Distinct subdivisions of subcortical U-fiber regions in the gyrencephalic ferret brain

The human cerebrum contains a large amount of cortico-cortical association fibers. Among them, U-fibers are short-range association fibers located in white matter immediately deep to gray matter. Although U-fibers are thought to be crucial for higher cognitive functions, the organization within U-fiber regions are still unclear. Here we investigated the properties of U-fiber regions in the ferret cerebrum using neurochemical, neuronal tracing, immunohistochemical and electron microscopic techniques. We found that U-fiber regions can be subdivided into two regions, which we named outer and inner U-fiber regions. We further uncovered that outer U-fiber regions have smaller-diameter axons with thinner myelin compared with inner U-fiber regions. These findings may indicate functional complexity within U-fiber regions in the cerebrum.

Comparison of the Efficacy of Low Dose Tadalafil with Tamsulosin against Lower Urinary Tract Symptoms and Sexual Dysfunction after Low Dose Rate Prostate Brachytherapy

PURPOSE/OBJECTIVE(S)

Patients with clinically localized prostate cancer (PCa) can be curatively treated with different modalities, including low dose rate (LDR) prostate brachytherapy (PB). LDR-PB allows the patient a relatively short recovery time compared with other treatment modalities such as prostatectomy. However, PB might exert distinct impact on quality of life, lower urinary tract symptoms (LUTS) and sexual dysfunction (SD) are two major concerns. The aim of present study was to assess prospectively the efficacy of low dose tadalafil treatment on both SD and LUTS compared with tamsulosin treatment in patients treated PB for localized PCa.

MATERIALS/METHODS

Patients scheduled for PB with I-125 seeds for low or intermediate-risk localized PCa at our institution were eligible for this study. The prescribed dose was set at 160 gray. Participants were randomized into two groups; those started treating with a daily use of 0.2 mg of tamsulosin hydrochloride or 5 mg of tadalafil just after PB. The duration of the study was 12 months and the patients were assessed for urinary and sexual function status at baseline, and 1, 3, 6, and 12 months after PB. The primary study endpoints were both changes from baseline in urinary and sexual function status.

RESULTS

Between July 2015 and August 2020, 120 participants were enrolled in this study. The median age was 68 years with the median PSA of 6.5 ng/ml. A total 15 patients were excluded within 6 months after randomization. All subjective LUTS findings, including International Prostate Symptom Score (IPSS), and Over Active Bladder Symptom Score (OABSS), were significantly deteriorated at 1, 3, and 6 months after PB compared with baseline in both groups, respectively (p<0.05). Among objective LUTS findings, a significant decrease in maximum urinary flow rate (Qmax) was found at 1, 3, 6, and 12 months after PB compared with baseline in both groups, respectively (p<0.05). A significant increase in post void residual urine (PVR) was found at 1, 3, and 6 months after PB compared to baseline in tadalafil group, whereas no significant increase was seen in tamsulosin group. There were no statistically significant differences between the 2 groups in scores of the total International Index of Erectile Function (IIEF)-15 and Erection Hardness Score (EHS) before and at 1 month post PB. The EHS was significantly higher in tadalafil group compared with tamsulosin group at 3, 6 and 12 months (p = 0.001, p = 0.004, and p = 0.019, respectively). The EHS after PB in tadalafil group was not significantly decreased from baseline.

CONCLUSION

After LDR-PB, tamsulosin treatment significantly decreased PVR compared with tadalafil. On the other hand, tadalafil contributed to maintain erection hardness compared with tamsulosin.

Tmem2 Deficiency Leads to Enamel Hypoplasia and Soft Enamel in Mouse

Teeth consist of 3 mineralized tissues: enamel, dentin, and cementum. Tooth malformation, the most common craniofacial anomaly, arises from complex genetic and environmental factors affecting enamel structure, size, shape, and tooth eruption. Hyaluronic acid (HA), a primary extracellular matrix component, contributes to structural and physiological functions in periodontal tissue. Transmembrane protein 2 (TMEM2), a novel cell surface hyaluronidase, has been shown to play a critical role during embryogenesis. In this study, we demonstrate Tmem2 messenger RNA expression in inner enamel epithelium and presecretory, secretory, and mature ameloblasts. Tmem2 knock-in reporter mice reveal TMEM2 protein localization at the apical and basal ends of secretory ameloblasts. Micro-computed tomography analysis of epithelial-specific Tmem2 conditional knockout (Tmem2-CKO) mice shows a significant reduction in enamel layer thickness and severe enamel deficiency. Enamel matrix protein expression was remarkably downregulated in Tmem2-CKO mice. Scanning electron microscopy of enamel from Tmem2-CKO mice revealed an irregular enamel prism structure, while the microhardness and density of enamel were significantly reduced, indicating impaired ameloblast differentiation and enamel matrix mineralization. Histological evaluation indicated weak adhesion between cells and the basement membrane in Tmem2-CKO mice. The reduced and irregular expressions of vinculin and integrin β1 suggest that Tmem2 deficiency attenuated focal adhesion formation. In addition, abnormal HA accumulation in the ameloblast layer and weak claudin 1 immunoreactivity in Tmem2-CKO mice indicate impaired tight junction gate function. Irregular actin filament assembly was also observed at the apical and basal ends of secretory ameloblasts. Last, we demonstrated that Tmem2-deficient mHAT9d mouse ameloblasts exhibit defective adhesion to HA-containing substrates in vitro. Collectively, our data highlight the importance of TMEM2 in adhesion to HA-rich extracellular matrix, cell-to-cell adhesion, ameloblast differentiation, and enamel matrix mineralization.

