Pilot study of the combination of sorafenib and fractionated irinotecan in pediatric relapse/refractory hepatic cancer (FINEX pilot study).

BACKGROUND: Preclinical observations suggested a synergistic effect of sorafenib (SFN) and irinotecan (CPT-11) in hepatoblastoma (HB). Thus, we conducted a feasibility study of fractionated CPT-11 combined with SFN to develop a new therapy against relapsed/refractory pediatric hepatic cancer (HC). PROCEDURE: The study was originally designed as a phase I, standard 3+3 dose-finding study to evaluate dose-limiting toxicities (DLTs) for the regimen and the optimal CPT-11 dose in combination with SFN against relapsed/refractory pediatric HC, including HB and hepatocellular carcinoma (HCC). The enrolled patients received SFN at 200 mg/m2 every 12 hours or 400 mg/m2 every 24 hours daily combined with CPT-11 at 20 mg/m2 /day on days 1 to 5 as an initial level 1 dose. RESULTS: Six patients with HB (n = 4) or HCC (n = 2) were enrolled and treated with CPT-11 dose level 1. The median age at enrollment was 8.7 (6.2-16.3) years. All patients received platinum-containing chemotherapy, and five or two patients received CPT-11 or SFN before enrollment, respectively. Regimen toxicities were evaluable in all patients. One of six patients experienced a grade 4 transaminase levels increase, which was defined as a DLT per protocol. Grade 3/4 neutropenia and a grade 3 transaminase level increase occurred in three patients and one patient, respectively. All patients reported grade 1/2 toxicities such as anemia, skin toxicity, gastrointestinal symptoms, and hypoalbuminemia. CONCLUSIONS: Although the study was terminated before determining the maximum-tolerated CPT-11 dose, SFN and CPT-11 at the level 1 dose were concluded to be tolerable in pediatric patients with HC.

Impact of catheter tip-tissue contact on three-dimensional left atrial geometries: Relationship between the external structures and anatomic distortion of 3D fast anatomical mapping and high contact force guided images.

BACKGROUND: A high catheter tip-tissue contact force (CF) with the myocardium may cause 3-dimensional (3D) map distortion, however, the influence of external structures surrounding the left atrium (LA) on that distortion remains unknown. This study characterized the impact of high CF mapping on the local LA geometry distortion. METHODS: Thirty AF patients underwent 3D-ultrasound merged with CT images (3D-Merge-CT). The LA area in contact with external structures was identified by enhanced CT. Fast-electroanatomical-mapping (FAM) geometries were created by two methods, point-by-point mapping with high (>10g) CFs (high-CF guided-FAM), followed by that with multielectrode-mapping catheters (conventional-FAM). The resulting geometries were compared with the 3D-Merge-CT images. RESULTS: Three representative anatomical contact areas (ascending aorta-vs.-anterior wall, descending aorta-vs.-left pulmonary vein [PV], and vertebrae-vs.-posterior wall) were identified. The PV antrum distorted distance on the 3D-Merge-CT was significantly longer for high-CF guided-FAMs than conventional-FAMs (1.7[0-3.6] vs. 0[0-1.8]mm, P<0.0001). In high-CF maps, the distorted distance significantly differed between regions with and without contact areas in both the PV antrum (0[0-0.17] vs. 1.7[0-3.9]mm, P=0.0201) and LA body region (0[0-1.5] vs. 1.7[0.7-2.2]mm, P<0.005). The catheter tip-tissue CF did not correlate with the distorted distance (r=0.08, P=0.46), and a multivariate analysis revealed that the absence of anatomical contact areas was strongly associated with significant local distortion, independent of the CF. CONCLUSIONS: High-CF guided mapping yields greater 3D-image anatomical distortion than conventional-FAM methods. That distortion was attenuated by regions with anatomical contact areas, suggesting that regional anatomic distortion is involved in the existence of external structures surrounding the LA.

Spatial Relation Between Left Atrial Anatomical Contact Areas and Circular Activation in Persistent Atrial Fibrillation.

