Digital coincidence counting with 4πβ(PPC)-γ for the standardization of 60Co

A 4πβ(PPC)-γ coincidence system has been made at KRISS based on a digital DAQ. 60Co sources were measured to verify the system. The maximum detection efficiency for beta particles was estimated to be 96.7 %. Massic activities for sample sources had 0.005 % of the sample variability error, which was well within the expanded standard uncertainty of 0.54 % (k = 2).

A Prospective Study of Bevacizumab and Neoadjuvant Concurrent Chemoradiation in Locally Advanced Esophageal Squamous Cell Carcinoma: Paradoxical Increase in Circulating Vascular Endothelial Growth Factor-A and Effect on Outcome

PURPOSE/OBJECTIVE(S)

In the prior prospective biomarker study, high serum vascular endothelial growth factor-A (VEGF-A) was associated with a poor prognosis. We conducted a prospective phase II trial of adding Bevacizumab, an anti-VEGF-A monoclonal antibody, to neoadjuvant concurrent chemoradiation (neoCCRT) for patients with locally advanced esophageal squamous cell carcinoma (LA-ESCC). This prospective biomarker study aims to evaluate the expressions of angiogenesis-associated circulating biomarkers before and after neoCCRT and compare clinical outcomes for patients receiving platinum/5-fluorouracil (PF) with or without Bevacizumab.

MATERIALS/METHODS

Patients with biopsy-proven resectable non-T4 LA-ESCC were enrolled for the prospective phase II trial investigating PF-neoCCRT plus Bevacizumab (BPF group). A parallel patient cohort enrolled in a prospective biomarker study receiving PF-neoCCRT was included in the present analysis as the control group (PF group). Radiotherapy was delivered with 40 Gy in 20 fractions. All patients had restaging workups after enoCCRT and underwent radical esophagectomy if the disease remained resectable. Serums were collected before and after neoCCRT. The serum concentrations of angiogenesis-associated biomarkers were determined by the multiplex enzyme-linked immunosorbent assay. Survival analyses were performed by the Kaplan-Meier method. The t-test and log-rank test were used to compare differences in biomarker expression and survival between groups.

RESULTS

From 2016 to 2019, 43 patients (BPF/PF group: 21/22) were enrolled in the study. Twenty patients in each group had serum samples available for biomarker analysis. 15 out of 21 patients in the BPF group and 20 out of 22 patients in the PF group underwent radical esophagectomy. Six patients in the BPF group and nine patients in the PF group achieved pathological complete responses. The median overall survival for the BPF and PF group was 20.8 months and not-reached, respectively (hazard ratio = 1.33, long rank p = 0.58). In the BPF group, the serum VEGF-A level was significantly increased from an average value of 446 pg/mL to 723 pg/mL after neoCCRT (p = 0.037), while its level was decreased from 815 ng/mL to 380 pg/mL in the PF group (p = 0.104). In addition, the expression value of circulating Angiopoietin-1 was not changed in the BPF group (before neoCCRT, mean value = 828 pg/mL; after neoCCRT, mean value 762 pg/mL, p = 0.67). In contrast, serum Angiopoietin-1 level was reduced from an average value of 659 pg/mL before neoCCRT to 271 pg/mL after neoCCRT (p = 0.002) in the PF group.

CONCLUSION

The addition of Bevacizumab to PF-neoCCRT did not improve pathological or survival outcomes in patients with resectable LA-ESCC. Adding a single dose of Bevacizumab paradoxically increases circulating VEGF-A while maintaining the Angiopoietin-1 serum level after neoCCRT. Further investigation by using additional VEGF-A inhibition may be required to achieve sustained angiogenesis blocked for tumor control.

Glomerular Diseases Across Lifespan: Key Differences in Diagnostic and Therapeutic Approaches

Glomerular diseases are common causes of chronic kidney disease in childhood, adolescence, and adulthood. The epidemiology of glomerular diseases differs between different age groups, with minimal change disease being the leading cause of nephrotic syndrome in childhood, while membranous nephropathy and focal segmental glomerulosclerosis are more common in adulthood. IgA vasculitis is also more common in childhood. Moreover, there is a difference in disease severity with more children presenting with a relapsing form of nephrotic syndrome and a more acute presentation of antineutrophil cytoplasmic antibody-associated vasculitis and concomitant glomerulonephritis, as highlighted by the higher percentage of cellular crescents on kidney biopsy specimens in comparison with older patients. There is also a female preponderance in antineutrophil cytoplasmic antibody-associated vasculitis and more children present with tracheobroncholaryngeal disease. This article aims to summarize differences in the presentation of different glomerular diseases that are encountered commonly by pediatric and adult nephrologists and potential differences in the management.

Transient disruption of functional connectivity and depression of neural fluctuations in a mouse model of acute septic encephalopathy

Septic encephalopathy leads to major and costly burdens for a large percentage of admitted hospital patients. Elderly patients are at an increased risk, especially those with dementia. Current treatments are aimed at sedation to combat mental status changes and are not aimed at the underlying cause of encephalopathy. Indeed, the underlying pathology linking together peripheral infection and altered neural function has not been established, largely because good, acutely accessible readouts of encephalopathy in animal models do not exist. Behavioral testing in animals lasts multiple days, outlasting the time frame of acute encephalopathy. Here, we propose optical fluorescent imaging of neural functional connectivity (FC) as a readout of encephalopathy in a mouse model of acute sepsis. Imaging and basic behavioral assessment were performed at baseline, Hr8, Hr24, and Hr72 following injection of either lipopolysaccharide or phosphate buffered saline. Neural FC strength decreased at Hr8 and returned to baseline by Hr72 in motor, somatosensory, parietal, and visual cortical regions. Additionally, neural fluctuations transiently declined at Hr8 and returned to baseline by Hr72. Both FC strength and fluctuation tone correlated with neuroscore indicating this imaging methodology is a sensitive and acute readout of encephalopathy.

Sex-differences in prevalence and outcomes of the different endotypes of chronic coronary syndrome – analysis from the multi-center international ILIAS Registry

Introduction

Guideline-directed management of chronic coronary syndrome (CCS) remains focused on obstructive causes of angina, and is based on established therapies derived from studies predominantly including men. This occurs despite documented higher mortality from cardiovascular causes in women compared to men, which is hypothesized to be related to a higher prevalence of coronary microvascular dysfunction (CMD) in women. However, data on the relationship between sex, the different endotypes of CCS, and related sex-specific clinical outcomes are limited.

Purpose

This study aimed to investigate the relationship between sex and the different endotypes of CCS, as well as sex-specific clinical outcomes of CCS endotypes.

Method

In patients with stable angina undergoing coronary angiography, the following invasive coronary hemodynamics were characterized: fractional flow reserve (FFR; <0.80 considered abnormal), coronary flow reserve (CFR; <2.0 considered abnormal) and microcirculatory resistance (MR) (hyperemic microvascular resistance; >2.5mmHg/cm/sec or index of microvascular resistance >25 considered abnormal). Patients were stratified into three groups: 1) hemodynamically significant obstructive coronary artery disease (oCAD) (FFR abnormal or a severe coronary stenosis requiring revascularization), 2) no-obstructive coronary artery disease but with CMD (FFR normal, but abnormal CFR and/or MR), or 3) no-obstructive coronary artery disease and no CMD (FFR normal, and normal CFR and MR). We assessed the prevalence of the CCS endotypes across sex, and sex-specific cardiovascular outcomes over a follow-up of 7 years defined as the composite endpoint of death or acute myocardial infarction.

Results

Amongst a total of 1987 included patients, 1435 (72.2%) were men and 552 (27.8%) were women. oCAD occurred in 904 (45.5%) patients, which was significantly more prevalent in men (48.9% (701/1435) of men vs. 36.8% (203/552) of women, p<0.001). In contrast, CMD was significantly more prevalent in women (19.6% (281/1435) of men vs. 24.1% (133/552) of women, p=0.031). Across the population, either oCAD or CMD occurred in 68.4% of men versus 60.9% of women (p=0.002). There were no sex-specific differences in cardiovascular outcomes across CCS entities (Figure 1).

Conclusion

In patients evaluated for CCS who underwent clinically indicated coronary angiography and physiological assessment, men were more likely to have oCAD and women were more likely to be classified as CMD. There were no sex-related differences in the prognosis associated with the individual CCS endotypes. Therefore, pathophysiological changes in the coronary circulation potentially underlying angina pectoris are similarly prevalent in men and women, but the high incidence of CMD in women makes women prone to underdiagnosis if no additional physiological measurements are assessed.

Funding Acknowledgement

Type of funding sources: None.

Hyperaemic and non-hyperaemic pressure indices of coronary stenosis severity in patients with chronic kidney disease

Background

Evidence regarding the use of pressure indices for the assessment of coronary stenoses in patients with chronic kidney disease (CKD) is scarce.

