Examining the molecular epidemiology of Giardia and Eimeria species in Japan: a comprehensive review

Globally, animals and humans suffer from diarrheal illnesses due to protozoan parasites such as Giardia and Eimeria species. The molecular epidemiology of these parasites in Japan is summarized in this review. In humans, researchers found only one main species of Giardia, which is most referred to as G. lamblia, but it's also known by different names like G. duodenalis or G. intestinalis. However, within this species, six assemblages (A, B, C, D, E, and F) were found in animals, and assemblage B was frequently recorded in human and monkey populations, whereas assemblages A and E were predominant in calves. Assemblage A was found in sika deer and assemblages A, C, D, and F were predominant in dogs, cats, and ferret. Eimeria bovis, E. zuernii, and other species found in animals made up the group of species known as Eimeria spp., with E. bovis and E. zuernii being the most common in cattle. Our review highlighted a notable lack of data investigations regarding these two pathogens in water and environmental sources. Giardia cysts were found in the few studies that have been done on water sources, suggesting that water may play a significant role in the transmission of Giardia species. Our review suggests that further research is necessary to fully comprehend the molecular diversity and dynamics of transmission of Giardia spp. and Eimeria spp. in humans, animals, and environmental sources in Japan.

Clinical Characteristics of Cryopyrin-Associated Periodic Syndrome and Long-Term Real-World Efficacy and Tolerability of Canakinumab in Japan: Results of a Nationwide Survey

OBJECTIVE

We assess the clinical characteristics of patients with cryopyrin-associated periodic syndrome (CAPS) in Japan and evaluate the real-world efficacy and safety of interleukin-1 (IL-1) inhibitors, primarily canakinumab.

METHODS

Clinical information was collected retrospectively, and serum concentrations of canakinumab and cytokines were analyzed.

RESULTS

A total of 101 patients were included, with 86 and 15 carrying heterozygous germline and somatic mosaic mutations, respectively. We identified 39 mutation types, and the common CAPS-associated symptoms corresponded with those in previous reports. Six patients (5.9% of all patients) died, with four of the deaths caused by CAPS-associated symptoms. Notably, 73.7% of patients (100%, 79.6%, and 44.4% of familial cold autoinflammatory syndrome, Muckle-Wells syndrome, and chronic infantile neurological cutaneous articular syndrome/neonatal onset multisystem inflammatory disease, respectively) achieved complete remission with canakinumab, and early therapeutic intervention was associated with better auditory outcomes. In some patients, canakinumab treatment stabilized the progression of epiphysial overgrowth and improved height gain, visual acuity, and renal function. However, 23.7% of patients did not achieve inflammatory remission with crucial deterioration of organ damage, with two dying while receiving high-dose canakinumab treatment. Serological analysis of canakinumab and cytokine concentrations revealed that the poor response was not related to canakinumab shortage. Four inflammatory nonremitters developed inflammatory bowel disease (IBD)-unclassified during canakinumab treatment. Dual biologic therapy with canakinumab and anti-tumor necrosis factor-α agents was effective for IBD- and CAPS-associated symptoms not resolved by canakinumab monotherapy.

CONCLUSION

This study provides one of the largest epidemiologic data sets for CAPS. Although early initiation of anti-IL-1 treatment with canakinumab is beneficial for improving disease prognosis, some patients do not achieve remission despite a high serum concentration of canakinumab. Moreover, IBD may develop in CAPS after canakinumab treatment.

Detection of Developmental Asexual Stage-Specific RNA Editing Events in Plasmodium falciparum 3D7 Malaria Parasite

Transcriptional variation has been studied but post-transcriptional modification due to RNA editing has not been investigated in Plasmodium. We investigated developmental stage-specific RNA editing in selected genes in Plasmodium falciparum 3D7. We detected extensive amination- and deamination-type RNA editing at 8, 16, 24, 32, 40, and 46 h in tightly synchronized Plasmodium. Most of the editing events were observed in 8 and 16 h ring-stage parasites. Extensive A-to-G deamination-type editing was detected more during the 16 h ring stage (25%) than the 8 h ring stage (20%). Extensive U-to-C amination-type editing was detected more during the 16 h ring stage (31%) than the 8 h ring stage (22%). In 28S, rRNA editing converted the loop structure to the stem structure. The hemoglobin binding activity of PF3D7_0216900 was also altered due to RNA editing. Among the expressed 28S rRNA genes, PF3D7_0532000 and PF3D7_0726000 expression was higher. Increased amounts of the transcripts of these two genes were found, particularly PF3D7_0726000 in the ring stage and PF3D7_0532000 in the trophozoite and schizont stages. Adenosine deaminase (ADA) expression did not correlate with the editing level. This first experimental report of RNA editing will help to identify the editing machinery that might be useful for antimalarial drug discovery and malaria control.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Tislelizumab versus chemotherapy as second-line treatment for European and North American patients with advanced or metastatic esophageal squamous cell carcinoma: a subgroup analysis of the randomized phase III RATIONALE-302 study

BACKGROUND

The phase III RATIONALE-302 study evaluated tislelizumab, an anti-programmed cell death protein 1 antibody, as second-line (2L) treatment for advanced/metastatic esophageal squamous cell carcinoma (ESCC). This prespecified exploratory analysis investigated outcomes in patients from Europe and North America (Europe/North America subgroup).

PATIENTS AND METHODS

Patients with tumor progression during/after first-line systemic treatment were randomized 1 : 1 to open-label tislelizumab or investigator's choice of chemotherapy (paclitaxel, docetaxel, or irinotecan).

RESULTS

The Europe/North America subgroup comprised 108 patients (tislelizumab: n = 55; chemotherapy: n = 53). Overall survival (OS) was prolonged with tislelizumab versus chemotherapy (median: 11.2 versus 6.3 months), with a hazard ratio (HR) of 0.55 [95% confidence interval (CI) 0.35-0.87]; HR was similar irrespective of programmed death-ligand 1 score [≥10%: 0.47 (95% CI 0.18-1.21); <10%: 0.55 (95% CI 0.30-1.01)]. Median progression-free survival was 2.3 versus 2.7 months with tislelizumab versus chemotherapy [HR: 0.97 (95% CI 0.64-1.47)]. Overall response rate was greater with tislelizumab (20.0%) versus chemotherapy (11.3%), with more durable response (median duration of response: 5.1 versus 2.1 months). Tislelizumab had a favorable safety profile versus chemotherapy, with fewer patients experiencing ≥grade 3 treatment-related adverse events (13.0% versus 51.0%). Those on tislelizumab experienced less deterioration in health-related quality of life, physical functioning, and/or disease- and treatment-related symptoms (i.e. fatigue, pain, and eating problems) as compared to those on chemotherapy, per the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (QLQ-C30) and QLQ-OES18 scores.

CONCLUSIONS

As a 2L therapy for advanced/metastatic ESCC, tislelizumab improved OS and had a favorable safety profile as compared to chemotherapy in European/North American ESCC patients in the randomized phase III RATIONALE-302 study.

Effects of monosaccharides including rare sugars on proliferation of Entamoeba histolytica trophozoites in vitro

Entamoeba histolytica is a parasitic protozoan with roles in pathogenicity of intestinal amoebiasis. E. histolytica trophozoites lack functional mitochondria and their energy production depends mostly on glycolysis. D-Glucose has a pivotal role in this process and trophozoites store this sugar as glycogen in glycogen granules. Rare sugars, which are defined as sugars present in nature in limited amounts, are of interest as natural low-calorie sweeteners for improving physical conditions of humans. One such rare sugar, D-allose, can be absorbed by a sodium-dependent glucose cotransporter as a substitute for D-glucose, and some rare sugars are known to inhibit growth of cancer cells, Caenorhabditis elegans and Tritrichomonas foetus. Based on these observations, we examined the effects of rare sugars on growth of E. histolytica trophozoites, together with those of D-galactose and D-fructose. The results indicate that treatment with D-allose or D-psicose (D-allulose) alone inhibits proliferation of E. histolytica trophozoites, but that these sugars enhance proliferation of trophozoites in the presence of D-glucose or D-galactose. The trophozoites could take up D-glucose and D-galactose, but not D-fructose, D-allose or D-psicose. Cell sizes of the trophozoites also differed depending on the culture medium.

Antiplasmodial and interferon-gamma-modulating activities of the aqueous extract of stone breaker (Phyllanthus niruri Linn.) in malaria infection

Plasmodium falciparum parasites are the primary cause of malaria across Africa. The problem of drug resistance to malaria is ever growing and novel therapeutic strategies need to be developed, particularly those targeting the parasite and also the host or host-pathogen interaction. Previous studies have shown that the development of cerebral malaria (CM) is related to dysregulation of the immune system in a murine malaria model of experimental cerebral malaria. It involves a complex interaction of events and interferon-gamma seems to be the unifying factor. Therefore, the antiplasmodial activity targeting the parasite and immunomodulatory strategies that reduce overall host inflammation, with IFN-γ in focus, could delay CM onset and prove beneficial in malaria infection therapy. Phyllanthus niruri is used to treat fever and other symptoms of malaria in Nigeria. Its modes of action as an anti-malarial remedy have not been exhaustively investigated. This study therefore examined the aqueous extract of P. niruri (PE) for its antiplasmodial activity in vitro using the Plasmodium falciparum HB3 strain. Furthermore, in vivo murine malaria model using the Plasmodium berghei ANKA strain was used to investigate its anti-malarial effects. We showed that PE has multiple anti-malarial effects, including anti-parasitic and host immunomodulatory activities. Co-culture of P. falciparum with PE and some of its phytoconstituents drastically reduced parasite number. PE also decreased parasitemia, and increased the survival of infected mice. We also observed that the integrity of the blood-brain barrier was maintained in the PE-treated mice. The results confirmed that PE showed moderate antiplasmodial activity. In vivo murine malaria model using P. berghei ANKA for experimental cerebral malaria revealed that PE suppressed parasite growth, and modulate the production of interferon-gamma. The findings demonstrate that PE affects malaria progression, targeting parasites and host cells.