Increasing the class of foundational medication for heart failure is associated with improved prognosis in hospitalized patients with heart failure with reduced or mildly reduced ejection fraction

Aim

To clarify the association between changes in the number of foundational medications for heart failure (FMHF) during hospitalization for worsening heart failure and post-discharge prognosis.

Methods and results

We retrospectively analyzed a combined dataset of three large-scale registries of hospitalized patients with heart failure in Japan (NARA-HF, WET-HF, and REALITY-AHF) and included patients already diagnosed with heart failure with reduced or mildly reduced left ventricular ejection fraction (HFr/mrEF) before admission. Patients were stratified by changes in the number of prescribed FMHF classes, namely angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, beta blockers, and mineralocorticoid receptor blockers, from admission to discharge. The primary endpoint was defined as the combined endpoint of heart failure rehospitalization and all-cause death within 1-year of discharge. The cohort consisted of 1,113 patients, and 482 combined endpoints were observed. In total, 413 (37.1%) patients were on increased FMHF (increased group), 607 (54.5%) remained unchanged (unchanged group), and 93 (8.4%) had a decreased number of FMHF (decreased group) at discharge compared to the time of admission. In multivariable analysis, the increased group was associated with a significantly lower incidence of the primary endpoint compared with the unchanged group (hazard ratio 0.56, 95% confidence interval 0.45–0.60; P&lt;0.001) and decreased group (hazard ratio 0.58, 95% confidence interval 0.40–0.84; P=0.004).

Conclusion

Increasing the number of FMHF cases during heart failure hospitalization is associated with a better prognosis in patients with HFr/mrEF.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): REALITY registry was funded by the Cardiovascular Research Fund of Japan.WET-HF registry was supported by a Grant-in-Aid for Young Scientists (Y.S. JSPS KAKENHI, 18K15860).

Hydroxynonenal Causes Hepatocyte Death by Disrupting Lysosomal Integrity in Nonalcoholic Steatohepatitis

BACKGROUND & AIMS

The lipid oxidation is a key factor for damaging hepatocytes and causing cell death. However, the mechanisms underlying hepatocyte death and the role of the most popular lipid peroxidation product 4-hydroxy-2-nonenal (HNE) in nonalcoholic steatohepatitis (NASH) remains unclear.

METHODS

We demonstrated using hepatoma cell lines, a NASH mouse model, HNE-treated monkeys, and biopsy specimens from patients with NASH that HNE induced hepatocyte death by disintegrating the lysosomal limiting membrane.

RESULTS

The degree of HNE deposition in human NASH hepatocytes was more severe in cases with high lobular inflammation, ballooning, and fibrosis scores, and was associated with enlargement of the staining of lysosomes in hepatocytes. In in vitro experiments, HNE activated μ-calpain via G-protein coupled receptor (GPR) 120. The resultant rupture/permeabilization of the lysosomal limiting membrane induced the leakage of cathepsins from lysosomes and hepatocyte death. The blockade of G-protein coupled receptor 120 (GPR120) or μ-calpain expression suppressed lysosomal membrane damage and hepatocyte death by HNE. Alda-1, which activates aldehyde dehydrogenase 2 to degrade HNE, prevented HNE-induced hepatocyte death. Intravenous administration of HNE to monkeys for 6 months resulted in hepatocyte death by a mechanism similar to that of cultured cells. In addition, intraperitoneal administration of Alda-1 to choline-deficient, amino-acid defined treated mice for 8 weeks inhibited HNE deposition, decreased liver inflammation, and disrupted lysosomal membranes in hepatocytes, resulting in improvement of liver fibrosis.

CONCLUSIONS

These results provide novel insights into the mechanism of hepatocyte death in NASH and will contribute to the development of new therapeutic strategies for NASH.

Membrane Vesicles Derived From Clostridium botulinum and Related Clostridial Species Induce Innate Immune Responses via MyD88/TRIF Signaling in vitro

Clostridium botulinum produces botulinum neurotoxin complexes that cause botulism. Previous studies elucidated the molecular pathogenesis of botulinum neurotoxin complexes; however, it currently remains unclear whether other components of the bacterium affect host cells. Recent studies provided insights into the role of bacterial membrane vesicles (MVs) produced by some bacterial species in host immunity and pathology. We herein examined and compared the cellular effects of MVs isolated from four strains of C. botulinum with those of closely related Clostridium sporogenes and two strains of the symbiont Clostridium scindens. MVs derived from all strains induced inflammatory cytokine expression in intestinal epithelial and macrophage cell lines. Cytokine expression was dependent on myeloid differentiation primary response (MyD) 88 and TIR-domain-containing adapter-inducing interferon-β (TRIF), essential adaptors for toll-like receptors (TLRs), and TLR1/2/4. The inhibition of actin polymerization impeded the uptake of MVs in RAW264.7 cells, however, did not reduce the induction of cytokine expression. On the other hand, the inhibition of dynamin or phosphatidylinositol-3 kinase (PI3K) suppressed the induction of cytokine expression by MVs, suggesting the importance of these factors downstream of TLR signaling. MVs also induced expression of Reg3 family antimicrobial peptides via MyD88/TRIF signaling in primary cultured mouse small intestinal epithelial cells (IECs). The present results indicate that MVs from C. botulinum and related clostridial species induce host innate immune responses.

