Discovery of a Novel Potent EGFR Inhibitor Against EGFR Activating Mutations and On-Target Resistance in NSCLC

PURPOSE

Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKI) serve as the standard first-line therapy for EGFR-mutated non-small cell lung cancer (NSCLC). Despite the sustained clinical benefits achieved through optimal EGFR-TKI treatments, including the third-generation EGFR-TKI osimertinib, resistance inevitably develops. Currently, there are no targeted therapeutic options available postprogression on osimertinib. Here, we assessed the preclinical efficacy of BI-4732, a novel fourth-generation EGFR-TKI, using patient-derived preclinical models reflecting various clinical scenarios.

EXPERIMENTAL DESIGN

The antitumor activity of BI-4732 was evaluated using Ba/F3 cells and patient-derived cell/organoid/xenograft models with diverse EGFR mutations. Intracranial antitumor activity of BI-4732 was evaluated in a brain-metastasis mouse model.

RESULTS

We demonstrated the remarkable antitumor efficacy of BI-4732 as a single agent in various patient-derived models with EGFR_C797S-mediated osimertinib resistance. Moreover, BI-4732 exhibited activity comparable to osimertinib in inhibiting EGFR-activating (E19del and L858R) and T790M mutations. In a combination treatment strategy with osimertinib, BI-4732 exhibited a synergistic effect at significantly lower concentrations than those used in monotherapy. Importantly, BI-4732 displayed potent antitumor activity in an intracranial model, with low efflux at the blood-brain barrier.

CONCLUSIONS

Our findings highlight the potential of BI-4732, a selective EGFR-TKI with high blood-brain barrier penetration, targeting a broad range of EGFR mutations, including C797S, warranting clinical development.

Comparison of endoscopic healing and durability between infliximab originator and CT-P13 in pediatric patients with inflammatory bowel disease

Background and aims

Favourable clinical data were published on the efficacy of CT-P13, the first biosimilar of infliximab (IFX), in pediatric inflammatory bowel disease (IBD); however, few studies have compared the effect on endoscopic healing (EH) and drug retention rate between the IFX originator and CT-P13. Therefore, we aimed to compare EH and the drug retention rate between the IFX originator and CT-P13.

Methods

Children with Crohn's disease (CD) and ulcerative colitis (UC)/IBD-unclassified (IBD-U) at 22 medical centers were enrolled, with a retrospective review conducted at 1-year and last follow-up. Clinical remission, EH and drug retention rate were evaluated.

Results

We studied 416 pediatric patients with IBD: 77.4% had CD and 22.6% had UC/IBD-U. Among them, 255 (61.3%) received the IFX originator and 161 (38.7%) received CT-P13. No statistically significant differences were found between the IFX originator and CT-P13 in terms of corticosteroid-free remission and adverse events. At 1-year follow-up, EH rates were comparable between them (CD: P=0.902, UC: P=0.860). The estimated cumulative cessation rates were not significantly different between the two groups. In patients with CD, the drug retention rates were 66.1% in the IFX originator and 71.6% in the CT-P13 group at the maximum follow-up period (P >0.05). In patients with UC, the drug retention rates were 49.8% in the IFX originator and 56.3% in the CT-P13 group at the maximum follow-up period (P >0.05).

Conclusions

The IFX originator and CT-P13 demonstrated comparable therapeutic response including EH, clinical remission, drug retention rate and safety in pediatric IBD.

Chemical upcycling of PVC-containing plastic wastes by thermal degradation and catalysis in a chlorine-rich environment

Chlorine (Cl)-containing chemicals, including hydrogen chloride, generated during thermal degradation of polyvinyl chloride (PVC) and corresponding mixture impede the chemical recycling of PVC-containing plastic wastes. While upgrading plastic-derived vapors, the presence of Cl-containing chemicals may deactivate the catalysts. Accordingly, herein, catalytic upgrading of pyrolysis vapor prepared from a mixture of PVC and polyolefins is performed using a fixed-bed reactor comprising zeolites. Among the H-forms of zeolites (namely, ZSM-5, Y, β, and chabazite) used in this study, a higher yield of gas products composed of hydrocarbons with lower carbon numbers is obtained using H-ZSM-5, thus indicating further decomposition of the pyrolysis vapor to C1-C4 hydrocarbons on it. Although the formation of aromatic compounds is better on H-ZSM-5, product distributions can be adjusted by further modifying the acidic properties via the alteration of the Si/Al molar ratio, and maximum yields of C1-C4 compounds (60.8%) and olefins (64.7%) are achieved using a Si/Al molar ratio of 50. Additionally, metal ion exchange on H-ZSM-5 is conducted, and upgrading of PVC-containing waste-derived vapor to aromatic chemicals and small hydrocarbon molecules was successfully performed using Co-substituted H-ZSM-5. It reveals that the highest yield of gas products on 1.74 wt% cobalt (Co)-substituted H-ZSM-5 is acquired via the selection of an appropriate metal and metal ion concentration adjustment. Nevertheless, introduction of excess Co into the H-ZSM-5 surface decreases the cracking activity, thereby implying that highly distributed Co is required to achieve excellent cracking activity. The addition of Co also adjusted the acid types of H-ZSM-5, and more Lewis acid sites compared to Brønsted acid sites selectively produced olefins and naphthenes over paraffins and aromatics. The proposed approach can be a feasible process to produce valuable petroleum-replacing chemicals from Cl-containing mixed plastic wastes, contributing to the closed loops for upcycling plastic wastes.

Responsiveness and meaningful thresholds of PROMIS pain interference, fatigue, and physical function forms in adults with idiopathic inflammatory myopathies: Report from the OMERACT Myositis Working Group

BACKGROUND

A series of qualitative studies conducted by the OMERACT Myositis Working Group identified pain interference, fatigue, and physical function as highly important life impact domains for adults with idiopathic inflammatory myositis (IIM). In this study, our goal was to assess the responsiveness and minimal important difference of PROMIS pain interference (6a), fatigue (7a), and physical function (8b).

METHODS

Adults with IIM from USA, Netherlands, Korea, Sweden, and Australia with two "clinical" visits were enrolled in this prospective study. Anchor questions on a Likert scale were collected at baseline, and manual muscle testing (MMT), physician and patient reported global disease activity, and PROMIS instruments were collected at both visits. Responsiveness was assessed with i) ANOVA, ii) paired t-test, effect size and standardized response mean, and iii) Pearson correlation. Minimal important difference (MID), minimal important change (MIC) and minimal detectable change (MDC) values were calculated.

RESULTS

114 patients with IIM (median age 60, 60 % female) completed both visits. Changes in PROMIS instruments were significantly different among anchor categories. Patients who reported improvement had a significant improvement in their PROMIS scores with at least medium effect size, while patients who reported worsening and stability did not show a significant change with weak effect size. PROMIS instruments had weak to moderate correlations with MMT, patient and physician global disease activity. MID was approximately 2-3 points for Pain Interference and 3-4 points for Fatigue and Physical Function forms based on the method used. MIC was approximately 4-5 for improvement of all the instruments, while MDC was 1.7-2 points for Pain Interference and Physical Function and 3.2-3.9 for Fatigue.

CONCLUSION

This study provides evidence towards the responsiveness of the PROMIS instruments in a large international prospective cohort of adults with IIM supporting their use as PROMs in adult myositis.

Detection of novel drug-adverse drug reaction signals in rheumatoid arthritis and ankylosing spondylitis: analysis of Korean real-world biologics registry data

This study aimed to detect signals of adverse drug reactions (ADRs) associated with biological disease-modifying antirheumatic drugs (DMARDs) and targeted therapies in rheumatoid arthritis (RA) and ankylosing spondylitis (AS) patients. Utilizing the KOrean College of Rheumatology BIOlogics & Targeted Therapy Registry (KOBIO) data, we calculated relative risks, excluded previously reported drug-ADR pairs, and externally validated remaining pairs using US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) and single centre's electronic health records (EHR) data. Analyzing data from 2279 RA and 1940 AS patients, we identified 35 significant drug-ADR pairs in RA and 26 in AS, previously unreported in drug labels. Among the novel drug-ADR pairs from KOBIO, 15 were also significant in the FAERS data. Additionally, 2 significant drug-laboratory abnormality pairs were found in RA using CDM MetaLAB analysis. Our findings contribute to the identification of 14 novel drug-ADR signals, expanding our understanding of potential adverse effects related to biological DMARDs and targeted therapies in RA and AS. These results emphasize the importance of ongoing pharmacovigilance for patient safety and optimal therapeutic interventions.

