groin pain recurrence remain unclear. We performed arthroscopic IPT release after THA and report midterm outcomes in two young patients with acetabular cup malposition.

CASE SUMMARY

In the two patients, groin pain started early after THA. Physical examination revealed nonspecific findings, and laboratory tests showed no evidence of infection. Radiography and computed tomography showed reduced acetabular component anteversion angle and anterior cup prominence of more than 16 mm. For therapeutic diagnosis, ultrasonography-guided lidocaine with steroid was injected into the IPT sheath. In both patients, groin pain improved initially but worsened after a few months. Therefore, the patients underwent arthroscopic IPT release under spinal anesthesia. Arthroscopy revealed synovitis with fibrous tissues around the IPT and various lesions related to the implants after THA. IPT tenotomy and debridement with biopsy were performed; histopathologic studies showed chronic inflammation with synovial hyperplasia. Both patients were encouraged to start walking immediately after surgery, and they returned to complete daily function early after surgery. They experienced no recurrence of groin pain or any implant-related problems 5 years postoperatively.

CONCLUSION

Arthroscopic IPT release for cup malposition produced excellent midterm outcomes without recurrence of groin pain and implant-related problems.

Bipolar hemiarthroplasty using microarc oxidation-coated cementless stem in patients with unstable intertrochanteric fracture

PURPOSE

Treatment for an unstable intertrochanteric fracture in elderly patients is challenging. Bipolar hemiarthroplasty (HA) using microarc oxidation (MAO) coating has been a treatment option alternative to internal fixation. However, the outcome of bipolar HA using MAO-coated stem in these patients is unknown.

METHODS

From July 2007 to April 2016, 234 (older than 65 years) patients (234 hips) who were diagnosed as having unstable intertrochanteric fractures were treated with bipolar HA using a fully MAO-coated standard-length rectangular cementless stem. During the arthroplasty, the greater trochanteric and the medial fracture fragments were attached to the stem and fixed with two to three 16-gauge wires. Forty-eight patients (48 hips) died within postoperative 2 years. The remaining 186 patients (186 hips) were followed up for a mean of 4.3 (range 2-10) years.

RESULTS

With the exception of 4 patients who died during hospitalization, 176 of 230 ( 76.5%) patients could ambulate independently with or without an assistive device at the time of hospital discharge. Venous thromboembolism occurred in seven patients (3.0%). One hip dislocated due to a fall 1 month after the arthroplasty. Periprosthetic femoral fracture occurred in four patients and periprosthetic acetabular fracture in one patient. One patient had periprosthetic of acute pyelonephritis. There was no focal osteolysis around the femoral stem.

CONCLUSION

The result of cementless HA using MAO-coated stem enabled early ambulation in most (76.5%) of elderly patients with unstable intertrochanteric fractures and the results were encouraging.

Normal Ischiofemoral Distance and Its Associated Factors: Computed Tomography-Based Study

PURPOSE

The purposes of this study are (1) to measure the ischiofemoral distance (IFD) in nondiseased hips and (2) to reveal patient demographic and anatomical factors associated with IFD.

METHODS

In this retrospective study, we identified patients who had unilateral osteonecrosis of the femoral head on computed tomography (CT) scan from November 2005 to July 2018 and assessed the unaffected contralateral hips of the patients. Among the contralateral hips, we excluded hips with hip pain, incomplete or poor-quality CT image, incomplete medical record, degenerative arthritis of the hip, or previous hip surgery. IFD was measured on the axial CT image, and correlated demographic factors (age, sex, height, weight, and body mass index) and anatomical parameters (neck-shaft angle of the femur and femoral anteversion) with IFD were evaluated.

RESULTS

Five hundred seventeen patients (517 hips) were evaluated. There were 302 men and 215 women, and their mean age was 51.7 years (range 15-83 years). The mean IFD was 33.2 (±9.2) mm in men and 24.3 (±8.9) mm in women (P < .001). Interobserver and intraobserver reliability (intraclass correlation coefficients) were 0.99 (95% confidence interval 0.98-1.0) and 0.98 (95% confidence interval 0.97-0.99), respectively. The mean neck-shaft angle was 129.31° ± 5.04° in males and 129.93° ± 6.29° in females. The mean femoral anteversion was 9.72° ± 7.95° in males and 12.61° ± 8.91° in females. IFD was positively correlated with height (correlation coefficient [r] = 0.464, P < .001) and weight (0.286, P < .001), whereas it was negatively correlated with age (-0.198, P < .001), neck-shaft angle (-0.123, P = .005), and femoral anteversion (-0.346, P < .001). There was no correlation between body mass index and IFD (P = .522). In multivariate regression analysis, IFD was positively associated with height (β = .632), and negatively associated with neck-shaft angle of the femur and femoral anteversion (β = -0.155 and -0.328. respectively).

