Pretreatment ADC Histogram Analysis as a Prognostic Imaging Biomarker for Patients with Recurrent Glioblastoma Treated with Bevacizumab: A Systematic Review and Meta-analysis

BACKGROUND

The mean ADC value of the lower Gaussian curve (ADC_L) derived from the bi-Gaussian curve-fitting histogram analysis has been reported as a predictive/prognostic imaging biomarker in patients with recurrent glioblastoma treated with bevacizumab; however, its systematic summary has been lacking.

PURPOSE

We applied a systematic review and meta-analysis to investigate the predictive/prognostic performance of ADC_L in patients with recurrent glioblastoma treated with bevacizumab.

DATA SOURCES

We performed a literature search using PubMed, Scopus, and EMBASE.

STUDY SELECTION

A total of 1344 abstracts were screened, of which 83 articles were considered potentially relevant. Data were finally extracted from 6 studies including 578 patients.

DATA ANALYSIS

Forest plots were generated to illustrate the hazard ratios of overall survival and progression-free survival. The heterogeneity across the studies was assessed using the Cochrane Q test and I² values.

DATA SYNTHESIS

The pooled hazard ratios for overall survival and progression-free survival in patients with an ADC_L lower than the cutoff values were 1.89 (95% CI, 1.53-2.31) and 1.98 (95% CI, 1.54-2.55) with low heterogeneity among the studies. Subgroup analysis of the bevacizumab-free cohort showed a pooled hazard ratio for overall survival of 1.20 (95% CI, 1.08-1.34) with low heterogeneity.

LIMITATIONS

The conclusions are limited by the difference in the definition of recurrence among the included studies.

CONCLUSIONS

This systematic review with meta-analysis supports the prognostic value of ADC_L in patients with recurrent glioblastoma treated with bevacizumab, with a low ADC_L demonstrating decreased overall survival and progression-free survival. On the other hand, the predictive role of ADC_L for bevacizumab treatment was not confirmed.

Development of large-scale microalgae production in the Middle East

Microalgae in the Middle East can theoretically address food security without competing for arable land, but concerns exist around scalability and durability of production systems under the extreme heat. Large-scale Chlorella sorokiniana production was developed in outdoor raceway ponds in Oman and monitored for 2 years to gather data for commercial production. Biological and technical challenges included construction, indoor/outdoor preculturing, upscaling, relating productivity to water temperature and meteorological conditions, harvesting, drying, and quality control. Small cultivation systems required cooling for initial scale-up, but, despite maximum temperatures of 49.7 °C, water temperatures were at acceptable levels by evaporative cooling in larger raceway ponds. Contamination with Vampirovibrio chlorellavorus was identified by 16S rDNA amplicon sequencing and addressed by culture replacement. Productivities ranged from 8 to 30 g-dry weight m^-2d^-1, with estimated annual productivity of 16 g-dry weight m^-2d^-1 as functions of solar intensity and water temperature, confirming that the region is suitable for commercial microalgae production.

Nocturnal blood pressure surge in seconds is a new determinant of left ventricular mass index

Nocturnal blood pressure (BP) surge in seconds (sec‐surge), which is characterized as acute transient BP elevation over several tens of seconds, could be a predictor of target organ damage. However, it is not clear that the severity of sec‐surge is different between sec‐surges induced by sleep apnea (SA) (apnea/hypopnea detected by polysomnography (PSG) or oxygen desaturation) and those induced by non‐SA factors (rapid eye movement, micro arousal, etc.), and sec‐surge variables associate with left ventricular hypertrophy (LVH) independently of conventional BP variables. The authors assessed these points with 41 patients (mean age 63.2±12.6 years, 29% female) who underwent full PSG, beat‐by‐beat (BbB) BP, and cuff‐oscillometric BP measurement during the night. All patients were included for the analysis comparing sec‐surge severity between inducing factors (SA and non‐SA factors). There were no significant differences in the number of sec‐surges/night between SA‐related sec‐surges and non‐SA‐related sec‐surges (19.5±26.0 vs. 16.4±29.8 events/night). There were also no significant differences in the peak of sec‐surges, defined as the maximum systolic BPs (SBPs) in each sec‐surge, between SA‐related sec‐surges and non‐SA‐related sec‐surges (148.2±18.5 vs. 149.3±19.2 mm Hg). Furthermore, as a result of multiple regression analysis (n = 18), the peak of sec‐surge was significantly and strongly associated with the left ventricular mass index (standardized β = 0.62, p = .02), compared with the mean nocturnal SBPs measured by oscillometric method (β = −0.04, p = .87). This study suggests that peak of sec‐surge could be a better predictor of LVH compared to parameters derived from regular nocturnal oscillometric SBP.