Pleural and pericardial effusions with fever and altered mental status: an atypical presentation of bartonellosis

A male in his 60s presented to the emergency department (ED) with a 3-week history of fever and progressive confusion. Initial laboratory and radiographic workup was largely unremarkable except for moderate bilateral pleural effusions. The patient was admitted on broad-spectrum antibiotics and further workup for fever of unknown aetiology. The differential diagnosis was broadened to different zoonotic infections, and subsequent laboratory testing showed a markedly elevated Bartonella henselae IgG and Bartonella quintana IgG (1:4096 and 1:512, respectively) in addition to positive B. henselae IgM titre (>1:20). During hospitalisation, the patient became more hypoxic and was found to have enlarging pleural effusions as well as a new pericardial effusion. The patient was treated with intravenous then oral doxycycline 100 mg two times per day and oral rifampin 300 mg two times per day for 4 weeks with subsequent improvement in clinical status as well as both effusions. This case highlights a unique presentation of Bartonella and its rare manifestation of pleural and pericardial effusions.

Proteogenomic Analysis of Human Uterine Cervical Cancer (UCC) Reveals Treatment-Resistant Subtypes of UCC

PURPOSE/OBJECTIVE(S)

Locally advanced uterine cervical cancer (UCC) is treated by radiotherapy with concurrent chemotherapy, but heterogenous treatment responses are frequently observed. To better optimize therapeutic options based on molecular signatures, we performed proteogenomic analysis of UCC.

MATERIALS/METHODS

UCC tissue and blood samples were collected from patients who underwent primary radiotherapy ± chemotherapy at the National Cancer Center (NCC) in Korea from July 2004 to March 2020. Most samples were obtained via biopsy. Genomic DNA for WES was isolated from frozen biopsy tumor tissues and peripheral blood buffy-coat of patients. Both global proteome and phosphoproteome were analyzed using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Whole exome sequencing, RNA sequencing, global proteomics and phosphoproteomics were performed using 253, 337, and 147 cervical cancer samples, respectively. Patient-derived xenograft were established using intratongue implantation using 2 primary cell lines from sub3 and sub5, and flow cytometric analysis was performed.

RESULTS

Fourteen significantly mutated genes (SMG) were found in our study cohort which include 5 newly identified SMGs. Mutation-phosphorylation analysis revealed association with apoptosis and actin cytoskeleton pathway. Proteogenomic analysis defined 6 molecular subtypes of UCC. Of those, 3 subtypes (i.e., Sub3, Sub5 and Sub6) were associated with treatment-resistant phenotypes. The cell-type deconvolution analysis suggested activated stroma with activation of cancer-associated fibroblast in Sub 3, while Sub5 showed low levels of activated stroma and high levels of myeloid immune cells. FACS analysis of UCC mouse models established from these 2 radio-resistant primary cell lines showed high component of PDGFRA+CAF infiltration in Sub 3, and high level of PVR+CD45+ immune cells mainly composed of polymorphonuclear myeloid-derived suppressor cells (PMN-MDSC) in Sub5. For Sub6, genes and/or protein signatures represented mucin-related processes (e.g., mucin glycosylation/sugar metabolism), which are linked to metastasis-associated Tn antigen production.

CONCLUSION

The proteogenomic analysis thus suggests potential targets for radiotherapy-resistant subtypes of UCC; secretory factors from activated stroma and cancer-associated fibroblast (Sub3); RHOA signaling, PVR, and PMN-MDSCs (Sub5), and keratin/chondroitin sulfate proteoglycan and Tn antigen production (Sub6). Our study shows the importance of proteogenomic analysis in unveiling the subtype specific molecular pathways of UCC that are beyond reach by genomic data alone. The validity of our molecular pathway and cellular signatures linking these pathways should be further validated through detailed functional experiments and in larger UCC cohorts.

The efficacy of detecting arrhythmia is higher with 7-day continuous electrocardiographic patch monitoring than with 24-h Holter monitoring

Background

Detecting high-risk arrhythmia is important in diagnosing patients with palpitations. We compared the diagnostic accuracies of 7-day patch-type electrocardiographic (ECG) monitoring and 24-h Holter monitoring for detecting significant arrhythmias in patients with palpitations.

Methods

This was a single-center prospective trial with 58 participants who presented with palpitations, chest pain or syncope. Outcomes were defined as the detection of any one of six arrhythmias, including supraventricular tachycardia (SVT), atrial fibrillation or atrial flutter lasting more than 30 s, pauses of more than 3 s, high-degree atrioventricular block, ventricular tachycardia (VT) >3 beats, or polymorphic VT/ventricular fibrillation. The McNemar test for paired proportions was used to compare arrhythmia detection rates.

Results

The overall arrhythmia detection rate was higher with 7-day ECG patch monitoring than with 24-h Holter monitoring (34.5% vs. 19.0%, p = .008). Compared with the use of 24-h Holter monitors, the use of 7-day ECG patch monitors was associated with higher detection of SVT (29.3% vs. 13.8%, p = .042). No serious adverse skin reactions were reported among the ECG patch-monitored participants.

Conclusions

The results suggest that a 7-day patch-type continuous ECG monitor is more effective for the detection of supraventricular tachycardia than is a 24-h Holter monitor. However, the clinical significance of device detected arrhythmia should be consolidated.

Mechanically Robust Ultrathin Solid Electrolyte Membranes Using a Porous Net Template for All-Solid-State Batteries

All-solid-state batteries (ASBs) have been identified as a potential next-generation technology for safe energy storage. However, the current pellet form of solid electrolytes (SEs) exhibits low cell-level energy densities and mechanical brittleness, and this has hampered the commercialization of ASBs. In this work, we report on the development of an ultrathin SE membrane that can be reduced to a thickness of 31 μm with minimal thermal shrinkage at 140 °C, while exhibiting robust mechanical properties (tensile strength of 19.6 MPa). Due to its exceptional ionic conductivity of 0.55 mS/cm and the corresponding areal conductance of 84 mS/cm², the SE membrane-incorporated ASB displays cell-level gravimetric and volumetric energy densities of 127.9 Wh/kg_cell and 140.7 Wh/L_cell, respectively. These values represent a 7.6- and 5.7-fold increase over those achieved with conventional SE pellet cells. Our results demonstrate the potential of the developed SE membrane to overcome the critical challenges in the commercialization of ASBs.

Abstract 3884: Targeting the ARID1A mutations overcomes primary resistance to ALK inhibitors in EML4-ALK posistive NSCLC

Introduction: Anaplastic lymphoma kinase (ALK)-tyrosine kinase inhibitors (TKIs) have improved an initial clinical response of non-small-cell lung cancer (NSCLC) patients with ALK-rearrangements. However, a subset of patients shows a poor response to ALK-TKIs. Here, we aimed to identify novel mechanism of primary resistance in preclinical model from a patient who presented an impressive resistance to sequential treatment with ALK TKIs.

Experimental design: The PDC YU-1076 cells were established from pleural effusion of the patient at the time he was receiving chemotherapy and radiotherapy after failure of ALK-TKI treatment. Sanger sequencing confirmed ML4-ALK variant 1 detected at the initial diagnosis. No resistance mutations in the ALK kinase domain were detected. To investigate co-occurring genetic alterations, we performed whole exome sequencing (WES) on YU-1076 cells and the matched blood sample. We further investigated the molecular profile of YU-1076 cells using RNA-sequencing analysis.

Results: YU-1076 cells exhibited cross-resistance to clinically available ALK-TKIs including crizotinib, ceritinib, alectinib, and lorlatinib. However, immunoblot analysis of YU-1076 cells treated with incremental doses of TKIs unexpectedly revealed an effective reduction of ALK

activity and downstream signals. We noticed that YU-1076 cells gradually changed from a small, round shape to a fibroblast-like shape following the treatment of ALK-TKIs. Transcriptome analysis confirmed enrichment for gene signatures related epithelial-to-mesenchymal transition (EMT) in ALK TKI-treated YU-1076 cells, suggesting that ALK-TKIs treatment promotes YU-1076 cells toward a more mesenchymal phenotype. WES analysis identified a major chromatin remodeling complex subunit, AT-rich interacting domain 1A (ARID1A), as well as MYC amplification, CDKN2A loss, and TP53 mutations. We focused on a synthetic lethal strategies using the SFK inhibitor dasatinib and the EZH2 inhibitor GSK126 in ARID1A mutant cancers. The combination of dasatinib with ALK-TKIs restored the sensitivity to the ALK TKIs in YU-1076 cells, accompanied by suppression of EMT marker genes VIM and CDH2 and increase of apoptotic markers BIM, PARP, and CAS3. Congruently, dasatinib significantly impaired tumor growth in YU-1076-xenografts. GSK126 also induced synergistic inhibition of cell growth with upregulation of apoptosis marker genes in YU-1076 cells, but did not affect the expression of EMT marker genes.

Conclusion: Our data indicate that ARID1A could be potentially used as a predictive biomarker for unfavorable ALK-TKI response. In this context, a combination strategy of ALK TKI with dasatinib may be effective in overcoming primary resistance.

Citation Format: Seung Yeon Oh, You Won Lee, Eun Ji Lee, Ju Young Kim, Sewon Park, Ju Yeon Park, Su-Jin Choi, Mi Ra Yu, Jii Bum Lee, Jiyun Lee, Chang Gon Kim, Sun Min Lim, Min Hee Hong, Mi Ran Yun, Byoung Chul Cho. Targeting the ARID1A mutations overcomes primary resistance to ALK inhibitors in EML4-ALK posistive NSCLC. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 3884.

