Kluyvera intermedia bacteremia with septic shock: A case report

Background

Kluyvera intermedia is a bacterium indigenous to humans. But Kluyvera intermedia bacteremia has been not reported thus far. We report a case of Kluyvera intermedia bacteremia with septic shock due to left obstructive pyelonephritis as a result of urolithiasis.

Case presentation

A 66-year-old woman with septic shock due to left obstructive pyelonephritis was transferred to our hospital. Tazobactam/Piperacillin 4.5 g was administered every 8 h for 5 days. The patient's condition improved, and she was transferred back to the previous hospital. Kluyvera intermedia was obtained by blood cultures. The patient was successfully treated with a two-week course of antibiotics.

Conclusions

We describe the first case of bacteremia with septic shock caused by Kluyvera intermedia. Kluyvera intermedia can be a causative pathogen of septic shock. Since this bacterium has not been reported in the past, we expect further reports and the accumulation of cases in the future.

Carotid endarterectomy for acute carotid thrombosis after carotid artery stenting with CASPER Rx® stent: A case report

Background

Acute carotid stent thrombosis (ACST) is a rare but devastating complication for carotid artery stenting (CAS). That requires early diagnosis and immediate treatment. Although administration of drugs or endovascular treatment is the most widely used approach for patients with ACST, there is no consensus on the standard treatment of this disease.

Case Description

The present study reports on an 80-year-old female patient with the right internal carotid artery stenosis (ICS) that had been followed up by ultrasonography for 8 years. Although the optimal medical treatment was followed, the patient's right ICS worsened, and the patient was subsequently hospitalized for CAS. On the 12^th day after CAS, left paralysis and dysarthria were observed. Head magnetic resonance imaging (MRI) showed acute obstruction of the stent and scattered cerebral infarction in the right cerebral hemisphere caused possibly by the discontinuation of temporary antiplatelet drug therapy as a means to prepare for embolectomy of the femoral artery. Stent removal and carotid endarterectomy (CEA) were selected as the appropriate treatment approach. CEA was performed with the precaution of stent removal and distal embolism, and complete recanalization was obtained. Postoperative head MRI showed no new findings of cerebral infarction, and the patients remained symptom-free after 6 months of postoperative follow-up.

Conclusion

Stent removal with CEA could be an appropriate curative option in some cases with ACST except in patients at high risk of CEA and in the chronic phase after CAS.

Quadricuspid Pulmonary Valve: Case Report and the Comparison with Quadricuspid Aortic Valve

BACKGROUND

Quadricuspid pulmonary valve (QPV) is a rare congenital anomaly. Simple QPV had been mainly diagnosed at the time of autopsy before 2000, and the frequency rates of QPV are approximately 0.02%-0.41%. QPV was initially diagnosed using transthoracic echocardiography (TTE) after 2000 and with contrast computed tomography (CT) or cardiac magnetic resonance imaging (CMR) after 2009. Obtaining the cross-sectional view of the pulmonary valve using TTE is difficult. We aimed to review the papers regarding the incidence, embryology, diagnosis, associated congenital heart anomalies, and prognosis in patients with QPV, and furthermore to compare with those in patients with quadricuspid aortic valve (QAV).

CASE PRESENTATION

We diagnosed QPV with mild stenosis in a 12-month-old infant. With a slight angulation of the transducer superiorly from the left high parasternal short-axis view, a short-axis view of QPV was obtained.

RESULTS

In QPV cases diagnosed at autopsy, Hurwitz's type-b with three equal cusps and one smaller cusp is dominant, whereas Hurwitz's type-a with four equal cusps is dominant in clinically diagnosed cases. Congenital heart anomaly and valvular stenosis are more frequent in patients with QPV than in patients with QAV. Coronary artery anomalies and infectious endocarditis are more frequent in patients with QAV than in patients with QPV. The incidence of PR is more common in type-a QPV than in type-b QPV. There is no difference between type-a QAV and type-b QAV with respect to the incidence of aortic regurgitation (AR). It is assumed that QPV is a risk factor for a Ross operation. However, QPVs have been used as autografts in certain patients.