CONCLUSIONS

In asymptomatic hips, the mean IFD was 33.2 ± 9.2 mm in males and 24.3 ± 8.9 mm in females. The IFD was positively correlated with height and negatively with neck-shaft angle of the femur and femoral anteversion.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

P5350Atrial fibrillation prediction using P wave signal-averaged ECG in patients with embolic stroke of undetermined source

Background

Approximately 10–25% of ischemic strokes are of unknown origin. Determining their potential association with subclinical atrial fibrillation (SCAF) is important for proper secondary prevention. We investigated whether SCAF can be predicted by assessing the atrial substrate with signal-averaged electrocardiography (SAECG).

Methods

Between April 2015 and February 2018, we recruited 125 consecutive patients with embolic stroke of undetermined source (ESUS) and 125 patients with paroxysmal atrial fibrillation (AF) patients as control. All participants underwent P wave SAECG at baseline and ESUS patients were followed up with ECG and Holter ECG, at baseline, 3, 6, and 12 months after discharge, and every 12 months thereafter.

Results

In the ESUS group (69 males, 68.4±12.1 years), 32 (25.6%) patients were diagnosed with SCAF during follow-up. There were no significant differences between both groups in terms of P wave duration [PWD] (ESUS vs. AF, P=0.321). PWD demonstrated a significant predictive efficacy for SCAF detection during follow-up (C-index of standard PWD=0.657, 95% confidence interval (CI) 0.552–0.761, P=0.008).

Stroke recurrence occurred in 22 patients (17.6%) and was significantly associated with PWD but not SCAF (odds ratio 2.756, 95% CI 1.061–7.161, P=0.037).

Conclusion

PWD, an ECG biomarker associated with atrial substrate directly contributes to AF and ESUS, is useful for predicting SCAF. The potential for using this simple ECG biomarker for screening for SCAF amongst ESUS patients merits further exploration.

Preoperative Iron Supplementation and Restrictive Transfusion Strategy in Hip Fracture Surgery

Background

Hip fracture surgery (HFS) is often associated with perioperative blood loss, and it frequently necessitates transfusion. However, the hemoglobin (Hb) threshold for transfusion remains controversial in hip fracture patients. We evaluated the usefulness of the restrictive strategy and preoperative intravenous iron supplementation in HFS.

Methods

We retrospectively reviewed the medical records of 1,634 patients (> 60 years of age) who underwent HFS between May 2003 and June 2014 and were followed up for 1 year or more after surgery. We used the liberal transfusion strategy until May 2009 to determine the transfusion threshold; afterwards, we switched to the restrictive transfusion strategy. Patients with the restrictive transfusion strategy (restrictive group) received intravenous iron supplementation before surgery. We compared the transfusion rate, morbidity, and mortality of the restrictive group with those of the patients with the liberal transfusion strategy (liberal group).

Results

Preoperative intravenous iron supplementation was not associated with any adverse reactions. The transfusion rate was 65.3% (506/775) in the liberal group and 48.2% (414/859) in the restrictive group (p < 0.001). The mean hospital stay was shorter in the restrictive group (21.5 vs. 28.8 days, p < 0.001). There was no significant difference in the postoperative medical complications including myocardial infarction and cerebrovascular event. Mortality at postoperative 30, 60, and 90 days was similar between the two groups.

Conclusions

Our blood management protocol involving restrictive strategy combined with preoperative intravenous iron supplementation appears to be effective and safe in HFS of elderly patients.

Endometriosis fertility index predicts live births following surgical resection of moderate and severe endometriosis

STUDY QUESTION

Can live birth be accurately predicted following surgical resection of moderate-severe (Stage III-IV) endometriosis?

SUMMARY ANSWER

Live births can accurately be predicted with the endometriosis fertility index (EFI), with adnexal function being the most important factor to predict non-assisted reproductive technology (non-ART) fertility or the requirement for ART (www.endometriosisefi.com).

