Ramucirumab plus FOLFIRI as second-line treatment for patients with RAS wild-type metastatic colorectal cancer previously treated with anti-EGFR antibody: JACCRO CC-16

BACKGROUND

Chemotherapy in combination with anti-epidermal growth factor receptor (EGFR) antibody is considered a first-line treatment regimen for RAS wild-type and left-sided metastatic colorectal cancer (mCRC), whereas second-line treatment regimens have not yet been established. Few studies have prospectively evaluated second-line treatment with anti-vascular endothelial growth factor antibody after first-line anti-EGFR antibody therapy for RAS wild-type mCRC.

PATIENTS AND METHODS

This non-randomized phase II trial investigated the clinical outcomes of second-line ramucirumab (RAM) plus fluorouracil, levofolinate, and irinotecan (FOLFIRI) after first-line anti-EGFR antibody in combination with doublet or triplet regimen in patients with RAS wild-type mCRC. The primary endpoint was the 6-month progression-free survival (PFS) rate. The secondary endpoints were PFS, overall survival (OS), objective response rate (ORR), rate of early tumor shrinkage (ETS), and safety. We hypothesized a threshold 6-month PFS rate of 30% and an expected 6-month PFS rate of 45%. Treatment was considered effective if the lower limit of the 90% confidence interval (CI) of the 6-month PFS rate was >0.30.

RESULTS

Ninety-two patients were enrolled in the study. The primary tumor was located on the left side in 86 (95.6%) patients. Twenty (22.0%) patients had received triplet plus cetuximab as previous therapy. Six-month PFS rate was 58.2% (90% CI 49.3% to 66.2%) with a median PFS of 7.0 months (95% CI 5.7-7.6 months). Median OS was 23.6 months (95% CI 16.5-26.3 months). The ORR and ETS rate were 10.7% and 16.9%, respectively, in 83 patients with measurable lesions. The 6-month PFS rate was comparable between patients previously treated with doublet and triplet regimens; however, median PFS was longer for the doublet regimen (7.4 versus 6.4 months, P = 0.036).

CONCLUSIONS

Our study demonstrated prospectively that RAM plus FOLFIRI is an effective second-line treatment after anti-EGFR antibody-containing first-line therapy in RAS wild-type and left-sided mCRC. Furthermore, the results were similar for patients who were previously treated with triplet regimen.

Bi-directional relationships of arterial stiffness with hypertension and diabetes mellitus from the early pathophysiological stages: a 16-year prospective observational study

Background

Hypertension and diabetes mellitus frequently coexist; however, it has not yet been clarified if the bidirectional longitudinal relationships between arterial stiffness and hypertension are independent of those between arterial stiffness and diabetes mellitus.

Methods

In this 16-year prospective observational study, 3960 middle-aged employees of a Japanese company without hypertension/diabetes mellitus at the study baseline underwent annual repeated measurements of the blood pressure, serum glycosylated hemoglobin A1c levels (HbA1c), and brachial-ankle pulse wave velocity (baPWV).

Results

By the end of the study period, 664, 779, 154, and 406 subjects developed hypertension, prehypertension, diabetes mellitus, and prediabetes, respectively. Increased baPWV at the baseline was associated with a significant odds ratio (per 1 standard deviation increase) for new onset of prehypertension/hypertension with (2.45/3.28, P<0.01) or without (2.49/2.76, P<0.01) coexisting prediabetes/diabetes mellitus, but not for new onset of prediabetes/diabetes mellitus without coexisting hypertension. Analyses using the latent growth curve model confirmed the bidirectional relationships between baPWV and hypertension, but no such relationship was observed between baPWV and abnormal glucose metabolism. Moreover, after the adjustments, higher mean blood pressure at baseline accelerated the increases in the baPWV over follow-up (unstandardized coefficient [B] = 0.39, standard error [SE] = 0.05x10–1, P<0.01). Similarly, higher baPWV at baseline accelerated the increases in mean blood pressure over follow-up (B = 0.02x10–1, SE = 0.01x10–1, P<0.01) (Figure 1). On the other hands, higher HbA1c levels at baseline accelerated the increases in the baPWV over follow-up (B = 0.43, SE = 0.05x10–1, P<0.01), but higher baPWV at baseline did not accelerate the increases in HbA1c levels over follow-up (B <0.01, SE <0.01, P=0.52) (Figure 2).