Prognostic impact of polypharmacy by drug essentiality in patients on hemodialysis

Although polypharmacy is common among patients on hemodialysis (HD), its association with prognosis remains unclear. This study aimed to elucidate the association between the number of prescribed medicines and all-cause mortality in patients on HD, accounting for essential medicines (i.e., antihypertensives, antidiabetic medicines, and statins) and non-essential medicines. We evaluated 339 patients who underwent maintenance HD at Nagasaki Renal Center between July 2011 and June 2012 and followed up until June 2021. After adjusting for patient characteristics, the number of regularly prescribed medicines (10.0 ± 4.0) was not correlated with prognosis (hazard ratio [HR]: 1.01, 95% confidence interval [CI] 0.97-1.05, p = 0.60). However, the number of non-essential medicines (7.9 ± 3.6) was correlated with prognosis (HR: 1.06, 95% CI 1.01-1.10, p = 0.009). Adjusting for patient characteristics, patients who were prescribed more than 10 non-essential medicines were found to have a significantly higher probability of mortality than those prescribed less than five non-essential medicines, with a relative risk of 2.01 (p = 0.004). In conclusion, polypharmacy of non-essential medicines increases the risk of all-cause mortality in patients on HD. As such, prescribing essential medicines should be prioritized, and the clinical relevance of each medicine should be reviewed by physicians and pharmacists.

Development of Small and Lightweight Beat-By-Beat Blood Pressure Monitoring Device Based on Tonometry

Blood pressure (BP) variability (BPV) is one of the important risk factors of cardiovascular (CV) disease. Particularly, nocturnal short-term BPV, characterized as acute transient BP elevation over several tens of seconds (BP surge), can trigger CV events. To accurately detect BP surge, it is necessary to monitor BP at each heartbeat. Although continuous BP monitors have been developed and validated, they are too large to measure beat-by-beat (BbB) BP at home. Therefore, we developed a small and lightweight BbB BP monitoring device (BbB device) based on tonometry. In this study, the BbB device was evaluated in terms of size, weight, and performance compared with a validated conventional continuous BP monitoring device based on tonometry (conventional device). The performance was evaluated using the correlation coefficient of pulse wave signals and the difference in BbB BP values between the two devices. Measurement data obtained from 30 subjects with a total of 81 sets, including short-term BPV by the Valsalva maneuver, was used for the evaluation of the performance. The results showed that the conventional device consists of two units (a control unit and a sensor unit), while the BbB device has integrated them into a single unit, with a weight of 150 g (approximately 1/45th of the conventional device). The BbB device was significantly smaller and more lightweight than the conventional device. The correlation coefficient of pulse wave signals between the two devices was 0.98 ± 0.02. The BbB systolic BP and diastolic BP differences were -0.3 ± 4.7 mmHg and 0.7 ± 3.4 mmHg, respectively. The developed BbB device was demonstrated to have an almost equivalent performance as the validated conventional device. In conclusion, we realized a small and lightweight continuous BP monitor that can evaluate the BP for each heartbeat using the BbB device without limitations regarding measurement location. Our device can monitor changes in BP at each heartbeat and short-term BPV, which would be important index for preventing CV events.

Correlation of preference- and profile-based quality of life of Japanese oral cancer patients during the perioperative period measured using EQ-5D-5L and FACT-H&N

The EuroQol 5-dimension 5-level (EQ-5D-5L) instrument is among the most used preference-based quality of life (QOL) measures for cost-utility analysis. Each dimension is evaluated on five levels. The aim of this study was to clarify whether the EQ-5D-5L, which consists of only five items, correlates with profile-based QOL measures in Japanese oral cancer patients during the perioperative period. One hundred participants with oral cancer undergoing radical therapy completed QOL assessments before treatment, at treatment completion, and 1 and 3 months after treatment using the EQ-5D-5L and Functional Assessment of Cancer Therapy - Head & Neck instrument (FACT-H&N, Japanese version). To clarify how the EQ-5D-5L reflects the FACT-H&N, multiple regression analyses were performed using FACT-H&N subscales. The ceiling effect of the EQ-5D-5L was investigated. The EQ-5D-5L moderately correlated with the FACT-H&N over the entire perioperative period (r_s = 0.586, P < 0.01). In the multiple regression analysis, the EQ-5D-5L was strongly reflected in the physical wellbeing subscale of the FACT-H&N, excluding social wellbeing. The pre-treatment EQ-5D-5L score was decreased owing to the impacts of the dimensions of pain/discomfort and anxiety/depression. The EQ-5D-5L did not have a ceiling effect in oral cancer patients. The EQ-5D-5L appears to generally correlate with the FACT-H&N for oral cancer patients during the perioperative period.

