Urinary tract symptoms that should be improved to enhance post-operative urinary quality of life in patients treated with low-dose-rate brachytherapy for prostate cancer: An importance-performance analysis.

Purpose: To evaluate international prostate symptom score and urinary quality of life in patients with prostate cancer who underwent low-dose-rate brachytherapy, and to identify lower urinary tract symptoms that must be improved to enhance post-operative urinary quality of life and factors associated with lower urinary tract symptoms. Material and methods: This study included 193 patients who underwent low-dose-rate brachytherapy alone (145 Gy). Importance-performance analysis was conducted to identify lower urinary tract symptoms that should be prioritized to improve urinary quality of life. Association between lower urinary tract symptom scores and each factor was investigated. Receiver operating characteristic curve analysis was used to evaluate dosimetric parameters related to lower urinary tract symptom score to predict an average score of ≥ 3. Cut-off values were determined. Results: One to nine months post-implantation was a period of significantly increased urinary quality of life scores compared with baseline (p < 0.05 each). The importance-performance analysis conducted for 1-9 months revealed that frequency, nocturia, and weak stream required improvement. Multivariate analysis showed that each lower urinary tract symptom score presented a significant association with its baseline value (p < 0.001 each, positive correlation). Frequency, incomplete emptying, urgency, and straining scores were significantly associated with prostate volume, whereas weak stream and intermittency scores were associated with dose covering 90% of the prostate and dose covering 90% of the urethra, respectively (p < 0.05 each, positive correlations). Cut-off values for these doses were 167.01 Gy and 136.84 Gy, respectively. Conclusions: This study highlights the importance of prioritizing specific lower urinary tract symptoms for improvement in post-operative urinary quality of life, and identifies the associated factors that can help in personalized treatment planning and goal-setting for better patient satisfaction.

Notch appearance as a novel radiological predictor of transient expansion and good outcome of expanding schwannoma after radiotherapy.

OBJECTIVES: Schwannoma expansion after radiotherapy has not been well-studied despite the clinical importance of distinguishing transient increase from permanent expansion. Thus, this study aimed to identify the underlying mechanism and novel radiological predictors of schwannoma expansion after radiotherapy. MATERIALS & METHODS: We retrospectively examined the therapeutic effects of radiotherapy on schwannomas and magnetic resonance images of 43 patients with vestibular schwannomas who underwent stereotactic radiotherapy or radiosurgery at our facility between June 1, 2012 and September 1, 2018. Based on the size change pattern, the treated tumors were classified into six groups, including transient-expansion and consistent-increase groups. The apparent diffusion coefficient (ADC) ratio and appearance of any notch were included as evaluation items based on our hypothesis that transient expansion is due to edema with increased extracellular free water. A log-rank test was performed to evaluate the relationship between the local control rate and radiological signs. RESULTS: The mean overall 5-year local control rate was 90%, and the median follow-up period was 62 (24-87) months. Approximately 28% of the tumors showed transient expansion; all ADC ratios synchronized with size change, and 75% showed a new notch appearance. Approximately 9% of tumors showed consistent increase, with no notch on the outline. The log-rank test revealed a difference in the local control rate with or without notch appearance in expanding irradiated schwannomas. All tumors with notch appearance showed a significant regression 5 years after radiation. CONCLUSIONS: New notch appearance on the outline could indicate favorable long-term outcomes of expanding schwannomas post-treatment. CLINICAL RELEVANCE STATEMENT: Notch appearance can help differentiate a transient schwannoma from a real tumor expansion, and it is a novel predictor of better outcomes of expanding schwannomas after radiotherapy.

Receptor activity-modifying proteins of adrenomedullin (RAMP2/3): Roles in the pathogenesis of ARDS.