“Target Heart Rate” calculated aiming at zero overlap of mitral E and A waves is useful for prediction of long-term outcome for patients with heart failure and reduced ejection fraction

Background

Lower heart rate (HR) is associated with more favourable long-term outcome in patients with heart failure with reduced ejection fraction (HFrEF). However, an optimal threshold of HR remains unclear. Targeted HR (THR), defined by echocardiographic deceleration time (DCT) to eliminated overlap of E and A waves, may aid in risk stratification of HFrEF patients.

Purpose

In this study, we aimed to clarify the impact of on long-term clinical outcome in patients with HFrEF.

Methods

In the multicenter WET-HF registry, 4000 consecutive patients hospitalized for acute decompensated HF (ADHF) were registered between 2006 and 2017. Among them, the patients with EF ≥40% or a history of atrial fibrillation were excluded. THR was calculated based on their DCT value measured in compensated HF phase during the index admission. The following formula was applied; THR (bpm)=93 - 0.13 × deceleration time (DCT, msec). A total of 876 patients with HFrEF were included in the present analysis (age: 72 [60–81], male: 69%) and the patients were divided into the 2 groups of HR at discharge ≤ THR (L group) and &gt; THR (H group). The primary endpoint (PE) was defined as the composite of all-cause death and ADHF re-admission.

Results

Compared to the H group, the L group showed higher prevalence of males (74% vs. 66%, P=0.025) with higher body mass index (BMI, 23.2 vs. 22.2, P=0.016), hemoglobin (Hb, 12.9 vs. 12.4, P=0.031), albumin (Alb, 3.7 vs. 3.6, P=0.039) and larger left atrial diameter (LAD, 44 mm vs. 41 mm, P=0.002) and tricuspid regurgitation pressure gradient (TRPG, 29 mmHg vs. 27 mmHg, P=0.012). Age, estimated glomerular filtration rate (eGFR), LVEF (29% vs. 30%, P=NS) and E/e' (17.7 vs. 16.8, P=NS) were similar for both groups. At discharge, HR was lower in L group (66 [60–71] bpm vs. 80 [74–86] bpm, P&lt;0.001), albeit there were no significant differences in b-blocker prescription (90% vs. 85%, P=0.069) or its dose (3.75 [1.25–7.25] mg vs. 2.5 [1.25–5] mg, P=0.11).

In the survival analysis, the L group showed a significantly lower rate of PE (P=0.03), whereas there was no significant difference in the incidence of PE between the patients with HR at discharge ≥70 bpm and &lt;70 bpm (P=NS).

Multivariate Cox hazard analysis showed that HR at discharge ≤ THR was an independent predictor of PE (hazard ratio 0.67 [0.46–0.97], P=0.037), even after adjusting for confounding factors including age, sex, BMI, Hb, Alb, and b-blocker prescription, whereas HR at discharge &lt;70 bpm was not (hazard ratio 0.94 [0.65–1.33], P=0.71).

Conclusion

THR was associated with long-term outcomes in patients with HFrEF after acute decompensation, suggesting that it may aid in tailored treatment for HR reduction in these patients.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Pre-operative endovascular coil embolisation for chronic pulmonary aspergillosis

OBJECTIVE: To retrospectively evaluate the clinical outcomes of pre-operative endovascular coil embolisation (ECE) for chronic pulmonary aspergillosis (CPA).METHODS: We evaluated surgical patients with CPA between November 2016 and April 2020. Pre-operative ECE for CPA with severe adhesions was selectively performed to reduce intra-operative blood loss. ECE procedures, operative procedures, intra-operative blood loss and complications were evaluated.RESULTS: Twenty-eight patients (21 males and 7 females; median age: 55 years) were included in the study. Of the 28 patients, 8 (28.6%) underwent pre-operative ECE. Technical success rate in pre-operative ECE was 100%. The median time required for ECE procedures was 123 min. The median number of vessels embolised per procedure was 2.5. The median period between embolisation and surgery was 5 days. Major complications were observed in three patients (10.7%). There were no significant differences between patients with and without pre-operative ECE in operative time (284 vs. 365 min, respectively, P = 0.7602) and intra-operative blood loss (294 vs. 228 mL, respectively, P = 0.8987).CONCLUSIONS: Pre-operative ECE for CPA appears to be feasible and safe; however, its role in reducing intra-operative blood loss needs further investigation.

A genetically defined signature of responsiveness to erlotinib in early-stage pancreatic cancer patients: Results from the CONKO-005 trial

Background

high recurrence rates of up to 75% within 2 years in pancreatic ductal adenocarcinoma (PDAC) patients resected for cure indicate a high medical need for clinical prediction tools and patient specific treatment approaches. Addition of the EGFR inhibitor erlotinib to adjuvant chemotherapy failed to improve outcome but its efficacy in some patients warrants predictors of responsiveness.

Patients and Methods

we analysed tumour samples from 293 R0-resected patients from the randomized, multicentre phase III CONKO-005 trial (gemcitabine ± erlotinib) with targeted sequencing, copy number, and RNA expression analyses.