Diagnostic Role of Diffusion-Weighted and Dynamic Contrast-Enhanced Perfusion MR Imaging in Paragangliomas and Schwannomas in the Head and Neck

BACKGROUND AND PURPOSE

Distinguishing schwannomas from paragangliomas in the head and neck and determining succinate dehydrogenase (SDH) mutation status in paragangliomas are clinically important. We aimed to assess the clinical usefulness of DWI and dynamic contrast-enhanced MR imaging in differentiating these 2 types of tumors, as well as the SDH mutation status of paragangliomas.

MATERIALS AND METHODS

This retrospective study from June 2016 to June 2020 included 42 patients with 15 schwannomas and 27 paragangliomas (10 SDH mutation-positive and 17 SDH mutation-negative). ADC values, dynamic contrast-enhanced MRI parameters, and tumor imaging characteristics were compared between the 2 tumors and between the mutation statuses of paragangliomas as appropriate. Multivariate stepwise logistic regression analysis was performed to identify significant differences in these parameters.

RESULTS

Fractional plasma volume (P ≤ .001), rate transfer constant (P = .038), time-to-maximum enhancement (P < .001), maximum signal-enhancement ratio (P < .001) and maximum concentration of contrast agent (P < .001), velocity of enhancement (P = .002), and tumor characteristics including the presence of flow voids (P = .001) and enhancement patterns (P = .027) showed significant differences between schwannomas and paragangliomas, though there was no significant difference in ADC values. In the multivariate logistic regression analysis, fractional plasma volume was identified as the most significant value for differentiation of the 2 tumor types (P = .014). ADC values were significantly higher in nonhereditary than in hereditary paragangliomas, while there was no difference in dynamic contrast-enhanced MR imaging parameters.

CONCLUSIONS

Dynamic contrast-enhanced MR imaging parameters show promise in differentiating head and neck schwannomas and paragangliomas, while DWI can be useful in detecting SDH mutation status in paragangliomas.

Assessment of MR Imaging and CT in Differentiating Hereditary and Nonhereditary Paragangliomas

BACKGROUND AND PURPOSE

Head and neck paragangliomas have been reported to be associated with mutations of the succinate dehydrogenase enzyme family. The aim of this study was to assess whether radiologic features could differentiate between paragangliomas in the head and neck positive and negative for the succinate dehydrogenase mutation.

MATERIALS AND METHODS

This single-center retrospective review from January 2015 to January 2020 included 40 patients with 48 paragangliomas (30 tumors positive for succinate dehydrogenase mutation in 23 patients and 18 tumors negative for the succinate dehydrogenase mutation in 17 patients). ADC values and tumor characteristics on CT and MR imaging were evaluated by 2 radiologists. Differences between the 2 cohorts in the diagnostic performance of ADC and normalized ADC (ratio to ADC in the medulla oblongata) values were evaluated using the independent samples t test. P < .05 was considered significant.

RESULTS

ADC_mean (1.07 [SD, 0.25]/1.04 [SD, 0.12] versus 1.31 [SD, 0.16]/1.30 [SD, 0.20]× 10^-3 mm²/s by radiologists 1 and 2; P < .001), ADC_maximum (1.49 [SD, 0.27]/1.49 [SD, 0.20] versus 2.01 [SD, 0.16]/1.87 [SD, 0.20] × 10^-3 mm²/s; P < .001), normalized ADC_mean (1.40 [SD, 0.33]/1.37 [SD, 0.16] versus 1.73 [SD, 0.22]/1.74 [SD, 0.27]; P < .001), and normalized ADC_maximum (1.95 [SD, 0.37]/1.97 [SD, 0.27] versus 2.64 [SD, 0.22]/2.48 [SD, 0.28]; P < .001) were significantly lower in succinate dehydrogenase mutation-positive than mutation-negative tumors. ADC_minimum, normalized ADC_minimum, and tumor characteristics were not statistically significant.

CONCLUSIONS

ADC is a promising imaging biomarker that can help differentiate succinate dehydrogenase mutation-positive from mutation-negative paragangliomas in the head and neck.

Efficacy of early administration of liposomal amphotericin B in patients with septic shock: A nationwide observational study

INTRODUCTION

Liposomal amphotericin B (L-AMB), a broad spectrum anti-fungicidal drug, is often administered to treat invasive fungal infections (IFIs). However, the most suitable time to initiate treatment in septic shock patients with IFI is unknown.

