Antiproliferative Activities of Cynaropicrin and Related Compounds against Cancer Stem Cells

Glioblastoma (GBM) has a high mortality rate despite the availability of various cancer treatment options. Although cancer stem cells (CSCs) have been associated with poor prognosis and metastasis, and play an important role in the resistance to existing anticancer drugs and radiation; no CSC-targeting drugs are currently approved in clinical practice. Therefore, the development of antiproliferative agents against CSCs is urgently required. In this study, we evaluated the antiproliferative activities of 21 sesquiterpenoids against human GBM U-251 MG CSCs and U-251 MG non-CSCs. Particularly, the guaianolide sesquiterpene lactone cynaropicrin (1) showed strong antiproliferative activity against U-251 MG CSCs (IC50 = 20.4 µM) and U-251 MG non-CSCs (IC50 = 10.9 µM). Accordingly, we synthesized six derivatives of 1 and investigated their structure-activity relationships. Most of the guaianolide sesquiterpene lactones with the α-methylene-γ-butyrolactone moiety showed antiproliferative activities against U-251 MG cells. We conclude that the 5,7,5-ring and the α-methylene-γ-butyrolactone moiety are both important for antiproliferative activities against U-251 MG cells. The results of this study suggest that the α,β-unsaturated carbonyl moiety, which has recently become a research hotspot in drug discovery, is the active center of 1. Therefore, we consider 1 as a potential lead for developing novel drugs targeting CSCs.

Cytotoxic activities of alkaloid constituents from the climbing stems and rhizomes of Sinomenium acutum against cancer stem cells

From the methanolic extract of the climbing stems and rhizomes of Sinomenium acutum, two new aporphine analogues, acutumalkaloids I and II, were isolated together with fifteen known compounds including lysicamine. The chemical structures of the isolated new compounds were elucidated based on chemical/physicochemical evidence such as NMR and MS spectra. For acutumalkaloids I and II, the absolute configurations were established by comparison of experimental and predicted electronic circular dichroism (ECD) data. We compared anti-proliferative activities of isolated compounds with reported naturally occurring Wnt/β-catenin pathway inhibitor, nuciferine. Among the isolated compounds, we found lysicamine have anti-proliferative activity against both of HT-29 human colon cancer cell line and its cancer stem cells (CSCs). The IC50 values of lysicamine against non-CSCs and its CSCs were lower than that of nuciferine. In addition, the results of western blotting analysis suggested that lysicamine inhibited the expression of Wnt/β-catenin pathway target protein such as survivin. These results suggested that lysicamine show cytotoxic activity via inhibition of Wnt/β-catenin pathway.

[Development of Functional Compounds Using Chemically Unstable Compounds Obtained from Medicinal Plants]

Sulfur- or nitrogen-containing compounds from medicinal plants exhibit various biological activities such as anticancer potential. Developing efficient strategies to isolate or synthesize these compounds or their derivatives is a remarkable achievement. We have isolated several sulfur-containing compounds such as tetrahydro-2H-difuro[3,2-b:2',3'-c]furan-5(5aH)-one derivatives from Allium plants. We have devised a unique approach for the rapid preparation of thiopyranones using the regioselective sequential double Diels-Alder reaction; we used a naturally-occurring chemically-unstable intermediate such as thioacrolein, which is produced from allicin, a major component in garlic. The cytotoxicity of the synthetic thiopyranones against cancer stem cells (CSCs) was equal to or higher than that of (Z)-ajoene, the reference compound.

Dual Chalcogen-Bonding Interactions for the Conformational Control of Urea

Dual chalcogen-bonding interactions is proposed as a novel means for the conformational control of urea derivatives. The formation of a chalcogen-bonding interaction at both sides of the urea carbonyl group was unambiguously confirmed by X-ray diffraction as well as computational studies including non-covalent interaction (NCI) plot index analysis, quantum theory of atoms in molecules (QTAIM) analysis, and natural bond orbital (NBO) analysis via DFT calculations. By virtue of this dual interaction, urea derivatives that bear chalcogen atoms (X=S and Se) adopt a planar structure via the carbonyl oxygen (O) with an X⋅⋅⋅O⋅⋅⋅X arrangement on the same side of the molecule. The rigidity of the conformational lock was evaluated using the molecular arrangement in the crystal and the rotational barrier of benzochalcogenophene ring, which indicated a stronger conformational lock in benzoselenophene than in benzothiophene urea derivatives. Furthermore, the acidity of the urea derivatives increases according to the Lewis-acidic properties of the chalcogen-bonding interactions, whereby benzoselenophene urea is more acidic than benzothiophene urea. Tweezer-shaped urea derivatives were prepared, and their stereostructure proved the viability of the conformational control for defining the location of the substituents on the urea framework.

New biofunctional effects of oleanane-type triterpene saponins

In the current review, we describe the novel biofunctional effects of oleanane-type triterpene saponins, including elatosides, momordins, senegasaponins, camelliasaponins, and escins, obtained from Aralia elata (bark, root cortex, young shoot), Kochia scoparia (fruit), Polygala senega var. latifolia (roots), Camellia japonica (seeds), and Aesculus hippocastanum (seeds), considering the following biofunctional activities: (1) inhibitory effects on elevated levels of blood alcohol and glucose in alcohol and glucose-loaded rats, respectively, (2) inhibitory effects on gastric emptying in rats and mice, (3) accelerative effects on gastrointestinal transit in mice, and (4) protective effects against gastric mucosal lesions in rats. In addition, we describe (5) suppressive effects of the extract and chakasaponins from Camellia sinensis (flower buds) on obesity based on inhibition of food intake in mice. The active saponins were classified into the following three types: (1) olean-12-en-28-oic acid 3-O-monodesmoside, (2) olean-12-ene 3,28-O-acylated bisdesmoside, and (3) acylated polyhydroxyolean-12-ene 3-O-monodesmoside. Furthermore, common modes of action, such as involvements of capsaicin-sensitive nerves, endogenous NO and PGs, and possibly sympathetic nerves, as well as common structural requirements, were observed. Based on our findings, a common mechanism of action might mediate the pharmacological effects of active saponins. It should be noted that the gastrointestinal tract is an important action site of saponins, and the role of the saponins in the gastrointestinal tract should be carefully considered.