Methods

We assessed the relation between eGFR, FFR and resting Pd/Pa in 1147 consecutive patients (1316 vessels) included in the International Collaboration of Comprehensive Physiologic Assessment Study. We also compared FFR and Pd/Pa against a standardized cut-off of coronary flow reserve (CFR<2.0). Finally, we examined the occurrence of vessel-oriented composite outcome (VOCO: cardiac death, vessel-specific revascularization, vessel-specific myocardial infarction) across negative/positive results of both FFR and CFR in patients with and without CKD.

Results

FFR increases as renal function worsens (beta −10.5, 95% CI −20.0 to −11.03, p=0.030), a relation that was not seen with resting Pd/Pa (beta −6.14, 95% CI −19.9 to 6.78, p=0.351). Both indices had similar diagnostic accuracies for the detection of a CFR<2.0 in the presence of CKD (AUC 0.629 for FFR vs 0.663 for resting Pd/Pa, p=0.192). However, CKD patients showed a higher proportion of vessels with negative FFR but low CFR (24.5% vs 13.4%, p=0.015).

CFR decreased linearly with deteriorating eGFR, and this was mainly driven by higher resting coronary flow in CKD patients (p=0.026), while hyperaemic coronary flow remained similar (p=0.403). IMR did not change significantly with eGFR (beta −0.02, 95% −0.09 to 0.05, p=0.557).

The incidence of VOCO was higher in patients with CKD and FFR>0.80 when compared to non-CKD patients and FFR>0.80 (12.7% vs 6.90%, p=0.062). Prognosis was worse for those with CKD, negative FFR and CFR<2.0 (20.59% vs. 8.44% in non-CKD, p=0.038).

Conclusions

The assessment of a given coronary stenosis in patients with CKD with either FFR or resting Pd/Pa is equivalent when compared to underlying coronary flow. In CKD, impaired CFR is caused by a state of increased resting flow. The assessment of CFR on top of standard pressure wire examination significantly improves prognostic stratification in CKD patients.

Funding Acknowledgement

Type of funding sources: None.

Impact of obesity paradox between genders on in-hospital mortality in cardiogenic shock: a retrospective cohort study

Background

In a few studies, obesity was associated with better outcomes in patients with cardiogenic shock (CS). Although this phenomenon, the “obesity paradox”, reportedly manifests differently based on sex in other disease entities, it has not yet been investigated in CS patients.

Methods and results

1,227 patients with CS from The REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy of left ventricular assist device for Korean patients with cardiogenic shock (RESCUE) registry in Korea were analyzed. The study population was classified into obese and non-obese groups according to Asian-Pacific criteria (BMI >25.0 kg/m2 for obese). Clinical impact of obesity on in-hospital mortality according to sex was analyzed using logistic regression analysis and restricted cubic spline curves. In-hospital mortality rate was significantly lower in obese men than non-obese men (34.2% vs. 24.1%, p=0.004) while the difference was not significant in women (37.3% vs. 35.8%, p=0.884). As a continuous variable, higher BMI showed a protective effect in men conversely, BMI was not associated with clinical outcomes in women. Comparing to normal-weight patients, obesity was associated with a decreased risk of in-hospital death in men (multivariable-adjusted OR 0.63, CI 0.43–0.92, p=0.016), not in women (multivariable-adjusted OR 0.94, 95% CI 0.55–1.61, p=0.828). Interaction P value for the association between BMI and sex was 0.023.

Conclusions

Obesity paradox exists and apparently occurs in men among CS patients. The differential effect of BMI on in-hospital mortality was observed according to sex.

Funding Acknowledgement

Type of funding sources: None.

Sodium-glucose co-transporter-2 inhibitors after acute myocardial infarction in type 2 diabetes patients: a population-based investigation from South Korea

Background

Whether the early use of sodium-glucose co-transporter-2 (SGLT2) inhibitors has cardioprotective effects following acute myocardial infarction (AMI) is unknown.

Purpose

We aimed to evaluate the association between the early initiation of SGLT2 inhibitors and cardiac event rates in diabetes patients with AMI undergoing percutaneous coronary intervention (PCI).

Methods

Based on the National Health Insurance claims data in South Korea, patients aged 18 years or older who had undergone PCI for the diagnosis of AMI between 2014 and 2018 were analyzed. Patients treated with SGLT2 inhibitors or other glucose-lowering drugs were matched based on a propensity score. The primary endpoint was a composite of all-cause mortality and hospitalizations for heart failure (HF). Major adverse cardiac events (MACE; a composite of all-cause death, non-fatal MI, and ischemic stroke) were compared as the secondary endpoint.

Results

After 1:2 propensity score matching, a total of 26,814 patients were assigned to the SGLT2 inhibitors group (938 patients) and the no use of SGLT2 inhibitors group (1,876 patients), respectively. During a median follow-up of 2.1 years, compared to no use of SGLT2 inhibitors, the early use of SGLT2 inhibitors was associated with lower risks of both the primary endpoint (9.8% vs. 13.9%, adjusted hazard ratio [HR] = 0.68, 95% confidence interval [CI]: 0.54 to 0.87, p=0.002) and secondary endpoint (9.1% vs. 11.6%, adjusted HR = 0.77, 95% CI: 0.60 to 0.99, p=0.04) (Figure 1). All-cause mortality and hospitalizations for HF were significantly lower in the early use of SLGT2 inhibitors group (adjusted HR = 0.55; 95% CI: 0.37 to 0.80; p=0.002; and HR = 0.74; 95% CI: 0.56 to 0.98; p=0.03, respectively). The incidence of non-fatal MI and ischemic stroke were not statistically different (Figure 2).

Conclusions

The early use of SGLT2 inhibitors in diabetes patients treated with PCI for AMI was associated with a significantly lower risk of cardiovascular events including all-cause mortality, hospitalizations for HF, and MACE. Our results suggest that the use of SGLT2 inhibitors could expand to the acute phase of AMI survivors with diabetes to reduce mortality and the subsequent development of congestive HF and ischemic events.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): This work was partly supported by the Research Institute of Medical Science, The Catholic University of Korea, Eunpyeong St. Mary's Hospital, Seoul, Republic of Korea.

Atypical periprosthetic femoral fracture with stem breakage: a case report

Although the American Society for Bone and Mineral Research definition of atypical femoral fracture excludes periprosthetic fractures, fractures around the prosthesis with clinical features of atypical femoral fractures have been reported in the literature. All fractures reported thus far have been distal to the prosthetic segment; however, we encountered a case of a stress fracture in the middle of the femoral component segment. An 86-year-old woman with a history of bisphosphonate osteoporosis treatment and revisional total hip arthroplasty visited our outpatient clinic complaining of pain in the left thigh and groin. We diagnosed an incomplete atypical femoral fracture around the hip prosthesis; medical treatment was implemented. Two months later, the patient visited the emergency department with a complete subtrochanteric fracture with stem breakage. Without revision of the broken stem, two plates were applied after reduction. In this case, we recognized the possibility of a stress fracture but overlooked the possibility of stem breakage in an atypical femoral fracture. Even if it is not evident on the radiograph before complete fracture, clinicians should be alert to the signs of stress fracture in the middle of the femoral component segment, as they may be clues to atypical periprosthetic femoral fracture with stem failure. Isolated medical treatment plans are not recommended for incomplete subtrochanteric atypical periprosthetic femoral fracture. Instead, concomitant prophylactic plate fixation is recommended.

Induction and maintenance of remission with mycophenolate mofetil in ANCA-associated vasculitis: A systematic review and meta-analysis

BACKGROUND

Uncertainties exist about the use of mycophenolate mofetil (MMF) in anti-neutrophil cytoplasmatic antibody (ANCA)-associated vasculitis (AAV), particularly for remission maintenance.

METHODS

Systematic review and meta-analysis of phase II and III trials assessing the use of MMF in AAV (granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA)). A comprehensive search of several databases (Medline, EMBASE, Cochrane, Web of Science, Scopus) from inception to May 5th, 2020 has been conducted. Trial data were extracted to estimate odds ratios (ORs) and estimates (ES) for MMF efficacy (remission-induction and maintenance). Severe adverse effects (SAEs) were collected.

RESULTS

From 565 articles captured, 10 met the predefined criteria, five phase II and five III trials, 4 assessed remission-induction, 3 remission-maintenance, 3 both. The pooled OR for remission-induction at 6 months was 1.06 (95% CI: [0.74, 1.52]), with no significant difference by subgroup meta-analysis of trials stratified by different study-level features (i.e. kidney disease, MPA, myeloperoxidase-ANCA-positivity, newly diagnosed disease) (p > 0.05).The overall ES for remission-maintenance at the end of follow-up ranged between 51%-91% (I2 = 74.8%). Subgroup meta-analysis identified kidney involvement as a possible source of heterogeneity, yielding a significantly higher rate of sustained remission in trials enrolling only patients with kidney involvement (92% [76%-100%]) versus those enrolling patients with and without kidney involvement (56% [45%-66%]). Results were similar in multiple sensitivity analyses.During follow-up, the frequency of SAEs in MMF-based treatment arms was 31.8%.