METHODS

Patients with septic shock treated with L-AMB were identified from the Japanese Diagnosis Procedure Combination national database and were stratified according to L-AMB treatment initiation either at septic shock onset (early L-AMB group) or after the onset (delayed L-AMB group) to determine their survival rates following septic shock onset and the shock cessation period.

RESULTS

We identified 141 patients administered L-AMB on the day of or after septic shock onset: 60 patients received early treatment, whereas 81 patients received delayed treatment. Survival rates after septic shock onset were higher in the early L-AMB group than in the delayed L-AMB group (4 weeks: 68.4% vs 57.9%, P = 0.197; 6 weeks: 62.2% vs 44.5%, P = 0.061; 12 weeks: 43.4% vs 35.0%, P = 0.168, respectively). The septic shock cessation period was shorter in the early L-AMB group than in the delayed L-AMB group (7.0 ± 7.0 days vs 16.5 ± 15.4 days, P < 0.001), with a significant difference confirmed after adjusting for confounding factors with propensity score matching (7.1 ± 7.2 days vs 16.7 ± 14.0 days, P = 0.001).

CONCLUSION

Early L-AMB administration at septic shock onset may be associated with early shock cessation.

The Potential of Bone Debris as a Bioactive Composite for Bone Grafting in Arthroscopic Ankle Arthrodesis

Arthroscopic ankle arthrodesis (AAA) has advantages of being less invasive and achieving a high bone union rate. However, there are still some nonunion or delayed union cases, especially those of high-grade deformity. During AAA, curettage of the subchondral bone using an abrader burr provides bone debris, and there is the possibility of bone debris being used as autograft to improve bone union. The purpose of this study is to analyze bone debris histologically, and the effect of its implantation on bone union of AAA. Bone debris from 6 patients was collected during AAA. Bone debris/atelocollagen composite was made and cultured for 4 weeks. Histological analyses were performed before and after culture. Twenty-six patients with AAA were divided into 2 groups with or without bone debris implantation, and the time to union after surgery was evaluated. In histological analysis of bone debris/atelocollagen composite, bone debris contained bone, cartilage and synovium fragment at time 0. After 4 weeks of culture, osteocalcin positive cells migrated and proliferated in the gel. Ki67 positive cells significantly increased after culture. In clinical cases, time to union was significantly shorter in the bone debris group (9.3 ± 1.3 weeks) than that in the control (12.4 ± 3.1 weeks). This study showed that bone debris contained the osteochonductive and osteoinductive properties, and there is the potential for its implantation into the ankle joint to improve bone union in ankle arthrodesis.

Safety of Renal Biopsy by Physicians with Short Nephrology Experience

Percutaneous renal biopsy is an essential tool for diagnosing various renal diseases; however, little is known about whether renal biopsy performed by physicians with short nephrology experience is safe in Japan. This study included 238 patients who underwent percutaneous renal biopsy between April 2017 and September 2020. We retrospectively analyzed the frequency of post-renal biopsy complications (hemoglobin decrease of ≥10%, hypotension, blood transfusion, renal artery embolization, nephrectomy and death) and compared their incidence among physicians with varied experience in nephrology. After renal biopsy, a hemoglobin decrease of ≥10%, hypotension and transfusion occurred in 13.1%, 3.8% and 0.8% of patients, respectively. There were no cases of post-biopsy renal artery embolism, nephrectomy, or death. The composite complication rate was 16.0%. The incidence of post-biopsy complications was similar between physicians with ≥3 years and <3 years of clinical nephrology experience (12.5% vs. 16.8%, p = 0.64). Furthermore, the post-biopsy composite complication rates were similar between physicians with ≥6 months and <6 months of clinical nephrology experience (16.3% vs. 15.6%, p > 0.99). Under attending nephrologist supervision, a physician with short clinical nephrology experience can safely perform renal biopsy.

[Survey of occupational health-related activities conducted at hospitals in the Kanto region (2020)]

OBJECTIVE

To survey occupational health-related activities conducted at hospitals certified by the Japan Council for Quality Health Care in the Kanto region of Japan.

METHODS

The survey tool was sent to 470 hospitals and comprised the following items: hospital size, occupational health system, infection control practices, mental health services, promotion of work system reforms, and priorities in achieving occupational health.

RESULTS

A total of 140 hospitals completed the survey. A monthly workplace inspection was conducted in approximately 60% of the hospitals. Testing of new employees for hepatitis and four other viruses was conducted in approximately 65% of the hospitals, and influenza vaccination was administered to the employees in all the hospitals. Most hospitals provided mental health services to their workers, which included consultation with an occupational physician. Work system reforms for changing conference time and task shifting or sharing were adopted in approximately 50% of the hospitals. Prevention of blood-borne pathogens, respiratory infections, and healthcare coverage for healthcare workers was identified as areas of improvement in several hospitals.

