Large-Scale Prospective Genome-Wide Association Study of Oxaliplatin in Stage II/III Colon Cancer and Neuropathy

IMPORTANCE

The severity of oxaliplatin (L-OHP)-induced peripheral sensory neuropathy (PSN) exhibits substantial interpatient variability, and some patients suffer from long-term, persisting PSN.

OBJECTIVE

To identify single-nucleotide polymorphisms (SNPs) predicting L-OHP-induced PSN using a genome-wide association study (GWAS) approach.

DESIGN, SETTING, PARTICIPANTS

A large prospective GWAS including 1,379 patients with stage II/III colon cancer who received L-OHP-based adjuvant chemotherapy (mFOLFOX6/CAPOX) under the phase II (JOIN/JFMC41) or the phase III (ACHIVE/JFMC47) trial.

MAIN OUTCOMES AND MEASURES

First, GWAS comparison of worst grade PSN (grade 0/1 vs. 2/3) was performed. Next, to minimize the impact of ambiguity in PSN grading, extreme PSN phenotypes were selected and analyzed by GWAS. SNPs that could predict time to recovery from PSN were also evaluated. In addition, SNPs associated with L-OHP-induced allergic reactions (AR) and time to disease recurrence were explored.

RESULTS

No SNPs exceeded the genome-wide significance (p < 5.0 × 10^-8) in either GWAS comparison of worst grade PSN, extreme PSN phenotypes, or time to recovery from PSN. Association study focusing on AR or time to disease recurrence also failed to reveal any significant SNPs.

CONCLUSION AND RELEVANCE

Our results highlight the challenges of utilizing SNPs for predicting susceptibility to L-OHP-induced PSN in daily clinical practice.

AB0131 DIFFERENCES IN CLINICAL PARAMETERS AND LABORATORY DATA OF RHEUMATOID ARTHRITIS PATIENTS IN REMISSION OR WITH LOW DISEASE ACTIVITY TREATED WITH BIOLOGIC AGENTS OR JANUS KINASE INHIBITORS

Background:

There are four kinds of drugs for rheumatoid arthritis (RA) patients who are refractory or intolerant to methotrexate (MTX) or other conventional synthetic disease-modifying anti-rheumatic drugs, namely, tumor necrosis factor inhibitors (TNFi), inteleukin-6 inhibitors (IL-6i), abatacept (ABT) and Janus kinase inhibitors (JAKi). Although these drugs have distinct mechanism of action (MOA) to reduce disease activity of RA, the effects of these drugs of reducing disease activity or inhibiting joint damage are similar according past clinical trials. However, their different MOA may induce different change in body of RA patients. If there are some differences in body of RA patients treated different drugs which have different MOA, some differences may appear in clinical parameters and laboratory data we clinician are able to know in daily clinical practice.

Objectives:

This retrospective cross-sectional study assessed differences in clinical parameters and laboratory data in RA patients who met the treatment goal with biologic agents (BIO) or JAKi.

Methods:

Data from the Toyohashi RA database (TRAD) was used. The TRAD is a collection of single-center retrospective data. Participants were BIO- or JAK-treated RA patients with clinical disease activity remission (REM) or low disease activity (LDA) [clinical disease activity index (CDAI) ≤ 10]categorized by BIO treatment with TNFi (reference), IL-6i, or ABT, and JAKi treatment. Clinical parameters [tender joint counts (TJ), swollen joint counts (SJ), patient’s global assessment (PtGA), patient’s pain assessment (PainVAS), physician’s global assessment (PhGA) and modified health assessment questionnaire (mHAQ)] and laboratory data [C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), matrix metalloprotease-3 (MMP-3), white blood cell counts (WBC), hemoglobin (Hb), platelet cell counts (PLT), neutrophils counts (Neut), lymphocyte counts (Lymph) and estimated glomerular filtration rate (eGFR)] were investigated in cross-sectional manner. They are statistically compared using the Dunnett test.

