Socio-economic factors and medical conditions affecting regular stomach cancer screening in Korea: a retrospective longitudinal study using national public health data for 11 years

OBJECTIVE

This study aimed to explore socio-economic factors and medical conditions that affect regular stomach cancer (SC) screening among Korean adults.

STUDY DESIGN

This was a retrospective observational study.

METHODS

Study subjects were 5545 adults aged ≥40 years who participated in the 2007-2012 Korean National Health and Nutrition Examination Survey and were followed up to year 2017 based on data linking to the Korean National Health Insurance Service and Korean Health Insurance Review and Assessment. Socio-economic factors included sex, age, residential area, education, occupation, marital status, disability, public and private health insurance, service through local public health organizations, history of cancer except for SC, and family history of SC. Medical factors included six gastric lesions with the possibility of facilitating SC screening, including benign gastric neoplasm, chronic atrophic gastritis, gastric polyp, Helicobacter pylori infection, intestinal metaplasia, and peptic ulcers. The outcome was adherence to SC screening, which was divided into non-adherence, irregular adherence, and regular adherence.

RESULTS

After adjusting for the effects of socio-economic factors, multivariate ordinal logistic regression revealed that participants with a history of four types of gastric lesions were more likely to regularly participate in SC screening: chronic atrophic gastritis (odds ratio [OR] 1.567; 95% confidence interval [CI] = 1.276-1.923), gastric polyps (OR 1.565; 95% CI = 1.223-2.003), H. pylori infection (OR 1.637; 95% CI = 1.338-2.003), and peptic ulcer (OR 2.226; 95% CI 1.750-2.831).

CONCLUSIONS

To improve participation in SC screening, it is necessary to implement personalized strategies for individuals at risk for gastric cancer in addition to population-based strategies for vulnerable groups.

Beneficial Role of Multi-Disciplinary Treatment for Anaplastic Thyroid Cancer with Initial Distant Metastasis

PURPOSE/OBJECTIVE(S)

Anaplastic thyroid cancer (ATC) is a rare, highly aggressive tumor, with median survival around 5 months. Approximately half of the ATC patients presents with distant metastases at diagnosis, showing even more devastating prognosis, yet no outcome analysis had been reported. In this study, we aim to evaluate the clinical outcome of M1 ATC patients, and to define the group of patients who would benefit from local treatment based on multi-disciplinary approach.

MATERIALS/METHODS

A total of 133 histology-confirmed ATC patients underwent protocol-based multidisciplinary treatment including surgery and chemoradiotherapy (CRT) between May 2016 and January 2022. Patients received intensity-modulated radiotherapy of 30 fractions concurrently with paclitaxel on days 1, 8 and 15 every 4 weeks, and lenvatinib was added upon progression. After 18 fractions of CRT, interim response analysis using modified RECIST was conducted for adaptive treatment planning. We reviewed 58 patients with distant metastasis at diagnosis (stage IVC). Overall survival (OS) and progression-free survival (PFS) were measured from the day of diagnosis.

RESULTS

Most common metastatic site was lung (91.4%), followed by bone (31.0%) and brain (5.2%). Lenvatinib was added for 35 patients after any sign of progression. Fourteen patients received upfront surgery (16 debulking and 5 total) followed by adjuvant CRT in 16 patients. Thirty-one patients received upfront CRT with 2 patients receiving total resection after sufficient down-staging. Six (10%) patients could not complete radiotherapy but continued receiving systemic treatment. The median follow-up was 5.9 months. The median and 1-year OS were 6.2 months and 20.5%, and PFS were 3.7 months and 3.5%. Total RT dose over 60 Gy significantly improved median OS (7.5 vs 4.1 months, p = 0.012) and median PFS (4.4 vs 3.0, p = 0.010). Patients with less than 10 initial metastatic tumors showed better median OS (9.1 vs 4.6 months, p = 0.002) but not PFS (5.1 vs 3.6, p = 0.485). At interim analysis, early response (CR, PR and SD) of primary tumor was not associated with survival, while progression of distant metastases showed significantly worse median OS (9.8 vs 4.6 months, p = 0.001). More than 10 metastatic tumors (HR 2.73, 95% CI 1.32-5.66) and stable metastasis at interim analysis (HR 2.39, 95% CI 1.04-5.48) remained as significant factor in the multivariable cox regression analysis. Median OS and PFS of patients with less than 10 metastases showing no progression at interim analysis were 9.1 months, and 5.1 months.

CONCLUSION

Local treatment combined with chemotherapy for M1 ATC patients showed outcome comparable to those of non-metastatic ATC results. Active local treatment should be considered especially for patients with less than 10 metastases, and patients without distant progression in early response evaluation.

Hemorrhagic morbidity in nulliparous patients with placenta previa without placenta accrete spectrum disorders

Background

Placental adhesion spectrum (PAS) is a disease in which the trophoblast invades the myometrium, and is a well-known high-risk condition associated with placental previa.

Aim

The morbidity of nulliparous women with placenta previa without PAS disorders is unknown.

Patients and Methods

The data from nulliparous women who underwent cesarean delivery were collected retrospectively. The women were dichotomized into malpresentation (MP) and placenta previa groups. The placenta previa group was categorized into previa (PS) and low-lying (LL) groups. When the placenta covers the internal cervical os, it is called placenta previa, when the placenta is near the cervical os, it is called the low-lying placenta. Their maternal hemorrhagic morbidity and neonatal outcomes were analyzed and adjusted using multivariate analysis based on univariate analysis.

Results

A total of 1269 women were enrolled: 781 women in the MP group and 488 women in the PP-LL group. Regarding packed red blood cell transfusion, PP and LL had adjusted odds ratio (aOR) of 14.7 (95% confidence interval (CI): 6.6 - 32.5), and 11.3 (95% CI: 4.9 - 26) during admission, and 51.2 (95% CI: 22.1 - 122.7) and 10.3 (95% CI: 3.9 - 26.6) during operation, respectively. For intensive care unit admission, PS and LL had aOR of 15.9 (95% CI: 6.5 - 39.1) and 3.5 (95% CI: 1.1 - 10.9), respectively. No women had cesarean hysterectomy, major surgical complications, or maternal death.

Conclusion

Despite placenta previa without PAS disorders, maternal hemorrhagic morbidity was significantly increased. Thus, our results highlight the need for resources for those women with evidence of placenta previa including a low-lying placenta, even if those women do not meet PAS disorder criteria. In addition, placenta previa without PAS disorder was not associated with critical maternal complications.

Amyloid Against Amyloid: Dimeric Amyloid Fragment Ameliorates Cognitive Impairments by Direct Clearance of Oligomers and Plaques

Amyloid-β (Aβ) in the form of neurotoxic aggregates is regarded as the main pathological initiator and key therapeutic target of Alzheimer's disease. However, anti-Aβ drug development has been impeded by the lack of a target needed for structure-based drug design and low permeability of the blood-brain barrier (BBB). An attractive therapeutic strategy is the development of amyloid-based anti-Aβ peptidomimetics that exploit the self-assembling nature of Aβ and penetrate the BBB. Herein, we designed a dimeric peptide drug candidate based on the N-terminal fragment of Aβ, DAB, found to cross the BBB and solubilize Aβ oligomers and fibrils. Administration of DAB reduced amyloid burden in 5XFAD mice, and downregulated neuroinflammation and prevented memory impairment in the Y-maze test. Peptide mapping assays and molecular docking studies were utilized to elucidate DAB-Aβ interaction. To further understand the active regions of DAB, we assessed the dissociative activity of DAB with sequence modifications.

Aryloxypropanolamine targets amyloid aggregates and reverses Alzheimer-like phenotypes in Alzheimer mouse models

BACKGROUND

Aggregated amyloid-β (Aβ) is considered a pathogenic initiator of Alzheimer's disease (AD), in strong association with tau hyperphosphorylation, neuroinflammation, synaptic dysfunction, and cognitive decline. As the removal of amyloid burden from AD patient brains by antibodies has shown therapeutic potential, the development of small molecule drugs inducing chemical dissociation and clearance of Aβ is compelling as a therapeutic strategy. In this study, we synthesized and screened aryloxypropanolamine derivatives and identified 1-(3-(2,4-di-tert-pentylphenoxy)-2-hydroxypropyl)pyrrolidin-1-ium chloride, YIAD002, as a strong dissociator of Aβ aggregates.

METHODS

The dissociative activity of aryloxypropanolamine derivatives against Aβ aggregates were evaluated through in vitro assays. Immunohistochemical staining, immunoblot assays, and the Morris water maze were used to assess the anti-Alzheimer potential in YIAD002-treated 5XFAD and transgenic APP/PS1 mice. Target-ligand interaction mechanism was characterized via a combination of peptide mapping, fluorescence dissociation assays, and constrained docking simulations.