Findings

a total of 1086 mutations and 4157 copy-number aberrations (CNAs) with a mean of 17.9 /tumour were identified. Main pathways affected by genetic aberrations were the MAPK-pathway (99%), cell cycle control (92%), TGFβ signalling (77%), chromatin remodelling (71%), and the PI3K/AKT pathway (65%). Based on genetic signatures extracted with non-negative matrix factorization we could define five patient clusters, which differed in mutation patterns, gene expression profiles, and survival. In multivariable Cox regression analysis, SMAD4 aberrations were identified as a negative prognostic marker in the gemcitabine arm, an effect that was counteracted when treated with erlotinib (DFS: HR=1.59, p = 0.016, and OS: HR = 1.67, p = 0.014). Integration of differential gene expression analysis established SMAD4 alterations with low MAPK9 expression (n = 91) as a predictive biomarker for longer DFS (HR=0.49; test for interaction, p = 0.02) and OS (HR = 0.32; test for interaction, p = 0.001).

Interpretation

this study identified five biologically distinct patient clusters with different actionable lesions and unravelled a previously unappreciated association of SMAD4 alteration status with erlotinib effectiveness. Confirmatory studies and mechanistic experiments are warranted to challenge the hypothesis that SMAD4 status might guide addition of erlotinib treatment in early-stage PDAC patients.

Effect of air pollution on acute heart failure hospitalization differ across specific heart failure populations

Introduction

Several report showed the association between ambient air pollution including particular matter under 2.5um (PM2.5) and increasing rate of hospitalization for heart failure. However, these report analyzed mainly cross-sectional, epidemiological data, thus the reports regarding association between vulnerability to PM2.5 and specific populations in acute heart failure (AHF) were scarce.

Purpose

1. To analyze the association between air pollution and rate of hospitalization for AHF

2. To analyze whether the vulnerability to air pollution differ between specific populations in AHF. Methods

A case-cross over analysis was conducted to 4980 consecutive patients registered for multicenter acute heart failure registry in 2017 in our city Japan. This registry enrolled patients transferred to cardiovascular care unit (80 institutions) via emergency medical services across our city area. Logistic regression analysis were conducted to estimate percentage changes in the rate of acute heart failure hospitalization associated with per 1μg/m3 PM2.5 concentration increase. We also conducted subgroup analysis for patients stratified by age, gender, comorbidities, left ventricular ejection fraction, and clinical scenario.

Results

An increase in 1 μg/m3 PM2.5 concentration corresponded to 2.9% (95% CI 1.2–4.6%) increase in AHF hospitalization. Patients with age younger than 75, without prior heart failure hospitalization, without history of hypertension, without anemia, and with reduced ejection fraction were more susceptible to increase in PM2.5 concentration (Figure).

Conclusions

Increase in PM2.5 concentration was associated with increased rate of AHF hospitalization. Effect of PM2.5 may differ across specific AHF subpopulations.

Figure 1

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Tokyo Metropolitan Government

Utility of synthetic MRI in predicting the Ki-67 status of oestrogen receptor-positive breast cancer: a feasibility study

AIM

To evaluate the utility of synthetic magnetic resonance imaging (MRI) of the breast in predicting the Ki-67 status in patients with oestrogen receptor (ER)-positive breast cancer.

MATERIALS AND METHODS

Forty-nine patients with 50 histopathologically proven breast cancers who underwent additional synthetic MRI were enrolled in the present study. Using synthetic MRI images, T1 and T2 relaxation times and their standard deviations (SD) in the breast lesions before (T1-Pre, T2-Pre, PD-Pre, SD of T1-Pre, SD of T2-Pre, SD of PD-Pre) and after (T1-Gd, T2-Gd, PD-Gd, SD of T1-Gd, SD of T2-Gd, SD of PD-Gd) contrast agent injection were obtained. These quantitative values were compared between the low Ki-67 expression (<14%) lesions (low-proliferation group: n=23) and high Ki-67 expression (≥14%) lesions (high-proliferation group: n=27).

RESULTS

The univariate analysis showed that the SD of T1-Gd (p<0.001) and T2-Gd (p=0.042) were significantly higher in the high-proliferation group than in the low-proliferation group. Multivariate analysis further showed that the SD of T1-Gd was a significant and independent predictor of Ki-67 expression, with an area under the receiver operating characteristic (AUROC) curve of 0.885. The sensitivity, specificity, and accuracy of the SD of T1-Gd with an optimal cut-off value of 98.5 were 77.8%, 87%, and 82%, respectively.

CONCLUSION

The SD of T1-Gd obtained from synthetic MRI was useful to predict Ki-67 status.

P5411Prognostic communication with hospitalized heart failure patients; the patients' perspective

Background

Informing heart failure (HF) patients about their prognosis is an important part of clinical management, particularly at the time of hospitalization. Current European Society of Cardiology guidelines recommend communicating this information to HF patients at the time of hospitalization and with any change in clinical status. However, little is known about actual patient preferences, understanding, and attitudes towards prognostic communication with their treating physicians.

Methods

We surveyed 113 consecutive hospitalized HF patients in a single university hospital. We assessed patient understanding of prognosis (likelihood of survival beyond 2 years), and compared patient expectations to model predictions. Model-predicted 2-year survival rate was calculated by the Seattle Heart Failure Model (SHFM). We also assessed patient preferences for information disclosure using the Prognosis and Treatment Perception Questionnaire (PTPQ). The PTPQ assesses patient beliefs regarding 1) the importance of knowing about prognosis, 2) the importance of knowing about treatment option, and 3) frequency of having a conversation about prognosis during the hospital stay.