Predicting habitual water intake from lifestyle questions

OBJECTIVE

Previous studies have used selective recall and descriptive dietary record methods, requiring considerable effort for assessing food and water intake. This study created a simplified lifestyle questionnaire to predict habitual water intake (SQW), accurately and quickly assessing the habitual water intake. We also evaluated the validity using descriptive dietary records as a cross-sectional study.

SUBJECTS AND METHODS

First, we used crowdsourcing and machine learning to collect data, predict water intake records, and create questionnaires. We collected 305 lifestyle-related questions as predictor variables and selective recall methods for assessing water intake as an outcome variable. Random forests were used for the machine learning models because of their interpretability and accurate estimation. Random forest and single regression correlation analysis were augmented by the synthetic minority oversampling that trained the model. We separated the data by sex and evaluated our model using unseen hold-out testing data, predicting the individual and overall habitual water intake from various sources, including non-alcoholic beverages, alcohol, and food.

RESULTS

We found a 0.60 Spearman's correlation coefficient for total water intake between the predicted and the selective recall method values, reflecting the target value to be achieved. This question set was then used for feasibility tests. The descriptive dietary record method helped to obtain a ground-truth value. We categorized the data by gender, season, and source: non-alcoholic beverages, alcohol, food, and total water intake, and the correlation was confirmed. Consequently, our results showed a Pearson's correlation coefficient of 0.50 for total water intake between the predicted and the selective recall method values.

CONCLUSIONS

We hypothesize that dissemination of SQW can lead to better health management by easily determining the habitual water intake.

Quantitative analysis of taxiphyllin, a cyanogenic glycoside, in the leaves of Hydrangea macrophylla var. thunbergii

The dried and fermented leaves of Hydrangea macrophylla var. thunbergii are currently used as crude drugs (Sweet Hydrangea Leaf) with a sweet taste for patients with diabetes. In recent years, cases of food poisoning with symptoms of vomiting etc. have been reported after drinking a decoction of this crude drug. Cyanogenic glycosides have been suggested as potential causative agents. However, cyanogenic glycosides from H. macrophylla var. thunbergii was ambiguous. In the present study, we found that the leaves contained the cyanogenic glycoside taxiphillin (1). Next, the content of 1 in leaves of different sizes, colors, parts, and growth periods was quantified. In addition, we prepared the leaves of plants grown in five types of soils with different pH values (pH 5.0-7.5). The content of 1 in the leaves of the plants grown in these soils was quantified. The content of 1 varied greatly, with more than a three-fold difference, depending on when the leaves were collected from the plants. Furthermore, we compared the content of 1 in the crude drug obtained under different processing conditions for H. macrophylla var. thunbergii. The results showed that 1 was mostly hydrolyzed during plant processing. It has been suggested that cyanogenic glycosides are not the causative constituents of food poisoning.

Effect of Sodium-Glucose Cotransporter-2 Inhibitor Administration on Cardiac Rehabilitation in Patients with Type 2 Diabetes Mellitus with Heart Failure

Cardiac rehabilitation in patients with diabetes mellitus and heart failure may be affected by anti-diabetic drugs. However, there are few reports on the effects of sodium-glucose cotransporter-2 (SGLT2) inhibitors on cardiac rehabilitation. Thus, we retrospectively investigated the patient backgrounds and effects of cardiac rehabilitation in 44 patients admitted to our hospital with heart failure and pre-existing diabetes mellitus. Our results showed that the patients tended to be older, and those who received SGLT2 inhibitors had lower systolic blood pressure and left ventricular ejection fraction on admission than those who did not. Cardiac rehabilitation significantly improved the Short Physical Performance Battery (SPPB) score in all patients, and there was no significant difference in body mass index or in body weight. There were no significant differences in SPPB score at admission, discharge, or change from admission to discharge with or without SGLT2 inhibitors. These results suggest that SGLT2 inhibitors do not affect the change in SPPB scores. SGLT2 inhibitors may thus be used safely without affecting cardiac rehabilitation while adhering to the necessary safety precautions.

Plantainoside B in Bacopa monniera Binds to Aβ Aggregates Attenuating Neuronal Damage and Memory Deficits Induced by Aβ

Alzheimer's disease (AD) is a progressive neurodegenerative disease characterized by dementia. The most characteristic pathological changes in AD brain include extracellular amyloid-β (Aβ) accumulation and neuronal loss. Particularly, cholinergic neurons in the nucleus basalis of Meynert are some of the first neuronal groups to degenerate; accumulating evidence suggests that Aβ oligomers are the primary form of neurotoxicity. Bacopa monniera is a traditional Indian memory enhancer whose extract has shown neuroprotective and Aβ-reducing effects. In this study, we explored the low molecular weight compounds from B. monniera extracts with an affinity to Aβ aggregates, including its oligomers, using Aβ oligomer-conjugated beads and identified plantainoside B. Plantainoside B exhibited evident neuroprotective effects by preventing Aβ attachment on the cell surface of human induced pluripotent stem cell (hiPSC)-derived cholinergic neurons. Moreover, it attenuated memory impairment in mice that received intrahippocampal Aβ injections. Furthermore, radioisotope experiments revealed that plantainoside B has affinity to Aβ aggregates including its oligomers and brain tissue from a mouse model of Aβ pathology. In addition, plantainoside B could delay the Aβ aggregation rate. Accordingly, plantainoside B may exert neuroprotective effects by binding to Aβ oligomers, thus interrupting the binding of Aβ oligomers to the cell surface. This suggests its potential application as a theranostics in AD, simultaneously diagnostic and therapeutic drugs.

Production of Dihydroisocoumarins by Callus Induction from Hydrangea macrophylla var. thunbergii Leaves

Dihydroisocoumarins, hydrangenol 8-O-β-D-glucopyranoside (1), phyllodulcin 8-O-β-D-glucopyranoside (2), hydrangenol (3), and phyllodulcin (4), are well-known as the major secondary metabolites in the leaves of Hydrangea macrophylla var. thunbergii. Dihydroisocoumarins are pharmaceutical compounds with diverse bioactivity. Although dihydroisocoumarins are commonly isolated from Hydrangea plants or via organic chemical synthesis, their production via callus induction is considered a promising alternative. In the present study, callus induction and proliferation of H. macrophylla var. thunbergii, and constituents 1-4 were quantified in calluses cultured in 17 different media. We found that the combination of the phytohormones 2,4-dichlorophenoxyacetic acid (2,4-D) and 6-benzylaminopurine (BA) was useful for callus proliferation in H. macrophylla var. thunbergii. The balance and concentrations of indole-3-acetic acid (IAA) and BA greatly affected the contents of 1-4. Particularly, 1 (2.03-3.46% yield from the dry callus) was successfully produced from the callus induced by IAA (0.5 mg/L) and BA (1.0 mg/L) at yields comparable to isolated yields from plants. To the best of our knowledge, this is the first study to show that the calluses of H. macrophylla var. thunbergii contained 1. These findings may be useful for producing bioactive dihydroisocoumarins.

