Association of circulating CD34+ cells level and prognosis after ischemic stroke

BACKGROUND

CD34 is a transmembrane phosphoglycoprotein and a marker of hematopoietic and nonhematopoietic stem/progenitor cells. In experimental studies, CD34+ cells are rich sources of endothelial progenitor cells and can promote neovascularization and endothelial repair. The potential role of CD34+ cells in stroke patients remains unclear.

AIMS

We aimed to assess the prognostic effect of circulating CD34+ cell levels on the risk of vascular events and functional prognosis in stroke patients.

PATIENTS AND METHODS

In this prospective observational study, patients with ischemic stroke were consecutively enrolled within 1 week of onset and followed up for 1 year. Patients were divided into three groups according to tertiles of the level of circulating CD34+ cells (Tertile 1, <0.51/µL; Tertile 2, 0.51-0.96/µL; and Tertile 3, >0.96/µL). The primary outcome was a composite of major adverse cardiovascular events (MACEs), including nonfatal stroke, nonfatal acute coronary syndrome, major peripheral artery disease, and vascular death. The secondary outcomes included the modified Rankin scale (mRS) scores.

RESULTS

A total of 524 patients (mean age, 71.3 years; male, 60.1%) were included. High CD34+ cell levels were associated with younger age (p < 0.001) and low National Institutes of Health Stroke Scale scores at admission (p = 0.010). No significant differences were found in the risk of MACEs among the three groups (annual rates: 15.0%, 13.4%, and 12.6% in Tertiles 1, 2, and 3, respectively; log-rank p = 0.70). However, there were significant differences in the mRS scores at 3 months (median (interquartile range); 2 (1-4), 1 (1-3), and 1 (0-2) in Tertiles 1, 2, and 3, respectively; p = 0.010) and 1 year (3 (1-4), 2 (1-4), and 1 (0-3); p < 0.001) among these groups. After multivariable adjustments, a higher CD34+ cell level was independently associated with good functional outcomes (mRS score of 0-2) at 3 months (adjusted odds ratio (OR), 1.43; 95% confidence interval (CI), 1.01-2.05) and 1 year (adjusted OR, 1.53; 95% CI, 1.09-2.16).

CONCLUSION

Although no correlations were found between circulating CD34+ cell levels and vascular event risk, elevated CD34+ cell levels were associated with favorable functional recovery in stroke patients.

DATA ACCESS STATEMENT

Data supporting the findings of this study are available from the corresponding author on reasonable request.

CLINICAL TRIAL REGISTRATION

The TWMU Stroke Registry is registered at https://upload.umin.ac.jp as UMIN000031913.

Development of a Pseudocellular System to Quantify Specific Interactions Determining the G-Quadruplex Function in Cells

Intracellular chemical microenvironments, including ion concentrations and molecular crowding, play pivotal roles in cell behaviors, such as proliferation, differentiation, and cell death via regulation of gene expression. However, there is no method for quantitative analysis of intracellular environments due to their complexity. Here, we have developed a system for highlighting the environment inside of the cell (SHELL). SHELL is a pseudocellular system, wherein small molecules are removed from the cell and a crowded intracellular environment is maintained. SHELL offers two prominent advantages: (1) It allows for precise quantitative biochemical analysis of a specific factor, and (2) it enables the study of any cell, thereby facilitating the study of target molecule effects in various cellular environments. Here, we used SHELL to study G-quadruplex formation, an event that implicated cancer. We show that G-quadruplexes are more stable in SHELL compared with in vitro conditions. Although malignant transformation perturbs cellular K+ concentrations, environments in SHELL act as buffers against G-quadruplex destabilization at lower K+ concentrations. Notably, the buffering effect was most pronounced in SHELL derived from nonaggressive cancer cells. Stable G-quadruplexes form due to the binding of the G-quadruplex with K+ in different cancer cells. Furthermore, the observed pattern of G-quadruplex-induced transcriptional inhibition in SHELL is consistent with that in living cells at different cancer stages. Our results indicate that ion binding to G-quadruplexes regulates gene expression during pathogenesis.

Changes in the composition of molecular species of covalently bound and free ceramides [EOS], and their correlation with disease severity in atopic dermatitis

Ceramides are major constituents of stratum corneum (SC) intercellular lipids involved in skin barrier function. The ratio of molecular species of ceramides and their correlation with disease severity was examined in patients with atopic dermatitis (AD). Thirty-eight patients with AD and 32 healthy controls (HCs) were assessed for transepidermal water loss, SC collection and clinical assessment. The ceramide content of different molecular species in the samples was quantified using high-performance liquid chromatography coupled with tandem mass spectrometry. Unsaturated acyl chains of both covalently bound and free ceramides [EOS] were higher in AD lesional skin than those in AD non-lesional or normal HC skin. The proportion of unsaturated acyl chains (C30:1, C32:1 and C34:1) was higher than other ceramide molecular species among covalently bound and free ceramides [EOS] in patients with AD. The proportion of unsaturated acyl chains in covalently bound ceramides was positively correlated with transepidermal water loss (r = 0.600) when considering the total number of non-lesional and lesional skin. Additionally, thymus and activation-regulated chemokine (TARC) showed a positive correlation with unsaturated acyl chains proportion in AD non-lesional (r = 0.676) and lesional (r = 0.503) skin. Our study is the first to show the increase in unsaturated acyl chains of both covalently bound and free ceramides [EOS] in lesional and non-lesional skin in AD for each molecular species. This increase is associated with dryness and impaired barrier function, which correlates with TARC levels, a marker for the degree of type 2 inflammation. We speculate that type 2 inflammation exacerbation leads to abnormal epidermal lipid metabolism in the skin of patients with AD.

Diastolic Dysfunction as a Positive Predictor of Recurrent Vascular Events in Patients With Noncardioembolic Stroke

BACKGROUND

This study aimed to assess the effects of left ventricular diastolic dysfunction (LVDD) on vascular outcomes among patients with stroke of noncardioembolic origins.

METHODS

This prospective observational study enrolled 563 patients with noncardioembolic stroke (mean age, 67.9 years; 66.7% men and 33.3% women individuals) registered in the Tokyo Women's Medical University Stroke Registry between 2013 and 2020. Then, patients were divided into the LVDD and non-LVDD groups. The primary outcome was a composite of major adverse cardiovascular events, including nonfatal stroke, nonfatal acute coronary syndrome, and vascular death 1 year after stroke onset. The effect of LVDD on vascular events was assessed using multivariable Cox regression analyses.

RESULTS

A total of 130 (23.1%) patients had any grade of LVDD, and patients with LVDD had a higher risk of major adverse cardiovascular event at 1 year than those without LVDD (annual rate, 20.9% versus 10.8%; log-rank P=0.001). The multivariable Cox proportional hazards regression model demonstrated that the presence of LVDD was independently associated with the major adverse cardiovascular event risk (hazard ratio, 1.79 [95% CI, 1.02-3.12]; P=0.019). Furthermore, the LVDD grade was proportional to the risk of major adverse cardiovascular events and recurrent stroke.

CONCLUSIONS

LVDD may be associated with further vascular events after a noncardioembolic stroke, suggesting the importance of LVDD evaluations in risk stratification and secondary prevention in patients with noncardioembolic stroke.

