Three cases of relapsed eosinophilic sinusitis without eosinophilia during mepolizumab maintenance therapy for eosinophilic granulomatosis with polyangiitis

We present three cases of eosinophilic granulomatosis with polyangiitis (EGPA) where patients experienced relapse of eosinophilic sinusitis without peripheral eosinophilia while on remission maintenance therapy with mepolizumab (MPZ), an anti-interleukin (IL)-5 monoclonal antibody. Despite the initial control of symptoms with high-dose prednisolone (PSL) and MPZ, patients experienced a relapse of nasal obstruction and eosinophilic infiltration in nasal mucosal biopsies. Notably, relapses occurred despite normal peripheral eosinophil counts, indicating the localized nature of eosinophilic inflammation. While IL-5 inhibitors effectively reduce peripheral blood eosinophils, eosinophilic sinusitis may persist due to local factors such as IL-4-mediated inflammation. IL-4 has been implicated in promoting eosinophil migration into nasal tissues, suggesting that IL-5 inhibitors alone may not sufficiently suppress eosinophilic infiltration in such cases. These findings highlight the importance of considering the possibility of eosinophilic sinusitis relapse in EGPA patients treated with IL-5 inhibitors and reduced glucocorticoid doses. Further research is warranted to elucidate the mechanisms underlying local eosinophilic inflammation and optimize treatment strategies for EGPA patients.

Characteristics of the magnetic resonance imaging findings of cervical gastric-type adenocarcinoma

AIMS

This study identified the distinct magnetic resonance imaging findings of cervical gastric-type adenocarcinoma (GAS) that can help differentiate it from squamous cell carcinoma (SCC) and usual-type endocervical adenocarcinoma (UEA) and reveal the radiologic-pathologic correlation.

MATERIALS AND METHODS

All consecutive patients with cervical GAS treated at our hospital from November 2009 to August 2021 were included. The SCC and UEA cases were considered controls. Tumor location, tumor shape, presence and size of cysts, presence of uterine fluid, and apparent diffusion coefficient (ADC) were evaluated.

RESULTS

Overall, 18 GAS, 55 SCC, and 23 UEA cases were evaluated. The tumor was located in the entire cervix in 13/18 GAS cases, whereas it was predominantly located in the lower cervix in 38/55 SCC cases and 14/23 UEA cases. Most GAS cases exhibited a diffuse infiltration growth pattern (17/18), whereas most SCC and UEA cases exhibited a mass-forming pattern (39/55 and 20/23, respectively). Moreover, the percentages of cases presenting microcysts or macrocysts and undergoing uterine fluid collection were significantly higher in the GAS group (14/18 and 13/18) than in the SCC and UEA groups. ADC was significantly higher in the GAS group than in the SCC group (1.092 × 10-3 vs. 0.819 × 10-3 mm2/s).

CONCLUSION

This study revealed that GAS is characterized by tumor presence in the entire cervix, infiltrative growth pattern, intrauterine fluid collection, and frequent microcyst or macrocyst formation. Moreover, ADC was significantly higher in the GAS group than in the SCC group.

Pharmacokinetics of monoclonal antibodies locally-applied into the middle ear of guinea pigs

Countless therapeutic antibodies are currently available for the treatment of a broad range of diseases. Some target molecules of therapeutic antibodies are involved in the pathogenesis of sensorineural hearing loss (SNHL), suggesting that SNHL may be a novel target for monoclonal antibody (mAb) therapy. When considering mAb therapy for SNHL, understanding of the pharmacokinetics of mAbs after local application into the middle ear is crucial. To reveal the fundamental characteristics of mAb pharmacokinetics following local application into the middle ear of guinea pigs, we performed pharmacokinetic analyses of mouse monoclonal antibodies to FLAG-tag (FLAG-mAbs), which have no specific binding sites in the middle and inner ear. FLAG-mAbs were rapidly transferred from the middle ear to the cochlear fluid, indicating high permeability of the round window membrane to mAbs. FLAG-mAbs were eliminated from the cochlear fluid 3 h after application, similar to small molecules. Whole-body autoradiography and quantitative assessments of cerebrospinal fluid and serum demonstrated that the biodistribution of FLAG-mAbs was limited to the middle and inner ear. Altogether, the pharmacokinetics of mAbs are similar to those of small molecules when locally applied into the middle ear, suggesting the necessity of drug delivery systems for appropriate mAb delivery to the cochlear fluid after local application into the middle ear.