Conclusions

In middle-aged employees of a Japanese company, in contrast to the bidirectional relationships that exist between arterial stiffness and hypertension, increased arterial stiffness preceding the development of diabetes mellitus may represent that associated with the development of hypertension, as it is observed only in cases of diabetes mellitus coexisting with hypertension. Therefore, arterial stiffness may be associated to a greater degree with the development of hypertension than with the development of diabetes mellitus.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Omron Health Care Company (Kyoto, Japan),Teijin Pharma Company (Tokyo, Japan)

Age-related differences in longitudinal associations between alcohol intake and arterial stiffness, pressure wave reflection, and inflammation in male employees

Backgrounds

While arterial stiffness and abnormal pressure wave reflection are independent cardiovascular risk, the difference of their association with alcohol intake have not been fully clarified.

Aim

This prospective observational study, which utilized repeated annual measurements performed over a 9-year period, applied mixed model analyses to examine age-related differences in longitudinal associations between alcohol intake and arterial stiffness, pressure wave reflection, and inflammation.

Methods

In 4016 middle-aged (43±9 years) healthy Japanese male employees, alcohol intake, brachial-ankle pulse wave velocity (baPWV), radial augmentation index (rAI), and serum C-reactive protein (CRP) levels were measured annually during a 9-year study period. Based on the questionnaire, alcohol intake was classified as non-drinker, mild-moderate drinker (ethanol 1–20 g/day) and heavy drinker (>20 g/day).

Results

The estimated marginal mean baPWV (non-drinkers = 1306 cm/s, mild-moderate drinkers = 1311 cm/s, and heavy drinkers = 1337 cm/s, P<0.01) and that of rAI showed significant stepped increases in an alcohol dose-dependent manner in the entire cohort, but an increase in rAI was not observed in subjects aged ≥50 years. The estimated slope of the annual increase in baPWV, but not rAI, was higher for heavy drinkers than for non-drinkers (slope difference, 2.73; P<0.01), especially for subjects aged <50 years. The estimated marginal mean of the serum CRP levels was lower for drinkers than for non-drinkers.

Conclusion

In middle-aged male Japanese employees, alcohol intake may attenuate inflammatory activity. While alcohol intake may exacerbate the progression of arterial stiffening in a dose-dependent manner without mediating inflammation, especially in subjects under 50 years of age, it may promote pressure wave reflection abnormalities with aging at earlier ages without further exacerbation at older ages.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Omroncarpis

O-288 Association of initial zygote cleavage, compaction pattern and euploidy rates: possible implications for embryo correction mechanisms

Study question

Is the morula compaction pattern associated with early zygote cleavage anomalies and euploidy rates? Can it represent a possible mechanism of embryonic correction?

Summary answer

Abnormalities in the first divisions give rise to dysfunctional blastomeres, which were excluded from compaction process. This process represent a possible embryonic correction mechanism.

What is known already

IVF embryos have historically been analyzed based on morphological characteristics focusing on days 2/3 (cleavage stage) and 5/6 (blastocyst). The morula stage, usually reached on day 4, represent a transitional phase resulting from the embryonic genome activation and has received little attention in clinical embryology. However, during this crucial stage, cell differentiation begins, metabolism reaches higher levels, changes in cell shape and cell-destination mechanisms are enhanced, providing opportunities for “quality control”. At morula stage, embryos with severe genetic abnormalities are sorted out by natural selection or possibly self-correction events may occurs, reducing the load of aneuploid cells in mosaic embryos.

Study design, size, duration

We evaluated laboratory and clinical outcomes of 836 blastocysts (195 ICSI cycles) cultured in a time-lapse system and biopsied for preimplantation genetic testing for aneuploidy (PGT-A), from April-2018 to June-2020. Time-lapse videos were retrospectively analyzed to assess morphokinetic parameters of initial zygote cleavages and morula compaction. These parameters were evaluated and associated to genetic and embryonic outcomes. Blastocyst outcomes were also assessed according to maternal age <35 (n = 140), 35-37 (n = 175), 38-40 (n = 314) and >40 (n = 207).

Participants/materials, setting, methods

The zygote initial cleavages were classified as normal (1-2-4 cleavage) or anomalous: 1-3 cleavage (zygote splits directly into three blastomeres); 1-2-3 cleavage (2-3 in < 3h); and 1-2-5 cleavage (after the first normal cleavage, one blastomere splits directly into three blastomeres). Morula were classified as: Fully Compacted Morulae (FCM); Partially Compacted Morulae (PCM). The PCM could have cells excluded from the compaction process (Exc-PCM), extruded from an already compacted morula (Ext-PCM), or both situations (Exc/Ext-PCM).