REGISTRATION

URL: https://upload.umin.ac.jp; Unique identifier: UMIN000031913.

In-Cell Stability Prediction of RNA/DNA Hybrid Duplexes for Designing Oligonucleotides Aimed at Therapeutics

In cells, the formation of RNA/DNA hybrid duplexes regulates gene expression and modification. The environment inside cellular organelles is heterogeneously crowded with high concentrations of biomolecules that affect the structure and stability of RNA/DNA hybrid duplexes. However, the detailed environmental effects remain unclear. Therefore, the mechanistic details of the effect of such molecular crowding were investigated at the molecular level by using thermodynamic and nuclear magnetic resonance analyses, revealing structure-dependent destabilization of the duplexes under crowded conditions. The transition from B- to A-like hybrid duplexes due to a change in conformation of the DNA strand guided by purine-pyrimidine asymmetry significantly increased the hydration number, which resulted in greater destabilization by the addition of cosolutes. By quantifying the individual contributions of environmental factors and the bulk structure of the duplex, we developed a set of parameters that predict the stability of hybrid duplexes with conformational dissimilarities under diverse crowding conditions. A comparison of the effects of environmental conditions in living cells and in vitro crowded solutions on hybrid duplex formation using the Förster resonance energy transfer technique established the applicability of our parameters to living cells. Moreover, our derived parameters can be used to estimate the efficiency of transcriptional inhibition, genome editing, and silencing techniques in cells. This supports the usefulness of our parameters for the visualization of cellular mechanisms of gene expression and the development of nucleic acid-based therapeutics targeting different cells.

Dosimetric Comparison of Nodal Clinical Target Volume for Locally Advanced Non-Small Cell Lung Cancer: Options for Geometric Expansion vs. Lymph Node Stations

PURPOSE/OBJECTIVE(S)

We investigated whether dosimetric differences existed in nodal clinical target volume (CTV) using options for geometric expansion and lymph node stations based on the European Society for Radiotherapy and Oncology (ESTRO) guideline for locally advanced non-small cell lung cancer (NSCLC).

MATERIALS/METHODS

With treatment planning computed tomographic images in 17 patients who underwent radiotherapy for cT4N2M0 NSCLC from 2017 to 2022 at our institution, we retrospectively contoured nodal CTVs based on the guideline's options of: (1) geometric expansion, CTV including the nodal gross tumor volume plus 5 mm margin: (2) lymph node stations, CTV including the affected lymph node stations. The 5 mm margins for planning target volume (PTV) were added to the nodal and primary tumors' CTVs. Treatment planning of 60 Gy in 30 fractions to the PTV D50% was performed using volumetric modulated arc therapy; Dn% was irradiated dose to n% of volume of the structure; VnGy was percentage of volume of the structure at least irradiated n Gy. We compared dose-volume parameters between the two options using Wilcoxon rank sum test.

RESULTS

Primary tumors were located in the right and left lobes in 12 and five patients, and in the upper and lower lobes in 13 and four patients, respectively. Median PTV size/D95% of the options for geometric expansion and lymph node stations were 569 cc (range, 149-2005 cc)/58.2 Gy (range, 57.5-58.7 Gy) and 635 cc (range, 184-2109 cc)/58.1 Gy (range, 57.5-58.7 Gy), respectively. Median mean dose of the esophagus/heart in the two options were 12.2 Gy (range, 6.6-24.9 Gy)/3.3 Gy (range, 0.6-19.1 Gy) and 16.1 Gy (range, 13.6-30.5 Gy)/4.6 Gy (range, 0.7-18.9 Gy), respectively. Median V20 Gy/mean dose of the lungs in the options for geometric expansion and lymph node stations were 20.5% (range, 14.8-33.9%)/12.2 Gy (range, 8.7-18.4 Gy) and 24.0% (range, 15.1-36.7%)/13.5 Gy (range, 9.5-19.4 Gy), respectively. In the eight patients (47%) with lymph node metastases in stations 2 or 3, a significant dosimetric difference between the two options existed on V20 Gy of the lungs; median values of the difference were 2.8% and 0.5% with and without lymph node metastases in stations 2 or 3, respectively (p = 0.027).

CONCLUSION

Of the ESTRO guideline for the nodal CTV, using the option for geometric expansion might be able to reduce V20 Gy of the lungs in patients with lymph node metastases in stations 2 or 3.

Evaluation of the Possibility of Dose Realignment Adaptation by Shifting the Isocenter in Proton Beam Therapy for Pancreatic Cancer

PURPOSE/OBJECTIVE(S)

In pancreatic cancer, a tumor is surrounded by the gastrointestinal (GI) tract, which is subject to changes in location, shape, and contents. Due to these inter-fractional changes, proton beam therapy (PBT) for pancreatic cancer may result in unintentionally high doses to the GI tract. Daily adaptive re-planning can solve this problem, but is not yet established with PBT due to its resource intensive characteristics. This study aims to evaluate the GI tract dose using weekly computed tomography (CTw) and the possibility of dose realignment adaptation by shifting the isocenter (IC) of the PBT plan, which does not require re-planning.

MATERIALS/METHODS

We retrospectively analyzed 6 consecutive patients with unresectable pancreatic cancer treated with real-time-image gated PBT using a fiducial marker. The planning CT was scanned at the natural expiration of respiration and a PBT plan of 60 GyE in 25 fractions (baseline plan, PLANbase) was created. The CTw images were acquired the day before start of PBT and once a week during the PBT course thereafter. The PLANbase was rigidly transferred to the CTw based on the relationship between the three-dimensional coordinates of the fiducial marker and those of the IC in the PLANbase. The PLANeval was created by recalculating the PLANbase on the CTw. We evaluated the doses to the stomach, duodenum, and intestines in the PLANeval according to the following criteria: Dmax of the stomach < 60 GyE, duodenum and intestines < 55 GyE, and D1cc of the stomach < 55 GyE, duodenum and intestines < 54 GyE. In addition, we investigated the GI tract dose realignment adaptation for the PLANeval with its IC shifted 2mm, 4mm, and 6mm in each of 6 directions (right, left, ventral, dorsal, cranial, and caudal), respectively.

RESULTS

A total of 35 PLANeval were created for the CTw. In the PLANbase of the 6 patients, the average of Dmax and D1cc of the stomach, duodenum and intestines were 50.7 GyE (range, 46.7-53.6) and 50.0 GyE (45.0-53.2), 49.2 GyE (44.3-51.7) and 48.8 GyE (43.7-51.5), and 49.2 GyE (44.8-52.0) and 48.9 GyE (44.6-51.8), respectively. In the PLANeval, the average of Dmax and D1cc of the stomach, duodenum, and intestines were 53.3GyE (43.8-61.4) and 52.8 GyE (43.2-61.1), 51.0 GyE (36.1-60.0) and 50.3 GyE (35.4-59.8), and 52.5 GyE (36.6-61.0) and 51.9 (34.4-60.9) GyE, respectively. Twenty-two of the 35 PLANeval (63 %) did not meet at least one of the GI tract dose criteria. In 11 of 22 PLANeval with higher doses to the GI tract, the IC shift resulted in GI dose reductions and all dose criteria were met. The minimum amount of the IC shift required to meet the criteria was 2 mm for 8 plans and 4 mm for 3 plans. The remaining 11 PLANeval did not meet the criteria using dose realignment adaptation by shifting the isocenter.

