Background We evaluated the possibility of diagnosing pleural mesothelioma (PM) through pleural effusion cytology in a multicentric prospective clinical trial (MesoCyto study). Methods We included patients with pleural effusion and suspected PM scheduled for thoracentesis and pleural biopsy. Both pleural effusion cytology including cell block and pleural histology were independently performed and compared to assess the diagnostic reliability of pleural effusion cytology. The primary endpoint aimed to demonstrate that the specificity of PM diagnosis by pleural effusion cytology reached 100%. Secondary endpoints included the frequency of adverse events during thoracentesis and pleural biopsy and assessment of diagnostic accuracy of pleural effusion cytology for each histological type. Results Of the 50 enrolled patients, histological examination confirmed PM in 42 patients. Whereas in pleural effusion cytology, 29 patients met the diagnostic criteria of PM, 7 patients did not meet the criteria, and 13 patients did not observe atypical cells. All 29 cytologically positive patients were histologically diagnosed as PM, and 8 histologically negative patients did not meet the criteria of pleural effusion cytology, therefore the specificity of pleural effusion cytology was 100%. The diagnostic concordance rate by pleural effusion cytology for each histological type was 72.2% for epithelioid, 75% for biphasic, and 0% for sarcomatoid. No adverse events were associated with thoracentesis, but the incidence of adverse events during pleural biopsy was 14%. Conclusions Pleural cytology using the cell block technique and immunohistochemical staining can provide a definitive diagnosis in many cases of PM.

Abstract Background Left atrial low-voltage areas (LVAs) were known to be associated with atrial fibrosis and atrial fibrillation (AF) recurrence after catheter ablation. However, the association between body mass index (BMI) and prevalence of LVAs has not been fully elucidated. We hypothesized that LVAs were more frequently found in patients with abnormal BMI than in those with normal BMI. Purpose The purpose of this study was to clarify the association between body mass index (BMI) and the prevalence of LVAs in patients with AF ablation. Methods Between December 2014 and March 2022, 1,479 (age, 68±10 years; female, 500 [34%]) consecutive patients who underwent initial AF ablation were enrolled. BMI was divided into four groups, namely <18.5 kg/m², 18.5-25 kg/m², 25-30 kg/m², ≥30 kg/m². LVAs was defined as areas with bipolar voltage of <0.5 mV covered ≥5 cm² of left atrium. Rhythm outcome following the catheter ablation procedure was also followed for 24 months. Results LVAs were found in 349 (24%) patients. J-curved phenomenon existed between BMI and the prevalence of LVAs (Figure 1). In particular, BMI <18.5 kg/m² was an independent predictor of LVAs on multivariate analysis (odds ratio, 1.9; 95% confidence interval: 1.01–3.5; p=0.046). As for rhythm outcome, there was significant difference in freedom from AF recurrence among groups stratified by BMI (Figure 2). Conclusions Between BMI and the prevalence of LVAs, J-curved phenomenon existed in patients with AF ablation. There was significant difference in rhythm outcome following AF ablation among groups stratified by BMI.Figure 1Figure 2

Abstract Introduction Diabetes mellitus (DM) is a well-known cause of atrial remodeling in patients with atrial fibrillation (AF). Although additional left atrial ablation following pulmonary vein isolation (PVI) is a strategy to modify AF substrate, its efficacy has not been well elucidated in patients with DM. We hypothesized that the efficacy of additional ablation was different in patients with DM and in those without. Purpose The purpose of this study was to investigate the efficacy of additional ablation following PVI in patients with or without DM. Methods The EARNEST-PVI was a multicenter, prospective, randomized controlled trial. In this sub-analysis, 493 consecutive patients of persistent AF (age, 65 ± 9 years; female, 120 [24%] patients) who underwent the initial radiofrequency catheter ablation were analyzed. Patients were randomized to be treated with PVI only (PVI-alone) or PVI plus linear and/or complex fractionated atrial electrogram ablation (PVI-plus). Primary outcome measure was defined as AF recurrence during the 12 months follow-up periods. Results In total, 84 (17%) patients had DM. Primary outcome occurred in 120 (24%) patients. In patients without DM, freedom from AF recurrence was significantly higher in PVI-plus group than in PVI-alone group (80.0% versus 71.1%, p=0.03) (Figure 1A). Conversely, in patients with DM, freedom from AF recurrence was similar between PVI-plus group and PVI-alone group (75.4% versus 72.9%, p=0.70) (Figure 1B). Conclusion Additional ablation following PVI reduced AF recurrence after radiofrequency catheter ablation only in patients without DM.Figure 1