In Vivo Efficacy of Curcumin and Curcumin Nanoparticle in Trypanosoma congolense, Broden 1904 (Kinetoplastea: Trypanosomatidae)-Infected Mice

Curcumin (CUR) is known for its wide folkloric effects on various infections; however, its solubility status has remained a hindrance to its bioavailability in the host. This study evaluated the comparative effects of CUR and CUR-nanoparticle in vitro on T. congolense, T. b. brucei, and T. evansi. Additionally, CUR and CUR-nanoparticle anti-Trypanosoma efficacy were assessed in vivo against T. congolense. All the CUR-nanoparticles were two folds more effective on the T. congolense as compared to CUR in vitro, with recorded efficacy of 3.67 ± 0.31; 7.61 ± 1.22; and 6.40 ± 3.07 μM, while the CUR-nanoparticles efficacy was 1.56 ± 0.50; 28.16 ± 9.43 and 13.12 ± 0.13 μM on T. congolense, T. b. brucei, and T. evansi, respectively. Both CUR and CUR-nanoparticles displayed moderate efficacy orally. The efficacy of CUR and CUR-nanoparticles in vivo was influenced by solubility, presence of food, and treatment period. CUR-treated mice were not cured of the infection; however, the survival rate of the orally treated mice was significantly prolonged as compared with intraperitoneal-treated mice. CUR-nanoparticles resulted in significant suppression of parasitemia even though relapsed was observed. In conclusion, CUR and CUR-nanoparticles possess moderate efficacy orally on the trypanosomes as compared to the intraperitoneal treatment.

Bilateral video-assisted thoracic surgery for esophageal cancer with left inferior pulmonary vein invasion following chemoradiation therapy

BACKGROUND

The surgical strategy for thoracic esophageal cancer that invades the lungs is controversial. In particular, invasion of the pulmonary vein is often regarded unresectable. We successfully applied bilateral video-assisted thoracic surgery (VATS) in esophagectomy for esophageal cancer with left inferior pulmonary vein invasion following induction chemoradiotherapy (CRT), with a favorable response.

CASE PRESENTATION

A 64-year-old woman was diagnosed with squamous cell carcinoma of the lower third of the esophagus. Computed tomography (CT) revealed that the tumor was suspected to be invading the main trunk of the left lower pulmonary vein and left lower lung. We initiated induction CRT comprising 5-fluorouracil, cisplatin, and concurrent radiotherapy at 50.4 Gy/28Fr. CT revealed shrinkage of the tumor, and the main trunk of the left inferior pulmonary vein was released from the tumor invasion. We considered the tumor to be completely resectable. VATS esophagectomy is usually performed using a right-sided approach. However, the right-sided approach is inappropriate for evaluating tumors around the left inferior pulmonary vein. We started with left-sided VATS to determine tumor resectability and dissected between the esophagus and the main trunk of the left inferior pulmonary vein. We only needed to perform partial resection of the left lower lobe. We then performed a right-sided VATS esophagectomy and lymphadenectomy with partial en bloc resection of the left lower lobe. Following this, we performed hand-assisted laparoscopic proximal gastrectomy and reconstruction using the gastric remnant. The postoperative course was uneventful. The patient was discharged on postoperative day 14. Histopathological examination of the surgical specimen revealed a complete pathological response without any remnant tumor or lymph node metastasis. There were no signs of recurrence or metastasis at the 1-year follow-up.

CONCLUSIONS

Curative resection for thoracic esophageal cancer that invades the pulmonary vein could be possible via the bilateral VATS approach following induction CRT with a favorable response.

PYloroplasty versus No Intervention in GAstric REmnant REconstruction after Oesophagectomy: study protocol for the PYNI-GAREREO phase III randomized controlled trial

BACKGROUND

After esophagectomy for esophageal and esophagogastric cancer, more than half of patients have lost > 10% of their body weight at 12 months. In most cases, the gastric remnant is used for reconstruction after esophagectomy. One of the most serious nutritional complications of this technique is delayed gastric emptying caused by gastric remnant mobilization and denervation of the vagus nerve. The aim of the PYloroplasty versus No Intervention in GAstric REmnant REconstruction after Oesophagectomy (PYNI-GAREREO) trial is to analyze the clinical outcome of modified Horsley pyloroplasty (mH-P) as a method of preventing delayed gastric emptying.

METHODS

The PYNI-GAREREO trial is designed as an open randomized, single-center superiority trial. Patients will be randomly allocated to undergo gastric remnant reconstruction with mH-P (intervention group) or no intervention (control group) in parallel groups. All patients with esophageal cancer or esophagogastric cancer planning to undergo curative minimally invasive esophagectomy will be considered for inclusion. A total of 140 patients will be included in the study and randomized between the groups in a 1:1 ratio. The primary outcome is the body weight change at 6 months postoperatively, and the secondary outcomes are the nutritional status, postoperative complications, functional outcome, and quality of life until 1 year postoperatively.

DISCUSSION

We hypothesize that mH-P after minimally invasive esophagectomy more effectively maintains patients' nutritional status than no pyloroplasty.

TRIAL REGISTRATION

UMIN Clinical Trials Registry UMIN000045104. Registered on 25 August 2021. https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000051346 .

L-tryptophan-titanium oxide nanoparticles showed selective anti-Toxoplasma gondii activity and improved host biocompatibility

Toxoplasma gondii, the etiological agent of toxoplasmosis, currently affects nearly one-third of the human population. Treatment options for toxoplasmosis are limited, which underscores the need for new drugs. In the present study, we screened nanoparticles (NPs) of titanium dioxide (TiO₂) and molybdenum (Mo) for their potential to inhibit the growth of T. gondii in vitro. NPs of TiO₂ and Mo showed non-dose-dependent anti-T. gondii activity with EC₅₀ values of 157.6 and 253 µg/mL, respectively. Previously, we showed that amino acid modification of NPs enhances their selective anti-parasite toxicity. Therefore, to enhance the selective anti-parasitic action of TiO₂, we modified the NP surface using alanine, aspartate, arginine, cysteine, glutamate, tryptophan, tyrosine, and bovine serum albumin. The bio-modified TiO₂ showed anti-parasite activity with EC₅₀ values ranging from 45.7 to 286.4 µg/mL. At effective anti-parasite concentrations, modified-TiO₂ showed no appreciable host cytotoxicity. Of the eight bio-modified TiO₂, tryptophan-TiO₂ showed the most promising anti-T. gondii specificity and improved host biocompatibility with a selectivity index (SI) of 49.1 versus 7.5 for TiO₂ (note, pyrimethamine, a standard drug for toxoplasmosis, has an SI of 2.3). Furthermore, our data indicate that redox modulation may be part of the anti-parasite action of these NPs. Indeed, augmentation with trolox and l-tryptophan reversed the growth restriction caused by the tryptophan-TiO₂ NPs. Collectively, these findings suggest that the parasite toxicity was selective and not a result of general cytotoxic action. Furthermore, surface modification with amino acids such as l-tryptophan not only enhanced the anti-parasitic action of TiO₂ but also improved the host biocompatibility. Overall, our findings indicate that the nutritional requirements of T. gondii represent a viable target for the development of new and effective anti-T. gondii agents.

Associations of fat mass index with hot flashes and lean mass index with insomnia in middle-aged women

OBJECTIVE

This cross-sectional study examined the relationship between body composition and physical and mental symptom severity in middle-aged women.

METHODS

The first-visit records of 554 women aged 40-64 years were examined. The fat mass index (FMI) and lean mass index (LMI) were defined as fat mass and lean mass divided by the height squared, respectively. The participants were divided into two groups according to their median values.

RESULTS

The only menopausal symptom with significantly different severity between the high and low FMI groups was hot flashes (HF) on the Menopausal Health-Related Quality of Life Questionnaire. The factors associated with severe HF were investigated using multiple logistic regression analysis. After adjusting, the FMI (kg/m²) was independently positively associated with severe HF (odds ratio, 1.08; 95% confidence interval, 1.02-1.15). Insomnia was the only menopausal symptom with significantly different severity between the LMI groups (defined as Athens Insomnia Scale score ≥10 points). The factors associated with moderate-to-severe insomnia were investigated using multiple logistic regression analysis. After adjusting, the LMI (kg/m²) was independently negatively associated with moderate-to-severe insomnia (odds ratio, 0.72; 95% confidence interval, 0.55-0.94).

CONCLUSIONS

The FMI was positively associated with severe HF, whereas the LMI was negatively associated with moderate-to-severe insomnia in middle-aged women.

A complementary approach for genetic diagnosis of inborn errors of immunity using proteogenomic analysis

Advances in next-generation sequencing technology have identified many genes responsible for inborn errors of immunity (IEI). However, there is still room for improvement in the efficiency of genetic diagnosis. Recently, RNA sequencing and proteomics using peripheral blood mononuclear cells (PBMCs) have gained attention, but only some studies have integrated these analyses in IEI. Moreover, previous proteomic studies for PBMCs have achieved limited coverage (approximately 3000 proteins). More comprehensive data are needed to gain valuable insights into the molecular mechanisms underlying IEI. Here, we propose a state-of-the-art method for diagnosing IEI using PBMCs proteomics integrated with targeted RNA sequencing (T-RNA-seq), providing unique insights into the pathogenesis of IEI. This study analyzed 70 IEI patients whose genetic etiology had not been identified by genetic analysis. In-depth proteomics identified 6498 proteins, which covered 63% of 527 genes identified in T-RNA-seq, allowing us to examine the molecular cause of IEI and immune cell defects. This integrated analysis identified the disease-causing genes in four cases undiagnosed in previous genetic studies. Three of them could be diagnosed by T-RNA-seq, while the other could only be diagnosed by proteomics. Moreover, this integrated analysis showed high protein-mRNA correlations in B- and T-cell-specific genes, and their expression profiles identified patients with immune cell dysfunction. These results indicate that integrated analysis improves the efficiency of genetic diagnosis and provides a deep understanding of the immune cell dysfunction underlying the etiology of IEI. Our novel approach demonstrates the complementary role of proteogenomic analysis in the genetic diagnosis and characterization of IEI.