CONCLUSIONS

In AAV, MMF use significantly associated with higher sustained remission rates in trials enrolling only patients with kidney involvement. These findings might influence clinical practice.

Standardization of 129I using the movable 4πβ(LS)-X(NaI(Tl)) system

The ¹²⁹I standardization, using the movable 4πβ(LS)-X(NaI(Tl)) coincidence system, was performed for two ¹²⁹I radioactive sources - one was dissolved in 0.1M NaOH solution and the other in 0.1M HNO₃ solution. The system incorporates three movable PM tubes for a β-counter placed on a plane and a X-ray detector that can be moved up to the bottom of the vial. The β-efficiency depending on the amount of radioactive solution was investigated with 14 liquid scintillation samples prepared by gravimetrically dispensing 4.4-145 mg of ¹²⁹I radioactive solution. The β-efficiencies above 90% were observed at less than 56 mg, but it was at most 70% at 145 mg. This occurred regardless of the activity of the sample or the type of chemical solution used to dissolve ¹²⁹I source. The activity concentration of each ¹²⁹I source was determined by efficiency-extrapolation method for samples with an activity range of 0.28-4.5 kBq. The β-efficiency points were derived over 10 intervals by moving 3-PM tubes in fine steps of about 1 mm from the sample. The highest value for β-efficiency was 95%. The combined uncertainty were 0.25% and 0.26%, respectively. The stated precision obtained using the system is better than that previously reported in the literature obtained by the triple to double coincidence ratio (TDCR) or the CIEMAT/NIST efficiency tracing method.

Retrograde transvenous obliteration for the prevention of variceal rebleeding in patients with hepatocellular carcinoma: a multicentre retrospective study

AIM

To evaluate the effectiveness and safety of retrograde transvenous obliteration (RTO) for the prevention of variceal rebleeding variceal rebleeding in patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

This multicentre retrospective study enrolled 79 patients with HCC who underwent RTO for the prevention of variceal rebleeding. Successful occlusion of the gastrorenal shunt and obliteration of the gastric varices were achieved in 74 patients, with a technical success rate of 93.7%. Of the remaining 74 patients (mean age, 64.9±10.3 years; 56 men), 66 (90.4%) had gastroesophageal varices and seven (9.6%) had isolated gastric varices. Thirty-two patients (43.8%) underwent balloon-occluded RTO, 40 patients (54.8%) underwent plug-assisted RTO, and one patient (1.4%) underwent coil-assisted RTO. No patients had major procedural complications.

RESULTS

Rebleeding occurred in seven patients (9.6%) during the follow-up period. The 6-week and 1-year actuarial probabilities of patients remaining free of rebleeding were 90.8±3.6% and 88.6±4.1%, respectively. The median survival was 12.6 (95% confidence interval [CI] 8-17.3) months. The 6-week, 1-year, and 3-year actuarial probabilities of survival were 83.2±4.4%, 51.1±6.6%, and 32.7±7%, respectively. New or worsening ascites and oesophageal varices occurred in 12 (16.4%) and 13 patients (17.8%), respectively, during the follow-up period. Overt hepatic encephalopathy occurred in one patient (1.4%) during the follow-up period. The Child-Pugh score remained comparable to that at baseline at 1 and 3 months.

CONCLUSION

RTO was effective and safe in preventing variceal rebleeding in patients with HCC.

Development of a movable 4πβ(LS)-γ coincidence counting system for activity standardization of β-γ emitters

A new movable 3PM-γ coincidence system, based on 4πβ(LS)-γ coincidence counting, for activity measurement of β-γ emitters has been designed at the Korea Research Institute of Standards and Science (KRISS). The system incorporates 3 PM tubes on the plane and two detectors placed above and below the center of the plane. The 3 PM tubes for β-counters in the plane are movable up to 100 mm from a liquid scintillation vial, thus enabling the variation of β-detection efficiencies by a geometrical technique. A NaI(Tl) γ-counter was set above for the present work. The β-event is determined by counting the logical sum of three double coincidences. All the necessary electronics, i.e., logical sum, adjusting the duration of dead-time of each counting channel and coincidence resolving times, and analyzing coincidence relation, were specially designed to be fabricated in an integrated circuit. Details of the detectors, the electronics, the overall movable 3PM-γ coincidence system are presented, as well as the results of investigations to assess its operating characteristics. Validation measurements have been performed with ⁶⁰Co and ⁵⁷Co sources. The highest β-detection efficiency achieved with ⁶⁰Co and ⁵⁷Co was 97% and 95%, respectively. The activity concentration determined with a new system agreed with calibrated values within the uncertainty range. Further results from validation measurements and the corresponding uncertainty budgets are presented.

The Long-Term Effect of Preterm Birth on Renal Function: A Meta-Analysis

The preterm-born adult population is ever increasing following improved survival rates of premature births. We conducted a meta-analysis to investigate long-term effects of preterm birth on renal function in preterm-born survivors. We searched PubMed and EMBASE to identify studies that compared renal function in preterm-born survivors and full-term-born controls, published until 2 February 2019. A random effects model with standardized mean difference (SMD) was used for meta-analyses. Heterogeneity of the studies was evaluated using Higgin’s I² statistics. Risk of bias was assessed using the Newcastle–Ottawa quality assessment scale. Of a total of 24,388 articles screened, 27 articles were finally included. Compared to full-term-born controls, glomerular filtration rate and effective renal plasma flow were significantly decreased in preterm survivors (SMD −0.54, 95% confidence interval (CI), −0.85 to −0.22, p = 0.0008; SMD −0.39, 95% CI, −0.74 to −0.04, p = 0.03, respectively). Length and volume of the kidneys were significantly decreased in the preterm group compared to the full-term controls (SMD −0.73, 95% CI, −1.04 to −0.41, p < 0.001; SMD −0.82, 95% CI, −1.05 to −0.60, p < 0.001, respectively). However, serum levels of blood urea nitrogen, creatinine, and cystatin C showed no significant difference. The urine microalbumin to creatinine ratio was significantly increased in the preterm group. Both systolic and diastolic blood pressures were also significantly elevated in the preterm group, although the plasma renin level did not differ. This meta-analysis demonstrates that preterm-born survivors may be subject to decreased glomerular filtration, increased albuminuria, decreased kidney size and volume, and hypertension even though their laboratory results may not yet deteriorate.

Significance of sonographically detected bladder debris in children less than 2 years old with febrile urinary tract infection

PURPOSE

To investigate the relationship between bladder debris found on renal and bladder ultrasonography (RBUS) and the first febrile urinary tract infection (UTI) episode in children under 2 years old.

METHODS

We retrospectively reviewed the data of children aged <2 years with the first febrile UTI. We recorded bladder debris on RBUS and other findings (blood test, urinalysis, and urine culture). Other RBUS findings (renal pelvis debris, renal parenchymal change, wall thickening, and renal collecting system [RCS] dilatation) were recorded. Patients were divided into the debris (D) and non-D groups.

RESULTS

Of 128 patients (boys: girls = 81:47, mean age = 5.6 ± 4.2 months), 24 (18.8%) had bladder debris. The mean C-reactive protein (CRP) levels were higher in the D group (6.1 ± 4.0 vs 4.3 ± 3.5, P = .03). Twenty-one patients in the D group (87.5%) had hematuria (odds ratio = 3.706, 95% confidence interval = 1.035-13.267, P = .04). No significant differences were seen in the urine culture results between both groups. Significant associations were seen between bladder debris and other RBUS findings such as debris in renal pelvis, renal parenchymal change, and RCS wall thickening.

CONCLUSION

Bladder debris on RBUS is a common finding in children aged <2 years during the first febrile UTI. Bladder debris was related to higher CRP levels, hematuria and sonographic findings, but not to urine culture results.

Lower albumin level and longer disease duration are risk factors of acute kidney injury in hospitalized children with nephrotic syndrome

BACKGROUND

Children with nephrotic syndrome (NS) are at an increased risk of acute kidney injury (AKI) and the incidence of AKI in this population is reportedly increasing. This study aimed to investigate the incidence, clinical profiles, and risk factors of AKI in hospitalized children with NS through a nationwide study.

METHODS

This retrospective multicenter study included 14 pediatric nephrology centers in Korea. From 2013 to 2017, a total of 814 patients with idiopathic NS were cared for at participating centers. Among them, 363 patients were hospitalized for NS and investigated in this study.