Abstract Background Although left atrial additional ablation other than pulmonary vein (PV) isolation is often performed in order to modify arrhythmogenic substrate, rhythm outcome in patients with long-standing persistent atrial fibrillation (LS-PerAF) is still challenging. Left atrial low-voltage areas (LVAs) is correlated with degeneration of atrial myocardium, and atrial fibrillation (AF) recurrence following catheter ablation. However, in patients with LS-PerAF, the association between the prevalence of LVAs and rhythm outcome has not been clarified. We hypothesized that AF recurrence after AF ablation more frequently occurred in patients with LVAs than in those without, and that the prevalence of LVAs was associated with the efficacy of left atrial additional ablation. Purpose The purpose of this study was to investigate the association between the prevalence of LVAs and rhythm outcome or efficacy of left atrial additional ablation in patients with LS-PerAF ablation. Methods In total, 123 (age, 66 ± 9 years; female, 28 [23%]) consecutive patients who underwent initial ablation for LS-PerAF were included. Left atrial additional ablation was defined as an ablation for left atrium other than PV isolation and ablation for non-PV foci. The definition of LVAs was sites with a bipolar voltage of <0.5 mV covering ≥5 cm² of left atrium. Rhythm outcome after the catheter ablation was followed for 24 months. Results LVAs was found in 31 (25%) patients, and left atrial additional ablation was performed for 31 (25%) patients. Freedom from AF recurrence was significantly lower in patients with LVAs than in those without (Figure 1A). In contrast, freedom from AF recurrence was similar between patients with left atrial additional ablation and those without (Figure 1B). In patients without LVAs, freedom from AF recurrence was significantly higher in patients with left atrial additional ablation than in those without (Figure 2A). On the contrary, in patients with LVAs, freedom from AF recurrence during was similar between patients with left atrial additional ablation and those without (Figure 2B). Conclusions In patients undergoing LS-PerAF ablation, AF recurrence more frequently occurred in patients with LVAs than in those without. Only in patients without LVAs, freedom from AF recurrence was significantly higher in patients with left atrial additional ablation than in those without.Figure 1Figure 2

Regulation of lineage biases in hematopoietic stem and progenitor cells (HSPCs) is pivotal for balanced hematopoietic output. However, little is known about the mechanism behind lineage choice in HSPCs. Here, we show that messenger RNA (mRNA) decay factors regnase-1 (Reg1; Zc3h12a) and regnase-3 (Reg3; Zc3h12c) are essential for determining lymphoid fate and restricting myeloid differentiation in HSPCs. Loss of Reg1 and Reg3 resulted in severe impairment of lymphopoiesis and a mild increase in myelopoiesis in the bone marrow. Single-cell RNA sequencing analysis revealed that Reg1 and Reg3 regulate lineage directions in HSPCs via the control of a set of myeloid-related genes. Reg1- and Reg3-mediated control of mRNA encoding Nfkbiz, a transcriptional and epigenetic regulator, was essential for balancing lymphoid/myeloid lineage output in HSPCs in vivo. Furthermore, single-cell assay for transposase-accessible chromatin sequencing analysis revealed that Reg1 and Reg3 control the epigenetic landscape on myeloid-related gene loci in early stage HSPCs via Nfkbiz. Consistently, an antisense oligonucleotide designed to inhibit Reg1- and Reg3-mediated Nfkbiz mRNA degradation primed hematopoietic stem cells toward myeloid lineages by enhancing Nfkbiz expression. Collectively, the collaboration between posttranscriptional control and chromatin remodeling by the Reg1/Reg3-Nfkbiz axis governs HSPC lineage biases, ultimately dictating the fate of lymphoid vs myeloid differentiation.