WHAT IS KNOWN ALREADY

Fertility prognosis is important to many women with severe endometriosis. Controversy persists regarding optimal post-operative management to achieve pregnancy and the counselling of patients regarding duration of conventional treatments before undergoing ART. The EFI is reported to correlate with expectant management pregnancy rate, although external validation has been performed without specifically addressing fertility in women with moderate and severe endometriosis.

STUDY DESIGN, SIZE, DURATION

Retrospective cohort study of 279 women from September 2001 to June 2016.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

We included women undergoing laparoscopic resection of Stage III-IV endometriosis who attempted pregnancy post-operatively. The EFI was calculated based on detailed operative reports and surgical images. Fertility outcomes were obtained by direct patient contact. Kaplan-Meier model, log rank test and Cox regression were used for analyses.

MAIN RESULTS AND THE ROLE OF CHANCE

The follow-up rate was 84% with a mean duration of 4.1 years. A total of 147 women (63%) had a live birth following surgery, 94 of them (64%) without ART. The EFI was highly associated with live births (P < 0.001): for women with an EFI of 0-2 the estimated cumulative non-ART live birth rate at five years was 0% and steadily increased up to 91% with an EFI of 9-10, while the proportion of women who attempted ART and had a live birth, steadily increased from 38 to 71% among the same EFI strata (P = 0.1). A low least function score was the most significant predictor of failure (P = 0.003), followed by having had a previous resection (P = 0.019) or incomplete resection (P = 0.028), being older than 40 compared to <35 years of age (P = 0.027), and having leiomyomas (P = 0.037).

LIMITATIONS REASONS FOR CAUTION

The main limitation of this study is its retrospective design. Imprecision was higher with low EFI due to smaller sample size in this subgroup. Finally, the EFI is somewhat subjective and could be prone to intra- and inter-observer variations.

WIDER IMPLICATIONS OF THE FINDINGS

Women with a high EFI score have excellent fertility prognosis and may be advised to try to become pregnant with timed intercourse compared to women with a low score, for which prompt referral to ART seems more reasonable. Other prognostic factors can be used to guide the management of women with an intermediate EFI score. These data follow women over many years post-resection and represent longitudinal fertility data rarely demonstrated in such a cohort. The location and impact of lesions on the ability of the adnexa to function seems crucial for the fertility prognosis and should be further investigated.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the GRACE Research funds. S.M.-L. is the recipient of a Training Award from the Fonds de Recherche Quebec-Sante. D.A. is the primary author of the Endometriosis Fertility Index. All authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Phase I dose escalation study of the PI3kinase pathway inhibitor BKM120 and the oral poly (ADP ribose) polymerase (PARP) inhibitor olaparib for the treatment of high-grade serous ovarian and breast cancer

Background

Based upon preclinical synergy in murine models, we carried out a phase I trial to determine the maximum tolerated dose (MTD), toxicities, pharmacokinetics, and biomarkers of response for the combination of BKM120, a PI3K inhibitor, and olaparib, a PARP inhibitor.

Patients and methods

Olaparib was administered twice daily (tablet formulation) and BKM120 daily on a 28-day cycle, both orally. A 3 + 3 dose-escalation design was employed with the primary objective of defining the combination MTD, and secondary objectives were to define toxicities, activity, and pharmacokinetic profiles. Eligibility included recurrent breast (BC) or ovarian cancer (OC); dose-expansion cohorts at the MTD were enrolled for each cancer.

Results

In total, 69 of 70 patients enrolled received study treatment; one patient never received study treatment because of ineligibility. Twenty-four patients had BC; 46 patients had OC. Thirty-five patients had a germline BRCA mutation (gBRCAm). Two DLTs (grade 3 transaminitis and hyperglycemia) were observed at DL0 (BKM120 60 mg/olaparib and 100 mg b.i.d.). The MTD was determined to be BKM120 50 mg q.d. and olaparib 300 mg b.i.d. (DL8). Additional DLTs included grade 3 depression and transaminitis, occurring early in cycle 2 (DL7). Anticancer activity was observed in BC and OC and in gBRCAm and gBRCA wild-type (gBRCAwt) patients.

Conclusions

BKM120 and olaparib can be co-administered, but the combination requires attenuation of the BKM120 dose. Clinical benefit was observed in both gBRCAm and gBRCAwt pts. Randomized phase II studies will be needed to further define the efficacy of PI3K/PARP-inhibitor combinations as compared with a PARP inhibitor alone.