Results

Enrolled patients were predominantly male (65.5%), with a mean age of 73.6±9.6 years and mean left ventricular ejection fraction was 46.2±15.4%. Median SHFM-estimated 2-year survival rate was 89.2% (interquartile range: 83.8–92.9%). Overall, patient understanding about prognosis was suboptimal. Among patients with a guarded 2-year survival (SHFM <90%: N=60), 44% reported that their likelihood of 2-year survival was >90% (Figure; red box). However, among patients with favorable 2-year survival (>90%: N=53), 38% reported a likelihood of <90% (Figure; blue box). Regarding treatment options, most patients (98%) desired to learn as many details as possible. Responses varied with regard to information on individual prognosis; whereas 51% wanted to know more about prognosis than their present status alone, a significant number (28%) of subjects answered “never” or “less often” to a query on the frequency of discussion about prognosis. Patient preference for more information about prognosis was associated with female sex (odds ratio [OR]: 2.52; 95% confidence interval [CI]: 1.12–5.69), fewer symptoms of depression (1-point increase on Patient Health Questionnaire-2, OR: 0.66; 95% CI: 0.49–0.87), and previous stroke (OR: 2.92; 95% CI: 1.04–8.19), but not other social/demographic or clinical factors (e.g., age, education, caregiver support, HF phenotype and severity, and other comorbid conditions).

Figure 1

Conclusions

There were substantial discrepancies in patient understanding of prognosis and in desire for more information from physicians. Interventions to improve prognostic understanding are warranted for HF patients, and hospitalization for HF could represent an opportunity for optimization.

P6531Evidence-practice gap in the preprocedural risk assessment for contrast-induced acute kidney injury

Background

Contrast-induced acute kidney injury (CI-AKI) is one of the frequently encountered and costly complications after percutaneous coronary intervention (PCI). Clinical practice guidelines strongly recommend that PCI patients should universally undergo preprocedural assessment for the risk of CI-AKI, and the contrast volume (CV) should be minimized to an achievable level, particularly among the high AKI risk patients. However, data on the CV use based on the comprehensive preprocedural risk assessment is still lacking.

Purpose

Our study aimed to 1) assess the impact of CV increase with the incidence of AKI among high AKI risk patients, and 2) retrospectively evaluate the used CV based on the preprocedural comprehensive risk assessment for patients undergoing PCI within multicenter longitudinal registry.

Methods

Between 2009 and 2018, 22,373 patients underwent PCI in 14 participating facilities, and consecutive patient data was registered. AKI was defined as a >0.3mg/dl absolute or >1.5-fold relative increase in post-PCI creatinine or new initiation of dialysis, based on the Acute Kidney Injury Network criteria. The post-procedural creatinine was defined as the highest value within 30 days after the indexed procedure. Congruent with the National Cardiovascular Data Registry (NCDR) definition, if more than 1 post-procedural creatinine level was measured, the highest value was used for determining AKI. We divided the patients into four groups according to quartile of NCDR AKI risk scores.

Results

Mean age of the patients were 68.7±11.1 years, and 79.1% were male. Mean CV use was 161.4±74.8ml. The incidence of CI-AKI was 8.9%, and was particularly high among high AKI risk patients (21.1%); CV (per 1ml linear increase) was directly associated with the occurrence of AKI (OR: 1.002 per unit in CV; 95% CI: 1.001–1.003; P<0.001) in these patients. CV during PCI decreased with the progression of chronic kidney disease (CKD), but it did not alter by the overall NCDR AKI risk score (Figure). After multivariable adjustment, CV was predicted by stage of CKD (−13.68ml; 95% CI: −12.05 to −15.30ml; P<0.001), but not by the value of pre-procedure prediction score (NCDR AKI risk score, P=0.575).

CV according to CKD/NCDR AKI risk score

Conclusions

Higher CV was directly associated with the occurrence of AKI among higher AKI risk patients. However, CV use was largely influenced by the stage of renal disease, and not with overall patient risk presented by contemporary risk scores. Our results have identified an important evidence-practice gap and emphasizes the importance of total preprocedural assessment to minimize CV and prevent subsequent AKI.

Acknowledgement/Funding

KAKENHI (16KK0186, 16H05215, 25460630, 25460777), Bayer, Daiichi Sankyo, Bristol-Myers Squibb, Teikoku Seiyaku, Sumitomo Dainippon, AstraZeneka, Pfizer

P2622Use of intravenous vasodilators in patients hospitalized with acute heart failure: insights from Tokyo cardiovascular care unit network database

Background

Despite recommendations from clinical practice guidelines, there is scant evidence confirming the effects of vasodilators on clinical outcomes in patients with acute heart failure (AHF).

Purpose

We sought to investigate the effects of intravenous vasodilators on clinical outcomes and to identify the potential patient populations that would benefit from its use.

Methods

Data of 26 212 consecutive patients urgently hospitalized for AHF between 2009 and 2015 were extracted from a multicenter data registration system (Tokyo Cardiovascular Care Unit Network Database, including 72 institutions within the Tokyo metropolitan area in Japan). Patients who did not present with typical AHF episodes, including those without pulmonary congestion on physical and/or chest X-ray and serum B-type natriuretic peptide level <500 pg/ml, as well as those who had hypotension and/or hypoperfusion (systolic blood pressure [SBP] <100 mmHg) as dominant presentation, were excluded. Propensity scores were calculated with multiple imputation and 1:1 matching performed between patients with and without vasodilators. The primary endpoint was in-hospital mortality and the secondary endpoints were length of intensive/cardiovascular care unit (ICU/CCU) stay and hospital stay.