Abstract Background Although left atrial low-voltage areas (LVAs) are well-known indicator of atrial fibrosis and atrial fibrillation (AF) recurrence after catheter ablation, the association between anemia and prevalence of LVAs has not been clarified. We hypothesized that LVAs were more frequently found in patients with anemia than in those with normal hemoglobin levels. Purpose The purpose of this study was to investigate the association between hemoglobin levels and the prevalence of LVAs in patients with AF ablation. Methods In total, 1,473 (age, 68±10 years; female, 492 [33%]; persistent AF, 895 [61%]; CHA2DS2-VASc score, 2.5±1.5 points) consecutive patients who underwent initial AF ablation were enrolled in this study. Hemoglobin levels were measured before the ablation procedure, and anemia was defined as hemoglobin levels < 13.5 g/dL in male and < 12.0 g/dL in female. LVAs was defined as areas with bipolar voltage of <0.5 mV covered ≥5 cm² of left atrial surface area. Results Of 1,473 patients, LVAs existed in 348 (24%) patients. Hemoglobin levels was significantly lower in patients with LVAs than those without (13.4 ± 1.7 vs. 14.2 ± 1.5 g/dL, p <0.001). On classification by gender, only in male, hemoglobin levels were significantly lower in patients with LVAs than those without (Figure 1). The prevalence of LVAs increased with decreasing hemoglobin levels (Figure 2). On multivariate analysis including gender as a variable, anemia was an independent predictor of LVAs (odds ratio, 1.6; 95% confidence interval: 1.1–2.3; p=0.03). Conclusions The prevalence of LVAs increased with decreasing hemoglobin levels in patients with AF ablation. In particular, hemoglobin levels < 13.5 g/dL in male and < 12.0 g/dL in female was an independent predictor of LVA presence.Hemoglobin levels and LVAs presenceHemoglobin and the prevalence of LVAs

Abstract Background Femoropopliteal (FP) in-stent occlusion (ISO), which increases the risk of repetition of reintervention and worsens the limb prognosis, is substantially encountered in clinical setting.1,2 Although previous study demonstrated that dual pathway inhibitor therapy (DPIT) reduced major adverse cardiovascular and limb events, whether this would be effective as anti-thrombotic therapy after endovascular therapy (EVT) for FP-ISO.3 Purpose To investigate whether DPIT reduces a risk of recurrent ISO after EVT for FP-ISO. Methods We retrospectively studied 117 limbs (chronic limb-threatening ischemia: 52%, chronic total occlusion: 74%) in 110 symptomatic patients with lower extremity arterial disease (male: 55%, diabetes mellitus: 49%) due to FP-ISO between August 2012 and October 2021. We compared the clinical outcomes of patients who were switched from dual antiplatelet therapy (DAPT) to DPIT with those who continued DAPT (DPIT group: 25 limbs in 25 patients, DAPT group: 92 limbs in 85 patients) after FP-ISO revascularization. The outcome measures were recurrent ISO and bleeding complications defined as the bleeding academic research criteria (BARC) and the International Society on Thrombosis and Haemostasis (ISTH). Cox proportional hazards regression models were used to identify prognostic factor of recurrent ISO. Results The 1-year cumulative incidence of recurrent ISO was significantly lower in DPIT group. (24.0±9.4% vs. 54.1±5.8%, p=0.037, Figure 1). The 1-year cumulative incidence of bleeding complications were similar between two groups (BRAC 3 or 5 bleeding: 4.2% vs. 2.4%, p=0.63), ISTH major bleeding: 12.6% vs. 11.4%, p=0.86) (Figure 2). Multivariate analysis revealed that DPIT group (hazard ratio [HR]: 0.34, 95% confidential interval [CI] 0.13-0.86, P=0.004) significantly associated with a reduced risk of recurrent ISO, whereas higher age (HR: 1.05, 95%CI 1.01-1.09, P=0.006) and poor BTK run-off (HR: 4.77, 95%CI 1.76-12.91, P=0.002) were significantly associated with an increased risk. Conclusion Switching from DAPT to DPIT after EVT for FP-ISO reduced the risk of recurrent ISO without increasing the risk of bleeding, while higher age and poor BTK run-off increased the risk of recurrent ISO.Figure 1Figure 2

Table S4 includes immune signature and iCluster results.