RESULTS

A total of 363 children with NS were hospitalized 574 times. AKI occurred in 93 admissions (16.2%) of 89 patients: 30 (32.3%) stage 1; 24 (25.8%) stage 2; and 39 (41.9%) stage 3. Multivariate logistic regression analysis showed that longer disease duration, lower albumin level, and methylprednisolone pulse treatment were significantly associated with AKI development in hospitalized children with NS. AKI was associated with a longer hospital stay than non-AKI (median 10 vs. 7 days, P = 0.001). Among 93 admissions, 85 (91.4%) episodes recovered from AKI without complication, whereas 6 (6.5%) progressed to advanced chronic kidney disease (CKD).

CONCLUSIONS

AKI is not uncommon in hospitalized children with NS, and its incidence in this nationwide study was 16.2%. Risk factors for AKI in hospitalized children with NS include longer disease duration, lower albumin level, and methylprednisolone pulse therapy. Pediatric NS patients with these characteristics should be under more strict scrutiny for the occurrence of AKI. Graphical abstract.

The Effect of Interleukin-4 and Dexamethasone on RNA-Seq-Based Transcriptomic Profiling of Human Podocytes: A Potential Role in Minimal Change Nephrotic Syndrome

Interleukin-4 (IL-4) expression is implicated in the pathogenesis of nephrotic syndrome (NS). This study aimed to investigate the changes in the transcriptomes of human podocytes induced by IL-4 treatment and to analyze whether these changes could be affected by simultaneous steroid treatment. Three groups of human podocytes were treated with control, IL-4, and IL-4 plus dexamethasone (DEX), respectively. We performed whole-transcriptome sequencing to identify differentially expressed genes (DEGs) between the groups. We investigated relevant biological pathways using Gene Ontology (GO) enrichment analyses. We also attempted to compare and validate the DEGs with the genes listed in PodNet, a literature-based database on mouse podocyte genes. A total of 176 genes were differentially expressed among the three groups. GO analyses showed that pathways related to cytoskeleton organization and cell signaling were significantly enriched. Among them, 24 genes were listed in PodNet, and 12 of them were previously reported to be associated with IL-4-induced changes in human podocytes. Of the 12 genes, the expression levels of BMP4, RARB, and PLCE1 were reversed when podocytes were simultaneously treated with DEX. In conclusion, this study explored changes in the transcriptome profiles of human podocytes treated with IL-4. Few genes were reported in previous studies and were previously validated in experiments with human podocytes. We speculate that IL-4 may exert pathogenic effects on the transcriptome of human podocytes, and a few genes may be involved in the pathogenesis.

Current understandings in treating children with steroid-resistant nephrotic syndrome

Steroid-resistant nephrotic syndrome (SRNS) remains a challenge for paediatric nephrologists. SRNS is viewed as a heterogeneous disease entity including immune-based and monogenic aetiologies. Because SRNS is rare, treatment strategies are individualized and vary among centres of expertise. Calcineurin inhibitors (CNI) have been effectively used to induce remission in patients with immune-based SRNS; however, there is still no consensus on treating children who become either CNI-dependent or CNI-resistant. Rituximab is a steroid-sparing agent for patients with steroid-sensitive nephrotic syndrome, but its efficacy in SRNS is controversial. Recently, several novel monoclonal antibodies are emerging as treatment option, but their efficacy remains to be seen. Non-immune therapies, such as angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, have been proven efficacious in children with SRNS and are recommended as adjuvant agents. This review summarizes and discusses our current understandings in treating children with idiopathic SRNS.

An Unusual Pediatric Case of Seronegative Systemic Lupus Erythematosus Presented With Acute Abdominal Pain and Gross Hematuria

ABSTRACT

A child with acute abdomen with gross hematuria occasionally visits the emergency department (ED). Usually, such a condition is subject to differential diagnosis for stones, injuries, or sometimes malignancies in the urinary tract. Here we introduce an unusual case of a 9-year-old girl who presented to ED with acute lower abdominal pain and gross hematuria. She had no medical history. An urgent computed tomographic image revealed a renal vein thrombosis. Laboratory tests for autoimmune diseases and coagulaopathies were performed, and the results were within normal ranges. At the time, she did not fulfil the criteria for systemic lupus erythematosus or antiphospholipid syndrome. Later at follow-up, however, she had a recurrent episode of renal vein thrombosis. A kidney biopsy was performed to reveal histology of membranous lupus nephropathy. The case emphasizes the importance for both ED physicians and pediatricians to have a clinical suspicion of autoimmune diseases in cases with major vessel thrombosis, even when the patient is seronegative.

Strong correlation between flux pinning and epitaxial strain in the GdBa2Cu3O7-x /La0.7Sr0.3MnO3 nanocrystalline heterostructure

The effect of magnetic flux pinning is investigated in GdBa₂Cu₃O₇ (GdBCO) thin films with two different types of ferromagnetic La_0.7Sr_0.3MnO₃ (LSMO) buffers (nanoparticles and a layer) deposited on an STO substrate. Magnetization analyses reveal the presence of multiple flux pinning mechanisms responsible for the improvement in the critical current density of GdBCO films. While core pinning becomes a dominant pinning mechanism in GdBCO films with LSMO nanoparticles, a hybrid effect of magnetic-volume and core-point pinning is observed in GdBCO films with LSMO layers. Examinations of local structures for both LSMO and GdBCO using extended X-ray absorption fine structure spectroscopy (EXAFS) exhibit a close relation between the parameters in the pinning force scaling and the length ratio of the Mn–O bond to the Cu–O bond. This result implies that the origin of core pinning is probably attributed to epitaxial strain induced by lattice mismatch between LSMO and GdBCO. Therefore, an appropriate strain state of LSMO is required for an effective operation of magnetic pinning.

The effect of magnetic flux pinning is investigated in GdBa₂Cu₃O₇ (GdBCO) thin films with two different types of ferromagnetic La_0.7Sr_0.3MnO₃ (LSMO) buffers (nanoparticles and a layer) deposited on an STO substrate.

First Case of Peroxisomal D-bifunctional Protein Deficiency with Novel HSD17B4 Mutations and Progressive Neuropathy in Korea

Peroxisomal D-bifunctional protein (DBP), encoded by the HSD17B4 gene, catalyzes β-oxidation of very long chain fatty acids (VLCFAs). The deficiency of this peroxisomal enzyme leads to the accumulation of VLCFAs, causing multisystemic manifestations including the brain, retina, adrenal gland, hearing, and skeletal system. Herein, we report the first Korean neonatal case of peroxisomal DBP deficiency and the clinical prognosis over 2 years. This patient showed craniofacial dysmorphism, club foot, and seizures with cyanosis one day after birth. Elevated VLCFAs levels were indicative of a peroxisomal disorder. Targeted exome sequencing was performed and two missense mutations p.Asp117Val and p.Phe279Ser in the HSD17B4 gene were identified. The patient had type III DBP deficiency; therefore, docosahexaenoic acid and non-soluble vitamins were administered. However, progressive nystagmus, optic nerve atrophy, and bilateral hearing defects were observed and follow-up brain imaging revealed leukodystrophy and brain atrophy. Multiple anti-epileptic drugs were required to control the seizures. Over two years, the patient achieved normal growth with home ventilation and tube feeding. Hereby, the subject's parents had support during the second pregnancy from the proven molecular information. Moreover, targeted exome sequencing is an effective diagnostic approach, considering genetic heterogeneity of Zellweger spectrum disorders.

The alternative complement pathway in ANCA-associated vasculitis: further evidence and a meta-analysis

We compared the common pathway components C3a, C5a and membrane attack complex (MAC), also known as C5b-9, and the alternative pathway components factor B and properdin in patients with ANCA-associated vasculitis (AAV) and healthy controls, and conducted a meta-analysis of the available clinical evidence for the role of complement activation in the pathogenesis of AAV. Complement components were evaluated in 59 patients with newly diagnosed or relapsing granulomatosis with polyangiitis or microscopic polyangiitis and 36 healthy volunteers. In 28 patients, testing was repeated in remission. Next, we performed a meta-analysis by searching databases to identify studies comparing complement levels in AAV patients and controls. A random-effects model was used for statistical analyses. The median concentrations of MAC, C5a, C3a and factor B were higher in active AAV patients (P < 0·001). Achievement of remission was associated with reductions in C3a (P = 0·005), C5a (P = 0·035) and factor B levels (P = 0·045), whereas MAC and properdin levels did not change. In active AAV, there were no effects of ANCA specificity, disease phenotype, previous immunosuppression or disease severity on complement levels. A total of 1122 articles were screened, and five studies, including this report, were entered into the meta-analysis. Plasma MAC, C5a and factor B in patients with active AAV were increased compared to patients in remission (excluding factor B) and controls. Changes in C3a were of borderline significance. Our findings and the results of the meta-analysis support activation of the complement system predominantly via the alternative pathway in AAV patients.