CONCLUSION

Adaptive replanning is necessary for PBT for pancreatic cancers due to excessive GI tract doses in more than 60% of the plans. Dose realignment adaptation by shifting the IC, which does not require re-planning, may be an option in adaptive treatment strategies.

A Risk Prediction Model for Severe Radiation Induced Lymphopenia in Patients with Pancreatic Cancer Treated with Concurrent Chemoradiotherapy

PURPOSE/OBJECTIVE(S)

In pancreatic cancer, radiation induced lymphopenia (RIL) is associated with a poor prognosis. However, normal tissue complication probability (NTCP) models predicting RIL in pancreatic cancer treated with concurrent chemoradiotherapy (CCRT) have yet to be developed. This study aims to develop a least absolute shrinkage and selection operator (LASSO)-based multivariate NTCP model to predict severe RIL in patients with pancreatic cancer during CCRT and to validate the model internally.

MATERIALS/METHODS

We retrospectively reviewed patients with localized pancreatic cancer who underwent CCRT using three-dimensional conformal radiation therapy from 2013 to 2021. The exclusion criteria were patients with distant metastasis; patients who did not complete RT due to tumor progression; patients who did not have absolute lymphocyte count (ALC) data available before or during RT. An ALC of < 0.5 K/μL during CCRT was defined as severe RIL. A NTCP model of severe RIL was developed by LASSO-based multivariate analysis. We used age, sex, Karnofsky performance status, maximum tumor size, carbohydrate antigen 19-9 level before RT, ALC before RT, volume of planning target volume (PTV), and dosimetric parameters for surrounding organs (including spleen, vertebrae, liver, bilateral kidneys, gastrointestinal tracts) as variables for LASSO. In addition, internal validation was performed by the bootstrap method. The predictive performance of the model was evaluated by the area under the curve (AUC) of the receiver operating characteristic curve and scaled Brier score.

RESULTS

Of the 131 patients included in the study, the median age was 68 years (range, 42-84), and 55% were male. The median ALC before RT was 1.37 K/µL (0.52-3.50). The median PTV volume was 315.4 ml (86.3-1079.3). The median dose of radiotherapy was 50.4 Gy (16.2-50.4), with 1.8 Gy per fraction. Combination chemotherapy was S-1 in 99 cases (75.6%) and gemcitabine in 32 cases (24.4%). Induction chemotherapy before CCRT was performed in 39 patients (29.8%). Severe RIL was observed in 84 (63.6%) patients. The LASSO showed that low baseline ALC (p = 0.0002), large PTV volume (p < 0.0001), and a large kidney V5 defined as the percentage of bilateral kidneys receiving 5 Gy or more (p = 0.0338) were selected as parameters of the prediction model for severe RIL (AUC = 0.917) and scaled Brier score was 0.511. As a result of internal validation by the bootstrap method, the average AUC was 0.918 (95% confidence interval, 0.849-0.954).

CONCLUSION

Severe RIL occurred frequently during CCRT for pancreatic cancer, and a NTCP model for severe RIL developed and validated internally in this study showed good predictive performance. External validation is needed before this NTCP model can be used as a benchmark for treatment planning to reduce the risk of severe RIL and for considering future treatment approaches.

Theranostic approach to specifically targeting the interloop region of BCL2 i-motif DNA by crystal violet

Ligands that recognise specific i-motif DNAs are helpful in cancer diagnostics and therapeutics, as i-motif formation can cause cancer. Although the loop regions of i-motifs are promising targets for ligands, the interaction between a ligand and the loop regions based on sequence information remains unexplored. Herein, we investigated the loop regions of various i-motif DNAs to determine whether these regions specifically interact with fluorescent ligands. Crystal violet (CV), a triphenylmethane dye, exhibited strong fluorescence with the i-motif derived from the promoter region of the human BCL2 gene in a sequence- and structure-specific manner. Our systematic sequence analysis indicated that CV was bound to the site formed by the first and third loops through inter-loop interactions between the guanine bases present in these loops. As the structural stability of the BCL2 i-motif was unaffected by CV, the local stabilisation of the loops by CV could inhibit the interaction of transcription factors with these loops, repressing the BCL2 expression of MCF-7 cells. Our finding suggests that the loops of the i-motif can act as a novel platform for the specific binding of small molecules; thus, they could be utilised for the theranostics of diseases associated with i-motif DNAs.

Five Novel Silver-Based Coordination Polymers as Photoluminescent Sensing Platforms for the Detection of Nitrobenzene

Nitrobenzene (NB) is a highly toxic chemical and a cause for concern to human health and the environment. Hence, it is worth designing new efficient and robust sensing platforms for NB. In this study, we present three newly synthesized luminescent silver cluster-based coordination polymers, {[Ag10 (StBu)6 (CF3 COO)4 (hpbt)] (DMAc)2 (CH3 CN)2 }n (hpbt=N,N,N',N'N",N"-hexa(pyridine-4-yl)benzene-1,3,5-triamine), [Ag12 (StBu)6 (CF3 COO)6 (bpva)3 ]n (bpva=9,10-Bis(2-(pyridin-4-yl)vinyl)anthracene), and {[Ag12 (StBu)6 (CF3 COO)6 (bpb)(DMAc)2 (H2 O)2 ] (DMAc)2 }n (bpb=1,4-Bis(4-pyridyl)benzene) composed of Ag10 , Ag12 and Ag12 cluster cores, respectively, connected by multidentate pyridine linkers. In addition, two new luminescent polymorphic silver(I)-based coordination polymers, [Ag(CF3 COO)(dpa)]n (dpa=9,10-di(4-pyridyl)anthracene) referred to as Agdpa (H) and Agdpa (R), where H and R denote hexagon- and rod-like crystal shapes, respectively, have been prepared. The coordination polymers exhibit highly sensitive luminescence quenching effects to NB, attributed to the π-π stacking interactions between the polymers and NB as well as the electron-withdrawing character of NB.

Hyperhomocysteinemia Increases Vascular Risk in Stroke Patients with Chronic Kidney Disease

AIMS

We aimed to assess the prognostic impact of hyperhomocysteinemia (HHcy) on the recurrent vascular event risk in stroke patients with or without chronic kidney disease (CKD).

METHODS

In this prospective observational study, 621 patients (mean age, 69.5 years; male, 62.2%) with ischemic stroke or transient ischemic attack were consecutively enrolled within 1 week of onset and followed-up for 1 year. HHcy was defined as elevated levels of fasting total homocysteine ＞15 µmol/L. CKD was defined as an estimated glomerular filtration rate of ＜60 mL/min/1.73 m2 or a history of renal replacement therapy. The primary outcome was a composite of major adverse cardiovascular events (MACEs), including nonfatal stroke, nonfatal acute coronary syndrome, major peripheral artery disease, and vascular death.