Main results and the role of chance

Most blastocysts showed normal zygotic cleavage (83.3%). Anomalous cleavage such as 1-3 (0.8%), 1-2-3 (7.2%) and 2-5 (8.7%) were less prevalent and no differences were observed according to female age (p = 0.268). Overall, FCM (61.0%) was a more frequent pattern than PCM (39.0%). According to compaction pattern of PCM, Exc-PCM (25.1%) was more prevalent than Ext-PCM (11.5%) and Exc/Ext-PCM (2.4%). There was also no difference in the prevalence of the morulae compaction pattern according to female age (p = 0.124). FCM occurred in 511 embryos (73.4%) from zygotes with normal cleavage (n = 696), but no FCM was observed among anomalous cleaved zygotes (p < 0.001). Genetic and embryonic outcomes were displayed as follows: normal cleavage and FCM (NC-FCM, n = 511), normal cleavage and PCM (NC-PCM, n = 185), and anomalous cleavage and PCM (AC-PCM, n = 140). NC-FCM and AC-PCM groups showed statistically similar euploidy rates (39.3% and 38.6%, p = 0.870), that were both significantly higher than the NC-PCM group euploidy rate (23.8%, p < 0.001). However, morphokinetic scores (KidScore) and percentage of top-quality blastocysts at morphological evaluation were discordant: NC-FCM (6.4±1.7; 81.4%), NC-PCM (5.0±1.8; 47.6%) and AC-PCM (4.3±2.0; 37.9%). Euploidy rate decreased with female age for all groups: NC-FCM (<35:54.7%, 35-37:56.0%, 38-40:33.3%, >40:24.1%); NC-PCM (<35:37.5%, 35-37:19.0%, 38-40:25.0%, >40:19.0%); AC-PCM (<35:66.7%, 35-37:48.5%, 38-40:39.0%, >40:3.7%).

Limitations, reasons for caution

The retrospective design of the study represents a general limitation. In addition, this study evaluated only embryos that reached the blastocyst stage and showed enough quality to be biopsied. Therefore, the association between anomalies in the first and second mitotic cleavages and the embryonic development could not be evaluated.

Wider implications of the findings

Similar euploidy rates among NC-FCM and AC-PCM support the hypothesis that cell exclusion/extrusion in compaction stage of anomalous-cleaved zygotes can represent a potential correction mechanism, even though lower morphological/morphokinetic scores are seen on AC-PCM. That process is supposed to rescue embryos from the mosaic aneuploidy which occurs after abnormal cleavage.

Trial registration number

not applicable

Dynamic changes in RAS gene status in circulating tumour DNA: a phase II trial of first-line FOLFOXIRI plus bevacizumab for RAS-mutant metastatic colorectal cancer (JACCRO CC-11)

Background

Few prospective studies have used liquid biopsy testing in RAS-mutant metastatic colorectal cancer (mCRC), and its clinical significance remains unknown. Therefore, this study aimed to carry out a biomarker analysis by liquid biopsy using updated data of the phase II trial of FOLFOXIRI plus bevacizumab as first-line chemotherapy for RAS-mutant mCRC.

Materials and methods

A total of 64 patients who received modified FOLFOXIRI regimen (irinotecan 150 mg/m², oxaliplatin 85 mg/m², levofolinate 200 mg/m², and fluorouracil 2400 mg/m²) plus bevacizumab biweekly were enrolled. The primary endpoint was the objective response rate (ORR). Plasma samples were collected at pre-treatment, 8 weeks after treatment, and progression in participants included in the biomarker study. The levels of circulating tumour DNA (ctDNA) and specific KRAS and NRAS variants were evaluated using real-time PCR assays.

Results

There were 62 patients (median age: 62.5 years, 92% performance status 0, 27% right side) who were assessable for efficacy and 51 for biomarker analysis. ORR was 75.8% (95% confidence interval 65.1% to 86.5%). The median progression-free survival was 12.1 months, and the median overall survival (OS) was 30.2 months. In 78% of patients, RAS mutations disappeared in the ctDNA at 8 weeks after treatment; these patients tended to have better outcomes than those with RAS mutations. Interestingly, RAS mutations remained undetectable during progression in 62% of patients. Survival analysis indicated that the median OS from progression was significantly longer in patients with RAS mutation clearance than in those with RAS mutation in the ctDNA at disease progression (15.1 versus 7.3 months, hazard ratio: 0.21, P = 0.0046).

Conclusions

Our biomarker study demonstrated no RAS mutations in ctDNA at disease progression in 62% of patients with RAS-mutant mCRC. Both OS and post-progression survival were better in patients with clearance of RAS mutations in ctDNA after triplet-based chemotherapy.

•

First-line FOLFOXIRI plus bevacizumab is effective for RAS-mutant mCRC with comparable efficacy in elderly patients.