Results:

171 TNFi, 71 IL-6i, 50 ABT, and 18 JAKi cases are categorized in REM or LDA. Patients’ characteristics (means) are as follows (TNFi/IL-6i/ABT/JAKi). Age (63.1/63.7/72.4/60.6; years old), RA duration (17.0/12.7/18.2/11.3; years), %female (83.0/71.8/88.0/83.3), %rheumatoid factor positive (81.9/80.3/90.0/88.9), %anti-cyclic citrullinated peptide antibody (84.6/74.6/97.9/73.3), %prednisolone (PSL) concomitant (3.5/4.2/18.0/11.1) and %MTX concomitant (77.2/15.5/26.0/83.3). Parameters with statistical significance (means) were: TNFi/IL-6i-ESR 34.5/14.0 mm/hr, MMP-3 47.5/71.9 ng/mL, WBC 6124/5404 /µL, Lymph 2112/1646 µL; TNFi/ABT-TJ 0.4/1.0, PtGA 13.3/20.0 mm, PainVAS 15.7/21.6 mm, PhGA 7.4/11.1 mm, CRP 0.1/0.4 mg/dL, ESR 34.5/44.2 mm/hr, MMP-3: 47.5/72.9 ng/mL, Lymph 2112/1816 µL, Neut 3364/4233 µL, eGFR 75.4/65.3 mL/min/1.73m2; and TNFi/JAKi-PLT 21.7/29.3 104/µL, Lymph 2112/1326 µL.

Conclusion:

Although differences of rates of administering concomitant PSL or MTX should be considered, clinical parameter and laboratory data differences result from differences in the targeted cytokine between TNFi and IL-6i, differences in patient characteristics between TNFi and ABT, and differences in the MOA between TNFi and JAKi.

Disclosure of Interests:

None declared

POS0450 INCIDENCE RATES OF DIFFICULT-TO-TREAT RHEUMATOID ARTHRITIS IN REAL-WORLD CLINICAL PRACTICE

Background:

A definition of difficult-to-treat rheumatoid arthritis (D2T RA) was recently proposed by the European League Against Rheumatism (EULAR) [1]. However, information on the incidence rates of D2T RA in real-world clinical practice is lacking.

Objectives:

The aim of this retrospective cross-sectional study was to evaluate the incidence rates of D2T RA in clinical practice in Japan.

Methods:

Data from the Toyohashi RA database (TRAD) was used. The TRAD is a collection of single-center retrospective data. Patients with RA who fulfilled the following three requirements were included in this study: (1) had been treated with >1 biological or targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD); (2) >1 year had passed since b/tsDMARD treatment was initiated; and (3) regularly visited our institute at the time of investigation. The number of targeted patients was 363. The criteria of D2T RA used in this study were modified from the EULAR definition for simplification of the investigation as follows: (a) ≥2 b/t DMARDs with different mechanisms of action had been administered; (b) at least moderate disease activity (DAS28-ESR > 3.2 or clinical disease activity index [CDAI] > 10) at the time of investigation; and (c) 7.5-mg/day of prednisolone (PSL) or more was administered at the time of investigation. In this study, D2T RA was defined as criteria (a) + (b) or (a) + (c) or (a) + (b) + (c). The 363 patients were categorized into four groups as follows: group A, DT2 RA; group B, patients with RA who had been treated with ≥2 b/tsDMARDs and did not fulfill the D2T RA definition; group C, RA patients who had been treated with one kind of b/tsDMARD with the same mechanism of action (e.g., two kinds of tumor necrosis factor inhibitors) and fulfilled either or both criteria (b) and (c); and group D, patients with RA who had been treated with one kind of b/tsDMARD with the same mechanism of action (e.g., a tumor necrosis factor inhibitors or two interleukin 6 inhibitors) and did not fulfill either or both criteria (b) and (c). The incidence rates of D2T RA were calculated, and the patients’ characteristics at the time of initiation of the b/tsDMARD treatment were compared between the groups.

Results:

The number of patients in groups A, B, C, and D were 34, 53, 94, and 182, respectively. Of all the patients included in this study, 9.4% were categorized into group A, those with D2T RA, and 39.1% were treated with ≥2 b/tsDMARDs and categorized into group A (Fig 1). The patients’ characteristics were as follows (group A/B/C/D): mean age (57.1/54.3/61.4/56.2 years), RA duration (10.0/6.7/13.8/8.2 years), %Steinbrocker stage III+IV (%; 84.0/60.0/77.3/54.3), %Steinbrocker class 3 + 4 (%; 68.0/33.3/43.4/23.0), methotrexate (MTX) concomitant rate (%; 79.4/92.5/74.5/91.8), PSL concomitant rate (%; 91.2/52.8/55.3/43.4), DAS28-ESR score (5.5/5.0/5.5/4.7), and CDAI score (12.3/13.7/22.7/16.9). There were statistically significant differences in RA duration, %stage III+IV, %class 3 + 4 and PSL concomitant rate between group A and B.