RESULTS

Among 11 aryloxypropanolamine derivatives, YIAD002 exerted strongest dissociative activity against β-sheet-rich Aβ aggregates. Upon oral administration, YIAD002 substantially reduced amyloid burden and accordingly, improved cognitive performance in the Morris water maze and attenuated major pathological hallmarks of AD including tauopathy, neuroinflammation, and synaptic protein loss. Mechanism studies suggest that YIAD002 interferes with intermolecular β-sheet fibrillation by directly interacting with KLVFFA and IGLMVG domains of Aβ. In addition, YIAD002 was found to possess dissociative activity against aggregates of pyroglutamate-modified Aβ and tau.

CONCLUSIONS

Collectively, our results evince the potential of chemical-driven dissociation of Aβ aggregates by aryloxypropanolamines as a therapeutic modality of the amyloid clearance approach.

Pattern of pericardial calcification determines the mid-term postoperative outcome after pericardiectomy in chronic constrictive pericarditis

Background/Introduction

Although pericardiectomy is an effective treatment of constrictive pericarditis (CP), clinical outcome is not always successful. Pericardial calcification is a unique finding in CP. However, the amount and localization of calcification vary. Computer tomography (CT) can visualize the pericardial calcification with high sensitivity and provide the anatomical assessment.

Purpose

We investigated that how the pattern and amount of pericardial calcification affect the mid-term postoperative outcome after pericardiectomy in CP.

Methods

All of the patients who underwent total pericardiectomy in our hospital from 2010 to 2020 were derived from electrical medical records (n=105). Among them, preoperative CT scans (non-gated non-contrast) of 98 patients were available and, thus, 98 consecutive patients were finally analyzed. Medical records were reviewed in a retrospective manner. Cardiovascular event is defined as cardiovascular death or hospitalization associated with a heart failure symptom and all cause event is defined as all events that require admission. CT scan was analyzed by Aquarius Workstation, and the volume and localization pattern of pericalcification were derived. Pericardium calcium score was given as an Agatston score.

Results

Of 98 patients, 25 (25.5%) patients were hospitalized with heart failure symptom after pericardiectomy. Median follow up duration of patients is 172 weeks. A group with cardiovascular event had higher NYHA grade (P<0.001), lower calcium volume (P=0.004), and lower calcium score (P=0.01). Multivariate cox proportional analysis showed that high ln(calcium score) before pericardiectomy was dependent predictor of cardiovascular event (hazard ratio, 0.90; P=0.04) and all cause event (hazard ratio, 0.91, P=0.04) after pericardiectomy. When we set the cut off value at 7.22, based on ROC curve, there was a significant difference in cardiovascular event between the groups divided by this cutoff value in Kaplan-Meier curve (P=0.002) and multivariate cox proportional analysis (P=0.04). In the subgroup analysis, myocardium invasion and circumferential calcification were more common in the high calcium score group. Idiopathic & tuberculosis pericarditis were more associated with high calcium score group and post-operative pericarditis, other reasons (infection, radiation, etc) were more associated with low calcium group.

Conclusion

Low burden of pericardial calcification was associated high rate of mid-term clinical event after pericardiectomy CP. Preoperative evaluation of pericardial calcification pattern can be used as predictor of postoperative outcomes.

Funding Acknowledgement

Type of funding sources: None.

Risk factors and clinical effects of late leaflet thrombosis after transcatheter aortic valve replacement

Background

As the indications for trans-catheter aortic valve replacement (TAVR) expand, it is expected that the number of TAVR patients would increase and the follow-up duration would be longer. It is known that the incidence of leaflet thrombosis is higher in TAVR than in surgical aortic valve replacement (SAVR), but not much is known about the risk factors of late leaflet thrombosis in TAVR.

Aim

Therefore, in this study, the incidence and risk factors of late leaflet thrombosis at late term after TAVR and the effect on clinical course of late leaflet thrombosis would be investigated.

Method

There were 176 patients undergone TAVR from January 2015 to October 2020 in one tertiary hospital of south korea. 94 patients had follow-up cardiovascular computed tomography (CT) between 3 months and 2 years after TAVR. Among 94 patients, late leaflet thrombosis was discovered at 20 patients, and risk factors were analyzed by comparing clinical factors, echocardiographic and cardiovascular CT information, and angiographic data between the group with and without late leaflet thrombosis. And the difference in aortic valve hemodynamics between the group with and without leaflet thrombosis was examined and clinical outcomes were compared. Clinical outcome was defined as the composite of all-cause death, stroke, heart failure (HF) admission, redo-aortic valve (AV) replacement and major bleeding after detection of late leaflet thrombosis.

Results

Indexed mean sinus of Valsalva diameter, AV calcium score and post procedure estimated orifice area (EOA) had predictability of late leaflet thrombosis with AUC value of 0.670 (95% CI [0.546–0.795], p value = 0.020), AUC value of 0.698 (95% CI [0.544–0.851], p value = 0.012) and AUC value of 0.665 (95 percent CI [0.548–0.782], p value = 0.031), respectively (Figure 1).

In echocardiography performed at the time of follow-up CT, AV max velocity and AV mean pressure gradient were higher in thrombosis group and EOA and Doppler velocity index were lower in thrombosis group than in no thrombosis group within normal range (Figure 2). Clinical outcome was not significant different between the two groups (log rank p value = 0.560).

Conclusion

Larger indexed sinus of Valsalva diameter, higher AV calcium score and smaller post procedure AV EOA were risk factors for late leaflet thrombosis after TAVR. Subclinical late leaflet thrombosis have a benign course when properly managed.

Funding Acknowledgement

Type of funding sources: None.

All-cause mortality, cardiovascular mortality, and incidence of cardiovascular disease according to a screening program of cardiovascular risk in South Korea among young adults: a nationwide cohort study

OBJECTIVES

We aimed to determine whether there are any differences in all-cause and cause-specific mortality with cardiovascular disease (CVD) risk between health screening attenders and non-attenders among young adults.

STUDY DESIGN

We performed a retrospective cohort study using claim data from the Korean National Health Insurance Service database.

METHODS

Individuals aged 20-39 years who had received health screening at least once between 2002 and 2005 were classified as attenders, and the others were classified as non-attenders. After propensity score matching according to attendance of health screening, 2,060,409 attenders and 2,060,409 non-attenders were included. We estimated adjusted hazard ratios (HRs) and 95% confidence interval (CI) for all-cause mortality, cause-specific mortality, and hospitalization of CVD from 2006 to 2015.

RESULTS

Survival from all-cause mortality was greater among attenders than among non-attenders (log rank P < 0.001). Similarly, death from CVD (log rank P = 0.007) and CVD events (log rank P < 0.001) were less likely among attenders. The risk for all-cause mortality in attenders was significantly lower than that in non-attenders (HR = 0.83, 95% CI = 0.81 to 0.84). The risk for CVD mortality (HR = 0.80, 95% CI = 0.73 to 0.87) and hospitalization of CVD (HR = 0.92, 95% CI = 0.91 to 0.94) were lower in attenders. In stratified analyses, the risk for all-cause and cause-specific mortalities was lower among attenders regardless of insurance type.

CONCLUSIONS

Among young adults, the risk for all-cause mortality, CVD mortality, and hospitalization of CVD were lower for those who underwent health screenings. Future studies that evaluate the cost-effectiveness of health screening with additional consideration of psychosocial aspects are needed.

Vaginal compared with intramuscular progestogen for preventing preterm birth in high-risk pregnant women (VICTORIA study): a multicentre, open-label randomised trial and meta-analysis

OBJECTIVE

To compare the efficacy of two types of progestogen therapy for preventing preterm birth (PTB) and to review the relevant literature.

DESIGN

A multicentre, randomised, open-label, equivalence trial and a meta-analysis.

SETTING

Tertiary referral hospitals in South Korea.

POPULATION

Pregnant women with a history of spontaneous PTB or short cervical length (<25 mm).

METHODS

Eligible women were screened and randomised at 16-22 weeks of gestation to receive either 200 mg of vaginal micronised progesterone daily (vaginal group) or an intramuscular injection of 250 mg 17α-hydroxyprogesterone caproate weekly (IM group). Stratified randomisation was carried out according to participating centres and indications for progestogen therapy. This trial was registered at ClinicalTrials.gov (NCT02304237).

MAIN OUTCOME MEASURE

Preterm birth (PTB) before 37 weeks of gestation.

RESULTS

A total of 266 women were randomly assigned and a total of 247 women (119 and 128 women in the vaginal and IM groups, respectively) were available for the intention-to-treat analysis. Risks of PTB before 37 weeks of gestation did not significantly differ between the two groups (22.7 versus 25.8%, P = 0.571). The difference in PTB risk between the two groups was 3.1% (95% CI -7.6 to 13.8%), which was within the equivalence margin of 15%. The meta-analysis results showed no significant differences in the risk of PTB between the vaginal and IM progestogen treatments.

CONCLUSION

Compared with vaginal progesterone, treatment with intramuscular progestin might increase the risk of PTB before 37 weeks of gestation by as much as 13.8%, or reduce the risk by as much as 7.6%, in women with a history of spontaneous PTB or with short cervical length.