•

RAS mutations disappeared in ctDNA after intensive chemotherapy in 62% of patients with mCRC with RAS-mutant tumours.

•

Survival time was longer in patients with RAS mutation clearance than in those with RAS mutations in ctDNA.

Sodium-glucose cotransporter 2 inhibitors in type 2 diabetes patients with renal function impairment slow the annual renal function decline, in a real clinical practice

AIMS/INTRODUCTION

The aim of this study was to elucidate whether sodium-glucose cotransporter 2 inhibitors (SGLT2is) treatment has any renoprotective effect for type 2 diabetes mellitus patients with an estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m2 in clinical practice.

MATERIALS AND METHODS

We evaluated the annual eGFR slope in 85 type 2 diabetes mellitus patients with renal impairment, treated with SGLT2is ≥2 years. Each patient's eGFR was <60 mL/min/1.73 m2 at the start of SGLT2is therapy. The calculation of the annual change in eGFR for each patient was obtained by acquired eGFR data before and after 2 years of the initial SGLT2is administration, followed by analysis of the changes in the mean eGFR slope.

RESULTS

The participants' mean age was 72.0 ± 9.4 years, and the mean eGFR was 47.1 ± 9.7 mL/min/1.73 m2 at the start of additional treatment with SGLT2is. The mean annual eGFR slope after SGLT2is administration (-0.11 ± 0.20 mL/min/1.73 m2 /year) was significantly slower than before SGLT2is administration (-2.93 ± 0.59 mL/min/1.73 m2 /year; P < 0.0001). Additionally, SGLT2is treatment slowed the annual decline of eGFR, independent of the levels of both the initial eGFR and albuminuria levels before SGLT2is therapy was started. In the patient groups who showed an annual eGFR decline of ≥3 and 1-3 mL/min/1.73 m2 , there was a significant slowing of the decline after SGLT2is therapy, compared with before the treatment (P < 0.001, respectively).

CONCLUSIONS

SGLT2is administration slows the decline observed in the annual renal function in type 2 diabetes mellitus patients with eGFR of <60 mL/min/1.73 m2 in clinical practice.

Anterior pituitary function in Rathke's cleft cysts versus nonfunctioning pituitary adenomas

Although Rathke's cleft cysts (RCCs) are common sellar/parasellar lesions, studies examining pituitary function in patients with nonsurgical RCC are limited. This study aimed to clarify the importance of RCCs, including small nonsurgical ones, as a cause of hypopituitarism by determining the prevalence of pituitary hormone secretion impairment and its relationship to cyst/tumor size in patients with RCC and in those with nonfunctioning pituitary adenoma (NFA). We retrospectively investigated the basal levels of each anterior pituitary hormone, its responses in the stimulation test(s), and cyst/tumor size in patients with RCC (n = 67) and NFA (n = 111) who were consecutively admitted to our hospital for endocrinological evaluation. RCCs were much smaller than NFAs (median height, 12 vs. 26 mm). The prevalence of gonadotropin, PRL, and GH secretion impairment in RCC was lower in comparison to NFA (19% vs. 44%, 34% vs. 61%, and 24% vs. 46%, respectively), whereas the prevalence of TSH and ACTH secretion impairment was comparable (21-27% and 17-24%, respectively). A significant positive relationship between cyst/tumor size and number of impaired hormones was observed in both groups, but smaller cysts could cause hormone secretion impairment in RCC. Stimulation tests suggested that most hormone secretion impairment was attributable to the interrupted hypothalamic-pituitary axis in both groups. Therefore, RCC, even small ones, can cause pituitary dysfunction. Different mechanisms may underlie hypothalamic-pituitary interruption in RCC and NFA.

Clinical effectiveness of efinaconazole 10% solution for treatment of onychomycosis with longitudinal spikes

Onychomycosis with longitudinal spikes in the nail plate has been reported to be refractory to oral drugs as with dermatophytoma. We evaluated the efficacy of 10% efinaconazole solution in the treatment of onychomycosis with longitudinal spikes. Of the 223 subjects who were enrolled in a previous study, a post‐hoc analysis of 82 subjects with longitudinal spikes was performed in this study. The opacity ratio of longitudinal spikes was decreased over time from 8.1 to 0.9 at the final assessment. In addition, the longitudinal spike disappearance rate increased early after the application to 81.7% at the final assessment. Therefore, 10% efinaconazole solution can be a first‐line drug for longitudinal spikes, which have been regarded as refractory to oral drugs.