The In Vitro Anti-Parasitic Activities of Emodin toward Toxoplasma gondii

Currently, toxoplasmosis affects nearly one-third of the world’s population, but the available treatments have several limitations. This factor underscores the search for better therapy for toxoplasmosis. Therefore, in the current investigation, we investigated the potential of emodin as a new anti-Toxoplasma gondii while exploring its anti-parasitic mechanism of action. We explored the mechanisms of action of emodin in the presence and absence of an in vitro model of experimental toxoplasmosis. Emodin showed strong anti-T. gondii action with an EC50 value of 0.03 µg/mL; at this same effective anti-parasite concentration, emodin showed no appreciable host cytotoxicity. Likewise, emodin showed a promising anti-T. gondii specificity with a selectivity index (SI) of 276. Pyrimethamine, a standard drug for toxoplasmosis, had an SI of 2.3. The results collectively imply that parasite damage was selective rather than as a result of a broad cytotoxic effect. Furthermore, our data confirm that emodin-induced parasite growth suppression stems from parasite targets and not host targets, and indicate that the anti-parasite action of emodin precludes oxidative stress and ROS production. Emodin likely mediates parasite growth suppression through means other than oxidative stress, ROS production, or mitochondrial toxicity. Collectively, our findings support the potential of emodin as a promising and novel anti-parasitic agent that warrants further investigation.

Spontaneous retroperitoneal hematoma: a case report

BACKGROUND

Spontaneous retroperitoneal hematoma is defined as bleeding in the retroperitoneal space without any triggers such as trauma, invasive procedures, and abdominal aortic aneurysm.

CASE PRESENTATION

A 48-year-old Japanese man who experienced sudden abdominal pain, severe hypotension, and decreased hemoglobin was diagnosed with spontaneous retroperitoneal hematoma. Contrast-enhanced computed tomography revealed massive left retroperitoneal hematoma; however, neither extravasation nor causative aneurysm was noted. Through conservative management with close monitoring, he was treated and discharged on the tenth hospital day without any morbidity.

CONCLUSIONS

Spontaneous retroperitoneal hematoma treatment comprises conservative management, transcatheter arterial embolization, and surgical intervention. The mortality rate of spontaneous retroperitoneal hematoma is so high that the optimal treatment timing needs to be carefully judged on the basis of detailed evaluation, and management algorithm with clear criteria.

The preoperative SOFA score and remnant small intestine length are postoperative risk factors for mortality in patients with non-occlusive mesenteric ischemia: a case-control study

Aim

Non-occlusive mesenteric ischemia (NOMI) is a fatal condition with a low survival rate in most cases. The risk factors for perioperative mortality in NOMI cases are unclear. The purpose of this study was to define the risk factors for mortality in patients with NOMI undergoing surgery.

Methods

Thirty-eight consecutive patients who underwent surgery for NOMI at Teine Keijinkai Hospital between 2012 and 2020 were included in the study. Patient information, including age, sex, physical findings, comorbidities, laboratory data, and computed tomography and surgical findings were retrospectively analyzed.

Results

Of the 38 patients, 18 (47%) died before discharge. Significant univariate predictors of mortality were a high Sequential Organ Failure Assessment (SOFA) score, high lactate level, low blood pH, and short intestinal length after surgery. In the multivariate analysis, a high SOFA score (odds ratio 1.33, P = 0.036) and short intestine length after surgery (odds ratio 34.7, P = 0.003) were identified as independent risk factors for perioperative mortality.

Conclusion

The preoperative SOFA score and postoperative residual intestinal length may be predictors of death in NOMI surgical patients, not age and the content of comorbidities.

The role of atypical MAP kinase 4 in the host interaction with Cryptosporidium parvum

Cryptosporidium parvum is an apicomplexan parasite that causes severe zoonotic diarrhea in humans and calves. Since there are no effective treatments or vaccines for infants or immunocompromised patients, it is important to understand the molecular mechanisms of the parasite-host interaction for novel drug discovery. Mitogen-activated protein kinase (MAP kinase) is a key host factor in interactions between host and various pathogens, including parasites. Although the function of conventional MAP kinases against parasite infection has been investigated, that of atypical MAP kinases remains largely unknown. Therefore, we focused on one of the atypical MAP kinases, MAPK4, and its effect on C. parvum infection in human intestinal cells. Here, we report that MAPK4-deficient intestinal cells showed a significant reduction in C. parvum infection. We also show that host MAPK4 has a role in host cell survival from C. parvum infection. In addition, we show that C. parvum requires host MAPK4 for its successful invasion and asexual reproduction. Taken together, our data suggest that MAPK4 is an important host factor contributing to C. parvum infection in human intestinal cells.

Revisiting Mt Fuji's groundwater origins with helium, vanadium and environmental DNA tracers

Known locally as the water mountain, for millennia Japan's iconic Mt Fuji has provided safe drinking water to millions of people via a vast network of groundwater and freshwater springs. Groundwater, which is recharged at high elevations, flows down Fuji's flanks within three basaltic aquifers, ultimately forming countless pristine freshwater springs among Fuji's foothills. Here we challenge the current conceptual model of Fuji being a simple system of laminar groundwater flow with little to no vertical exchange between its three aquifers. This model contrasts strongly with Fuji's extreme tectonic instability due to its unique location on top of the only known continental trench-trench-trench triple junction, its complex geology and its unusual microbial spring water communities. On the basis of a unique combination of microbial environmental DNA, vanadium and helium tracers, we provide evidence for prevailing deep circulation and a previously unknown deep groundwater contribution to Fuji's freshwater springs. The most substantial deep groundwater upwelling has been found along Japan's most tectonically active region, the Fujikawa-kako Fault Zone. Our findings broaden the hydrogeological understanding of Fuji and demonstrate the vast potential of combining environmental DNA, on-site noble gas and trace element analyses for groundwater science.

Snf2 Proteins Are Required to Generate Gamete Pronuclei in Tetrahymena thermophila

During sexual reproduction/conjugation of the ciliate Tetrahymena thermophila, the germinal micronucleus undergoes meiosis resulting in four haploid micronuclei (hMICs). All hMICs undergo post-meiotic DNA double-strand break (PM-DSB) formation, cleaving their genome. DNA lesions are subsequently repaired in only one ‘selected’ hMIC, which eventually produces gametic pronuclei. DNA repair in the selected hMIC involves chromatin remodeling by switching from the heterochromatic to the euchromatic state of its genome. Here, we demonstrate that, among the 15 Tetrahymena Snf2 family proteins, a core of the ATP-dependent chromatin remodeling complex in Tetrahymena, the germline nucleus specific Iswi in Tetrahymena IswiGTt and Rad5Tt is crucial for the generation of gametic pronuclei. In either gene knockout, the selected hMIC which shows euchromatin markers such as lysine-acetylated histone H3 does not appear, but all hMICs in which markers for DNA lesions persist are degraded, indicating that both IswiGTt and Rad5Tt have important roles in repairing PM-DSB DNA lesions and remodeling chromatin for the euchromatic state in the selected hMIC.

Calmodulinopathy is a common cause of critical cardiac phenotypes in fetus and infancy

Background

Cardiac calmodulinopathy is a life-threatening arrhythmia syndrome which presents several phenotypes of inherited primary arrhythmia syndrome (IPAS), and caused by mutations in calmodulin-encoded genes (CALM1–3). We aimed clarify the frequency and their clinical characteristics of calmodulinopathy in our IPAS cohort.

Methods

By using next generation sequencing, we screened arrhythmia related genes including calmodulin-encoding genes in 322 unrelated symptomatic children (0–12 years) who were suspected as IPAS; they included 40 cases with lethal arrhythmic attacks (LAE) under 6-year-old. After gene screening, we investigated their physiological and clinical characteristics about mutation carriers.

Results

Among 322 children, we identified 6 mutations of calmodulin-encoded genes in 9 probands (2.8%); one CALM1 in 2 probands (N98S), and 5 CALM2 in 7 probands (E46K, D96V, D96G, N98S, E141K). Their clinical diagnoses were long QT syndrome (LQTS, n=4), catecholaminergic polymorphic ventricular tachycardia (CPVT, n=3) and both (n=2). Their age of diagnosis ranges at 0–9 with the median of 5 years. There were three major clinical phenotypes; 1) CALM2-D96V, and E141K: two infants with advanced atrio-ventricular block, significant QTc prolongation, severe heart failure from their fetal period – both of them deceased within 1.5-year-old. Their clinical phenotypes resembled classical Timothy syndrome caused by CACNA1C mutations. 2) CALM1-N98S (n=2), CALM2-N98S (n=2), and CALM2-D96G: four preschoolers with LAEs and one syncope: all of them were 3–5 years old. In addition, a T wave morphology of CALM2-D96G carrier was very similar to LQT1. 3) CALM2-E46K (n=2): two were first diagnosed with neurological and developmental disorders, and showed phenotype of CPVT: their cardiac phenotypes were milder compared with that of 1) or 2). Overall, these phenotypes seemed to be mutation specific (indicated in figure). Their cardiac features were severer, and the onset of LAEs was earlier compared with other genotypes of LQTS/CPVT. As the treatment, β-blocker was effective for control of LAEs.

Conclusion

Cardiac calmodulinopathy presented serious and potentially lethal phenotypes in fetus or infancy. To prevent cardiac death in them, we must correctly diagnose and start the treatment as earlier as possible.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): MEXT KAKENHI from the Ministry of Education, Culture, Sports, Science, and Technology of Japan

Different prognosis of ARVC patients between DSG2 and PKP2 variant carriers

Background

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiomyopathy mainly caused by desmosomal gene variants. In Europe and North America, pathogenic variants in PKP2 were identified in most of the ARVC patients. On the other hand, we have reported that the genetic backgrounds of ARVC in Japanese were different from those in European; pathogenic variants in DSG2 were predominant in Japanese. Genotype-phenotype correlations, however, have not been clarified yet.