Effect of Lithium Substitution Ratio of Polymeric Binders on Interfacial Conduction within All-Solid-State Battery Anodes

Problematic issues with electrically inert binders have been less serious in the conventional lithium-ion batteries by virtue of permeable liquid electrolytes (LEs) for ionic connection and/or carbonaceous additives for electronic connection in the electrodes. Contrary to electron-conductive binders used to maximize an active loading level, the development of ion-conductive binders has been lacking owing to the LE-filled electrode configuration. Herein, we represent a tactical strategy for improving the interfacial Li⁺ conduction in all-solid-state electrolyte-free graphite (EFG) electrodes where the solid electrolytes are entirely excluded, using lithium-substitution-modulated (LSM) binders. Finely tuning a lithium substitution ratio, a conductive LSM-carboxymethyl cellulose (CMC) binder is prepared from a controlled direct Na⁺/Li⁺ exchange reaction without a hazardous acid involvement. The EFG electrode employing LSM with a maximum degree of substitution of lithium (DS_Li) of ∼68% in our study shows a considerably higher rate capability of 1.05 mA h cm^-2 at 1 C and a capacity retention of ∼61.9% after 200 cycles at 0.5 C than those using sodium-CMC (Na-CMC) (0.78 mA h cm^-2, ∼49.5%) and LSM with ∼35% lithium substitution (0.93 mA h cm^-2, ∼55.4%). More importantly, the correlation between the phase transition near the bottom region of the EFG electrode and the state of charge (SOC) is systematically investigated, clarifying that the improvement of the interfacial conduction is proportional to the DS_Li of the CMC binders. Theoretical calculations combined with experimental results further verify that creating the continuous interface through abundant pathways for mobile ions using the Li⁺-conductive binder is the enhancement mechanism of the interfacial conduction in the EFG electrode, mitigating serious charge transfer resistance.

Fecal Calprotectin Levels Significantly Correlate with Polyp Size in Children and Adolescents with Juvenile Colorectal Polyps

PURPOSE

We aimed to investigate factors that correlate with fecal calprotectin (FC) levels in children and adolescents with colorectal polyps.

METHODS

Pediatric patients aged <19 years who underwent colonoscopic polypectomy for a juvenile polyps (JPs) and FC tests were simultaneously conducted in a multicenter, retrospective study. Baseline demographics, colonoscopic and histological findings, and laboratory tests, including FC levels, were investigated. Correlations between the factors were investigated, and linear regression analysis revealed factors that correlated with FC levels. FC levels measured after polypectomies were investigated and the FC levels pre- and post-polypectomies were compared.

RESULTS

A total of 33 patients were included in the study. According to Pearson correlation analysis, the polyp size was the only factor that showed a statistically significant correlation with FC levels (r=0.75, p<0.001). Furthermore, according to the multivariate linear regression analysis, polyp size was the only factor that showed a statistically significant correlation with FC levels (adjusted R² =0.5718, β=73.62, p<0.001). The median FC level was 400 mg/kg (interquartile range [IQR], 141.6-1,000 mg/kg), and the median polyp size was 14 mm (IQR, 9-20 mm). Nineteen patients underwent post-polypectomy FC tests. FC levels showed a significant decrease after polypectomy from a median of 445.2 mg/kg (IQR, 225-1,000) to 26.5 mg/kg (11.5-51) (p<0.001).

CONCLUSION

FC levels significantly correlated with polyp size in children and adolescents with JPs.

Efficacy of fermented grain using Bacillus coagulans in reducing visceral fat among people with obesity: a randomized controlled trial

Background

Obesity is a socioeconomic problem, and visceral obesity, in particular, is related to cardiovascular diseases or metabolic syndrome. Fermented grains and various microorganisms are known to help with anti-obesity effects and weight management. Studies on the relationship between Bacillus coagulans and anti-obesity effects are not well known, and studies on the application of fermented grains and microorganisms to the human body are also insufficient.

Objectives

This study aimed to evaluate the efficacy of Curezyme-LAC, an ingredient mixed with six-grain types fermented by B. coagulans, in reducing fat mass in adults with obesity.

Methods

In this randomized double-blinded placebo-controlled study, 100 participants [aged 40-65 years; body mass index (BMI) ≥ 25 to ≤ 33 kg/m²) were randomly allocated to two groups: 4 g/day Curezyme-LAC administered as a granulated powder or placebo (steamed grain powder mixture).

Results

After 12 weeks, visceral adipose tissue decreased significantly in the Curezyme-LAC group compared with that in the placebo group (mean ± standard error, SE of -9.3 cm² ± 5.1) vs. (6.8 cm² ± 3.4; p = 0.008). Compared to the placebo group, the Curezyme-LAC group also showed significant reductions in total fat mass (-0.43 ± 0.24 kg vs. 0.31 ± 0.19 kg, p = 0.011), body weight (-0.4 ± 0.3 kg vs. 0.3 ± 0.2 kg, p = 0.021), BMI (-0.14 ± 0.12 vs. 0.10 ± 0.07, p = 0.028), and waist circumference (-0.6 ± 0.2 cm vs. -0.1 ± 0.2 cm, p = 0.018) without a change in dietary intake and physical activity.

Conclusion

Curezyme-LAC supplementation for 12 weeks may benefit individuals with obesity by reducing visceral fat mass.

Do statins benefit low-risk population for primary prevention of atherosclerotic cardiovascular disease: A retrospective cohort study

The reported beneficial effects of statins on cardiovascular outcome based on risk assessment are inconsistent. Therefore, we investigated statin therapy effectiveness for the primary prevention of cardiovascular disease (CVD), according to the Korean Risk Prediction Model (KRPM). Subjects aged 40–79 years with low density lipoprotein cholesterol (LDL-C) of < 190 mg/dL and without CVD history were categorized as statin users or non-users using the National Health Insurance Service-National Sample Cohort (NHIS-NSC) database, Korea, 2002–2015. The 10-year atherosclerotic CVD (ASCVD) risk was calculated using the validated KRPM and categorized as low, borderline, intermediate, or high-risk groups; the incidence of major adverse cardiovascular events (MACEs) was compared over a mean follow-up period of 5.7 years using Cox proportional hazard models. The MACE incidence risk was decreased in statin users [hazard ratio (HR) 0.90, 95% confidence interval (CI) (0.84–0.98)]. However, there was an increased risk of MACE incidence in low-risk statin users [HR 1.80, 95% CI (1.29–2.52)], and no significant relationship was identified between statin use and MACE in the borderline [HR 1.15, 95% CI (0.86–1.54)] and intermediate-risk [HR 0.94, 95% CI (0.85–1.03)] groups. The risk of MACE incidence decreased only in the high CVD risk group among statin users. Statin use is not associated with MACE reduction in low- to intermediate-risk participants. Therefore, individuals with LDL-C level of < 190 mg/dL and low ASCVD risk should consider statin therapy only when CVD risk is proved obvious using an appropriate ASCVD risk tool.

Impact of Sleep Duration on Decline in Kidney Function in Adult Patients with Hypertension: A Community-Based Prospective Cohort Study

Background

Sleep duration is associated with various health conditions, including chronic kidney disease. However, the association between sleep duration and decline in kidney function in the South Korean population remains unclear. We aimed to investigate the impact of sleep duration on kidney function decline in adult patients with hypertension.

Methods

This cohort study was performed using data obtained from the Korean Genome and Epidemiology Study; 2,837 patients with hypertension who initially had normal kidney function were included. Glomerular filtration rates (GFRs) were estimated at baseline and throughout the 16 years of follow-up. A person was considered to have a decline in kidney function if they had a GFR <60 mL/min/1.73 m². Sleep duration data were obtained through interviewer-assisted questionnaires. Sleep durations were classified as short (<6 hours), normal (≥6 hours but <9 hours), and long (≥9 hours). The Cox proportional hazards model was applied, with adjustments for covariates.

Results

After adjusting for covariates, sleep duration was not associated with a decline in kidney function. However, among men with poorly controlled hypertension at baseline, compared to men with normal sleep durations, men with sleep durations <6 hours had a significantly higher risk of kidney function decline (hazard ratio, 1.56; 95% confidence interval, 1.02–2.36).

Conclusion

Short sleep duration did not seem to be associated with an increased risk of decline in kidney function; however, it may be a risk factor for the decline in kidney function in men with poorly controlled hypertension.

Associations of Polyp Characteristics in Children and Adolescents Presenting with Less Than Five Colorectal Polyps: A Full Colonoscopy Is Still Required

Background/Aims

A full colonoscopy is currently required in children and adolescents with colorectal polyps, because of their potential of neoplastic transformation and complications such as intussusception. We aimed to analyze the associations of polyp characteristics in children and adolescents with colorectal polyps. Based on these findings, we also aimed to reevaluate the necessity of conducting a full colonoscopy.