Short communication: Evaluation of an eating time sensor for use in pasture-based dairy systems

The assessment of grazing behavior is important for research and practice in pasture-grazed dairy farm systems. However, few devices are available that enable assessment of cow grazing behavior at an individual animal level. This study investigated whether commercially available Smarttag "eating time" sensors (Nedap Livestock Management, Groenlo, the Netherlands) were suitable for recording the grazing time of cows. Smarttag sensors were mounted on the neck collars of multiparous Holstein-Friesian cows in a herd in Taranaki, New Zealand. Cows were randomly selected each observation day from the milking herd for 8 separate days across a 1-mo period. Trained observers conducted 90-min observation periods to evaluate the relationship between the sensor eating time measure and grazing time. A set of 5 defined cow behaviors (2 "head up" and 3 "head down" behaviors) were assessed. In total, observations of 37 cows were recorded in 14 sessions over 8 d in the study period, providing 55.5 total hours of observations. Observation data were aligned with sensor data according to the sensor time stamps and grouped into matching 15-min intervals. Interobserver reliability was assessed both before and after the main trial period, and the mean percentage eating time per observer had a coefficient of variation of 0.46% [mean 93.2, standard deviation (SD) 0.425] before and 0.07% (mean 96.3, SD 0.074) after. In the main trial, the relationship between observed (mean 70.8%) and sensor-derived (mean 69.3%) percentage eating time over the observation period gave a Pearson correlation coefficient of 0.971, concordance correlation coefficient 0.968, mean difference 1.50% points, and SD 5.8% points. Therefore, sensor-identified percentage "eating time" and observed percentage active grazing time were shown to be both very well correlated and concordant (in agreement, with high correlation and little bias). Therefore, the relationship between observed and sensor-derived data had a high degree of agreement for identifying cow grazing activity. In conclusion, Smarttag sensors are a valid and useful tool for estimating grazing activity at time periods of 1 h or more.

The primary system for measurement of beta emitting radioactive gases at KRISS

Korea Research Institute of Standards and Science (KRISS) is developing a length-compensated proportional counting (LCPC) system as a primary system for standardization of beta emitting radioactive gases. The pilot experiment was performed with ⁸⁵Kr and the optimized high voltage and pressure were found to be 1700 V and 0.203 MPa, respectively. The total activity of ⁸⁵Kr was deduced by the length compensation of each count. The expanded uncertainty was estimated to be around 0.8% (k = 2) for the ⁸⁵Kr measurement.

Design of optimal digital filter and digital signal processing for a CdZnTe high resolution gamma-ray system

We have developed an online digital signal processing system based on an FPGA. The system consists of pile-up rejection, baseline restorer, peak detection and pole-zero cancellation for evaluation of deposited energy in the detector. The shaping algorithm employed is a Moving Window Deconvolution (MWD) to shape digitized data into a trapezoidal form. For the purpose of verification, the developed digital system was tested for ¹³⁷Cs gamma rays. The entire system is programmed using the LabVIEW environment.

Long-term mortality of patients with tuberculosis in Korea

BACKGROUND: Long-term mortality following tuberculosis (TB) diagnosis in Korea remains unclear.METHODS: The present study used data from the National Health Insurance Service database, an extensive health-related database including most Korean residents. TB patients were identified using International Classification of Diseases, Tenth Revision coding (A15-19, U88.0-88.1) and the type of anti-TB drug(s) between 2003 and 2016. Long-term mortality and causes of death in TB patients were analysed.RESULTS: A total of 357 211 individuals had TB over the period from 2003 to 2016 and 103 682 died. The mean age of the cohort was 54.7 ± 20.7 years, and 59.8% were male. The survival probability of TB patients at 1, 5, and 10 years after diagnosis was 87.8%, 75.3%, and 63.3%, respectively. High mortality and TB-related death rates were especially prominent in the early stages after TB diagnosis. The overall standardized mortality ratio of TB patients to the general Korean population was 3.23 (95% confidence interval 3.21-3.25).CONCLUSION: Mortality in TB patients was especially high in the early stages of disease after TB diagnosis, and mostly due to TB. This figure was approximately three-times higher than the mortality rate in the general population.

Immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome: A systematic review

BACKGROUND

Immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome is a monogenic disorder characterized by early onset fatal multi-system autoimmunity due to loss-of-function mutations in the gene encoding the forkhead box P3 (FOXP3) transcription factor which is crucial for the development, maturation, and maintenance of CD4⁺ regulatory T (T-reg) cells. Various autoimmune phenomena such as enteropathy, endocrinopathies, cytopenias, renal disease, and skin manifestations are characteristic findings in patients affected by IPEX syndrome.

OBJECTIVES

In this systematic review, we focus on both clinical and demographic characteristics of IPEX patients, highlighting possible genotype-phenotype correlations and address prognostic factors for disease outcome.

METHODS

We performed a literature search to systematically investigate the case reports of IPEX which were published before August 7^th, 2017.

RESULTS

A total of 75 articles (195 patients) were identified. All IPEX patients included had FOXP3 mutations which were most frequently located in the forkhead domain (n = 68, 34.9%) followed by the leucine-zipper domain (n = 30, 15.4%) and repressor domain (n = 36, 18.4%). Clinical manifestations were as follows: enteropathy (n = 191, 97.9%), skin manifestations (n = 121, 62.1%), endocrinopathy (n = 104, 53.3%), hematologic abnormalities (n = 75, 38.5%), infections (n = 78, 40.0%), other immune-related complications (n = 43, 22.1%), and renal involvement (n = 32, 16.4%). Enteropathic presentations (P = 0.017), eczema (P = 0.030), autoimmune hemolytic anemia (P = 0.022) and food allergy (P = 0.009) were associated with better survival, while thrombocytopenia (P = 0.034), septic shock (P = 0.045) and mutations affecting the repressor domain (P = 0.021), intron 7 (P = 0.033) or poly A sequence (P = 0.025) were associated with increased risk of death. Immunosuppressive therapy alone was significantly associated with increased cumulative survival compared to patients who received no treatment (P = 0.041).

CONCLUSIONS

We report the most comprehensive summary of demographic and clinical profiles derived from a total of 195 IPEX patients with deleterious mutations in FOXP3. Analysis of our findings provides new insights into genotype/phenotype correlations, and clinical and genetic factors associated with increased risk of death and response to treatment strategies.

Human Activities Attract Harmful Mosquitoes in a Tropical Urban Landscape

Knowledge of the interrelationship of mosquito communities and land use changes is of paramount importance to understand the potential risk of mosquito disease transmission. This study examined the effects of land use types in urban, peri-urban and natural landscapes on mosquito community structure to test whether the urban landscape is implicated in increased prevalence of potentially harmful mosquitoes. Three land use types (park, farm, and forest nested in urban, peri-urban and natural landscapes, respectively) in Klang Valley, Malaysia, were surveyed for mosquito larval habitat, mosquito abundance and diversity. We found that the nature of human activities in land use types can increase artificial larval habitats, supporting container-breeding vector specialists such as Aedes albopictus, a dengue vector. In addition, we observed a pattern of lower mosquito richness but higher mosquito abundance, characterised by the high prevalence of Ae. albopictus in the urban landscape. This was also reflected in the mosquito community structure whereby urban and peri-urban landscapes were composed of mainly vector species compared to a more diverse mosquito composition in natural landscape. This study suggested that good environmental management practices in the tropical urban landscape are of key importance for effective mosquito-borne disease management.

Review on long-term non-renal complications of childhood nephrotic syndrome

BACKGROUND

Nephrotic syndrome (NS) is the most common glomerular childhood disease. A body of literature has described the long-term renal prognosis of childhood-onset idiopathic NS. However, the nonrenal outcomes have not been studied as much.

AIM

We aimed to discuss the long-term non-renal outcomes of childhood NS, highlighting studies with a follow-up period of more than 10 years.

RESULTS

We reviewed the literature and found that a number of immunosuppressive agents have stopped inflammation, stabilised the podocyte cytoskeleton and reduce proteinuria. However, prolonged treatment has frequently been associated with a high risk of renal and non-renal complications in patients with a complicated disease course, defined as frequent relapses or steroid dependency. Non-renal complications may include impaired longitudinal growth and pubertal development, undesirable fertility outcomes, ocular complications, bone mineral diseases and potential malignancies.

CONCLUSION

This review discusses and summarises the non-renal outcomes of idiopathic childhood NS.

P1368 Effect of angiotensin receptor blocker in patients with moderate or severe aortic stenosis: a randomized controlled trial

Funding Acknowledgements

This study was supported by grants from Boryung Pharmacy Research Fund.

Background/Introduction: Pathophysiology of aortic stenosis (AS) and several previous studies suggested the potential role of angiotensin receptor blocker (ARB) in patients with AS.

Purpose

We aimed to investigate the effects of Fimasartan, an ARB, on exercise capacity and progression of AS in patients with moderate to severe AS.