Purpose

In this study, we aimed to examine whether the genotype affect the phenotype and outcome in Japanese ARVC patients.

Methods and results

This study included 167 Japanese ARVC patients who received genetic testing (128 males [77%]). Their median age at diagnosis was 44 [24–55] years old and median follow-up duration was 10 [4–21] years. We found 90 patients with pathogenic variants: 52 in DSG2 (31%), 30 in PKP2 (18%), 3 in DSP (1.8%), 1 in DSC (0.6%), 1 in JUP (0.6%) and 3 in DES (1.8%). The age of the first sustained ventricular arrhythmia (SVT) were older in the patients with DSG2 than those with PKP2 variants (48±15 years vs. 35±15 years, P=0.008) but younger in DSG2 variant carriers at the first hospitalization for heart failure (41 [22–61] years vs. 67 [61–74] years, P=0.03). The left ventricular ejection fractions of DSG2 variant carriers were significantly lower at diagnosis than that of PKP2 (52 [41–60] % vs. 61 [56–66] %, P=0.002). Kaplan-Meier survival curve for lethal arrhythmic events including SVT, ventricular fibrillation and sudden death revealed that the event rate of DSG2 variant carriers was significantly lower than that of PKP2 (log-rank test, P=0.02) (Fig. 1).

Among 11 patients who had both SVT and hospitalizations for HF, 7 PKP2 variant carriers had SVT first, then, hospitalized for HF (48 [35–53] years and 67 [55–71] years, P=0.02). Contrary, the clinical course of 4 DSG2 variants carriers were different from those with PKP2 (54 [40–68] years for SVT and 65 [56–70, P=0.1] years for HF) (Fig. 2).

Conclusion

The patients with DSG2, which is the major causative gene for ARVC in Japanese, show different phenotype and outcome from those with PKP2. We should examine the effect of variants on the prognosis of ARVC patients in more large population including various ethnics.

Funding Acknowledgement

Type of funding sources: None.

Innate Immune Response and Inflammasome Activation During SARS-CoV-2 Infection

The novel coronavirus SARS-CoV-2, responsible for the COVID-19 outbreak, has become a pandemic threatening millions of lives worldwide. Recently, several vaccine candidates and drugs have shown promising effects in preventing or treating COVID-19, but due to the development of mutant strains through rapid viral evolution, urgent investigations are warranted in order to develop preventive measures and further improve current vaccine candidates. Positive-sense-single-stranded RNA viruses comprise many (re)emerging human pathogens that pose a public health problem. Our innate immune system and, in particular, the interferon response form an important first line of defense against these viruses. Flexibility in the genome aids the virus to develop multiple strategies to evade the innate immune response and efficiently promotes their replication and infective capacity. This review will focus on the innate immune response to SARS-CoV-2 infection and the virus’ evasion of the innate immune system by escaping recognition or inhibiting the production of an antiviral state. Since interferons have been implicated in inflammatory diseases and immunopathology along with their protective role in infection, antagonizing the immune response may have an ambiguous effect on the clinical outcome of the viral disease. This pathology is characterized by intense, rapid stimulation of the innate immune response that triggers activation of the Nod-like receptor family, pyrin-domain-containing 3 (NLRP3) inflammasome pathway, and release of its products including the pro-inflammatory cytokines IL-6, IL-18, and IL-1β. This predictive view may aid in designing an immune intervention or preventive vaccine for COVID-19 in the near future.

Identification of Multiple Domains of Entamoeba histolytica Intermediate Subunit Lectin-1 with Hemolytic and Cytotoxic Activities

Galactose and N-acetyl-D-galactosamine-inhibitable lectin of Entamoeba histolytica have roles in the pathogenicity of intestinal amoebiasis. Igl1, the intermediate subunit lectin-1 of E. histolytica, has been shown to have both hemolytic and cytotoxic activities that reside in the C-terminus of the protein. To identify the amino acid regions responsible for these activities, recombinant proteins were prepared and used in hemolytic and cytotoxic assays. The results revealed that Igl1 has multiple domains with hemolytic and cytotoxic activities and that amino acids 787-846, 968-1028 and 1029-1088 are involved in these activities. The hemolytic activities of the fragments were partly inhibited by mannose, galactose and N-acetylgalactosamine, and glucose showed lower or negligible inhibitory effects for the activities. This is the first report of a protozoan protein with hemolytic and cytotoxic activities in multiple domains.

Carbon dioxide embolism during transanal total mesorectal excision: A hint of prevention from a case report

Transanal total mesorectal excision is a relatively new approach for treating lower rectal cancer. Carbon dioxide embolism is a critical complication of this procedure. We report the case of a 69-year-old man with lower rectal cancer who underwent transanal total mesorectal excision followed by laparoscopic low anterior resection. He had a sudden intraoperative carbon dioxide embolism during the transanal mesorectal excision. During the ventral dissection of the rectum, end-tidal carbon dioxide and blood oxygen saturation suddenly decreased. We stopped the insufflation of carbon dioxide and suspended the procedure. There was no circulatory collapse, and the vital signs gradually recovered; therefore, we resumed the surgery approximately 30 minutes later and completed it without additional complications. Upon reviewing the video, we found a small injured vein that would aspirate carbon dioxide. These findings suggested that careful hemostasis is essential to prevent carbon dioxide embolus during transanal total mesorectal excision.

Tislelizumab versus chemotherapy as second-line treatment of advanced or metastatic esophageal squamous cell carcinoma (RATIONALE 302): impact on health-related quality of life

Background

RATIONALE 302 (NCT03430843) an open-label, phase III study of second-line treatment of advanced/metastatic esophageal squamous cell carcinoma (ESCC), reported that tislelizumab, relative to investigator-chosen chemotherapy (ICC), was associated with improvements in overall survival and a favorable safety profile. This study assessed the health-related quality of life (HRQoL) and ESCC-related symptoms of patients in RATIONALE 302.

Methods

Adults with advanced/metastatic ESCC whose disease progressed following prior systemic therapy were randomized 1 : 1 to receive either tislelizumab or ICC (paclitaxel, docetaxel, or irinotecan). HRQoL was measured using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 items (EORTC QLQ-C30), the EORTC Quality of Life Questionnaire Oesophageal Cancer Module 18 items (QLQ-OES18), and the EuroQoL Five-Dimensions Five-Levels (EQ-5D-5L) visual analogue scale. Mixed effect modeling for repeated measurements examined changes from baseline to weeks 12 and 18. The Kaplan–Meier method was used to examine time to deterioration.

Results

Overall, 512 patients were randomized to tislelizumab (n = 256) or ICC (n = 256). The tislelizumab arm maintained QLQ-C30 global health status/quality whereas the ICC arm worsened at week 12 {difference in least square (LS) mean change: 5.8 [95% confidence interval (CI): 2.0-9.5], P = 0.0028} and week 18 [difference in LS mean change: 8.1 (95% CI: 3.4-12.8), P = 0.0008]. Physical functioning (week 18) and fatigue (weeks 12 and 18) worsened less in the tislelizumab compared with the ICC arm. The tislelizumab arm improved in reflux symptoms, whereas the ICC worsened at week 12 [difference in LS mean change: −4.1 (95% CI: −7.6 to −0.6), P = 0.0229]. The visual analogue scale remained consistent in the tislelizumab arm whereas it worsened in the ICC arm. The hazard of time to deterioration was lower in tislelizumab patients compared with ICC for physical functioning and reflux.

Conclusions

HRQoL, including fatigue symptoms and physical functioning, was maintained in patients with advanced or metastatic ESCC receiving tislelizumab compared with ICC-treated patients. These results provide additional support for the benefits of tislelizumab in this patient population.

•

Global health status and HRQoL remained consistent in the tislelizumab arm whereas the ICC arm experienced worsening.

•

Fatigue and physical functioning worsened in both arms; however, the worsening was greater in the ICC arm.

•

The tislelizumab arm was at lower risk of reaching the threshold for worsening in physical functioning and reflux.

Development of Highly Sensitive Sandwich ELISA for the Early-Phase Diagnosis of Chikungunya Virus Utilizing rE2-E1 Protein

Introduction

Chikungunya is caused by an alpha virus transmitted to humans by an infected mosquito. Infection is generally considered to be self-limiting and non-critical. Chikungunya infection may be diagnosed by severe joint pain with fever, but it is difficult to diagnose because the symptoms of chikungunya are common to many pathogens, including dengue fever. Diagnosis mainly depends on viral culture, reverse transcriptase polymerase chain reaction (RT-PCR), and IgM ELISA. Early and accurate diagnosis of the virus can be achieved by the application of PCR methods, but the high cost and the need for a thermal cycler restrict the use of such methods. On the other hand, antibody-based IgM ELISA is considered to be inexpensive, but antibodies against chikungunya virus (CHIKV) only develop after 4 days of infection, so it has limited application in the earlier diagnosis of viral infection and the management of patients. Because of these challenges, a simple antigen-based sensitive, specific, and rapid detection method is required for the early and accurate clinical diagnosis of chikungunya.

Methods

The amino acid sequence of CHIKV ectodomain E1 and E2 proteins was analyzed using bioinformatics tools to determine the antigenic residues, particularly the B-cell epitopes and their characteristics. Recombinant E2-E1 CHIKV antigen was used for the development of polyclonal antibodies in hamsters and IgG was purified. Serological tests of 96 CHIKV patients were conducted by antigen-capture ELISA using primary antibodies raised against rCHIKV E2-E1 in hamsters and human anti-CHIKV antibodies.

Results

We observed high specificity and sensitivity, of 100% and 95.8%, respectively, and these values demonstrate the efficiency of the test as a clinical diagnostic tool. There was no cross-reactivity with samples taken from dengue patients.

Discussion

Our simple and sensitive sandwich ELISA for the early-phase detection of CHIKV infection may be used to improve the diagnosis of chikungunya.