Acute respiratory distress syndrome (ARDS) is a life-threatening lung condition characterized by widespread inflammation and pulmonary edema. Adrenomedullin (AM), a bioactive peptide with various functions, is expected to be applied in treating ARDS. Its functions are regulated primarily by two receptor activity-modifying proteins, RAMP2 and RAMP3, which bind to the AM receptor calcitonin receptor-like receptor (CLR). However, the roles of RAMP2 and RAMP3 in ARDS remain unclear. We generated a mouse model of ARDS via intratracheal administration of lipopolysaccharide (LPS), and analyzed the pathophysiological significance of RAMP2 and RAMP3. RAMP2 expression declined with LPS administration, whereas RAMP3 expression increased at low doses and decreased at high doses of LPS. After LPS administration, drug-inducible vascular endothelial cell-specific RAMP2 knockout mice (DI-E-RAMP2-/-) showed reduced survival, increased lung weight, and had more apoptotic cells in the lungs. DI-E-RAMP2-/- mice exhibited reduced expression of Epac1 (which regulates vascular endothelial cell barrier function), while RAMP3 was upregulated in compensation. In contrast, after LPS administration, RAMP3-/- mice showed no significant changes in survival, lung weight, or lung pathology, although they exhibited significant downregulation of iNOS, TNF-α, and NLRP3 during the later stages of inflammation. Based on transcriptomic analysis, RAMP2 contributed more to the circulation-regulating effects of AM, whereas RAMP3 contributed more to its inflammation-regulating effects. These findings indicate that, while both RAMP2 and RAMP3 participate in ARDS pathogenesis, their functions differ distinctly. Further elucidation of the pathophysiological significance and functional differences between RAMP2 and RAMP3 is critical for the future therapeutic application of AM in ARDS.

Factors Affecting Prostate Displacement During Volumetric Modulated Arc Therapy in Prone Position After High-Dose-Rate Brachytherapy for Prostate Cancer.

Purpose: In irradiating the prostate and pelvic lymph node regions, registration based on bony structures matches the pelvic lymph node regions but not necessarily the prostate position, and it is important to identify factors that influence prostate displacement. Therefore, we investigated factors influencing prostate displacement during volumetric modulated arc therapy after single-fraction high-dose-rate brachytherapy (HDR-BT) for prostate cancer and the trends in displacement for each fraction. Methods and Materials: Seventy patients who underwent pelvic volumetric modulated arc therapy of 46 Gy in the prone position 15 days after 13 Gy HDR-BT were included. Prostate displacement relative to bony structures was calculated using cone beam computed tomography. Systematic error (SE) and random error (RE) were evaluated in the right-left (RL), craniocaudal (CC), and anteroposterior (AP) directions. The association with clinical and anatomic factors on the planning computed tomography or magnetic resonance imaging was analyzed. Prostate volume change (PVC) was defined as the volume change at 2 days after HDR-BT. Displacement trends were individually examined from the first to 23rd fractions. Results: The mean SE in the RL, CC, and AP directions was -0.01 mm, -2.34 mm, and -0.47 mm, respectively. The root mean square of the RE in the RL, CC, and AP directions was 0.44 mm, 1.14 mm, and 1.10 mm, respectively. SE in the CC direction was independently associated with bladder volume (P = .021, t statistic = 2.352) and PVC (P < .001, t statistic = -8.526). SE in the AP direction was independently associated with bladder volume (P = .013, t statistic = -2.553), PVC (P < .001, t statistic = 5.477), and rectal mean area (P = .008, t statistic = 2.743). RE in the CC direction was independently associated with smoking (P = .035). RE in the AP direction was associated with PVC (P = .043). Gradual displacement caudally and posteriorly occurred during the irradiation period. Conclusions: Anatomic characteristics of the bladder, rectum, and prostate predict SE. Smoking and PVC predict RE. In particular, whether PVC is ≥140% affects setting internal margins.

Clinical Features, Genome Epidemiology, and Antimicrobial Resistance Profiles of Aeromonas spp. Causing Human Infections: A Multicenter Prospective Cohort Study.

Background: The genus Aeromonas is increasingly implicated in human infections, but knowledge of its clinical characteristics and antimicrobial resistance profiles has been limited owing to its complex taxonomy. Methods: We conducted a multicenter prospective cohort study of patients with Aeromonas infections at hospitals across Japan. Patients were eligible for inclusion if they had an Aeromonas spp. strain in a clinical culture and were considered infected at the culture site. Clinical data were collected, and isolates underwent susceptibility testing and whole-genome sequencing. Results: A total of 144 patients were included. Hepatobiliary infection accounted for a majority of infections (73% [105 of 144]), which mostly occurred in elderly patients with comorbid conditions, including hepatobiliary complications. The all-cause 30-day mortality rate was 10.0% (95% confidence interval, 4.9%-14.8%). By whole-genome sequencing, 141 strains (98%) belonged to 4 Aeromonas species-A caviae, A hydrophila, A veronii, and A dhakensis-with significant intraspecies diversity. A caviae was predominant in all infection sites except skin and soft tissue, for which A hydrophila was the prevailing species. The genes encoding chromosomally mediated class B, C, and D ß-lactamases were harbored by 92%-100% of the isolates in a species-specific manner, but they often lacked association with resistance phenotypes. The activity of cefepime was reliable. All isolates of A hydrophila and A dhakensis carried an mcr-3-like colistin resistance gene and showed reduced susceptibility to colistin. Conclusions: Hepatobiliary tract was the most common infection site of Aeromonas spp., with A caviae being the dominant causative species. The resistance genotype and phenotype were often incongruent for ß-lactam agents.