Methods

Pediatric patients <18 years of age who had undergone a colonoscopic polypectomy and those with <5 colorectal polyps were included in this multicenter, retrospective study. Baseline clinicodemographics, colonoscopic and histologic findings were investigated.

Results

A total of 91 patients were included. Multivariate logistic regression analysis showed that polyp size was the only factor associated with the presence of any polyps located proximal to the splenic flexure (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.28 to 4.28; p=0.007). Furthermore, polyp location proximal to the splenic flexure and sessile morphology were associated with the presence of any adenomatous polyp (OR, 8.51; 95% CI, 1.43 to 68.65; p=0.023; OR, 18.41; 95% CI, 3.45 to 173.81; p=0.002, respectively).

Conclusions

In children and adolescents presenting with <5 colorectal polyps, polyp size and the presence of any adenomatous polyp were positively associated with polyp location proximal to the splenic flexure. This finding supports the necessity of a full colonoscopic exam in pediatric patients with colorectal polyps for the detection of polyps before the occurrence of complications such as intussusception or neoplastic transformation.

Cardiac Complications Associated with Eating Disorders in Children: A Multicenter Retrospective Study

PURPOSE

Eating disorders often result in somatic complications, including cardiac abnormalities. Cardiac abnormalities may involve any part of the heart, including the cardiac conduction system, and can lead to sudden cardiac death. The current study aimed to evaluate the incidence of cardiac complications in pediatric patients with eating disorders and their associated factors.

METHODS

We retrospectively analyzed patients aged 10-18 years who were diagnosed with DSM-V (Diagnostic and Statistical Manual of Mental Disorder-V) eating disorders and underwent electrocardiography (ECG) and/or echocardiography between January 2015 and May 2020.

RESULTS

In total, 127 patients were included, of whom 113 (89.0%) were female. The median body mass index (BMI) was 15.05±3.69 kg/m². Overall, 74 patients (58.3%) had ECG abnormalities, with sinus bradycardia being the most common abnormality (91.9%). Patients with ECG abnormalities had significantly lower BMI (14.35±2.78 kg/m² vs. 16.06± 4.55 kg/m², p<0.001) than patients without ECG abnormalities, as well as lower phosphorus and higher cholesterol levels. Among the 46 patients who underwent echocardiographic evaluation, 23 (50.0%) had echocardiographic abnormalities, with pericardial effusion being the most common (60.9%). The median left ventricular mass (LVM) and ejection fraction were 67.97±21.25 g and 66.91±28.76%, respectively. LVM and BMI showed a positive correlation (r=0.604, p<0.001). After weight gain, the amount of pericardial effusion was reduced in 3 patients, and 30 patients presented with normal ECG findings.

CONCLUSION

Cardiac abnormalities are relatively frequent in patients with eating disorders. Physicians should focus on this somatic complication and careful monitoring is required.

Predictors and Impact of Sulcal SAH after Mechanical Thrombectomy in Patients with Isolated M2 Occlusion

BACKGROUND AND PURPOSE

Data on SAH after M2 mechanical thrombectomy are limited. We aimed to determine the prevalence of sulcal SAH after mechanical thrombectomy for M2 occlusion, its associated predictors, and the resulting clinical outcome.

MATERIALS AND METHODS

The study retrospectively reviewed the data of patients with acute ischemic stroke who underwent mechanical thrombectomy for isolated M2 occlusion. The patients were divided into 2 groups according to the presence of sulcal SAH after M2 mechanical thrombectomy. Angiographic and clinical outcomes were compared. Multivariable analysis was performed to identify independent predictors of sulcal SAH and unfavorable outcome (90-day mRS, 3-6).

RESULTS

Of the 209 enrolled patients, sulcal SAH was observed in 33 (15.8%) patients. The sulcal SAH group showed a higher rate of distal M2 occlusion (69.7% versus 22.7%), a higher of rate of superior division occlusion (63.6% versus 43.8%), and a higher M2 angulation (median, 128° versus 106°) than the non-sulcal SAH group. Of the 33 sulcal SAH cases, 23 (66.7%) were covert without visible intraprocedural contrast extravasation. Distal M2 occlusion (OR, 12.04; 95% CI, 4.56-35.67; P < .001), superior division (OR, 3.83; 95% CI, 1.43-11.26; P = .010), M2 angulation (OR, 1.02; 95% CI, 1.01-1.04; P < .001), and the number of passes (OR, 1.58; 95% CI, 1.22-2.09; P < .001) were independent predictors of sulcal SAH. However, covert sulcal SAH was not associated with an unfavorable outcome (P = .830).

CONCLUSIONS

After mechanical thrombectomy for M2 occlusion, sulcal SAH was not uncommon and occurred more frequently with distal M2 occlusion, superior division, acute M2 angulation, and multiple thrombectomy passes (≥3). The impact of covert sulcal SAH was mostly benign and was not associated with an unfavorable outcome.

Association between body mass index and fecal calprotectin levels in children and adolescents with irritable bowel syndrome

Irritable bowel syndrome (IBS) is a common pediatric functional gastrointestinal disorder. It is characterized by recurrent abdominal pain and changes in bowel habits and is more prevalent in obese patients. We investigated the association between obesity and IBS in pediatric patients through fecal calprotectin testing. Patients under 18 years of age with IBS who underwent fecal calprotectin testing from January 2015 through April 2020 were retrospectively investigated. The patients were divided into groups based on body mass index (BMI): group I (BMI < 85th percentile) and group II (BMI ≥ 85th percentile). Group II was divided into group IIa, overweight (85th percentile ≤ BMI < 95th percentile), and group IIb, obese (BMI ≥ 95th percentile). Among 277 included patients, 202 (72.9%) were in group I, and 75 (27.1%) were in group II (mean calprotectin levels, 75.60 ± 103.48 vs 45.89 ± 66.57 µg/g, respectively; P = .006). There were significant differences in mean calprotectin levels between groups I and IIa (75.60 ± 103.48 vs 45.45 ± 63.38 µg/g, respectively; P = .028) and groups I and IIb (75.60 ± 103.48 vs 46.22 ± 69.59 µg/g, respectively; P = .025). There was a significant difference in mean calprotectin levels between groups I and II (85.69 ± 142.13 vs 32.04 ± 28.17 µg/g, respectively; P = .029) among patients between 6 and 12 years of age but not among adolescents aged between 12 and 18 years (P = .139). Fecal calprotectin was lower when moderate-to-severe fatty livers were observed by ultrasound compared with normal livers (68.52 ± 97.22 vs 18.53 ± 18.56 µg/g, respectively; P = .017). Fecal calprotectin levels were higher in normal-weight pediatric IBS patients than in their obese counterparts, and this difference was more prominent in younger patients. In young children, IBS symptoms are thought to be influenced more by factors other than intestinal inflammation.

Effects of anxiety on sedation among pediatric patients undergoing esophagogastroduodenoscopy

We investigated whether the severity of anxiety among children undergoing endoscopy could affect sedation. We prospectively recruited patients under 18 years of age who were scheduled to undergo esophagogastroduodenoscopy (EGD). Baseline anxiety was evaluated using the Spence Children's Anxiety Scale (SCAS). Our analysis considered the type and dose of sedative drugs, degree of sedation, and complications associated with sedation according to the scale score. The mean total SCAS T-scores and each subscale score were significantly higher in the 6-12-year age group. The mean T-score among patients who exhibited irritability during EGD was higher than that among other patients, with significant differences in the Total, Obsessive Disorder, Panic Agoraphobia and General Anxiety subscales. The midazolam doses of children exhibiting irritability were more likely to need higher (p = 0.006). Other sedation-related complications were not associated with the T-scores in each subscale. Total sleep time was not associated with any T-score subscales. Anxiety levels were significantly higher among 6-12-year-olds and children exhibiting irritability. Anxiety was often associated with irritability, difficulties achieving adequate sedation during EGD, and additional sedative drug administration. We recommend higher doses or more potent drugs to facilitate endoscopy for children with high anxiety levels.

Full 2π tunable phase modulation using avoided crossing of resonances

Active metasurfaces have been proposed as one attractive means of achieving high-resolution spatiotemporal control of optical wavefronts, having applications such as LIDAR and dynamic holography. However, achieving full, dynamic phase control has been elusive in metasurfaces. In this paper, we unveil an electrically tunable metasurface design strategy that operates near the avoided crossing of two resonances, one a spectrally narrow, over-coupled resonance and the other with a high resonance frequency tunability. This strategy displays an unprecedented upper limit of 4π range of dynamic phase modulation with no significant variations in optical amplitude, by enhancing the phase tunability through utilizing two coupled resonances. A proof-of-concept metasurface is justified analytically and verified numerically in an experimentally accessible platform using quasi-bound states in the continuum and graphene plasmon resonances, with results showing a 3π phase modulation capacity with a uniform reflection amplitude of ~0.65.

Continuing perioperative estrogen therapy does not increase venous thromboembolic events in transgender patients: a systematic review and meta-analysis

OBJECTIVE

The aim of this study is to compare the risk of venous thromboembolic events (VTE) between patients suspending and continuing estrogen therapy perioperatively, in male to female gender-affirming surgery (vaginoplasty).