Imaging-based feedback cooling of a levitated nanoparticle

Imaging-based detection of the motion of levitated nanoparticles complements a widely used interferometric detection method, providing a precise and robust way to estimate the position of the particle. Here, we demonstrate a camera-based feedback cooling scheme for a charged nanoparticle levitated in a linear Paul trap. The nanoparticle levitated in vacuum was imaged using a complementary metal-oxide semiconductor (CMOS) camera system. The images were processed in real-time with a microcontroller integrated with a CMOS image sensor. The phase-delayed position signal was fed back to one of the trap electrodes, resulting in cooling by velocity damping. Our study provides a simple and versatile approach applicable for the control of low-frequency mechanical oscillators.

O-272 Letrozole-induced endometrial preparation improved pregnancy outcomes after frozen blastocyst transfer compared to the natural cycle

Study question

Does letrozole-induced endometrial preparation affect pregnancy outcomes, perinatal outcomes, and congenital anomalies after single vitrified-warmed blastocyst transfers (SVBTs) when compared with the natural cycle?

Summary answer

Letrozole-induced endometrial preparation improved live birth rate without any adverse effects on perinatal outcomes and congenital anomalies after SVBTs.

What is known already

Letrozole treatment is considered an effective option in endometrial preparation for frozen embryo transfers in patients with ovulation disorders or irregular menstruation; however, the effectiveness of letrozole-induced endometrial preparation is still unclear in ovulatory patients. Furthermore, there is no comparative study reporting on pregnancy complications and congenital anomalies after frozen embryo transfers comparing natural and letrozole-assisted cycles.

Study design, size, duration

This retrospective study, at a major academic fertility centre, analysed a total of 14,611 clinical records of women who underwent SVBTs comprising both natural and letrozole-assisted cycles between July 2015 and June 2020. The cycle characteristics, pregnancy outcomes (clinical pregnancy, ongoing pregnancy, and live birth), and the incidence of pregnancy complications and congenital anomalies were statistically compared between the natural and letrozole groups.

Participants/materials, setting, methods

The study reviewed ovulatory patients who underwent their first SVBT during the study period. Some patients took letrozole during the early proliferative phase to promote follicular development and maturation (letrozole group). Ovulation was triggered by GnRH agonist and SVBTs were performed on day five after ovulation. Propensity score matching was performed to reduce any bias from patient characteristics. Multivariate logistic analysis was performed to evaluate the effects of letrozole administration on pregnancy and perinatal outcomes.

Main results and the role of chance

After propensity score matching, the characteristics of patients and transferred blastocysts were comparable between groups. The serum progesterone level was also significantly increased in the letrozole group (P &lt; 0.0001). Although no difference was observed regarding implantation rate between groups, the rates of clinical pregnancy, ongoing pregnancy, and delivery in the letrozole group were all significantly higher than that in the natural group (P = 0.0273, P = 0.0162, P = 0.0479, respectively). The incidence of early pregnancy loss, miscarriage, and stillbirth were comparable between groups. Multivariate logistic regression analysis also demonstrated that the administration of letrozole during an SVBT cycle significantly improved the live birth rate (AOR, 1.160; P = 0.0355). The incidence of pregnancy complications was comparable between groups. The caesarean section rate was significantly lower in the letrozole group than that in the natural group (P = 0.0464). Gestational age, birth length, birth weight, and infant sex, as well as the incidence of pregnancy complications and birth defects, were statistically comparable between groups. Furthermore, multivariate logistic regression analysis showed that perinatal outcomes were not affected by letrozole-induced endometrial preparation, although the incidence of caesarean section was decreased in the letrozole group (AOR, 0.788; P = 0.0355).

Limitations, reasons for caution

Our findings are not compared with reported incidences of pregnancy complications and congenital anomalies in natural pregnancy. Furthermore, the study was retrospective in nature, and further multicentre studies are required to ascertain the generalisability of these findings for other clinics with different protocols and/or patient demographics.

Wider implications of the findings

Letrozole administration both extended the proliferative phase and increased luteal function, resulting in an improvement of live birth rates without any adverse effects. Therefore, letrozole-induced endometrial preparation might be a safe and more effective strategy for patients with shortened proliferative phase or insufficient luteal function.

Trial registration number

not applicable

O-064 Recovery culture of human cryopreserved blastocysts with prolactin after warming improves trophoblast outgrowth

Study question

Does prolactin (PRL) treatment during recovery culture affect human blastocyst outgrowth?

Summary answer

PRL treatment for 120 min promoted trophoblast outgrowth in cryopreserved human blastocysts by upregulating the expressions of epithelial-to-mesenchymal transition (EMT) and focal adhesion-related genes.

What is known already

Human embryos express the PRL receptor at the morula and the blastocyst stages. This expression correlates with the blastocyst diameter and the time required for the embryos to reach the blastocyst stage. Treatment with PRL from cleavage to the blastocyst stage improves blastocyst outgrowth to fibronectin. However, whether PRL treatment after warming cryopreserved blastocysts cultured to the blastocyst stage without PRL influences outgrowth competence remains unknown. Furthermore, the optimal time for post-warming PRL treatment remains to be ascertained.

Study design, size, duration

A total of 374 discarded human vitrified blastocysts donated for research by consenting couples were used. The study was approved by the Institutional Review Board. The blastocysts were randomly allocated to two groups, to be cultured in medium either with PRL (n = 208) or without PRL (control; n = 166). The gene expression level, blastocyst adhesion, outgrowth area, and distance of trophoblast migration were compared between the groups.

Participants/materials, setting, methods

Vitrified human blastocysts were cultured for 120 min after warming. Some blastocysts were treated with PRL for 15–120 min during the recovery period. The blastocysts were plated on fibronectin-coated dishes and cultured to assess blastocyst adhesion and outgrowth. The expressions of PRL-interacting genes were assessed by quantitative RT-PCR 12 h after outgrowth culture. The migration distance at the outer edge of the trophoblast cells was examined using time-lapse systems.

Main results and the role of chance

The mRNA expressions of ezrin, radixin, and moesin, which regulate cell adhesion and invasion by controlling actin reorganisation during EMT, was stimulated by PRL treatment for 120 min. The expressions of EMT-related genes, transforming growth factor β1, snail1, and twist1 were also promoted by treatment with PRL for 120 min. The blastocysts treated with PRL also exhibited augmented expression of cadherin2 and transcriptional repression of cadherin1. Higher mRNA expressions of integrin-based focal adhesion-related genes, ITGA5 and ITGB1, were observed after treatment with PRL for 120 min compared to that in the other groups. PRL treatment for 120 min did not alter the rate of blastocyst adhesion to fibronectin-coated dishes 96 h after the outgrowth culture assay. However, multiple linear regression analysis revealed that the outgrowth area was significantly increased in blastocysts treated with PRL. The migration distance of trophoblast cells was significantly increased after PRL treatment. Furthermore, a more beneficial effect of prolactin treatment on blastocyst outgrowth was observed when the blastocysts were vitrified on day 5 compared to that when the blastocysts were vitrified on day 6. Moreover, the outgrowth area was increased by PRL treatment when the blastocyst diameter was larger than 180 µm.

Limitations, reasons for caution

The results may vary between in vivo and in vitro conditions. Further clinical studies are required to explore the clinical efficacy of PRL treatment.

Wider implications of the findings

This study showed that PRL treatment for 120 min improved trophoblast migration in cryopreserved human blastocysts. Therefore, recovery culture with PRL treatment post-warming followed by blastocyst transfer could improve pregnancy outcomes.

Trial registration number

not applicable

O-006 Annotation-free embryo score calculated by iDAScore® correlated with live birth and has no correlation with neonatal outcomes after single vitrified-warmed blastocyst transfer

Study question

Does the embryo score calculated by annotation-free embryo scoring system based on deep learning and time-lapse sequence images correlate with live birth (LB) and neonatal outcomes?

Summary answer

Annotation-free embryo score calculated by iDAScore correlates with decreased miscarriage and increased LB and has no correlation with neonatal outcomes.

What is known already

Embryo ranking models have recently been developed based on artificial intelligence (AI) and deep learning to rank embryos according to their potential for pregnancy. The practicability and usability of such models have been reported. And the previous report suggested iDAScore which is one of the deep learning models for embryo scoring was superior to traditional morphological assessment methods and morphokinetic embryo assessment models. However, few studies have used independent datasets to analyze the correlation between the score calculated by AI models, LB, and neonatal outcomes.

Study design, size, duration

A total of 3,010 single vitrified-warmed blastocyst transfer (SVBT) cycles were analyzed retrospectively. The quality and scoring of embryos were assessed using iDAScore v1.0 (iDAScore, Vitrolife, Sweden). The cohort was divided into four groups based on the iDAScore according to the percentile (9.9-9.3, 9.2-8.7, 8.6-7.3 and, 7.2-1.0).

Participants/materials, setting, methods

Scores were calculated using the iDAScore software module in the Vitrolife Technology Hub (Vitrolife, Gothenburg, Sweden). The correlation between iDAScore, LB rates and total miscarriage (TM), including 1st and 2nd trimester miscarriage, were analysed using a trend-test and multivariable logistic regression analysis. Furthermore, similarly, correlation between the iDAScore and neonatal outcomes were analysed.

Main results and the role of chance

LB rates decreased as the iDAScore decreased (P &lt; 0.05), and a similar inverse trend was observed for the TM rates (P &lt; 0.05). Additionally, multivariate logistic regression analysis showed that iDAScore significantly correlated with increased LB (adjusted odds ratio: 1.742, 95% CI: 1.601–1.904, P &lt; 0.05) and decreased TM (adjusted odds ratio: 0.799, 95% CI: 0.706–0.905, P &lt; 0.05). There was no significant correlation between iDAScore and neonatal outcomes, including congenital malformations, sex, gestational age, and birth weight. Multivariate logistic regression analysis, which included maternal and paternal age, maternal body mass index, parity, smoking, and the presence or absence of caesarean section as confounding factors, revealed no significant difference in any neonatal characteristics (low birth weight, small for gestation, large for gestation, preterm birth, male sex rates, and major congenital malformation).