[COVID-19 development during the treatment of paroxysmal nocturnal hemoglobinuria].

Paroxysmal nocturnal hemoglobinuria (PNH) is a disorder in which an activated complement causes intravascular hemolysis of erythrocytes that do not have complement regulators. It is critical to monitor the rapid progression of hemolysis caused by infection and thrombosis. As far as we can tell, this is the first report of 5 COVID-19 patients with PNH in Japan. Three patients were being treated with ravulizumab, one with eculizumab, and one with crovalimab. All five cases had received two or more COVID-19 vaccinations. COVID-19 was classified as mild in four cases and moderate in one. None of the cases required the use of oxygen, and none became severe. All of them experienced breakthrough hemolysis, and two required red blood cell transfusions. In any case, no thrombotic complications were observed.

Role of Adrenomedullin 2/Intermedin in the Pathogenesis of Neovascular Age-Related Macular Degeneration.

Adrenomedullin 2 (AM2; also known as intermedin) is a member of the adrenomedullin (AM) peptide family. Similarly to AM, AM2 partakes in a variety of physiological activities. AM2 has been reported to exert protective effects on various organ disorders; however, its significance in the eye is unknown. We investigated the role of AM2 in ocular diseases. The receptor system of AM2 was expressed more abundantly in the choroid than in the retina. In an oxygen-induced retinopathy model, physiological and pathologic retinal angiogenesis did not differ between AM2-knockout (AM2-/-) and wild-type mice. In contrast, in laser-induced choroidal neovascularization, a model of neovascular age-related macular degeneration, AM2-/- mice had enlarged and leakier choroidal neovascularization lesions, with exacerbated subretinal fibrosis and macrophage infiltration. Contrary to this, exogenous administration of AM2 ameliorated the laser-induced choroidal neovascularization-associated pathology and suppressed gene expression associated with inflammation, fibrosis, and oxidative stress, including that of VEGF-A, VEGFR-2, CD68, CTGF, and p22-phox. The stimulation of human adult retinal pigment epithelial (ARPE) cell line 19 cells with TGF-ß2 and TNF-α induced epithelial-to-mesenchymal transition (EMT), whereas AM2 expression was also elevated. The induction of EMT was suppressed when the ARPE-19 cells were pretreated with AM2. A transcriptome analysis identified 15 genes, including mesenchyme homeobox 2 (Meox2), whose expression was significantly altered in the AM2-treated group compared with that in the control group. The expression of Meox2, a transcription factor that inhibits inflammation and fibrosis, was enhanced by AM2 treatment and attenuated by endogenous AM2 knockout in the early phase after laser irradiation. The AM2 treatment of endothelial cells inhibited endothelial to mesenchymal transition and NF-κB activation; however, this effect tended to be canceled following Meox2 gene knockdown. These results indicate that AM2 suppresses the neovascular age-related macular degeneration-related pathologies partially via the upregulation of Meox2. Thus, AM2 may be a promising therapeutic target for ocular vascular diseases.

Patterns of failure in glioblastoma multiforme following Standard (60 Gy) or Short course (40 Gy) radiation and concurrent temozolomide.