Epigenetic Regulation of Ameloblast Differentiation by HMGN Proteins

Dental enamel formation is coordinated by ameloblast differentiation, production of enamel matrix proteins, and crystal growth. The factors regulating ameloblast differentiation are not fully understood. Here we show that the high mobility group N (HMGN) nucleosomal binding proteins modulate the rate of ameloblast differentiation and enamel formation. We found that HMGN1 and HMGN2 proteins are downregulated during mouse ameloblast differentiation. Genetically altered mice lacking HMGN1 and HMGN2 proteins show faster ameloblast differentiation and a higher rate of enamel deposition in mice molars and incisors. In vitro differentiation of induced pluripotent stem cells to dental epithelium cells showed that HMGN proteins modulate the expression and chromatin accessibility of ameloblast-specific genes and affect the binding of transcription factors epiprofin and PITX2 to ameloblast-specific genes. Our results suggest that HMGN proteins regulate ameloblast differentiation and enamel mineralization by modulating lineage-specific chromatin accessibility and transcription factor binding to ameloblast regulatory sites.

Clinical Utility of Machine Learning Methods Using Regression Models for Diagnosing Eosinophilic Chronic Rhinosinusitis

Objective

Machine learning methods using regression models can predict actual values of histological eosinophil count from blood eosinophil levels. Therefore, these methods might be useful for diagnosing eosinophilic chronic rhinosinusitis, but their utility still remains unclear. We compared 2 statistical approaches, and investigated the utility of machine learning methods for diagnosing eosinophilic chronic rhinosinusitis.

Study Design

Retrospective study.

Setting

Medical center.

Methods

Data, including eosinophilic levels, obtained from blood and sinonasal samples of 264 patients with chronic rhinosinusitis (257 with and 57 without nasal polyps) were analyzed. We determined factors affecting histopathological eosinophil count in regression models. We also investigated optimal cutoff values for blood eosinophil percentages/absolute eosinophil counts (AECs) through receiver operating characteristic curves and machine-learning methods based on regression models. A histopathological eosinophil count ≥10/high-power field was defined as eosinophilic chronic rhinosinusitis.

Results

Blood eosinophil levels, nasal polyp presence, and comorbid asthma were factors affecting histopathological eosinophil count. Cutoffs between the 2 statistical approaches differed in the group with nasal polyps, but not in one without nasal polyps. Machine-learning methods identified blood eosinophil percentages ≥1% or AEC ≥100/μL as cut-offs for eosinophilic chronic rhinosinusitis with nasal polyps, while ≥6% or ≥400/μL for one without nasal polyps.

Conclusion

Cut-offs of blood eosinophil levels obtained by machine-learning methods might be useful when suspecting eosinophilic chronic rhinosinusitis prior to biopsy because of their ability to adjust covariates, dealing with overfitting, and predicting actual values of histological eosinophil count.

Effects of Unrestricted Kinematically Aligned Total Knee Arthroplasty with a Modified Soft-Tissue Respecting Technique on the Deformity of Limb Alignment in Japanese Patients