CONCLUSION

Between QPV and QAV, various differences were found in frequency rates, diagnostic methods, valve morphology, valve function, associated congenital heart diseases, and frequencies of infectious endocarditis.

VEGFR-TKI treatment for radiation-induced brain injury after gamma knife radiosurgery for brain metastases from renal cell carcinomas

OBJECTIVE

Antiangiogenic vascular endothelial growth factor receptor tyrosine kinase inhibitors play an essential role in systemic therapy for renal cell carcinoma. Given the anti-edematous effect of bevacizumab, an antiangiogenic antibody targeting vascular endothelial growth factor, vascular endothelial growth factor receptor tyrosine kinase inhibitors should exert therapeutic effects on radiation-induced brain injury after stereotactic radiosurgery. This preliminary study aimed to investigate the therapeutic effect of vascular endothelial growth factor receptor tyrosine kinase inhibitor against radiation-induced brain injury.

METHODS

Magnetic resonance images for six patients treated with vascular endothelial growth factor receptor tyrosine kinase inhibitors who were diagnosed with radiation-induced brain injury following gamma knife radiosurgery were retrospectively reviewed.

RESULTS

The median brain edema volume and tumour mass volume in the pre-tyrosine kinase inhibitor period were 57.6 mL (range: 39.4-188.2) and 3.2 mL (range: 1.0-4.6), respectively. Axitinib, pazopanib (followed by cabozantinib) and sunitinib were administered in four, one and one cases, respectively. The median brain edema volume and tumour mass volume in the post-tyrosine kinase inhibitor period were 4.8 mL (range: 1.5-27.8) and 1.6 mL (range: 0.4-3.6), respectively. The median rates of reduction in brain edema volume and tumour mass volume were 90.8% (range: 51.9-97.6%) and 57.2% (range: 20.0-68.6%), respectively. The post-tyrosine kinase inhibitor values for brain edema volume (P = 0.027) and tumour mass volume (P = 0.008) were significantly lower than the pre-tyrosine kinase inhibitor values. Changes in volume were correlated with tyrosine kinase inhibitor use.

CONCLUSION

This study is the first to demonstrate the therapeutic effects of vascular endothelial growth factor receptor tyrosine kinase inhibitors on radiation-induced brain injury in patients with brain metastases from renal cell carcinoma treated via gamma knife radiosurgery.

Anterior transpetrosal approach for microvascular decompression associated with the dolichoectatic vertebrobasilar artery in two patients with refractory trigeminal neuralgia: Technical note

Background

Trigeminal neuralgia (TN) due to compression from the dolichoectatic vertebrobasilar artery (DVBA) is extremely rare and difficult to treat due to its morphological characteristics. We report two cases of good transposition of DVBA and postoperative course obtained using the anterior petrosal approach and a new vasoculopexy method.

Methods

We describe two cases of microvascular decompression (MVD) for refractory TN associated with DVBA. In both cases, MVD was performed through the anterior petrosal approach. The DVBA was decompressed using a GORE-TEX sling and WECK clip in an inferomedial direction.

Results

Complete pain relief without new neurological deterioration was achieved immediately in both patients.

Conclusion

We experienced a rare condition of TN due to exclusion by the DVBA. The anterior transpetrosal approach was extremely effective in this case. This approach secured the surgical field, allowed transposition of the DVBA, and caused no perioperative complications.

Primary midbrain germinoma relapse-free for 5 years: A case report

Background

The biology and clinical course of intracranial germinomas differ as per their location of occurrence. Germinoma of the primary midbrain is particularly rare, and its clinical features, treatment strategies, and long-term prognosis remain uncertain.

Case Description

A 39-year-old man who had been diagnosed with midbrain germinoma by open biopsy through the occipital transtentorial approach had undergone chemoradiotherapy and achieved 5 years with no recurrence.

Conclusion

Germinomas should be considered as a differential diagnosis for adolescents and young adult men with mesencephalic tumors, and reliable sampling followed by chemoradiotherapy must be performed.