PURPOSE: The purpose of this study was to analyze the patterns of failure in patients with glioblastoma multiforme (GBM) treated using chemoradiotherapy in the Standard radiotherapy (60 Gy/30 fractions; Standard) or Short course (40 Gy/15 fractions: Short). MATERIALS AND METHODS: Ninety-three consecutive patients with newly diagnosed glioblastoma treated at our hospital between April 2007 and December 2016, and 68 patients who could be followed up were included. All patients underwent surgical resection followed by radiotherapy with concurrent temozolomide. We retrospectively analyzed treatment outcomes and recurrence patterns. RESULTS: The median follow-up period of the surviving patients was 82.8 months (range: 46.0-158.9 months). Of the 68 patients, 58 patients (85%) had recurrences, 34 underwent the Standard and 24 Short course. The Standard course was seen in younger age groups and had a better Karnofsky performance status (KPS) than the Short course. The median survival time (MST) was 25.8 months for the Standard and 15.4 months with the Short in all cases. Standard course had significantly longer MST than the Short (p = 0.001) course. For recurrent cases only, there was no significant difference between Standard and Short courses in OS (p = 0.06). The recurrences occurred at the radiation fields alone (Standard/Short: 85%/83%), only at distant sites (Standard/Short: 12%/13%), and at both the radiation fields and distant sites (Standard/Short: 3%/4%). There was no significant difference in recurrence pattern and frequency between the two protocols (p = 0.11). CONCLUSIONS: Standard course tended to be significant in younger age groups and have a better KPS than the Short course; therefore, the Standard course has a longer OS, but the recurrence pattern of the Short course is similar to that of the Standard treatment.

Ischemic proctitis after low-dose-rate brachytherapy using hydrogel spacer for prostate cancer.

Introduction: Recently, an absorbable hydrogel spacer is becoming more widespread to reduce rectal radiation dose for radiation therapy for localized prostate cancer. Case presentation: A 79-year-old male patient was referred to our hospital for radical treatment of organ-confined prostate cancer. Low-dose-rate brachytherapy was performed, and the hydrogel spacer injection was added. The spacer was properly injected between the prostate and the rectum, causing no acute complications during hospitalization. Two months after low-dose-rate brachytherapy, the patient visited our hospital with constipation and melena, without fever. He was diagnosed with ischemic proctitis based on clinical courses and examinations. He was hospitalized for 19 days and made a complete recovery with conservative treatment. Conclusions: Herein, we report the first case of ischemic proctitis after low-dose-rate brachytherapy using hydrogel spacer for prostate cancer.

Receptor Activity Modifying Protein RAMP Sub-Isoforms and Their Functional Differentiation, Which Regulates Functional Diversity of Adrenomedullin.

AM knockout (AM-/-) and RAMP2 knockout (RAMP2-/-) proved lethal for mice due to impaired embryonic vascular development. Although most vascular endothelial cell-specific RAMP2 knockout (E-RAMP2-/-) mice also died during the perinatal period, a few E-RAMP2-/- mice reached adulthood. Adult E-RAMP2-/- mice developed spontaneous organ damage associated with vascular injury. In contrast, adult RAMP3 knockout (RAMP3-/-) mice showed exacerbated postoperative lymphedema with abnormal lymphatic drainage. Thus, RAMP2 is essential for vascular development and homeostasis and RAMP3 is essential for lymphatic vessel function. Cardiac myocyte-specific RAMP2 knockout mice showed early onset of heart failure as well as abnormal mitochondrial morphology and function, whereas RAMP3-/- mice exhibited abnormal cardiac lymphatics and a delayed onset of heart failure. Thus, RAMP2 is essential for maintaining cardiac mitochondrial function, while RAMP3 is essential for cardiac lymphangiogenesis. Transplantation of cancer cells into drug-inducible vascular endothelial cell-specific RAMP2 knockout mice resulted in enhanced metastasis to distant organs, whereas metastasis was suppressed in RAMP3-/- mice. RAMP2 suppresses cancer metastasis by maintaining vascular homeostasis and inhibiting vascular inflammation and pre-metastatic niche formation, while RAMP3 promotes cancer metastasis via malignant transformation of cancer-associated fibroblasts. Focusing on the diverse physiological functions of AM and the functional differentiation of RAMP2 and RAMP3 may lead to the development of novel therapeutic strategies.

An Myh11 single lysine deletion causes aortic dissection by reducing aortic structural integrity and contractility.

Pathogenic variants in myosin heavy chain (Myh11) cause familial thoracic aortic aneurysms and dissections (FTAAD). However, the underlying pathological mechanisms remain unclear because of a lack of animal models. In this study, we established a mouse model with Myh11 K1256del, the pathogenic variant we found previously in two FTAAD families. The Myh11∆K/∆K aorta showed increased wall thickness and ultrastructural abnormalities, including weakened cell adhesion. Notably, the Myh11∆K/+ mice developed aortic dissections and intramural haematomas when stimulated with angiotensin II. Mechanistically, integrin subunit alpha2 (Itga2) was downregulated in the Myh11∆K/∆K aortas, and the smooth muscle cell lineage cells that differentiated from Myh11∆K/∆K induced pluripotent stem cells. The contractility of the Myh11∆K/∆K aortas in response to phenylephrine was also reduced. These results imply that the suboptimal cell adhesion indicated by Itga2 downregulation causes a defect in the contraction of the aorta. Consequently, the defective contraction may increase the haemodynamic stress underlying the aortic dissections.