Background and Objectives: Unrestricted kinematic alignment total knee arthroplasty (KA-TKA) with a soft-tissue respecting technique (STRT) is a soft-tissue-dependent tibial resection entailing the restoration of the original soft-tissue tension using ligamentotaxis after resurfacing the femur, based on the concept of restoring the native or pre-osteoarthritis alignment in each patient. However, there is no consensus on the indications of unrestricted KA-TKA with the STRT. We modified the STRT, followed by an investigation of the effects of surgery on the postoperative hip-knee-ankle angle (HKAA). Materials and Methods: We retrospectively analyzed the clinical background data, including the preoperative and postoperative HKAA, of 87 patients who underwent unrestricted KA-TKA with the modified STRT. Univariate and multivariate analyses were performed to determine the factors affecting the postoperative HKAA. A receiver operating characteristic (ROC) curve was plotted to investigate the change in the cut-off values of preoperative HKAA with respect to the safe zone of the postoperative HKAA. We generated two regression models, the linear regression model and generalized additive model (GAM) using machine learning, to predict the postoperative HKAA. Results: Univariate and multivariate analyses revealed the preoperative HKAA as the factor most relevant to the postoperative HKAA. ROC analysis revealed that the preoperative HKAA exhibited a high predictive utility, with a cut-off value of -10°, when the safe range of postoperative HKAA was set at ±5°. The GAM was the superior machine learning model, indicating a non-linear association between the preoperative and postoperative HKAA. Patients with preoperative HKAAs ranging from -18° to 4° were more likely to fall within the ±5° safe range of the postoperative HKAA. Conclusions: The preoperative HKAA influences the postoperative HKAA in unrestricted KA-TKA with the modified STRT. Machine learning using the GAM may contribute to the selection of patients eligible for the surgical approach.

Comorbidity of eosinophilic chronic rhinosinusitis in chronic eosinophilic pneumonia

We aimed to elucidate details of comorbid chronic rhinosinusitis (CRS) in chronic eosinophilic pneumonia (CEP) under the collaboration between otolaryngologists and pulmonologists in a prospective study. The CEP diagnosis was performed by pulmonologists based on clinical symptoms, laboratory findings, and/or eosinophilia detected in bronchoalveolar lavage. All patients were referred to otolaryngologists before undergoing oral corticosteroid treatment for CEP. Ten CEP cases visited to otolaryngologists. All cases showed bilateral sinonasal inflammation in computed tomography (CT), indicating comorbid CRS. Nasal polyps (NPs) were observed in 50% of patients on endoscopy. Eighty percent of patients were diagnosed with eosinophilic CRS. In blood eosinophil levels and the mucosal eosinophil count, there were no significant differences between CRS without and with NPs. In Lund-Mackay CT total scores, among-individual variability was observed in CRS with NPs. The collaboration revealed blood/sinonasal eosinophilia and the variability in Lund-Mackay CT total scores as remarkable findings about the comorbid CRS.

Psychological states affecting initial pupil size changes after olfactory stimulation in healthy participants

Odor perception affects physiological and psychological states. Pupillary light reflex (PLR) parameters can be affected by olfactory stimulation and psychological states, although it remains unclear whether the olfactory stimulation-induced psychological changes can associate with PLR parameter changes. This study aimed to investigate effects of olfactory stimulation-induced psychological changes on PLR parameter changes with repeated measurements. We collected data on six mood subscales of the profile of mood states, and on five PLR parameter measurements from 28 healthy participants. Participants underwent a 10-min olfactory stimulation on different days with six odorants available with the T&T olfactometer. As obtained data were clustered, we used linear mixed-effects models for statistical analyses. The olfactory stimulation using the no-odor liquid did not affect mood states and the initial pupil size (INIT). The sweat odorant worsened all mood subscales including fatigue-inertia (Fatigue)/Vigor-Activity (Vigor), and decreased INIT compared to the no-odor liquid. When comparing INIT responses related to changes in mood subscales between the no-odor liquid and the sweat odorant, worsened states of Fatigue/Vigor were associated with decreased INIT in the sweat odorant. Fatigue/Vigor can be used as mental fatigue indicators. Thus, mental fatigue can be associated with decreased INIT in the olfactory stimulation.