TWEETABLE ABSTRACT

Vaginal and intramuscular progestogen showed equivalent efficacy for preventing preterm birth before 37 weeks of gestation.

Survival of oral mucosal melanoma according to treatment, tumour resection margin, and metastases

Because of the poor prognosis and of oral mucosal melanoma, and patients' short survival, large, randomised, clinical studies are difficult. We have investigated its demographic characteristics and analysed the effect of treatment, resection margins, and metastases on survival. We recorded age, sex, site of primary tumour, and types of treatment, survival, and metastases in 74 patients treated at the Department of Oral and Maxillofacial Surgery, Seoul National University Dental Hospital. Survival was analysed based on bony invasion, depth of invasion, and resection margins, and we found that it varied depending on the primary site (p=0.002), and declined with liver (p=0.001) or brain (p=0.033) metastases. The two-year survival according to the primary site was as follows: palate 85% (n=32), anterior maxillary gingiva 53% (n=13), mandible 58% (n=13), and posterior maxillary gingival 74% (n=10) and buccal mucosa 50% (n=4). The two-year survival was 34% (n=8) in patients with liver metastases and 23% (n=7) in patients with brain metastases. In cases of bony invasion (p=0.005), depth of invasion (p=0.042), unclear resection margin (p=0.023), or higher T stages (p=0.009), the survival declined considerably. Neck dissection did not affect survival (p=0.343). Survival of the patients given chemotherapy was significantly lower (p=0.013) and the two-year survival was 54.0%. The patients given radiotherapy showed no significant difference in survival compared with those not given radiotherapy (p=0.107). In conclusion, primary site, bony invasion, resection margins, depth of invasion and systemic metastases were critical to predict prognosis and selection of treatment of oral mucosal melanoma.

1175 Comparison of fractional myocardial mass, a vessel-specific myocardial mass-at-risk, with coronary angiographic scoring systems for predicting myocardial ischemia

Aims The burden of coronary artery disease has been assessed by various semi-quantitative angiographic scores, which are frequently different each other. A non-invasive and quantitative modality may substitute angiographic sores for prognostic implication and decision of revascularization strategy. We compared fractional myocardial mass (FMM) with angiographic scores for predicting myocardial ischemia.

Methods In this multicenter registry, 411 patients who underwent coronary computed tomography angiography (CCTA) were followed by invasive coronary angiography and FFR measurement. CCTA–derived %FMM with diameter stenosis ≥70% (%FMM-70) or ≥50% (%FMM-50) were compared with 9 angiographic scores (APPROACH, Duke Jeopardy, BARI, CASS, SYNTAX, Jenkins, BCIS-1, Leaman, Modified Duke) and were tested regarding their performance for predicting FFR ≤ 0.80. Predictive performance of %FMM or angiographic scores for FFR ≤ 0.80 established in derivation cohort (N = 250) and tested in validation cohort (N = 161).

Results The performance of %FMM-70 and %FMM-50 were similar to most angiographic scores (%FMM-70, c-statistics = 0.76; %FMM-50, 0.71; angiographic scores, 0.68 – 0.79). The frequency of FFR ≤ 0.80 increased consistently according to %FMM-70, %FMM-50, and all angiographic scores (p &lt; 0.001, all). The optimal cutoff of %FMM-50 and %FMM-70 for FFR ≤ 0.80 were ≥34.5% and ≥9.8%, respectively. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of %FMM-50 were 83%, 56%, 73%, 70%, 72%, and of %FMM-70 were 72%, 78%, 75%, 75%, and 75% using these cutoffs. Validation cohort showed consistent results.

Conclusion %FMM correlated well with angiographic scores and had a potential to be used as a non-invasive alternative to the angiographic scores. The integration of the severity of stenosis and the amount of subtended myocardium may improve the detection of clinically significant coronary artery stenosis.

Abstract 1175 Figure. FMM vs angiographic score

P5279Pericardial inflammation basced on cardiac magnetic resonance imaging in patients with tuberculous pericarditis

Background

While constrictive pericarditis has been traditionally considered a disabling disease, reversible constrictive pericarditis has been described in previous studies. But there are limited studies on cardiac imaging of tuberculous pericarditis. In particular, no studies on cardiac magnetic resonance imaging (CMR) have been reported. We aimed to investigate CMR findings including pericardial late gadolinium enhancement (LGE) and T2 fat suppression and black blood sequences in patients with tuberculous pericarditis.

Methods

We retrospectively analyzed medical records of patients with tuberculous pericarditis between January 2010 and January 2017 in Samsung Medical Center. Definite diagnosis of tuberculous pericarditis is based on the identification of Mycobacterium tuberculosis in pericardial fluid or tissue; probable diagnosis was made when there was other evidence of tuberculosis elsewhere in patients with unexplained pericarditis. We performed CMR at initial diagnosis. Treatment consists of the standard 4-drug antituberculosis regimen for 6 months with or without steroids. Echocardiography was also conducted at initial diagnosis and 6 months later.

Results

Total 39 cases with tuberculous pericarditis in immunocompetent patients were enrolled. Ten patients were diagnosed as definite tuberculous pericarditis. CMR finding at initial diagnosis divided into five groups: 1) pericardial effusion only (n=20, 51.3%), 2) effusive constrictive pericarditis (n=5, 12.8%), 3) constrictive pericarditis (n=11, 28.2%), 4) pericardial abscess formation (n=4, 10.3%) and 5) absence of pericardial effusion and constrictive physiology (n=1, 2.6%). One of the 4 patients with pericardial abscess formation was together with pericardial effusion and the other was accompanied by effusive constrictive pericarditis. Pericardial thickness increased to more than 4mm in 25 patients (64.1%) and the mean pericardial thickness was 10.0±6.9mm. Delayed enhancement of pericardium was noticed in 29 patients (74.4%). In T2 fat suppression and black blood sequences, 30 patients showed increased T2 signal intensity indicating inflammation with extensive edema. Pericardial thickening (>4mm) with constriction (n=15) was not statistically significant in the delayed enhancement and increased T2 signal intensity compared with pericardial thickening without constrictive pericarditis (n=10) (delayed enhancement 93.8% vs. 77.8% p=0.287; increased T2 signal intensity 88.9% vs. 87.5%, p=0.713). After 6 months, only 3 patients still had constrictive pericarditis in echocardiography.

Effusive constrictive pericarditis

Conclusions

Pericardial thickening is associated with delayed enhancement and increased T2 signal intensity in patients with tuberculous pericarditis regardless of constrictive pericarditis. Even though there were hemodynamic feature of constrictive pericarditis and pericardial inflammation with extensive edema in CMR at initial diagnosis, 80% of the patients were improved from constrictive pericarditis.

Acknowledgement/Funding

None

Comparison of body surface area-based and weight-based dosing format for oral prednisolone administration in small and large-breed dogs

This study compared the pharmacokinetics of Prednisolone (PDS) in small- and large breed dogs with a dosing format based on body surface area (BSA) or body weight (BW). The maximum concentration and area under the curve in large-breed dogs orally administered 2 mg/kg PDS were significantly greater than those in small-breed dogs given 2 mg/kg and in large-breed dogs given 40 mg/m2. The higher blood concentrations that result from BW-based dosing of oral PDS in large-breed dogs can be more than required for effect. Meanwhile, BSA dosing at 40 mg/m may be suboptimal. These findings confirm important differences between standard PDS dosing schemes in dogs while highlighting the need to further optimize PDS dosing in large-breed dogs.

Salvage of failed osteosynthesis for an atypical subtrochanteric femoral fracture associated with long-term bisphosphonate treatment using a 95° angled blade plate

AIMS

The aim of this study was to evaluate the outcomes of a salvage procedure using a 95° angled blade plate for failed osteosynthesis of atypical subtrochanteric femoral fractures associated with the long-term use of bisphosphonates. These were compared with those for failed osteosynthesis of subtrochanteric fractures not associated with bisphosphonate treatment.

PATIENTS AND METHODS

Between October 2008 and July 2016, 14 patients with failed osteosynthesis of an atypical subtrochanteric femoral fracture were treated with a blade plate (atypical group). Their mean age was 67.8 years (60 to 74); all were female. During the same period, 21 patients with failed osteosynthesis of a typical subtrochanteric fracture underwent restabilization using a blade plate (typical group). Outcome variables included the time of union, postoperative complications, Harris Hip Score, and Sanders functional rating scale.

RESULTS

In the atypical group, union was achieved in 12 patients (85.7%) at a mean of 8.4 months (4 to 12). The mean follow-up was 31.2 months (12 to 92) The plate broke in one patient requiring further stabilization with a longer plate and strut-allograft. Another patient with failure of fixation and varus angulation at the fracture site declined further surgery. In the typical group, union was achieved in 18 patients (85.7%) at a mean of 7.9 months (4 to 12). There was no difference in the mean Harris Hip Score between the two groups (83.1 points vs 86.8 points; p = 0.522) at the time of final follow-up. Sanders functional rating scores were good or excellent in 78.6% of the atypical group and in 81.0% of the typical group.