Home and school interventions aided at-risk students' literacy during Covid-19: a longitudinal analysis

We examined whether different parent- and teacher-related factors had an effect on at-risk children's reading development during the first six months of the Covid-19 pandemic. Seventy Grade 1 English-speaking Canadian children (28 females, 42 males; M _age = 6.60, SD = 0.46) who were at-risk for reading difficulties were administered word and pseudoword reading, nonverbal IQ, and phonological awareness tasks before the school closures (February 2020; Time 1). Reading tasks were administered again when they returned to school in September 2020 (Time 2). In April-May 2020, their parents (n = 70) and teachers (n = 40) filled out a questionnaire on the home literacy environment and the frequency of teaching reading and providing reading materials, respectively. Results of multilevel regression analyses showed that children's reading enjoyment and home learning activities predicted both word and pseudoword reading at Time 2. Differentiation of instruction for struggling readers also predicted children's pseudoword reading at Time 2. These findings reinforce the important role of parents in their children's early reading development particularly when the typical agents of instruction (i.e., teachers) have less time and opportunities to interact with their students because of the pandemic.

How do I: Venous reconstruction of accidentally injured superficial sylvian vein during the clipping of an unruptured cerebral aneurysm

BACKGROUND

The transsylvian approach is a versatile treatment method for aneurysms of the anterior circulatory system. Studies have shown that sylvian veins run in various patterns, suggesting the need for dissection between veins to obtain appropriate surgical corridor. In case of inadvertent sylvian vein injury, serious complications such as venous congestion may occur.

METHOD

We herein describe the "side-to-side anastomosis reconstruction technique" of the resected superficial sylvian vein.

CONCLUSION

This technique can be effective for the reconstruction of other cortical veins, and indocyanine green videoangiography was effective in determining the indications for venous reconstruction.

Direct Clipping of Paraclinoid Aneurysm in Conjunction with Extradural Anterior Clinoidectomy: Technical Nuance and Functional Outcome

Objective Because of their anatomical features, treatment for paraclinoid aneurysms has remained to be challenging. Thus, the aim of this report is to prove the validity of our surgical method for unruptured paraclinoid aneurysms, together with surgical videos.

Study Design Between August 2017 and November 2019, we were able to perform surgical clipping for 11 patients with unruptured paraclinoid aneurysm using a completely unified method. This study investigated the effect of surgery on multiple measures, including visual impairment, brain contusion, temporalis muscle atrophy, and multiple neurocognitive functions.

Results Of the 67 unruptured aneurysms treated at our hospital, 17 were identified to be paraclinoid aneurysm, and 11 of them were treated by direct clipping using anterior clinoidectomy. Three were ophthalmic artery aneurysms, three were superior hypophyseal artery aneurysms, and five were anterior carotid wall aneurysms without branch projection. Only one patient had asymptomatic mild enlargement of the Marriott blind spots postoperatively. No brain contusion and temporalis muscle atrophy were observed in any cases. Only the Trail Making test (TMT) showed a significant worsening in the acute postoperative period: mean pre- and postoperative TMT scores were 59.1 ± 29.1 and 72.7 ± 37.3 for Part A (p = 0.018) and 80.5 ± 35.5 and 93.8 ± 39.9 for Part B (p = 0.030), respectively. However, it improved in the chronic phase.

Conclusion We can conclude that our surgical method is safe and can be considered an acceptable treatment. Although surgical stress can cause temporary executive dysfunction shortly after surgery, this decline is temporary.

Nodular fasciitis arising from the buccal region after segmentectomy with rapid growth mimicking postirradiation myxofibrosarcoma: A case report

RATIONALE

Nodular fasciitis (NF) can be misdiagnosed as a sarcoma because of its rapid growth and pathological features, such as nuclear atypia and mitoses.

PATIENT CONCERNS

We present a rare case of a 72-year-old Japanese man who developed NF with suspected postirradiation myxofibrosarcoma (MFS) after segmentectomy for left-sided osteoradionecrosis (ORN) of the mandible.