RESULTS

The prevalence of HHcy was 18.5%. Patients with HHcy were more likely to have intracranial (37.4% versus 24.8%; p=0.008) and extracranial (20.9% versus 13.0%; p=0.037) artery stenosis than were those without HHcy. At 1 year, patients with HHcy were at a greater risk of MACE than were those without HHcy (annual rate, 17.8% versus 10.4%; log-rank p=0.033). In the Cox proportional hazard regression models, HHcy was independently associated with an increased risk of MACE in patients with CKD (adjusted hazard ratio [HR], 2.06; 95% confidence interval [CI], 1.02-4.20), whereas HHcy was not predictive of MACE in those without CKD (adjusted HR, 1.00; 95% CI, 0.30-3.32).

CONCLUSIONS

Elevated levels of serum homocysteine can be an important modifiable risk factor in stroke patients with CKD, but not in those without CKD.

Silver cluster-assembled materials for label-free DNA detection

Herein, we report two newly synthesized silver cluster-assembled materials (SCAMs), [Ag₁₄(S^tBu)₁₀(CF₃COO)₄(bpa)₂]_n (bpa = 1,2-bis(4-pyridyl)acetylene) and [Ag₁₂(S^tBu)₆(CF₃COO)₆(bpeb)₃]_n (bpeb = 1,4-bis(pyridin-4-ylethynyl)benzene) composed of Ag₁₄ and Ag₁₂ chalcogenolate cluster cores, respectively, bridged by acetylenic bispyridine linkers. The linker structures and electrostatic interaction between positively charged SCAMs and negatively charged DNA confer the SCAMs with the ability to suppress the high background fluorescence of single-stranded (ss) DNA probes with SYBR Green I nucleic acid stain, leading to high signal-to-noise ratio for label-free target DNA detection.

Durvalumab with or without tremelimumab versus the EXTREME regimen as first-line treatment for recurrent or metastatic squamous cell carcinoma of the head and neck: KESTREL, a randomized, open-label, phase III study

BACKGROUND

Patients with recurrent or metastatic head and neck squamous cell carcinoma (R/M HNSCC) have a poor prognosis. The phase III KESTREL study evaluated the efficacy of durvalumab [programmed death-ligand 1 (PD-L1) antibody] with or without tremelimumab [cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) antibody], versus the EXTREME regimen in patients with R/M HNSCC.

PATIENTS AND METHODS

Patients with HNSCC who had not received prior systemic treatment for R/M disease were randomized (2 : 1 : 1) to receive durvalumab 1500 mg every 4 weeks (Q4W) plus tremelimumab 75 mg Q4W (up to four doses), durvalumab monotherapy 1500 mg Q4W, or the EXTREME regimen (platinum, 5-fluorouracil, and cetuximab) until disease progression. Durvalumab efficacy, with or without tremelimumab, versus the EXTREME regimen in patients with PD-L1-high tumors and in all randomized patients was assessed. Safety was also assessed.

RESULTS

Durvalumab and durvalumab plus tremelimumab were not superior to EXTREME for overall survival (OS) in patients with PD-L1-high expression [median, 10.9 and 11.2 versus 10.9 months, respectively; hazard ratio (HR) = 0.96; 95% confidence interval (CI) 0.69-1.32; P = 0.787 and HR = 1.05; 95% CI 0.80-1.39, respectively]. Durvalumab and durvalumab plus tremelimumab prolonged duration of response versus EXTREME (49.3% and 48.1% versus 9.8% of patients remaining in response at 12 months), correlating with long-term OS for responding patients; however, median progression-free survival was longer with EXTREME (2.8 and 2.8 versus 5.4 months). Exploratory analyses suggested that subsequent immunotherapy use by 24.3% of patients in the EXTREME regimen arm contributed to the similar OS outcomes between arms. Grade 3/4 treatment-related adverse events (TRAEs) for durvalumab, durvalumab plus tremelimumab, and EXTREME were 8.9%, 19.1%, and 53.1%, respectively.

CONCLUSIONS

In patients with PD-L1-high expression, OS was comparable between durvalumab and the EXTREME regimen. Durvalumab alone, and with tremelimumab, demonstrated durable responses and reduced TRAEs versus the EXTREME regimen in R/M HNSCC.

Reclassification and risk stratification of embolic stroke of undetermined source by ASCOD phenotyping

BACKGROUND

Common vascular diseases underlying stroke, including atherosclerosis, small-vessel disease (SVD), and cardioembolic pathology, can be present in patients with embolic stroke of undetermined source (ESUS), although these are not direct causes of stroke.

AIMS

To describe the frequency and degree of the three major diseases using atherosclerosis, SVD, cardiac pathology, other causes, and dissection (ASCOD) phenotyping and to assess their prognostic implications in ESUS.

METHODS

In this prospective observational study, 221 patients with ESUS within 1 week of onset were consecutively enrolled and followed up for 1 year. Vascular diseases associated with stroke were assessed using the ASCOD classification. The primary outcome was a composite of nonfatal stroke, nonfatal acute coronary syndrome, and vascular death.

RESULTS

Among 221 patients (mean age, 69.6 years; male, 59.7%), 135 (61.1%), 102 (46.2%), and 107 (48.4%) had any grade of atherosclerosis (A2 or A3), SVD (S3), and cardiac pathology (C2 or C3), respectively. ESUS patients graded as A2 or A3 (i.e. ipsilateral atherosclerotic plaque, contralateral ⩾ 50% stenosis, or aortic arch plaque) were at a significantly higher risk of composite vascular events than those graded as A0 (i.e. no atherosclerotic disease) (adjusted hazard ratio (95% confidence interval), 2.40 (1.01-5.72). No differences were observed in the event risk between patients with S3 (i.e. magnetic resonance imaging evidence of SVD) and S0 (i.e. no SVD) and between those with C2 or C3 (i.e. presence of any cardiac pathology) and C0 (i.e. no cardiac abnormalities).

CONCLUSIONS

Atherosclerotic diseases corresponding to ASCOD grade A2 or A3 were predictive of recurrent vascular events in ESUS patients. Reclassification of ESUS using ASCOD phenotyping provides important clues for risk prediction and may guide optimal management strategies.

Long-Term Outcome in Patients With Acute Ischemic Stroke and Heart Failure

BACKGROUND

This study aimed to identify the association between long term functional outcomes and acute ischemic stroke (AIS) in patients with heart failure (HF) in Japan and whether 1-year event risks can be related to these patients.Methods and Results: This was a prospective observational study, and 651 patients registered in the Tokyo Women's Medical University Stroke Registry were classified into the HF and non-HF groups. Functional outcome at 1 year after stroke onset was defined as either good (modified Rankin Scale [mRS] score of 0-2) or poor (mRS score of 3-6). The primary outcome was a composite of major adverse cardiovascular events (MACE), including non-fatal stroke, non-fatal acute coronary syndrome, and vascular death. Patients with HF had a higher poor functional outcome rate at 1 year than those without HF (54.7% vs. 28.2%, P<0.001). Multivariate logistic regression analysis also demonstrated the prevalence of HF was an independent predictor of an mRS score of ≥3 at 1 year after stroke onset (odds ratio, 1.05; 95% confidence interval, 1.00-1.10; P=0.036). Furthermore, patients with HF tended to have a higher risk of MACE and all-cause mortality than those without HF.

CONCLUSIONS

AIS patients with HF were associated with poor functional outcome at the 1-year follow up. Further multicenter studies involving a larger number of patients are warranted to verify these results.