CONCLUSION

The 95° angled blade plate was shown to be an effective fixation modality for nonunion of atypical subtrochanteric fractures with a high rate of union and functional improvement, comparable to those after fractures not associated with bisphosphonate treatment. Cite this article: Bone Joint J 2018;100-B:1511-17.

Clinical and laboratory features of patients with osteomalacia initially presenting with neurological manifestations

Patients with osteomalacia often visit the neurology department with conditions mimicking other myopathies. We analyzed clinical features of osteomalacia patients who visited the neurology department. These patients frequently presented with hypocalcemia, hypovitaminosis D, and pain with less severe weakness. Osteomalacia should be considered when patients present with pain and weakness.

INTRODUCTION

Osteomalacia is a disease of bone metabolism; however, some patients with osteomalacia initially visit the neurology department. As these patients often complain of weakness and gait disturbance, osteomalacia can be confused with other myopathies. We analyzed the clinical features of patients with osteomalacia who visited the neurology department.

METHODS

We retrospectively reviewed the medical records. Osteomalacia was diagnosed based on symptoms, laboratory features, and imaging results. We compared the characteristics of patients with osteomalacia who visited the neurology department with (1) those who did not visit the neurology department and (2) patients with idiopathic inflammatory myopathy.

RESULTS

Eighteen patients with osteomalacia visited the neurology department (NR group). The common etiologies in the NR group included tumors or antiepileptic medication, whereas antiviral medication was the most common in patients who did not visit the neurology department (non-NR group). The NR group showed lower serum calcium (p = 0.004) and 25-hydroxyvitamin D (p = 0.006) levels than the non-NR group. When compared with patients with inflammatory myopathy, both groups showed proximal dominant weakness. However, pain was more common in osteomalacia than in myopathy (p = 0.008), and patients with osteomalacia showed brisk deep tendon reflex more often (p = 0.017). Serum calcium (p = 0.003) and phosphate (p < 0.001) levels were lower in osteomalacia than in myopathy.

CONCLUSIONS

It was not uncommon for patients with osteomalacia to visit the neurology department. The clinical presentation of these patients can be more complex owing the superimposed neurological disease and accompanying hypocalcemia. Osteomalacia should be considered when patients present with pain and weakness.

Lysophosphatidylserine receptor P2Y10: A G protein-coupled receptor that mediates eosinophil degranulation

BACKGROUND

P2Y10, along with GPR34 and GPR174, is a G protein-coupled receptor that is activated by an endogenous lipid mediator lysophosphatidylserine (LysoPS). Its expression pattern and its function are completely unknown. We have previously shown that P2Y10 is one of the highly up-regulated genes at the late differentiation stage during in vitro eosinophilopoiesis.

OBJECTIVE

We explored the expression and functions of P2Y10 in human cord blood (CB)-derived and peripheral blood (PB) eosinophils.

METHODS

Real-time PCR, FACS, Western blot, ELISA, and chemotaxis assays were performed to determine the expression and function of P2Y10.

RESULTS

As CB cells differentiated towards eosinophils, P2Y10 mRNA and protein were abundantly expressed. P2Y10 was the most highly expressed in the granulocytes from PB, to a lesser extent in monocytes, and least in lymphocytes. Further fractionation of granulocytes revealed that eosinophils express P2Y10 much more strongly than do neutrophils. PB eosinophils solely expressed P2Y10 among the three LysoPS receptors, while PB neutrophils expressed the three at comparable levels. LysoPS activated both CB and PB eosinophils to induce a robust ERK phosphorylation. Importantly, LysoPS was capable of triggering degranulation of ECP in PB eosinophils. This response was significantly reduced by pharmacological inhibitors of TNF-alpha-converting enzyme (TACE), epidermal growth factor receptor (EGFR), and ERK1/2, which were known to be required in P2Y10-mediated signalling pathways. However, LysoPS had no effect on chemotaxis, differentiation, or eosinophil survival.

CONCLUSIONS AND CLINICAL RELEVANCE

LysoPS provokes eosinophil degranulation through P2Y10. Therefore, P2Y10 is a potential therapeutic target to control eosinophil-associated diseases.

Development of a finger-like mechanism of end-effector for micro surgery

Neurosurgery had been considered nearly impossible due to its technical difficulty and the danger to its special target organ, but with endoscopic methods, many such surgeries can be made safely through the nose. Endoscopic neurosurgery is limited by available instruments, however, and there remain some areas of the human body inaccessible to standard surgical tools. To overcome some of these limitations, in this study we developed a simple mechanism that could form a high curvature in a narrow space. The end product is a finger-like mechanism consisting of five body parts and four joints. All body parts are connected in series, having a total length of 20mm and a diameter of φ4mm. A four-bar linkage internally connects the body parts and joints, and a nitinol backbone was used to improve repeatability. The first joint is driven by a rod or wire, and the shape of the mechanism is determined by rotating the first joint, because the position of each joint depends on the position of the joint before it. The study verified that an image sensor in the end of the finger-like mechanism has a wider range of view, 210 degrees than a conventional endoscope of 100 degrees. Finally, skull model simulation suggests that this device could be used in real neurosurgical applications.

Polycystic ovary syndrome with hyperandrogenism as a risk factor for non-obese non-alcoholic fatty liver disease

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is known to be associated with polycystic ovary syndrome (PCOS). However, most studies investigated the prevalence of NAFLD in obese PCOS patients.

AIM

To compare the prevalence of non-obese NAFLD in women with or without PCOS, and to assess an independent association between PCOS and NAFLD in a non-obese Asian cohort.

METHODS

This was a case-control study using a prospective PCOS cohort. After subjects with other potential causes of chronic liver disease were excluded, 275 non-obese women with PCOS and 892 non-obese controls were enrolled. NAFLD was determined by hepatic ultrasonography. Main outcomes were the prevalence of NAFLD on hepatic ultrasonography between non-obese women with or without PCOS, and an independent association between non-obese NAFLD and PCOS.

RESULTS

Non-obese women with PCOS had a significantly higher prevalence of NAFLD than those without PCOS (5.5% vs. 2.8%, P = 0.027). PCOS was associated with non-obese NAFLD (odds ratio: 2.62, 95% confidence intervals: 1.25-5.48) after adjustment for age and body mass index (BMI). In women with PCOS, the level of androgenicity represented by free testosterone or free androgen index was associated with NAFLD after adjustment for age, BMI, lipid profile, insulin resistance or glycaemic status.

CONCLUSIONS

Non-obese NAFLD is more prevalent in women with polycystic ovary syndrome than in those without. In non-obese patients with polycystic ovary syndrome, hyperandrogenemia may be an independent risk factor for non-obese NAFLD.

Phosphorylation of a constrained azacyclic FTY720 analog enhances anti-leukemic activity without inducing S1P receptor activation

The frequency of poor outcomes in relapsed leukemia patients underscores the need for novel therapeutic approaches. The FDA-approved immunosuppressant FTY720 limits leukemia progression by activating protein phosphatase 2A and restricting nutrient access. Unfortunately, FTY720 cannot be re-purposed for use in cancer patients due to on-target toxicity associated with S1P receptor activation at the elevated, anti-neoplastic dose. Here we show that the constrained azacyclic FTY720 analog SH-RF-177 lacks S1P receptor activity but maintains anti-leukemic activity in vitro and in vivo. SH-RF-177 was not only more potent than FTY720, but killed via a distinct mechanism. Phosphorylation is dispensable for FTY720’s anti-leukemic actions. However, chemical biology and genetic approaches demonstrated that the sphingosine kinase 2- (SPHK2) mediated phosphorylation of SH-RF-177 led to engagement of a pro-apoptotic target and increased potency. The cytotoxicity of membrane-permeant FTY720 phosphonate esters suggests that the enhanced potency of SH-RF-177 stems from its more efficient phosphorylation. The tight inverse correlation between SH-RF-177 IC₅₀ and SPHK2 mRNA expression suggests a useful biomarker for SH-RF-177 sensitivity. In summary, these studies indicate that FTY720 analogs that are efficiently phosphorylated but fail to activate S1P receptors may be superior anti-leukemic agents compared to compounds that avoid cardiotoxicity by eliminating phosphorylation.

Discovery of pathogenic variants in a large Korean cohort of inherited muscular disorders

Inherited muscular disorders (IMDs) are clinically and genetically heterogeneous genetic disorders. We investigated the mutational spectrum and genotype-phenotype correlations in Korean patients with IMD. We developed a targeted panel of 69 known IMD genes and recruited a total of 209 Korean patients with IMD. Targeted capture sequencing identified 994 different variants. Among them, 98 variants were classified as pathogenic/likely pathogenic variants; 38 were novel variations. A total of 39 patients had the pathogenic/likely pathogenic variants. Among them, 75 (36%) patients were genetically confirmed, and 18 (9%) patients had one heterozygous variant of recessive myopathy. However, two genetically confirmed patients had an additional heterozygous variant of another recessive myopathy. Four patients with one heterozygous variant of a recessive myopathy showed different phenotypes, compared with the known phenotype of the identified gene. The major causative genes of Korean patients with IMDs were DMD (19 patients), COL6A1 (9), DYSF (9), GNE (7), LMNA (7), CAPN3 (6), and RYR1 (5). This study showed the mutational and clinical spectra in Korean patients with IMD and confirmed the usefulness of strategies utilizing targeted sequencing.