BACKGROUND:Mesothelioma is a neoplastic disease associated with asbestos exposure. It is highly malignant and has a poor prognosis; thus, early detection is desirable. Recent whole-genome analysis has revealed that mesothelioma is characterized by a high frequency of mutations in a set of genes involved in the Hippo pathway, such as NF2 and LATS2. However, a rapid, simple, and precise method for finding mesothelioma with these mutations has not yet been established.METHODS:Clustering of Hippo pathway gene alteration groups and the differential expression of each gene in mesothelioma patients were analyzed using The Cancer Genome Atlas database. Gene expression levels in various tumors and normal tissues were analyzed using public databases. Knockdown or transient expression of YAP1 or TAZ was performed to evaluate the regulation of gene expression by these genes. NT-proBNP was measured in the pleural effusions of 18 patients and was compared with NF2 expression in five cases where cell lines had been successfully established.RESULTS:NPPB mRNA expression was markedly higher in the group of mesothelioma patients with Hippo pathway gene mutations than in the group without them. NPPB expression was low in all normal tissues except heart, and was highest in mesothelioma. Mesothelioma patients in the high NPPB expression group had a significantly worse prognosis than those in the low NPPB expression group. NPPB expression was suppressed by knockdown of YAP1 or TAZ. NT-proBNP was abundant in the effusions of mesothelioma patients and was particularly high in those with impaired NF2 expression.CONCLUSIONS:NPPB, whose levels can be measured in pleural effusions of mesothelioma patients, has the potential to act as a biomarker to detect NF2-Hippo pathway gene alterations and/or predict patient prognosis. Additionally, it may provide useful molecular insights for a better understanding of mesothelioma pathogenesis and for the development of novel therapies.

Table S7 contains microbe screening results.

Table S1 contains cohort description, Master Patient Table and MutSigCV results.

Table S2 contains BAP1 analysis results, as well as detailed lists of YY1 and IRF8 target genes.

Table S6 contains results from the analysis of DNA methylation in SETD2 mutated and BAP1 inactivated samples.

Supplementary materials and methods, as well as supplementary figures S1-S7.

Abstract Background/Introduction Antiplatelet therapy is the standard therapy after stent implantation. Stent thrombosis (ST) has dramatically decreased by appropriate antiplatelet therapy and advancement in stent technology, but remains a life-threatening event if it occurs. Some patients develop ST even under intensive antiplatelet therapy (dual antiplatelet therapy; DAPT). The association of prognosis of ST and antiplatelet therapy at the onset of ST is unclear. Purpose We aimed to investigate the association of prognosis and antiplatelet therapy at the onset of ST. Methods We used the database of Long-term Outcomes following Occurrence of Stent Thrombosis registry, a multicenter, retrospective, observational study (Long ST registry). Definite ST cases from January 2008 to December 2017 were enrolled, and long-term clinical outcomes were investigated. Results A total of 187 patients (male: 86.1%, median age at the time of ST: 69.0) were eligible. Ninety patients were under DAPT at the onset of ST (DAPT group), whereas 97 patients were under single antiplatelet therapy or no antiplatelet therapy (non-DAPT group). The median follow-up duration was 1054.0 (inter-quartile range, 239.5 – 1850.0) days. Findings of intravascular ultra sounds at the time of ST were similar between two groups. Patients in DAPT group were independently associated with higher incidence of major adverse cardiac events (MACE: a composite of cardiovascular death, nonfatal myocardial infarction, and target lesion revascularization) than in non-DAPT group (adjusted hazard ratio: 2.36, 95% confidence interval [1.27 - 4.34], P value = 0.006). Conclusion Patients who developed ST under DAPT were independently associated with a higher incidence of MACE than patients under single or no antiplatelet therapy.