Multicentric Carpotarsal Osteolysis: a Contemporary Perspective on the Unique Skeletal Phenotype

PURPOSE OF REVIEW

Multicentric carpotarsal osteolysis (MCTO) is an ultra-rare disorder characterized by osteolysis of the carpal and tarsal bones, subtle craniofacial deformities, and nephropathy. The molecular pathways underlying the pathophysiology are not well understood.

RECENT FINDINGS

MCTO is caused by heterozygous mutations in MAFB, which encodes the widely expressed transcription factor MafB. All MAFB mutations in patients with MCTO result in replacement of amino acids that cluster in a phosphorylation region of the MafB transactivation domain and account for a presumed gain-of-function for the variant protein. Since 2012, fewer than 60 patients with MCTO have been described with 20 missense mutations in MAFB. The clinical presentations are variable, and a genotype-phenotype correlation is lacking. Osteolysis, via excessive osteoclast activity, has been regarded as the primary mechanism, although anti-resorptive agents demonstrate little therapeutic benefit. This paper appraises current perspectives of MafB protein action, inflammation, and dysfunctional bone formation on the pathogenesis of the skeletal phenotype in MCTO. More research is needed to understand the pathogenesis of MCTO to develop rational therapies.

Nearest-neighbor parameters for the prediction of RNA duplex stability in diverse in vitro and cellular-like crowding conditions

RNA performs various spatiotemporal functions in living cells. As the solution environments significantly affect the stability of RNA duplexes, a stability prediction of the RNA duplexes in diverse crowded conditions is required to understand and modulate gene expression in heterogeneously crowded intracellular conditions. Herein, we determined the nearest-neighbor (NN) parameters for RNA duplex formation when subjected to crowding conditions with an ionic concentration relevant to that found in cells. Determination of the individual contributions of excluded volume effect and water activity to each of the NN parameters in crowded environments enabled prediction of the thermodynamic parameters and their melting temperatures for plenty of tested RNA duplex formation in vitro and in cell with significant accuracy. The parameters reported herein will help predicting RNA duplex stability in different crowded environments, which will lead to an improved understanding of the stability-function relationship for RNAs in various cellular organelles with different molecular environments.

Endogenous G-quadruplex-forming RNAs inhibit the activity of SARS-CoV-2 RNA polymerase

Replication of RNA viruses is catalysed by virus-specific polymerases, which can be targets of therapeutic strategies. In this study, we used a selection strategy to identify endogenous RNAs from a transcriptome library derived from lung cells that interact with the RNA-dependent RNA polymerase (RdRp) of SARS-CoV-2. Some of the selected RNAs weakened the activity of RdRp by forming G-quadruplexes. These results suggest that certain endogenous RNAs, which potentially form G-quadruplexes, can reduce the replication of viral RNAs.

Role of glycerophosphodiester phosphodiesterase in rice leaf blades in elevated CO2 environments

Glycerophosphodiester phosphodiesterase (GDPD; EC 3.1.4.46) is involved in plant phosphate (Pi) utilization and its expression is upregulated under phosphorus (P)-deficient conditions. Although rice was grown under P-sufficient conditions, the transcript levels of specific OsGDPD were upregulated in mature rice leaf blades (LB) in elevated CO₂ (eCO₂ ) environments. Expression and subcellular localization of GDPD, and contents of Pi, sugar phosphates and carbohydrates were analysed to clarify the physiological function of GDPD in rice under eCO₂ . Under eCO₂ , expression of specific OsGDPD increased only in mature rice LB in which low Pi concentrations were observed. Moreover, eCO₂ -induced OsGDPD2 and OsGDPD3 were localized in the plastid, indicating that GDPD2 and GDPD3 may be related to plastidic functions, such as carbon assimilation. Although rice LB contained more carbohydrates under eCO₂ than under ambient CO₂ , the phosphoglucose content decreased under eCO₂ , suggesting that the need for excess phosphoglucose to synthesize carbohydrates under eCO₂ causes a local Pi deficiency. Furthermore, we confirmed that glycerol-3-phosphate produced by the catalysis of GDPD from glycerophosphodiester contributes to carbohydrate accumulation in rice LB. Our findings suggest that local Pi deficiency due to excess carbohydrate accumulation under eCO₂ influences GDPD to enhance glycerophosphodiester hydrolysis.

Pressure-temperature control of activity of RNA polymerase ribozyme

A representative role of nucleic acids (DNA and RNA) is in the storage of genetic information. In contrast, RNAs act as ribozymes that catalyze various biochemical reactions. The "RNA world" hypothesis suggests that the origin of life was RNA because a ribozyme that shows RNA replication activity has been identified. However, prebiotic conditions in the RNA world remain unknown. In this study, we investigated the effect of high pressure and temperature on RNA replication using an RNA polymerase ribozyme tC9Y. We found that pressure accelerated the RNA replication activity of tC9Y ribozyme at higher temperatures than physiological conditions. Furthermore, molecular crowding by concentrated polyethylene glycol 200 (average molecular weight 200) synergistically enhanced the replication activity at higher pressure and temperature because the negative effect of a volumetric contribution of hydration on the tC9Y ribozyme activity decreased under crowding conditions. As a comparison, proteinaceous RNA polymerase that exists in the modern era did not show accelerated activity under high pressure and temperature. Thus, these results imply that the prebiotic conditions for the RNA world were at high pressure and temperatures under crowding conditions.

Triglyceride-glucose index as a prognostic marker after ischemic stroke or transient ischemic attack: a prospective observational study

BACKGROUND

Triglyceride-glucose (TyG) index has been proposed as a simple and credible surrogate for insulin resistance and an independent predictor of cardiovascular outcomes. Due to lack of data on TyG index in stroke, we aimed to evaluate the predictive value of the index for recurrent vascular event risk among stroke patients.

METHODS

This was a prospective observational study, in which 866 patients (mean age, 70.1 years; male, 60.9%) with ischemic stroke (n = 781) or transient ischemic attack (n = 85) within 1 week of onset were consecutively enrolled and followed up for 1 year. The TyG index was calculated as ln (fasting triglycerides [mg/dL] × fasting glucose [mg/dL]/2). Patients were divided into 3 groups according to the tertile of TyG index levels: tertile 1, < 8.48; tertile 2, 8.48-9.01; and tertile 3, > 9.01. The primary outcome was a composite of major adverse cardiovascular events (MACE), including nonfatal stroke, nonfatal acute coronary syndrome, and vascular death.

RESULTS

The median TyG index was 8.74 (interquartile range, 8.34-9.16). Higher levels of TyG index were significantly associated with increased prevalence of ipsilateral extracranial carotid (P = 0.032) and intracranial (P = 0.003) atherosclerotic stenosis. There were significant differences in the MACE risk between the three groups (annual rate, 8.6%, 11.6%, and 17.3% in the tertile 1, tertile 2, tertile 3 groups, respectively; log-rank P = 0.005). After multivariable adjustments, the TyG index remains to be a significant predictor of MACE, with an adjusted hazard ratio for tertile 3 versus tertile 1 groups (95% confidence interval) of 2.01 (1.16-3.47). Similar results were also found for the risk of recurrent stroke.

CONCLUSIONS

TyG index is associated with cervicocerebral atherosclerosis and the MACE risk after a stroke, suggesting the potential value of TyG index to optimize the risk stratification of stroke patients. Trial registration URL:  https://upload.umin.ac.jp . Unique identifier: UMIN000031913.