Comparison of Growth in Hydrangea macrophylla var. thunbergii Grown in Different Soil pH and Quantitative Analysis of Its Sweetness-Related Constituents

Dried and fermented (processed) leaves of Hydrangea macrophylla Seringe var. thunbergii Makino (Hydrangeae Dulcis Folium) are currently used as a crude drug with a sweet taste for diabetic patients and as an oral refrigerant. The sweet taste of this crude drug is primarily attributed to phyllodulcin. However, there are currently no standards for the cultivation of H. macrophylla var. thunbergii and the isolation and production of the primary constituents of this crude drug. In the present study, we prepared five types of soils with different pH values (pH 7.5-5.0) and investigated the effects of these soils on the growth of this plant. The contents of phyllodulcin and its glycoside, phyllodulcin 8-O-β-D-glucopyranoside, in the leaves of plants grown in these soils were quantified. Furthermore, the correlation between the sweetness of Hydrangeae Dulcis Folium and phyllodulcin was investigated. The results showed that soils with pH ranging from 7.0 to 5.5 was not only suitable for plant growth but also increased the content of phyllodulcin and phyllodulcin 8-O-β-D-glucopyranoside in the leaves. Altogether, these findings could be useful for the development of high-quality Hydrangeae Dulcis Folium.

7,8-Dihydroxy-3-(4'-hydroxyphenyl)coumarin inhibits invasion and migration of osteosarcoma cells

Advances in pharmacy and medicine have led to the development of many anti-cancer and molecular targeted agents; however, there are few agents capable of suppressing metastasis. To prevent cancer recurrence, it is essential to develop novel agents for inhibiting metastasis. Coumarin-based compounds have multiple pharmacological activities including anti-cancer effects. We screened a compound library constructed at Kyoto Pharmaceutical University and showed that 7,8-dihydroxy-3-(4'-hydroxyphenyl)coumarin (DHC) inhibited invasion and migration of LM8 mouse osteosarcoma cells and 143B human osteosarcoma cells in a concentration-dependent manner. DHC decreased intracellular actin filament formation by downregulating Rho small GTP-binding proteins such as RHOA, RAC1, and CDC42, which regulate actin reorganization. However, DHC did not downregulate the corresponding mRNA transcripts, whereas it downregulated Rho small GTP-binding proteins in the presence of cycloheximide, suggesting that DHC enhances the degradation of these proteins. DHC treatment inhibited metastasis and prolonged overall survival in a spontaneous metastasis mouse model. These results indicate that DHC has the potential to suppress metastasis of osteosarcoma cells by downregulating Rho small GTP-binding proteins.

Antiproliferative Activities of Diterpenes from Leaves of Isodon trichocarpus against Cancer Stem Cells

Two new diterpenes named trichoterpene I (1) and trichoterpene II (2) were isolated from the extract from the leaves of Isodon trichocarpus together with 19 known diterpenes. Their chemical structures were elucidated on the basis of chemical and physicochemical properties. Among them, oridonin (3), effusanin A (4), and lasiokaurin (9) with the α,β-unsaturated carbonyl moiety showed antiproliferative activities against breast cancer MDA-MB-231 and human astrocytoma U-251 MG cells [i.e., non-cancer stem cells (non-CSCs)] and their cancer stem cells (CSCs) isolated by sphere formation. In particular, compound 4 (IC₅₀ = 0.51 µM) showed a higher antiproliferative activity against MDA-MB-231 CSCs than against MDA-MB-231 non-CSCs. The antiproliferative activity toward CSCs of compound 4 was equal to adriamycin (positive control, IC₅₀ = 0.60 µM).

Direct observations of energy transfer from resonant electrons to whistler-mode waves in magnetosheath of Earth

Electromagnetic whistler-mode waves in space plasmas play critical roles in collisionless energy transfer between the electrons and the electromagnetic field. Although resonant interactions have been considered as the likely generation process of the waves, observational identification has been extremely difficult due to the short time scale of resonant electron dynamics. Here we show strong nongyrotropy, which rotate with the wave, of cyclotron resonant electrons as direct evidence for the locally ongoing secular energy transfer from the resonant electrons to the whistler-mode waves using ultra-high temporal resolution data obtained by NASA’s Magnetospheric Multiscale (MMS) mission in the magnetosheath. The nongyrotropic electrons carry a resonant current, which is the energy source of the wave as predicted by the nonlinear wave growth theory. This result proves the nonlinear wave growth theory, and furthermore demonstrates that the degree of nongyrotropy, which cannot be predicted even by that nonlinear theory, can be studied by observations.

Excitation of whistler-mode waves by cyclotron instability is considered as the likely generation process of the waves. Here, the authors show direct observational evidence for locally ongoing secular energy transfer from the resonant electrons to the whistler-mode waves in Earth’s magnetosheath.

Atezolizumab plus bevacizumab versus lenvatinib or sorafenib in non-viral unresectable hepatocellular carcinoma: an international propensity score matching analysis

BACKGROUND

A growing body of evidence suggests that non-viral hepatocellular carcinoma (HCC) might benefit less from immunotherapy.

MATERIALS AND METHODS

We carried out a retrospective analysis of prospectively collected data from consecutive patients with non-viral advanced HCC, treated with atezolizumab plus bevacizumab, lenvatinib, or sorafenib, in 36 centers in 4 countries (Italy, Japan, Republic of Korea, and UK). The primary endpoint was overall survival (OS) with atezolizumab plus bevacizumab versus lenvatinib. Secondary endpoints were progression-free survival (PFS) with atezolizumab plus bevacizumab versus lenvatinib, and OS and PFS with atezolizumab plus bevacizumab versus sorafenib. For the primary and secondary endpoints, we carried out the analysis on the whole population first, and then we divided the cohort into two groups: non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH) population and non-NAFLD/NASH population.