Methods

We conducted a prospective, randomized, double-blind, placebo-controlled trial in 32 normotensive or controlled-hypertensive patients with moderate or severe AS. Study participants were randomized to Fimasartan 30 mg to 60 mg daily (n = 14) or placebo (n = 18) for 1 year, and underwent cardiopulmonary exercise test, 6-minute walk test, and echocardiography at 0, 6, and 12 months, with follow-up data available in 29 subjects.

Results

Significant reductions in blood pressures were observed in the Fimasartan group but not in the placebo group. Two of the 14 patients in the Fimasartan group withdrew the study due to mild symptoms probably related with the decreased blood pressure, and one patient decline the study protocol. After the 12-month treatment, the peak oxygen consumption (VO2; the primary outcome) in the Fimasartan group was significantly decreased (from 28.3 ± 5.9 to 25.4 ± 3.8 mL/min/kg, P = 0.021) but not in the placebo group (P for interaction = 0.046) (Figure 1A). The severity of AS showed a gradual progression in both groups, without inter-group differences (mean transaortic pressure; Fimasartan group, +4.0 ± 3.8 mmHg/year; placebo group, +5.3 ± 6.2 mmHg/year; P for interaction = 0.429) (Figure 1B). Parameters of left ventricular systolic and diastolic function did not change in both groups.

Conclusions

The use of ARB impaired exercise capacity in patients with moderate or severe AS, and did not prevent the progression of AS. However, due to the small number of participants, further studies are required to confirm these findings.

Abstract P1368 Figure.

Surgical outcomes of tympanoplasty using a sterile acellular dermal allograft: a prospective randomised controlled study

Acellular human dermal allografts have been shown to be effective for soft-tissue implantation. We compared treatment outcomes of tympanoplasty using tragal perichondrium and acellular human dermal allograft (MegaDerm^®). In a prospective randomised controlled study, 60 patients scheduled to undergo tympanoplasty were randomly assigned to the autologous tragal perichondrium group (n = 33) or acellular human dermal allograft group (n = 27). Postoperative hearing gain, graft success rate at 1 and 6 months and operation times were compared between groups. Graft success rate, defined as the complete closure of tympanic membrane perforation, did not show any significant intergroup difference (75.8% vs 85.2%, p = 0.519). Air conduction thresholds and air-bone gaps showed significant improvements in both groups; from 38.7 ± 15.9 dB to 30.2 ± 15.6 dB (p < 0.001) and from 17.8 ± 7.3 dB to 11.5 ± 7.0 (p = 0.001) in the autologous tragal perichondrium group, and from 30.4 ± 12.2 dB to 24.5 ± 13.0 dB (p = 0.006) and from 14.3 ± 5.1 dB to 7.6 ± 4.6 dB (p < 0.001) in the acellular human dermal allograft group. The amount of hearing gain (p = 0.31) and closure of air-bone gap (p = 0.863) were not meaningfully different between groups. The mean operation time was significantly lower in the acellular human dermal allograft group (35.2 min vs 27.4 min, p = 0.039). In this prospective randomised controlled study, acellular human dermal allograft was shown to be an effective alternative to tragal perichondrium, with similar graft success rates and postoperative hearing results, but with reduced operation times.

Inflammasomes and autoimmune and rheumatic diseases: A comprehensive review

Inflammasomes are a multi-protein platform forming a part of the innate immune system. Inflammasomes are at standby status and can be activated when needed. Inflammasome activation is an important mechanism for the production of active interleukin (IL)-1β and IL-18, which have important roles to instruct adaptive immunity. Active forms of inflammasomes trigger a series of inflammatory cascades and lead to the differentiation and polarization of naïve T cells and secretion of various cytokines, which can induce various kinds of autoimmune and rheumatic diseases such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), gout, Sjögren's syndrome, Behçet's disease, anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis and IgA vasculitis (former Henoch-Schönlein purpura ). In this review, we summarize studies published on inflammasomes and review their roles in various autoimmune diseases. Understanding of the role of inflammasomes may facilitate the diagnosis of autoimmune diseases and the development of tailored therapies in the future.

Levamisole in Children with Idiopathic Nephrotic Syndrome: Clinical Efficacy and Pathophysiological Aspects

Steroid sensitive nephrotic syndrome is one of the most common pediatric glomerular diseases. Unfortunately, it follows a relapsing and remitting course in the majority of cases, with 50% of all cases relapsing once or even more often. Most children with idiopathic nephrotic syndrome respond initially to steroid therapy, nevertheless repeated courses for patients with relapses induce significant steroid toxicity. Patients with frequent relapses or steroid dependency thus require alternative treatment, such as cyclophosphamide, cyclosporine, tacrolimus, mycophenolate mofetil, levamisole, or rituximab. To reduce the relapse rate, several drugs have been used. Among these, levamisole has been considered the least toxic and least expensive therapy. Several randomized controlled trials (RCT) showed that levamisole is effective in reducing the relapse risk in steroid sensitive forms of nephrotic syndrome with a low frequency of side effects. Levamisole is a synthetic imidazothiazole derivative with immune-modulatory properties. In this article, we review recent data from randomized trials and observational studies to assess the efficacy of levamisole in frequently relapsing nephrotic syndrome and steroid-dependent nephrotic syndrome.

Polaronic effect in the x-ray absorption spectra of La1-x Ca x MnO3 manganites

X-ray absorption spectroscopy (XAS) is performed to study changes in the electronic structures of colossal magnetoresistance (CMR) and charged ordered (CO) La_1-x Ca _x MnO₃ manganites with respect to temperature. The pre-edge features in O and Mn K-edge XAS spectra, which are highly sensitive to the local distortion of MnO₆ octahedral, exhibit contrasting temperature dependence between CMR and CO samples. The seemingly counter-intuitive XAS temperature dependence can be reconciled in the context of polarons. These results help identify the most relevant orbital states associated with polarons and highlight the crucial role played by polarons in understanding the electronic structures of manganites.

Trends in Breast MRI Use Among Women with BRCA Mutations: A National Claims Analysis 2006–2016

Women with BRCA mutations are recommended to receive breast MRI as an adjunct to annual mammography for breast cancer screening however adoption of these guidelines is unclear. We estimated breast MRI use from 2006–2016 among insured US women to understand use over time. Methods: Using medical care claims, we conducted a cohort study of breast MRI use in commercially-insured women aged 20–64 years continuously enrolled for ≥1 year in a large national insurer between 2006–2016. Women were identified as BCRA mutation carriers without a personal history of breast cancer using ICD9/10 diagnosis codes. We used CPT codes to identify breast MRIs and developed claims-based algorithms to categorized MRI indication as: screening, diagnostic or other. We calculated annual age-specific and age-adjusted rates of use overall and by indication among BCRA mutation carrier women. We used autoregressive time series models to estimate the yearly trend. Results: We identified 12,457 women with BRCA mutations during the study period. Breast MRI use overall among BRCA+ women aged 20–64 was 47/1000 women in 2006 and increased on average by 11 MRIs per year to a rate of 174/1000 in 2016 (P &lt; 0.001). Across this time period, use for screening accounted for over 80% of breast MRIs and rates mirrored the overall trend with a 4.8-fold increase from 31/1000 in 2006 to 146/1000 women by 2016. Over the same time period, use of breast MRI for diagnostic workup or other indications remained stable. Use of screening breast MRI was highest among older women aged 50–64 compared with women &lt;40 and 40–49 years (in 2016, 189, 95, and 177/1000, respectively) Discussion: Breast MRI screening increased dramatically over the past decade in women with BRCA mutations concordant with clinical guidelines. Additional research is needed to understand use of breast imaging relative to health outcomes for this high-risk population.

Abstract P1-05-05: eEF1A2 facilitates PTEN-GSK3β mediated Aurora-A protein degradation during S-G2 phase inactivated in PTEN-deficient breast cancer

The AURKA gene, encoding Aurora kinase-A (Aurora-A), is frequently amplified and overexpressed across multiple cancer types correlating with poor prognosis. Although the AURKA gene is frequently amplified in human cancers, underlying mechanism(s) for Aurora-A protein stability through different phases of cell cycle are not well elucidated. Inhibiting the kinase activity and promoting protein degradation are two well-validated conceptual strategies for targeting protein kinases in cancers. Here, we demonstrate that Eukaryotic Elongation Factor 1 Alpha 2 (eEF1A2) facilitates PTEN-GSK3β mediated Aurora-A protein degradation through the SCF complex (SKP1-Cul1-FBXW7) during the S/G2 phase of proliferating cells. In contrast, this mechanism is inactivated in cancer cells accompanying PTEN-GSK3β pathway deficiency. Mechanistically, eEF1A2 interacts with Aurora-A, GSK3β, FBXW7 and Cul1-E3 ligase, as the SCF complex, to facilitate Aurora-A polyubiquitination for 26S proteasomal degradation. eEF1A2 promotes PTEN phosphorylation at T366 and stability, inactivates AKT and activates GSK3β which in turn phosphorylates Aurora-A at S283, S284 and S342. The phosphorylation of Aurora-A at S342 is detected during S/G2 phase of cell mitosis in parallel with eEF1A2-SCF complex formation with active form of GSK3β and neddylated Cul1. Conversely, genetic ablation of EEF1A2 and PTEN, activation of AKT, inhibition of GSK3β, expression of Aurora-A phosphodeficient-mutant attenuates the Aurora-A protein degradation which is corroborated in Aurora-A overexpressing mouse mammary carcinomas and human breast carcinomas. This study identifies a novel mechanism of Aurora-A protein degradation mediated eEF1A2-PTEN-GSK3β pathway and provides a framework for the discovery of Aurora-A therapeutic targets in breast cancer that harbors deficiency of PTEN tumor suppressor pathway.