NANOS3 suppresses premature spermatogonial differentiation to expand progenitors and fine-tunes spermatogenesis in mice.

In the mouse testis, sperm originate from spermatogonial stem cells (SSCs). SSCs give rise to spermatogonial progenitors, which expand their population until entering the differentiation process that is precisely regulated by a fixed time-scaled program called the seminiferous cycle. Although this expansion process of progenitors is highly important, its regulatory mechanisms remain unclear. NANOS3 is an RNA-binding protein expressed in the progenitor population. We demonstrated that the conditional deletion of Nanos3 at a later embryonic stage results in the reduction of spermatogonial progenitors in the postnatal testis. This reduction was associated with the premature differentiation of progenitors. Furthermore, this premature differentiation caused seminiferous stage disagreement between adjacent spermatogenic cells, which influenced spermatogenic epithelial cycles, leading to disruption of the later differentiation pathway. Our study suggests that NANOS3 plays an important role in timing progenitor expansion to adjust to the proper differentiation timing by blocking the retinoic acid (RA) signaling pathway.

Prediction of post-radiotherapy survival for bone metastases: a comparison of the 3-variable number of risk factors model with the new Katagiri scoring system.

We investigated patient survival after palliative radiotherapy for bone metastases while comparing the prognostic accuracies of the 3-variable number of risk factors (NRF) model and the new Katagiri scoring system (Katagiri score). Overall, 485 patients who received radiotherapy for bone metastases were grouped as per the NRF model (groups I, II and III) and Katagiri score (low-, intermediate- and high-risk). Survival was compared using the log-rank or log-rank trend test. Independent prognostic factors were identified using multivariate Cox regression analyses (MCRA). MCRA and receiver operating characteristic (ROC) curves were used to compare both models' accuracy. For the 376 evaluable patients, the overall survival (OS) rates decreased significantly in the higher-tier groups of both models (P < 0.001). All evaluated factors except 'previous chemotherapy status' differed significantly between groups. Both models exhibited independent predictive power (P < 0.001). Per NRF model, hazard ratios (HRs) were 1.44 (P = 0.099) and 2.944 (P < 0.001), respectively, for groups II and III, relative to group I. Per Katagiri score, HRs for intermediate- and high-risk groups were 4.02 (P < 0.001) and 7.09 (P < 0.001), respectively, relative to the low-risk group. Areas under the curve (AUC) for predicting 6-, 18- and 24-month mortality were significantly higher when using the Katagiri score (P = 0.036, 0.039 and 0.022). Both models predict survival. Prognostic accuracy of the Katagiri score is superior, especially in patients with long-term survival potential; however, in patients with short prognosis, no difference occurred between both models; simplicity and patient burden should also be considered.

The effectiveness of high-dose-rate brachytherapy with external beam radiotherapy for clinically locally advanced and node-positive prostate cancer: long-term results of a retrospective study.

BACKGROUND: No standard treatment exists for locally advanced prostate cancer (PC). This study evaluated the long-term treatment outcomes and toxicity in patients with clinically locally advanced and/or lymph node (LN)-positive PC who underwent high-dose-rate brachytherapy (HDR-BT) with external beam radiotherapy (EBRT). METHODS: The treatment outcomes and toxicities of 152 patients with PC who underwent HDR-BT with EBRT and had at least 2 years of observation were examined. The treatment dose was 19- and 13-Gy HDR-BT in two and single fractions, respectively, both combined with external irradiation of 46 Gy in 23 fractions. Long-term androgen deprivation therapy (ADT) for patients harboring very high-risk tumors was used in combination. RESULTS: The median observation period was 59.7 (24.4-182.1) months. The 5-year prostate cancer-specific and recurrence-free (RFS) survival rates were 99.0% and 91.8%, respectively, with only two PC mortalities. When 5-year RFS was examined for each parameter, RFS was significantly lower in pre-radiotherapy (pre-RT) prostate-specific antigen (PSA) > 0.5 ng/mL (77.1%; p = 0.008), and presence of LN metastasis (68.1%; p = 0.017). Multivariable analysis demonstrated that pre-RT PSA (HR, 4.68; 95% CI, 1.39-15.67; p = 0.012) and presence of LN metastasis (HR, 4.70; 95% CI, 1.24-17.74; p = 0.022) were independent recurrence predictors. The 5-year cumulative incidence rate of grade ≥ 2 toxicities in genitourinary and gastrointestinal tracts were 15.4% and 1.3%, respectively. CONCLUSIONS: HDR-BT combined with EBRT and long-term ADT shows promising disease control and tolerant toxicities for clinically locally advanced and LN-positive PC.