RESULTS

One hundred and ninety patients received atezolizumab plus bevacizumab, 569 patients received lenvatinib, and 210 patients received sorafenib. In the whole population, multivariate analysis showed that treatment with lenvatinib was associated with a longer OS [hazard ratio (HR) 0.65; 95% confidence interval (CI) 0.44-0.95; P = 0.0268] and PFS (HR 0.67; 95% CI 0.51-0.86; P = 0.002) compared to atezolizumab plus bevacizumab. In the NAFLD/NASH population, multivariate analysis confirmed that lenvatinib treatment was associated with a longer OS (HR 0.46; 95% CI 0.26-0.84; P = 0.0110) and PFS (HR 0.55; 95% CI 0.38-0.82; P = 0.031) compared to atezolizumab plus bevacizumab. In the subgroup of non-NAFLD/NASH patients, no difference in OS or PFS was observed between patients treated with lenvatinib and those treated with atezolizumab plus bevacizumab. All these results were confirmed following propensity score matching analysis. By comparing patients receiving atezolizumab plus bevacizumab versus sorafenib, no statistically significant difference in survival was observed.

CONCLUSIONS

The present analysis conducted on a large number of advanced non-viral HCC patients showed for the first time that treatment with lenvatinib is associated with a significant survival benefit compared to atezolizumab plus bevacizumab, in particular in patients with NAFLD/NASH-related HCC.

Magnetically Hidden State on the Ground Floor of the Magnetic Devil's Staircase

We investigated the low-temperature and high-field thermodynamic and ultrasonic properties of SrCu_{2}(BO_{3})_{2}, which exhibits various plateaux in its magnetization curve above 27 T, called a magnetic Devil's staircase. The results of the present study confirm that magnetic crystallization, the first step of the staircase, occurs above 27 T as a first-order transition accompanied by a sharp singularity in heat capacity C_{p} and a kink in the elastic constant. In addition, we observe a thermodynamic anomaly at lower fields around 26 T, which has not been previously detected by any magnetic probes. At low temperatures, this magnetically hidden state has a large entropy and does not exhibit Schottky-type gapped behavior, which suggests the existence of low-energy collective excitations. Based on our observations and theoretical predictions, we propose that magnetic quadrupoles form a spin-nematic state around 26 T as a hidden state on the ground floor of the magnetic Devil's staircase.

PREMATURE MENOPAUSE AND OBESITY DUE TO OOCYTE LOSS IN FEMALE MICE CHRONICALLY EXPOSED TO LOW DOSE-RATE γ-RAYS

In previous reports, the authors showed a significant overall increase in neoplasms originating from the ovaries (2007) and increased body weights (2007, 2010) in female B6C3F1 mice chronically exposed to low dose-rate γ-rays at 20 mGy/day (total doses = 8 (2007) or 6 Gy (2010)), as well as significant increases in serum leptin, total cholesterol, adipose tissue deposits and liver lipid content (2010). The present study chronicles the progression of ovarian failure in relation to obesity and dyslipidemia in female B6C3F1 mice chronically exposed to low dose-rate of γ-rays from 9 to 43 weeks of age (total dose = 4.8 Gy). We monitored changes in body weights, estrus cycles, ovarian follicle counts, serum cholesterol and serum leptin. The number of mice with irregular estrus cycles and increased body weights (with increased fat deposits) significantly increased from 30-36 weeks of age. Depletion of oocytes in ovaries from irradiated mice at 30 weeks of age (accumulated dose = 3 Gy) was also observed. Findings suggest that obesity in female B6C3F1 mice continuously irradiated with low dose-rate of γ-rays at 20 mGy/day is a consequence of premature menopause due to radiation-induced oocyte depletion.

Quantifying the Size and Duration of a Microburst-Producing Chorus Region on 5 December 2017

Microbursts are impulsive (<1 s) injections of electrons into the atmosphere, thought to be caused by nonlinear scattering by chorus waves. Although attempts have been made to quantify their contribution to outer belt electron loss, the uncertainty in the overall size and duration of the microburst region is typically large, so that their contribution to outer belt loss is uncertain. We combine datasets that measure chorus waves (Van Allen Probes [RBSP], Arase, ground-based VLF stations) and microburst (>30 keV) precipitation (FIREBIRD II and AC6 CubeSats, POES) to determine the size of the microburst-producing chorus source region beginning on 5 December 2017. We estimate that the long-lasting (∼30 hr) microburst-producing chorus region extends from 4 to 8Δ MLT and 2-5Δ L. We conclude that microbursts likely represent a major loss source of outer radiation belt electrons for this event.

Collaborative Research Activities of the Arase and Van Allen Probes

This paper presents the highlights of joint observations of the inner magnetosphere by the Arase spacecraft, the Van Allen Probes spacecraft, and ground-based experiments integrated into spacecraft programs. The concurrent operation of the two missions in 2017-2019 facilitated the separation of the spatial and temporal structures of dynamic phenomena occurring in the inner magnetosphere. Because the orbital inclination angle of Arase is larger than that of Van Allen Probes, Arase collected observations at higher L -shells up to L ∼ 10 . After March 2017, similar variations in plasma and waves were detected by Van Allen Probes and Arase. We describe plasma wave observations at longitudinally separated locations in space and geomagnetically-conjugate locations in space and on the ground. The results of instrument intercalibrations between the two missions are also presented. Arase continued its normal operation after the scientific operation of Van Allen Probes completed in October 2019. The combined Van Allen Probes (2012-2019) and Arase (2017-present) observations will cover a full solar cycle. This will be the first comprehensive long-term observation of the inner magnetosphere and radiation belts.

POS0530 MOLECULAR SIGNATURE IN SUSTAINED CLINICAL REMISSION INDUCED BY TOCILIZUMAB IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Clinical remission is a clinical goal in the treatment of rheumatoid arthritis (RA). Sustained, biologics-free and true remission is an unachieved goal of the “treat-to-target” approach in most patients, and the determinants for achievement are still unclear. In our recent prospective study using multiomics analysis, we proposed that a molecular signature in peripheral whole blood can be a predictor for subsequent disease activity or activities of daily living.1 We also showed that tocilizumab (TCZ) induced deep clinical remission associated with gene expression in peripheral CD4+ T cells.2

Objectives

To consolidate and expand our hypothesis, we investigated the significance of molecular signatures in sustained remission in a larger scale cohort.