MATERIALS AND METHODS

The authors conducted a systematic review and meta-analysis of existing research on male to female gender-affirming study, which compared the risk of VTE among the usage of estrogen perioperatively.

RESULTS

A total of 209 studies were identified as potentially eligible among PubMed, Embase, and Cochrane library databases. Among the studies, 191 studies were excluded due to their abstract inappropriateness. Out of the remaining 18 studies, only 3 articles were eligible and were finally included. Meta-analysis was performed and showed odds ratio of 0.77 (95% CI: 0.04, 14.01).

CONCLUSIONS

Perioperative estrogen therapy does not increase VTE risk on male to female gender-affirming surgery. Therefore, estrogen therapy may be continued perioperatively in vaginoplasty. More prospective studies are needed.

Potential Utility of Fecal Calprotectin in Discriminating Colorectal Polyps From Other Major Etiologies in Children Presenting With Isolated Hematochezia

BACKGROUND

Colorectal polyps are the most common cause of isolated hematochezia in children, which requires a colonoscopy for diagnosis. We aimed to investigate the potential utility of fecal calprotectin (FC) in assessing colorectal polyps detected by colonoscopy among children presenting with isolated hematochezia.

METHODS

Pediatric patients of the age of < 18 years who had undergone both colonoscopy and FC tests for isolated hematochezia from June 2016 to May 2020 were included in the present multicenter, retrospective, cross-sectional study. Comparative analysis was conducted between major causes of isolated hematochezia and FC cut-offs for discriminating colorectal polyps were explored.

RESULTS

A total 127 patients were included. Thirty-five patients (27.6%) had colorectal polyps, followed by anal fissure (14.2%), ulcerative colitis (UC; 12.6%), and others. A significant difference in FC levels was observed between patients with colorectal polyps (median, 278.7 mg/kg), anal fissures (median, 42.2 mg/kg), and UC (median, 981 mg/kg) (P < 0.001). According to receiver operating characteristic curve analysis, among patients diagnosed with colorectal polyp or anal fissure, the most accurate FC cut-off for discriminating colorectal polyps from anal fissures on colonoscopy was 225 mg/kg (sensitivity, 59.4%; specificity, 94.4%; positive predictive value [PPV], 95.0%; negative predictive value [NPV], 56.7%; area under the curve [AUC], 0.8; 95% confidence interval [CI], 0.678-0.923; P < 0.001), while among patients diagnosed with colorectal polyp or UC, the most accurate FC cut-off for discriminating colorectal polyps from UC on colonoscopy was 879 mg/kg (sensitivity, 81.2%; specificity, 56.2%; PPV, 78.8%; NPV, 60.0%; AUC, 0.687; 95% CI, 0.521-0.852; P < 0.001).

CONCLUSION

FC may assist in assessing the cause of lower gastrointestinal tract bleeding in children who present with isolated hematochezia.

Development and Evaluation of the Korean Version of Hospital-Based Transitional Rehabilitation Program Using Daily Living Home for Spinal Cord Injury

Objective

To develop and evaluate the Korean version of a hospital-based transitional rehabilitation program (TRP), using daily living home for spinal cord injury (SCI) patients.

Methods

In this study, we developed the Korean version of a hospital-based TRP through domestic and overseas surveys and focus group meetings. By applying this to chronic SCI patients, we observed the functional and quality of life (QOL) changes and evaluated the degree of achievement of the core goals set for each patient during hospital-based TRP.

Results

Hospital-based TRP, for 21.8±3.9 days on average, was applied to four chronic SCI patients (two patients with long-term hospital stays and two homebound disabled individuals) with an average injury period of 736.8±185.4 days. The Korean version of the Spinal Cord Independence Measure (49.3±6.9 vs. 62.5±6.0; p<0.05) showed functional improvement at the end of TRP, when compared to that before the TRP. The Korean version of the World Health Organization’s QOL scale, abbreviated version (159.8±36.6 vs. 239.8±36.1; p<0.05), showed improvement in QOL. Goal attainment scaling showed a significant degree of achievement for the core goals through TRP (33.6±4.4 vs. 70.0±2.8; p<0.05). These results confirmed that the effect was maintained 1 month after the end of TRP. Additionally, two patients were successfully discharged after TRP completion, and the other two could start social activities.

Conclusion

The Korean version of the hospital-based TRP, applied to chronic SCI patients, showed the potential to improve the patients’ functioning and QOL and appeared to be effective in successful discharge and social participation.

Suicide associated with COVID-19 infection: an immunological point of view

OBJECTIVE

Coronavirus disease 2019 (COVID-19) is a pandemic and leading cause of death. Beyond the deaths directly caused by the virus and the suicides related to the psychological response to the dramatic changes as socioeconomic related to the pandemic, there might also be suicides related to the inflammatory responses of the infection. Infection induces inflammation as a cytokine storm, and there is an increasing number of studies that report a relationship between infection and suicide.

MATERIALS AND METHODS

We searched the World Health Organization status report and the PubMed database for keywords (COVID-19, suicide, infection, inflammation, cytokines), and reviewed five cytokine pathways between suicide and inflammation using two meta-analyses and two observational studies starting from November 31, 2020, focusing on the relationship between suicide and inflammation by infection. First, we discussed existing evidence explaining the relationship between suicidal behaviors and inflammation. Second, we summarized the inflammatory features found in COVID-19 patients. Finally, we highlight the potential for these factors to affect the risk of suicide in COVID-19 patients.

RESULTS

Patients infected with COVID-19 have high amounts of IL-1β, IFN-γ, IP10, and MCP1, which may lead to Th1 cell response activation. Also, Th2 cytokines (e.g., IL-4 and IL-10) were increased in COVID-19 infection. In COVID-19 patients, neurological conditions, like headache, dizziness, ataxia, seizures, and others have been observed.

CONCLUSIONS

COVID-19 pandemic can serve as a significant environmental factor contributing directly to increased suicide risk; the role of inflammation by an infection should not be overlooked.

The occurrence of infection-related systemic diseases in Korean children and adolescents has decreased after the spread of the COVID-19 pandemic: a multicenter retrospective study

BACKGROUND

The occurrences of infection-related systematic diseases, such as Henoch-Schönlein Purpura (HSP), intussusception, and mucocutaneous lymph node syndrome (MCLS) may have decreased, similarly to the decreased occurrence of infectious diseases following the Coronavirus disease 2019 (COVID-19) pandemic. We aimed to investigate whether there was a change in the occurrence of these diseases in South Korea after the spread of the COVID-19 pandemic.

METHODS

In this multicenter, retrospective study conducted in 16 medical centers in South Korea patients diagnosed with HSP, intussusception, and MCLS at the age of <18 years between January 2016 and December 2020 were included. New occurrences of these three diseases were investigated monthly and annually, while to compare between the pre- and post-COVID-19 era cases, new occurrences between 2017-2019 and 2020 were compared. Additionally, the total annual occurrence rate was calculated by dividing each center's occurrence into the annual population per 100,000 of the population <18 years in each region that the center covers.

RESULTS

A total 6,857 patients were included in this study. From 2017 to 2020, the number of patients diagnosed with HSP, intussusception, MCLS at the age of <18 years were 1,301, 1,693, and 3,863 patients, respectively. The average number of patients during the three years before the COVID-19 pandemic were each 379.7, 505.3, and 1,112.0 for HSP, intussusception, MCLS, respectively, which each decreased by 57.3%, 65.0%, 52.6% to 162, 177, 527 in 2020, respectively. Furthermore, the total annual occurrence rate showed a significant decrease in 2020 compared to 2017 to 2019 in all three diseases (2017-2020; HSP: 11.85, 12.96, 10.52, and 5.48; intussusception: 13.94, 16.97, 16.31, and 5.98; MCLS: 33.89, 35.11, 34.69, and 17.82, respectively).

CONCLUSIONS

We revealed that the occurrence of HSP, intussusception, and MCLS, which are representative of infection-related systemic diseases in the pediatric population, decreased significantly after the spread of the COVID-19 pandemic.

ANGPTL4 accelerates KRASG12D-Induced acinar to ductal metaplasia and pancreatic carcinogenesis

Oncogenic KRASG12D induces neoplastic transformation of pancreatic acinar cells through acinar-to-ductal metaplasia (ADM) and pancreatic intraepithelial neoplasia (PanIN), and drives pancreatic ductal adenocarcinoma (PDAC). Angiopoietin-like 4 (ANGPTL4) is known to be involved in the regulation of cancer growth and metastasis. However, whether ANGPTL4 affects KRASG12D-mediated ADM and early PDAC intervention remains unknown. In the current study, we investigated the role of ANGPTL4 in KRASG12D-induced ADM, PanIN formation, and PDAC maintenance. We found that ANGPTL4 was highly expressed in human and mouse ADM lesions and contributed to the promotion of KRASG12D-driven ADM in mice. Consistently, ANGPTL4 rapidly induced ADM in three-dimensional culture of acinar cells with KRAS mutation and formed ductal cysts that silenced acinar genes and activated ductal genes, which are characteristic of in vivo ADM/PanIN lesions. We also found that periostin works as a downstream regulator of ANGPTL4-mediated ADM/PDAC. Genetic ablation of periostin diminished the ADM/PanIN phenotype induced by ANGPTL4. A high correlation between ANGPTL4 and periostin was confirmed in human samples. These results demonstrate that ANGPTL4 is critical for ADM/PanIN initiation and PDAC progression through the regulation of periostin. Thus, the ANGPTL4/periostin axis is considered a potential target for ADM-derived PDAC.