Table S3 contains the karyotypes of 16 genome-wide LOH MPM cases from the BWH cohort.

Table S5 contains detailed miRs and lncRNAs results.

Background: Pulmonary arterial hypertension (PAH) is a type of pulmonary hypertension (PH) characterized by obliterative pulmonary vascular remodeling, resulting in right-sided heart failure. Although the pathogenesis of PAH is not fully understood, inflammatory responses and cytokines have been shown to be associated with PAH, in particular, with connective tissue disease-PAH. In this sense, Regnase-1, an RNase that regulates mRNAs encoding genes related to immune reactions, was investigated in relation to the pathogenesis of PH. Methods: We first examined the expression levels of ZC3H12A (encoding Regnase-1) in peripheral blood mononuclear cells from patients with PH classified under various types of PH, searching for an association between the ZC3H12A expression and clinical features. We then generated mice lacking Regnase-1 in myeloid cells, including alveolar macrophages, and examined right ventricular systolic pressures and histological changes in the lung. We further performed a comprehensive analysis of the transcriptome of alveolar macrophages and pulmonary arteries to identify genes regulated by Regnase-1 in alveolar macrophages. Results: ZC3H12A expression in peripheral blood mononuclear cells was inversely correlated with the prognosis and severity of disease in patients with PH, in particular, in connective tissue disease-PAH. The critical role of Regnase-1 in controlling PAH was also reinforced by the analysis of mice lacking Regnase-1 in alveolar macrophages. These mice spontaneously developed severe PAH, characterized by the elevated right ventricular systolic pressures and irreversible pulmonary vascular remodeling, which recapitulated the pathology of patients with PAH. Transcriptomic analysis of alveolar macrophages and pulmonary arteries of these PAH mice revealed that Il6, Il1b, and Pdgfa/b are potential targets of Regnase-1 in alveolar macrophages in the regulation of PAH. The inhibition of IL-6 (interleukin-6) by an anti–IL-6 receptor antibody or platelet-derived growth factor by imatinib but not IL-1β (interleukin-1β) by anakinra, ameliorated the pathogenesis of PAH. Conclusions: Regnase-1 maintains lung innate immune homeostasis through the control of IL-6 and platelet-derived growth factor in alveolar macrophages, thereby suppressing the development of PAH in mice. Furthermore, the decreased expression of Regnase-1 in various types of PH implies its involvement in PH pathogenesis and may serve as a disease biomarker, and a therapeutic target for PH as well.

AIM Genomic-based ancillary assays including immunohistochemistry (IHC) for BRCA-1 associated protein-1 (BAP1) and methylthioadenosine phosphorylase (MTAP), and fluorescence in situ hybridization (FISH) for CDKN2A are effective for differentiating pleural mesothelioma (PM) from reactive mesothelial proliferations. We previously reported a combination of MTAP and BAP1 IHC effectively distinguishes sarcomatoid PM from fibrous pleuritis (FP). Nevertheless, cases of sarcomatoid PM with desmoplastic features (desmoPM) are encountered where the IHC assessment is unclear. METHODS AND RESULTS We evaluated assessment of MTAP IHC, BAP1 IHC, and CDKN2A FISH in 20 desmoPM compared to 24 FP. MTAP and BAP1 IHC could not be assessed in 11 (55 %) and 10 (50 %) cases, respectively, due to loss or faint immunoreactivity of internal positive control cells, while CDKN2A FISH could be evaluated in all cases. The sensitivities for MTAP loss, BAP1 loss, and CDKN2A homozygous deletion in desmoPM were 40 %, 10 %, and 100 %. A combination of MTAP loss and BAP1 loss yielded 45 % of sensitivity. CONCLUSIONS MTAP IHC is a useful surrogate diagnostic marker in differentiating ordinary sarcomatoid PM from FP, but its effectiveness is limited in desmoPM. CDKN2A FISH is the most effective diagnostic assays with 100 % sensitivity and specificity in discriminating desmoPM from FP in the facilities where the FISH assay is available.