Limitations, reasons for caution

SVBT was performed following minimal stimulation and natural cycle in vitro fertilisation. Therefore, only a few cycles of elective blastocyst transfer were available. However, there was no bias in selecting embryos for SVBT.

Wider implications of the findings

Objective embryo assessment using a completely automatic and annotation-free model, like iDAScore, showed a good correlation with increased LB and decreased TM. Furthermore, it did not correlate with neonatal outcomes. Therefore, iDAScore may be an optimal LB prediction model after SVBT without affecting neonatal outcomes.

Trial registration number

not applicable

P-754 Perinatal outcomes and congenital anomalies after clomiphene citrate based minimal ovarian stimulation in vitro fertilisation stratified by embryo transfer method: a 10-year cohort study

Study question

Is the embryo transfer method associated with perinatal outcomes and congenital anomalies after minimal ovarian stimulation in vitro fertilisation (IVF) with clomiphene citrate (CC)?

Summary answer

Single vitrified-warmed blastocyst transfers in natural cycles had a lower incidence of pregnancy complications compared to single fresh cleaved embryo transfers after CC-based ovarian stimulation.

What is known already

Pregnancies resulting from IVF are associated with a higher risk of adverse perinatal outcomes compared to spontaneous conception; therefore, the next focus in reproductive medicine is to assess whether the increased risks are attributable to the IVF. Perinatal outcomes and congenital anomalies should be considered in addition to pregnancy outcomes in selecting the embryo transfer method. However, studies describing the influence of transfer methods on perinatal and maternal outcomes are limited.

Study design, size, duration

This study retrospectively analysed a single centre 10-year cohort. A total of 82,491 clinical records of women who underwent oocyte retrieval during a CC-based minimal stimulation cycle followed by single fresh cleaved embryo transfer (SFCT), single vitrified-warmed cleaved embryo transfer (SVCT), or single vitrified-warmed blastocyst transfer (SVBT) at the Kato Ladies Clinic between January 2008 and December 2017 were retrospectively analysed.

Participants/materials, setting, methods

The oocyte retrievals were performed in CC-based minimal ovarian stimulation. The embryos were transferred 2–3 days after retrieval, or vitrified at the cleavage or blastocyst stages. The vitrified embryos were warmed and transferred within the natural cycles. Perinatal outcomes and congenital anomalies were stratified by the transfer method. Multivariate logistic regression analysis was performed to evaluate the effect of transfer methods on pregnancy complications and congenital anomalies.

Main results and the role of chance

The perinatal outcomes and congenital anomalies in 19,069 singleton pregnancies were analysed. Multivariate logistic regression analysis revealed that the incidence of hypertensive disorders of pregnancy was significantly lower in the SVBT group compared with the SFCT group (adjusted odds ratio [AOR], 0.628; P &lt; 0.0001). The incidence of low-lying placenta (AOR 0.359 P = 0.0483; AOR 0.452 P &lt; 0.0001, respectively) and placenta previa (AOR 0.300 P = 0.0021; AOR 0.542 P &lt; 0.0001, respectively) were lower in the SVCT and SVBT groups than in the SFCT group. The rate of preterm delivery was lower in SVBT compared with SFCT (AOR 0.732 P &lt; 0.0001). The rate of low birth weight was significantly lower after SVCT and SVBT, compared with the SFCT group (AOR 0.751; P = 0.0261: AOR, 0.560; P &lt; 0.0001: respectively). A lower incidence of small for gestational age (AOR 0.720 P = 0.0436; AOR 0.494 P &lt; 0.0001, respectively) and higher incidence of large for gestational age (AOR 1.287 P = 0.0332; AOR 1.706 P &lt; 0.0001, respectively) were observed in the SVCT and SVBT groups compared to the SFCT group. The incidence of each congenital anomaly was similar among the groups.

Limitations, reasons for caution

The data was collected through self-reported parental questionnaires on neonatal outcomes and congenital malformations. Furthermore, this study was retrospective in nature; further studies are necessary to ascertain the generalisability of these findings to other clinics with different protocols and/or patient demographics.

Wider implications of the findings

This study demonstrated reassuring outcomes for SVBT, in terms of a lower incidence of pregnancy complications compared with SFCT. Our findings provide valuable knowledge to improve perinatal outcomes in CC-based stimulation and to inform couples of the possible benefits and harms of each type of embryo transfer method.

Trial registration number

not applicable

P-152 The first morphokinetic map of human abnormal fertilisation

Study question

What are the similarities and differences between the morphokinetics of abnormal, one- (1PN) and three-pronuclear (3PN) and normal bi-pronuclear (2PN) fertilisation?

Summary answer

The morphokinetic analysis of 1PN/3PN fertilisation reveals novel aspects of abnormal early development.

What is known already

Assisted reproduction technology has allowed the observation of early human development. Initially assessed statically at a single time point, fertilization has revealed its complexity once observed by Time-Lapse Microscopy (TLM). Detailed morphokinetic analysis of fertilisation has been reported in the last few years, unveiling previously unknown cytoplasmic phenomena (e.g. the cytoplasmic wave and halo) and the importance of cell symmetry for embryo development. At present, abnormal fertilization remains neglected, despite potential for understanding the physiology and pathology of early human development.

Study design, size, duration

This retrospective study involved TLM observation of normally (2PN, n = 2,685) and abnormally (1PN, n = 41; 3PN, n = 127) fertilised oocytes generated in ICSI cycles. Oocyte retrievals were carried out after the clomiphene citrate-based minimal ovarian stimulation, between October 2019 and December 2020. Oocytes of patients with different diagnoses of infertility were included in the analysis, while cases involving cryopreserved gametes or surgically retrieved sperm were excluded.

Participants/materials, setting, methods

Microinjected oocytes were assessed by a combined TLM-culture system (Embryoscope). Oocytes not suitable for TLM assessment, due to excess of residual corona cells or inadequate orientation for correct observation, were not analysed. Phenomena, relevant to meiotic resumption, pronuclear dynamics, cytoplasmic/cortical modifications, cleavage pattern, and embryo quality, were annotated and compared between groups.

Main results and the role of chance

Second polar body (PBII) extrusion was observed in all 1PN- and in a majority of 3PN-zygotes (92.1%). A 0.3-hour delay in PBII extrusion was confirmed in 3PN-zygotes (P = 0.0439). In a significant proportion of 3PN-zygotes, a third (female) PN formed from reabsorption of the PBII. The cytoplasmic wave was observed not only in 2PN- and 3PN-, but also in 1PN-zygotes. The presence and position of cytoplasmic halo were comparable among the three classes of zygotes. However, the duration of the cytoplasmic halo was prolonged in 1PN-zygotes (P &lt; 0.0001). PN juxtaposition immediately before PN breakdown was less frequent in 3PN- compared with 2PN-zygotes (P = 0.0159). Furthermore, asynchronous PN breakdown was increased in 3PN- compared with 2PN-zygotes (P = 0.0026). The PN area of 1PN- was larger than that of 2PN-zygotes; however, the PN area of 3PN-zygotes was smaller than that of 2PN-zygotes. In 1PN-zygotes, a developmental delay was observed starting from the disappearance of the cytoplasmic halo, reaching 9 hours at the time of cleavage (P &lt; 0.0001). A higher incidence of abnormal cleavage (P = 0.0019) and blastomere fragmentation (P &lt; 0.0001) was observed in 1PN-zygotes. Cleavage progression was increasingly affected especially in 1PN-zygotes, resulting in blastocyst formation rates of 70.2%, 12.2% and 53.5% in 2PN-, 1PN- and 3PN-zygotes, respectively (P &lt; 0.0001).

Limitations, reasons for caution

The study data derive from treatments carried out in a single centre. The study findings therefore require independent verification from other research groups.

Wider implications of the findings

These observations suggest that 1PN and 3PN fertilisation follow the general pattern of normal fertilization. Crucially, they also shed light on diverse and previously undescribed phenomena - e.g. reabsorption of the PBII in 3PN zygotes - underpinning the origins of abnormal fertilization and potentially clinically relevant.

Trial registration number

not applicable

A new accumulation assay of Schistosoma mansoni miracidia using square capillary glass tubes

Current control measures for schistosomiasis have only been partially successful in endemic areas due to socioeconomic constraints. One possibility for controlling the disease is to aim at the miracidial stage of the trematode to avoid infecting intermediate snail hosts by introducing more attractive substances for miracidia in the environment. Here, we introduce an accumulation assay of Schistosoma mansoni miracidia using a square glass tube for analysis of the positive responses of miracidia toward several substances, including snail-conditioned water of Biomphalaria glabrata, Bulinus globosus and insusceptible snails collected in the Nagasaki area in Japan. The substances are not proteins because miracidia accumulated in boiled snail-conditioned water and the secretion or emission level of substances depended on the feeding conditions of Biomphalaria glabrata. The present study also showed that substances emitted from Biomphalaria glabrata with a molecular weight around 10 kDa accumulated Schistosoma mansoni miracidia. Further, we showed that Schistosoma mansoni miracidia did not accumulate in response to mono- or disaccharides tested in the study.

POS0081 LONG-TERM EFFICACY AND SAFETY OF UPADACITINIB IN PATIENTS WITH PSORIATIC ARTHRITIS: 2-YEAR RESULTS FROM THE PHASE 3 SELECT-PsA 1 STUDY

Background

In SELECT-PsA 1, patients (pts) with psoriatic arthritis (PsA) and an inadequate response or intolerance to ≥1 non-biologic disease-modifying antirheumatic drug showed improvement in the signs and symptoms of PsA with upadacitinib 15 mg (UPA15) or 30 mg (UPA30), an oral Janus kinase (JAK) inhibitor, through week (wk) 56.1

Objectives

To evaluate the efficacy and safety of UPA and UPA vs adalimumab (ADA) at wk 104 from the ongoing long-term extension of SELECT-PsA 1.