INTRODUCTION: Atrial low-voltage zones (LVZs) may be related to maintenance of atrial fibrillation (AF). The influence of left atrial (LA) contact areas (CoAs) on reentrant or rotor-like sources maintaining AF has not been investigated. METHODS AND RESULTS: Forty patients with persistent AF (PsAF) were analyzed. Three representative CoA regions in the LA (ascending aorta: anterior wall; descending aorta: left inferior pulmonary vein; and vertebrae: posterior wall) were visualized by enhanced CT. Using circular catheters, the LVZs (<0.5 mV) were assessed after restoration of SR, and local activation mapping and frequency domain analyses were performed after induction of AF. Circular activation during AF was visually defined as sites with ≥2 rotations by serial electrograms encompassing >80% of the mean AF cycle length. A pivot was defined as the core of the localized circular activation. Anterior (39/40 patients, 98%), left pulmonary vein antrum (27/40, 68%), and posterior (19/40, 48%) CoAs were identified, and 80% (68/85) of those sites were overlapped by or close (<3 mm) to LVZs. Thirty-six (90%) patients demonstrated circular activation (3.1±1.7 sites/patients) along with significantly higher organized dominant frequencies (6.3 ± 0.5 Hz, regularity-index: 0.26 [0.23-0.41]) within the LA, and the average electrogram amplitude of those pivots was 0.30 mV (0.18-0.52). Of those sites, 55% (66/120) were located at or close to CoA regions. Catheter ablation including of LVZs neighboring CoAs terminated AF in 9 (23%) patients. CONCLUSIONS: External anatomical structures contacting the LA may be related to unique conduction properties in diseased myocardium necessary for PsAF maintenance.

The influence of the external structures in atrial fibrillation patients: Relationship to focal low voltage areas in the left atrium.

INTRODUCTION: Left atrial (LA) low voltage areas (LVAs) are suggested as an important factor for maintaining atrial fibrillation (AF). The relationship between focal LVAs and anatomical contact is still unclear. METHODS: Thirty paroxysmal AF (PAF) and 30 persistent AF (PsAF) patients underwent high density voltage mapping during sinus rhythm before any radiofrequency applications were performed. The relationship between the LVA (<0.5mV) and contact area (CoA) demonstrated by enhanced CT and the distance to near external structures were investigated. RESULTS: The anterior region, posterior wall and left pulmonary vein (LPV) antrum were the three most frequent LVA sites that corresponded to CoA sites, and LVAs mostly overlapped with CoAs (PAF 47/61: 77%, PsAF 63/74: 85%). In the PAF group, patients with posterior-LVAs had a shorter distance to the vertebrae than those without (2.8 ± 1.1 vs. 4.4 ± 1.9 mm; P=0.0086). The distance to the vertebrae was the only predictive factor of the existence of a posterior-LVA and the cut-off value was ≤2.9 mm (P<0.0001). Similarly, an LPV-LVA also had the same results (2.0 ± 0.5 vs. 2.7 ± 0.8mm, P=0.0127) and the cut-off value was ≤2.6mm (P=0.0391). In contrast, the PsAF patients had no difference in the distance when compared to the existence of an LVA. CONCLUSIONS: Anatomical CoAs demonstrated a spatial relationship to the LVAs in AF patients. In PAF patients, the distance to near external structures in the posterior region was a predictive factor for the existence of an LVA and may have had some influence on maintaining AF, while in PsAF patients no relationship was suggested.

Influence of left atrium anatomical contact area in persistent atrial fibrillation-relationship between low-voltage area and fractionated electrogram.

BACKGROUND: Atrial low-voltage areas are suggested to be related to maintenance of atrial fibrillation (AF). The influence of the left atrium (LA) contact area (CoA) has not been investigated. METHODS AND RESULTS: Twenty-two persistent AF patients underwent high-density mapping during AF and sinus rhythm (SR). Three representative CoA regions in the LA (ascending aorta: anterior wall; descending aorta: left inferior pulmonary vein [LIPV]; and vertebrae: posterior wall) were identified. Electrogram analysis of both high dominant frequency (high-DF; >8 Hz) and complex fractionated atrial electrogram (con-CFAE; <50 ms) regions during SR was done. The anatomical relationship between CoA and both the very low-voltage areas (vLVA; <0.2 mV) and high-frequency sources was determined. Forty-seven vLVA (194.4 cm(2)) and 60 CoA (337.0 cm(2)) were documented, and 32 vLVA directly overlapped CoA. The vLVA were preferentially found in the anterior (45%) and posterior (13%) walls of the LA, and in the LIPV (13%), and corresponded to CoA sites. The mean voltage during SR at high-DF sites was significantly lower than that at con-CFAE sites (0.62 vs.1.54 mV; P<0.0001). Seventy-two percent of high-DF sites overlapped CoA, while 54% of con-CFAE did. Furthermore, 44% of high-DF surface area directly overlapped CoA, while only 19% of con-CFAE did. CONCLUSIONS: Very low-voltage regions had a strong association with CoA. Sites with CoA had a higher incidence of fractionated electrograms both during SR and AF.