In vivo near-infrared imaging for the tracking of systemically delivered mesenchymal stem cells: tropism for brain tumors and biodistribution

Mesenchymal stem cell (MSC)-based gene therapy is a promising tool for the treatment of various neurological diseases, including brain tumors. However, the tracking of in vivo stem cell migration, distribution, and survival need to be defined for their clinical application. The systemic routes of stem cell delivery must be determined because direct intracerebral injection as a cure for brain tumors is an invasive method. In this study, we show for the first time that near-infrared (NIR) imaging can reveal the distribution and tumor tropism of intravenously injected MSCs in an intracranial xenograft glioma model. MSCs were labeled with NIR fluorescent nanoparticles, and the effects of the NIR dye on cell proliferation and migratory capacity were evaluated in vitro. We investigated the tumor-targeting properties and tissue distribution of labeled MSCs introduced by intravenous injection and followed by in vivo imaging analysis, histological analysis, and real-time quantitative polymerase chain reaction. We observed no cytotoxicity or change in the overall growth rate and characteristics of labeled MSCs compared with control MSCs. NIR fluorescent imaging showed the organ distribution and targeted tumor tropism of systemically injected human MSCs. A significant number of MSCs accumulated specifically at the tumor site in the mouse brain. These results suggest that NIR-based cell tracking is a potentially useful imaging technique to visualize cell survival, migration, and distribution for the application of MSC-mediated therapies in the treatment of malignant gliomas.

Expression of soluble adenylyl cyclase in acral melanomas

Soluble adenylyl cyclase (sAC) regulates melanocytic cells, and is a diagnostic marker for pigmented skin lesions. Because only a few studies on sAC expression in acral melanomas have been performed, we investigated the histopathological significance of sAC expression in 33 cases of acral melanoma, and assessed its diagnostic value in distinguishing melanoma in situ (MIS, n = 17) from acral invasive melanomas (n = 16) and melanocytic naevi (n = 11). Acral melanomas exhibited more marked nuclear immunopositivity compared with acral melanocytic naevi. sAC expression significantly correlated with the nuclear morphology of melanocytes and melanoma cells, namely, hyperchromatic nuclei and prominent nucleoli within vesicular nuclei. sAC expression was predominantly observed in the hyperchromatic nuclei of MIS and the prominent nucleoli invasive melanomas, respectively. In vitro culture models of melanocytes and melanoma cell lines exhibited sAC staining patterns similar to those of acral melanomas. Differentiation induction showed that nuclear and nucleolar expression varied depending on cell morphology. sAC immunostaining may be useful for the differential diagnosis of acral melanocytic lesions, and sAC expressed in the nucleus and nucleolus might be related to cytological and nuclear changes associated with invasion and progression of acral melanomas.

Mid-trimester amniotic fluid pro-inflammatory biomarkers predict the risk of spontaneous preterm delivery in twins: a retrospective cohort study

OBJECTIVE

To evaluate the association between the concentrations of immune-related proteins in mid-trimester amniotic fluid (AF) and the subsequent risk of spontaneous preterm delivery in twins.

STUDY DESIGN

The study population consisted of consecutive women with a twin pregnancy who underwent clinically indicated genetic amniocentesis at 15 to 20 weeks, and had a subsequent spontaneous delivery in the early preterm period (<32 weeks (cases)) or at term (37 to 42 weeks (controls)). AF was analyzed for cytokines (interleukin (IL)-1ß, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12, IL-13 and IL-15, interferon-γ, tumor necrosis factor-α), matrix metalloproteinases (MMP-1, MMP-2, MMP-3, MMP-8, MMP-9 and MMP-12), and chemokines (complement factor-D/Adipsin, Serpin E1/PAI-1, Adiponectin/Acrp30, C-Reactive Protein, CCL2/MCP-1, Leptin, Resistin) using multiplex immunoassay kits. The association between AF protein levels and subsequent early preterm birth were examined.

RESULT

A total of 96 sets of twins were enrolled, including 17 early preterm birth cases and 79 term controls. AF concentrations of IL-6, IL-8, MMP-3, MMP-8 and MMP-9, and CCL2/MCP-1 were significantly higher in cases than controls. Among these analytes, the combination of AF IL-8 and MMP-9 values had the highest predictive value for early preterm birth. The risk was 8% (10/132) for IL-8<1200 pg ml(-1) and MMP-9<1000 pg ml(-1), 30% (15/50) for IL-8>1200 pg ml(-1) or MMP-9>1000 pg ml(-1), and 90% (9/10) for IL-8>1200 pg ml(-1) and MMP-9>1000 pg ml(-1) (P<0.001).

CONCLUSION

High concentrations of IL-8 and MMP-9 in mid-trimester AF in twins predicted well the risk of early preterm birth.

Unusual cause of a facial pressure ulcer: the helmet securing the Sengstaken-Blakemore tube

Many medical devices, such as pulse oximetry, ventilation masks and other splints are put on critically ill patients. Although these devices are designed to deliver relatively low physical pressure to the skin of the patient, they can still cause pressure ulcers (PUs) in critically ill patients. There are reports of medical device-related PUs on the face. Here we describe forehead skin necrosis caused by the securing helmet for the Sengstaken-Blakemore tube. It is difficult to detect this kind of PU early, because most of the patients have decreased mental status or delirium due to varix bleeding. For this reason, medical staff should be aware of the risk of developing a PU by the device and take preventive measures accordingly.

Nodular Fasciitis of the Breast: A Case and Literature Review

Nodular fasciitis is a benign fibroblastic proliferation in soft tissue that is most commonly found in the upper extremities, trunk, head, and neck region. Its occurrence in the breast has been rarely reported. The most characteristic features are the sudden appearance and rapid growth of a palpable lesion. Nodular fasciitis can clinically, radiologically, and histopathologically mimic a breast carcinoma. We present a case of nodular fasciitis of the breast and a review of the relevant literature.

Role of second-look ultrasound examinations for MR-detected lesions in patients with breast cancer

PURPOSE

To assess the clinical value of second-look ultrasound (US) examination for the evaluation of additional enhancing lesions detected on magnetic resonance (MR) imaging.

MATERIALS AND METHODS

Between May 2008 and February 2011, 794 consecutive patients with histologically confirmed breast cancer underwent breast MR imaging. We included 101 patients with 132 additional enhancing breast lesions detected on MR imaging who underwent second-look US.  The imaging features and lesion category according to the Breast Imaging and Reporting and Data System (BI-RADS) were assessed with MR and US imaging, respectively.

RESULTS

According to the BI-RADS system, 67 lesions (50.8 %) were classified as category 0, 33 lesions (25.0 %) as category 3, and 32 lesions (24.2 %) as category 4. Of the 67 indeterminate lesions on MR imaging, 34 (50.7 %) were demonstrated on second-look US. 11 of these 34 lesions showed suspicious sonographic features, including 1 lesion that showed malignancy (9.1 %, 1/11). Most of the suspicious lesions on MR imaging (26 of 32 BI-RADS category 4 lesions, 81.3 %) were demonstrated on second-look US, and 17 were malignant (65.4 %, 17/26). Of the 6 BI-RADS category 4 lesions without sonographic correlation, 1 was malignant (16.7 %, 1/6).

CONCLUSION

Second-look US examination was useful for evaluating MR-detected lesions in patients with breast cancer.

Continuous-flow system and monitoring tools for the dielectrophoretic integration of nanowires in light sensor arrays

Although nanowires (NWs) may improve the performance of many optoelectronic devices such as light emitters and photodetectors, the mass commercialization of these devices is limited by the difficult task of finding reliable and reproducible methods to integrate the NWs on foreign substrates. This work shows the fabrication of zinc oxide NWs photodetectors on conventional glass using transparent conductive electrodes to effectively integrate the NWs at specific locations by dielectrophoresis (DEP). The paper describes the careful preparation of NW dispersions by sedimentation and the dielectrophoretic alignment of NWs in a home-made system. This system includes an impedance technique for the assessment of the alignment quality in real time. Following this procedure, ultraviolet photodetectors based on the electrical contacts formed by the DEP process on the transparent electrodes are fabricated. This cost-effective mean of contacting NWs enables front-and back-illumination operation modes, the latter eliminating shadowing effects caused by the deposition of metals. The electro-optical characterization of the devices shows uniform responsivities in the order of 106 A W(-1) below 390 nm under both modes, as well as, time responses of a few seconds.