Citation Format: Treekitkarnmongkol W, Solis LM, Kai K, Thompson AM, Tian W, Wistuba II, Sasai K, Jltsumori Y, Sahin AA, Hawke DH, Lee JM, Qin L, Bawa-Khalfe T, Rad R, Wong KK, Abbott CM, Katayama H, Sen S. eEF1A2 facilitates PTEN-GSK3β mediated Aurora-A protein degradation during S-G2 phase inactivated in PTEN-deficient breast cancer [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 P1-05-05.

Rapid-Onset Obesity with Hypoventilation, Hypothalamic, Autonomic Dysregulation, and Neuroendocrine Tumors (ROHHADNET) Syndrome: A Systematic Review

BACKGROUND AND AIM

ROHHADNET (rapid-onset obesity with hypoventilation, hypothalamic, autonomic dysregulation, neuroendocrine tumor) syndrome is a rare disease with grave outcome. Although early recognition is essential, prompt diagnosis may be challenging due to its extreme rarity. This study aimed to systematically review its clinical manifestation and to identify genetic causes.

MATERIALS AND METHODS

We firstly conducted a systematic review on ROHHAD/NET. Electronic databases were searched using related terms. We secondly performed whole exome sequencing (WES) and examined copy number variation (CNV) in two patients to identify genetic causes.

RESULTS

In total, 46 eligible studies including 158 patients were included. There were 36 case reports available for individual patient data (IPD; 48 patients, 23 ROHHAD, and 25 ROHHADNET) and 10 case series available for aggregate patient data (APD; 110 patients, 71 ROHHAD, and 39 ROHHADNET). The median age at onset calculated from IPD was 4 years. Gender information was available in 100 patients (40 from IPD and 60 from APD) in which 65 females and 35 males were showing female preponderance. Earliest manifestation was rapid obesity, followed by hypothalamic symptoms. Most common types of neuroendocrine tumors were ganglioneuromas. Patients frequently had dysnatremia and hyperprolactinemia. Two patients were available for WES. Rare variants were identified in PIK3R3, SPTBN5, and PCF11 in one patient and SRMS, ZNF83, and KMT2B in another patient, respectively. However, there was no surviving variant shared by the two patients after filtering.

CONCLUSIONS

This study systematically reviewed the phenotype of ROHHAD/NET aiming to help early recognition and reducing morbidity. The link of variants identified in the present WES requires further investigation.

Comparison of overall survival between antiviral-induced viral suppression and inactive phase chronic hepatitis B patients

Nucleot(s)ide analogues (NAs) reduce the risk of hepatocellular carcinoma (HCC) in chronic hepatitis B (CHB) patients. However, the risk of HCC is reportedly higher for NA-treated patients than for patients in the inactive CHB phase. This study aimed to compare the long-term outcomes of CHB patients with NA-induced viral suppression and those of patients with inactive CHB. This retrospective study involved 1118 consecutive CHB patients whose HBV DNA level was continuously <2000 IU/mL during follow-up with/without antiviral agents. The patients were classified into inactive CHB (n = 373) or NA groups (n = 745). The primary endpoint was overall survival. Secondary endpoints included development of HCC and other liver-related events. The median duration of follow-up was 41.0 (interquartile range = 26.5-55.0) months. The difference in overall survival between the NA group vs. the inactive CHB group was not significant (hazard ratio [HR] = 0.78; 95% confidence interval [CI] = 0.33-1.85; P = .57). The NA group showed a significantly higher risk of HCC (HR = 3.44; 95% CI = 1.82-6.52; P < .01), but comparable risk for non-HCC liver-related events (HR = 1.02; 95% CI = 0.66-1.59; P = .93), compared with the inactive CHB group. Among patients with cirrhosis, the NA group showed a significantly lower risk of death (HR = 0.31; 95% CI = 0.097-0.998; P = .05) and non-HCC liver-related events (HR = 0.51; 95% CI = 0.31-0.83; P < .01), but a slightly higher risk of HCC (HR = 2.39; 95% CI = 0.85-6.75; P = .09), compared to the inactive CHB group. The overall survival of untreated patients with inactive CHB and of CHB patients achieving viral suppression with NA was comparable. However, NA treatment of cirrhotic patients was significantly associated with longer overall survival and lower risk of liver-related events.

Entecavir and tenofovir reduce hepatitis B virus-related hepatocellular carcinoma recurrence more effectively than other antivirals

Nucleos(t)ide analogues (NAs) have been shown to decrease the risk of hepatocellular carcinoma (HCC) recurrence. This study evaluated whether high-potency NAs (entecavir and tenofovir disoproxil fumarate [TDF]) reduce the risk of tumour recurrence more potently than low-potency NAs after curative treatment of hepatitis B virus (HBV)-related HCC. This study included 607 consecutive HBV-related HCC patients treated with surgical resection or radiofrequency ablation. The patients were categorized into three groups according to antiviral treatment: group A (no antiviral; n = 261), group B (low-potency NA; n = 90) and group C (high-potency NA; n = 256). The primary end-point was recurrence-free survival (RFS). During the duration of follow-up, the median RFS was 29.4, 25.1, and 88.2 months in groups A, B and C, respectively (P < .001, log-rank test). The multivariate Cox analysis indicated that group C had a significantly longer RFS than both group A (adjusted hazard ratio [HR] = 0.39, P < .001) and group B (adjusted HR = 0.47, P < .001). When baseline characteristics were balanced using inverse probability weighting, group C still had a significantly longer RFS than group A (adjusted HR = 0.46, P < .001) and group B (adjusted HR = 0.59, P = .007). Group C had significantly lower risk of viral breakthrough than group B (HR = 0.19, P < .001). Viral breakthrough was an independent risk factor for shorter RFS among groups B and C (adjusted HR = 2.03, P = .007, time-dependent Cox analysis). Antiviral agents with high genetic barrier to resistance (entecavir and TDF) reduced the risk of HCC recurrence compared with other antivirals and no antiviral treatment, especially in patients with high baseline viral load.

Intensity of surveillance for hepatocellular carcinoma determines survival in patients at risk in a hepatitis B-endemic area

BACKGROUND

Data are insufficient regarding the survival benefit of surveillance for hepatocellular carcinoma (HCC).

AIM

To investigate the effectiveness of HCC surveillance in a hepatitis B-endemic population.

METHODS

This retrospective cohort study included 1402 consecutive patients who were newly diagnosed with HCC between 2005 and 2012 at a single tertiary hospital in Korea. The primary endpoint was overall survival. Lead-time and length-time biases were adjusted (sojourn time = 140 days) and sensitivity analyses were performed.

RESULTS

The most common aetiology was hepatitis B (80.4%). Cirrhosis was present in 78.2%. HCC was diagnosed during regular surveillance (defined as mean interval of ultrasonography <8 months, n = 834), irregular surveillance (n = 104) or nonsurveillance (n = 464). Patients in the regular surveillance group were diagnosed at earlier stages ([very] early stage, 64.4%) than the irregular surveillance (40.4%) or nonsurveillance (26.9%) groups and had more chance for curative treatments (52.4%) than the irregular surveillance (39.4%) or nonsurveillance (23.3%) groups (all P < 0.001). Mortality risk was significantly lower in the regular surveillance group (adjusted hazard ratio [aHR], 0.69; 95% [CI], 0.57-0.83) but not in the irregular surveillance group (aHR, 0.94; 95% CI, 0.69-1.28) compared with the nonsurveillance group after adjusting for confounding factors and lead-time. When the subjects were restricted to cirrhotic patients or Child-Pugh class A/B patients, similar results were obtained for mortality risk reduction between groups.

CONCLUSIONS

HCC surveillance was associated with longer survival owing to earlier diagnosis and curative treatment. Survival advantage was significant with regular surveillance but not with irregular surveillance.