Methods

To build and validate the diagnostic model, we collected 73 peripheral blood samples from 30 patients with active RA, 30 patients in clinical remission induced by TCZ and 13 healthy controls. We then collected another 23 samples at a point before TCZ was halted due to sustained clinical remission. In total, 96 samples were analyzed by a multiomics platform, which included RNA sequencing and comprehensive proteomics.

Results

We first developed an optimized partial least-squares regression (PLSR) model using data from 5,436 genes and 255 proteins extracted in our previous model.1 The odds ratio in the model clearly reflected the clinical state with high fidelity (Figure 1). In that study, TCZ induced nearly half of the patients with clinical remission into molecular remission, with an odds ratio of less than zero. To clarify the characteristics of the molecular signature at sustained clinical remission under TCZ continuation, 23 samples were applied to the model. The odds ratio was largely the same as that for clinical remission. Next, we investigated the association with disease flare after cessation of TCZ. At some points before cessation, the median odds ratio in patients who experienced disease flare after stopping TCZ tended to be higher than that in patients with sustained remission after stopping TCZ in the transcriptomics model but not in the proteomics model. Thirty-five differentially expressed genes were identified between the two groups under the conditions of a >1.5-fold change and P-value<0.05.

Figure 1.

Odds ratio in the partial least-squares regression model using transcriptomics (A) and proteomics (B) data from rheumatoid arthritis and healthy control groups

Conclusion

Our larger scale study validated the idea in our previous study that TCZ induces molecular remission. A certain substantial gap associated with prognosis after quitting TCZ may exist as a molecular signature of sustained clinical remission induced by TCZ. These multiomics data sets enable us to understand sustained clinical remission at a molecular level.

References

[1]Nat Commun. 9(1):2775, 2018, 2) Sci Rep.11(1):16691, 2021

Graphs:

Acknowledgements

We acknowledge funding by Chugai Pharmaceutical Co., Ltd.

Disclosure of Interests

Nobuhiko Kajio: None declared, Katsuya Suzuki Speakers bureau: AbbVie, AsahiKasei, Astellas, Ayumi, Bristol-Myers Squibb, Chugai, Eisai, Eli Lilly, Gilead, Janssen, Mitsubishi Tanabe, Pfizer, Sanofi, Viatris, Consultant of: AbbVie, Asahi Kasei, Janssen, Pfizer, Grant/research support from: Chugai, Daiichi-Sankyo, Eli Lilly, Mitsubishi Tanabe, Ono, Takeda, Kotaro Matsumoto: None declared, Hiroshi Iijima: None declared, Seiji Nakamura: None declared, Yohei Ishizawa: None declared, Jun Inamo: None declared, Masaru Takeshita: None declared, Keiko Yoshimoto: None declared, Yuko Kaneko Speakers bureau: Chugai, Consultant of: Chugai, Grant/research support from: Chugai, Tsutomu Takeuchi Speakers bureau: Chugai, Consultant of: Chugai, Grant/research support from: Chugai.

Analysis of Active Compounds Using Target Protein Cofilin―Cucurbitacins in Cytotoxic Plant Bryonia cretica

We examined a two-step target protein binding strategy that uses cofilin as the target protein to analyze the active constituents in Bryonia cretica. In the first step, we prepared the target protein, and used it to analyze the compounds binding to it in the second step. We used the methanolic extract of B. cretica as a library of possible active compounds. We conducted LC–MS analysis using information from our previous study. The peaks in the HPLC profile were identified as cucurbitacin D, isocucurbitacin D, and cucurbitacin I. As far as we know, there is no known study of the activity of isocucurbitacin D in this research field. Therefore, we examined the effects of isocucurbitacin D on cell proliferation and cofilin protein in human fibrosarcoma cell line HT1080 to confirm the effectiveness of this strategy. The cytotoxicity assay, the fibrous/globular actin ratio assay, and the immunoblotting analysis revealed that isocucurbitacin D showed a cytotoxic effect with disruption of target protein cofilin. The target protein binding strategy is a direct and straightforward method for finding new drug seeds from crude sources, such as natural plant extracts.

Chemical Structures of Phenylbutanoids From Rhizomes of Zingiber cassumunar

Zingiber cassumunar is widely distributed in Asia, and its rhizomes are used for asthma treatment in traditional medicine and as a spice. Five new phenylbutanoids, cassumunols I–M (1-5), were isolated from Z cassumunar rhizomes collected in Thailand, and their structures were characterized on the basis of physiochemical and chemical evidence.

Salivary Alpha-Amylase Activity and Mild Cognitive Impairment among Japanese Older Adults: The Toon Health Study

BACKGROUND

There is growing interest in examining objective markers for early identification and behavioral intervention to prevent dementia and mild cognitive impairment in clinical and community settings.

OBJECTIVE

To investigate the association between salivary alpha-amylase as an objective measure of psychological stress response and mild cognitive impairment for the implication of psychological stress in the development of mild cognitive impairment.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study involved 865 participants aged ≥ 65 years. A saliva sample was collected in the morning, and the levels of salivary alpha-amylase were assayed. Mild cognitive impairment was evaluated using the Japanese version of the Montreal Cognitive Assessment; a score < 26 was indicative of mild cognitive impairment. A multivariable logistic regression model was used to examine the association of salivary alpha-amylase and mild cognitive impairment after adjusting for age, sex, current drinking status, current smoking status, body mass index, hypertension, diabetes mellitus, physical activity, education, social support, social network, and heart rate variability.

RESULTS

Salivary alpha-amylase was associated with mild cognitive impairment (the multivariable-adjusted odds ratio [95% confidence interval] for the 1-standard deviation increment of log-transformed salivary alpha-amylase was 1.24 [1.07-1.44]). This significant association persisted after adjusting for various confounding factors.

CONCLUSION

Elevation of salivary alpha-amylase was associated with mild cognitive impairment among Japanese community-dwelling older adults. This suggests that salivary alpha-amylase is a useful objective marker of psychological stress responses associated with mild cognitive impairment.

