Neddylation of insulin receptor substrate acts as a bona fide regulator of insulin signaling and its implications for cancer cell migration

Irregularities in insulin signaling have significantly increased the risk of various cancers, yet the precise underlying mechanisms remain unclear. Within our study, we observed that inhibiting neddylation enhances cancer cell migration across different cancer types by activating both insulin receptor substrates 1 and 2 (IRS1 and IRS2), along with the PI3K/AKT signaling pathway. Notably, in the context of high-grade serous carcinoma (HGSC) patients, whether they had type 2 diabetes mellitus or not, IRS1 and IRS2 displayed a parallel relationship with each other while exhibiting an inverse relationship with NEDD8. We also identified C-CBL as an E3 ligase responsible for neddylating IRS1 and IRS2, with clinical evidence further confirming a reciprocal relationship between C-CBL and pAKT, thereby reinforcing the tumor suppressive role of C-CBL. Altogether, these findings suggest that neddylation genuinely participates in IRS1 and IRS2-dependent insulin signaling, effectively suppressing cancer cell migration. Thus, caution is advised when considering neddylation inhibitors as a treatment option for cancer patients, particularly those presenting with insulin signaling dysregulations linked to conditions like obesity-related type 2 diabetes or hyperinsulinemia.

Impact of the New ESTRO-ACROP Target Volume Delineation Guideline on Breast-Related Complications after Implant-Based Reconstruction and Postmastectomy Radiotherapy

PURPOSE/OBJECTIVE(S)

The European Society for Radiotherapy and Oncology Advisory Committee in Radiation Oncology Practice (ESTRO-ACROP) recently updated a new target volume delineation guideline for postmastectomy radiotherapy (PMRT) after implant-based reconstruction. This study aimed whether this change has impact on breast-related complications.

MATERIALS/METHODS

We retrospectively reviewed patients who underwent PMRT after mastectomy with tissue expander or permanent implant insertion from 2016 to 2021. In total, 412 patients were included; 277 received RT by the new ESTRO-ACROP target delineation (ESTRO-T), and 135 received RT by conventional target delineation (CONV-T). The primary endpoint was comparison between the target groups of major breast-related complication, including infection, capsular contracture, deformity and necrosis requiring re-operation or re-hospitalization during follow-up after RT or delayed implant replacement. Complications were evaluated according to the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0., and capsular contracture was graded by the Baker Classification.

RESULTS

The median follow-up was 29.5 months (range, 0.3-76.8). The 1-, 2-, and 3-year incidence rates of major breast-related complication were 5.7%, 10.0%, and 11.6% in the ESTRO-T group, and 8.2%, 13.8%, and 14.7% in the CONV-T groups; it did not show a difference between the groups (P = 0.55). In multivariate analyses, target delineation is not significantly associated with the major complications (hazard ratio [HR] = 0.93; P = 0.83, Table 1). There was no significant difference between the ESTRO-T and CONV-T groups in the incidence of any breast-related complications (3-year cumulative incidence, 37.3% vs. 29.4%, respectively; P = 0.28). Symptomatic RT-induced pneumonitis rates were 2.7% in the ESTRO-T group (7 patients) and 2.2% in the CONV-T group (3 patients). Only one local recurrence event occurred in the ESTRO-T group, which was within the ESTRO-target volume.

CONCLUSION

Target volume delineation according to the new ESTRO-ACROP guideline did not reduce the risk of major or any breast-related complications. As the dosimetric benefits of heart and lung have been reported, further analyses with long-term follow-up are necessary to evaluate whether it could be connected to better clinical outcomes.

Systemic proinflammatory-profibrotic response in aortic stenosis patients with diabetes and its relationship with myocardial remodeling and clinical outcome

Background

It is unclear whether and how diabetes mellitus may aggravate myocardial fibrosis and remodeling in the pressure-overloaded heart. We investigated the impact of diabetes on the prognosis of aortic stenosis (AS) patients and its underlying mechanisms using comprehensive noninvasive imaging studies and plasma proteomics.

Methods

Severe AS patients undergoing both echocardiography and cardiovascular magnetic resonance (CMR) (n=253 of which 66 had diabetes) comprised the imaging cohort. The degree of replacement and diffuse interstitial fibrosis by late gadolinium enhancement (LGE) and extracellular volume fraction (ECV) was quantified using CMR. Plasma samples were analyzed with the multiplex proximity extension assay for 92 proteomic biomarkers in a separate biomarker cohort of severe AS patients (n=100 of which 27 had diabetes).

Results

In the imaging cohort, diabetic patients were older (70.4±6.8 vs. 66.7±10.1 years) and had a higher prevalence of ischemic heart disease (28.8% vs. 9.1%), with more advanced ventricular diastolic dysfunction. On CMR, diabetic patients had increased replacement and diffuse interstitial fibrosis (LGE% 0.3 [0.0–1.6] versus 0.0 [0.0–0.5], p=0.009; ECV% 27.9 [25.7–30.1] versus 26.7 [24.9–28.5], p=0.025) (Figure 1).

Plasma proteomics analysis of the biomarker cohort revealed that 9 proteins (E-selectin, interleukin-1 receptor type 1, interleukin-1 receptor type 2, galectin-4, intercellular adhesion molecule 2, integrin beta-2, galectin-3, growth differentiation factor 15, and cathepsin D) are significantly elevated in diabetic AS patients (Figure 2). Pathway over-representation analyses of the plasma proteomics with Gene Ontology terms indicated that pathways related to inflammatory response and extracellular matrix components were enriched, suggesting that diabetes is associated with systemic effects that evoke proinflammatory and profibrotic response to the pressure-overloaded myocardium.

During follow-up (median 6.3 years [IQR 5.2–7.2]) of the imaging cohort, 232 patients received aortic valve replacement (AVR) with 53 unexpected heart failure admissions or death. Diabetes was a significant predictor of heart failure and death, independent of clinical covariates and AVR (hazard ratio 1.88, 95% confidence interval 1.06–3.31, p=0.030).

Conclusion

Plasma proteomic analyses indicate that diabetes potentiates the systemic proinflammatory and profibrotic milieu in AS patients. These systemic biological changes underlie the increase of myocardial fibrosis, diastolic dysfunction, and worse clinical outcomes in severe AS patients with concomitant diabetes.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): National Research Foundation of Korea

Augmented risk of ischemic stroke in hypertrophic cardiomyopathy patients without documented atrial fibrillation

Background

Ischemic stroke is a common complication in patients with hypertrophic cardiomyopathy (HCM) (1). Although atrial fibrillation (AF) is a well-established risk factor for ischemic stroke in HCM, the risk of ischemic stroke in patients with HCM without documented AF is less recognized (1, 2). This study aimed to determine the risk of ischemic stroke and identify its risk factors in patients with HCM without documented AF.

Methods

This nationwide population-based cohort study used the Korean National Health Insurance database. After excluding patients with a prior history of AF, thromboembolic events, cancer, or the use of anticoagulants, we identified 8,328 HCM patients without documented AF and 1:2 propensity score-matched 16,656 non-HCM controls. The clinical outcome was an incident ischemic stroke.

Results

During a mean follow-up of approximately 6 years, ischemic stroke occurred in 328/8,328 (3.9%) patients with HCM and 443/16,656 (2.7%) controls. Among individuals who developed ischemic stroke, the proportion of AF concomitantly detected accounted for 26.5% (87/328) and 5.8% (26/443) in the HCM and control groups, respectively. The overall incidence of ischemic stroke was 0.716/100 person-years in the HCM group, which was significantly higher than that in the control group (0.44/100 person-years) (HR 1.643; 95% CI, 1.424–1.895; P<0.001, Figure 1). The subgroup analysis according to age, sex, and comorbidities (chronic heart failure, hypertension, dyslipidemia, and vascular disease) consistently demonstrated a higher risk of ischemic stroke in the HCM group (P for interaction >0.05). In the HCM group, age ≥65 years (adjusted hazard ratio [HR] 2.741; 95% confidence interval [CI], 2.156–3.486; P<0.001) and chronic heart failure (adjusted HR 1.748; 95% CI, 1.101–2.745; P=0.018) were independent risk factors for ischemic stroke. Overall incidence was 1.360/100 in patients with HCM aged ≥65 and 2.315/100 person-years years in those with chronic heart failure, respectively. Also, compared to controls aged <65 years and without CHF, adjusted HR for ischemic stroke was 4.756 (95% CI 3.807–5.867) in patients with HCM aged ≥65 years and 2.539 (95% CI 1.638–3.936) in those with CHF, respectively (Figure 2).