Empirical assessment of biases in cerebrospinal fluid biomarkers of Alzheimer's disease: an umbrella review and re-analysis of data from meta-analyses

OBJECTIVE

Alzheimer's disease (AD) is a leading cause of years lived with disability in older age, and several cerebrospinal fluid (CSF) markers have been proposed in individual meta-analyses to be associated with AD but field-wide evaluation and scrutiny of the literature is not available.

MATERIALS AND METHODS

We performed an umbrella review for the reported associations between CSF biomarkers and AD. Data from available meta-analyses were reanalyzed using both random and fixed effects models. We also estimated between-study heterogeneity, small-study effects, excess significance, and prediction interval.

RESULTS

A total of 38 meta-analyses on CSF markers from 11 eligible articles were identified and reanalyzed. In 14 (36%) of the meta-analyses, the summary estimate and the results of the largest study showed non-concordant results in terms of statistical significance. Large heterogeneity (I2≥75%) was observed in 73% and small-study effects under Egger's test were shown in 28% of CSF biomarkers.

CONCLUSIONS

Our results suggest that there is an excess of statistically significant results and significant biases in the literature of CSF biomarkers for AD. Therefore, the results of CSF biomarkers should be interpreted with caution.

Waist circumference and the risk of lumbar and femur fractures: a nationwide population-based cohort study

Although obesity is known to have an influence on fracture, the relationship between lumbar and femur fractures and weight or waist circumference is controversial. We investigated the incidence of fracture with regards to waist circumference using the customised database of the Korean National Health Insurance Service (NHIS). Among 8,922,940 adults who participated at least twice in the NHIS National Health Check-up Program in South Korea between 2009 and 2011, 1,556,751 subjects (780,074 men and 776,677 women) were extracted. Over a mean follow-up of 6.5 years, multivariate-adjusted logistic regression analysis demonstrated that higher waist circumference was associated with an increased risk of femur fractures in both males and females. Moreover, the incidence of lumbar fractures was also positively associated with an increased waist circumference in males and females. An increased waist circumference showed a positive linear relationship with the risk of lumbar and femur fractures in both males and females.

Local Intra-arterial Thrombolysis during Mechanical Thrombectomy for Refractory Large-Vessel Occlusion: Adjunctive Chemical Enhancer of Thrombectomy

BACKGROUND AND PURPOSE

Data on adjunctive intra-arterial thrombolysis during mechanical thrombectomy for refractory thrombus are sparse. The aim of this study was to evaluate the efficacy and safety of local intra-arterial urokinase as an adjunct to mechanical thrombectomy for refractory large-vessel occlusion.

MATERIALS AND METHODS

We retrospectively evaluated patients with acute ischemic stroke who underwent mechanical thrombectomy for anterior circulation large-vessel occlusion between January 2016 and December 2019. Patients were divided into 2 groups based on the use of intra-arterial urokinase as an adjunctive therapy during mechanical thrombectomy for refractory thrombus: the urokinase and nonurokinase groups. Herein, refractory thrombus was defined as the target occlusion with minimal reperfusion (TICI 0 or 1) despite >3 attempts with conventional mechanical thrombectomy. The baseline characteristics, procedural outcomes, and clinical outcome were compared between the 2 groups.

RESULTS

One hundred fourteen cases of refractory thrombus were identified. A total of 45 and 69 patients were in the urokinase and the nonurokinase groups, respectively. The urokinase group compared with the nonurokinase group showed a higher rate of successful reperfusion (82.2% versus 63.8%, P = .034), with lower procedural times (54 versus 69 minutes, P = .137). The rates of good clinical outcome, distal embolism, and symptomatic intracranial hemorrhage were similar between the 2 groups. The use of intra-arterial urokinase (OR = 3.682; 95% CI, 1.156-11.730; P = .027) was an independent predictor of successful reperfusion.

CONCLUSIONS

The use of local intra-arterial urokinase as an adjunct to mechanical thrombectomy may be an effective and safe method that provides better recanalization than the conventional mechanical thrombectomy for refractory thrombus in patients with embolic large-vessel occlusion.

Fruit Intake and Changes of Cardio-Metabolic Risk Factors in People with Obesity

BACKGROUND

This study aimed to explore the relationship between fruit intake, changes in fruit intake, and changes in cardiometabolic factors in people with obesity.

METHODS

A total of 21,270 subjects (8,718 men, 12,552 women) aged 40 years and over, from the Korean-based Genome and Epidemiology Study, were followed up for an average of 4.4 years. Fruit intake was assessed using a food frequency questionnaire at baseline and the second follow-up. The beta coefficient and confidence intervals for changes in cardiometabolic risk factors according to fruit consumption were calculated using a linear regression model.

RESULTS

In men, the abdominal circumference decreased with changes in fruit intake (P=0.029). Fruit intake and increased fruit intake in men were associated with a lower systolic blood pressure (P=0.012 and P=0.02, respectively) and lower triglyceride levels (P=0.002 and P<0.001, respectively). In women, abdominal circumference decreased with both fruit intake and increased fruit intake (P<0.001 and P=0.013, respectively). Systolic blood pressure and triglycerides tended to decrease only with fruit intake (P=0.048 and P<0.001, respectively). Unlike in men, fasting blood glucose tended to decrease in women with both fruit intake and increased fruit intake (P=0.011 and P=0.005, respectively).

CONCLUSION

Fruit intake and increased fruit intake may have beneficial effects on cardiometabolic risk factors among individuals who are obese.

Clinical effectiveness of house dust mite immunotherapy in mono- versus poly-sensitised patients with allergic rhinitis: a systematic review and meta-analysis

Selecting an appropriate allergen-specific immunotherapy (AIT) regimen for polysensitised allergic rhinitis (AR) patients is challenging for clinicians. Although previous studies showed comparable effectiveness of single-allergen AIT with house dust mite (HDM) extract between monosensitised and polysensitised AR patients, there is no systematic review and meta-analysis demonstrating the comparable effectiveness of HDM AIT. In this meta-analysis, we analysed nine studies to compare the clinical effectiveness of HDM AIT. The primary outcome was nasal symptom score and secondary outcomes were medication and quality of life scores. The changes in nasal symptom score after HDM AIT did not significantly differ between monosensitised and polysensitised patients. The clinical effectiveness of HDM AIT regarding medication and quality of life score was not significantly different between monosensitised and polysensitised patients). In conclusion, single-allergen AIT with HDM extract showed comparable clinical effectiveness between polysensitised and monosensitised patients with AR.

Clinical Analysis of Hospitalized Patients with Hemophilia A: Single-hemophilia Treatment Center Experience in Korea over 10 years

Background

There is lack of data on admitted hemophilia patients in Korea. For this reason, this study was intended to analyze the hospitalization data of hemophilia patients in a regional Hemophilia Treatment Center (HTC) for the first time in Korea.

Methods

In this retrospective study, we surveyed hospitalized patients with Hemophilia A (HA) in a HTC for 14 years. Medical records of these hemophiliacs were reviewed and data regarding demographic characteristics, cause of admissions and their outcomes in each patient were obtained. In addition, the data of admitted days, type and amount of Coagulation factor concentrate (CFC) used, treatments other than CFC infusion during the admission days were also obtained from the medical record of each patient.

Results

A total 107 patients with hemophilia A were admitted during 14 years. Annual rate of admission of patients with HA was 8%. Mean age on admission was 29.63±19.51 years old and mean admission days were 11.28±5.46 days. Most admissions were occurred in severe and moderate hemophilia patients. The most common cause of admission was bleed control followed by surgery and other reasons. With modified WFH CFC supplementation guideline, all the bleeds were successfully controlled and all surgeries were also successfully conducted with less total CFC consumption compared to the consumed dose of other reports.

Conclusion

These results suggest that it is necessary to develop more specified regimens different from WFH guidelines of CFC supplementation for admitted Korean patients with hemophilia A.