Impact of left atrial appendage ridge ablation on the complex fractionated electrograms in persistent atrial fibrillation.

BACKGROUND: The left atrial appendage (LAA) is a possible key contributor to the maintenance of persistent atrial fibrillation (PsAF). The effect of LAA ostial ablation on global left atrial higher-frequency sources remains unclear. METHODS: Complex fractionated electrograms (CFEs) and dominant frequency (DF) maps acquired with a NavX system in 58 PsAF patients were enrolled and examined before and after LAA posterior ridge ablation, which followed a stepwise linear ablation. RESULTS: High-density left atrial mapping identified continuous CFE sites in 50 % and high-DFs (≥ 8 Hz) in 53 % of patients at the LAA posterior ridge. In 44 patients in whom AF persisted despite pulmonary vein isolation (PVI) and linear ablation, LAA ablation significantly increased the mean CFE cycle length from 98 ± 29 to 108 ± 30 ms (P<0.0001) and decreased DF from 6.1 ± 0.8 to 5.9 ± 0.8 Hz (P<0.005) within the coronary sinus (CS). A multivariate analysis showed single-procedure failures could be predicted by the left atrial volume index and absence of continuous CFEs at the LAA posterior ridge region. The percent decrease in the global left atrial DF after LAA posterior ridge ablation was significantly lower in the patients with than in those without an enlarged left atrium (LA) (>90 mL/m(2)) (median 0 vs 4.8 %; P<0.01) and significantly lower in the patients with than in those without the absence of continuous CFEs in the LAA posterior ridge region (median 0.6 vs 4.8 %; P<0.05). CONCLUSION: These findings suggested that an approach incorporating an LAA posterior ridge ablation was effective in modifying higher-frequency sources in the global LA in PsAF patients, but a lesser effect was documented in patients with electroanatomical remodeling of the LA.

An ignoring task improves validity of cortical evoked response audiometry.

This study examined the basis for introducing an ignoring task during cortical evoked response audiometry (CERA) using the N1-P2 response. Healthy hearing participants were assigned to two groups with and without an ignoring task (ignoring and listening groups) during CERA whose outcomes were compared with the pure-tone audiometry (PTA) in response to tone frequencies at 500-4000 Hz. The ignoring but not the listening group exhibited positive correlations between the PTA and CERA thresholds, and further showed negative correlations between the PTA threshold and the N1-P2 amplitude as the tone intensity decreased particularly for lower tone frequencies. Within the healthy hearing levels at least, conducting an ignoring task is thus considered to improve the validity of CERA for lower tone frequencies.

ERP evaluation of auditory sensory memory systems in adults with intellectual disability.

Auditory sensory memory stage can be functionally divided into two subsystems; transient-detector system and permanent feature-detector system (Naatanen, 1992). We assessed these systems in persons with intellectual disability by measuring event-related potentials (ERPs) N1 and mismatch negativity (MMN), which reflect the two auditory subsystems, respectively. Added to these, P3a (an ERP reflecting stage after sensory memory) was evaluated. Either synthesized vowels or simple tones were delivered during a passive oddball paradigm to adults with and without intellectual disability. ERPs were recorded from midline scalp sites (Fz, Cz, and Pz). Relative to control group, participants with the disability exhibited greater N1 latency and less MMN amplitude. The results for N1 amplitude and MMN latency were basically comparable between both groups. IQ scores in participants with the disability revealed no significant relation with N1 and MMN measures, whereas the IQ scores tended to increase significantly as P3a latency reduced. These outcomes suggest that persons with intellectual disability might own discrete malfunctions for the two detector systems in auditory sensory-memory stage. Moreover, the processes following sensory memory might be partly related to a determinant of mental development.

Attenuated BDNF-induced upregulation of GABAergic markers in neurons lacking Xbp1.