Diversity in the characteristics of spontaneous ruptured aortic plaques

Background

Spontaneous ruptured aortic plaques (SRAPs) act as emboli for systemic organs because SRAPs might contain CCs which cause inflammation besides mechanical obstruction. The purpose of the study is to clarify the difference of the characteristics of representative SRAPs, puff rupture and puff-chandelier rupture sampled by non-obstructive general angioscopy. (NOGA)

Methods

A total of 177 puff-chandelier ruptures which blown out spontaneously and glittered against the light of the angioscopic fiber and 105 puff ruptures which did not glitter were sampled by NOGA in patients having or suspected coronary artery disease. Sampled plaques were analyzed two kinds of methods, conventional Hematoxylin-eosin stain and methods without solvents. Samples were diagnosed if the component of atheroma was detected with either method. The percentage of content of CCs, the number of CCs, the longer and shorter diameters were compared between blood sampled from puff and puff-chandelier rupture.

Results

Samples were diagnosed as atheroma 56% of puff-chandelier rupture and 27% of puff- rupture. (p&lt;0.0001) Higher number of CCs was included in puff-chandelier rupture than in puff-rupture. (12,955 [3,977, 25,795] vs. 3,182 [909, 7,273]) The longer and shorter diameters of plaque components of puff rupture were smaller than those of puff-chandelier rupture. (p=0.0259 and p=0.0286, respectively.) CCs were tended to be included puff-chandelier rupture than puff-rupture. (53% vs. 16%, respectively; p&lt;0.0001) Visible debris was obtained only 13% of puff rupture and 26% of puff-chandelier rupture.

Conclusions

Diversity of SRAPs were shown as that puff rupture had less CCs and more fibrin than puff-chandelier rupture, suggesting that potentially less inflammation and more fibrinolytic.

Funding Acknowledgement

Type of funding sources: None.

Effects of liquid diet intake on nerve growth in salivary glands of growing rats

BACKGROUND

The growth of parotid glands is inhibited by liquid diet intake during growing period, while that of submandibular glands is not affected. This study examined how liquid diet intake affects nerve growth in the parotid and submandibular glands of growing rats, because nerves are closely involved in the maintenance of salivary gland structure.

MATERIALS AND METHODS

Male Wistar rats were weaned at 21 days of age. Then, rats were fed a pellet diet and a liquid diet in the control group and experimental group, respectively. At 0, 2, 4, or 8 weeks, they were euthanised by isoflurane overdose, and parotid and submandibular glands were removed. The frozen sections were made and immuno-stained with anti-protein gene product 9.5 (PGP 9.5) antibody (general nerve marker), anti-tyrosine hydroxylase (TH) antibody (sympathetic nerve marker), or anti-neuronal nitric oxide synthase (nNOS) antibody (parasympathetic nerve marker).

RESULTS

In control parotid glands, scattered punctate or short linear patterns of PGP 9.5-positive sites were observed at week 0. After 2 weeks, PGP 9.5-positive sites, some of which were arranged in long linear patterns, increased in number. There were some TH-positive sites at week 0. After 2 weeks, there were increasing numbers of TH-positive sites, often in long linear patterns. At week 0, there were very few nNOS-positive sites, and nNOS immunoreactivity increased over time. After week 4, they demonstrated linear patterns. In the experimental parotid glands, there were fewer PGP 9.5- and nNOS-positive sites than in control parotid glands at each time point, although TH immunoreactivity was similar between two groups at each time point. In control submandibular glands, few punctate exhibited PGP 9.5-positive site were observed at week 0. At week 4, PGP 9.5 immunoreaction increased and showed linear patterns. TH-positive sites demonstrated punctate or short linear patterns at week 0, and thereafter TH immunoreactivity increased and were arranged in long linear patterns. There were few nNOS-positive sites at week 0, and they gradually increased after week 4. The immunoreactivities of all antibodies in the experimental submandibular glands were similar to those in the control at each time point.

CONCLUSIONS

Parasympathetic nerve growth in rat parotid glands was inhibited by liquid diet intake during the growth period, while liquid diet intake did not affect parasympathetic nerve growth nor sympathetic nerve growth in rat submandibular glands.

Pooled analysis of drug-related interstitial lung disease and/or pneumonitis in nine trastuzumab deruxtecan monotherapy studies

Introduction

This pooled analysis of nine phase I and II trastuzumab deruxtecan (T-DXd) monotherapy studies described drug-related interstitial lung disease (ILD)/pneumonitis in patients treated with T-DXd.

Methods

Patients who received T-DXd across nine studies were included. Investigator-assessed ILD/pneumonitis events were retrospectively reviewed by an independent adjudication committee; events adjudicated as drug-related ILD/pneumonitis are summarized.

Results

The analysis included 1150 patients (breast cancer, 44.3%; gastric cancer, 25.6%; lung cancer, 17.7%; colorectal cancer, 9.3%; other cancer, 3.0%). Median treatment duration was 5.8 (range, 0.7-56.3) months, with a median of 4 (range, 1-27) prior lines of therapy. The overall incidence of adjudicated drug-related ILD/pneumonitis was 15.4% (grade 5, 2.2%). Most patients with ILD/pneumonitis experienced low-grade events (grade 1 or 2, 77.4%); 87.0% had their first event within 12 months [median, 5.4 (range, <0.1-46.8) months] of their first dose of T-DXd. Based on data review, adjudicated ILD/pneumonitis onset occurred earlier than identified by investigators for 53.2% of events [median difference in onset date, 43 (range, 1-499) days]. Stepwise Cox regression identified several baseline factors potentially associated with increased risk of adjudicated drug-related ILD/pneumonitis: age <65 years, enrollment in Japan, T-DXd dose >6.4 mg/kg, oxygen saturation <95%, moderate/severe renal impairment, presence of lung comorbidities, and time since initial diagnosis >4 years.

Conclusions

In this pooled analysis of heavily treated patients, the incidence of ILD/pneumonitis was 15.4%, with most being low grade and occurring in the first 12 months of treatment. The benefit–risk of T-DXd treatment is positive; however, some patients may be at increased risk of developing ILD/pneumonitis, and further investigation is needed to confirm ILD/pneumonitis risk factors. Close monitoring and proactive management of ILD/pneumonitis are warranted for all.

•

Interstitial lung disease (ILD)/pneumonitis is a significant adverse event related to trastuzumab deruxtecan (T-DXd).

•

This pooled analysis of nine T-DXd monotherapy studies evaluated ILD/pneumonitis risk in 1150 heavily pretreated patients.

•

Overall incidence of adjudicated T-DXd-related ILD/pneumonitis was 15.4% (grade 1 or 2, 77.4%; grade 5, 2.2%).

•

Within 12 months of their first T-DXd dose, 87.0% of patients had their first event [median, 5.4 (range, <0.1-46.8) months].

•

Proactive monitoring and prompt diagnosis and management are important to improving ILD/pneumonitis event outcomes.

The orthostatic hypotension in patients with Stanford type A aortic dissection after surgery

Funding Acknowledgements

Type of funding sources: None.