DIAGNOSIS

A mass appeared in the intraoral postoperative wound 1 year after left-sided mandibular segmentectomy and showed rapid growth, reaching a size of 50 mm within 2 months. Incisional biopsy revealed strongly Ki-67-positive spindle-shaped cells with large irregular nuclei and a diagnosis of postirradiation MFS.

INTERVENTIONS

The patient was diagnosed with oropharyngeal cancer (T4aN2bM0) and underwent surgical resection of primary oropharyngeal squamous cell carcinoma with selective neck dissection and reconstruction with a rectus abdominis musculocutaneous flap at the age of 57 years, followed by postoperative 66 Gy of radiotherapy combined with cisplatin administration. No recurrent or metastatic lesions of oropharyngeal squamous cell carcinoma have been detected for > 10 years. However, the ORN of the jaw worsened, and the patient underwent sequestrectomy 3 times on the right side of the mandible, followed by a left-sided segmentectomy at the age of 72 years. One year after segmentectomy, a 10-mm mass with soft-to-firm consistency appeared in the buccal mucosa of the wound and grew rapidly. An incisional biopsy revealed MFS. Complete resection under general anesthesia was immediately performed.

OUTCOMES

The histopathological diagnosis of the excised specimen was NF without any malignant findings. Two years after surgery, there was no evidence of recurrence or metastasis.

LESSONS

NF grows rapidly and has pathological features similar to sarcoma, making differential diagnosis difficult at the time of incisional biopsy. Further studies should be conducted to determine the clinical and pathological features of this tumor.

Traumatic pseudoaneurysm resulting from avulsion of the falcine branch of an azygos anterior cerebral artery: a case report

Traumatic anterior cerebral artery (ACA) aneurysms are extremely rare. Traumatic anterior ACA aneurysms are thought to develop when the ACA at the pericallosal segment travel adjacent to immobile falx cerebri. As the majority of aneurysms are pseudoaneurysms, direct neck clipping is usually not possible, and it is often necessary to carry out direct or endovascular trapping in conjunction with proficient bypass techniques. The authors describe the first reported case of a traumatic ACA pseudoaneurysm resulting from avulsion of the falcine branch of an azygos ACA. In this case, the lacerated aneurysm wall was successfully sutured, without the need for a bypass. Neurosurgeons should be aware that avulsion of the falcine branch arising from the ACA can occur, and that this may cause a traumatic aneurysm on the distal ACA. Furthermore, direct suturing of a lacerated arterial wall should be considered a treatment option for this type of traumatic intracranial aneurysm.

Interfractional change of tumor volume during fractionated stereotactic radiotherapy using gamma knife for brain metastases

PURPOSE

Fractionated stereotactic radiotherapy (FSRT) using gamma knife is useful for brain metastases. However, several uncertainties derived from fractionation pose issues for maintaining high-level accuracy. This study analyzed interfractional tumor change by performing radiological reassessment at the midterm of FSRT with ≥ 10 fractions, and the significance of replanning was evaluated.

METHODS

Data of FSRT using gamma knife with ≥ 10 fractions were retrospectively collected. Interfractional volume changes in MRI at the midterm of the irradiation period were analyzed. Radiological changes after FSRT and final outcomes were also investigated.

RESULTS

Overall, 114 lesions in 74 treatments from 66 patients were included, with previously irradiated lesions accounting for 46%. The median interval between planning and the interfractional MRI was 7 days. The interfractional change rates of tumor volume ranged from - 48 to + 72%. Significant interfractional enlargement was observed in 16 lesions (14%); evident regression was confirmed in 17 lesions (15%). Predictive factors for interfractional enlargement were small tumor and cystic lesion; high biologically effective dose was associated with regression. After FSRT, most lesions regressed within 6 months despite interfractional change type. The incidences of tumor control and radiation necrosis indicated no differences between interfractionally-regressed lesions and others.

CONCLUSION

This is the first study to evaluate interfractional tumor change in FSRT using gamma knife with ≥ 10 fractions, indicating significant volume changes in 29% of the lesions. These preliminary results suggest that interfractional reassessment of a treatment plan in FSRT with irradiation periods exceeding a week is necessary for more adaptive treatment.