Conclusions

Patients with HCM without documented AF are at a higher risk of ischemic stroke than the propensity score-matched general population. Age ≥65 years and chronic heart failure are two strong independent risk factors for ischemic stroke in this population.

Funding Acknowledgement

Type of funding sources: None.

Pediatric Traumatic Brain Injury : The Epidemiology in Korea

Traumatic brain injury (TBI) is one of the leading causes of death in the pediatric population in Korea. In addition, it can cause disability in children and adolescents, with physical and mental consequences. This causes a substantial burden on the health care system and occurs globally and not just in Korea. We searched and reviewed current data on the epidemiologic characteristics of pediatric TBI in Korea. Our review provides the recent epidemiological trend mainly focusing on incidence and mortality along with worldwide reported data. This review will be helpful to understand the global epidemiology of pediatric TBI and its differences between countries.

Impact of atrial fibrillation on the progression and outcomes of isolated mild functional tricuspid regurgitation

Background

Atrial fibrillation (AF) is increasingly recognized as a cause of tricuspid regurgitation (TR) in the structurally normal tricuspid valve. However, there are limited data regarding the impact of AF on TR progression and its long-term cardiovascular outcomes.

Purpose

We aimed to investigate the association of AF with the significant TR progression and its impact on clinical outcomes among patients with isolated mild functional TR.

Methods

We studied 834 patients with mild function TR identified on the echocardiography between 2007 and 2019, whose follow-up echocardiography beyond 1-year was available. Major exclusion criteria were the overt causes of primary and secondary TR (i.e., concomitant left-sided heart disease). Primary endpoint was the significant TR progression to more than a moderate degree on the follow-up echocardiography. Composite cardiac event was defined as cardiovascular death, TR surgery, and heart failure admission due to TR.

Results

Of 834 patients with isolated mild functional TR (mean age 65.6 years, 41% men), 292 (35.0%) patients had AF at the baseline. Patients with AF were older and had larger left atrium compared to those without. During the median of 4.55 years follow-up (interquartile interval 2.56–7.24 years), 36 patients developed a significant TR ≥ moderate degree. The cumulative rate of TR progression was significantly higher in patients with AF than those without (11.3% versus 0.6%, P<0.001) (Figure 1). Multivariable Cox analyses showed that AF was associated with a 3-fold higher risk of TR progression (adjusted hazard ratio 3.50, 95% confidence interval 1.42–8.65). Regarding the cardiovascular outcomes, patients who developed significant TR had a higher rate of composite cardiac events compared to those who did not (cardiac events: 38.9% versus 6.3% P<0.001) (Figure 2).

Conclusions

AF is a strong risk factor for TR progression among patients with isolated mild functional TR. In addition, the development of significant TR is associated with worse cardiovascular outcomes. These findings highlight the important pathophysiology of AF on TR development and its clinical consequences.

Funding Acknowledgement

Type of funding sources: None.

Benign meningioma manifesting with acute subdural hematoma and cerebral edema: a case report and review of the literature

Background

Spontaneous subdural hematoma rarely presents with a hypervascular or malignant tumor but even less frequently in a benign tumor like meningioma. We encountered a patient with acute subdural hematoma associated with benign meningioma. Here, we report this case along with a review of previous reports, especially focusing on their clinical features and possible bleeding mechanisms.

Case presentation

A 53-year-old Asian woman presented with severe headache and progressive neurologic deterioration due to cerebral edema. The patient was submitted to open surgery for evacuation of the subdural hematoma and concurrent tumor removal on the ipsilateral parietal convexity. A hypervascular, encapsulated mass was identified during surgery and completely removed including the adjacent dura mater (Simpson grade 0). The tumor was histologically confirmed as an angiomatous meningioma (World Health Organization grade I). Her clinical course was uneventful after surgery.

Conclusions

Although meningiomas are commonly benign according to their histological traits, they can lead to spontaneous bleeding and cause neurologically unstable condition. Therefore, meningiomas need to be considered as a cause of spontaneous subdural hematoma if radiologically suspicious, which should be reflected by proper management for a positive outcome.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13256-021-02935-x.

The Effect of Neddylation Blockade on Slug-Dependent Cancer Cell Migration Is Regulated by p53 Mutation Status

Simple Summary

Neddylation is a process in which the small ubiquitin-like molecule NEDD8 is covalently conjugated to target proteins by sequential enzymatic reactions. Because neddylation plays critical roles in regulating cancer growth and migration, it is emerging as an effective therapeutic target. The major tumor suppressor protein p53 reduces cancer cell migration and is inhibited by neddylation. As p53 is lost or mutated in 50% of various cancer types, this study attempted to investigate how neddylation affects cancer cell migration according to p53 status. Neddylation blockade reduced or caused no change in migration of wild type or mutant p53 cancer cell lines. In contrast, neddylation blockade induced migration of p53-null cancer cell lines. These results were mediated by the differential effect of neddylation blockade on the epithelial–mesenchymal transition activator Slug according to p53 status. Thus, the p53 status of cancer cells should be considered when developing neddylation-targeted anticancer drugs.

Abstract

The tumor suppressor protein p53 is frequently inactivated in human malignancies, in which it is associated with cancer aggressiveness and metastasis. Because p53 is heavily involved in epithelial–mesenchymal transition (EMT), a primary step in cell migration, p53 regulation is important for preventing cancer metastasis. p53 function can be modulated by diverse post-translational modifications including neddylation, a reversible process that conjugates NEDD8 to target proteins and inhibits the transcriptional activity of p53. However, the role of p53 in cancer migration by neddylation has not been fully elucidated. In this study, we reported that neddylation blockade induces cell migration depending on p53 status, specifically via the EMT-promoting transcription factor Slug. In cancer cell lines expressing wild type p53, neddylation blockade increased the transcriptional activity of p53 and expression of its downstream genes p21 and MDM2, eventually promoting proteasomal degradation of Slug. In the absence of p53, neddylation blockade increased cell migration by activating the PI3K/Akt/mTOR/Slug signaling axis. Because mutant p53 was transcriptionally inactivated but maintained the ability to bind to Slug, neddylation blockade did not affect the migration of cells expressing mutant p53. Our findings highlight how the p53 expression status influences neddylation-mediated cell migration in multiple cancer cell lines via Slug.

Neddylation blockade induces HIF-1α driven cancer cell migration via upregulation of ZEB1

Neddylation is a process by which NEDD8 is covalently conjugated to target proteins by sequential enzymatic reaction. Its role in cancer cell migration has only been recently acknowledged. Previously in cancer cell migration, the epithelial to mesenchymal transition (EMT) process has been well-known to play an important role in both invasion and metastasis by promoting mesenchymal phenotype in epithelial cells. However, the role of neddylation in the EMT process and its mechanistic details are yet to be elucidated. We recently reported that neddylation plays a crucial role in cancer cell migration through the PI3K-Akt pathway. Here, we report that inhibiting neddylation activates the hypoxia-inducible factor 1α (HIF-1α) through the PI3K-Akt pathway, which eventually regulates the EMT-activator ZEB1 (zinc finger E-box binding homeobox 1) in various cancer cell lines. As induction of HIF-1α is known to deteriorate the state of cancer and EMT process is one of the hallmarks of metastasis in cancer, our findings uncover the role of neddylation between HIF-1α and ZEB1.

Abstract 4873: Molecular mechanism of neddylation-dependent suppression of cancer cell migration

Neddylation is a process by which NEDD8 is covalently conjugated to target proteins by sequential enzymatic reaction. Its role in cancer cell migration has only been recently acknowledged. Previously in cancer cell migration, the epithelial to mesenchymal transition (EMT) process has been well-known to play an important role in both invasion and metastasis by promoting mesenchymal phenotype in epithelial cells. However, the role of neddylation in the EMT process and its mechanistic details are yet to be elucidated. We recently reported that neddylation plays a crucial role in cancer cell migration through the PI3K-Akt pathway. Here, we report that inhibiting neddylation activates the hypoxia-inducible factor-1α through the PI3K-Akt pathway, which eventually regulates the EMT-activator zinc finger E-box binding homeobox 1 in various cancer cell lines. As induction of hypoxia-inducible factor-1α is known to deteriorate the state of cancer and EMT process is one of the hallmarks of metastasis in cancer, our findings uncover the novel association of hypoxia-inducible factor-1α and zinc finger E-box binding homeobox 1 through the process of neddylation.

Citation Format: Yang-Sook Chun, Jieun Seo, Jun Bum Park. Molecular mechanism of neddylation-dependent suppression of cancer cell migration [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 4873.