XBP1 is a transcription factor induced by unconventional splicing associated with endoplasmic reticulum stress and plays a role in development. Brain-derived neurotrophic factor (BDNF) causes splicing of Xbp1 mRNA in neurites, and Xbp1 is required for BDNF-induced neurite extension and branching. To search for the molecular mechanisms of how Xbp1 plays a role in neural development, comprehensive gene expression analysis was performed in primary telencephalic neurons obtained from Xbp1 knockout mice at embryonic day 12.5. By searching for the genes induced by BDNF in wild type neurons but not in Xbp1 knockout mice, we found that upregulation of three GABAergic markers, somatostatin (Sst), neuropeptide Y (Npy), and calbindin (Calb1), were compromised in Xbp1 knockout neurons. Attenuated upregulation of Npy and Calb1 in Xbp1 knockout neurons was confirmed by quantitative RT-PCR. This finding may be relevant to impaired BDNF-induced neurite extension in Xbp1 knockout neurons.

Attention-related modulation of auditory brainstem responses during contralateral noise exposure.

As determinants facilitating attention-related modulation of the auditory brainstem response (ABR), two experimental factors were examined: (i) auditory discrimination; and (ii) contralateral masking intensity. Tone pips at 80 dB sound pressure level were presented to the left ear via either single-tone exposures or oddball exposures, whereas white noise was delivered continuously to the right ear at variable intensities (none--80 dB sound pressure level). Participants each conducted two tasks during stimulation, either reading a book (ignoring task) or detecting target tones (attentive task). Task-related modulation within the ABR range was found only during oddball exposures at contralateral masking intensities greater than or equal to 60 dB. Attention-related modulation of ABR can thus be detected reliably during auditory discrimination under contralateral masking of sufficient intensity.

Attention effects at auditory periphery derived from human scalp potentials: displacement measure of potentials.

It is known in humans that electrophysiological measures such as the auditory brainstem response (ABR) are difficult to identify the attention effect at the auditory periphery, whereas the centrifugal effect has been detected by measuring otoacoustic emissions. This research developed a measure responsive to the shift of human scalp potentials within a brief post-stimulus period (13 ms), that is, displacement percentage, and applied it to an experiment to retrieve the peripheral attention effect. In the present experimental paradigm, tone pips were exposed to the left ear whereas the other ear was masked by white noise. Twelve participants each conducted two conditions of either ignoring or attending to the tone pips. Relative to averaged scalp potentials in the ignoring condition, the shift of the potentials was found within early component range during the attentive condition, and displacement percentage then revealed a significant magnitude difference between the two conditions. These results suggest that, using a measure representing the potential shift itself, the peripheral effect of attention can be detected from human scalp potentials.

Site-specific incorporation of non-natural amino acids into proteins in mammalian cells with an expanded genetic code.

We describe a detailed protocol for incorporating non-natural amino acids, 3-iodo-L-tyrosine (IY) and p-benzoyl-L-phenylalanine (pBpa), into proteins in response to the amber codon (the UAG stop codon) in mammalian cells. These amino acids, IY and pBpa, are applicable for structure determination and the analysis of a network of protein-protein interactions, respectively. This method involves (i) the mutagenesis of the gene encoding the protein of interest to create an amber codon at the desired site, (ii) the expression in mammalian cells of the bacterial pair of an amber suppressor tRNA and an aminoacyl-tRNA synthetase specific to IY or pBpa and (iii) the supplementation of the growth medium with these amino acids. The amber mutant gene, together with these bacterial tRNA and synthetase genes, is introduced into mammalian cells. Culturing these cells for 16-40 h allows the expression of the full-length product from the mutant gene, which contains the non-natural amino acid at the introduced amber position. This method is implemented using the conventional tools for molecular biology and treating cultured mammalian cells. This protocol takes 5-6 d for plasmid construction and 3-4 d for incorporating the non-natural amino acids into proteins.

Asymmetrical mismatch negativity in humans as determined by phonetic but not physical difference.

A two-tone oddball procedure was employed to examine the effect of a phonemic category on the mismatch negativity (MMN). One of the stimuli was a phoneme prototype of Japanese /e/, and the other, [e/ö], which was perceived by Japanese participants as showing deviance from typicality but is nonetheless included in the category /e/. As control stimuli, a pair of pure tones (1940 and 1794 Hz), corresponding to the F2 frequencies of /e/ and [e/ö], respectively, was presented within the same oddball procedure. The MMN for deviant [e/ö] revealed greater amplitude than that of deviant /e/, although there was no significant difference in amplitude between the pure tones. The results suggest that a phonemic category determines the auditory sensory memory.