Torsade de pointes in an older patient with Takotsubo cardiomyopathy caused by licorice‐induced pseudoaldosteronism: A case report

Takotsubo cardiomyopathy (TCM) causes QT interval prolongation, potentially leading to a fatal arrhythmia. We report the first case of TCM associated with licorice‐induced pseudoaldosteronism causing fatal arrhythmia in an older patient on polypharmacy including yokukansan (TJ‐54) and galantamine. Polypharmacy should be resolved to prevent unexpected adverse events in older patients.

[Superficial Temporal Artery:Middle Cerebral Artery Bypass Technique as the Basis for Emergency Revascularization]

The superficial temporal artery-middle cerebral artery(STA-MCA)bypass technique is extremely important as the basis for both cerebral revascularization in chronic-stage ischemia and emergency surgical revascularization, including open surgical embolectomy. The sophisticated technique of microvascular bypass could also contribute to rescuing inadvertent vascular injuries, such as those occurring in difficult tumor surgery. Therefore, novice neurosurgeons should practice mastering the microvascular suturing technique.

P-185 The migration speed of nucleolar precursor bodies in pronuclei affects in vitro fertilization-derived human embryo ploidy status

Study question

Does the migration speed of nucleolar precursor bodies (NPBs) in male and female pronuclei (mPN and fPN) affect in vitro fertilization (IVF)-derived embryo ploidy status?

Summary answer

The NPB migration speed in mPN impacts the IVF-derived human embryo ploidy status and this indicator could be an attractive marker for noninvasive embryo selection.

What is known already

NPBs are not considered as simple nucleolar components transmitted from an oocyte to an embryo, and they could participate in genome remodeling during embryo development. NPBs are essential only shortly after fertilization, suggesting that they may actively participate in centromeric chromatin establishment. A previous study demonstrated that NPBs migrated faster in intracytoplasmic sperm injection-derived zygotes having the potential to develop into a blastocyst and eventually into a baby (Inoue et al., 2021). However, the relationship between NPB migration speed and IVF-derived embryo ploidy status is unclear.

Study design, size, duration

The relationship between the NPB migration speed and embryo ploidy status was retrospectively analyzed in patients with recurrent assisted reproductive technology failure (euploid n =18; aneuploid n =19; and total = 219 NPBs). Archived time-lapse videos (images were recorded every 5 min; Geri+) from incubation after IVF were retrieved after the patients were identified for the study, and the NPB migration speed was analyzed. The retrospective analyses were performed with the patient’s identities masked.

Participants/materials, setting, methods

mPN and fPN were identified by appearance location in a zygote (fPN appearance is just below the polar bodies). The mPN, fPN, and 2–3 NPBs/PN central coordinates were measured by Kinovea (motion capture software). Their central coordinates were confirmed/revised every image and were decided. The migration distance of NPBs between two sequential images was calculated as the standard of the central PN coordinates. Thereafter, the migration speed of NPBs was calculated.

Main results and the role of chance

Both NPB speeds were significantly faster in the euploid than in the aneuploid groups (mPN: 4.08±0.61 vs. 3.54±0.54 µm/h, P =0.003, power [1-β]: 0.999, fPN: 4.03±0.89 vs. 3.26±0.45 µm/h, P <0.003, 1-β: 0.987). The NPB speed in mPN was correlated with that in fPN (rs =0.523, P =0.001). The ploidy status was related to the NPB speeds in mPN and fPN (P <0.05) in univariate logistic analysis including male/female ages, ICM/TE grades, and 29 morphokinetic parameters. The factors associated with ploidy status were the NPB speed in mPN (odds ratio [OR], 10.2; 95% confidence interval [CI], 1.90–54.90; P =0.007) and female age (OR, 0.8; 95%CI, 0.64–0.98; P =0.03) in multivariate logistic analysis. The cutoff value for the NPB speeds in mPN and fPN were 3.65 μm/h (specificity, 73.7%; sensitivity, 77.8%; AUC, 0.78; 95%CI, 0.62–0.93) and 3.77 μm/h (specificity, 89.5%; sensitivity, 66.7%; AUC, 0.78; 95%CI, 0.62–0.94). When the zygotes were categorized by their cutoff values, the euploid rate in zygotes with NPB speeds greater than the cutoff value was significantly higher than that in zygotes with the speeds less than the cutoff value (mPN = 73.7% vs. 22.2% [P =0.003]; fPN = 85.7% vs. 26.1% [P <0.001]).