CONCLUSIONS

Legally required infection control and occupational health-related practices were conducted in most hospitals. Additionally, several hospitals undertook work system reforms, including the management of changes in conference time and task shifting or sharing.

Association Between Trough Level of Tacrolimus and Change in Estimated Glomerular Filtration Rate 1 Year After Living Donor Liver Transplantation

Background

Although the risk factors for chronic kidney disease progression after deceased donor liver transplantation have been widely reported, there are few reports describing the factors associated with kidney function changes in patients after living donor liver transplantation (LDLT). This study aims to further investigate these kidney function change factors.

Material/Methods

This retrospective study was performed using the data of patients who underwent LDLT at the Nagasaki University Hospital, Japan from August 2000 to November 2017. Factors contributing to post-transplantation estimated glomerular filtration rate (eGFR) changes were analyzed.

Results

A total of 191 cases were reviewed. The average age was 53.8 years, and 108 (56.5%) patients were male. Compared to pre-transplantation eGFR levels, eGFR 1 year after LDLT improved in 65 patients (34%) and deteriorated in 126 patients (66%). Multivariate regression analysis revealed that pre-transplant diuretics (P=0.04) and tacrolimus trough value 1 year after transplantation (P=0.04) were significantly associated with elevated eGFR changes. eGFR elevation 1 year after LDLT was more pronounced in patients with a low tacrolimus trough level 1 year after LDLT (P=0.01). Therefore, mycophenolate mofetil was added to tacrolimus in patients with poor renal function before LDLT.

Conclusions

Tacrolimus trough level was associated with eGFR changes 1 year after LDLT. The adjusted dose of tacrolimus and combined use of other immunosuppressants may be important to maintain renal function after LDLT.

Geochemical distribution of heavy metal elements and potential ecological risk assessment of Matsushima Bay sediments during 2012-2016

Heavy metal pollution of marine sediments has attracted a great deal of attention because of its persistence, bioaccumulation, and toxicity. To evaluate the effects of mega-tsunami, anthropogenic activities, and redox conditions on heavy metal accumulation in coastal areas, sediments from Matsushima Bay, Miyagi Prefecture, Japan, were sampled to test variations in heavy metal spatial distribution on the bay floor during 4 years following the 2011 Tohoku Earthquake tsunami. Cluster analysis and principal component analysis were performed to assess the influencing factors and potential sources of heavy metal enrichment in the sediments of the bay. Additionally, the sediment enrichment levels of heavy metals were assessed on the basis of the enrichment factor (EF). The results of multivariate statistical analyses showed that the Ti, Fe, V, Pb, and Zn contents in Matsushima Bay sediments, which were transported mainly from Sendai Bay, depended on the mud content. The value of EF < 2 for Fe, V, Pb, and Zn indicated that these elements were not enriched. The value of EF > 7 for Cu suggested that the contamination levels in western Matsushima Bay were moderate to severe in every sampling year from 2012 to 2016 by anthropogenic activities. From the values of EF > 5 for U and Mo during 2012 and 2014, the severe enrichment of both elements in these periods may be explained by contamination with 2011 tsunami deposits; the improvement in 2015-2016 suggests that there was recovery of the tsunami-affected sediment composition to its original state. The values of EF > 3 for Mn and As indicated moderate to severe contamination with these heavy metals in the bay mouth area during 2015. This was likely explained by more oxic bottom conditions in the mouth of Matsushima Bay during that year.

Safe angles of ATFL and CFL anchor insertion into anatomical attachment of fibula in a lateral ankle ligament repair

BACKGROUND

Lateral ankle ligament repair for chronic lateral ankle instability is common, and arthroscopic repair of the anterior talofibular ligament (ATFL) has been widely performed. However, it is desirable to repair of calcaneofibular ligament (CFL) combined with arthroscopic ATFL repair to obtain good long term clinical outcomes. Repairing CFL through small skin incision, there is the possibility to interfere with ATFL and CFL anchors because of close attachment of ATFL and CFL at fibula. The purpose of this study is to determine the safety anchor insertion angles for ATFL and CFL on CT images and to achieve ATFL and CFL repair with minimally invasive technique.

METHODS

Fifty ankles in 50 patients were included in this study. On a sagittal CT image, the anchor drill hole angles for ATFL and CFL were measured to avoid interference with these anchors. Then, arthroscopic ATFL repair combined with CFL repair was performed on 15 patients according to the safety insertion angles obtained by CT. CFL repair was performed through 1.5 cm length of accessory anterolateral portal. Clinical outcome was evaluated using the Japanese Society for the Surgery of the Foot (JSSF) ankle hindfoot scale and the Karlsson score before surgery and at final follow-up.