Methods

Pts received UPA15, UPA30, ADA 40 mg, or placebo (PBO) for 24 wks, at which point, PBO pts switched to UPA15 or UPA30. Efficacy endpoints were analyzed using non-responder imputation (NRI) and as observed (AO) (binary endpoints) or mixed-effect model repeated measures and AO (continuous endpoints), with nominal P-values shown, for continuous UPA and ADA treatment groups. Treatment-emergent adverse events were summarized for pts who received ≥1 dose of study drug using a visit-based cut-off at wk 104.

Results

1704 pts received ≥1 dose of study drug. At wk 104, 25.4% of patients had discontinued study drug. The proportions of pts who achieved ACR20/50/70, MDA, PASI75/90/100, and resolution of enthesitis or dactylitis showed consistent responses, or further improvements, from wk 561 to wk 104 (Table 1). ACR20/50/70 and MDA responses, as well as mean change from baseline (BL) in HAQ-DI, patient’s assessment of pain, BASDAI, and ASDAS, were greater with UPA vs ADA. Mean change from BL in modified total Sharp/van der Heijde Score (mTSS) was generally similar across groups and comparable to wk 56.1 The safety profile of UPA was generally comparable to ADA (Figure 1) and consistent with wk 561 data. Rates of serious infection, herpes zoster, lymphopenia, and elevated CPK remained numerically higher with UPA30 vs UPA15; rates in both UPA groups were higher vs ADA. Rates of malignancies, MACE, or VTE were similar across groups, and consistent with wk 561 data. Two deaths were reported with UPA15, 1 with UPA30, and 1 with ADA.

Table 1.

Efficacy Endpoints at Week 104

EndpointUPA15(n=429)UPA30(n=423)ADA(n=429)Proportion of Pts (%)aNRIAONRIAONRIAOACR2069.087.969.587.963.485.1ACR5053.667.459.3*74.147.162.3ACR7038.0*47.443.5*54.429.439.1Minimal Disease Activity (MDA)42.054.845.9*56.837.850.3PASI75b57.973.462.478.658.876.5PASI90b46.759.053.366.548.863.3PASI100b34.143.442.451.434.144.0Resolution of enthesitis by LEIc53.375.552.272.049.173.9Resolution of dactylitis by LDId69.994.571.796.272.495.2Change from BLeMMRMAOMMRMAOMMRMAOHealth Assessment Questionnaire - Disability Index (HAQ-DI)-0.55*-0.57-0.55*-0.59-0.45-0.47Patient’s assessment of pain (numeric rating scale)-3.3-3.5-3.4*-3.6-3.0-3.2Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)f-3.0-3.2-3.3-3.6-2.7-2.6Ankylosing Spondylitis Disease Activity Score (ASDAS)f-1.6-1.8-1.9*-2.1-1.5-1.6Modified total Sharp/van der Heijde Score (mTSS)0.030.010.010.000.110.11

ACR20/50/70, ≥20%/50%/70% improvement in American College of Rheumatology criteria; ADA, adalimumab; AO, as observed; BL, baseline; LDI, Leeds Dactylitis Index; LEI, Leeds Enthesitis Index; MMRM, mixed effect model repeated measurement; NRI, non-responder imputation; PASI75/90/100, ≥75%/90%/100% improvement in Psoriasis Area and Severity Index; pts, patients; UPA, upadacitinib.

aData shown as NRI and AO for binary endpoints.

bFor pts with psoriasis affecting ≥3% of body surface area at BL.

cFor pts with LEI >0 at BL; resolution LEI=0.

dFor pts with LDI >0 at BL; resolution LDI=0.

eData shown as MMRM (LS mean) and AO (mean) for continuous endpoints.

fFor pts with psoriatic spondylitis at BL.

Nominal *P<0.05, UPA15 or UPA30 vs ADA for NRI and MMRM; AO descriptive only.

Conclusion

In PsA pts, efficacy responses were similar or greater with UPA15 or UPA30 vs ADA at wk 104, and inhibition of radiographic progression was maintained. No new safety signals were identified with long-term exposure to UPA up to 2 years.

References

[1]McInnes I, et al. RMD Open, 2021; 7(3):e001838.

Acknowledgements

AbbVie and the authors thank the patients, study sites, and investigators who participated in this clinical trial (NCT03104400). AbbVie funded this study and participated in the study design, research, analysis, data collection, interpretation of data, reviewing, and approval of the publication. All authors had access to relevant data and participated in the drafting, review, and approval of this publication. No honoraria or payments were made for authorship. Medical writing support was provided by Monica R.P. Elmore, PhD of AbbVie.

Disclosure of Interests

Iain McInnes Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Gilead, Janssen, Novartis, Pfizer, Sanofi Regeneron, and UCB Pharma, Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Gilead, Janssen, Novartis, Pfizer, Sanofi Regeneron, and UCB Pharma, Koji Kato Shareholder of: Employee of AbbVie and may hold stock or options, Employee of: Employee of AbbVie, Marina Magrey Consultant of: UCB, Novartis, Eli Lilly, Pfizer, and Janssen, Grant/research support from: Amgen, AbbVie, and UCB Pharma, Joseph F. Merola Consultant of: Merck, Bristol-Myers Squibb, AbbVie, Dermavant, Eli Lilly, Novartis, Janssen, UCB, Celgene, Sanofi, Regeneron, Arena, Sun Pharma, Biogen, Pfizer, EMD Sorono, Avotres, and Leo Pharma, Mitsumasa Kishimoto Consultant of: AbbVie, Amgen-Astellas BioPharma, Asahi-Kasei Pharma, Astellas, Ayumi Pharma, BMS, Celgene, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Janssen, Kyowa Kirin, Novartis, Ono Pharma, Pfizer, Tanabe-Mitsubishi, Teijin Pharma, and UCB Pharma, Derek Haaland Speakers bureau: AbbVie, Amgen, AstraZeneca, Bristol-Myers Squibb, GlaxoSmithKline, Janssen, Novartis, Pfizer, Roche, Sanofi Genzyme, Takeda, Consultant of: AbbVie, Amgen, AstraZeneca, Bristol-Myers Squibb, Eli-Lilly, GlaxoSmithKline, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi Genzyme, Takeda, UCB, Grant/research support from: AbbVie, Adiga Life-Sciences, Amgen, Bristol-Myers Squibb, Can-Fite Biopharma, Celgene, Eli-Lilly, Gilead, GlaxoSmithKline, Janssen, Novartis, Pfizer, Regeneron, Sanofi-Genzyme, UCB, Liang Chen Shareholder of: Employee of AbbVie and may hold stock or options, Employee of: Employee of AbbVie, Yuanyuan Duan Shareholder of: Employee of AbbVie and may hold stock or options, Employee of: Employee of AbbVie, Jianzhong Liu Shareholder of: Employee of AbbVie and may hold stock or options, Employee of: Employee of AbbVie, Ralph Lippe Shareholder of: Employee of AbbVie and may hold stock or options, Employee of: Employee of AbbVie, Peter Wung Shareholder of: Employee of AbbVie and may hold stock or options, Employee of: Employee of AbbVie

OP0024 DIFFERENTIATION BETWEEN IL-6 AND IL-17 PATHWAY INHIBITION IN RELATIONSHIP WITH CLINICAL OUTCOMES IN NON-BIOLOGICAL DMARD-IR AND BIOLOGICAL DMARD-IR PSORIATIC ARTHRITIS PATIENTS TREATED WITH UPADACITINIB IN SELECT-PsA 1 AND SELECT-PsA 2 STUDIES

Background

The differential contribution of IL-6 and IL-17 pathways to the pathogenesis of psoriatic arthritis (PsA) is not fully understood. Upadacitinib (UPA), an oral JAK inhibitor, was more effective than placebo (PBO) in improving key clinical manifestations of PsA in two global phase 3 trials, SELECT-PsA 1 (non-biological DMARD-IR, nbDMARD-IR) and SELECT-PsA 2 (biological DMARD-IR, bDMARD-IR).1,2 Targeted proteomic analysis suggested that UPA modulates multiple biological pathways in innate and adaptive immune systems via direct and indirect inhibition of key regulators, including IL-6 and IL-17 pathways, with a possible shift from Th1 predominance in nbDMARD-IR PsA to a more Th17 bias in bDMARD-IR PsA.3

Objectives

We assessed the relationship between IL-6 and IL-17 pathway modulation and different clinical outcomes after UPA treatment in nbDMARD-IR and bDMARD-IR PsA patients.

Methods

A subset of patients was randomly selected from SELECT-PsA 1 (n=74 of UPA 15 mg QD, n=74 of PBO) and PsA 2 studies (n=90 of UPA 15 mg QD, n=81 of PBO). Serum levels of IL-6, IL-17A, IL-17F, and beta-defensin 2 (BD2) proteins were measured at baseline, week 2, and week 12 by validated immunoassays. The quantitative cytokine measurements were transformed as log10, and PASI score was transformed as log10 (x+1) prior to analysis. A Repeated Measure Mixed Linear Model was used to compare UPA versus PBO treatment effects in overall selected patients and between responders and non-responders defined by PASDAS score ≤ 3.6 (Minimal Disease Activity, MDA)4 and PASI75 at week 12, respectively. The relationships between cytokines and clinical outcomes (PASI and DAS28-CRP) were assessed by Pearson’s correlation at baseline and after treatment.

Results

In nbDMARD-IR PsA patients, baseline IL-17A, IL-17F, and BD2 levels correlated with each other and with PASI, while IL-6 appeared independent from the IL-17 pathway and correlated with DAS28-CRP. At week 12, UPA treatment significantly decreased IL-6 and BD2. The decrease of IL-6 was more pronounced in PASDAS MDA responders and correlated with DAS28-CRP improvement, but the decrease of BD2 was significant in PASI75 responders and correlated with PASI improvement. In contrast, IL-17A and IL-17F were not significantly changed after UPA treatment, neither correlated with clinical outcomes at week 12.