Limitations, reasons for caution

The NPB migration in the z-axis direction could not be analyzed. NPB tracking could not be performed when NPBs were large in number or drastically moved. Our findings should help in elucidating the relationship, although they did not completely explain the relationship between NPB migration and embryo development.

Wider implications of the findings

The migration speed of NPBs impacts human embryo ploidy status. NPB migration speed may add clinical value for embryo selection, which may be associated with live birth, and consequently, the time of the live birth could be shorter. The indicator could be an attractive marker for noninvasive embryo selection.

Trial registration number

Not applicable

The prognostic value of 18F-FDG PET/CT taken immediately after completion of radiotherapy for lung cancer treated with concurrent chemoradiotherapy: A pilot study

PURPOSE

The prognostic value of F-18 fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) taken immediately after completion of radiotherapy in lung cancer patients is not well known. The purpose of this study is to assess the prognostic value of PET/CT taken immediately after completion of radiotherapy in lung cancer patients.

MATERIALS AND METHODS

Patients with primary lung cancer planned to undergo concurrent chemoradiotherapy were enrolled. Patients underwent PET/CT scans at 3 time points: before radiotherapy, within 24hours of completing radiotherapy (im-PET/CT), and 2-9 months after radiotherapy (post-PET/CT). Maximum standardized uptake value (SUV_max) was obtained. A post-PET/CT-SUV_max cut-off of 2.5 was determined as radiotherapy success.

RESULTS

Nineteen patients were enrolled. im-PET/CT-SUV_max for patients in the high post-PET/CT-SUV_max group was significantly higher than that of the low group (P=0.004). Receiver operator curve analysis indicated that im-PET/CT-SUV_max of 4.35 was an optimal cut-off value to discriminate between the two groups. Multivariable analysis showed that a high im-PET/CT-SUV_max was significantly associated with a high post-PET/CT-SUV_max (P=0.003).

CONCLUSION

PET/CT-SUV_max taken immediately following radiotherapy was associated with that evaluated 2-9 months after radiotherapy.

STA-A3 Bypass Using Radial Artery Graft for Progressive Cerebral Infarction of Bilateral ACA Region after STA-MCA Bypass Surgery for Moyamoya Disease

Direct revascularization surgery, such as superficial temporal artery (STA)-middle cerebral artery (MCA) bypass, is effective in preventing ischemia and hemorrhage for moyamoya disease. On the other hand, when ischemia of the anterior cerebral artery (ACA) region progresses after ipsilateral STA-MCA bypass, it is difficult to perform revascularization from the viewpoint of the donor artery. A 55-year-old woman with right hemiparesis was diagnosed with cerebral infarction due to moyamoya disease. Left STA-MCA bypass was performed with no postoperative complications, but memory impairment and decreased motivation were observed 2 months after the operation. Magnetic resonance imaging and angiography revealed new infarction in the bilateral ACA area and deterioration in the signal intensity of bilateral ACAs. Revascularization of the bilateral ACA regions was considered necessary, but the left STA was already used in the previous surgery. Therefore, STA-radial artery (RA)-A3 bypass using RA graft combined with right STA-MCA bypass was performed. STA-A3 bypass using an RA graft may be the optimal treatment for ischemia of the ACA region that progresses after STA-MCA bypass.