Results

Overall, 8 863 patients were included in the present analysis; they were predominantly male (57%) with a median age of 79 (interquartile range: 70–86) years. Compared with the group without vasodilator use, the vasodilator group had higher SBPs and heart rates and higher frequency of assisted ventilation use, but lower frequency of intravenous diuretics use. After propensity score matching, there were no significant differences in in-hospital mortality rates (7.8% vs. 8.9% in patients without vasodilators, p=0.16) or in length of ICU/CCU stay (5.8 days vs. 5.4 days, p=0.44) and hospital stay (22.7 days vs. 23.8 days, p=0.22) between the groups. However, in subgroup analyses, favorable impacts of vasodilator use on in-hospital mortality were observed among patients who had higher SBPs and among those who had no atrial fibrillation upon admission (Figure). In addition, vasodilators were likely to be more effective in AHF patients with SBP increasing; while levels below 140 mmHg of SBP appeared to be associated with an increased risk for mortality among patients treated with vasodilators compared with those without vasodilators.

Figure 1

Conclusions

In patients with AHF, vasodilator use was not universally associated with improved in-hospital outcomes; however, its effect was dependent of individual clinical presentation. Detailed phenotyping might aid tailoring of treatment strategies for patients with AHF.

Acknowledgement/Funding

the Tokyo Metropolitan Government

Deletion of CD38 Suppresses Glial Activation and Neuroinflammation in a Mouse Model of Demyelination

CD38 is an enzyme that catalyzes the synthesis of cyclic adenosine diphosphate-ribose from nicotinamide adenine dinucleotide (NAD⁺). We recently reported that this molecule regulates the maturation and differentiation of glial cells such as astrocytes and oligodendrocytes (OLs) in the developing brain. To analyze its role in the demyelinating situation, we employed cuprizone (CPZ)-induced demyelination model in mice, which is characterized by oligodendrocyte-specific apoptosis, followed by the strong glial activation, demyelination, and repopulation of OLs. By using this model, we found that CD38 was upregulated in both astrocytes and microglia after CPZ administration. Experiments using wild-type and CD38 knockout (KO) mice, together with those using cultured glial cells, revealed that CD38 deficiency did not affect the initial decrease of the number of OLs, while it attenuated CPZ-induced demyelination, and neurodegeneration. Importantly, the clearance of the degraded myelin and oligodendrocyte repopulation were also reduced in CD38 KO mice. Further experiments revealed that these observations were associated with reduced levels of glial activation and inflammatory responses including phagocytosis, most likely through the enhanced level of NAD⁺ in CD38-deleted condition. Our results suggest that CD38 and NAD⁺ in the glial cells play a critical role in the demyelination and subsequent oligodendrocyte remodeling through the modulation of glial activity and neuroinflammation.

Vascular RAGE transports oxytocin into the brain to elicit its maternal bonding behaviour in mice

Oxytocin sets the stage for childbirth by initiating uterine contractions, lactation and maternal bonding behaviours. Mice lacking secreted oxcytocin (Oxt^−/−, Cd38^−/−) or its receptor (Oxtr^−/−) fail to nurture. Normal maternal behaviour is restored by peripheral oxcytocin replacement in Oxt^−/− and Cd38^−/−, but not Oxtr^−/− mice, implying that circulating oxcytocin crosses the blood-brain barrier. Exogenous oxcytocin also has behavioural effects in humans. However, circulating polypeptides are typically excluded from the brain. We show that oxcytocin is transported into the brain by receptor for advanced glycation end-products (RAGE) on brain capillary endothelial cells. The increases in oxcytocin in the brain which follow exogenous administration are lost in Ager^−/− male mice lacking RAGE, and behaviours characteristic to abnormalities in oxcytocin signalling are recapitulated in Ager^−/− mice, including deficits in maternal bonding and hyperactivity. Our findings show that RAGE-mediated transport is critical to the behavioural actions of oxcytocin associated with parenting and social bonding.

Yasuhiko Yamamoto et al. show that oxytocin is transported into the brain by the receptor for advanced glycation end-products (RAGE) on the blood-brain barrier. This study explains how circulating oxytocin crosses the blood-brain barrier, which is important to manifest oxytocin’s maternal bonding effects.

Abstract P3-06-04: Clonal evolution of non-malignant proliferative lesions into breast cancers

[Introduction] Non-malignant proliferative lesions in the breast have been implicated in the development of invasive breast cancer. Previous studies showed that adjacent atypical proliferative lesions and breast cancers shared common genetic alterations, suggesting that these evolved from the same ancestral cell. However, the clonal structure of atypical proliferative lesions and their clonal dynamics during progression to cancer are poorly understood. In this study, we compared genetic profiles (with and without pathogenic germline mutations) of normal mammary ducts, non-malignant proliferative lesions, and cancer tissues from the same patients to illustrate the clonal evolution of cancer from a non-malignant epithelial cell.

[Methods] Multiple samples were collected from different proliferative lesions within the cancer-borne breast, including invasive cancers, using micro-dissection from formalin-fixed, paraffin-embedded surgical specimens. Somatic mutations and copy number alterations (CNAs) were then evaluated by whole exome sequencing.