Construction of sulfur-containing compounds with anti-cancer stem cell activity using thioacrolein derived from garlic based on nature-inspired scaffolds

Sulfur-containing compounds, such as cyclic compounds with a vinyl sulfane structure, exhibit a wide range of biological activities including anticancer activity. Therefore, the development of efficient strategies to synthesize such compounds is a remarkable achievement. We have developed a unique approach for the rapid and modular preparation of nature-inspired cyclic and acyclic sulfur-containing compounds using thioacrolein, a naturally occurring chemically unstable intermediate. We constructed thiopyranone derivatives through the regioselective sequential double Diels-Alder reaction of thioacrolein produced by allicin, a major component in garlic, and two molecules of silyl enol ether as the diene partner. The cytotoxicity toward cancer stem cells of the thiopyranones was equal to or higher than that of (Z)-ajoene (positive control) derived from garlic, and the thiopyranones had higher chemical stability than (Z)-ajoene.

Nonalcoholic steatohepatitis in hepatocarcinoma: new insights about its prognostic role in patients treated with lenvatinib

BACKGROUND

Hepatocellular carcinoma (HCC) treatment remains a big challenge in the field of oncology. The liver disease (viral or not viral) underlying HCC turned out to be crucial in determining the biologic behavior of the tumor, including its response to treatment. The aim of this analysis was to investigate the role of the etiology of the underlying liver disease in survival outcomes.

PATIENTS AND METHODS

We conducted a multicenter retrospective study on a large cohort of patients treated with lenvatinib as first-line therapy for advanced HCC from both Eastern and Western institutions. Univariate and multivariate analyses were performed.

RESULTS

Among the 1232 lenvatinib-treated HCC patients, 453 (36.8%) were hepatitis C virus positive, 268 hepatitis B virus positive (21.8%), 236 nonalcoholic steatohepatitis (NASH) correlate (19.2%) and 275 had other etiologies (22.3%). The median progression-free survival (mPFS) was 6.2 months [95% confidence interval (CI) 5.9-6.7 months] and the median overall survival (mOS) was 15.8 months (95% CI 14.9-17.2 months). In the univariate analysis for OS NASH-HCC was associated with longer mOS [22.2 versus 15.1 months; hazard ratio (HR) 0.69; 95% CI 0.56-0.85; P = 0.0006]. In the univariate analysis for PFS NASH-HCC was associated with longer mPFS (7.5 versus 6.5 months; HR 0.84; 95% CI 0.71-0.99; P = 0.0436). The multivariate analysis confirmed NASH-HCC (HR 0.64; 95% CI 0.48-0.86; P = 0.0028) as an independent prognostic factor for OS, along with albumin-bilirubin (ALBI) grade, extrahepatic spread, neutrophil-to-lymphocyte ratio, portal vein thrombosis, Eastern Cooperative Oncology Group (ECOG) performance status and alpha-fetoprotein. An interaction test was performed between sorafenib and lenvatinib cohorts and the results highlighted the positive predictive role of NASH in favor of the lenvatinib arm (P = 0.0047).

CONCLUSION

NASH has been identified as an independent prognostic factor in a large cohort of patients with advanced HCC treated with lenvatinib, thereby suggesting the role of the etiology in the selection of patients for tyrosine kinase treatment. If validated, this result could provide new insights useful to improve the management of these patients.

Effective Search of Triterpenes with Anti-HSV-1 Activity Using a Classification Model by Logistic Regression

Natural products are an excellent source of skeletons for medicinal seeds. Triterpenes and saponins are representative natural products that exhibit anti-herpes simplex virus type 1 (HSV-1) activity. However, there has been a lack of comprehensive information on the anti-HSV-1 activity of triterpenes. Therefore, expanding information on the anti-HSV-1 activity of triterpenes and improving the efficiency of their exploration are urgently required. To improve the efficiency of the development of anti-HSV-1 active compounds, we constructed a predictive model for the anti-HSV-1 activity of triterpenes by using the information obtained from previous studies using machine learning methods. In this study, we constructed a binary classification model (i.e., active or inactive) using a logistic regression algorithm. As a result of the evaluation of predictive model, the accuracy for the test data is 0.79, and the area under the curve (AUC) is 0.86. Additionally, to enrich the information on the anti-HSV-1 activity of triterpenes, a plaque reduction assay was performed on 20 triterpenes. As a result, chikusetsusaponin IVa (11: IC₅₀ = 13.06 μM) was found to have potent anti-HSV-1 with three potentially anti-HSV-1 active triterpenes. The assay result was further used for external validation of predictive model. The prediction of the test compounds in the activity test showed a high accuracy (0.83) and AUC (0.81). We also found that this predictive model was found to be able to successfully narrow down the active compounds. This study provides more information on the anti-HSV-1 activity of triterpenes. Moreover, the predictive model can improve the efficiency of the development of active triterpenes by integrating many previous studies to clarify potential relationships.

Validity of a selective recall method for assessing water intake and its relationship with hydration status

OBJECTIVE

We previously established a descriptive dietary record method that accurately quantifies habitual water intake from food and beverages, to ascertain the relationship between water intake and health. Here, we verified the validity of a selective recall method, which is easy for users to answer and analyze.

PATIENTS AND METHODS

Japanese men and women aged 20-44 years (n = 16) and 45-64 years (n = 16) participated over three working days and one non-working day. The day following each of the surveyed days, participants collected their first morning urine for urinalysis and completed a selective recall and descriptive dietary record questionnaire.

RESULTS

The two methods of determining water intake were positively correlated (r = 0.94, p < 0.0001). Water intake volumes from non-alcoholic beverages (r = 0.94, p < 0.0001), alcoholic beverages (r = 1.00, p < 0.0001), and food (r = 0.72, p < 0.0001), calculated using the two methods, exhibited strong correlation. No correlation was observed between urinalysis parameters and total water intake. A significant, negative correlation was observed between urine osmolarity and total water intake in men (r = -0.55, p = 0.0011) and women (r = -0.51, p = 0.0032) aged 20-44 years.

CONCLUSIONS

Selective recall is a valid method for assessing water intake from food and beverages.

A validation study of combined resection and ablation therapy for multiple hepatocellular carcinoma

AIM

To validate the utility of hepatic resection combined with complementary radiofrequency ablation (RFA) compared with resection alone for patients with multiple hepatocellular carcinoma (HCC), and to compare these results with those of a previous report.

MATERIALS AND METHODS

A total of 78 HCC patients with multiple (≤5) tumours who were initially treated with hepatic resection only (Resection group) or with combined hepatic resection and RFA (Combination group) were included. Overall and disease-free survival were analysed.