Conclusion:

D2T RA occurred in 9.4% of patients treated with b/tsDMARDs. Incidence rate was increased to 39.1% after the treatment with ≥2 b/tsDMARDs. The patients with D2T RA tended to be older, have a long RA duration, be treated without concomitant MTX, be treated with concomitant PSL, and have higher disease activity at the time of starting the b/tsDMARD treatment. The baseline patient characteristics in group C were similar to those in group A. In the future, we suggest that patients with D2T RA be included in group C.

References:

[1]Nagy et al. Ann Rheum Dis 2021; 80: 31-35.

Disclosure of Interests:

None declared

AB0222 COMPARISON OF SELF-INJECTION DEVICES FOR ADMINISTERING ANTI-TUMOR NECROSIS FACTOR AGENTS USING THE ORIGINAL QUESTIONNAIRE IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Self-injection of biological agents has become a general practice in the treatment of rheumatoid arthritis (RA). Self-injectable biological agents differ in shape, needle thickness, drug fluid volume, and so on. These differences may affect patients’ evaluations of self-injection devices. Five kinds of anti-tumor necrosis factor (TNF) agents can be administered by self-injection in clinical practice in Japan. Information on patients’ evaluations of self-injection devices is important in choosing the agent for the treatment of RA among several agents with the same mechanism of action.

Objectives:

The aim of this retrospective cross-sectional study was to compare patient evaluations of anti-TNF self-injection devices in the treatment of RA.

Methods:

RA patients in whom etanercept (ETN) pen 50 mg (Embrel Pen) was switched to ETN biosimilar (BS) 50 mg (ETN-BS [MA]), adalimumab (ADA) syringe 40 mg (Humira syringe) was switched to ADA pen 40 mg (Humira pen), golimumab (GLM) syringe 50 mg (Simponi syringe) was switched to GLM autoinjector (Simponi AI), and certolizumab pegol (CZP) syringe (Cimzia syringe) was switched to CZP autoclicks (Cimzia AC) were asked to answer an originally developed questionnaire (Toyohashi Self-injection Assessment Questionnaire [T-SAQ]; Table 1) before and after switching agents. T-SAQ included 18 questions. A score of 0 indicated “best” and 4 indicated “worst” for each question, with a highest possible score of 72. The patients’ characteristics and T-SAQ scores before and after switching agents were investigated. A statistical analysis of the difference in T-SAQ score between before and after switching was performed using the Wilcoxon signed-rank test. A P value < 0.05 was considered significant.

Results:

The patients were divided into groups according to the agents they received with switching as follows: switchers from ETN pen to ETN-BS, n = 32; switchers from ADA syringe to ADA pen, n = 28; switchers from GLM syringe to GLM-AI, n = 25; and switchers from CZP syringe to CZP-AC, n = 10. The total T-SAQ scores were as follows, respectively: ETN pen and ETN-BS, 23.5 and 19.0; ADA syringe and ADA pen, 25.8 and 14.9; GLM syringe and GLM-AI, 23.8 and 17.4; and CZP syringe and CZP-AC, 30.6 and 18.8. The total T-SAQ was significantly improved after switching to the pen devices in all the switching groups. In the switchers from ETN pen to ETN-BS, the scores for questions 5, 10, 11, 12, 16, 17, and 18 were significantly improved after switching. The total T-SAQ scores were significantly improved for questions 1, 2, 3, 4, 5, 7, 11, 12, 13, 15, 16, and 17 in the switchers from ADA syringe to ADA pen, for questions 1, 2, 5, 7, 10, 16, and 17 in the switchers from GLM syringe to GLM-AI, and for questions of 1, 2, 3, 4, 5, 7, 11, and 15 in the switchers from CZP syringe to GLM-AC.