Background

Orthostatic hypotension (OH) is sometimes observed during cardiac rehabilitation in patients with surgery for aortic dissection. However, little is known about the primary determinant of OH and influence of surgical range on incidence of OH.

Purpose

The aim of this study was to elucidate the incidence of OH in patients with surgery for aortic dissection, and compare it between the patients with ascending aortic replacement surgery (ascending group) and those with ascending aorta and hemiarch or total arch replacement surgery (arch group).

Methods

We analyzed 59 patients who underwent emergent surgery due to Stanford type A aortic dissection from January 2014 to March 2018, and compared the incidence of OH between ascending group (n = 28, age 69.8 ± 11.3 years) and arch group (n = 31, age 64.1 ± 13.0 years).

Results

The incidence of OH in total patients was 30.5%. There were no significant differences in patient characteristics including body tall, body weight, antihypertensive use and progress of rehabilitation between 2 groups. The arch group showed a significant higher incidence of OH as compared with ascending group (arch group: 46.4% vs. ascending group: 16.1%, p = 0.03). Moreover, the patients who occurred OH were significantly taller than those who did not occur OH.

Conclusions

OH was observed in about one third of patients with surgery for aortic dissection and it showed a close relationship with patient’s height and the range repaired by surgical operation. More careful cardiac rehabilitation is needed for tall patients with large area replacement of aorta.

Volumetric Strategy for Quantitatively Elucidating a Local Hydration Network around a G-Quadruplex

Hydration around nucleic acids, such as DNA and RNA, is an important factor not only for the stability of nucleic acids but also for their interaction with binding molecules. Thus, it is necessary to quantitatively elucidate the hydration properties of nucleic acids around a certain structure. In this study, volumetric changes in G-quadruplex (G4) RNA formation were investigated by systematically changing the number of G-quartet stacks under high pressure. The volumetric contribution at the level of each G4 structural unit revealed that the core G4 helix was significantly more dehydrated than the other parts, including the edges of G-quartets and loops. These findings will help in predicting the binding of G4 ligands on the surface of G4, depending on the chemical structure of the ligand and solution environment. Therefore, the preset volumetric parameter provides information that can predict molecular interactions in G4 formations during molecular crowding in cells.

Ruthenium Polypyridyl Complex Bound to a Unimolecular Chair-Form G-Quadruplex

The DNA G-quadruplex is known for forming a range of topologies and for the observed lability of the assembly, consistent with its transient formation in live cells. The stabilization of a particular topology by a small molecule is of great importance for therapeutic applications. Here, we show that the ruthenium complex Λ-[Ru(phen)₂(qdppz)]²⁺ displays enantiospecific G-quadruplex binding. It crystallized in 1:1 stoichiometry with a modified human telomeric G-quadruplex sequence, GGGTTAGGGTTAGGGTTTGGG (htel21T₁₈), in an antiparallel chair topology, the first structurally characterized example of ligand binding to this topology. The lambda complex is bound in an intercalation cavity created by a terminal G-quartet and the central narrow lateral loop formed by T₁₀–T₁₁–A₁₂. The two remaining wide lateral loops are linked through a third K⁺ ion at the other end of the G-quartet stack, which also coordinates three thymine residues. In a comparative ligand-binding study, we showed, using a Klenow fragment assay, that this complex is the strongest observed inhibitor of replication, both using the native human telomeric sequence and the modified sequence used in this work.

Prognostic Role of Hypertriglyceridemia in Patients With Stroke of Atherothrombotic Origin

BACKGROUND AND OBJECTIVES

Hypertriglyceridemia is perceived to promote atherosclerotic pathology, but its role in stroke has not been well defined. We aimed to assess the contribution of hypertriglyceridemia to residual vascular risk in patients with atherothrombotic stroke.

METHODS

The Tokyo Women's Medical University Stroke Registry is an ongoing prospective, observational registry, in which 870 patients with acute ischemic stroke or TIA within 1 week of onset were consecutively enrolled and followed up for 1 year. Hypertriglyceridemia was defined as serum triglycerides levels of ≥150 mg/dL under fasting conditions. Significant stenosis of the cervicocephalic arteries was defined as having 50% or greater stenosis or occlusion. The primary outcome was major adverse cardiovascular events, including nonfatal stroke, nonfatal acute coronary syndrome, and vascular death.

RESULTS

Of 870 patients (mean age, 70.1 years; male, 60.9%), 217 (24.9%) had hypertriglyceridemia. High triglycerides levels were significantly associated with an increased prevalence of intracranial artery stenosis, particularly in the anterior circulation, rather than extracranial artery stenosis. Patients with hypertriglyceridemia had a greater risk of major adverse cardiovascular events than those without (annual rate, 20.9% vs. 9.7%; P<0.001), even after adjustment for potential confounders, including baseline low-density lipoprotein cholesterol and statin use (adjusted hazard ratio, 2.46; 95% confidence interval, 1.62-3.74). The higher risk of vascular events in hypertriglyceridemia versus non-hypertriglyceridemia patients was observed among patients with stroke of atherothrombotic origin (n=174; annual rate, 35.1% vs. 14.2%; P=0.001), those with significant intracranial artery stenosis (n=247; annual rate, 29.9% vs. 14.7%; P=0.006), and those with significant extracranial carotid artery stenosis (n=123; annual rate, 23.0% vs. 9.4%; P=0.042). In contrast, hypertriglyceridemia was not predictive of recurrent vascular events in patients with cardioembolic stroke (n=221; annual rate, 19.1% vs. 10.5%; P=0.18).

DISCUSSION

Hypertriglyceridemia is an important modifiable risk factor that drives residual vascular risk in patients with stroke of atherothrombotic origin, even while on statin therapy.

TRIAL REGISTRATION INFORMATION

The Tokyo Women's Medical University Stroke Registry is registered at UMIN000031913 (https://upload.umin.ac.jp).

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that in patients with atherothrombotic stroke, hypertriglyceridemia is associated with an increased risk of major cardiovascular events.

Dielectricity of a molecularly crowded solution accelerates NTP misincorporation during RNA-dependent RNA polymerization by T7 RNA polymerase

In biological systems, the synthesis of nucleic acids, such as DNA and RNA, is catalyzed by enzymes in various aqueous solutions. However, substrate specificity is derived from the chemical properties of the residues, which implies that perturbations of the solution environment may cause changes in the fidelity of the reaction. Here, we investigated non-promoter-based synthesis of RNA using T7 RNA polymerase (T7 RNAP) directed by an RNA template in the presence of polyethylene glycol (PEG) of various molecular weights, which can affect polymerization fidelity by altering the solution properties. We found that the mismatch extensions of RNA propagated downstream polymerization. Furthermore, PEG promoted the polymerization of non-complementary ribonucleoside triphosphates, mainly due to the decrease in the dielectric constant of the solution. These results indicate that the mismatch extension of RNA-dependent RNA polymerization by T7 RNAP is driven by the stacking interaction of bases of the primer end and the incorporated nucleotide triphosphates (NTP) rather than base pairing between them. Thus, proteinaceous RNA polymerase may display different substrate specificity with changes in dielectricity caused by molecular crowding conditions, which can result in increased genetic diversity without proteinaceous modification.