Towards actionable international comparisons of health system performance: expert revision of the OECD framework and quality indicators

OBJECTIVE

To review and update the conceptual framework, indicator content and research priorities of the Organisation for Economic Cooperation and Development's (OECD) Health Care Quality Indicators (HCQI) project, after a decade of collaborative work.

DESIGN

A structured assessment was carried out using a modified Delphi approach, followed by a consensus meeting, to assess the suite of HCQI for international comparisons, agree on revisions to the original framework and set priorities for research and development.

SETTING

International group of countries participating to OECD projects.

PARTICIPANTS

Members of the OECD HCQI expert group.

RESULTS

A reference matrix, based on a revised performance framework, was used to map and assess all seventy HCQI routinely calculated by the OECD expert group. A total of 21 indicators were agreed to be excluded, due to the following concerns: (i) relevance, (ii) international comparability, particularly where heterogeneous coding practices might induce bias, (iii) feasibility, when the number of countries able to report was limited and the added value did not justify sustained effort and (iv) actionability, for indicators that were unlikely to improve on the basis of targeted policy interventions.

CONCLUSIONS

The revised OECD framework for HCQI represents a new milestone of a long-standing international collaboration among a group of countries committed to building common ground for performance measurement. The expert group believes that the continuation of this work is paramount to provide decision makers with a validated toolbox to directly act on quality improvement strategies.

Gender differences in clinical and angiographic findings of patients with Takayasu arteritis

OBJECTIVES

Because Takayasu arteritis (TA) predominantly affects females, few data regarding gender differences have been reported. The aim of the present study is to describe clinical features and angiographic findings of patients with TA according to gender.

METHODS

According to the 1990 American College of Rheumatology criteria, 294 patients were diagnosed with TA between September 1994 and April 2014 at a single tertiary hospital. We reviewed clinical, laboratory, and radiologic data at the time of diagnosis.

RESULTS

Among the 294 patients studied, 257 (87.4%) were female (male:female ratio=1:6.9). Female patients had a higher tendency to exhibit blood pressure differences between arms (p=0.595) and a weak pulse at the brachial artery (p=0.063). In male patients, we observed higher serum creatinine levels (p=0.038) and hypertension more frequently (p=0.061) than in females. Females exhibited more common lesions in the thoracic aorta and its branches, while males had more frequent lesions in the abdominal aorta and its branches. An analysis of angiographic classification according to the International TA Conference in Tokyo 1994 classification revealed that male patients had a higher incidence of type IV and females showed a higher incidence of types I, IIa, and IIb.

CONCLUSIONS

Female patients with TA have more frequent involvement of the thoracic aorta and its branches, whereas involvement of the abdominal aorta and its branches is more common in males. Considering these gender-specific differences, adjustment of diagnostic criteria for TA according to gender may be necessary.

The effect of a Foley catheter balloon on cervical ripening

The Foley catheter balloon may affect cervical ripening through changes in biochemical mediators by immunoassay and immunohistochemistry, when it is used for pre-induction cervical ripening. The aim of the study was to evaluate the changes in the biochemical mediators from the extra-amniotic space and immunohistochemistry in ripened cervical tissue after the insertion of a Foley catheter balloon (FCB) for pre-induction cervical ripening. A total of 18 pregnant women with a Bishop's score < 6, who were undergoing labour induction, were evaluated in this prospective study. The FCB was irrigated with 10 ml of phosphate buffered saline and the irrigant was collected 0, 2, 4 and 8 h after placement of the FCB or until spontaneous expulsion of the FCB occurred. Irrigant specimens were also collected from 10 spontaneous labouring (SL) women in the active phase of labour. The levels of interleukin (IL)-6, IL-8, matrix metalloproteinase (MMP)-8 and NO were measured. Cervical specimens were obtained from 12 women, including four undergoing induction; four SL and four non-pregnant (NP) women. Immunohistochemical staining was performed to localise hyaluronic acid synthase (HAS)-1, IL-6, IL-8, MMP-8, endothelial nitric oxide synthase (eNOS) and inducible NOS (iNOS). Results showed that the levels of IL-6, IL-8, and MMP-8 significantly increased over time in FCB group (p < 0.01). In the immunohistochemical analysis of cervical tissues, immunoreactivity of HAS-1 in the after FCB group was stronger than any of the other groups. The protein expressions of IL-6, IL-8, MMP-8, eNOS and iNOS were more prominent in the after FCB and SL groups than in the NP and the before FCB groups. iNOS was only observed in the after FCB and SL groups. It was concluded that FCB may affect cervical ripening through changes in biochemical mediators by immunoassay and immunohistochemistry, when it is used for pre-induction cervical ripening.

IL-8 enhances the angiogenic potential of human bone marrow mesenchymal stem cells by increasing vascular endothelial growth factor

The beneficial effects of mesenchymal stem cells (MSCs) are mediated partly by the paracrine production of cytoprotective and trophic factors. Vascular endothelial growth factor (VEGF) is released from MSCs as a paracrine trophic factor and contributes to the therapeutic effects of the stem cell by regulating angiogenesis and promoting revascularization in injured tissues. Interleukin-8 (IL-8), an inflammatory chemokine with potent proangiogenic properties, is upregulated in the ischemic brain and has been shown to promote homing of bone marrow-derived cells to injured sites. However, the effect of IL-8 on MSCs paracrine function remains unknown. We found that IL-8 induced VEGF production and phosphorylation of Akt and ERK. Both effects could be blocked by inhibitors (LY294002, PD098059) or siRNA-mediated silencing of Akt and ERK in human bone marrow MSCs (hBM-MSCs). IL-8-induced VEGF production in hBM-MSCs significantly increased tube formation on Matrigel compared with basal secreted VEGF. In a rat stroke model, administration of IL-8-treated hBM-MSCs decreased the infarction volume and increased angiogenesis in the ischemic boundary zone compared with hBM-MSC treatment alone. In conclusion, IL-8 stimulates VEGF production in hBM-MSCs in part via the PI3K/Akt and MAPK/ERK signal transduction pathways and that administration of IL-8-treated hBM-MSCs increases angiogenesis after stroke. This approach may be used to optimize MSC-based therapies for numerous diseases including stroke, myocardial ischemia, and spinal cord injury.

Potential application of temozolomide in mesenchymal stem cell-based TRAIL gene therapy against malignant glioma

Because the tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) selectively kills tumor cells, it is one of the most promising candidates for cancer treatment. TRAIL-secreting human mesenchymal stem cells (MSC-TRAIL) provide targeted and prolonged delivery of TRAIL in glioma therapy. However, acquired resistance to TRAIL of glioma cells is a major problem to be overcome. We showed a potential therapy that used MSC-TRAIL combined with the chemotherapeutic agent temozolomide (TMZ). The antitumor effects of the combination with MSC-TRAIL and TMZ on human glioma cells were determined by using an in vitro coculture system and an in vivo experimental xenografted mouse model. Intracellular signaling events that are responsible for the TMZ-mediated sensitization to TRAIL-induced apoptosis were also evaluated. Treatment of either TRAIL-sensitive or -resistant human glioma cells with TMZ and MSC-TRAIL resulted in a significant enhancement of apoptosis compared with the administration of each agent alone. We demonstrated that TMZ effectively increased the sensitivity to TRAIL-induced apoptosis via extracellular signal-regulated kinase-mediated upregulation of the death receptor 5 and downregulation of antiapoptotic proteins, such as X-linked inhibitor of apoptosis protein and cellular FLICE-inhibitory protein. Subsequently, this combined treatment resulted in a substantial increase in caspase activation. Furthermore, in vivo survival experiments and bioluminescence imaging analyses showed that treatment using MSC-TRAIL combined with TMZ had greater therapeutic efficacy than did single-agent treatments. These results suggest that the combination of clinically relevant TMZ and MSC-TRAIL is a potential therapeutic strategy for improving the treatment of malignant gliomas.

Abstract P2-18-04: No further axillary dissection in sentinel lymph node-negative breast cancer after neoadjuvant chemotherapy in patients with initial cytologically-proven axillary node metastasis

Background

In patients with fine needle aspiration (FNA)-proven axillary lymph node metastasis at diagnosis (cN+), the current standard surgical procedure is axillary lymph node dissection (ALND) at definitive surgery after neoadjuvant chemotherapy (NAC). However, growing evidences suggest that SLNB after NAC is feasible and may demonstrate acceptable performance in selected patients. We performed sentinel lymph node biopsy in patients treated with cytologically-confirmed axillary lymph nodes metastases at presentation, who converted to a clinically negative axillary status after NAC (ycN0).

Patients and methods

We retrospectively evaluated 240 patients with invasive breast cancer with ultrasound-guided FNA-proven axillary nodal metastases at the time of diagnosis. All patients received NAC and underwent surgery at Samsung medical center between October 2007 and May 2013. Among these patients, 75 patients underwent SLNB. These patients converted to clinically node-negative disease (ycN0) after NAC on breast MRI or PET/CT scan. A combined detection technique was used with radioisotope and blue dye for the detection of SLN. Patients with negative SLN on frozen pathology and low clinical suspicion of metastasis during operation were not performed further ALND.