Conclusion:

The pen devices were favorably assessed by the RA patients in whom syringe devices were switched to pen devices for the same agent. The total T-SAQ score improved in the RA patients in whom ETN pen was switched to ETN-BS probably because the thickness of the needle was thinner in the ETN-BS than in the ETN pen. The total T-SAQ score for the ADA pen was lowest probably because the thinnest needle was used (29 gauge) and the amount of drug fluid is smallest (0.4ml). The total T-SAQ score for the CZP syringe was the lowest probably because the thickest needle was used (25 gauge).

Disclosure of Interests:

None declared

Treatment of twin-reversed arterial perfusion sequence using high-intensity focused ultrasound

We describe our experience of high-intensity focused ultrasound (HIFU) for fetal therapy in twin-reversed arterial perfusion (TRAP) sequence. Six pregnant women underwent HIFU therapy, five before 16 weeks and one at 26 weeks. Two types of HIFU system were used: the first-generation system, which comprised a biaxial transducer and continuous exposure pattern, and the second-generation system, which comprised a coaxial transducer and sequential exposure pattern. The first-generation apparatus was used in four cases and the second-generation apparatus was used in two. In three cases, occlusion of the blood vessels mediating flow to the acardiac twin was achieved by HIFU. Two cases experienced intrauterine fetal death despite vessel occlusion. The total survival rate of pump fetuses 2 years after HIFU was 67% and the efficiency rate (the proportion of cases with occlusion or reduced blood flow on ultrasound after HIFU) was 83%. After more than 2 years of follow-up, the surviving infants had no severe clinical complications and no postnatal developmental problems. There was no significant difference in survival rate compared with TRAP cases managed expectantly. Given that complete occlusion of the blood vessels was not achieved in half of the cases, we could not show that HIFU therapy is superior to other treatments. However, HIFU can reduce the cardiac load of the pump fetus and, as it does not require uterine puncture for fetal therapy, there were no fatal complications, such as bleeding, rupture of membranes or infection. Thus, HIFU therapy may represent a less-invasive treatment for TRAP sequence in early pregnancy. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Living Kidney Donation From a Donor With Pulmonary Sarcoidosis: A Case Report and Review of the Literature

BACKGROUND

Sarcoidosis is a chronic systemic disease that is characterized by the formation of noncaseating granuloma and whose etiology is unclear. It is unclear whether patients with sarcoidosis are suitable organ donors.

CASE

We treated a 56-year-old woman with pulmonary sarcoidosis who donated her kidney. She was previously in good health and was diagnosed with pulmonary sarcoidosis during her preoperative examination. Because she presented with no symptoms and was otherwise in good condition, donor nephrectomy was performed.

RESULTS

Baseline biopsy examination showed no evidence of sarcoidosis. One year after transplantation, both the donor and the recipient had not developed kidney dysfunction or recurrence of sarcoidosis.

CONCLUSION

This is a rare case in which a patient with pulmonary sarcoidosis donated a kidney for transplantation, and both the recipient and the donor were clinically healthy. A patient with sarcoidosis and no kidney lesion can donate a living kidney, because transplantation appears to be safe for both the recipient and the donor.

Immunoglobulin A Nephropathy in a Living Kidney Donor Diagnosed and Treated After Transplantation: A Case Report

OBJECTIVE

We report the clinical course and pathologic findings of a kidney transplant donor who was diagnosed with immunoglobulin A (IgA) nephropathy by means of preimplantation biopsy and was later treated with methylprednisolone and tonsillectomy.

CASE REPORT

The patient was a 57-year-old woman who met the criteria for kidney donation and was accepted as a donor. Donor nephrectomy was performed, and the preimplantation biopsy revealed that the donor had IgA nephropathy. One month after the nephrectomy, the donor's laboratory findings indicated proteinuria and hematuria. Because these findings indicated active IgA nephropathy, we decided to perform tonsillectomy and methylprednisolone pulse therapy. Soon after these treatments, the patient's proteinuria and hematuria were no longer observed.

CONCLUSIONS

Subclinical IgA nephropathy can be incidentally found on preimplantation biopsies of living kidney donors. As demonstrated in this case, IgA nephropathy can become exacerbated and requires therapeutic intervention after kidney donation. Informed consent and careful observation should be used before and after transplantation, even for donors who have been determined to be eligible for kidney donation.

