Triple bypass for multisystem smooth muscle dysfunction syndrome due to Arg179His ACTA2 mutation

Missense mutations in the smooth muscle-specific isoform of the alpha-actin (ACTA2) gene, which encodes smooth muscle actin, congenitally cause systemic smooth muscle dysfunction, leading to multiple systemic smooth muscle dysfunction syndrome. This disease is often diagnosed through the development of congenital mydriasis, patent ductus arteriosus, or thoracic aortic aneurysm at a young age. Some patients develop cerebrovascular lesions, also known as ACTA2 cerebral arteriopathy, which cause ischemic stroke and require surgical revascularization. However, an effective and safe treatment has not yet been established owing to the rarity of the disease. Furthermore, most reports of this disease involve children, with only a few reports on adults and few detailed reports on treatment outcomes published to date. We report a 46-year-old woman with ACTA2 cerebral arteriopathy caused by Arg179His, the most common mutation in this disease; she is the oldest patient reported with this disease to the best of our knowledge. The patient was diagnosed with multiple systemic smooth muscle dysfunction syndrome and ACTA2 cerebral arteriopathy after experiencing a stroke in the right cingulate gyrus. She underwent direct triple bypass with three anastomoses of the right superficial temporal artery to the middle and anterior cerebral arteries. She developed an ischemic stroke as a postoperative complication.The efficacy and safety of this procedure have not been clearly confirmed owing to the frailty of the donor superficial temporal artery and the poor development of collateral circulation; however, direct bypass should be considered a treatment option for patients experiencing progressive multiple strokes.

Differences in cellular and microstructural properties of the semitendinosus muscle tendon between young and adult patients

BACKGROUND

Poor outcomes associated with anterior cruciate ligament reconstruction in paediatric patients are a major concern. The tendon structure and its cellular characteristics are key factors that affect the mechanical properties of tendons. This study aimed to evaluate the effects of growth on the cellular and microstructural properties of the tendon of the semitendinosus muscle in humans.

METHODS

Semitendinosus muscle tendon samples from 76 patients who underwent ligament reconstruction were examined and divided into three groups: immature (10.8 ± 2.7 years old), young (16.5 ± 1.8 years old), and adult (35.2 ± 8.6 years old), based on age and the state of the epiphyseal plate in the distal femur. The number of tendon cells per unit area was assessed, and the major-to-minor-length ratio of the tendon cell nuclei was calculated to evaluate the shape of the nuclei using haematoxylin and eosin staining. The collagen fibril diameter and distribution were determined using electron microscopy.

RESULTS

The major-to-minor-length ratio of the tendon cell nuclei significantly increased with age (p-value; immature vs. young: 0.018, young vs adult: 0.001, immature vs adult: 0.001). The shape of the tendon cell nuclei was rounder in the immature group and more elongated in the adult group. A significant decrease in the number of tendon cells was observed with age (immature: 565 ± 134/mm², young: 356 ± 105/mm², adult: 272 ± 81/mm²; p-value: immature vs young: 0.001, young vs adult: 0.012, immature vs adult: 0.001). The mean fibril diameter in the immature group was significantly smaller (p-value: immature vs young: 0.018, young vs adult: 0.001, immature vs adult: 0.001). The distribution of the collagen fibrils changed from right skewed in the immature group to flat in the adult group.

CONCLUSIONS

The characteristics of the tendon cells and the microstructure of collagen in muscle tendons significantly changed with age.

Intracranial Mycotic Aneurysm after Left Ventricular Assist Device Implantation Treated with Trans-arterial Embolization via the Brachial Artery: A Case Report

Implantation of left ventricular assist device (LVAD) is widely performed in patients with end-stage chronic heart failure. Infection and stroke are major complications after LVAD implantation. However, the incidence of intracranial mycotic aneurysm after LVAD implantation is rare, and with no standard of care. In this study, we describe a case of an intracranial mycotic aneurysm after LVAD implantation that was successfully treated with trans-arterial embolization (TAE) with N-butyl 2-cyanoacrylate (NBCA) via the brachial artery. A 49-year-old man with a history of implantation of LVAD for ischemic cardiomyopathy was admitted to our institution. He had infectious endocarditis and was administered systemic antibiotics. At 3 weeks after admission, intracranial mycotic aneurysm of the left posterior parietal artery was detected during a diagnostic examination for asymptomatic intracranial hemorrhage. Anticoagulant therapy was administered to prevent thromboembolic complications of LVAD implantation. Under local anesthesia, TAE with NBCA was performed via the brachial artery because of the tortuous anatomy of the origin of the innominate artery and implant of the aortic arch. The aneurysm was completely obliterated. The patient was discharged without neurological deficits. TAE using NBCA could be an effective modality for the treatment of intracranial mycotic aneurysm after LVAD implantation.