Production of single- and multiple-gene-modified mice via maternal SpCas9-based gene editing.

Maternally and transiently accumulated SpCas9 (maternal SpCas9) in a zygote derived from a systemically SpCas9-expressing transgenic mouse strain was used to generate single- and multiple-gene-modified mice. Maternal SpCas9-based gene editing allows for high indel and knockin mutation efficiency, low mosaicism, increased pup delivery rate, and simultaneous induction of mutations at multiple loci in contrast to conventional CRISPR/SpCas9-based gene editing. For complete details on the use and execution of this protocol, please refer to Sakurai et al. (2020).

Adrenomedullin Ameliorates Pulmonary Fibrosis by Regulating TGF-ß-Smads Signaling and Myofibroblast Differentiation.

Pulmonary fibrosis is an irreversible, potentially fatal disease. Adrenomedullin (AM) is a multifunctional peptide whose activity is regulated by receptor activity-modifying protein 2 (RAMP2). In the present study, we used the bleomycin (BLM)-induced mouse pulmonary fibrosis model to investigate the pathophysiological significance of the AM-RAMP2 system in the lung. In heterozygous AM knockout mice (AM+/-), hydroxyproline content and Ashcroft scores reflecting the fibrosis severity were significantly higher than in wild-type mice (WT). During the acute phase after BLM administration, FACS analysis showed significant increases in eosinophil, monocyte, and neutrophil infiltration into the lungs of AM+/-. During the chronic phase, fibrosis-related molecules were upregulated in AM+/-. Notably, nearly identical changes were observed in RAMP2+/-. AM administration reduced fibrosis severity. In the lungs of BLM-administered AM+/-, the activation level of Smad3, a receptor-activated Smad, was higher than in WT. In addition, Smad7, an antagonistic Smad, was downregulated and microRNA-21, which targets Smad7, was upregulated compared to WT. Isolated AM+/- lung fibroblasts showed less proliferation and migration capacity than WT fibroblasts. Stimulation with TGF-ß increased the numbers of α-SMA-positive myofibroblasts, which were more prominent among AM+/- cells. TGF-ß-stimulated AM+/- myofibroblasts were larger and exhibited greater contractility and extracellular matrix production than WT cells. These cells were α-SMA (+), F-actin (+), and Ki-67(-) and appeared to be nonproliferating myofibroblasts (non-p-MyoFbs), which contribute to the severity of fibrosis. Our findings suggest that in addition to suppressing inflammation, the AM-RAMP2 system ameliorates pulmonary fibrosis by suppressing TGF-ß-Smad3 signaling, microRNA-21 activity and differentiation into non-p-MyoFbs.

Adrenomedullin-RAMP2 and -RAMP3 Systems Regulate Cardiac Homeostasis during Cardiovascular Stress.

Adrenomedullin (AM) is a peptide hormone with multiple physiological functions, which are regulated by its receptor activity-modifying proteins, RAMP2 and RAMP3. We previously reported that AM or RAMP2 knockout (KO) (AM-/-, RAMP2-/-) is embryonically lethal in mice, whereas RAMP3-/- mice are apparently normal. AM, RAMP2, and RAMP3 are all highly expressed in the heart; however, their functions there are not fully understood. Here, we analyzed the pathophysiological functions of the AM-RAMP2 and AM-RAMP3 systems in hearts subjected to cardiovascular stress. Cardiomyocyte-specific RAMP2-/- (C-RAMP2-/-) and RAMP3-/- showed no apparent heart failure at base line. After 1 week of transverse aortic constriction (TAC), however, C-RAMP2-/- exhibited significant cardiac hypertrophy, decreased ejection fraction, and increased fibrosis compared with wild-type mice. Both dP/dtmax and dP/dtmin were significantly reduced in C-RAMP2-/-, indicating reduced ventricular contractility and relaxation. Exposing C-RAMP2-/- cardiomyocytes to isoproterenol enhanced their hypertrophy and oxidative stress compared with wild-type cells. C-RAMP2-/- cardiomyocytes also contained fewer viable mitochondria and showed reduced mitochondrial membrane potential and respiratory capacity. RAMP3-/- also showed reduced systolic function and enhanced fibrosis after TAC, but those only became apparent after 4 weeks. A reduction in cardiac lymphatic vessels was the characteristic feature in RAMP3-/-. These observations indicate the AM-RAMP2 system is necessary for early adaptation to cardiovascular stress through regulation of cardiac mitochondria. AM-RAMP3 is necessary for later adaptation through regulation of lymphatic vessels. The AM-RAMP2 and AM-RAMP3 systems thus play separate critical roles in the maintenance of cardiovascular homeostasis against cardiovascular stress.