Preemptive Living Donor Kidney Transplantation and Kidney Function at the Initial Hospital Visit: A Single-Center Case-Control Study

BACKGROUND

Studies have revealed that patients who undergo preemptive kidney transplantation (PKT) have favorable prognoses compared with those who undergo kidney transplantation after the initiation of dialysis. The number of PKT cases performed worldwide has been increasing. The goal of this study was to determine the clinical characteristics of patients who may successfully receive PKT.

METHODS

A single-center, case-control study was conducted to determine the clinical factors that lead to referral for PKT.

RESULTS

Between April 1, 2009, and August 1, 2015, a total of 118 patients underwent living donor kidney transplantation. Thirty of these patients had not undergone dialysis before their initial visit to the study hospital. Of these, 20 received kidney transplantation before and after dialysis initiation, respectively (group PKT+, successful PKT; group PKT-, failed PKT). The baseline characteristics at the primary visit were compared between groups. The median duration from the first visit to the study institution to PKT was 5.6 ± 0.7 months. Serum creatinine (Cr) levels differed significantly between groups (PKT+ vs PKT-, 6.0 ± 0.3 mg/dL vs 7.5 ± 0.5 mg/dL; P = .03). The receiver-operating characteristic curves revealed that a serum Cr level >5.7 mg/dL at the initial visit to the unit was a cutoff point for predicting the success of PKT (area under the curve, 0.721; P = .02).

CONCLUSIONS

Our results indicate that PKT should be performed within ∼6 months of the initial visit to the transplant center. Serum Cr levels <5.7 mg/dL predict successful PKT.

Large-scale prospective pharmacogenomics study of oxaliplatin-induced neuropathy in colon cancer patients enrolled in the JFMC41-1001-C2 (JOIN Trial)

BACKGROUND

Peripheral sensory neuropathy (PSN) is a dose-limiting toxicity of oxaliplatin-based chemotherapy. Several genetic markers have been shown to predict oxaliplatin-induced PSN; however, results remain to be validated in a large-scale and prospective pharmacogenomics study.

PATIENTS AND METHODS

Among 882 patients enrolled in the JFMC41-1001-C2 (JOIN trial), which was designed to investigate the tolerability of adjuvant-modified FOLFOX6 (mFOLFOX6) in Japanese Patients with stage II or III colon cancers undergoing curative resection, 465 patients were eligible for this pharmacogenomics analysis. Twelve single-nucleotide polymorphisms (SNPs) were selected based on published data. The effect of each genotype on time to PSN onset was evaluated in all patients (n = 465) using the Cox proportional hazard model. For the association analysis between severity of PSN and 12 SNP markers, 84 patients who failed to complete 12 cycles of mFOLFOX6 from grade 0/1 PSN group were excluded because the termination of the protocol treatment had been caused by reasons other than PSN.

RESULTS

Comparison of grade 0/1 PSN with grade 2/3 PSN or grade 3 PSN showed no significant associations with any of the 12 SNP markers after adjustment for total dose of oxaliplatin. Time-to-onset analysis also failed to reveal any significant differences.

CONCLUSIONS

Our large-scale and prospective pharmacogenomics study of Japanese patients receiving protocol treatment of adjuvant mFOLFOX6 could not verify a role for any of the 12 SNP markers reported as being significantly associated with PSN. Considering the OR observed in this study (range: 0.76-1.89), further evaluation of these 12 SNP markers in the context of L-OHP-induced PSN is unlikely to be clinically informative.

The Piccolo Intronic Single Nucleotide Polymorphism rs13438494 Regulates Dopamine and Serotonin Uptake and Shows Associations with Dependence-Like Behavior in Genomic Association Study