Tooth Loss Predicts Myocardial Infarction, Heart Failure, Stroke, and Death

We investigated whether oral health, represented by missing teeth, was associated with an increased risk of cardiovascular disease, including myocardial infarction (MI), heart failure (HF), stroke, and all-cause mortality. Subjects who underwent routine dental examinations and health checkups provided by the Korean National Health Insurance from 2007 to 2008 ( n = 4,440,970) were followed up for incident MI, HF, stroke, and death until 2016. During follow-up of 7.56 y, 68,063 (1.5%) subjects died, and 31,868 (0.7%) were admitted for MI, 22,637 (0.5%) for HF, and 30,941 (0.7%) for stroke. Cardiovascular events and mortality increased in proportion to tooth loss. Tooth loss was an independent risk factor for cardiovascular events after multivariable analysis adjusted for cardiovascular risk, behavioral, and income factors. Each missing tooth was associated with an approximately 1% increase in MI (HR, 1.010; 95% CI, 1.007 to 1.014), 1.5% increase in HF (HR, 1.016; 95% CI, 1.013 to 1.019) and stroke (HR, 1.015; 95% CI, 1.012 to 1.018), and 2% increase in mortality (HR, 1.022; 95% CI, 1.020 to 1.023). Having ≥5 missing teeth substantially increased risk for cardiovascular outcomes, and even a small number of missing teeth (1 to 4) was associated with an increased risk for MI, stroke, and death. This association was consistent in subgroup analyses and especially strong among the younger subjects (age <65 y) and those with periodontitis. In this large Korean nationwide cohort study, we found that tooth loss showed a dose-dependent association with incident MI, HF, ischemic stroke, and all-cause death and was a good predictor of cardiovascular outcome. In clinical practice, the number of missing teeth can aid physicians in discriminating patients with a higher cardiovascular risk.

P1274 Early surgery versus watchful waiting in patients with moderate aortic stenosis and left ventricular systolic dysfunction

Background

Aortic stenosis (AS) induces significant pressure overload to the left ventricle (LV) and its burden may increase if there is concomitant LV systolic dysfunction. Severe AS with LV systolic dysfunction is a class I indication for aortic valve replacement (AVR) irrespective of symptoms, however, this recommendation is not well established in those with moderate AS and LV systolic dysfunction. In this study, we sought to investigate the clinical impact of surgical AVR among patients with moderate AS and LV systolic dysfunction.

Methods

From 2001 to 2017, we retrospectively but consecutively identified patients with moderate AS and LV systolic dysfunction from a single tertiary hospital. Moderate AS was defined as aortic valve area between 1.0 and 1.5cm2 and LV systolic dysfunction as LV ejection fraction less than 50%. The primary outcome was all-cause death and we additionally analyzed cardiac death as a secondary endpoint. The outcomes were compared between those who underwent early surgical AVR at the stage of moderate AS versus those who were followed without AVR at the outpatient clinic.

Results

Among a total of 257 patients with moderate AS and concomitant LV systolic dysfunction (70.0 ± 11.3 years, 63.4% of male), 34 patients received early AVR. Patients in the AVR group was younger than the observation group (64.2 ± 8.1 vs. 70.9 ± 11.5, respectively), and had a lower prevalence of hypertension and chronic kidney disease. During a mean of 3-year follow up, 112 patients (47.5%) died and the overall death rate was 15.367 per 100 person-year (PY). The AVR group showed a significantly lower rate of all-cause death than the observation group (5.241PY vs. 18.160PY, p-value = 0.002). After multivariable Cox proportional hazard regression adjusting for age, sex, comorbidities and laboratory data, early AVR at the stage of moderate AS significantly reduced the risk of all-cause death (hazard ratio [HR] 0.340, 95% confidence interval [CI] 0.117 - 0.985, p-value = 0.047). However, there was no risk reduction of cardiac death (HR 0.578 95% CI 0.150 - 2.231, p-value = 0.426).

Conclusions

In patients with moderate AS and LV systolic dysfunction, AVR reduces the risk of all-cause death. A prospective design study is warranted to confirm our findings in the near future.

Abstract P1274 Figure. Kaplan-Meier curves for deaths

P1603 Changes of cardiac function in cirrhotic patients after liver transplantation

Funding Acknowledgements

This study was supported by the grant of CJ healthcare 2016 research fund.

Background

Liver cirrhosis (LC) has been known to affect cardiovascular performance. Limited study have evaluated the alteration of myocardial function in patients with LC after liver transplantation (LT).

Purpose

The aim of study was to evaluate changes of cardiac function in patients with cirrhosis following LT using conventional and speckle-tracking echocardiography and late gadolinium enhancement (LGE) of cardiac magnetic resonance (MR).

Methods

Thirty-five patients with cirrhosis (mean age, 57.1 ± 9.0; male, 75%) who were listed for LT were prospectively enrolled. Patients underwent conventional, speckle-tracking echocardiography, and cardiac MR imaging with LGE. Echocardiography and cardiac MR were performed at pre and 1 year after LT. Cirrhotic patients were compared with normal control (n = 20, mean age, 65.0 ± 14.8; men, 11(55%)) and echocardiographic and cardiac MR data were compared pre and post LT.

Results

Conventional and speckle-tracking echocardiography and Cardiac MR imaging demonstrated hyperdynamic left ventricular (LV) function in patients with cirrhosis (LV ejection fraction (EF) with cardiac MR 67.8 ± 7.0% in LC vs. 63.4 ± 6.4% in control, P = 0.028; global longitudinal strain (GLS) -24.3 ± 2.6% in LC vs. -18.6 ± 2.2% in control, P &lt; 0.001). There were no LGE in patients with cirrhosis and no significant differences in LV size, LV wall thickness, LV mass index, and diastolic function between cirrhotic patients and control group (all P &gt; 0.1). Corrected QT interval (QTc) in electrocardiogram was prolonged in LC patients (P &lt; 0.001). One-year after LT, LV end-diastolic diameter and LV end-diastolic volume significantly decreased (P = 0.016 and 0.022, respectively). Although LVEF showed no significant changes 1 year post-LT (P = 0.362), LV-GLS (from -24.7 ± 1.8% to -20.8 ± 3.4%, P &lt; 0.001) significantly decreased. QTc interval also decreased 1 year after LT (from 470.4 ± 29.6msec to 428.2 ± 31.6msec, P = 0.001).

Conclusions

The present study demonstrated that cirrhotic patients showed hyperdynamic circulation and prolonged QTc interval compared with normal controls. After 1 year LT, LV size reduced and augmented LV function was normalized. Given that no LGE in cardiac MR and normalized GLS and QTc after LT, cardiac dysfunction in LC patients could be reversed by LT.

P1368 Effect of angiotensin receptor blocker in patients with moderate or severe aortic stenosis: a randomized controlled trial

Funding Acknowledgements

This study was supported by grants from Boryung Pharmacy Research Fund.

Background/Introduction: Pathophysiology of aortic stenosis (AS) and several previous studies suggested the potential role of angiotensin receptor blocker (ARB) in patients with AS.

Purpose

We aimed to investigate the effects of Fimasartan, an ARB, on exercise capacity and progression of AS in patients with moderate to severe AS.

Methods

We conducted a prospective, randomized, double-blind, placebo-controlled trial in 32 normotensive or controlled-hypertensive patients with moderate or severe AS. Study participants were randomized to Fimasartan 30 mg to 60 mg daily (n = 14) or placebo (n = 18) for 1 year, and underwent cardiopulmonary exercise test, 6-minute walk test, and echocardiography at 0, 6, and 12 months, with follow-up data available in 29 subjects.

Results

Significant reductions in blood pressures were observed in the Fimasartan group but not in the placebo group. Two of the 14 patients in the Fimasartan group withdrew the study due to mild symptoms probably related with the decreased blood pressure, and one patient decline the study protocol. After the 12-month treatment, the peak oxygen consumption (VO2; the primary outcome) in the Fimasartan group was significantly decreased (from 28.3 ± 5.9 to 25.4 ± 3.8 mL/min/kg, P = 0.021) but not in the placebo group (P for interaction = 0.046) (Figure 1A). The severity of AS showed a gradual progression in both groups, without inter-group differences (mean transaortic pressure; Fimasartan group, +4.0 ± 3.8 mmHg/year; placebo group, +5.3 ± 6.2 mmHg/year; P for interaction = 0.429) (Figure 1B). Parameters of left ventricular systolic and diastolic function did not change in both groups.

Conclusions

The use of ARB impaired exercise capacity in patients with moderate or severe AS, and did not prevent the progression of AS. However, due to the small number of participants, further studies are required to confirm these findings.

Abstract P1368 Figure.