Adrenomedullin-Receptor Activity-Modifying Protein 2 System Ameliorates Subretinal Fibrosis by Suppressing Epithelial-Mesenchymal Transition in Age-Related Macular Degeneration.

Age-related macular degeneration (AMD) is a leading cause of visual impairment. Anti-vascular endothelial growth factor drugs used to treat AMD carry the risk of inducing subretinal fibrosis. We investigated the use of adrenomedullin (AM), a vasoactive peptide, and its receptor activity-modifying protein 2, RAMP2, which regulate vascular homeostasis and suppress fibrosis. The therapeutic potential of the AM-RAMP2 system was evaluated after laser-induced choroidal neovascularization (LI-CNV), a mouse model of AMD. Neovascular formation, subretinal fibrosis, and macrophage invasion were all enhanced in both AM and RAMP2 knockout mice compared with those in wild-type mice. These pathologic changes were suppressed by intravitreal injection of AM. Comprehensive gene expression analysis of the choroid after LI-CNV with or without AM administration revealed that fibrosis-related molecules, including Tgfb, Cxcr4, Ccn2, and Thbs1, were all down-regulated by AM. In retinal pigment epithelial cells, co-administration of transforming growth factor-ß and tumor necrosis factor-α induced epithelial-mesenchymal transition, which was also prevented by AM. Finally, transforming growth factor-ß and C-X-C chemokine receptor type 4 (CXCR4) inhibitors eliminated the difference in subretinal fibrosis between RAMP2 knockout and wild-type mice. These findings suggest the AM-RAMP2 system suppresses subretinal fibrosis in LI-CNV by suppressing epithelial-mesenchymal transition.

Incidence and dosimetric predictive factors of late rectal toxicity after low-dose-rate brachytherapy combined with volumetric modulated arc therapy in high-risk prostate cancer at a single institution: Retrospective study.

PURPOSE: The purpose of this study is to investigate the incidence of rectal toxicity and to identify the associated dosimetric predictive parameters after I-125 seed low-dose-rate brachytherapy (LDR-BT) combined with volumetric modulated arc therapy (VMAT) and dose constraints. METHODS AND MATERIALS: In total, 110 patients with high-risk prostate cancer received 110 Gy LDR-BT, followed by 45 Gy VMAT. Rectal toxicity was recorded according to Common Terminology Criteria for Adverse Events v.4.03. The dosimetric factors associated with LDR-BT and VMAT were analyzed to determine their relationship with rectal toxicity. Receiver operating characteristic (ROC) curve analysis was performed for ≥ grade 2 (G2) rectal toxicity prediction. RESULTS: The follow-up duration was 10.1-115.2 months (median 60.5 months). Seven patients had G2 rectal hemorrhage, and none of the patients had grade 3 rectal hemorrhage. In the univariate analysis, the rectal volume receiving 100% of the prescribed dose (rV100) (p < 0.001), the dose covering 2 cc of the rectum (rD2cc) during LDR-BT (p = 0.002), and the combined rD2cc during LDR-BT and VMAT (p = 0.001) were identified as predictors of G2 rectal hemorrhage. In the ROC curve analysis, the cutoff value was 0.46 cc for rV100, 74.0 Gy for rD2cc, and 86.8 GyEQD2 for combined rD2cc. CONCLUSION: Predictors of late ≥ G2 rectal hemorrhage are rV100, rD2cc, and combined rD2cc. The incidence of rectal toxicity is low and acceptable in this setting and is highly dependent on the rectal dose of LDR-BT. The use of higher-quality LDR-BT and VMAT dose constraints may further reduce the rate of rectal hemorrhage.