Piccolo (PCLO) inhibits methamphetamine-induced neuropharmacological effects via modulation of dopamine (DA) uptake and regulation of the transport of synaptic vesicles in neuronal cells. Clinical studies have recently suggested that the single nucleotide polymorphism (SNP) rs13438494 in the intron 24 of the PCLO gene is associated with psychiatric disorder, in the meta-analysis of GWAS. Therefore, in this study, we attempted to evaluate the possible role of the PCLO SNP in the mechanisms of uptake of monoamines. To characterize rs13438494 in the PCLO gene, we constructed plasmids carrying either the C or A allele of the SNP and transiently transfected them into SH-SY5Y cells to analyze genetic effects on the splicing of PCLO mRNA. The C and A allele constructs produced different composition of the transcripts, indicating that the intronic SNP does affect the splicing pattern. We also transfected DA and serotonin (5-hydroxytryptamine; 5- HT) transporters into cells and analyzed their uptakes to elucidate the association to psychiatric disorders. In the cells transfected with the C allele, both the DA and 5-HT uptake were enhanced compared to the A allele. We also conducted a clinical study, in order to clarify the genetic associations. PCLO rs13438494 exhibits a relationship with the symptoms of drug dependence or related parameters, such as the age of first exposure to methamphetamine, eating disorders, tobacco dependence and fentanyl requirement. Our findings suggest that rs13438494 is associated with drug abuse and contributes to the pathogenesis of psychiatric disorders via modulation of neurotransmitter turnover.

A DFT and multi-configurational perturbation theory study on O2 binding to a model heme compound via the spin-change barrier

Potential energy surface of the O₂ binding to a model heme compound via minimum energy intersystem crossing point (MEISCP) was investigated with DFT and MS-CASPT2. The porphyrin's symmetric shrinking vibration mode contributes to reach the MESICP from the T₁ minimum.

Prediction of early- and late-onset pregnancy-induced hypertension using placental volume on three-dimensional ultrasound and uterine artery Doppler

OBJECTIVES

To determine whether uterine artery (UtA) Doppler findings and three-dimensional (3D) ultrasound measurement of placental volume during the first trimester allowed prediction of early- and late-onset pregnancy-induced hypertension (early PIH and late PIH).

METHODS

Subjects with singleton pregnancy who underwent an ultrasound scan at 11-13 weeks' gestation and delivered between 2011 and 2013 were enrolled prospectively into the study. The UtA Doppler indices and placental volume on 3D ultrasound at 11-13 weeks' gestation in cases that developed early PIH (< 34 weeks) or PIH later in pregnancy (≥ 34 weeks) were compared with values in unaffected pregnancies.

RESULTS

Ten cases of early PIH, 67 cases of late PIH and 1285 unaffected pregnancies were analyzed. The UtA pulsatility index (PI) was higher in cases of early PIH than that in unaffected pregnancies (median, 2.35 vs. 1.79; P = 0.043) but did not differ between cases of late PIH and unaffected pregnancies. Placental volume was smaller in cases of early PIH than that in unaffected pregnancies (median, 43 cm3 vs. 62 cm(3) ; P = 0.003) but did not differ between cases of late PIH and unaffected pregnancies. The area under the receiver-operating characteristics curve for the prediction of early PIH, by combining UtA-PI and placental volume, was 0.832 (95% CI, 0.742-0.921), with this combination providing a detection rate for early PIH of 67.5% for a 5% false-positive rate.

CONCLUSIONS

High UtA-PI and small placental volume were observed more often in cases of early PIH compared with unaffected pregnancies, but not in cases of late PIH. These results may indicate that there are differences in pathophysiology between early PIH and late PIH.

Factors associated with deterioration of mini nutritional assessment-short form status of nursing home residents during a 2-year period

OBJECTIVE

A number of other studies have been conducted to verify the Mini Nutritional Assessment (MNA) or the MNA short form (MNA-SF) as a nutritional assessment/screening tool in various clinical settings or communities. However, there are few longitudinal studies using these tools to analyze which factors affect the incidence of deteriorating nutritional status. We tried to identify the factors associated with deterioration of MNA-SF status of nursing home residents during a 2-year period.

METHODS

Participants were 392 people with a mean age of 84.3 in 12 nursing homes in Japan. The factors associated with deterioration in MNA-SF categories during the study period compared to stable/improved MNA-SF categories were identified.

RESULTS

At baseline, 19.9% of the participants were malnourished and 60.2% were at risk of malnutrition, according to the MNA-SF classification. After 2 years, 66.3% participants maintained and 6.1% participants improved their nutritional status according to the MNA-SF classification, while 27.6% showed deterioration in MNA-SF status. Stepwise logistic-regression procedure indicated that basic ADL impairment and hospitalization during the follow-up period were associated with declining MNA-SF status.