Results

The detection rate of SLNB was 93.3% (70/75), and median number of retrieved sentinel lymph nodes was 3.0 (range 1-8). False negative rate was 6.7% (1/15). Of these 75 patients, 35 (46.6%) patients had positive sentinel lymph nodes (ypN+) and underwent ALND. Thirty-five (46.6%) patients had tumor-free sentinel lymph nodes (ypN0sn) and 20 patients of them were followed without subsequent ALND. In these SLN-negative patients without further ALND, 9 patients were HER2-enriched subtypes and 9 patients, TNBC subtypes. Only two of them were Luminal B subtypes. The median follow-up period was 12.0 months (range 0-26 months) with 2 events; 1 regional recurrence in ipsilateral supraclavicular node and 1 systemic recurrence in brain on postoperative 7 months and 5 months, respectively. There has not occurred an ipsilateral axillary recurrence so far.

Conclusions Although the follow-up was not long enough to conclude, this study tried to demonstrate that SLNB after NAC was feasible and further ALND may not be necessary in patients with SLN-negative disease (ypN0sn).

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-18-04.

Detection of ischaemic myocardial lesions with coronary CT angiography and adenosine-stress dynamic perfusion imaging using a 128-slice dual-source CT: diagnostic performance in comparison with cardiac MRI

OBJECTIVE

We assessed the diagnostic performance of adenosine-stress dynamic CT perfusion (ASDCTP) imaging and coronary CT angiography (CCTA) for the detection of ischaemic myocardial lesions using 128-slice dual-source CT compared with that of 1.5 T cardiac MRI.

METHODS

This prospective study included 33 patients (61±8 years, 82% male) with suspected coronary artery diseases who underwent ASDCTP imaging and adenosine-stress cardiac MRI. Two investigators independently evaluated ASDCTP images in correlation with significant coronary stenosis on CCTA using two different thresholds of 50% and 70% diameter stenosis. Hypoattenuated myocardial lesions on ASDCTP associated with significant coronary stenoses on CCTA were regarded as true perfusion defects. All estimates of diagnostic performance were calculated and compared with those of cardiac MRI.

RESULTS

With use of a threshold of 50% diameter stenosis on CCTA, the diagnostic estimates per-myocardial segment were as follows: sensitivity, 81% [95% confidence interval (CI): 70-92%]; specificity, 94% (95% CI: 92-96%); and accuracy 93% (95% CI: 91-95%). With use of a threshold of 70%, the diagnostic estimates were as follows: sensitivity, 48% (95% CI: 34-62%); specificity, 99% (95% CI: 98-100%); and accuracy, 94% (95% CI: 92-96%).

CONCLUSION

Dynamic CTP using 128-slice dual-source CT enables the assessment of the physiological significance of coronary artery lesions with high diagnostic accuracy in patients with clinically suspected coronary artery disease.

ADVANCES IN KNOWLEDGE

Combined CCTA and ASDCTP yielded high accuracy in the detection of perfusion defects regardless of the threshold of significant coronary stenosis.

Conversion of twice-daily tacrolimus to once-daily tacrolimus formulation in stable pediatric kidney transplant recipients: pharmacokinetics and efficacy

The pharmacokinetics, efficacy and safety of once-daily tacrolimus formulation (Tac-OD) were assessed in 34 stable pediatric kidney transplant recipients. Enrolled patients received their dose of twice-daily tacrolimus formulation (Tac-BID) on study Days 0 through 7. On the morning of study Day 8, the total daily doses for patients were converted to Tac-OD on a 1:1 basis and maintained on a once-daily morning dosing regimen. Tacrolimus pharmacokinetic profiles were obtained on study Days 7, 14 and 28 (after dose adjustment). Although the mean C0 concentrations (4.10 ± 1.16-3.53 ± 1.10 ng/mL, p = 0.004), and AUC0-24 (151.8 ± 41.6-129.8 ± 39.3 ng h/mL, p < 0.001) were decreased significantly after a 1:1 based conversion, there was high interindividual variability. The dose of Tac-OD was decreased in 26.5% and increased in 44.1% of patients. The resultant tacrolimus dose and pharmacokinetic profiles on study Day 28 were comparable to those on Day 7. There were no serious adverse events. In conclusion, Tac-BID can be safely converted to Tac-OD in stable pediatric kidney transplant patients with the heightened therapeutic drug monitoring. Effects of drug conversion on the cardiovascular risk factors, neurological side effects and adherence should be further evaluated.

Serum 25-hydroxyvitamin D levels, obesity and the metabolic syndrome among Korean children

BACKGROUND AND AIM

Evidence of the relationship between serum vitamin D levels and cardiovascular risk factors in children is limited. We investigated the associations between serum vitamin D levels (25-hydroxyvitamin D [25(OH)D]) and obesity and metabolic syndrome and its components in Korean children.

METHODS AND RESULTS

We recruited 1660, nine-year-old, Korean children (904 boys and 756 girls) who voluntarily participated in this study while being examined during school-based health examinations. We measured anthropometric variables (height and weight), metabolic parameters (blood pressure, fasting plasma glucose, triglyceride, and HDL cholesterol levels) and serum vitamin D levels. We analyzed the data using multivariate logistic regression models. Mean 25(OH)D levels were lower in children defined as obese or abdominally obese (P <0.001). When serum levels of 25(OH)D were divided into quartiles, BMI, waist circumference, and triglyceride levels were lower, and HDL cholesterol levels were higher, as vitamin D levels increased. Using children from the highest quartile of 25(OH)D levels as a referent, the adjusted ORs (95% CI) for obesity in those in the third, second, and lowest quartiles of 25(OH)D levels were 1.55 (1.01-2.40), 1.87 (1.22-2.85), and 2.59 (1.71-3.90), respectively (P for trend <0.001). For abdominal obesity the ORs (CI) were 2.08 (1.20-3.60), 2.32 (1.36-3.95), and 2.96 (1.75-5.00) (P for trend<0.001), and for metabolic syndrome they were 2.60 (1.08-6.30), 4.00 (1.73-9.26), and 4.25 (1.84-9.85), respectively (P for trend <0.05).

CONCLUSIONS

We found low vitamin D levels in Korean children to be associated with obesity and metabolic syndrome. Insufficient serum vitamin D levels in children may be a risk factor of obesity and metabolic syndrome.

Effective combination of human bone marrow mesenchymal stem cells and minocycline in experimental autoimmune encephalomyelitis mice

INTRODUCTION

Multiple sclerosis (MS) is the most common inflammatory demyelinating disorder of the central nervous system (CNS). Minocycline ameliorates the clinical severity of MS and exhibits antiinflammatory, neuroprotective activities, and good tolerance for long-term use, whereas it is toxic to the CNS. Recently, the immunomodulation and neuroprotection capabilities of human bone marrow mesenchymal stem cells (hBM-MSCs) were shown in experimental autoimmune encephalomyelitis (EAE). In this study, we evaluated whether the combination of hBM-MSCs and a low-dose minocycline could produce beneficial effects in EAE mice.

METHODS

The sensitivity of hBM-MSCs to minocycline was determined by an established cell-viability assay. Minocycline-treated hBM-MSCs were also characterized with flow cytometry by using MSC surface markers and analyzed for their multiple differentiation capacities. EAE was induced in C57BL/6 mice by using immunization with MOG35-55. Immunopathology assays were used to detect the inflammatory cells, demyelination, and neuroprotection. Interferon gamma (IFN-γ)/tumor necrosis factor alpha (TNF-α) and interleukin-4 (IL-4)/interleukin-10 (IL-10), the hallmark cytokines that direct Th1 and Th2 development, were detected with enzyme-linked immunosorbent assay (ELISA). terminal dUTP nick-end labeling (TUNEL) staining was performed to elucidate the cell apoptosis in the spinal cords of EAE mice.

RESULTS

Minocycline did not affect the viability, surface phenotypes, or differentiation capacity of hBM-MSCs, while minocycline affected the viability of astrocytes at a high dose. In vivo efficacy experiments showed that combined treatment, compared to the use of minocycline or hBM-MSCs alone, resulted in a significant reduction in clinical scores, along with attenuation of inflammation, demyelination, and neurodegeneration. Moreover, the combined treatment with hBM-MSCs and minocycline enhanced the immunomodulatory effects, which suppressed proinflammatory cytokines (IFN-γ, TNF-α) and conversely increased anti-inflammatory cytokines (IL-4, IL-10). In addition, TUNEL staining also demonstrated a significant decrease of the number of apoptotic cells in the combined treatment compared with either treatment alone.

CONCLUSIONS

The combination of hBM-MSCs and minocycline provides a novel experimental protocol to enhance the therapeutic effects in MS.