P785 Left ventricular geometry and myocardial contractility modulate impact of statins on prognosis in patients with acute heart failure

Funding Acknowledgements

N/A

Background/Introduction: The benefit of statins in patients with heart failure (HF) remains controversial and the mechanism of action is largely speculative. We investigated whether survival benefit with statins differs according to left ventricular (LV) geometry and myocardial contractility in acute HF patients.

Methods

We enrolled 1792 acute HF patients receiving statins and 2296 patients not receiving statins admitted from 2009 to 2016. The LV and right ventricular (RV) global longitudinal strain (GLS) was assessed as a measure of myocardial contractility. Patients were classified into 2 groups based on ischemic etiology of HF and further divided into 4 subgroups according to the median values of LV-GLS or RV-GLS. The primary outcome was 5-year all-cause mortality. The study protocol was approved by the ethics committee at each institute and complied with the Declaration of Helsinki. The need for written informed consent was waived.

Results

During the 5-year follow-up, 1740 (40.4%) patients died and they had more unfavorable baseline characteristics. Statin therapy was significantly associated with improved survival in overall patients and in both groups with and without ischemic etiology (all p &lt;0.001). Patients with concentric remodeling/hypertrophy and eccentric hypertrophy demonstrated survival benefit with statin therapy (P = 0.033, 0.004, and 0.008, respectively), while those with normal geometry did not (p = 0.123). In the non-ischemic HF group, survival benefit with statin therapy was confined to patients with low LV-GLS (p = 0.045) or those with low RV-GLS p = 0.003). On the contrary, in ischemic HF group, survival benefit with statin therapy was observed in all patients regardless of the values of LV-GLS or RV-GLS. Significant interactions were present between statin use and diabetes mellitus and IHD (p for interaction = 0.027 and 0.003, respectively) regarding mortality.

Conclusions

LV geometry and myocardial contractility may modulate the effects of statins in patients with acute HF. These echocardiographic measures can provide prognostic information to guide tailored statin treatment in this population. Our findings may also help to develop more well-designed prospective studies, in terms of a more homogenous study population, to confirm survival benefit with statin therapy.

Abstract P785 Figure. Multivariate Cox survival curves

A new definition for wide-necked cerebral aneurysms

Background

Endovascular management of wide-necked aneurysms often requires assisted-techniques with adjunctive devices. Wide-necked aneurysm can be defined with a dome-to-neck ratio or aspect ratio; however, clinical definitions of wide-necked aneurysms vary. This study aimed to determine the most useful definition of wide-necked aneurysm to predict the need for an adjunctive device.

Methods

Among 552 cases of aneurysms, 343 (62.1%) and 209 (37.9%) cases of unruptured and ruptured aneurysms, respectively, were treated in a single institution. For each aneurysm, the (1) dome-to-neck ratio, (2) aspect ratio, and (3) K-ratio (defined as [dome height+maximum dome width]/[2×maximum neck width]) were measured. We statistically analyzed patient data to determine which of the three ratios was most predictive of the need for adjunctive devices.

Results

Among 552 cases of aneurysms, 277 (50.2%) and 275 (49.8%) cases were treated with and without adjunctive techniques, respectively. The mean dome-to-neck ratio, aspect ratio, and K-ratio were 1.17±0.39, 1.58±0.61, and 1.37±0.47, respectively. The K-ratio was the strongest predictor of the use of adjunctive devices (P<0.001), and 1.3 was the most appropriate K-ratio cut-off value (sensitivity, 72.9%; specificity, 63.6%).

Conclusions

K-ratio was the most useful predictor of the need for adjunctive devices in the treatment of endovascular aneurysms. These results suggest that the K-ratio may be used to define wide-necked aneurysms requiring complicated management via adjunctive devices.

P3429A novel prediction model for mortality after cardiac surgery using institutional case volume

Purpose

A number of risk prediction models have been developed to identify short term mortality after cardiovascular surgery. Most models include patient characteristics, laboratory data, and type of surgery, but no consideration for the amount of surgical experience. With numerous reports on the impact of case volume on patient outcome after high risk procedures, we attempted to develop a risk prediction models for in-hospital and 1-year mortality that takes institutional case volume into account.

Methods

We identified adult patients who underwent cardiac surgery from January 2008 to December 2017 from the National Health Insurance Service (NHIS) database by searching for patients with procedure codes of coronary artery bypass grafting, valve surgery, and surgery on thoracic aorta during the hospitalization. Study subjects were randomly assigned to either the derivation cohort or the validation cohort. In-hospital mortality and 1-year mortality data were collected using the NHIS database. Risk prediction models were developed from the derivation cohort using Cox proportional hazards regression. The prediction performances of models were evaluated in the validation cohort.

Results

The models developed in this study demonstrated fair discrimination for derivation cohort (N=22,004, c-statistics, 0.75 for in-hospital mortality; 0.73 for 1-year mortality) and acceptable calibration in the validation cohort. (N=22,003, Hosmer-Lemeshow χ2-test, P=0.08 and 0.16, respectively). Case volume was the key factor of mortality prediction models after cardiac surgery. (50≤ x <100 case per year. 100≤ x <200 case per year, ≥200 case per year are correlated with OR 3.29, 2.49, 1.85 in in-hospital mortality, 2.76, 1.99, 1.69 in 1-year mortality respectively, P value <0.001.)

Annual case volume as risk factor Variables In-hospital mortality 1-year mortality OR (95% CI) p-value OR (95% CI) p-value Annual case-volume (reference: ≥200) – – 100–200 1.69 (1.48, 1.93) <0.001 1.85 (1.58, 2.18) <0.001 50–100 1.99 (1.75, 2.25) <0.001 2.49 (2.15, 2.89) <0.001 <50 2.76 (2.44, 3.11) <0.001 3.29 (2.85, 3.79) <0.001 OR: Odds ratio; CI: confidence interval; Ref: Reference.

Discrimination and calibration

Conclusion

We developed and validated new risk prediction models for in-hospital and 1-year mortality after cardiac surgery using the NHIS database. These models may provide useful guides to predict mortality risks of patients with basic information and without laboratory findings.

Relationship between Circadian Variation in Ictus of Aneurysmal Subarachnoid Hemorrhage and Physical Activity

OBJECTIVE

The circadian pattern of the onset time of aneurysmal subarachnoid hemorrhage (aSAH) has been reported by various authors. However, the effect of the degree of physical exertion on the circadian pattern has not been studied in detail. Therefore, we conducted this study to investigate the effect of physical exertion on the circadian pattern of aSAH.

METHODS

Of the 335 patients presenting with aSAH from January 2012 to December 2017, 234 patients with identifiable onset time and metabolic equivalent (MET) values were enrolled. The onset time of aSAH was divided into 4-hour intervals. The patient's physical exertion was then assessed on a scale between 1 and 8 METs using generally accepted MET values, and categorized into two groups-light exertion (1 to 4 METs) and moderate to heavy exertion (5 to 8 METs)-to determine the effect of the degree of physical exertion on the onset time distribution of aSAH. Multivariate analysis was used to calculate the odds ratio (OR) between the two groups to determine the effect of the degree of physical exertion on each set of time periods.

RESULTS

There was a definite bimodal onset pattern that peaked at 08:00-12:00 hours followed by 16:00-20:00 hours (p <0.001). MET values at all time intervals were found to be significantly higher than the night time (00:00-04:00 hours) values (p<0.031). The MET value distribution showed a unimodal pattern that slightly differed from the bimodal distribution of the onset time of aSAH. There were no significant differences in the ORs of each time interval according to the degree of the MET value.

CONCLUSION

This study reaffirmed that aSAH occurs in a bimodal pattern, especially showing the highest prevalence in the morning. Although aSAH could be related to daily activity, there were no significant changes in diurnal variations affected by the degree of physical exertion.

Histone demethylase PHF2 activates CREB and promotes memory consolidation

Long-term memory formation is attributed to experience-dependent gene expression. Dynamic changes in histone methylation are essential for the epigenetic regulation of memory consolidation-related genes. Here, we demonstrate that the plant homeodomain finger protein 2 (PHF2) histone demethylase is upregulated in the mouse hippocampus during the experience phase and plays an essential role in memory formation. PHF2 promotes the expression of memory-related genes by epigenetically reinforcing the TrkB-CREB signaling pathway. In behavioral tests, memory formation is enhanced by transgenic overexpression of PHF2 in mice, but is impaired by silencing PHF2 in the hippocampus. Electrophysiological studies reveal that PHF2 elevates field excitatory postsynaptic potential (fEPSP) and NMDA receptor-mediated evoked excitatory postsynaptic current (EPSC) in CA1 pyramidal neurons, suggesting that PHF2 promotes long-term potentiation. This study provides insight into the epigenetic regulation of learning and memory formation, which advances our knowledge to improve memory in patients with degenerative brain diseases.