Microfluidic device with brain extracellular matrix promotes structural and functional maturation of human brain organoids

Brain organoids derived from human pluripotent stem cells provide a highly valuable in vitro model to recapitulate human brain development and neurological diseases. However, the current systems for brain organoid culture require further improvement for the reliable production of high-quality organoids. Here, we demonstrate two engineering elements to improve human brain organoid culture, (1) a human brain extracellular matrix to provide brain-specific cues and (2) a microfluidic device with periodic flow to improve the survival and reduce the variability of organoids. A three-dimensional culture modified with brain extracellular matrix significantly enhanced neurogenesis in developing brain organoids from human induced pluripotent stem cells. Cortical layer development, volumetric augmentation, and electrophysiological function of human brain organoids were further improved in a reproducible manner by dynamic culture in microfluidic chamber devices. Our engineering concept of reconstituting brain-mimetic microenvironments facilitates the development of a reliable culture platform for brain organoids, enabling effective modeling and drug development for human brain diseases.

Viral stimulation modulates endotype-related ACE2 expression in eosinophilic chronic rhinosinusitis

BACKGROUND

Angiotensin-converting enzyme 2 (ACE2), a receptor targeted by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is highly expressed in the nasal mucosa. Chronic rhinosinusitis (CRS) shows diverse endotypes and is aggravated by viral infection. Whether viral stimulation and CRS endotype influence ACE2 expression remains unclear. We investigated the expression of ACE2 and the transmembrane protease, serine 2 (TMPRSS2), which mediate the entry of SARS-CoV-2 into cells, and assessed polyinosinic:polycytidylic acid (poly[I:C])-induced changes based on CRS endotype.

METHODOLOGY

ACE2 and TMPRSS2 expression was evaluated based on CRS phenotype, endotype, and tissue type. Correlations between ACE2/TMPRSS2 expression and inflammatory mediators in nasal polyps (NP) were examined. Air-liquid interface culture experiments were performed to assess the effects of major cytokines or poly(I:C) stimulation on ACE2/TMPRSS2 expression in primary epithelial cells from healthy nasal mucosa, eosinophilic NP (ENP), and non-eosinophilic NP (NENP).

RESULTS

In primary nasal epithelial cells, interleukin (IL)-13 decreased ACE2 expression but increased TMPRSS2. Eosinophilic CRS showed lower ACE2 expression than non-eosinophilic CRS, regardless of CRS phenotype. CRS endotype was an independent factor associated with ACE2/TMPRSS2 expression in NP. Serum and tissue eosinophilic marker levels were inversely correlated with ACE2 expression, whereas tissue neutrophilic marker levels and ACE2 expression were positively correlated in NP. ACE2 expression was suppressed in ENP tissues; however, a combination of poly(I:C) and IL-13 induced ACE2/TMPRSS2 upregulation in ENP.

CONCLUSIONS

ENP tissues have lower ACE2 expression than NENP; however, viral stimulation promotes ACE2/TMPRSS2 upregulation in ENP.

Factors Associated with the Immunogenicity of Anti-Tumor Necrosis Factor Agents in Pediatric Patients with Inflammatory Bowel Disease

Background/Aims

Anti-drug antibodies (ADAs) can develop during treatment with anti-tumor necrosis factor (TNF) agents. We aimed to investigate the factors associated with immunogenicity of anti-TNF agents in pediatric patients with inflammatory bowel disease (IBD) and observe the clinical course of ADA-positive patients.

Methods

Pediatric IBD patients receiving maintenance treatment with anti-TNF agents who had been tested for ADAs against infliximab (IFX) or adalimumab (ADL) were included in this cross-sectional study. Factors associated with ADA positivity were investigated by analyzing clinicodemographic, laboratory, and treatment-related factors.

Results

A total of 76 patients (Crohn’s disease, 65; ulcerative colitis, 11) were included. Among these, 59 and 17 patients were receiving IFX and ADL, respectively. ADAs were found in 10 patients (13.2%), all of whom were receiving IFX. According to multivariable logistic regression analysis, the IFX trough level (TL) was associated with ADA positivity (odds ratio, 0.25; 95% confidence interval [CI], 0.08 to 0.51; p=0.002). According to the receiver operating characteristic analysis, the optimal cutoff of the IFX TLs for stratifying patients based on the presence of ADAs against IFX was 1.88 μg/mL (area under curve, 0.941; 95% CI, 0.873 to 1.000; sensitivity, 80.0%; specificity, 95.9%; p<0.001). Among the 10 patients with ADAs against IFX, five patients (50%) switched to ADL within 1 year, while five patients (50%) kept receiving IFX. Transient ADAs were observed in three patients (30%).

Conclusions

IFX TL was the only factor associated with ADA formation in pediatric IBD patients receiving IFX. Future studies based on serial and proactive therapeutic drug monitoring are required in the future.

Dual role of endothelial Myct1 in tumor angiogenesis and tumor immunity

The cross-talk between angiogenesis and immunity within the tumor microenvironment (TME) is critical for tumor prognosis. While pro-angiogenic and immunosuppressive TME promote tumor growth, anti-angiogenic and immune stimulatory TME inhibit tumor progression. Therefore, there is a great interest in achieving vascular normalization to improve drug delivery and enhance antitumor immunity. However, anti-vascular endothelial growth factor (VEGF) mechanisms to normalize tumor vessels have offered limited therapeutic efficacies for patients with cancer. Here, we report that Myct1, a direct target of ETV2, was nearly exclusively expressed in endothelial cells. In preclinical mouse tumor models, Myct1 deficiency reduced angiogenesis, enhanced high endothelial venule formation, and promoted antitumor immunity, leading to restricted tumor progression. Analysis of The Cancer Genome Atlas (TCGA) datasets revealed a significant (P < 0.05) correlation between MYCT1 expression, angiogenesis, and antitumor immunity in human cancers, as suggested by decreased FOXP3 expression and increased antitumor macrophages in patients with low MYCT1 expression. Mechanistically, MYCT1 interacted with tight junction protein Zona Occludens 1 and regulated Rho GTPase-mediated actin cytoskeleton dynamics, thereby promoting endothelial motility in the angiogenic environment. Myct1-deficient endothelial cells facilitated trans-endothelial migration of cytotoxic T lymphocytes and polarization of M1 macrophages. Myct1 targeting combined with anti-PD1 treatment significantly (P < 0.05) increased complete tumor regression and long-term survival in anti-PD1-responsive and -refractory tumor models in mice. Our data collectively support a critical role for Myct1 in controlling tumor angiogenesis and reprogramming tumor immunity. Myct1-targeted vascular control, in combination with immunotherapy, may become an exciting therapeutic strategy.

Limitation of Conventional Audiometry in Identifying Hidden Hearing Loss in Acute Noise Exposure

PURPOSE

The concept of hidden hearing loss can explain the discrepancy between a listener's perception of hearing ability and hearing evaluation using pure tone audiograms. This study investigated the utility of the suprathreshold auditory brainstem response (ABR) for the evaluation of hidden hearing loss in noise-exposed ear with normal audiograms.

MATERIALS AND METHODS

A total of 15 patients (24 ears) with normal auditory thresholds and normal distortion product otoacoustic emissions were included in a retrospective analysis of medical records of 80 patients presenting with histories of acute noise exposure. The control group included 12 subjects (24 ears) with normal audiograms and no history of noise exposure. Pure tone audiometry and suprathreshold ABR testing at 90 dB peSPL were performed. The amplitudes and latencies of ABR waves I and V were compared between the noise-exposed and control groups.

RESULTS

We found no significant difference in the wave I or V amplitude, or the wave I/V ratio, between the two groups. The latencies of ABR wave I, V, and I-V interpeak interval were compared, and no significant intergroup difference was observed.

CONCLUSION

The results suggest that either hidden hearing loss may not be significant in this cohort of patients with acute noise exposure history, or the possible damage by noise exposure is not reflected in the ABRs. Further studies are needed to inquire about the role of ABR in identification of hidden hearing loss.

Body mass index and mortality in patients with cardiovascular disease: an umbrella review of meta-analyses

OBJECTIVE

Although many previous meta-analyses of epidemiological studies have demonstrated a relationship between body mass index (BMI) and mortality, inconsistent findings among cardiovascular disease patients have been observed. Thus, we performed an umbrella review to understand the strength of evidence and validity of claimed associations between BMI and mortality in patients with cardiovascular diseases.

MATERIALS AND METHODS

We comprehensively re-analyzed the data of meta-analyses of observational studies and randomized controlled trials on associations between BMI and mortality among patients with cardiovascular diseases. We also assessed the strength of evidence of the re-analyzed outcomes, which were determined from the criteria including statistical significance of the p-value of random-effects, as well as fixed-effects meta-analyses, small-study effects, between-study heterogeneity, and a 95% prediction interval.

RESULTS

We ran comprehensive re-analysis of the data from the 21 selected studies, which contained a total of 108 meta-analyses; 23 were graded as convincing evidence and 12 were suggestive, 42 were weak, and 23 were non-significant.

CONCLUSIONS

Underweight increased mortality in acute coronary syndrome (ACS), heart failure, and after therapeutic intervention for patients with cardiovascular diseases. Overweight, on the other hand decreased mortality in patient's ACS, atrial fibrillation, and heart failure with convincing evidence.