RESULTS

There were 21 women and 57 men with a median age of 72.5 (64.3-76.8) years. Fifty-three patients were treated with resection alone and 25 received combination therapy. The 3-, 5-, and 7-year cumulative overall survival rates were 81.2%, 68.2%, and 57.1%, respectively, in the Resection group, and 81.3%, 59.6%, and 42.4%%, respectively, in the Combination group (hazard ratio [HR], 1.462; 95% confidence interval [CI], 0.682-3.136; p=0.329). The 1-, 3-, and 5-year cumulative disease-free survival rates were 61.4%, 45.7%, and 39.8%, respectively, in the Resection group, and 53.1%, 18.6%, and 0%, respectively, in the Combination group (HR, 2.080; 95% CI, 1.157-3.737; p=0.014). The overall survival rate was not significantly different between the Resection and Combination groups in patients within the up-to-seven HCC criteria (n=56; HR, 2.101; 95% CI, 0.805-5.486; p=0.130) or those beyond these criteria (n=22; HR, 0.804; 95% CI, 0.197-3.286; p=0.761).

CONCLUSIONS

The combination of hepatic resection and RFA therapy may be an effective strategy for HCC patients with multiple tumours.

Direct comparison of bioabsorbable and biodurable polymer everolimus-eluting stent in neointimal stent coverage and in-stent thrombus using high-resolution angioscope

Background/Introduction

Although second-generation drug eluting stent (DES) employing biodurable polymer drastically shortened the duration of dual antiplatelet therapy (DAPT), previous reports raised concerns that switching from DAPT to single antiplatelet therapy increased rates of subsequent stent thrombosis with time. Third-generation DES employing bioabsorbable polymer has been introduced so as not to hinder the healing process of the vessel wall, however, at present, both DES with bioabsorbable polymer and those with biodurable polymer are used in parallel. It means there is no conclusive evidence regarding pros and cons of these two types of polymers.

Purpose

This study aims to clarify how bioabsorbable polymer and biodurable polymer act on the human coronary artery by observing neointimal stent coverage (NIC) and in-stent thrombus by comparing the third-generation DES with bioabsorbable-polymer cobalt-platinum everolimus-eluting stent (BP CoPt-EES), and the second-generation DES with biodurable-polymer cobalt-chromium everolimus-eluting stent (DP CoCr-EES).

Methods

This is a multicenter observational study including 11 hospitals. We investigated 70 stents (BP CoPt-EES: 40, DP CoCr-EES: 30) of 60 cases, who underwent stent implantation followed by simultaneous observation by coronary angiography, IVUS and angioscopy within 6 to 12 months. For angioscopy, we used a recently available, high-resolution angioscope with a pixel count of 9,000 which realized both stent coverage analysis and planar thrombus detection precisely. Neointimal stent coverage was graded from G0: non coverage to G3: full coverage, and heterogeneity value of neointima was measured as the difference between maximum and minimum NIC grade.

Results

A strong relationship was observed between NIC grade and in-stent thrombus in all stents (p=0.0011), and between the heterogeneity value and stent thrombus (p=0.012). There was no statistical difference in NIC grade between BP CoPt-EES vs. DP CoCr-EES; grade 0: 0 (0.0%) vs. 2 (6.7%), grade 1: 13 (32.5%) vs. 11 (36.7%), grade 2: 6 (15.0%) vs. 6 (20.0%), grade 3: 21 (52.5%) vs. 11 (36.7%), p=0.17) and neither in the heterogeneity value of neointima (p=0.49). The ratio of stent thrombus did not reach statistical difference; 16 (40.0%) in BP CoPt-EES vs. 17 (56.7%) in DP CoCr-EES (p=0.23).

Conclusion

The existence of stent thrombus was associated with the neointimal stent coverage. There was no significant difference both in neointimal stent coverage and stent thrombus between bioabsorbable polymer cobalt-platinum EES and biodurable polymer cobalt-chromium EES after 6 to 12 months following stent deployment.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Boston Scientific JapanOvalis ltd

Penetration of MeV electrons into the mesosphere accompanying pulsating aurorae

Pulsating aurorae (PsA) are caused by the intermittent precipitations of magnetospheric electrons (energies of a few keV to a few tens of keV) through wave-particle interactions, thereby depositing most of their energy at altitudes ~ 100 km. However, the maximum energy of precipitated electrons and its impacts on the atmosphere are unknown. Herein, we report unique observations by the European Incoherent Scatter (EISCAT) radar showing electron precipitations ranging from a few hundred keV to a few MeV during a PsA associated with a weak geomagnetic storm. Simultaneously, the Arase spacecraft has observed intense whistler-mode chorus waves at the conjugate location along magnetic field lines. A computer simulation based on the EISCAT observations shows immediate catalytic ozone depletion at the mesospheric altitudes. Since PsA occurs frequently, often in daily basis, and extends its impact over large MLT areas, we anticipate that the PsA possesses a significant forcing to the mesospheric ozone chemistry in high latitudes through high energy electron precipitations. Therefore, the generation of PsA results in the depletion of mesospheric ozone through high-energy electron precipitations caused by whistler-mode chorus waves, which are similar to the well-known effect due to solar energetic protons triggered by solar flares.

Electric Quadrupolar Contributions in the Magnetic Phases of UNi_{4}B

We present acoustic signatures of the electric quadrupolar degrees of freedom in the honeycomb-layer compound UNi_{4}B. The transverse ultrasonic mode C_{66} shows softening below 30 K both in the paramagnetic phase and antiferromagnetic phases down to ∼0.33  K. Furthermore, we traced magnetic field-temperature phase diagrams up to 30 T and observed a highly anisotropic elastic response within the honeycomb layer. These observations strongly suggest that Γ_{6}(E_{2g}) electric quadrupolar degrees of freedom in localized 5f^{2} (J=4) states are playing an important role in the magnetic toroidal dipole order and magnetic-field-induced phases of UNi_{4}B, and evidence some of the U ions remain in the paramagnetic state even if the system undergoes magnetic toroidal ordering.

Zinc finger protein-440 promotes cartilage degenerative mechanisms in human facet and knee osteoarthritis chondrocytes

OBJECTIVES

To investigate the role of zinc finger protein 440 (ZNF440) in the pathophysiology of cartilage degeneration during facet joint (FJ) and knee osteoarthritis (OA).