CONCLUSIONS

Poor basic ADL status and hospitalization during the follow-up period were associated with malnutrition and risk of malnutrition as assessed by MNA-SF of nursing homes residents during a 2-year period.

Genome-wide association study identifies a potent locus associated with human opioid sensitivity

Opioids, such as morphine and fentanyl, are widely used as effective analgesics for the treatment of acute and chronic pain. In addition, the opioid system has a key role in the rewarding effects of morphine, ethanol, cocaine and various other drugs. Although opioid sensitivity is well known to vary widely among individual subjects, several candidate genetic polymorphisms reported so far are not sufficient for fully understanding the wide range of interindividual differences in human opioid sensitivity. By conducting a multistage genome-wide association study (GWAS) in healthy subjects, we found that genetic polymorphisms within a linkage disequilibrium block that spans 2q33.3-2q34 were strongly associated with the requirements for postoperative opioid analgesics after painful cosmetic surgery. The C allele of the best candidate single-nucleotide polymorphism (SNP), rs2952768, was associated with more analgesic requirements, and consistent results were obtained in patients who underwent abdominal surgery. In addition, carriers of the C allele in this SNP exhibited less vulnerability to severe drug dependence in patients with methamphetamine dependence, alcohol dependence, and eating disorders and a lower 'Reward Dependence' score on a personality questionnaire in healthy subjects. Furthermore, the C/C genotype of this SNP was significantly associated with the elevated expression of a neighboring gene, CREB1. These results show that SNPs in this locus are the most potent genetic factors associated with human opioid sensitivity known to date, affecting both the efficacy of opioid analgesics and liability to severe substance dependence. Our findings provide valuable information for the personalized treatment of pain and drug dependence.

First successful case of non-invasive in-utero treatment of twin reversed arterial perfusion sequence by high-intensity focused ultrasound

High-intensity focused ultrasound (HIFU) has excellent potential as a non-invasive therapeutic tool in various fields of medicine. We present a case of twin reversed arterial perfusion sequence, in which non-invasive blood flow occlusion in the acardiac fetus was successfully achieved by means of HIFU exposure from outside the maternal abdomen. HIFU was applied to blood vessels of the acardiac fetus at the point at which the umbilical cord entered the body in a series of four procedures at 3-day intervals starting at 13 weeks' gestation, and in a final procedure with higher power at 17 weeks. The HIFU intensity was set at approximately 2300 W/cm(2) for the initial series of procedures and at 4600 W/cm(2) for the final procedure, with exposure periods of 10 s. As color Doppler examination revealed absence of blood flow to the acardiac fetus after the second round of HIFU exposure, we concluded that complete occlusion of target vessels had been achieved. Delivery was by Cesarean section at 37 weeks' gestation. A male neonate (the pump fetus) was born weighing 1903 g with Apgar scores of 8 and 9 at 1 and 5 min, respectively. At the time of writing, the baby was healthy and growing normally, with the exception of congenital pseudarthrosis.

Evaluation of chlorinated benz[a]anthracene on hepatic toxicity in rats and mutagenic activity in Salmonella typhimurium

Chlorinated benz[a]anthracenes (Cl-BaA) are halogenated aromatic compounds (typified by dioxins) found in the environment at relatively high concentrations. Fischer 344 rats were intragastrically administered 0, 1, or 10 mg of Cl-BaA or its parent compound benz[a]anthracene (BaA) per kg of body weight for 14 consecutive days. Both chemicals at 10 mg/kg/day inhibited the gain in body weight, and consequent increase in relative liver weight. Hepatic gene expression of cytochrome P450 (CYP) 1A1, 1A2, and 1B1 was significantly stimulated by administration of BaA (10 mg/kg/day) compared with the control. After administration of Cl-BaA, only the CYP1A2 gene was significantly induced, even at the lower dosage; CYP1A1 and 1B1 mRNA levels remained unchanged in Cl-BaA-treated rats compared with controls. To elucidate the role of such Cl-BaA exposure and induced CYPs at toxicity onset, we investigated the mutagenicity of BaA and Cl-BaA using Salmonella typhimurium TA98 and TA100. BaA and Cl-BaA at 10 μg/plate produced positive results in both strains in the presence of rat S-9. Incubation of Cl-BaA with recombinant rat CYP1A2 produced a significantly higher number of revertant colonies in TA98 and TA100 than in controls, but no such change was observed for BaA. In conclusion, BaA changes its own physiological and toxicological actions by its chlorination; (1) daily exposure to Cl-BaA selectively induces hepatic CYP1A2 in rats and (2) Cl-BaA induces frameshift mutations in the presence of CYP1A2, although BaA does not exert mutagenicity. This indicates that CYP1A2 may metabolize Cl-BaA to active forms.