Recommendation of using both initial pupil size and constriction latency in pupillary light reflex as objective indicators reflecting subacute pain-related mental fatigue

A previous study examining clinical subacute pain models under different methodological conditions showed that pain-induced mental fatigue can be associated with decreased initial pupil size (INIT)/shortened constriction latency (LAT) in the pupillary light reflex (PLR). We aimed to investigate the potential of INIT/LAT as objective indicators reflecting mental fatigue under the same methodological conditions. We recruited 118 patients planning to undergo three types of representative otolaryngological head and neck surgery procedures. We used the numerical rating scale (NRS) to assess subjective pain intensity and two mental fatigue-related mood categories of the Profile of Mood States, as well as INIT and LAT measurements (1) in the afternoon one day before surgery (pre1-surgery), (2) in the morning of the day of surgery (pre2-surgery), and (3) in the morning of the day following surgery (post-surgery). We assessed time point-dependent changes using one- or two-way analysis of variance, as well as responses of PLR parameters to mental fatigue using linear mixed-effects models (LMMs). As a result, NRS scores, the two mood categories, as well as LAT and INIT, showed significant time point-dependent changes. In post-hoc analyses, only INIT showed significant changes between the two pre-surgery time points. Thus, INIT values fluctuated even under pain-free conditions due to differences in the time of the day. LMMs demonstrated decreased INIT/shortened LAT related to mental fatigue. All surgical groups showed similar associations between mental fatigue and INIT/LAT findings. As each parameter has advantages and disadvantages, it is recommended to use both INIT and LAT as the indicators.

Alterations in prefrontal cortical neuregulin-1 levels in post-pubertal rats with neonatal ventral hippocampal lesions

Genetic studies in humans have implicated the gene encoding neuregulin-1 (NRG-1) as a candidate susceptibility gene for schizophrenia. Furthermore, it has been suggested that NRG-1 is involved in regulating the expression and function of the N-methyl-D-aspartate receptor and the GABA_A receptor in several brain areas, including the prefrontal cortex (PFC), the hippocampus, and the cerebellum. Neonatal ventral hippocampal lesioned (NVHL) rats have been considered as a putative model for schizophrenia with characteristic post-pubertal alteration in response to stress and neuroleptics. In this study, we examined NRG-1, erb-b2 receptor tyrosine kinase 4 (erbB4), and phospho-erbB4 (p-erbB4) levels in the PFC and the distribution of NRG-1 in the NVHL rats by using immunoblotting and immunohistochemical analyses. Neonatal lesions were induced by bilateral injection of ibotenic acid in the ventral hippocampus of postnatal day 7 Sprague-Dawley (SD)-rats. NVHL rats showed significantly decreased levels of NRG-1 and p-erbB4 in the PFC compared to sham controls at post-pubertal period, while the level of erbB4 did not differ between sham and NVHL rats. Moreover, microinjection of NRG-1 into the mPFC improved NVHL-induced prepulse inhibition deficits. Our study suggests PFC NRG-1 alteration as a potential mechanism in schizophrenia-like behaviors in the NVHL model.

Infants’ Prediction of Humanoid Robot’s Goal-Directed Action

Several studies have shown that infants anticipate human goal-directed actions, but not robot’s ones. However, the studies focusing on the robot goal-directed actions have mainly analyzed the effect of mechanical arms on infant’s attention. To date, the prediction of goal-directed actions in infants has not yet been studied when the agent is a humanoid robot. Given this lack of evidence in infancy research, the present study aims at analyzing infants’ action anticipation of both a human’s and a humanoid robot’s goal-directed action. Data were acquired on thirty 17-month-old infants, watching four video clips, where either a human or a humanoid robot performed a goal-directed action, i.e. reaching a target. Infants looking behavior was measured through the eye-tracking technique. The results showed that infants anticipated the goal-directed action of both the human and the robot and there were no differences in the anticipatory gaze behavior between the two agents. Furthermore, the findings indicated different attentional patterns for the human and the robot, showing a greater attention paid to the robot's face than the human’s face. Overall, the results suggest that 17-month-old infants may infer also humanoid robot’ underlying action goals.