The mechanisms of age-realted difference of annual changes in ankle-brachial pressure index

 

In addition to both pulse wave velocity (PWV; a marker of arterial stiffness) and augmentation index (AI; a marker of central hemodynamics), not only the decrease of ankle-brachial pressure index (ABI) but also its increase predict the future cardiovascular events. While arterial stiffness and central hemodynamics have been proposed to affect the increase in ABI logically, their effects on increase in ABI have not been fully clarified. The present cross-sectional and longitudinal studies were conducted to examine the associations of arterial stiffness and central hemodynamics with increase in ABI and also examine the age-related difference of those associations. In 4016 men (42±9 years old), ABI, brachial-ankle PWV (baPWV) and radial AI (rAI) were measured annually for 9 years' observation period. In the cross-sectional analyses adjusted with age, heart rate and mean blood pressure, both baPWV and rAI were associated with ABI in men aged &lt;50, but not in men aged &gt;50. As shown in Figure, ABI was annually increased in subjects aged &lt;50 (n=2870), but not in those aged &gt;50 (n=1146) during the follow-up period. The mixed model linear regression analysis (MMA) conducted in 9 years' annual repeated measurement data demonstrated that increased baPWV (estimate = 0.017, p&lt;0.05) and increased rAI (estimate 0.254, p&lt;0.05) were significant determinant of annual increase of ABI (p&lt;0.01) in men aged &lt;50, but not in men aged &gt;50. In conclusion, the arterial stiffness and central hemodynamics may individually affect the increase in ABI in men aged &lt;50, but not in men &gt;50. Thus, further studies are needed to clarify whether ABI, arterial stiffness, and central hemodynamics individually predicts future cardiovascular events, and their age-related difference of their predictabilities.

figure1

Funding Acknowledgement

Type of funding source: Private hospital(s). Main funding source(s): Tokyo Medical University

The associations among arterial stiffness, endothelial dysfunction and the progression of carotid atherosclerosis in hypertensive subjects with/without carotid atherosclerosis

Background

While arterial stiffness and endothelial dysfunction, which are diffuse vascular damage, are phenotypes of vascular damage, their associations with the progression of atherosclerosis, which is focal vascular damage, has not been fully clarified. The present prospective observational study was conducted to examine whether arterial stiffness and endothelial dysfunction predict the progression of carotid atherosclerosis in subjects medicated for hypertension with/without carotid atherosclerosis.

Methods and results

In 617 subjects receiving antihypertensive treatment, we conducted flow-mediated vasodilatation (FMD), brachial-ankle pulse wave velocity (baPWV) and common carotid artery intima-media thickness mean and maximal (IMTmean and IMTmax) at the baseline and the end (3 years' later) of study periods. During the study period, FMD was decreased and baPWV, IMTmean and IMTmax were increased significantly. In subjects without carotid atherosclerosis (IMTmax &lt;1.1mm, n=416), baPWV, but not FMD, at baseline had significant associations with IMTmean and IMTmax at both the baseline and end of study period. As shown in Figure, the changes of IMTmean and also IMTmax during the study period were higher in the highest tertile ranges of baPWV at the baseline than in the lowest tertile range of baPWV. On the other hand, in subjects with carotid atherosclerosis (IMTmax &gt;1.1mm, n=201), both baPWV and FMD were not associated with any markers of carotid atherosclerosis and also their changes during the study period.

Conclusion

In subjects with hypertension, arterial stiffness rather than endothelial dysfunction may be associated with the progression of carotid atherosclerosis, and this association may be significant in the premature stage of atherosclerosis.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Omron Healthcare, Asahikasei Calpis

Case report of superior mesenteric artery syndrome that developed in a lean type 2 diabetes patient and was associated with rapid body weight loss after sodium-glucose cotransporter 2 inhibitor administration

A 58-year-old women who was diagnosed with type 2 diabetes 20 years earlier had been treated with antidiabetic medicines since she was aged 40 years. After sodium-glucose cotransporter 2 inhibitors administration, her bodyweight rapidly decreased from 40 to 30 kg over a period of 3 weeks. She had abdominal symptoms, including nausea, especially after a meal. On admission, physical examinations and laboratory data showed euglycemic ketoacidosis, dehydration and low insulin secretion levels. Additionally, abdominal contrast computed tomography showed the finding of superior mesenteric artery syndrome. This case urges caution, including rapid excessive bodyweight loss and euglycemic ketoacidosis, on the use of sodium-glucose cotransporter 2 for lean diabetes patients.