METHODS

Expression of ZNF440 in FJ and knee cartilage was determined by immunohistochemistry, quantitative (q)PCR, and Western blotting (WB). Human chondrocytes isolated from FJ and knee OA cartilage were cultured and transduced with ZNF440 or control plasmid, or transfected with ZNF440 or control small interfering RNA (siRNA), with/without interleukin (IL)-1β. Gene and protein levels of catabolic, anabolic and apoptosis markers were determined by qPCR or WB, respectively. In silico analyses were performed to determine compounds with potential to inhibit expression of ZNF440.

RESULTS

ZNF440 expression was increased in both FJ and knee OA cartilage compared to control cartilage. In vitro, overexpression of ZNF440 significantly increased expression of MMP13 and PARP p85, and decreased expression of COL2A1. Knockdown of ZNF440 with siRNA partially reversed the catabolic and cell death phenotype of human knee and FJ OA chondrocytes stimulated with IL-1β. In silico analysis followed by validation assays identified scriptaid as a compound with potential to downregulate the expression of ZNF440. Validation experiments showed that scriptaid reduced the expression of ZNF440 in OA chondrocytes and concomitantly reduced the expression of MMP13 and PARP p85 in human knee OA chondrocytes overexpressing ZNF440.

CONCLUSIONS

The expression of ZNF440 is significantly increased in human FJ and knee OA cartilage and may regulate cartilage degenerative mechanisms. Furthermore, scriptaid reduces the expression of ZNF440 and inhibits its destructive effects in OA chondrocytes.

Neurokinin 3 receptor-selective agonist, senktide, decreases core temperature in Japanese Black cattle

Heat stress disrupts reproductive function in cattle. In summer, high ambient temperature and humidity elevate core body temperature, which is considered to be detrimental to reproductive abilities in cattle. Neurokinin B (NKB) is a factor that generates pulsatile GnRH and subsequent LH secretion in mammals. Recent studies have reported that NKB-neurokinin 3 receptor (NK3R) signaling is associated with heat-defense responses in rodents. The present study aimed to clarify the role of NKB-NK3R signaling in thermoregulation in cattle. We examined the effects of an NK3R-selective agonist, senktide, on vaginal temperature as an indicator of core body temperature in winter and summer. In both seasons, continuous infusion of senktide for 4 h immediately decreased vaginal temperature, and the mean temperature change in the senktide-treated group was significantly lower than that of both vehicle- and GnRH-treated groups. Administration of GnRH induced LH elevation, but there was no significant difference in vaginal temperature change between GnRH- and vehicle-treated groups. Moreover, we investigated the effects of senktide on ovarian temperature. Senktide treatment seemed to suppress the increase in ovarian temperature from 2 h after the beginning of administration, although the difference between groups was not statistically significant. Taken together, these results suggest that senktide infusion caused a decline in the vaginal temperature of cattle, in both winter and summer seasons, and this effect was not due to the gonadotropin-releasing action of senktide. These findings provide new therapeutic options for senktide to support both heat-defense responses and GnRH/LH pulse generation.

Estrogenic and antiandrogenic activities of methoxyflavans isolated from the fruit of Mauritia Flexuosa (Moriche Palm)

Moriche palm is consumed as both a fresh fruit and processed food in Peru and Brazil. Although its fruit contains phytoestrogens, the active compounds have not yet been identified. Therefore, we purified moriche palm extract (MPE) and identified compounds exhibiting estrogenic and antiandrogenic activities. Estrogenic activity was assessed by the estrogen-dependent growth of MCF-7 cells and increases in uterine weights in mice. Antiandrogenic activity was evaluated by 5α-reductase inhibitory activity and prostate-specific antigen (PSA) expression in LNCaP cells. In vivo antiestrogenic activity was also assessed based on testosterone-induced prostate growth in castrated mice. Four methoxyflavans were isolated from MPE and all, except for 7,4'-dihydroxy-5-methoxyflavan, promoted MCF-7 cell growth, indicating estrogenic activity. Uterine and ovary weights increased in mice orally administered MPE (400 mg/kg) for 2 weeks. Regarding antiandrogenic activity, among the four methoxyflavans isolated, 6,7,4'-trihydroxy-5-methoxyflavan (1 µg/ml) suppressed the mRNA and protein expression of PSA in LNCaP cells. Furthermore, prostate growth was suppressed in mice orally administered MPE (200 mg/kg) for 2 weeks. All methoxyflavans inhibited 5α-reductase activity with IC₅₀ less than 10 µg/ml. Collectively, the present results demonstrated that orally administered MPE exhibited estrogenic and antiandrogenic activities. Methoxyflavans, particularly 6,7,4'-trihydroxy-5-methoxyflavan, appear to be the active compounds for these activities. PRACTICAL APPLICATIONS: The fruit of Mauritia flexuosa (moriche palm) has been used for beverages and processed foods. Although it is said to contain phytoestrogens, the active compounds have not yet been identified. In this study, we isolated and identified methoxyflavans exhibiting estrogenic and antiandrogenic activities. Among them, 6,7,4'-trihydroxy-5-methoxyflavan appeared to be the most effective compounds for these activities.

Sex-differences in outcomes after PCI or CABG for left main disease: from the DELTA registries

Background

Women have worse outcomes than men after PCI, with some studies suggesting a lower mortality of CABG vs PCI in females.

Purpose

To assess the outcomes of CABG and PCI according to sex in a large registry population of patients with unprotected left main coronary artery (ULMCA) disease.

Methods

The DELTA and DELTA 2 registries are two multicentric, prospective registries evaluating the outcomes of subjects undergoing coronary revascularization for ULMCA disease.

Results

Total population was 6253 patients, 27% women. Table 1 shows baseline clinical characteristics. Median follow up was of 880 days. Women undergoing CABG had lower incidence of death, myocardial infarction (MI) or cerebrovascular accidentc (CVA) (HR 0.53, 95% CI 0.35–0.79) and a lower risk of death (HR 0.40, 95% CI 0.24–0.67). No significant differences were observed in men (Figure 1A). SIgnificant interaction was observed between sex and revascularization strategy for both outcomes (p&lt;0.01-Figure 1B). CABG was associated with lower risk of target-vessel and target-lesion revascularization consistently inwomen and men (pint=0.49 and pint=0.89, respectively–Figure 1B).

Conclusions

In women undergoing coronary revascularization for ULMCA disease, CABG is associated to lower risk of death, MI or CVA. Further dedicated studies are needed to determine the optimal revascularization strategy in women with ULMCA disease.

Figure 1

Funding Acknowledgement

Type of funding source: None