Clinical Impact of a Protocolized Kidney Donor Follow-up System

BACKGROUND

Adequate kidney donor management after donation is increasingly emphasized due to concerns of renal function impairment after nephrectomy with increasing life expectancy. In this study, the clinical impact of a protocolized kidney donor follow-up system by nephrologists was evaluated.

METHODS

A total of 427 living kidney donors underwent nephrectomy from January 2010 to December 2014 and were followed for at least 2 years at the Samsung Medical Center. Donors were followed-up by nephrologists after the establishment of a donor clinic with systemized protocols in January 2013. The primary outcomes were incidence of post-donation low estimated glomerular filtration rate (eGFR) and renal function adaptability. Secondary outcomes were changes in compliance and incidence of hyperuricemia and microalbuminuria.

RESULTS

The patients were divided into 2 groups according to the time of nephrectomy: the pre-donor clinic period (n = 182) and the donor clinic period (n = 172). Preoperative eGFR in patients in the pre-donor clinic period was higher than that in patients in the donor clinic period. After donation, poor renal adaptation was less frequent in the donor clinic period compared to the pre-donor clinic period. Low eGFR tended to be less common during the donor clinic period. Shorter mean outpatient clinic visit intervals with more visits within 6 months after donation and earlier detection of de novo hyperuricemia were found during the donor clinic period.

CONCLUSION

A protocolized donor clinic run by nephrologists may improve post-nephrectomy renal outcomes and compliance and facilitate better management of potential risk factors of chronic kidney disease in donors.

Transfer printing of vertical-type microscale light-emitting diode array onto flexible substrate using biomimetic stamp

We report the transfer printing of GaN-based microscale vertical-type light-emitting diodes (μ-VLEDs) using a functional layer and a biomimetic stamp. An oxide-based functional layer is inserted onto the structure of a μ-VLED and used to separate the chip from the μ-VLED wafer by absorbing the pulse of a UV pulse laser during pick-up of the transfer printing process. Polydimethylsiloxane (PDMS)-based biomimetic stamps have been fabricated to mimic the gecko lizard cilia for improved adhesion and repeatability. The biomimetic stamp has an adhesion force of 25.6 N/cm², which is 12 times the adhesion of a flat stamp; an adhesion force of 10 N/cm² or more was maintained after 100,000 repeated adhesion tests. A flexible 10 × 10 prototype array on a polyimide substrate was fabricated, and its bending test results indicated that the strain effect on the forward voltage and the output power was less than 1%. The stable bending test results of the prototype indicate that μ-VLEDs using biomimetic stamps allow the necessary stability for practical transfer printing.

Post-factum autopsy to confirm cardiac structures visible on computed tomography images of Korean mummies: the radiological basis of paleo-cardiology

Accurate interpretation of radiological data is important for reliable paleopathological study of mummies. This is especially true for the mummified heart, an anatomically complicated organ that is distorted and displaced due to long-term dehydration and the action of gravity. In the present study, we compared post-factum autopsy results for mummified hearts of differing preservation statuses with corresponding radiological (computed tomography [CT]-image) findings in order to obtain information necessary for accurate radiological diagnosis. We found that the valvular apparatus (especially the aortic valve and chordae tendinae) was easily distinguishable on the CT images of mummies in which more cardiac structures were preserved. We also identified several situations that are known to incur misdiagnosis of cardiac CT images: the presence of pseudo-cavities in the cardiac wall, confusion of the valvular apparatus with cardiac-wall debris, and invisibility of cardiac structures on CT images due to collapse or adhesion. While acknowledging the merits of top-priority CT scanning in non-invasive research, post-factum autopsy also has value as a complementary and confirmatory analysis for enhanced accuracy of diagnoses in paleo-radiological studies.

Does Neurosurgical Clipping or Endovascular Coiling Lead to More Cases of Delayed Hydrocephalus in Patients with Subarachnoid Hemorrhage?

Objective

We investigated whether clipping or endovascular treatment (EVT) can reduce the incidence of delayed hydrocephalus. We also investigated whether additional procedures, namely lumbar drainage and extra-ventricular drainage (EVD), decrease the incidence of delayed hydrocephalus in patients with subarachnoid hemorrhage (SAH).

Materials and Methods

One-hundred and fifty-two patients who had undergone an operation for SAH were enrolled in this study. Clinical data, radiological data, and procedural data were investigated. Procedural data included the operating technique (clipping vs. EVT) and the use of additional procedures (no procedure, lumbar drainage, or EVD). Delayed hydrocephalus was defined as a condition in which the Evan's index was 0.3 or higher, as assessed using brain computed tomography more than 2 weeks after surgery, requiring shunt placement due to neurological deterioration.

Results

Of the 152 patients, 45 (29.6%) underwent surgical clipping and 107 (70.4%) underwent EVT. Twenty-five (16.4%) patients developed delayed hydrocephalus. Age (p = 0.019), procedure duration (p = 0.004), and acute hydrocephalus (p = 0.030) were significantly correlated with the incidence of delayed hydrocephalus. However, the operation technique (p = 0.593) and use of an additional procedure (p = 0.378) were not significantly correlated with delayed hydrocephalus incidence.

Conclusion

No significant difference in the incidence of delayed hydrocephalus was associated with operation technique or use of an additional procedure in patients with SAH. However, delayed hydrocephalus was significantly correlated with old age, long procedural duration, and acute hydrocephalus. Therefore, we recommend that additional procedures should be discontinued as soon as possible.

Differences in the oral health status and oral hygiene practices according to the extent of post-stroke sequelae

Oral health and hygiene are crucial parameters in stroke patients. However, few studies have evaluated the oral health status and oral hygiene practices according to the level of function in stroke patients. The aim of this study was to evaluate the oral health status and oral hygiene practices according to ambulation and personal hygiene levels in patients with stroke. Data from the fifth (2010-2012) and sixth (2013-2015) editions of the Korea National Health and Nutrition Examination Survey (KNHANES) for 6 years were combined. A total of 700 stroke patients were enrolled in our study. Subjective oral health was significantly poorer in patients who experienced a moderate problem with walking (adjusted OR [AOR], 1.68; 95% CI, 1.21-2.33) and bed-bound patients (AOR, 2.92; 95% CI, 1.01-8.44) than in patients who could walk without difficulty. Patients who were unable to bathe or dress independently exhibited a significantly higher risk of dental caries than did those who could perform the same activities unassisted. The probability of brushing teeth ≥2 times daily was 69% lower in bed-bound patients (AOR, 0.31; 95% CI, 0.11-0.87) than in patients who could walk without difficulty and 76% lower in patients who were unable to bathe or dress independently (AOR, 0.24; 95% CI, 0.09-0.62) than in those who could perform the same activities without difficulty. There were differences in oral health status and oral hygiene practices, according to ambulation level and functional independence, in the stroke patient group. These results indicate the need for oral care for stroke patients who exhibit ambulatory and functional limitations.

Pediatric Glioma at the Optic Pathway and Thalamus

Gliomas are the most common pediatric tumors of the central nervous system. In this review, we discuss the clinical features, treatment paradigms, and evolving concepts related to two types of pediatric gliomas affecting two main locations: the optic pathway and thalamus. In particular, we discuss recently revised pathologic classification, which adopting molecular parameter. We believe that our review contribute to the readers' better understanding of pediatric glioma because pediatric glioma differs in many ways from adult glioma according to the newest advances in molecular characterization of this tumor. A better understanding of current and evolving issues in pediatric glioma is needed to ensure effective management decision.

Hydro-nanofibrous mesh deep cell penetration: a strategy based on peeling of electrospun coaxial nanofibers

A two-step strategy for coaxial electrospinning and postelectrospinning is an effective method for fabricating superfine nanofibers composed of highly swellable hydrogels. Alginate and poly(ε-caprolactone) [PCL] were coelectrospun via fibrous meshes with a coaxial nozzle; alginate at the core was subsequently cross-linked in calcium chloride solution. The PCL sheath was removed from the meshes by repeated organic-phase washing. The peeling process was monitored by scanning electron microscopy, transmission electron microscopy, and differential scanning calorimetry, and the complete removal of the PCL outer layers was confirmed by the thinning of the fiber volume. The obtained alginate hydronanofiber showed extreme water-swellability and mass erosion depending on the degree of cross-linking. We also measured the nanoscale and macroscale mechanical properties of a single nanofiber and of the whole mesh by atomic force microscopy and rheometry. Quantitative analysis of nanomechanical properties indicated that the hydronanofiber with higher cross-linking density had higher stiffness and Derjaguin-Müller-Toporov modulus. Cells laid on the mesh and the vertical infiltration distance were visualized and quantified by confocal laser scanning microscopy. Cells on the mesh with higher cross-linking density infiltrated deeply to the bottom of the mesh. Thus, hydrogel-like nanofibrous meshes are versatile matrices allowing for deep infiltration of cells throughout the mesh via manipulation of the mechanical properties of the nanofiber.