Mineral trioxide aggregate suppresses pro-inflammatory cytokine expression via the calcineurin/nuclear factor of activated T cells/early growth response 2 pathway in lipopolysaccharide-stimulated macrophages

AIM

To elucidate mechanisms by which mineral trioxide aggregate (MTA) suppresses pro-inflammatory cytokine mRNA expression in lipopolysaccharide (LPS)-stimulated RAW264.7 macrophages.

METHODOLOGY

Mineral trioxide aggregate extracts were prepared by immersing set ProRoot MTA in culture medium. RAW264.7 cells were cultured in the presence of LPS and MTA extracts. mRNA expression levels of interleukin (IL)-1α, IL-6, early growth response 2 (Egr2), suppressor of cytokine signalling 3 (Socs3) and IL-10 were quantified with reverse transcription-quantitative polymerase chain reaction. Phosphorylation of nuclear factor-kappa B (NF-κB) p65 in RAW264.7 cells was analysed by Western blotting. Intracellular calcium imaging was performed with Fluo-4 AM. The activity of nuclear factor of activated T cells (NFAT) was determined by luciferase assays. Enforced expression and silencing of Egr2 in RAW264.7 cells were carried out using an expression vector and specific RNAi, respectively. In vivo kinetics of Egr2⁺ cells in MTA-treated rat molar pulp tissues were examined using immunohistochemistry. Data were analysed by one-way analysis of variance, followed by the Tukey-Kramer test (P < 0.05).

RESULTS

Exposure to MTA extracts resulted in reduced mRNA expression levels of IL-1α and IL-6, as well as reduced expression of phosphorylated NF-κB, in LPS-stimulated RAW264.7 cells. Exposure to MTA extracts induced Ca²⁺ influx, which was blocked by NPS2143, an antagonist of calcium-sensing receptor (CaSR); Ca²⁺ influx then triggered activation of calcineurin/NFAT signalling and enhanced mRNA expression of Egr2. Enforced expression of Egr2 in RAW264.7 cells promoted the expression of both IL-10 and Socs3. In vivo application of MTA onto rat molar pulp tissue resulted in the appearance of Egr2-expressing cells that coexpressed CD163, a typical M2 macrophage marker.

CONCLUSIONS

Mineral trioxide aggregate extracts induced downregulation of IL-1α and IL-6 in LPS-stimulated RAW264.7 cells via CaSR-induced activation of calcineurin/NFAT/Egr2 signalling and subsequent upregulation of IL-10 and Socs3.

Prevalence of human papillomavirus in oral gargles and tonsillar washings

OBJECTIVES

Human papillomavirus (HPV) infection drives carcinogenesis in the oropharynx. No standard sampling or HPV detection methods for evaluating oropharyngeal HPV infection exist. The prevalence of oral HPV infection in Japan is unknown.

MATERIALS AND METHODS

We examined 435 healthy Japanese individuals to address whether adding tonsillar washing to oral gargling would improve HPV detection. We compared HPV assessment using GENOSEARCH HPV31 versus nested PCR and direct sequencing. Associations between HPV infection and demographic and behavioral characteristics were examined.

RESULTS

Most participants who were HPV-positive based on oral gargles were also HPV-positive based on tonsillar washings: 11 (64.7%) of 17 on nested PCR and 12 (70.6%) of 17 on GENOSEARCH HPV31. Although HPV infection was more prevalent in oral gargles followed by tonsillar washings than in oral gargles alone, the difference was not statistically significant (nested PCR, 4.8% vs. 3.9%, P = 0.46; GENOSEARCH HPV31, 5.3% vs. 3.9%, P = 0.33). The overall agreement between nested PCR and GENOSEARCH HPV31 was 98.6%, with 76.0% positive agreement. The overall prevalence of oral HPV infection in Japan was 5.7% (95% confidence interval, 3.9-8.3%). Men had a significantly higher prevalence of oral HPV infection than women (8.3% vs. 2.6%, P = 0.02). Infection increased with number of lifetime sexual partners (P < 0.001 for trend).

CONCLUSION

The oropharynx is probably the major source of HPV-infected cells in oral gargles. Oral gargling could be a standard sampling method for evaluating oropharyngeal HPV infection. GENOSEARCH HPV31 could be an option for oral HPV detection.

P1632A possible independent contribution of liver stiffness to the development of heart failure in its early stage

Background

Heart failure (HF) is a heterogeneous condition. The reduced liver blood flow and hepatic congestion associated with HF causes liver damages leading to liver sclerosis. Fibrosis 4 score (FIB-4 score), a marker of liver sclerosis, is easily calculated from age, serum aspartate aminotransferase (AST), alanine aminotransferase (ALT) level and blood platelet count (PLT). Liver stiffness is known to be associated with vascular damages, including arterial stiffness and central hemodynamics. These vascular damages also cause the new onset of HF. However, it remains to be clarified whether liver stiffness is a direct risk factor for HF or whether its association with HF is mediated by vascular damage. We conducted cross-sectional and prospective longitudinal studies to examine whether FIB-4 score is directly associated with the serum NT-pro-BNP levels or the association is mediated by arterial stiffness and/or abnormal central hemodynamics.