Open-label phase II study of the efficacy of nivolumab for cancer of unknown primary

BACKGROUND

Cancer of unknown primary (CUP) has a poor prognosis. Given the recent approval of immune checkpoint inhibitors for several cancer types, we carried out a multicenter phase II study to assess the efficacy of nivolumab for patients with CUP.

PATIENTS AND METHODS

Patients with CUP who were previously treated with at least one line of systemic chemotherapy constituted the principal study population. Previously untreated patients with CUP were also enrolled for exploratory analysis. Nivolumab (240 mg/body) was administered every 2 weeks for up to 52 cycles. The primary endpoint was objective response rate in previously treated patients as determined by blinded independent central review according to RECIST version 1.1.

RESULTS

Fifty-six patients with CUP were enrolled in the trial. For the 45 previously treated patients, objective response rate was 22.2% [95% confidence interval (CI), 11.2% to 37.1%], with a median progression-free survival and overall survival of 4.0 months (95% CI, 1.9-5.8 months) and 15.9 months (95% CI, 8.4-21.5 months), respectively. Similar clinical benefits were also observed in the 11 previously untreated patients. Better clinical efficacy of nivolumab was apparent for tumors with a higher programmed death-ligand 1 expression level, for those with a higher tumor mutation burden, and for microsatellite instability-high tumors. In contrast, no differences in efficacy were apparent between tumor subgroups based on estimated tissue of origin. Adverse events were consistent with the known safety profile of nivolumab. No treatment-related death was observed.

CONCLUSIONS

Our results demonstrate a clinical benefit of nivolumab for patients with CUP, suggesting that nivolumab is a potential additional therapeutic option for CUP.

Characteristics and Prognosis of Stroke in Living Donor Renal Transplant Recipients

Aims: We aimed to determine the characteristics and vascular outcomes of stroke in renal transplant (RT) recipients and compare them with those in patients on hemodialysis (HD) and those with no renal replacement therapy (RRT).

Methods: In this prospective observational study, 717 patients (mean age, 70.8 years; male, 60.5%) with acute ischemic stroke within one week of onset were consecutively enrolled and followed for one year. The patients were classified into three groups: (1) living donor RT recipients (n=27); (2) patients on maintenance HD before the index stroke (n=39); and (3) those with no history of RRT (n=651). The primary outcome was a composite of major adverse cardiovascular events (MACE).

Results: Diabetic nephropathy was the most common reason for RRT in both RT and HD patients. RT patients were more likely to have embolic stroke of undetermined source (33.3%) than others, whereas HD patients more often had cardioembolism (51.3%). No difference was observed in the MACE risk between the patients in RT and non-RRT groups (annual rate, 11.3% vs. 13.1%; log-rankP=0.82; hazard ratio [95% confidence interval], 0.92 [0.29-2.98]). In contrast, HD patients had a greater risk of MACE than those with no RRT (annual rate, 28.2% vs. 13.1%; log-rankP=0.019; hazard ratio [95% confidence interval], 2.24 [1.16-4.3]).

Conclusions: The underlying etiologies of stroke differed in RT and HD patients. The one-year risk of MACE for stroke patients who had received an RT was lower than that for patients undergoing HD and comparable with that of patients with no RRT.

Chemical Modulation of DNA Replication along G-Quadruplex Based on Topology-Dependent Ligand Binding

Ligands that bind to and stabilize guanine-quadruplex (G4) structures to regulate DNA replication have therapeutic potential for cancer and neurodegenerative diseases. Because there are several G4 topologies, ligands that bind to their specific types may have the ability to preferentially regulate the replication of only certain genes. Here, we demonstrated that binding ligands stalled the replication of template DNA at G4, depending on different topologies. For example, naphthalene diimide derivatives bound to the G-quartet of G4 with an additional interaction between the ligand and the loop region of a hybrid G4 type from human telomeres, which efficiently repressed the replication of the G4. Thus, these inhibitory effects were not only stability-dependent but also topology-selective based on the manner in which G4 structures interacted with G4 ligands. Our original method, referred to as a quantitative study of topology-dependent replication (QSTR), was developed to evaluate correlations between replication rate and G4 stability. QSTR enabled the systematic categorization of ligands based on topology-dependent binding. It also demonstrated accuracy in determining quantitatively how G4 ligands control the intermediate state of replication and the kinetics of G4 unwinding. Hence, the QSTR index would facilitate the design of new drugs capable of controlling the topology-dependent regulation of gene expression.

Atherogenic Dyslipidemia and Residual Vascular Risk After Stroke or Transient Ischemic Attack

BACKGROUND AND PURPOSE

Notwithstanding the current guideline-based management, patients with stroke retain a substantial risk of further vascular events. We aimed to assess the contribution of atherogenic dyslipidemia (AD) to this residual risk.

METHODS

This was a prospective observational study, in which 792 patients (mean age, 70.1 years; male, 60.2%) with acute ischemic stroke (n=710) or transient ischemic attack (n=82) within 1 week of onset were consecutively enrolled and followed for 1 year. AD was defined as having both elevated levels of triglycerides ≥150 mg/dL and low HDL-C (high-density lipoprotein cholesterol) <40 mg/dL in men or <50 mg/dL in women, under fasting conditions. The primary outcome was a composite of major adverse cardiovascular events, including nonfatal stroke, nonfatal acute coronary syndrome, and vascular death.

RESULTS

The prevalence of AD was 12.2%. Patients with AD more often had intracranial artery stenosis than those without (42.3% versus 24.1%; P=0.004), whereas no differences were observed in the prevalence of extracranial artery stenosis (17.7% versus 12.9%; P=0.62) or aortic plaques (33.3% versus 27.0%; P=0.87). At 1 year, patients with AD were at a greater risk of major adverse cardiovascular events (annual rate, 24.5% versus 10.6%; hazard ratio [95% CI], 2.33 [1.44-3.80]) and ischemic stroke (annual rate, 16.8% versus 8.6%; hazard ratio [95% CI], 1.84 [1.04-3.26]) than those without AD. When patients were stratified according to baseline LDL-C (low-density lipoprotein cholesterol) level, AD was predictive of major adverse cardiovascular events among those with LDL-C ≥100 mg/dL (n=509; annual rate, 20.5% versus 9.6%; P=0.036) as well as those with LDL-C <100 mg/dL (n=283; annual rate, 38.6% versus 12.4%; P<0.001).

CONCLUSIONS

AD is associated with intracranial artery atherosclerosis and a high residual vascular risk after a stroke or transient ischemic attack. AD should be a promising modifiable target for secondary stroke prevention. Registration: URL: https://upload.umin.ac.jp; Unique identifier: UMIN000031913.

OPERA tau neutrino charged current interactions

The OPERA experiment was designed to discover the vτ appearance in a vμ beam, due to neutrino oscillations. The detector, located in the underground Gran Sasso Laboratory, consisted of a nuclear photographic emulsion/lead target with a mass of about 1.25 kt, complemented by electronic detectors. It was exposed from 2008 to 2012 to the CNGS beam: an almost pure vμ beam with a baseline of 730 km, collecting a total of 1.8·1020 protons on target. The OPERA Collaboration eventually assessed the discovery of vμ→vτ oscillations with a statistical significance of 6.1 σ by observing ten vτ CC interaction candidates. These events have been published on the Open Data Portal at CERN. This paper provides a detailed description of the vτ data sample to make it usable by the whole community.