RESULTS

On the CT image, the mean angles between the ATFL drill hole and anterior border of the fibula was 59.4 ± 6.5°, and those between the longitudinal axis of the fibula and ATFL drill hole, and the CFL drill hole were 34.6 ± 5.0°, and 15.1 ± 5.7°, respectively. Postoperative CT after arthroscopic ATFL repair combined with CFL repair showed that no interference with 2 anchors, and JSSF scale and the Karlsson score were significantly improved from preoperative to final follow-up.

CONCLUSIONS

This study showed how safety ATFL and CFL anchor insertion angles comprise a minimally invasive anatomical repair technique.

Urinary Liver-Type Fatty Acid-Binding Protein Predicts Residual Renal Function Decline in Patients on Peritoneal Dialysis

Background

Liver-type fatty acid-binding protein (L-FABP) is a predictive marker for the early detection of acute kidney injury; however, less is known about how useful it is for predicting residual renal function (RRF) decline in patients on peritoneal dialysis (PD).

Material/Methods

The study subjects were 35 patients on PD who underwent multiple peritoneal equilibration tests (PETs) between October 2011 and October 2019. Urinary L-FABP levels were analyzed with enzyme-linked immunosorbent assay. The relationship between baseline clinical data, including urinary L-FABP levels and the subsequent annual rate of renal Kt/V decline, was investigated.

Results

The median follow-up duration was 11 months and the rate of renal Kt/V decline was 0.29/y. Compared with outcomes in the group with renal Kt/V preservation, renal Kt/V decline was associated with both high daily levels of urinary protein excretion (0.60 g/d [range, 0.50–0.87] vs. 0.36 g/d [range, 0.19–0.48]; P=0.01) and high daily levels of urinary L-FABP excretion (111.2 mg/d [range, 76.1–188.6] vs. 61.5 mg/d [range, 35.7–96.0]; P=0.002). Multiple logistic regression analysis showed that only high daily levels of urinary L-FABP excretion were independently associated with renal Kt/V decline (odds ratio 1.03, 95% confidence interval 1.00–1.05; P=0.001). Furthermore, higher daily levels of urinary L-FABP excretion were significantly correlated with the higher annual rate of renal Kt/V decline (r=0.71, P<0.001).

Conclusions

We demonstrated that daily levels of urinary L-FABP are associated with RRF decline in patients on PD. The results of the present study indicate that assessment of urinary L-FABP levels may help predict RRF decline in patients on PD.

Renal outcomes of treatment with telmisartan in patients with stage 3-4 chronic kidney disease: A prospective, randomized, controlled trial (JINNAGA)

Objectives:

Although angiotensin II receptor blockers are effective for patients with chronic kidney disease, dose-dependent renoprotective effects of angiotensin II receptor blockers in patients with moderate to severe chronic kidney disease with non-nephrotic proteinuria are not known. Our aim was to elucidate the dose-dependent renoprotective effects of angiotensin II receptor blockers on such patients.

Methods:

A multicenter, prospective, randomized trial was conducted from 2009 to 2014. Patients with non-nephrotic stage 3–4 chronic kidney disease were randomized for treatment with either 40 or 80 mg telmisartan and were observed for up to 104 weeks. Overall, 32 and 29 patients were allocated to the 40 and 80 mg telmisartan groups, respectively. The composite primary outcome was renal death, doubling of serum creatinine level, transition to stage 5 chronic kidney disease, and death from any cause. Secondary outcomes included the level of urinary proteins and changes in the estimated glomerular filtration rate.

Results:

There was no difference in the primary outcome (p = 0.78) and eGFR (p = 0.53) between the two groups; however, after 24 weeks, urinary protein level was significantly lower in the 80 mg group than in the 40 mg group (p < 0.05). No severe adverse events occurred in either group, and the occurrence of adverse events did not significantly differ between them (p = 0.56).

Conclusion:

Our findings do not demonstrate a direct dose-dependent renoprotective effect of telmisartan. The higher telmisartan dose resulted in a decrease in the amount of urinary protein. Even though high-dose angiotensin II receptor blockers may be preferable for patients with stage 3–4 chronic kidney disease, the clinical importance of the study results may be limited. The study was registered in the UMIN-CTR (https://www.umin.ac.jp/ctr) with the registration number UMIN000040875.