Decreased initial pupil size and shortened constriction latency due to negative mood states and mental fatigue in clinical subacute pain models

Previous clinical studies on pupillary light reflex parameters showed shortened constriction latency (LAT) and decreased initial pupil size (INIT) due to increased numeric rating scale (NRS) scores, reflecting subjective pain intensity, in subacute pain models. As noxious stimulation causes pupil dilation, decreased INIT (pupil constriction) was an unexpected finding. Pain-related negative moods and mental fatigue might have caused this finding. We aimed to investigate how psychological states affect LAT/INIT in two subacute pain models. For psychological assessment, we used the Profile of Mood States (POMS) and calculated the total mood disturbance (TMD) score using six mood categories. We collected data on NRS scores, POMS-related scores, LAT, and INIT through a longitudinal study. Using linear mixed-effects models, we evaluated the association of TMD scores with NRS scores, LAT, and INIT. Furthermore, we performed subanalyses targeting two mood categories that represent mental fatigue: Fatigue-Inertia (Fatigue) and Vigor-Activity (Vigor). We investigated whether obtained results can be identical in both models. In total, 141 patients were enrolled. Increased NRS scores were associated with increased TMD/Fatigue scores and decreased Vigor scores, being associated with shortened LAT/decreased INIT in both models. Score changes in NRS, TMD, Fatigue, and Vigor indicated that increased subjective pain intensity can be associated with negative mood states, especially mental fatigue. This study revealed that negative moods and mental fatigue induced by acute pain can be associated with shortened LAT/decreased INIT in both models, indicating clinical potential of LAT/INIT as objective indicators reflecting the psychological states for pain assessment.

Current status of countermeasures for ageing of nuclear power plants in Japan

This paper summarizes ageing countermeasure program of the nuclear power plants performed by the Japanese Government and industries and related activities, and describes current research program and utilization of the research results for the aged nuclear power plants. Regulatory bodies (NISA of METI: Nuclear and Industrial Safety Agency of the Ministry of Economy, Trade and Industry') reviewed the ageing issues of nuclear power plants to enhance countermeasures for the aged plants. Nuclear Power Plant Life Engineering Center (PLEC) entrusted by NISA is carrying out the task relating to the aged plants.

Clinical potential of pupillary light reflex and heart rate variability parameters as objective indicators of tonsillectomy-induced pain

Establishing objective indicators of subjective pain intensity is important in pain assessment. Pupillary light reflex (PLR) and heart rate variability (HRV) indicate autonomic nervous system (ANS) activity and may serve as pain indicators because pain can affect ANS activity. In this prospective longitudinal study, we aimed to investigate the potential of PLR/HRV parameters as objective indicators of subjective pain intensity after tonsillectomy. Sixty-seven patients undergoing tonsillectomy were enrolled. Subjective pain intensity based on a numeric rating scale (NRS) and eight PLR/HRV parameters were assessed at five time points. We investigated the changes in the NRS values over time. We estimated regression coefficients reflecting parameter changes per unit change in the NRS score using linear mixed-effects models. The mean NRS score was 0 at two pre-surgery time points, 5 on postoperative days (PODs) 1 and 2, and 0 at postoperative week 3. Two parameters (initial pupil size [INIT] and constriction latency [LAT]) showed significant changes on POD1 and POD2 in comparison to baseline data measured at the pre-surgery time point. Among these parameters, only LAT showed no significant changes between POD1 and POD2. Significant regression coefficients with the narrowest 95% confidence intervals were observed for INIT and LAT. Increased NRS scores were associated with decreased INIT and shortened LAT. LAT was a robust indicator of subjective pain intensity. Our patients showed decreased INIT with increased NRS scores, indicating the predominance of the parasympathetic, not sympathetic, tone in pupils. Further studies are required to investigate factors causing this predominance.

Long working hours, depression and suicidality among OB/GYNs in Japan

Background

There is abundant evidence linking long working hours among physicians with adverse health effects; however, most studies have focused on medical residents. In Japan, obstetrician/gynaecologists (OB/GYNs) work the longest hours, yet no studies have investigated potential relationships between excessive overtime and depression and suicidal ideation within this population.

Aims

To investigate the relationship between long working hours and depression and suicidal ideation among OB/GYNs in Japan.

Methods

We administered a survey questionnaire to OB/GYNs and received 919 valid responses. Multivariate logistic regression was performed with depression and suicidal ideation as the outcome variables and number of working hours per week, gender, age, marital status, hospital type and geographical area type as the explanatory variables.