Clopidogrel Response Variability in Unruptured Intracranial Aneurysm Patients Treated with Stent-Assisted Endovascular Coil Embolization : Is Follow-Up Clopidogrel Response Test Necessary?

Objective

The purpose of this study was to analyze the variability of clopidogrel responses according to duration of a clopidogrel drug regimen after stent-assisted coil embolization (SAC), and to determine the correlation between the variability of clopidogrel responses and thromboembolic or hemorrhagic complications.

Methods

A total of 47 patients who underwent SAC procedures to treat unruptured intracranial aneurysms were enrolled in the study. Preoperatively, patients received more than seven days of aspirin (100 mg) and clopidogrel (75 mg), daily. P2Y12 reaction unit (PRU) was checked with the VerifyNow test one day before the procedure (pre-PRU) and one month after the procedure (post-PRU). PRU variability was calculated as the difference between the initial response and the follow-up response. Patients were sorted into two groups based on their response to treatment : responsive and hypo-responsive.

Results

PRU variability was significantly greater in the hypo-responsive group when compared to the responsive group (p=0.019). Pre-PRU and serum platelets counts were significantly correlated with PRU variation (p=0.005 and p=0.004, respectively). Although thromboembolic complication had no significant correlated factors, hemorrhagic complication was correlated with pre-PRU (p=0.033).

Conclusion

In conclusion, variability of clopidogrel responses during clopidogrel medication was correlated to serum platelet counts and the initial clopidogrel response. Thromboembolic and hemorrhagic complications did not show correlation with the variability of clopidogrel response, or the clopidogrel response after one month of medication; however, hemorrhagic complication was associated with initial clopidogrel response. Therefore, it is recommended to test patients for an initial clopidogrel response only, as further tests would be insignificant.

Quantitative analysis in peritumoral volumes of brain metastases treated with stereotactic radiotherapy

PURPOSE

The purpose of this study was to verify changes in diffusion tensor imaging (DTI) factors in patients with brain metastases treated with stereotactic radiotherapy (SRT). We also investigated the impact of SRT on peritumoral volumes though the use of DTI.

METHODS

A total of 28 patients with brain metastases who had undergone SRT between March 2014 and December 2015 were enrolled. Magnetic resonance imaging with DTI factors, such as fractional anisotropy (FA) and apparent diffusion tensor (ADC) value, was performed 1 day before the procedure and 3 months after the procedure. DTI data from tumor lesions, edema volumes, and the volumes that received 12Gy were measured.

RESULTS

Tumor volume (P=0.001) and ADC values in the volumes that received 12Gy (P=0.018) and the edema volumes (P=0.003) significantly decreased after the procedure. Decreases in tumor volume were only correlated with decreases in edema volumes (P<0.001). Decreases in edema volumes were correlated with increases in FA values and decreases in ADC values of the volumes that received 12Gy [P=0.019 (FA)/0.002 (ADC)] and the edema volumes [P=0.011 (FA)/0.002 (ADC)].

CONCLUSIONS

It was possible to quantify changes in peritumoral volumes in patients with brain metastases after SRT by using DTI. ADC values of peritumoral volumes decreased significantly after SRT. Therefore, it was confirmed through DTI that performing SRT on tumor lesions has a positive effect on the structure and function of peritumoral volumes.

Effect of Changes in Body Mass Index on Cardiovascular Outcomes in Kidney Transplant Recipients

BACKGROUND

A higher body mass index (BMI) before kidney transplantation (KT) is associated with increased mortality and allograft loss in kidney transplant recipients (KTRs). However, the effect of changes in BMI after KT on these outcomes remains uncertain. The aim of this study was to investigate the effect of baseline BMI and changes in BMI on clinical outcomes in KTRs.

METHODS

A total of 869 KTRs were enrolled from a multicenter observational cohort study from 2012 to 2015. Patients were divided into low and high BMI groups before KT based on a BMI cutoff point of 23 kg/m². Differences in acute rejection and cardiovascular disease (CVD) between the 2 groups were analyzed. In addition, clinical outcomes across the 4 BMI groups divided by BMI change 1 year after KT were compared. Associations between BMI change and laboratory findings were also evaluated.

RESULTS

Patients with a higher BMI before KT showed significantly increased CVD after KT (P = .027) compared with patients with a lower BMI. However, among the KTRs with a higher baseline BMI, only persistently higher BMI was associated with increased CVD during the follow-up period (P = .003). Patients with persistently higher BMI had significantly decreased high-density lipoprotein cholesterol and increased hemoglobin, triglyceride, and hemoglobin A1c levels. Baseline BMI and post-transplantation change in BMI were not related to acute rejection in KTRs.

CONCLUSIONS

BMI in the 1st year after KT as well as baseline BMI were associated with CVD in KTRs. More careful monitoring of obese KTRs who do not undergo a reduction in BMI after KT is required.

Differential Expression Patterns of Irf3 and Irf7 in Pediatric Lymphoid Disorders

Interferon regulatory factors (IRFs) are multifunctional transcriptional factors. To define the role of IRFs in lymphoid disorders, we determined the expression patterns of IRF3 and IRF7 by immunohistochemistry in 5 normal lymph nodes, 12 reactive hyperplastic lymph nodes, and 27 pediatric lymphomas. IRF3 was prominently expressed in the nuclei of the histiocytes, and was expressed very weakly in the cytoplasm of most of the lymphocytes of the normal lymph nodes. However, IRF7 was expressed strongly in the nuclei of over 50% of the lymphocytes throughout the normal lymph nodes, but the histiocytes and fibroblasts were spared. In the reactive hyperplastic lymph nodes, the number of IRF3- and IRF7-positive cells in the nuclei was elevated. In the lymphomas, the number of IRF3-positive cells in the nucleus appeared to have decreased, and the cells were scattered throughout the lymphoma tissue in no specific pattern. However, in most cases the number of IRF7-positive cells was elevated.

These results suggested that IRF3 was activated principally in the histiocytes and T cells under inflammatory conditions, but IRF3 activation was attenuated in cases of lymphoma. However, the number of IRF7-positive cells was found to be elevated in the reactive hyperplastic lymph nodes and pediatric lymphoma.

Simultaneous Subtotal Pancreatectomy and Streptozotocin Injection for Diabetes Modeling in Cynomolgus Monkeys

BACKGROUND

In an experimental animal model of islet transplantation, stable induction of insulin-dependent diabetes mellitus (IDDM) and islet isolation from donor pancreas are essential. Total pancreatectomy for IDDM induction and islet procurement in nonhuman primates leads to unwanted loss of exocrine function and may lead to morbidities associated with IDDM.

METHODS

IDDM induction with streptozotocin (STZ) is associated with drug toxicity of STZ and necessitates the killing of another animal for islet procurement. In this study, we performed a subtotal pancreatectomy combined with reduced STZ injection to induce IDDM and procure islets in a nonhuman primate model.

RESULTS

Twelve cynomolgus monkeys received low-dose STZ injections (60 mg/kg) simultaneously with subtotal pancreatectomy. All monkeys recovered from the procedure without complications. IDDM was induced in the animals. 57,691 ± 16,050 islets were isolated from the resected pancreas and transplanted into other monkeys.

CONCLUSIONS

Simultaneous subtotal pancreatectomy and low-dose STZ injection represent an effective and safe method to create an animal model of insulin dependence diabetes, while at the same time providing sufficient amounts of fresh islet cells for allotransplantation without requiring killing of additional animals.

Predictive Factors of Renal Adaptation After Nephrectomy in Kidney Donors

BACKGROUND

Despite compensatory hyperfiltration in remaining nephrons following donor nephrectomy, some donors show impaired renal adaptation and low estimated glomerular filtration rate (eGFR). We investigated the factors predicting early renal adaptation after nephrectomy and identified kidney donors at risk of inadequate renal adaptation.

METHODS

A total of 265 living kidney donors from 2010 to 2013 were retrospectively analyzed. Renal function was serially followed for 6 months after the operation. Regression analyses were performed to identify the independent predictors of low eGFR (eGFR <60 mL/min/1.73 m²) and impaired renal adaptation (%Modification of Diet in Renal Disease [MDRD] <66% of baseline eGFR).