Benefits of active middle ear implants over hearing aids in patients with sloping high tone hearing loss: comparison with hearing aids

In this retrospective chart review we compared the subjective and objective benefits of active middle ear implants (AMEIs) with conventional hearing aids (HAs) in patients with sloping high tone hearing loss. Thirty-four patients with sensorineural hearing loss were treated with AMEIs. Of these, six had sloping high tone hearing loss and had worn an HA for more than 6 months. Objective assessments, a pure-tone audiogram, as well as a word recognition test, and the Korean version of the Hearing in Noise Test (K-HINT), and a subjective assessment, the Abbreviated Profile of Hearing Aid Benefit (APHAB) questionnaire, were performed. Tests were conducted under three circumstances: 1) the unaided state before surgery; 2) the HA-aided state before surgery; and 3) the AMEI-aided state 3 months after surgery. The average high-frequency hearing gain (≥ 2 kHz) was significantly better with AMEIs than with HAs. Although the result had no statistical significance, AMEIs showed a superior word recognition score (WRS) compared to HAs. However, the most comfortable hearing level at which the WRS was tested was significantly decreased with an AMEI compared to an HA. In the K-HINT, patients with an AMEI showed greater recognition than those fitted with an HA under both quiet and noisy conditions. The APAHB scores revealed that patients were more satisfied with an AMEI rather than an HA on all subscales. The use of vibroplasty in patients with sloping high tone loss resulted in positive hearing outcomes when compared to conventional HAs. Based on the data from this study, AMEIs provided better objective and subjective results and could, therefore, be a better alternative for the treatment of sloping hearing loss.

Electroencephalographic markers of brain development during sevoflurane anaesthesia in children up to 3 years old

Background

General anaesthetics generate spatially defined brain oscillations in the EEG that relate fundamentally to neural-circuit architecture. Few studies detailing the neural-circuit activity of general anaesthesia in children have been described. The study aim was to identify age-related changes in EEG characteristics that mirror different stages of early human brain development during sevoflurane anaesthesia.

Methods

Multichannel EEG recordings were performed in 91 children aged 0–3 yr undergoing elective surgery. We mapped spatial power and coherence over the frontal, parietal, temporal, and occipital cortices during maintenance anaesthesia.

Results

During sevoflurane exposure: (i) slow–delta (0.1–4 Hz) oscillations were present in all ages, (ii) theta (4–8 Hz) and alpha (8–12 Hz) oscillations emerge by ∼4 months, (iii) alpha oscillations increased in power from 4 to 10 months, (iv) frontal alpha-oscillation predominance emerged at ∼6 months, (v) frontal slow oscillations were coherent from birth until 6 months, and (vi) frontal alpha oscillations became coherent ∼10 months and persisted in older ages.

Conclusions

Key developmental milestones in the maturation of the thalamo-cortical circuitry likely generate changes in EEG patterns in infants undergoing sevoflurane general anaesthesia. Characterisation of anaesthesia-induced EEG oscillations in children demonstrates the importance of developing age-dependent strategies to monitor properly the brain states of children receiving general anaesthesia. These data have the potential to guide future studies investigating neurodevelopmental pathologies involving altered excitatory–inhibitory balance, such as epilepsy or Rett syndrome.

Results of an international comparison of activity measurements of 68Ge

An international key comparison, identifier CCRI(II)-K2.Ge-68, has been performed. The National Institute of Standards and Technology (NIST) served as the pilot laboratory, distributing aliquots of a 68Ge/68Ga solution. Results for the activity concentration, CA, of 68Ge at a reference date of 12h00 UTC 14 November 2014 were submitted by 17 laboratories, encompassing many variants of coincidence methods and liquid-scintillation counting methods. The first use of 4π(Cherenkov)β-γ coincidence and anticoincidence methods in an international comparison is reported. One participant reported results by secondary methods only. Two results, both utilizing pure liquid-scintillation methods, were identified as outliers. Evaluation using the Power-Moderated Mean method results in a proposed Comparison Reference Value (CRV) of 621.7(11)kBqg-1, based on 14 results. The degrees of equivalence and their associated uncertainties are evaluated for each participant. Several participants submitted 3.6mL ampoules to the BIPM to link the comparison to the International Reference System (SIR) which may lead to the evaluation of a Key Comparison Reference Value and associated degrees of equivalence.

Evaluation of abundance of artificial radionuclides in food products in South Korea and sources

Food samples are collected nationwide from January 2016 to February 2017 and their contents of artificial radionuclides are measured to address the growing concerns regarding the radioactive contamination of food products in Korea. Specifically, 900 food samples are collected for this study and their contents of representative artificial radionuclides ¹³⁴Cs, ¹³⁷Cs, ^239,240Pu, and ⁹⁰Sr are analyzed. The analysis shows that the activity concentrations of ¹³⁷Cs in fish range from minimum detectable activity (MDA) to 340 mBq/kg of fresh weight. The concentration factor (CF) determined for ¹³⁷Cs as a measure of its bioavailability is calculated to be ca. 74 and found to be very similar to that (100) recommended by the International Atomic Energy Agency. With an MDA of <0.221 mBq/kg, the results reveal that ^239,240Pu values in fish are below the MDA. The activity concentrations of ¹³⁷Cs and ⁹⁰Sr are lower than the MDA in both shellfish and seaweed, while the activity concentrations of ^239,240Pu in shellfish range from 0.26 to 2.18 mBq/kg, and for seaweed samples range from 2.07 to 3.38 mBq/kg. The atom ratios of ²⁴⁰Pu/²³⁹Pu in shellfish caught at the Korean coast vary from 0.209 to 0.237, with a mean of 0.227. The higher ²⁴⁰Pu/²³⁹Pu atom ratio determined in shellfish is thought to be caused by the plutonium transported from the Pacific Proving Grounds rather than other sources such as the Fukushima nuclear power plant accident. The activity concentrations of ¹³⁷Cs in mushrooms are found to vary from 1.0 to 21.4 Bq/kg, with the highest concentrations observed in the Oak (shiitake) and Sarcodon asparatus. ¹³⁴Cs is detected in three mushroom specimens collected from Jeju Island and about 3-3.6% of ¹³⁷Cs present in the wild mushrooms native to the Jeju Island are introduced as a result of the Fukushima nuclear plant accident. The annual effective doses of ¹³⁷Cs received through consumption of mushrooms and fish are 2.0 × 10^-4 mSv yr^-1 and 3.9 × 10^-5 mSv yr^-1, and those values are negligible compared to the annual effective doses limit of 1 mSv yr^-1.

Frequency and risk factors of drug-induced liver injury during treatment of multidrug-resistant tuberculosis

OBJECTIVES

To investigate the risk factors for drug-induced liver injury (DILI) during the treatment of multidrug-resistant tuberculosis (MDR-TB) and to compare the frequency of DILI in patients with and those without chronic liver disease (CLD).

SETTING

This was a retrospective observational cohort study including 299 consecutive patients who started MDR-TB treatment from January 2009 to December 2013.

DESIGN

Of the 299 patients, 35 had alcoholic liver disease (ALD group), 16 had hepatitis B virus infection (HBV group) and 11 had hepatitis C virus infection (HCV group). The remaining 237 patients without CLD were selected as the control group.

RESULTS

DILI occurred in 29 (9.7%) patients. The frequency of DILI was significantly higher in the ALD (17.1%, P = 0.038), HBV (31.3%, P = 0.005) and HCV groups (27.3%, P = 0.037) than in the control group (6.3%). Among all patients taken together, having HBV and HCV infection were independent risk factors for the occurrence of DILI during MDR-TB treatment.

CONCLUSION

DILI during MDR-TB treatment occurred more frequently in patients with CLD due to ALD, HBV and HCV infection than in those without CLD.

Longitudinal cortical thinning and cognitive decline in patients with early- versus late-stage subcortical vascular mild cognitive impairment

BACKGROUND AND PURPOSE

Biomarker changes in cognitively impaired patients with small vessel disease are largely unknown. The rate of amyloid/lacune progression, cortical thinning and cognitive decline were evaluated in subcortical vascular mild cognitive impairment (svMCI) patients.

METHODS

Seventy-two svMCI patients were divided into early stage (ES-svMCI, n = 39) and late stage (LS-svMCI, n = 33) according to their Clinical Dementia Rating Sum of Boxes score. Patients were annually followed up with neuropsychological tests and brain magnetic resonance imaging for 3 years, and underwent a second [¹¹ C] Pittsburgh compound B (PiB) positron emission tomography scan within a mean interval of 32.4 months.

RESULTS

There was no difference in the rate of increase in PiB uptake or lacune number between the ES-svMCI and LS-svMCI. However, LS-svMCI showed more rapid cortical thinning and cognitive decline than did the ES-svMCI.

CONCLUSIONS

We suggest that, whilst the rate of change in pathological burden did not differ between ES-svMCI and LS-svMCI, cortical thinning and cognitive decline progressed more rapidly in the LS-svMCI.