Methods and results

In 3,040 health Japanese subjects with serum NT-pro-BNP levels <125 pg/ml, the FIB-4 score was calculated, and the serum NT-pro-BNP levels, brachial-ankle pulse wave (baPWV) velocity, radial augmentation index (rAI), second peak of the radial pressure waveform (SBP2) and PP2 (SBP2 – diastolic blood pressure) were measured. These parameters were measured again after a 3-year interval in 2,135 subjects. Pearson's correlation analysis demonstrated that FIB-4 score was significantly correlated with baPWV, rAI, SBP2, PP2 and the log-transformed the serum NT-pro-BNP levels. Multivariate linear regression analysis demonstrated a significant cross-sectional association of the FIB-4 scores with the log-transformed the serum NT-pro-BNP levels (beta = 0.08, p<0.01), but not with the baPWV, rAI, SBP2 and PP2. The change of serum NT-pro BNP levels during the study period was significantly higher in subjects with increase of the FIB-4 score during the study period (8.2±22.5 pg/ml) than that in those with decrease/no change (5.4±22.3 pg/ml) (p<0.05). The change of FIB-4 score during the study period was significantly associated with the change of the serum NT-pro-BNP levels during the study period (beta = 0.09, p<0.01).

Conclusion

Liver stiffness may have a significant direct association with the development of HF from the early stage, without the mediation of arterial stiffness and/or abnormal central hemodynamics. Therefore, the FIB-4 score appears to serve as a direct risk factor for HF from the early stage, and its association with HF may not be mediated by vascular damages.

Efficacy of long-term treatment with efinaconazole 10% solution in patients with onychomycosis, including severe cases: A multicenter, single-arm study

We evaluated the efficacy of efinaconazole 10% topical solution in long‐term use, for up to 72 weeks, for onychomycosis, including severe cases. Among 605 participants, 219 patients diagnosed as having onychomycosis were evaluated for the efficacy of efinaconazole. The treatment success rate (<10% clinical involvement of the target toenail) at the final assessment time point was 56.6%, the complete cure rate was 31.1% and the mycological cure rate was 61.6%, all of which increased over time, demonstrating that continuous application contributed to the improvement of cure rate. Even in severe cases, reduction of the affected nail area was observed, showing the potential efficacy of the treatment. Responses to a quality of life questionnaire among patients with onychomycosis, OnyCOE‐t, suggested that efinaconazole treatment improved the patients’ quality of life. The incidence of adverse drug reaction in the patients eligible for the assessment was 6.3%, and this developed only in the administration site in all cases. No systemic adverse event was observed. In addition, no increase in the incidence of adverse drug reaction due to long‐term use was found. Efinaconazole therapy was proved to exhibit excellent balance between efficacy and safety, and thus may serve as a useful treatment option for onychomycosis.

Effect of switching to teneligliptin from other dipeptidyl peptidase-4 inhibitors on glucose control and renoprotection in type 2 diabetes patients with diabetic kidney disease

AIMS/INTRODUCTION

The objective of the present study was to elucidate the effect of switching to teneligliptin from other dipeptidyl peptidase-4 (DPP-4) inhibitors on glucose control and renoprotection in type 2 diabetes mellitus patients with diabetic kidney disease.

MATERIALS AND METHODS

The present study was a single-arm, open-label, observational study. A total of 23 patients, who had urinary albumin/creatinine ratios (UACR) ≥30 mg/gCr in their first urine in the early morning, and received other DPP-4 inhibitors and renin-angiotensin system inhibitors, switched to teneligliptin 20 mg/day. After switching to teneligliptin for 24 weeks, we evaluated changes in glycated hemoglobin (HbA1c), fasting plasma glucose levels, plasma DPP-4 activity and UACR.

RESULTS

HbA1c, fasting plasma glucose and UACR values showed no significant change after 24 weeks compared with baseline. However, plasma DPP-4 activity was significantly reduced after 24 weeks (0.57 ± 0.26 nmol/min/mL, P = 0.012, vs baseline), compared with baseline (1.49 ± 1.73 nmol/min/mL), and there was a positive relationship between the change rate of plasma DPP-4 activity (Δ%DPP-4) for 24 weeks and the levels of plasma DPP-4 activity (r = -0.5997, P = 0.0025) and fasting plasma glucose (r = -0.4235, P = 0.0440) at baseline. Additionally, the Δ%DPP-4 for 24 weeks was significantly correlated to the change rate of UACR (r = 0.556, P = 0.0059). However, there was no relationship between Δ%DPP-4 and ΔHbA1c (amount of HbA1c change).