Factors affecting impingement and dislocation after total hip arthroplasty - Computer simulation analysis

BACKGROUND

Studies on the causes and factors affecting dislocation after total hip arthroplasty have revealed conflicting results. The purpose of this study was to evaluate the factors affecting impingement and dislocation after total hip arthroplasty, using a 3-dimensional dynamic motion analysis.

METHODS

The CT data of 53 patients (53 hips: anterior dislocation; 11 cases, and posterior dislocation; 42 cases) who experienced hip dislocation after total hip arthroplasty with posterior approach, and 120 control patients (120 hips) without dislocation were analyzed. Parameters related to implant alignment, offset and leg length were evaluated. The impingement type was also analyzed using a software.

FINDINGS

Considering implant settings affecting dislocation, patients at risk for posterior dislocation had decreased stem anteversion, combined anteversion, femoral offset, and leg length. Nevertheless, patients at risk for anterior dislocation had only lower leg length, and these patients may also be at risk for a higher incidence of recurrent dislocation. Bony impingement occurred in almost half of the cases with posterior dislocation, while implant impingement was associated with anterior dislocation. Importantly, anterior dislocation was not as common as posterior dislocation even in cases with occurrence of posterior impingement.

INTERPRETATION

Bony impingement substantially affects dislocation even in the situation where the implant position and alignment are determined by the so-called "safe zone", especially on the anterior side, while implant impingement affects anterior dislocation. The restoration of anterior offset (i.e., prescribed by the stem anteversion and femoral offset) and combined anteversion is critical for avoidance of posterior dislocation after total hip arthroplasty.

The clinical usage of liposomal amphotericin B in patients receiving renal replacement therapy in Japan: a nationwide observational study

Background

Liposomal amphotericin B (L-AMB), a broad-spectrum antifungicidal drug, is often used to treat fungal infections. However, clinical evidence of its use in patients with renal dysfunction, especially those receiving renal replacement therapy (RRT), is limited. Therefore, we evaluated the usage and occurrence of adverse reactions during L-AMB therapy in patients undergoing RRT.

Methods

Using claims data and laboratory data, we retrospectively evaluated patients who were administered L-AMB. The presence of comorbidities, mortality rate, treatment with L-AMB and other anti-infective agents, and the incidence of adverse reactions were compared between patients receiving RRT, including continuous renal replacement therapy (CRRT) and maintenance hemodialysis (HD), and those that did not receive RRT.

Results

In total, 900 cases met the eligibility criteria: 24, 19, and 842 cases in the maintenance HD, CRRT, and non-RRT groups, respectively. Of the patients administered L-AMB, mortality at discharge was higher for those undergoing either CRRT (15/19; 79%) or maintenance HD (16/24; 67%) than for those not receiving RRT (353/842; 42%). After propensity score matching, the average daily and cumulative dose, treatment duration, and dosing interval for L-AMB were not significantly different between patients receiving and not receiving RRT. L-AMB was used as the first-line antifungal agent for patients undergoing CRRT in most cases (12/19; 63%). Although the number of subjects was limited, the incidence of adverse events did not markedly differ among the groups.

Conclusion

L-AMB may be used for patients undergoing maintenance HD or CRRT without any dosing, duration, or interval adjustments.

Bone Mineralization Changes in the Subchondral Bone of the Medial Gutter in Chronic Lateral Ankle Instability

BACKGROUND

Chronic ankle instability (CAI) induces osteoarthritis (OA) by inflicting abnormal stresses on the medial gutter. It is important to detect early OA change and to explore factors likely to induce the OA. The purpose of this study was to evaluate subchondral bone change in the medial gutter of CAI using computed tomography (CT) scans.

METHODS

Thirty-five ankles with CAI (CAI group) and 35 ankles without CAI (control group) were included. The region of interest (ROI) in the subchondral bone of the medial gutter on CT axial images was set on the tibia and talus. The Hounsfield unit (HU) in ROIs was measured and corrected by the HU of the fibula in the same slice. HU ratios were compared between the CAI and control groups. In the CAI group, the relationship between the HU ratio and the talar tilt angle (TTA), OA change, and the anterior talofibular ligament (ATFL) remnant quality were analyzed.

RESULTS

The mean HU ratio in the CAI group was significantly higher than that in the control. In the CAI group, HU ratios in ≥10 degrees of TTA were significantly higher than those in <10 degrees. But there was no significant difference in the HU ratios with or without OA change in the medial gutter. A good-quality ATFL remnant showed a low HU ratio compared with that with poor quality.

CONCLUSION

CAI patients exhibited subchondral bone change in the medial gutter, which suggests that the elimination of instability may help to prevent or decrease the development and/or progression of osteoarthritis.

LEVEL OF EVIDENCE

Level III, comparative series.