RESULTS

A total of 148 donors belonged to the low eGFR group, and changes in eGFR (ΔeGFR) at postoperative (PO) 1 day and 1 month were identified as independent predictors of low eGFR. Impaired renal adaptation was related to age, ΔeGFR PO 2-3 days, and ΔeGFR PO 1 month. Early renal adaptation was associated with age, male gender, and residual kidney computerized tomography angiography (CTA) volume. The best sensitivity and specificity were obtained with a cutoff value of ΔeGFR 31 at PO 1 day and 1 month for predicting low eGFR and with a value of ΔeGFR 27 at PO 2-3 days and 1 month for predicting impaired renal adaptation.

CONCLUSIONS

Our study showed that the degree of early renal adaptation determines subsequent renal function in kidney donors. Closer monitoring and management may be required in old or male donors with small residual CTA kidney volume as well as donors with persistent ΔeGFR >27 within 1 month of nephrectomy.

Major Histocompatibilty Complex-Restricted Adaptive Immune Responses to CT26 Colon Cancer Cell Line in Mixed Allogeneic Chimera

BACKGROUND

Although the induction of mixed allogeneic chimera shows promising clinical tolerance results in organ transplantation, its clinical relevance as an anti-cancer therapy is yet unknown. We introduced a mixed allogenic chimera setting with the use of a murine colon cancer cell line, CT26, by performing double bone marrow transplantation.

METHODS

We analyzed donor- and recipient-restricted anti-cancer T-cell responses, and phenotypes of subpopulations of T cells. The protocol involves challenging 1 × 10⁵ cells of CT26 cells intra-hepatically on day 50 after bone marrow transplantation, and, by use of CT26 lysates and an H-2L^d-restricted AH1 pentamer, flow cytometric analysis was performed to detect the generation of cancer-specific CD4⁺ and CD8⁺ T cells at various time points.

RESULTS

We found that immunocompetence against tumors depends heavily on cancer-specific CD8⁺ T-cell responses in a major histocompatibility complex-restricted manner; the evidence was further supported by the increase of interferon-γ-secreting CD4⁺ T cells. Moreover, we demonstrated that during the effector immune response to CT26 cancer challenge, there was a presence of central memory cells (CD62L^hiCCR7⁺) as well as effector memory cells (CD62L^loCCR7^-). Moreover, mixed allogeneic chimeras (BALB/c to C56BL/6 or vice versa) showed similar or heightened immune responses to CT26 cells compared with that of wild-type mice.

CONCLUSIONS

Our results suggest that the responses of primary immunocompetency and of pre-existing memory T cells against allogeneic cancer are sustained and preserved long-term in a mixed allogeneic chimeric environment.

Anakinra Protects Against Serum Deprivation-Induced Inflammation and Functional Derangement in Islets Isolated From Nonhuman Primates

We investigated whether serum deprivation induces islet amyloid polypeptide (IAPP) oligomer accumulation and/or a proinflammatory response and, if so, whether the addition of interleukin (IL)-1 receptor antagonist to the culture medium can relieve the proinflammatory response during serum-deprived culture of nonhuman primate (NHP) islets. After culture in medium with and without Ana under serum-deprived culture conditions, IAPP oligomer/amyloid accumulation, in vitro viability, islet function, cytokine secretion, and posttransplantation outcome in streptozotocin-induced diabetic nude mice were determined in islets isolated from heterozygote human IAPP transgenic (hIAPP^+/- ) mice and/or NHP islets. Serum deprivation induced accumulation of IAPP oligomer, but not amyloid, in NHP islets. Anakinra (Ana) protected islets from the serum deprivation-induced impairment of in vitro viability and glucose-stimulated insulin secretion and attenuated serum deprivation-induced caspase-1 activation, transcription, and secretion of IL-1β, IL-6, and tumor necrosis factor-α in hIAPP^+/- mice and NHP islets. Supplementation of medium with Ana during serum-deprived culture also improved posttransplantation in vivo outcomes of NHP islets. In conclusion, serum deprivation induced accumulation of IAPP oligomers and proinflammatory responses in cultured isolated islets. Supplementation of the culture medium with Ana attenuated the functional impairment and proinflammatory responses induced by serum deprivation in ex vivo culture of NHP islets.

Health-Related Quality of Life of Kidney Transplantation Patients: Results from the KoreaN Cohort Study for Outcome in Patients With Kidney Transplantation (KNOW-KT) Study

BACKGROUND

As patient and graft survival rates have been improving after kidney transplantation, health-related quality of life (HR-QOL) has become an important indicator of effective treatment. This study aimed to evaluate changes in HR-QOL after kidney transplantation.

MATERIALS AND METHODS

The KoreaN cohort study for Outcome in patients With Kidney Transplantation (KNOW-KT) is a multicenter, observational, 9-year, cohort study. The HR-QOL of patients in the KNOW-KT study was assessed before transplantation and 2 years after transplantation using the Kidney Disease Quality of Life Short Form (KDQOL-SF) including chronic kidney disease targeted area and the Medical Outcome Study 36-item Short Form Health Survey (SF-36). Multivariate linear regression was used to identify significant factors associated with follow-up QOL scores.

RESULTS

A total of 175 patients from 8 centers were analyzed. All QOL scores including the total QOL score, chronic kidney disease targeted score, and SF-36 at the 2-year follow-up were significantly increased compared to baseline values. Both physical and mental scale scores were improved after transplantation.

CONCLUSION

The QOL scores for both the mental and physical scales were improved at 2 years after kidney transplantation. High glomerular filtration rate at 2 years, high baseline QOL score, and low body mass index were associated with good follow-up QOL scores. Kidney transplantation for an Asian population with end-stage renal disease can result in better QOL as well as better patient and graft survival.

Short-Term Outcomes of ABO-Incompatible Living Donor Kidney Transplantation With Uniform Protocol: Significance of Baseline Anti-ABO Titer

Antibody-mediated rejection (AMR) is one of the major causes of poor outcomes in ABO-incompatible kidney transplantation (ABOi KT). Studies investigating AMR risk factors found that anti-ABO titer is a major issue. However, the significance of antibody titer has been debated. This retrospective study analyzed AMR risk factors in 59 patients who underwent ABOi KT between August 2010 and January 2015. We also analyzed AMR risk factors in recipients with high anti-ABO baseline titers (≥1:64 on dithiothreitol at 37°C phase or ≥1:256 on antihuman globulin phase). The 2-year patient survival rate was 95.8%, and the 2-year graft survival rate was 94.9%. Nine patients (15.3%) experienced clinical (6 of 59 [10.2%]) or subclinical (3 of 59 [5.1%]) AMR. One patient experienced graft loss from hyperacute rejection. AMR risk factor analysis revealed that baseline antibody titer was associated with incidence of AMR. In patients with high baseline titers, low doses of rituximab (200-mg single-dose), an antibody against CD20, was predictive for AMR. Six patients who received pretransplant intravenous immunoglobulin did not experience AMR even when they had high baseline antibody titers. Our results indicate that a high baseline antibody titer affected the incidence of AMR. ABOi KT candidates with high baseline titers need to undergo an intensified preconditioning protocol, including high-dose rituximab (375 mg/m(2)) and intravenous immunoglobulin.

A Case of Intracranial Wooden Foreign Body: Mimicking Pneumocephalus

Intracranial wooden foreign bodies are rare. In addition, such objects are difficult to identify with conventional radiographic techniques, such as X-ray radiography or brain computed tomography. A 48-year-old man presented to our emergency room with a headache. Even though he had a history of trauma, he had no external wounds and showed no neurological deficits at the initial examination. He was initially diagnosed with trauma-related pneumocephalus. He developed a delayed intracranial infection and underwent surgery to remove the wooden foreign body. The present case illustrates the necessity for special attention to patients suspected of having pneumocephalus with a rare presentation during the initial examination. Early surgical removal of the intracranial foreign body is necessary to prevent complications.

Correlation between Head Trauma and Outcome of Chronic Subdural Hematoma

Objective

Our study examined the prognostic factors involved in the outcome of patients with chronic subdural hematoma (CSDH) who had undergone burr hole drainage procedures, and investigated the association between outcome and traumatic head injury. In addition, we explored factors related to recurrence.

Methods

This study enrolled 238 patients with CSDH who had undergone burr hole drainage. Patients with history of head injury were categorized into the head trauma group and were compared with the no head trauma group. Outcome was considered good when modified Rankin Scale scores improved from admission to discharge and the final follow-up.

Results

Among 238 patients, 127 (53.4%) were included in the head trauma group. One hundred thirty-three (55.9%) patients demonstrated good outcome at discharge, and 171 (71.8%) patients demonstrated good outcome at the final follow-up. None of the factors examined was significantly correlated with good outcome at discharge. However, only history of head injury (p=0.033, odds ratio 0.511, 95% confidence interval 0.277-0.946) was significantly correlated with poor outcome at long-term follow-up. Recurrence occurred in 20 (8.4%) cases in the total cohort and 11 (55%) patients in the head trauma group.