[Results] We analyzed a total of 34 samples from 5 premenopausal females carrying estrogen receptor-positive cancers, where the samples were obtained from normal ducts (N = 6), non-atypical (N = 1) and atypical (N = 8) proliferative lesions, and non-invasive (N = 16) and invasive (N = 3) cancers. The number of somatic mutations per sample ranged from 1 to 276 and increased with disease progression, regardless of the germline mutation status. Two cases with bilateral cancers had a pathogenic germline mutation of either BRCA2 or TP53, where no somatic mutations or CNAs were shared by individual proliferative lesions, suggesting multifocal independent cancerous evolutions. By contrast, in the remaining three unilateral cases, no pathogenic germline mutations were detected, but all proliferative lesions, which were separated by a distance of 7-25 mm, shared one or more driver alterations, such as an AKT1 mutation (UID: KU01), concurrent 1q gain and 16q loss (der(1;16)) (UID: KU02), and a GATA3 mutation and der(1;16) (UID: KU03), while harboring private mutations and/or CNAs of their own. The phylogenetic analysis based on the number of shared mutations predicted an early origin of these founder mutations, which frequently predated decades before the onset of cancer.

[Conclusions] Our results suggest that early breast cancer development is shaped by the evolution of multiple precancerous clones. These clones are originated from a common ancestor that acquired a founder mutation long before the onset of cancer, followed by branching evolution of multiple clones that acquired additional driver mutations of their own, from which an invasive cancer ultimately develops. In hereditary cases, this process is thought to be substantially promoted multi-focally from within the entire breasts by a germline mutation shared by all mammary cells, frequently resulting in bilateral and/or multifocal breast cancers. Our findings provide unique insight into the early development of breast cancer.

Citation Format: Nishimura T, Yoshida K, Kawata Y, Takeuchi Y, Kakiuchi N, Shiozawa Y, Aoki K, Hirata M, Kataoka TR, Sakurai T, Baba S, Shiraishi Y, Chiba K, Takeuchi K, Haga H, Miyano S, Toi M, Ogawa S. Clonal evolution of non-malignant proliferative lesions into breast cancers [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-06-04.

CCR2 upregulation in DRG neurons plays a crucial role in gastric hyperalgesia associated with diabetic gastropathy

Background

Diabetic gastropathy is a complex neuromuscular dysfunction of the stomach that commonly occurs in diabetes mellitus. Diabetic patients often present with upper gastrointestinal symptoms, such as epigastric discomfort or pain. The aim of this study was to assess gastric sensation in streptozocin-induced diabetes mellitus (DM) rats and to determine the contribution of C-C motif chemokine receptor 2 (CCR2) signaling to gastric hyperalgesia.

Results

DM rats showed signs of neuropathy (cutaneous mechanical hyperalgesia) from two weeks after streptozocin administration until the end of the experiment. Accelerated solid gastric emptying was observed at two weeks after streptozocin administration compared to the controls. Intense gastric hyperalgesia also developed in DM rats at two weeks after streptozocin administration, which was significantly reduced after intrathecal administration of the CCR2 antagonist INCB3344. Immunochemical analysis indicated that CCR2 expression was substantially upregulated in small and medium-sized dorsal root ganglia neurons of DM rats, although the protein level of monocyte chemoattractant protein-1, the preferred ligand for CCR2, was not significantly different between the control and DM groups.

Conclusions

These data suggest that CCR2 activation in nociceptive dorsal root ganglia neurons plays a role in the pathogenesis of gastric hyperalgesia associated with diabetic gastropathy and that CCR2 antagonist may be a promising treatment for therapeutic intervention.

Long-term results of concurrent chemoradiotherapy with daily-low-dose continuous infusion of 5-fluorouracil and cisplatin (LDFP) for Stage I-II esophageal carcinoma

We investigated long-term treatment outcomes and the feasibility of chemoradiotherapy consisting of daily-low-dose 5-fluorouracil and cisplatin (LDFP) chemotherapy plus radiotherapy for Stage I-II squamous cell esophageal cancer. Treatment records from the 2000 through 2008 period were reviewed retrospectively. Fractionated radiotherapy was performed with a total dose of 60 Gy delivered in 2 Gy per fraction. LDFP chemotherapy, as continuous infusion of 200 mg/m2 5-fluorouracil combined with one hour infusion of 4 mg/m2 cisplatin, was administered on the same days as radiotherapy. Survival was calculated by the Kaplan-Meier method. Survival, responses, failure patterns, and toxicities were evaluated. Seventy-six (47 stage I and 29 stage II) patients were analyzed with a median follow-up of 93.6 months. The 8-year overall survival (OS), progression-free survival (PFS) and cause-specific survival (CSS) rates were 63.4%, 49.8%, and 76.7%, respectively. The 8-year OS, PFS, and CSS for stage I and stage II patients were 71.0%/56.1%/82.9% and 45.2%/40.2%/66.6%, respectively. Sixty-eight patients (89.5%) completed the treatment regimen. A complete response (CR) was achieved in 68 patients (89.5%). Twenty-five patients (36.8%) experienced recurrence after CR. The failure patterns were (overlap included): local failure (n = 12), nodal metastasis (n = 12), distant metastasis (n = 3), details unknown (n = 2). Salvage therapy was performed for local failure; endoscopic therapy (n = 7) or surgery (n = 2). Six patients remain alive without relapse after salvage endoscopic therapy. Major Grade 3 or higher acute adverse events were leukopenia (22%), anorexia (17%), and esophagitis (11%). Major late toxicities (Grade 3 or 4) involved pericardial effusion (12%), pleural effusion (4%), and esophageal stenosis (3%). Chemoradiotherapy with LDFP provided favorable long-term survival with acceptable toxicity for Stage I-II squamous cell esophageal cancer. The tumor response was excellent, but close endoscopic follow-up is essential for detecting and treating local recurrence.