High-intensity focused ultrasound treatment for twin reversed arterial perfusion sequence

Twin reversed arterial perfusion (TRAP) sequence is a serious complication of monochorionic twin pregnancies, in which arterioarterial anastomoses allow blood flow from a 'pump' fetus to an acardiac fetus via reversed flow in the latter's umbilical artery. Several trial treatments for TRAP sequence have been reported, but all of these have been invasive. We present a case of TRAP sequence in which high-intensity focused ultrasound (HIFU) was applied to the umbilical artery of the anomalous twin at 26 weeks as a non-invasive fetal therapy. The HIFU intensity was set at approximately 2300 W/cm(2) with exposure periods of 10 s. Color Doppler ultrasound showed a decrease in blood supply to the anomalous twin, although complete occlusion of the targeted vessel was not achieved. Delivery was by Cesarean section at 29 weeks' gestation and the pump twin survived, without severe clinical complications at 6 months.

Detection of umbilical venous constriction by Doppler flow measurement at midgestation

OBJECTIVES

To investigate whether umbilical venous velocity and venous velocity pulsation are associated with umbilical vein diameter, umbilical ring diameter and umbilical cord coiling index at midgestation.

METHODS

Two hundred and eighty pregnant women were enrolled in the study at between 18 and 24 weeks of gestation. The diameter of the umbilical cord and internal diameter of the umbilical vein in a free loop and at the ring, and the umbilical coiling index, were measured using ultrasonography. Umbilical venous velocities were measured by Doppler ultrasonography at the umbilical ring and a free loop of the cord.

RESULTS

All variables were successfully measured in 92% of the patients. There were negative correlations between the diameters of the umbilical ring and of the umbilical vein at the ring and the venous velocity at the umbilical ring. The venous velocity at the umbilical ring was significantly higher and the umbilical ring diameter was significantly lower in fetuses with umbilical venous pulsation at the free loop. Significant correlations were observed between the venous velocity and amplitude of pulsation. Venous pulsations at the free loop were frequently observed in fetuses with a hypercoiled cord.

CONCLUSION

High venous velocity and increased venous pulsation at the umbilical ring may be associated with umbilical cord constriction.

Predisposing factors for massive hemorrhage during Cesarean section in patients with placenta previa

OBJECTIVES

To investigate whether maternal history and ultrasound findings can be predictors for massive hemorrhage during Cesarean section in patients with placenta previa and adherence of the placenta.

METHODS

We reviewed 127 singleton pregnancies with placenta previa. Maternal history, antenatal ultrasound findings of the placenta, including location, presence of placental lacunae, lack of a clear zone, presence of sponge-like findings of the cervix and presence of a marginal sinus in cases of placenta previa were reviewed retrospectively, and their association with amount of bleeding during Cesarean section was analyzed.

RESULTS

Logistic regression analysis revealed that advanced maternal age (odds ratio (OR), 5.4; 95% CI, 1.8-16.4), previous Cesarean section (OR, 20.4; 95% CI, 4.0-105.2) and sponge-like findings in the cervix (OR, 5.6; 95% CI, 1.8-17.0) were associated with massive bleeding (> 2500 mL). Placental adherence occurred in five cases and was more frequent in cases where the placenta was located at the site of the scar of a previous Cesarean section (OR, 123.1; 95% CI, 4.5-3395.2) and where there was lack of a clear zone (OR, 48.0; 95% CI, 3.8-604.7).

CONCLUSIONS

Advanced maternal age, previous Cesarean section and presence of sponge-like findings in the cervix are risk factors for massive bleeding during Cesarean section in cases of placenta previa, regardless of whether placental adherence is present. Placental location on the scar of a previous Cesarean section and lack of a clear zone are risk factors for placental adherence. When these findings are identified preoperatively, management should be tailored accordingly.