Association of glypican-4 with body fat distribution, insulin resistance, and nonalcoholic fatty liver disease

CONTEXT AND OBJECTIVE

Glypican-4 was identified as a novel adipokine capable of enhancing insulin signaling and modulating adipocyte differentiation. We investigated associations between glypican-4 and body composition, insulin resistance, arterial stiffness, and nonalcoholic fatty liver disease (NAFLD) in nondiabetic Asian subjects.

DESIGN AND PARTICIPANTS

We analyzed baseline cross-sectional data from the Korean Sarcopenic Obesity Study, an ongoing prospective cohort study. NAFLD was diagnosed by unenhanced computed tomography using the liver attenuation index. We also examined the effects of a 3-month combined aerobic and resistance exercise program on glypican-4 levels and cardiometabolic risk factors.

RESULTS

Circulating glypican-4 levels were higher in men than in women (1.83 [1.19, 2.78] ng/mL vs 1.17 [0.66, 2.00] ng/mL, P < .001) and had a significant positive relationship with the waist-to-hip ratio (WHR) (r = 0.20, P = .014) and the ratio of visceral to sc fat area (r = 0.30, P < .001). Furthermore, glypican-4 levels in women were correlated with cardiometabolic risk factors, including insulin resistance and arterial stiffness, and were independently associated with NAFLD by multiple logistic regression analysis (P = .017, R² = 0.33). The 3-month combined exercise training program significantly improved several cardiometabolic parameters and reduced retinol binding protein-4 levels. Changes in glypican-4 levels after the exercise program were significantly different between subjects with an increased WHR compared with those with a decreased WHR (P = .034).

CONCLUSION

A gender-based difference in circulating glypican-4 levels was apparent as these were increased in women with NAFLD and related to body fat distribution, insulin resistance, and arterial stiffness.

Insecure attachment and anxiety in student athletes

AIM

The main purpose of our research was to examine attachment type and competition anxiety in high school student athletes and general high school students.

METHODS

We recruited 465 student athletes and 543 general students to participate in our study. The Revised Korean version of the Experiences in Close Relationships Scale (K-ECRS) and the Competitive State Anxiety Inventory-2 (CSAI-2) were given to all students.

RESULTS

In χ2 tests, athletes showed attachment types in the following order of prevalence: fearful, dismissive, and preoccupied, compared to the fearful, preoccupied, and dismissive order observed in general students. In parametric, independent t-tests, athletes reported significantly higher cognitive anxiety scores, relative to general students. Further, athletes with insecure attachment compared to those with secure attachment reported higher cognitive anxiety scores and self-confidence scores. In both the athletes with insecure attachment and general students with insecure attachment groups, the K-ECRS anxiety subscale was significantly correlated with CSAI-2 total score. In post hoc analysis in the athletes with insecure attachment group, the K-ECRS anxiety subscale was also significantly correlated with the CSAI-2 cognitive anxiety subscale.

CONCLUSION

These results suggest that anxious athletes with an insecure attachment style tend to exaggerate threats from both external and internal sources, which negatively affect their performances.

Risk factors for post-operative venous thromboembolism in patients with a malignancy of the lower limb

It is important to be able to identify patients with an increased risk of venous thromboembolism (VTE) in order to minimise the risk of an event. We investigated the incidence and risk factors for post-operative VTE in 168 consecutive patients with a malignancy of the lower limb. The period of study included ten months before and 12 months after the introduction of chemical thromboprophylaxis. All data about the potential risk factors were identified and classified into three groups (patient-, surgery- and tumour-related). The outcome measure was a thromboembolic event within 90 days of surgery. Of the 168 patients, eight (4.8%) had a confirmed symptomatic deep-vein thrombosis and one (0.6%) a fatal pulmonary embolism. Of the 28 variables tested, age > 60 years, higher American Society of Anesthesiologists grade and metastatic tumour were independent risk factors for VTE. The overall rate of symptomatic VTE was not significantly different between patients who received chemical thromboprophylaxis and those who did not. Knowledge of these risk factors may be of value in improving the surgical outcome of patients with a malignancy of the lower limb.

Loss of TSC2 confers resistance to ceramide and nutrient deprivation

Nutrient stress that produces quiescence and catabolism in normal cells is lethal to cancer cells, because oncogenic mutations constitutively drive anabolism. One driver of biosynthesis in cancer cells is the mammalian target of rapamycin complex 1 (mTORC1) signaling complex. Activating mTORC1 by deleting its negative regulator tuberous sclerosis complex 2 (TSC2) leads to hypersensitivity to glucose deprivation. We have previously shown that ceramide kills cells in part by triggering nutrient transporter loss and restricting access to extracellular amino acids and glucose, suggesting that TSC2-deficient cells would be hypersensitive to ceramide. However, murine embryonic fibroblasts (MEFs) lacking TSC2 were highly resistant to ceramide-induced death. Consistent with the observation that ceramide limits access to both amino acids and glucose, TSC2(-/-) MEFs also had a survival advantage when extracellular amino acids and glucose were both reduced. As TSC2(-/-) MEFs were resistant to nutrient stress despite sustained mTORC1 activity, we assessed whether mTORC1 signaling might be beneficial under these conditions. In low amino acid and glucose medium, and following ceramide-induced nutrient transporter loss, elevated mTORC1 activity significantly enhanced the adaptive upregulation of new transporter proteins for amino acids and glucose. Strikingly, the introduction of oncogenic Ras abrogated the survival advantage of TSC2(-/-) MEFs upon ceramide treatment most likely by increasing nutrient demand. These results suggest that, in the absence of oncogene-driven biosynthetic demand, mTORC1-dependent translation facilitates the adaptive cellular response to nutrient stress.

Lipoxygenase inhibitor MK886 potentiates TRAIL-induced apoptosis through CHOP- and p38 MAPK-mediated up-regulation of death receptor 5 in malignant glioma

Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) triggers specific apoptosis in tumor cells and is one of the most promising candidates for cancer gene therapy. However, resistance to TRAIL is one of the main impediments to use of TRAIL in cancer treatment. We showed previously that the lipoxygenase inhibitor MK886 in combination with TRAIL exhibits enhanced antitumor activities compared with each agent alone in human glioma cells. In this study, we elucidated the molecular mechanisms responsible for MK886-mediated sensitization to TRAIL-induced apoptosis. We found that MK886 sensitized glioma cells to TRAIL-induced apoptosis by upregulating the death receptor 5 (DR5) and that specific knockdown of DR5 attenuated cell death. The mechanisms underlying this sensitization involved activation of the MK886-induced p38 mitogen-activated protein kinase (MAPK) pathway and subsequent DR5 overexpression. However, treatment with a specific inhibitor or gene silencing of p38 MAPK abolished both the DR5 induction and the increase in apoptosis caused by TRAIL. Taken together, our findings indicate that the increased expression of DR5 in a p38 MAPK-dependent manner plays an important role in the sensitization of MK886 to TRAIL-induced apoptosis.

Comparison of erythrocyte membrane fatty acid contents in renal transplant recipients and dialysis patients

BACKGROUND

Alterations of erythrocyte membrane fatty acid (FA) composition play important roles in cellular function because they change the membrane microenvironment, including transmembrane receptors. The erythrocyte membrane oleic acid content is higher among patients with acute coronary syndrome and also in dialysis patients. However, available data are limited concerning erythrocyte membrane FA content in kidney transplant recipients (KTP). We sought to test the hypothesis that erythrocyte membrane FA content among KTP were different from those in dialysis patients.

METHODS

In this cross-sectional study, we recruited 35 hemodialysis, 33 peritoneal dialysis 49 KTP, and 33 normal control subjects (CTL). Their erythrocyte membrane FA content were measured by gas chromatography.

RESULTS

The mean ages of the enrolled dialysis patients, KTP, and CTL were 56.4 ± 10.1, 48.9 ± 10.4, and 49.5 ± 8.3 years, respectively. Mean kidney transplant duration was 89.8 ± 64.8 months and mean dialysis duration, 49.0 ± 32.6 months. The intakes of vegetable lipid and vegetable protein including total calories were significantly increased among KTP versus dialysis patients. Total cholesterol (P < .001) and high density lipoprotein cholesterol (HDL; P < .001) levels were significantly higher and C-reactive protein was significantly lower among KTP compared with dialysis patients. The erythrocyte membrane content of palmitoleic acid (P < .001) was significantly higher but oleic acid (P < .001) significantly lower in KTP compared with dialysis patients. The erythrocyte membrane contents of arachidonic acid and docosahexaenoic acid were significantly higher, and linoleic acid and the omega-6 FA to omega-3 FA ratio (P < .001) significantly lower in KTP compared with dialysis patients. The erythrocyte membrane content of oleic acid was independently associated with monounsaturated fatty acid (beta = 0.771, P < .001), eicosapentaeonic acid (beta = -0.244, P = .010), and HDL (beta = -0.139, P = .049) in KTP.

CONCLUSIONS

FA contents of erythrocyte membranes were significantly different in KTP compared with dialysis patients. These differences may have been associated with improved dietary intake and immunosuppression after kidney transplantation.