Foetal development of the human gluteus maximus muscle with special reference to its fascial insertion

The human gluteus maximus muscle (GMX) is characterised by its insertion to the iliotibial tract (a lateral thick fascia of the thigh beneath the fascia lata), which plays a critical role in lateral stabilisation of the hip joint during walking. In contrast, in non-human primates, the GMX and biceps femoris muscle provide a flexor complex. According to our observations of 15 human embryos and 11 foetuses at 7-10 weeks of gestation (21-55 mm), the GMX anlage was divided into 1) a superior part that developed earlier and 2) a small inferior part that developed later. The latter was adjacent to, or even continuous with, the biceps femoris. At 8 weeks, both parts inserted into the femur, possibly the future gluteal tuberosity. However, depending on traction by the developing inferior part as well as pressure from the developing major trochanter of the femur, most of the original femoral insertion of the GMX appeared to be detached from the femur. Therefore, at 9-10 weeks, the GMX had a digastric muscle-like appearance with an intermediate band connecting the major superior part to the small inferior mass. This band, most likely corresponding to the initial iliotibial tract, extended laterally and distally far from the muscle fibres. The fascia lata was still thin and the tensor fasciae latae seemed to develop much later. It seems likely that the evolutionary transition from quadripedality to bipedality and a permanently upright posture would require the development of a new GMX complex with the iliotibial tract that differs from that in non-human primates. (Folia Morphol 2018; 77, 1: 144-150).

Frequent somatic mutations in epigenetic regulators in newly diagnosed chronic myeloid leukemia

Although tyrosine kinase inhibitors (TKIs) have significantly improved the prognosis of chronic myeloid leukemia (CML), the ability of TKIs to eradicate CML remains uncertain and patients must continue TKI therapy for indefinite periods. In this study, we performed whole-exome sequencing to identify somatic mutations in 24 patients with newly diagnosed chronic phase CML who were registered in the JALSG CML212 study. We identified 191 somatic mutations other than the BCR-ABL1 fusion gene (median 8, range 1–17). Age, hemoglobin concentration and white blood cell counts were correlated with the number of mutations. Patients with mutations ⩾6 showed higher rate of achieving major molecular response than those<6 (P=0.0381). Mutations in epigenetic regulator, ASXL1, TET2, TET3, KDM1A and MSH6 were found in 25% of patients. TET2 or TET3, AKT1 and RUNX1 were mutated in one patient each. ASXL1 was mutated within exon 12 in three cases. Mutated genes were significantly enriched with cell signaling and cell division pathways. Furthermore, DNA copy number analysis showed that 2 of 24 patients had uniparental disomy of chromosome 1p or 3q, which disappeared major molecular response was achieved. These mutations may play significant roles in CML pathogenesis in addition to the strong driver mutation BCR-ABL1.

CD38 positively regulates postnatal development of astrocytes cell-autonomously and oligodendrocytes non-cell-autonomously

Glial development is critical for the function of the central nervous system. CD38 is a multifunctional molecule with ADP-ribosyl cyclase activity. While critical roles of CD38 in the adult brain such as oxytocin release and social behavior have been reported, those in the developing brain remain largely unknown. Here we demonstrate that deletion of Cd38 leads to impaired development of astrocytes and oligodendrocytes in mice. CD38 is highly expressed in the developing brains between postnatal day 14 (P14) and day 28 (P28). In situ hybridization and FACS analysis revealed that CD38 is expressed predominantly in astrocytes in these periods. Analyses of the cortex of Cd38 knockout (Cd38^-/- ) mice revealed delayed development of astrocytes and subsequently delayed differentiation of oligodendrocytes (OLs) at postnatal stages. In vitro experiments using primary OL cultures, mixed glial cultures, and astrocytic conditioned medium showed that astrocytic CD38 regulates the development of astrocytes in a cell-autonomous manner and the differentiation of OLs in a non-cell-autonomous manner. Further experiments revealed that connexin43 (Cx43) in astrocytes plays a promotive role for CD38-mediated OL differentiation. Finally, increased levels of NAD⁺ , caused by CD38 deficiency, are likely to be responsible for the suppression of astrocytic Cx43 expression and OL differentiation. Our data indicate that CD38 is a positive regulator of astrocyte and OL development.

Identification of cell-type-specific mutations in nodal T-cell lymphomas

Recent genetic analysis has identified frequent mutations in ten-eleven translocation 2 (TET2), DNA methyltransferase 3A (DNMT3A), isocitrate dehydrogenase 2 (IDH2) and ras homolog family member A (RHOA) in nodal T-cell lymphomas, including angioimmunoblastic T-cell lymphoma and peripheral T-cell lymphoma, not otherwise specified. We examined the distribution of mutations in these subtypes of mature T-/natural killer cell neoplasms to determine their clonal architecture. Targeted sequencing was performed for 71 genes in tumor-derived DNA of 87 cases. The mutations were then analyzed in a programmed death-1 (PD1)-positive population enriched with tumor cells and CD20-positive B cells purified by laser microdissection from 19 cases. TET2 and DNMT3A mutations were identified in both the PD1+ cells and the CD20+ cells in 15/16 and 4/7 cases, respectively. All the RHOA and IDH2 mutations were confined to the PD1+ cells, indicating that some, including RHOA and IDH2 mutations, being specific events in tumor cells. Notably, we found that all NOTCH1 mutations were detected only in the CD20+ cells. In conclusion, we identified both B- as well as T-cell-specific mutations, and mutations common to both T and B cells. These findings indicate the expansion of a clone after multistep and multilineal acquisition of gene mutations.