Results

Sixteen per cent of the participants were depressed, and 3% reported suicidal ideation. Working 100 or more hours per week increased the odds for both depression and suicidal ideation [odds ratio (OR): 2.08 (95% confidence interval {CI}: 1.07–4.05, P = 0.03); and OR: 7.03 (95% CI: 1.95–25.38, P < 0.001), respectively].

Conclusions

The results suggest that the Japanese Government should vigorously promote physicians’ work-style reform, so that a lowered upper limit of overtime hours will be enforced from 2024 to improve physicians’ health and patients’ safety.

Clinical factors affecting pupillary light reflex parameters: a single-centre, cross-sectional study

PURPOSE

To evaluate the effects of stimulus intensity, aging, sex, smoking and eye symmetry on pupillary light reflex (PLR) parameters.

METHODS

We evaluated 2812 eyes from 1406 subjects in a single-centre, cross-sectional study. PLR data were collected using four different stimulus intensities. We prepared two models for each of the eight PLR parameters, and defined the model with the lowest values of Akaike's information criterion (AIC) as being the best-fit. Model A was a linear regression model without adjustment for among-individual variability, while the Model B linear mixed-effects models (LMMs) were adjusted for among-individual variability. The regression coefficients of the two models were compared.

RESULTS

Model B showed the lowest AIC values for all parameters and the best fit. For light stimulus intensity, age and eye symmetry, the two models yielded similar results for all PLR parameters. For sex and smoking index, some PLR parameters showed the opposite results, i.e., Model A showed significant effects while Model B did not.

CONCLUSION

These results indicate that light stimulus intensity, aging, sex, smoking and eye symmetry are factors that affect PLR parameters. These should be adjusted when evaluating the clinical potential of PLR as a diagnostic tool. In addition, adjusting for among-individual variability due to LMMs can improve the model fit and reduce false positives. This can reveal the association between clinical factors and PLR parameters with increased accuracy.

Quantification of Oscillatory Shear Stress from Reciprocating CSF Motion on 4D Flow Imaging

BACKGROUND AND PURPOSE

Oscillatory shear stress could not be directly measured in consideration of direction, although cerebrospinal fluid has repetitive movements synchronized with heartbeat. Our aim was to evaluate the important of oscillatory shear stress in the cerebral aqueduct and foramen magnum in idiopathic normal pressure hydrocephalus by comparing it with wall shear stress and the oscillatory shear index in patients with idiopathic normal pressure hydrocephalus.

MATERIALS AND METHODS

By means of the 4D flow application, oscillatory shear stress, wall shear stress, and the oscillatory shear index were measured in 41 patients with idiopathic normal pressure hydrocephalus, 23 with co-occurrence of idiopathic normal pressure hydrocephalus and Alzheimer-type dementia, and 9 age-matched controls. These shear stress parameters at the cerebral aqueduct were compared with apertures and stroke volumes at the foramen of Magendie and cerebral aqueduct.

RESULTS

Two wall shear stress magnitude peaks during a heartbeat were changed to periodic oscillation by converting oscillatory shear stress. The mean oscillatory shear stress amplitude and time-averaged wall shear stress values at the dorsal and ventral regions of the cerebral aqueduct in the idiopathic normal pressure hydrocephalus groups were significantly higher than those in controls. Furthermore, those at the ventral region of the cerebral aqueduct in the idiopathic normal pressure hydrocephalus group were also significantly higher than those in the co-occurrence of idiopathic normal pressure hydrocephalus with Alzheimer-type dementia group. The oscillatory shear stress amplitude at the dorsal region of the cerebral aqueduct was significantly associated with foramen of Magendie diameters, whereas it was strongly associated with the stroke volume at the upper end of the cerebral aqueduct rather than that at the foramen of Magendie.

CONCLUSIONS

Oscillatory shear stress, which reflects wall shear stress vector changes better than the conventional wall shear stress magnitude and the oscillatory shear index, can be directly measured on 4D flow MR imaging. Oscillatory shear stress at the cerebral aqueduct was considerably higher in patients with idiopathic normal pressure hydrocephalus.