Submicrometer particle removal indoors by a novel electrostatic precipitator with high clean air delivery rate, low ozone emissions, and carbon fiber ionizer

A novel positive-polarity electrostatic precipitator (ESP) was developed using an ionization stage (0.4 × 0.4 × 0.14 m(3) ) with 16 carbon fiber ionizers in each channel and a collection stage (0.4 × 0.4 × 0.21 m(3) ) with parallel metallic plates. The single-pass collection efficiency and clean air delivery rate (CADR) were measured by standard tests using KCl particles in 0.25-0.35 μm. Performance was determined using the Deutsch equation and established diffusion and field charging theories and also compared with the commercialized HEPA filter-type air cleaner. Experimental results showed that the single-pass collection efficiency of the ESP ranged from 50 to 95% and decreased with the flow rate (10-20 m(3) /min), but increased with the voltage applied to the ionizers (6 to 8 kV) and collection plates (-5 to -7 kV). The ESP with 18 m(3) /min achieved a CADR of 12.1 m(3) /min with a voltage of 8 kV applied to the ionization stage and with a voltage of -6 kV applied to the collection stage. The concentration of ozone in the test chamber (30.4 m(3) ), a maximum value of 5.4 ppb over 12 h of continuous operation, was much lower than the current indoor regulation (50 ppb).

Prognostic significance of metabolic adaptation for hypoxic environment in oral squamous cell carcinoma

6082

Background: During tumor growth, tumor adapts the hypoxic environment and increases glycolysis. This metabolic switch is related to the aggressive malignant behavior. We investigated the connection between the biomarkers related to the glycolytic metabolism (HIF-1α, PDK-1, LDH-5) and clinicopathologic characteristics in oral cavity and oropharynx squamous cell carcinoma (SCC). Methods: Eligibility criteria was the patients diagnosed oral SCC, received curative radical resection and had available tissue samples. Immunohistochemical stain of the HIF-1α, PDK-1, and LDH-5 was done. Statistical analysis was performed to compare biomarkers between patients and time point. Results: Overall 74 patients were enrolled and stage grouping of the patients was as follows: stage I, 25 (33.8%) patients; stage II 17 (23.0%); stage III 8 (10.8%); stage IV 24 (32.4%). 25 patients were relapsed and 5-year disease-free survival (DFS) rate was 61.4%. High expression of HIF-1α was related to the advanced T stage (p = 0.029), more invasive tumor (p = 0.003) and tumor recurrence (p = 0.037). High expression of PDK-1 was related to the advanced N stage (p = 0.026) and high expression of LDH-5 was related to the lymphatics invasion (p = 0.028), advanced N stage (p = 0.020) and more invasive tumor (p = 0.015). The high expression of HIF-1α, PDK-1, and LDH-5 showed a significant correlation to each other. 16 (21.6%) patients were highly expressed all three markers. High expression of all three markers correlated with more invasive tumor (p = 0.004) and tumor recurrence (p = 0.017). In survival analysis, high expression of HIF-1α and LDH-5 associated with shorter DFS in log rank test (p = 0.002 and p = 0.016, respectively). High expression of all three markers was also associated with shorter DFS (p = 0.002). In multivariate Cox regression analysis, high expression of all three markers was strong independent prognostic factor for DFS (p = 0.021). Conclusions: The oral SCC which glycolytic metabolism was changed showed a more invasive and aggressive phenotype. Taken together, biomarkers related tumor metabolism may be independent prognostic markers for the DFS in the patients with oral SCC.

No significant financial relationships to disclose.

Predictive and prognostic functions of microtubule-associated protein-tau and topoisomerase IIα protein in early breast cancer