In bDMARD-IR PsA patients, baseline IL-17A level was significantly elevated compared to nbDMARD-IR patients but weakly correlated with other cytokines and show no correlation with PASI. At week 12, the reduction of IL-6 after UPA treatment was not different between responders and non-responders (PASDAS MDA or PASI75) and did not correlate with DAS28-CRP improvement, while the reduction of BD2 remained significant in PASI75 responders and correlated with PASI improvement. Further, UPA treatment significantly reduced IL-17A in PASDAS MDA responders and IL-17F in PASI75 responders compared to non-responders, respectively. The reduction of IL-17F correlated with PASI improvement at week 12.

Conclusion

IL-6 and IL-17 pathway inhibition after UPA treatment showed different profiles in relationship with clinical outcomes in nbDMARD-IR versus bDMARD-IR PsA patients. IL-6 decrease was more pronounced in nbDMARD-IR PsA patients and associated with joint manifestation improvement, while IL-17A and IL-17F decreases were only observed in bDMARD-IR PsA patients and associated with psoriasis improvement. BD2, a biomarker of Th17-associated skin pathology, significantly decreased after UPA treatment in both nbDMARD-IR and bDMARD-IR PsA studies, which likely contributed to UPA effects on psoriasis improvement in a broad range of PsA patients.

References

[1]McInnes IB, et al. N Engl J Med 2021;384:1227-39.

[2]Mease PJ, et al. Ann Rheum Dis 2020;80:312-20.

[3]Sornasse T, et al. Ann Rheum Dis 2021;80:433.

[4]Salaffi F, et al. Biomed Res Int 2014;2014:528105.

Acknowledgements

AbbVie, Inc., in collaboration with the authors, contributed to the study design, data collection and analysis, interpretation of the results, and preparation, review and approval of the final version. No honoraria or payments were made for authorship.

Disclosure of Interests

Fang Cai Shareholder of: AbbVie, Employee of: AbbVie, Thierry Sornasse Shareholder of: AbbVie, Employee of: AbbVie, Melanie Ruzek Shareholder of: AbbVie, Employee of: AbbVie, Yuni Fang Shareholder of: AbbVie, Employee of: AbbVie, Koji Kato Shareholder of: AbbVie, Employee of: AbbVie, Peter Wung Shareholder of: AbbVie, Employee of: AbbVie, Iain McInnes Consultant of: AbbVie, AstraZeneca, BMS, Lilly, Amgen, Causeway, Oxford Biodynamics, Novartis, Janssen, Pfizer, Boehringer, and UCB, Grant/research support from: AbbVie, AstraZeneca, BMS, Lilly, Amgen, Causeway, Oxford Biodynamics, Novartis, Janssen, Pfizer, Boehringer, and UCB.

Case Report: A Case of Epstein-Barr Virus-Associated Acute Liver Failure Requiring Hematopoietic Cell Transplantation After Emergent Liver Transplantation

Hepatic manifestations of Epstein-Barr virus (EBV) infection are relatively common, mild, and self-limiting. Although fulminant hepatic failure has been reported in a few cases, the contributing factors are unclear. This report discusses a pediatric case of EBV-associated acute liver failure that required urgent liver transplantation; however, liver damage continued to progress post-liver replacement. Monoclonal CD8+ T cells that preferentially infiltrated the native and transplanted liver were positive for EBV-encoded small RNA, suggesting a pathophysiology similar to that of EBV-associated hemophagocytic lymphohistiocytosis and chronic active EBV infection. Therefore, subsequent chemotherapy and hematopoietic cell transplantation was conducted, which led to cure. This is the first case of EBV-associated acute liver failure that relapsed post-liver transplant. As such, it sheds light on an under-recognized clinical entity: liver-restricted hyperinflammation caused by EBV-infected monoclonal CD8+ T cells. This phenomenon needs to be recognized and differentiated from hepatitis/hepatic failure caused by EBV-infected B cells, which has a relatively benign clinical course.

Thymoquinone Induced Leishmanicidal Effect via Programmed Cell Death in Leishmania donovani

Visceral leishmaniasis (VL) or kala-azar is a vector-borne dreaded protozoal infection that is caused by the parasite Leishmania donovani. With increases in the dramatic infection rates, present drug toxicity, resistance, and the absence of an approved vaccine, the development of new antileishmanial compounds from plant sources remains the keystone for the control of visceral leishmaniasis. In this study, we evaluated the leishmanicidal effect of thymoquinone against L. donovani with an in vitro and ex vivo model. Thymoquinone exhibited potent antipromastigote activity with IC₅₀ and IC₉₀ concentrations achieved at 6.33 ± 1.21 and 20.71 ± 2.15 μM, respectively, whereas the IC₅₀ and IC₉₀ concentrations were found to be 7.83 ± 1.65 and 27.25 ± 2.20 μM against the intramacrophagic form of amastigotes, respectively. Morphological changes in promastigotes and growth reversibility study following treatment confirmed the leishmanicidal effect of thymoquinone. Further, thymoquinone exhibited leishmanicidal activities against L. donovani promastigote through cytoplasmic shrinkage, membrane blebbing, chromatin condensation, cellular and nuclear shrinkage, and DNA fragmentation, as observed under scanning and transmission electron microscopy analyses. The antileishmanial activity was exerted via programmed cell death as proved by exposure of phosphatidylserine, DNA nicking by TUNEL assay, and loss of mitochondrial membrane potential. Thymoquinone at a concentration of 200 μM was devoid of any cytotoxic effects against mammalian macrophage cells. Thymoquinone showed strong leishmanicidal activity against L. donovani, which is mediated via an apoptosis mode of parasitic cell death, and accordingly, thymoquinone may be the source of a new lead molecule for the cure of VL.

Preoperative embolization strategy for the combined resection of replaced right hepatic artery in pancreaticoduodenectomy: a small case series

Background

Replaced right hepatic artery (rRHA) is a common vascular variation, and combined resection of this vessel is sometimes needed for the curative resection of pancreatic head malignancy. Safe surgical management has not been established, and there is a small number of reported cases. Here, we reported five cases, wherein preoperative embolization of rRHA was performed for combined resection.

Case presentation

All patients had pancreatic head malignancies that were in contact with rRHA. We performed a preoperative embolization of the rRHA before the scheduled pancreaticoduodenectomy for the combined resection. Arterial embolization was safely accomplished, and the communicating arcade from the left hepatic artery via the hilar plate was clearly revealed in all cases. Four patients underwent the operative procedure, except for one patient who had liver metastasis at laparotomy. No patient suffered from a severe abnormal liver function during the management; however, one patient had multiple liver infarctions during the postoperative course.

Conclusions

Preoperative embolization for the combined resection of rRHA in pancreaticoduodenectomy can be a management option for the precise evaluation of hemodynamics after sacrificing rRHA. In our cases, arterial flow to the right liver lobe was supplied by the left hepatic artery via the bypass route, including the communicating arcade of the hilar plate.

Association of circulating tumor DNA dynamics with clinical outcomes in the adjuvant setting for patients with colorectal cancer from an observational GALAXY study in CIRCULATE-Japan

9

Background: Circulating tumor DNA (ctDNA)-based molecular residual disease (MRD) has the potential to select patients who may benefit more from standard-of-care (SOC) adjuvant chemotherapy (ACT) by accurately assessing recurrence-risk post-surgery and by evaluating ACT efficacy. Here we present an analysis from GALAXY study, an observational study monitoring MRD, to evaluating the association of ctDNA dynamics with a short-term clinical outcome and ACT efficacy. Methods: A personalized tumor-informed assay (Signatera bespoke multiplex-PCR NGS assay) was used for post-surgical MRD detection in colorectal cancer (CRC) patients. Six-month disease-free survival (6M-DFS) rates were analyzed excluding patients enrolled in associated phase III trials (VEGA and ALTAIR). Results: Total 1,365 CRC patients enrolled between June 2020 and April 2021 were included in this analysis; 116 pStage I, 478 pStage II, 503 pStage III, and 268 oligomet resectable pStage IV (16% [42/268] received neoadjuvant chemotherapy). 6M-DFS rate by ctDNA dynamics from 4w to 12w were 98% in ‘negative to negative’ group (N = 618), 59% in ‘negative to positive’ (N = 32), 100% in ‘positive to negative’ (N = 58), and 45% in ‘positive to positive’ (N = 78), with a significant difference between ‘positive to negative’ and ‘positive to positive’ groups with hazard ratio (HR) of 52.3 (95% CI: 7.2-380.5; p < 0.001), with a median follow-up time of 6.6 months. Further, out of 188 patients who were MRD+ at 4w with available MRD status at 12w, 95 received SOC ACT (80/95 received fluoropyrimidine [FP] + oxaliplatin and 15 received FP alone) by an investigator’s decision. ctDNA clearance rate at 12w was significantly higher in ACT vs. non-ACT; 57% (54/95) vs. 8% (7/93) in pStage I-IV (p < 0.001), and 58% (42/72) vs. 11% (4/37) in pStage II-III (p < 0.001). In addition, ctDNA clearance rate at 24w was also significantly higher in ACT vs. non-ACT; 26% (7/27) vs. 0% (0/30) in pStage I-IV (p = 0.003), and 33% (7/21) vs. 0% (0/15) in pStage II-III (p = 0.03). Cumulative incidence of ctDNA clearance was significantly higher in ACT vs. non-ACT (67% vs. 7% by 24w; cumulative HR = 17.1; 95% CI: 6.7-43.4, p < 0.001). Among 4w-MRD+ patients, 6M-DFS rate was significantly higher in ACT vs. non-ACT; 84% vs. 34% (HR = 0.15; 95% CI: 0.078-0.25; p < 0.001), which was seen in all stages, including pStage II. Conclusions: This analysis from the GALAXY study, is the largest MRD study to date, demonstrating the association of ctDNA dynamics with improved clinical outcomes in MRD+ patients. Our study shows that stratifying post-surgical treatment decisions using the assay can identify patients likely to benefit from ACT across all stages, including pStage II. ctDNA-guided adjuvant strategy will further be established by ongoing randomized VEGA and ALTAIR studies and will be presented in the future conferences. Clinical trial information: jRCT1031200006.