CONCLUSIONS

Switching to teneligliptin from other DPP-4 inhibitors for 24 weeks reduces plasma DPP-4 activity, which is associated with a reduction in albuminuria, independent of the change in glucose levels, in type 2 diabetes mellitus patients with diabetic kidney disease.

Podoplanin suppresses the cell adhesion of epidermal keratinocytes via functional regulation of β1-integrin

Epidermal stem cells adhere more efficiently to the extracellular matrix (ECM) than the less adhesive differentiating cells due to their high expression of cell adhesion molecules including β1-integrin. Podoplanin is majorly expressed in the markedly proliferative and differentiating basal cells of the wounded and psoriatic epidermis. This study was designed to reveal podoplanin's function in human epidermal keratinocytes (HEK) focusing on its interaction with β1-integrin. We analyzed the adhesion and differentiation of HEK in both podoplanin-overexpressing and -knock-down cells, considering their β1-integrin levels. The basal layer of IL-22-treated hyperproliferative reconstituted epidermis cells (simulating basal hyperproliferative psoriatic epidermal basal cells) expressed higher podoplanin levels than the untreated control cells. The adhesiveness of HaCaT cells, which do not express podoplanin, was reduced after the overexpression of podoplanin. HEK with podoplanin overexpression suppressed the cell adhesion to type I collagen (while downregulating β1-integrin functions) and podoplanin silencing augmented it (by increasing active ECM-bound β1-integrin). The increased cell adhesion to type I collagen induced by podoplanin silencing could be reversed by addition of P5D2, a neutralizing antibody against β1-integrin. In the psoriatic epidermis, podoplanin expression was especially upregulated on the rete ridges of the basal cell layer. This expression pattern was inversely correlated with the total/ECM-bound active β1-integrin-expression, which was stronger at the basal cell layer covering the dermal papillae. Our results indicate that podoplanin inhibits the cell ECM attachment by suppressing β1-integrin and initiating HEK differentiation. Podoplanin is presumably involved in the pathogenesis of psoriasis.

Effects of pruritogens and algogens on rostral ventromedial medullary ON and OFF cells

Rostroventromedial medulla (RVM) ON and OFF cells are thought to facilitate and inhibit spinal nociceptive transmission, respectively. However, it is unknown how ON and OFF cells respond to pruritic stimuli or how they contribute to descending modulation of spinal itch signaling. In pentobarbital sodium-anesthetized mice, single-unit recordings were made in RVM from ON and OFF cells identified by their respective increase or decrease in firing that occurred just before nocifensive hindlimb withdrawal elicited by paw pinch. Of RVM ON cells, 75% (21/28) were excited by intradermal histamine, 50% (10/20) by intradermal chloroquine, and 75% (27/36) by intradermal capsaicin. Most chemically responsive units also responded to a scratch stimulus applied to the injected hindpaw. Few ON cells responded to intradermal injection of vehicle (saline: 5/32; Tween 2/17) but still responded to scratching. For OFF cells, intradermal histamine and scratching inhibited 32% (6/19) with no effect of histamine in the remainder. Intradermal chloroquine inhibited 44% (4/9) and intradermal capsaicin inhibited 61% (11/18) of OFF cells. Few OFF cells were affected by vehicles (Tween: 1 inhibited, 7 unaffected; saline: 3 excited, 1 inhibited, 8 unaffected). Both ON and OFF cells that responded to one chemical usually also responded to others, whereas units unresponsive to the first-tested chemical tended not to respond to others. These results indicate that ascending pruriceptive signals activate RVM ON cells and inhibit RVM OFF cells. These effects are considered to facilitate and disinhibit spinal pain transmission, respectively. It is currently not clear if spinal itch transmission is similarly modulated. NEW & NOTEWORTHY The rostroventromedial medulla (RVM) contains ON and OFF cells that are, respectively, excited and inhibited by noxious stimuli and have descending projections that facilitate and inhibit spinal nociceptive transmission. Most RVM ON cells were excited, and OFF cells inhibited, by intradermal injection of the pruritogens histamine and chloroquine, as well as the algogen capsaicin. These results indicate that itchy stimuli activate RVM neurons that presumably give rise to descending modulation of spinal itch transmission.