e22169

Background: Topoisomerase IIα protein(topo II) is the molecular target of topo II inhibitors such as anthracyclines and Microtubule-Associated Protein(MAP)-tau protein is associated with taxane sensitivity. Anthracyclins and taxanes are major cytotoxic agents of breast cancer in the adjuvant setting. The aim of this study was to evaluate the predictive and prognostic functions of MAP-tau and topo II in early breast cancers. Methods: Representative breast tumor sections were constructed from paraffin embedded specimens from 78 node positive breast cancer patients. MAP-tau and topo II protein were assessed by immunochemistry using antibody clone 4F1(Affinity BioReagents,USA) and clone Ki-S1 antibody(Dakocytomation,USA). MAP-tau staining of tumor cells was semiquantatively scored as 0, 1+, 2+, 3+ and cases with 0 or 1+ staining intensity were considered MAP-tau negative. Topo II protein over- expression was defined as the detection of nuclear staining in more than median value of evaluated cells. Results: Thirty- four cases (43.6%) of 78 samples showed topo II overexpression and 35 cases(44.9%) showed MAP-tau overexpression in node positive breast cancers. HER2 overexpression was noted in 28 samples (35.9%) and 56 cases (71.8%) were compatible with the luminal type. In 43 patients (55.1%), anthracyclin and taxane were used as adjuvant therapy and in this group, both MAP-tau and topo II overexpression showed lower disease-free survival (DFS) than the others, but statistically not significant. In luminal type, MAP-tau overexpression was poor prognostic factor on DFS in Cox regression.(HR 5.644, 95% CI 1.14–28.07, p=0.034) Conclusions: Topo II overexpression and MAP-tau overexpression in node positive breast cancers were not significant predictive factors for anthracyclin and taxane therapies. As several investigators reported, MAP-tau is associated endocrine therapy sensitivity in patients without chemotherapy, but higher MAP-tau in luminal type was a strong poor prognostic factor in patients who were given chemotherapy and hormonal therapy.

No significant financial relationships to disclose.

A study of methods to reduce groundwater contamination around the Kimpo landfill in Korea

Four different methods were studied to reduce the groundwater contamination around the Kimpo landfill in Korea by leakage of a leachate. The hydraulic parameters were measured for this study and then the groundwater flow and contaminant transport systems around the Kimpo landfill were simulated with MODFLOW and MT3D models. Both the method of establishing 5 sets of Radial Collector Well Laterals (RCWLs) within the landfill and a method utilizing the wells for dewatering condensed water brought about a 70% leachate elimination efficiency. Their construction costs were cheap, and the maximum concentrations of chloride and phenol in the leachate effluent were high. Meanwhile, a method establishing an interception wall to the 2nd layer at the cirumference of the landfill and 22 sets of RCWLs within it brought about a 92% leachate elimination efficiency. Its construction cost was expensive, and the maximum concentrations of chloride and phenol in the leachate effluent were low. A method of establishing an interception wall to the 3rd layer and 40 sets of RCWLs brought about a 97% leachate elimination efficiency. Its construction cost was the most expensive, and the maximum concentrations of chloride and phenol were low. Conclusively, a method of establishing 22 sets of RCWLs was evaluated as the most stable and economical option to reduce groundwater contamination concentration below drinking water standard.

Repeated evolution of dioecy from monoecy in Siparunaceae (Laurales)

Siparunaceae comprise Glossocalyx with one species in West Africa and Siparuna with 65 species in the neotropics; all have unisexual flowers, and 15 species are monoecious, 50 dioecious. Parsimony and maximum likelihood analyses of combined nuclear ribosomal ITS and chloroplast trnL-trnF intergenic spacer sequences yielded almost identical topologies, which were used to trace the evolution of the two sexual systems. The African species, which is dioecious, was sister to all neotropical species, and the monoecious species formed a grade basal to a large dioecious Andean clade. Dioecy evolved a second time within the monoecious grade. Geographical mapping of 6,496 herbarium collections from all species sorted by sexual system showed that monoecy is confined to low-lying areas (altitude < 700 m) in the Amazon basin and southern Central America. The only morphological trait with a strong phylogenetic signal is leaf margin shape (entire or toothed), although this character also correlates with altitude, probably reflecting selection on leaf shapes by temperature and rainfall regimes. The data do not reject the molecular clock, and branch lengths suggest that the shift to dioecy in the lowlands occurred many million years after the shift to dioecy in the ancestor of the Andean clade.

Students' stress in China, Japan and Korea: a transcultural study

In this transcultural comparison of stress among Chinese, Japanese and Korean students, the authors examined stressors with the Stress Questionnaire Form for College Students, strategies for coping with Ways of Coping-Revised, and physical reactions to the stressors with the Physical Symptom Scale of Stress. Compared to the Japanese and Korean students, Chinese students had a multitude of stressors and experienced the highest level of stress. In coping with stressful events, Koreans were the most active, Chinese the least active and Japanese were intermediately active. Physical symptoms were found to be most serious in Koreans and less serious in Chinese and Japanese. Coping techniques seemed unrelated to alleviating physical symptoms in Koreans but mildly related in Chinese and Japanese.