Efficacy of Emergent STA–MCA Bypass for Acute Atherosclerotic ICA Stenosis/Occlusion with Concomitant Chronic Contralateral ICA Occlusion/Stenosis: Two Case Reports

Recombinant tissue-type plasminogen activator with/without endovascular regimen is sometimes not effective for the treatment of acute hemodynamic stroke. Emergent superficial temporal artery-middle cerebral artery (STA–MCA) bypass has been reportedly effective in patients with progressive hemodynamic stroke; however, the effectiveness of urgent STA–MCA bypass for acute internal carotid artery (ICA) stenosis/occlusion with concomitant contralateral chronic ICA stenosis/occlusion, that is considered the worst hemodynamic situations, is unclear. Two cases of acute left ICA stenosis with concomitant right chronic ICA occlusion wherein both developed hemodynamic infarction and were initially treated by maximal medical treatment. Nevertheless, the patients' symptoms had gradually worsened, thus we performed emergency STA–MCA bypass for both cases. Postoperatively, deterioration of imaging and neurological findings was successfully stopped and the patients' condition gradually stabilized. An urgent STA–MCA bypass can be considered as a last resort to prevent progressive neurological deterioration for patients with progressive infarction due to ICA stenosis/occlusion concomitant with contralateral ICA stenosis/occlusion.

POS0875 LATENT TRAJECTORY MODELING OF PULMONARY ARTERY PRESSURE IN SYSTEMIC SCLEROSIS: A RETROSPECTIVE COHORT STUDY

Background

Systemic sclerosis (SSc) is an autoimmune disease that is characterized by systemic vasculopathy and fibrosis. Pulmonary hypertension (PH), defined as elevated pulmonary arterial pressure (PAP), is one of the leading causes of death of SSc1. In recent years, various therapies have been developed to target each of the pathogenesis of SSc – autoimmunity, vasculopathy, and fibrosis. Accordingly, treatment strategies based on risk stratification for PH progression are aspired; however, prediction of changes in PAP in diverse patients with SSc has not been established2.

Objectives

To visualize the patterns of PAP elevation in SSc and to identify the clinical characteristics of each trajectory, by applying latent trajectory modeling for PAP measured repeatedly by echocardiography.

Methods

This was a multicenter, retrospective cohort study conducted at four referral hospitals in Kyoto, Japan. Patients with SSc who visited the study site between April 2008 and March 2021 and had at least three echocardiographic measurements of systolic pulmonary arterial pressure (sPAP) were included in this study. Follow-up concluded in March 2021. A group-based trajectory model3 was applied to the change in sPAP over time, and individual patients were classified into distinct subgroups that followed similar trajectories. The number and shape of the trajectories were estimated based on adequacy, goodness of fit, parsimony, and interpretability of the model. Clinical plausibility was assessed by comparing PH-free survival, i.e., time to either PH or death, for each trajectory. Multinomial logistic regression analysis was performed for baseline clinical characteristics associated with trajectory assignment.

Results

A total of 236 patients with a total of 1097 sPAP measurements were included. We identified five trajectories following the quadratic function as “rapid progression (n=9, 3.8%)”, “early elevation (n=30, 12.7%)”, “mid elevation (n=54, 22.9%)”, “late elevation (n=24, 10.2%)”, and “low stable (n=119, 50.4%)”. Each trajectory, in this order, showed earlier elevation of sPAP and shorter PH-free survival (Figure 1). In the multinomial logistic regression (with the “low stable” as reference), cardiac involvement was associated with the “rapid progression” (adjusted odds ratio [OR] 28.9, 95% confidence interval [CI] 3.21–259.5), diffuse cutaneous SSc was associated with the “early elevation” (OR 4.08, 95% CI 1.27–13.1), anti-centromere antibody positive was associated with the “mid elevation” (OR 4.50, 95% CI 1.11–18.2), and older age of onset was associated with the above three trajectories.

Conclusion

The pattern of changes in pulmonary artery pressure over time in SSc can be classified into five distinct trajectories. Each trajectory differed in baseline clinical characteristics and outcomes.

References

[1]Pokeerbux MR, et al. Survival and prognosis factors in systemic sclerosis: data of a French multicenter cohort, systematic review, and meta-analysis of the literature. Arthritis Res Ther. 2019;21(1):86.

[2]Denton CP, et al. Systemic sclerosis. Lancet. 2017;390(10103):1685-1699.

[3]Nagin DS, et al. Group-based trajectory modeling in clinical research. Annu Rev Clin Psychol. 2010;6:109-38.

Disclosure of Interests

None declared