Conclusion

History of head trauma is correlated with poor outcome at long-term follow-up in CSDH patients having undergone burr hole drainage. Therefore, CSDH patients with history of head injury are susceptible to poor outcome, warranting more careful evaluation and treatment after burr hole drainage.

Pure Intrasellar Meningioma Mimicking Pituitary Macroadenoma: Magnetic Resonance Imaging and Review of the Literature

Intrasellar meningioma originating from the sellar floor is extremely rare and is often indistinguishable from pituitary macroadenoma, both clinically and radiologically. Here, we report a case involving a 68-year-old patient with intrasellar meningioma possibly originating from the sellar floor and present a brief review of all previous cases reported in the English literature.

The Introduction of Human Heme Oxygenase-1 and Soluble Tumor Necrosis Factor-α Receptor Type I With Human IgG1 Fc in Porcine Islets Prolongs Islet Xenograft Survival in Humanized Mice

Apoptosis during engraftment and inflammation induce poor islet xenograft survival. We aimed to determine whether overexpression of human heme oxygenase-1 (HO-1) or soluble tumor necrosis factor-α receptor type I with human IgG1 Fc (sTNF-αR-Fc) in porcine islets could improve islet xenograft survival. Adult porcine islets were transduced with adenovirus containing human HO-1, sTNF-αR-Fc, sTNF-αR-Fc/HO-1 or green fluorescent protein (control). Humanized mice were generated by injecting human cord blood-derived CD34(+) stem cells into NOD-scid-IL-2Rγ(null) mice. Both HO-1 and sTNF-αR-Fc reduced islet apoptosis under in vitro hypoxia or cytokine stimuli and suppressed RANTES induction without compromising insulin secretion. Introduction of either gene into islets prolonged islet xenograft survival in pig-to-humanized mice transplantation. The sTNF-αR-Fc/HO-1 group showed the best glucose tolerance. Target genes were successfully expressed in islet xenografts. Perigraft infiltration of macrophages and T cells was suppressed with decreased expression of RANTES, tumor necrosis factor-α and IL-6 in treatment groups; however, frequency of pig-specific interferon-γ-producing T cells was not decreased, and humoral response was not significant in any group. Early apoptosis of islet cells was suppressed in the treatment groups. In conclusion, overexpression of HO-1 or sTNF-αR-Fc in porcine islets improved islet xenograft survival by suppressing both apoptosis and inflammation. HO-1 or sTNF-αR-Fc transgenic pigs have potential for islet xenotransplantation.

A single center, open-label, randomized pilot study to evaluate the safety and efficacy of tacrolimus modified release, Advagraf, versus tacrolimus twice daily, Prograf, in stable renal recipients (single)

BACKGROUND

Compliance with immunosuppressive regimens may affect clinical outcomes in renal transplant recipients. The aim of this study was to assess the safety and efficacy of standard-dose tacrolimus modified-release (TAC-MR) once daily versus tacrolimus (TAC) twice daily in stable renal transplant recipients.

METHODS

Ninety-nine stable renal transplant recipients were randomized to receive standard-dose tacrolimus twice daily or standard-dose modified-release tacrolimus once daily on a 1:1 (mg:mg) basis. The primary end point was the incidence of adverse events (AEs) in both groups. Secondary end points included biopsy-proven acute rejection, graft survival, patient survival, clinical indicators, and change in score of questionnaire.

RESULTS

The incidence of AEs was not different between the TAC and TAC-MR groups (56.0% vs 53.1%, P > .05). There were no significant differences in mean calculated glomerular filtration rate, blood pressure, glycosylated hemoglobulin (HbA1c), blood concentration of tacrolimus, and drug compliance. The scores of all items in the 36-item short form health survey (SF-36) were not different between groups, except for vitality. With respect to the subject questionnaire, there was no difference in question scores between the two treatment groups.

CONCLUSION

A regimen of TAC-MR once daily can be considered as an effective and safe alternative formulation of tacrolimus in stable renal transplant patients.

A Single-Institution Retrospective Study of Jugular Foramen Schwannoma Management: Radical Resection Versus Subtotal Intracranial Resection Through a Retrosigmoid Suboccipital Approach Followed by Radiosurgery

BACKGROUND

Despite advances in skull base surgery, achieving effective surgical management of jugular foramen schwannomas (JFSs) that avoids postoperative cranial nerve (CN) deficits remains a challenge. Subtotal resection followed by radiosurgery (rather than radical resection) is increasingly being viewed as a better treatment strategy. Here, an institutional database was retrospectively analyzed for outcomes after surgical treatment of JFSs to evaluate the optimal strategy for managing JFSs.

METHODS

Twenty-two patients with JFSs were operated on by either radical resection (n = 13) or conservative resection plus radiosurgery (n = 9). These 2 different groups were compared in terms of early (≤4 weeks after surgery) and late postoperative functional outcome and oncologic control.

RESULTS

No deaths occurred in either group, but there were 3 surgery-related complications in the radical resection group. Postoperative CN deficits and additional procedures related to CN morbidity were generally higher in the radical resection group, but the differences were not statistically significant. The conservative surgery group showed a statistically significant improvement in the level of dysphagia and dysphagia-related functional state in the late postoperative period. There was 1 case of recurrence after radical resection over a mean follow-up period of 73 months. All tumors in the conservative surgery group were controlled over a mean period of 34 months.

CONCLUSIONS

Our results suggest that conservative resection of JFSs via a familiar intracranial approach plus radiosurgery may be an effective surgical alternative for improving functional outcome with adequate oncologic control.

Importance of RNF213 polymorphism on clinical features and long-term outcome in moyamoya disease

OBJECT Moyamoya disease (MMD) is an idiopathic cerebrovascular occlusive disorder prevalent in East Asia. In the pathogenesis of MMD, the important role of genetic factors is being elucidated, and RNF213 has recently been identified as a susceptibility gene for MMD. The aim of this retrospective study was to investigate the RNF213 genotype in patients with MMD and to determine their genotype-phenotype associations. METHODS The study involved 165 Korean MMD patients from 155 unrelated families who were diagnosed with MMD at a single center from 1995 to 2013. Their demographic, radiological, and clinical findings were evaluated. Direct sequencing of the major RNF213 single nucleotide polymorphisms was performed. The association of the common RNF213 variant with MMD risk was evaluated using historical controls for comparison. Correlations between RNF213 genotype and phenotype were statistically analyzed. RESULTS The c.14429G>A (p.R4810K) variant was identified in 125 (75.8%) of 165 MMD patients. Most patients (112) were heterozygous, and 13 patients had 2 copies of the c.14429G>A variant. A novel heterozygous variant, c.12086A>G (p.Q4029R), was found in 1 additional patient. The minor allele frequency of the c.14429G>A variant was significantly higher in the MMD group (138 [41.8%] of 330 patients) than in the control group (8 [1.36%] of 588 subjects; p < 0.001). The c.14429G>A (p.R4810K) variant significantly increased the risk of MMD in Korean patients, with an OR of 52.11 (p < 0.001) compared with controls. Moreover, c.14429G>A (p.R4810K) genotypes occurred more frequently in patients with a family history of MMD. The homozygous variant was highly associated with early-onset MMD (age at onset < 5 years), cerebral infarction at diagnosis, and cognitive impairment in long-term outcome. CONCLUSIONS The findings indicate that the c.14429G>A (p.R4810K) allele of RNF213 is strongly associated with Korean patients with MMD. The homozygous c.14429G>A (p.R4810K) variant is particularly related to early-onset MMD, severe symptomatic manifestations at diagnosis, and poor prognosis. This genotypic variant may be a useful biomarker for early-onset MMD or unstable MMD with cerebral infarction, which requires early diagnosis and revascularization treatment.

Bone tumors in pre-modern skulls from human skeletal series of Joseon Dynasty

To date, there are still very few reports on benign-tumor cases based on East Asian skeletal series, even though other regions and continents have been well represented. In our study on the Joseon Human Skeletal Series, we identified benign bone tumors in two skeletons (cases Nos. 75 and 96). Our radiological analyses showed both cases to be homogeneous sclerotic bone masses aligned with the cranial vault suture. In a subsequent series of differential diagnoses, we determined both cases to be osteoma, the most common bone-tumor type reported for archaeological samples. Our study is the osteoarchaeological basis for this, the first-ever report on benign bone neoplasm in a pre-modern East Asian population.