Suppression of gastric acid secretion decreased cardiovascular events independent of severe bleeding events in patients after percutaneous coronary intervention – sub-analysis from multicenter registry

Background

Suppression of gastric acid secretion by proton-pump inhibitor (PPI) or potassium-competitive acid blocker (P-CAB) has recently been developed as a standard strategy for preventing gastrointestinal bleeding for patients receiving antiplatelet therapy after percutaneous coronary intervention (PCI). However, there has been limited evidences on the association between PPI/P-CAB administration and adverse cardiovascular events in patients undergoing PCI.

Purpose

We aimed to evaluate the prognostic impact of the prescription of PPI/P-CAB on clinical outcomes in patients after PCI.

Methods

This study is a subanalysis from the TWINCRE registry that is a multicentral prospective cohort including patients who underwent PCI at 12 hospitals in Japan between 2017 and 2019. Among registered patients, we ultimately evaluated 1,428 patients who were followed-up. They were divided into two groups by the prescriptions of PPI or P-CAB at discharge for the index PCI; the PPI/P-CAB group (n=1,023), and the Non-PPI/P-CAB group (n=407). The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE) including death, acute coronary syndrome, stent thrombosis, hospitalization due to heart failure and ischemic stroke. Secondary endpoints was major bleeding events defined BARC3, 4 and 5.

Results

The average age of the study population was 70.3 years and 80.3% were male. Baseline clinical profiles were comparable between the groups, except that the PPI/P-CAB group included significantly higher rate of patients who had history of prior PCI (28.4% vs 18.7%, P=0.02). Additionally, there was no significant difference in the duration of dual antiplatelet therapy between the PPI/P-CAB group and Non-PPI/P-CAB group (average duration; 287±8 vs. 285±8 days, P=0.66). Overall, MACCE was developed in 132 patients (9.3%), and bleeding event was observed in 24 patients (1.7%) during 574 days of median follow-up period. Kaplan-Meier analysis showed that patients in the PPI/P-CAB group had a significantly lower rate of MACCE than those in the Non-PPI/P-CAB group (Log-rank test, p=0.0003, Figure 1A). Multivariate Cox regression analysis revealed that the prescription of PPI/P-CAB still was independently associated with the primary endpoint (hazard ratio 0.532, 95% confidence interval 0.369–0.766, p=0.0007), even after the adjustment by diverse covariates. Whereas, there was no significant difference in the bleeding event (p=0.64, Figure 1B).

Conclusion

PPI or P-CAB therapy was associated with better clinical outcomes after PCI, independent of the incidences of severe bleeding events.

Figure 1

Funding Acknowledgement

Type of funding source: None

MRI Findings of Immune Checkpoint Inhibitor-Induced Hypophysitis: Possible Association with Fibrosis

BACKGROUND AND PURPOSE

Hypophysitis is one of the well-known adverse effects of immune checkpoint inhibitors. Immune checkpoint inhibitor-induced hypophysitis frequently causes irreversible hypopituitarism, which requires long-term hormone replacement. Despite the high frequency and clinical significance, characteristic MR imaging findings of immune checkpoint inhibitor-induced hypophysitis have not been established. In the present study, we aimed to review and extract the MR imaging features of immune checkpoint inhibitor-induced hypophysitis.

MATERIALS AND METHODS

This retrospective international multicenter study comprised 20 patients with melanoma who were being treated with immune checkpoint inhibitors and clinically diagnosed with immune checkpoint inhibitor-induced hypophysitis. Three radiologists evaluated the following MR imaging findings: enlargement of the pituitary gland and stalk; homogeneity of enhancement of the pituitary gland; presence/absence of a well-defined poorly enhanced area and, if present, its location, shape, and signal intensity in T2WI; and enhancement pattern in contrast-enhanced dynamic MR imaging. Clinical symptoms and hormone levels were also recorded.

RESULTS

Enlargement of the pituitary gland and stalk was observed in 12 and 20 patients, respectively. Nineteen patients showed poorly enhanced lesions (geographic hypoenhancing lesions) in the anterior lobe, and 11 of these lesions showed hypointensity on T2WI. Thyrotropin deficiency and corticotropin deficiency were observed in 19/20 and 12/17 patients, respectively, which persisted in 12/19 and 10/12 patients, respectively, throughout the study period.

CONCLUSIONS

Pituitary geographic hypoenhancing lesions in the anterior lobe of the pituitary gland are characteristic and frequent MR imaging findings of immune checkpoint inhibitor-induced hypophysitis. They reflect fibrosis and are useful in distinguishing immune checkpoint inhibitor-induced hypophysitis from other types of hypophysitis/tumors.