Artificial intelligence-predicted poor responders to catheter ablation for atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Although atrial fibrillation (AF) catheter ablation is effective for rhythm control, in some patients it is hard to maintain sinus rhythm in spite of repeated AF catheter ablation (AFCA) procedures and anti-arrhythmic drugs (AADs). We explored the pre-procedural predictors for poor responders to AFCA and tested whether artificial intelligence (AI) assists the prediction of poor responders in the independent cohort by determining the invasive parameters.

Methods

Among 1,214 patients who underwent AFCA and regular rhythm follow-up for 56.2 ± 33.8 months (59 ± 11 years, 73.5% male, 68.6% paroxysmal AF), we differentiated 92 poor responders defined as those with sustained AF despite repeat AFCAs, AADs, or electrical cardioversion. Using the Youden index, we identified advanced LA remodeling with lower LA voltage under 1.109mV. AI model, which was derived from development cohort using medical record, was applied to predict LA voltage &lt;1.109mV in the independent cohort (n = 634, poor responders = 24) using a grad-cam score.

Results

The patients with lower LA voltage under 1.109mV showed significantly poorer rhythm outcomes (Log-rank p &lt; 0.001). We determined invasive parameter LA voltage by using the multiple variables (age, female sex, AF type, CHA2DS2VASc score, LA dimension, E/em, hemoglobin, PR interval) and achieved relatively good prediction power of AI for LA voltage &lt;1.109mV (AUC = 0.734, sensitivity 0.729, specificity 0.643) in the test cohort. In the independent cohort, the AI model showed good discrimination power for poor responders (AUC 0.751, p &lt; 0.001) by estimating LA voltage, which is an invasive variable. The patients with predicted lower LA voltage (grad-cam score &lt;0) showed poorer rhythm outcome after active rhythm control (Log-rank p &lt; 0.001)

Conclusions

The patients with advanced atrial remodeling with low LA voltage, which can be predicted by an AI, showed significantly higher recurrence of AF after AFCA with AADs or cardioversion. AI may assist to select these poor responder patients before the AFCA procedure. Abstract Figure.

Procedural Sedation for Pediatric Upper Gastrointestinal Endoscopy in Korea

BACKGROUND

Sedative upper endoscopy is similar in pediatrics and adults, but it is characteristically more likely to lead to respiratory failure. Although recommended guidelines for pediatric procedural sedation are available within South Korea and internationally, Korean pediatric endoscopists use different drugs, either alone or in combination, in practice. Efforts are being made to minimize the risk of sedation while avoiding procedural challenges. The purpose of this study was to collect and analyze data on the sedation methods used by Korean pediatric endoscopists to help physicians perform pediatric sedative upper endoscopy (PSUE).

METHODS

The PSUE procedures performed in 15 Korean pediatric gastrointestinal endoscopic units within a year were analyzed. Drugs used for sedation were grouped according to the method of use, and the depth of sedation was evaluated based on the Ramsay scores. The procedures and their complications were also assessed.

RESULTS

In total, 734 patients who underwent PSUE were included. Sedation and monitoring were performed by an anesthesiologist at one of the institutions. The sedative procedures were performed by a pediatric endoscopist at the other 14 institutions. Regarding the number of assistants present during the procedures, 36.6% of procedures had one assistant, 38.8% had 2 assistants, and 24.5% had 3 assistants. The average age of the patients was 11.6 years old. Of the patients, 19.8% had underlying diseases, 10.0% were taking medications such as epilepsy drugs, and 1.0% had snoring or sleep apnea history. The average duration of the procedures was 5.2 minutes. The subjects were divided into 5 groups as follows: 1) midazolam + propofol + ketamine (M + P + K): n = 18, average dose of 0.03 + 2.4 + 0.5 mg/kg; 2) M + P: n = 206, average dose of 0.06 + 2.1 mg/kg; 3) M + K: n = 267, average dose of 0.09 + 0.69 mg/kg; 4) continuous P infusion for 20 minutes: n = 15, average dose of 6.6 mg/kg; 5) M: n = 228, average dose of 0.11 mg/kg. The average Ramsay score for the five groups was 3.7, with significant differences between the groups (P < 0.001). Regarding the adverse effects, desaturation and increased oxygen supply were most prevalent in the M + K group. Decreases and increases in blood pressure were most prevalent in the M + P + K group, and bag-mask ventilation was most used in the M + K group. There were no reported incidents of intubation or cardiopulmonary resuscitation. A decrease in oxygen saturation was observed in 37 of 734 patients, and it significantly increased in young patients (P = 0.001) and when ketamine was used (P = 0.014). Oxygen saturation was also correlated with dosage (P = 0.037). The use of ketamine (P < 0.001) and propofol (P < 0.001) were identified as factors affecting the Ramsay score in the logistic regression analysis.

CONCLUSION

Although the drug use by Korean pediatric endoscopists followed the recommended guidelines to an extent, it was apparent that they combined the drugs or reduced the doses depending on the patient characteristics to reduce the likelihood of respiratory failure. Inducing deep sedation facilitates comfort during the procedure, but it also leads to a higher risk of complications.

Tunable high-temperature itinerant antiferromagnetism in a van der Waals magnet

Discovery of two dimensional (2D) magnets, showing intrinsic ferromagnetic (FM) or antiferromagnetic (AFM) orders, has accelerated development of novel 2D spintronics, in which all the key components are made of van der Waals (vdW) materials and their heterostructures. High-performing and energy-efficient spin functionalities have been proposed, often relying on current-driven manipulation and detection of the spin states. In this regard, metallic vdW magnets are expected to have several advantages over the widely-studied insulating counterparts, but have not been much explored due to the lack of suitable materials. Here, we report tunable itinerant ferro- and antiferromagnetism in Co-doped Fe₄GeTe₂ utilizing the vdW interlayer coupling, extremely sensitive to the material composition. This leads to high T_N antiferromagnetism of T_N ~ 226 K in a bulk and ~210 K in 8 nm-thick nanoflakes, together with tunable magnetic anisotropy. The resulting spin configurations and orientations are sensitively controlled by doping, magnetic field, and thickness, which are effectively read out by electrical conduction. These findings manifest strong merits of metallic vdW magnets as an active component of vdW spintronic applications.

Metallic van der Waals magnets have considerable technological promise, due to their ability to be strongly coupled with electronic currents and integrated in two dimensional heterostructures. Here, Seo et al. demonstrate highly tunable itinerant antiferromagnetism in a van der Waals magnet.

Prevalence and Progression of Stage 0 Macular Hole in Fellow Eyes of Patients with Idiopathic Full-thickness Macular Hole

Purpose

To assess the prevalence and progression of a stage 0 macular hole in the fellow eye of patients with an idiopathic full-thickness macular hole.

Methods

The fellow eyes of 189 patients who underwent idiopathic full-thickness macular hole surgery were examined by biomicroscopy and spectral domain-optical coherence tomography (SD-OCT). A subset of 21 fellow eyes with a stage 0 macular hole was observed. Changes in the macular hole were evaluated by biomicroscopy and SD-OCT for an average of 29 months.

Results

Among the 21 eyes, 15 showed no change in perifoveal vitreous detachment (71.4%). Two eyes (9.5%) developed complete vitreofoveal separation, and one of the two developed a separation after progression to stage 1A. Among 21 eyes, 5 (23.8%) developed above stage 1A, and one of the five progressed to stage 1B after five years, which was successfully treated with vitrectomy and gas tamponade.

Conclusions

Perifoveal vitreous detachment in the fellow eye on SD-OCT, defined as a stage 0 macular hole, occurred at an earlier phase than stage 1A macular holes and may progress to an advanced stage. Therefore, patients who undergo macular hole surgery and have a stage 0 macular hole or perifoveal vitreous detachment in the fellow eye should be followed closely.

Genetic analysis of the Gitelman syndrome coexisting with Osteogenesis imperfecta

Gitelman syndrome (GS) is an autosomal recessive disorder caused by loss-of-function mutations in SLC12A3, which encodes the Na-Cl cotransporter (NCC). Osteogenesis imperfecta (OI) is an autosomal dominant disorder caused by the inheritance of mutations mainly in the COL1A1 gene, resulting in bone fragility and deformity. In this study, we aimed to investigate the clinical and genetic manifestations in a 7-year-old boy with OI, who had electrolyte abnormalities and his four family members. Complete sequence analysis of COL1A1 revealed a novel mutation, c.268G>T, p.Glu90del. The gene mutation of OI in the patient's older brother was inherited from his mother, and the younger brother had no mutation. Two pathogenic mutations (c.179C>T, p.Thr60Met and c.1763C>T, p.Ala588Val) in SLC12A3 resulting in GS were also identified in the patient. The OI-related genetic mutation in the patient was consistent with that in the patient's mother. The GS-related genetic mutations were inherited from each parent. This study is the first to identify compound heterozygous variants in the SLC12A3 gene and a novel mutation in the COL1A1 gene in patients with OI and GS. Our findings indicate that genetic analysis is recommended to differentiate GS from BS, as clinical manifestations do not provide an accurate diagnosis.