Genes for tRNA recycling are upregulated in response to infection with Theiler's mouse encephalitis virus

The concept of tRNA recycling has recently emerged from the studies of ribosome-associated quality control. Therein tRNase Z^S removes the 2', 3'>p from the ANKZF1-cleaved tRNA and the subsequent TRNT1 action re-generates the intact tRNA. To know the roles of the tRNA recycling in vivo, we investigated how viral infection affects the tRNA recycling system by analyzing the mRNA levels of tRNase Z^S and TRNT1. We found that both genes in HeLa cells are upregulated in response to infection of Theiler's mouse encephalitis virus but not to that of an influenza A virus. Upregulation was also observed in cells infected with encephalomyocarditis virus with reduced efficiency. The levels of the IFN-β mRNA appeared to positively correlate with those of the tRNase Z^S and TRNT1 mRNAs. The tRNase Z^S gene may be regulated post-transcriptionally in the cells infected with Theiler's mouse encephalitis virus.

Insights Into the Inhibition of MOX-1 β-Lactamase by S02030, a Boronic Acid Transition State Inhibitor

The rise of multidrug resistant (MDR) Gram-negative bacteria has accelerated the development of novel inhibitors of class A and C β-lactamases. Presently, the search for novel compounds with new mechanisms of action is a clinical and scientific priority. To this end, we determined the 2.13-Å resolution crystal structure of S02030, a boronic acid transition state inhibitor (BATSI), bound to MOX-1 β-lactamase, a plasmid-borne, expanded-spectrum AmpC β-lactamase (ESAC) and compared this to the previously reported aztreonam (ATM)-bound MOX-1 structure. Superposition of these two complexes shows that S02030 binds in the active-site cavity more deeply than ATM. In contrast, the SO₃ interactions and the positional change of the β-strand amino acids from Lys315 to Asn320 were more prominent in the ATM-bound structure. MICs were performed using a fixed concentration of S02030 (4 μg/ml) as a proof of principle. Microbiological evaluation against a laboratory strain of Escherichia coli expressing MOX-1 revealed that MICs against ceftazidime are reduced from 2.0 to 0.12 μg/ml when S02030 is added at a concentration of 4 μg/ml. The IC₅₀ and K_i of S02030 vs. MOX-1 were 1.25 ± 0.34 and 0.56 ± 0.03 μM, respectively. Monobactams such as ATM can serve as informative templates for design of mechanism-based inhibitors such as S02030 against ESAC β-lactamases.

Prediction of cross-clamp-induced cerebral ischemia during carotid endarterectomy using arterial blood flow assessment

BACKGROUND

Cross-clamping during carotid endarterectomy (CEA) is associated with the risk of cerebral ischemia. Various studies have evaluated different criteria for detecting cerebral ischemia, but difficulties arise when ischemic changes appear after the carotid artery is cross-clamped and incised. Here, we explored a parameter that can predict cerebral ischemia prior to cross-clamping during CEA using a blood-flow meter.

METHODS

The carotid arterial blood flow was measured directly (direct ABF) in the common carotid artery prior to cross-clamping. The anatomical information in preoperative magnetic resonance imaging, cerebral blood flow in xenon-enhanced computed tomography, and carotid peak systolic flow velocity by carotid echo from the skin surface were also evaluated. A decrease in the short-latency somatosensory evoked potentials (SSEP) during cross-clamping to insert a shunt was assessed, and a decrease in amplitude of ≥50% was considered an indicator for cerebral ischemia. Surgery was performed under general anesthesia, and a shunt was inserted in all cases.

RESULTS

Of 156 CEA patients between April 2013 and March 2020, 30 had decreased SSEP during cross-clamping. The baseline characteristics and intra- and postoperative findings were not significantly different between patients with and without a decrease in SSEP. Among the evaluated parameters, only the direct-ABF ratio (ABF-internal carotid artery/ABF-common carotid artery) differed significantly between the two groups (p=0.011). The direct-ABF ratio ≤0.58 was predictive of cerebral ischemia during CEA.

CONCLUSIONS

Direct-ABF measurement with an ultrasonic blood-flow meter can be useful for predicting cerebral ischemia prior to carotid artery cross-clamping during CEA.

Aspergillus sphenoiditis growth on long cut ends of a non-absorbable sellar floor dura closure suture

Background:

Cerebrospinal fluid (CSF) rhinorrhea is a common complication after transsphenoidal surgery (TSS). Suturing of sellar dura is effective in the prevention of postoperative CSF rhinorrhea, but it may cause rare postoperative infections. Herein, we report a case of Aspergillus sphenoiditis with the growth noted on cut ends of a polyvinylidene fluoride (PVDF) suture used for dural closure.

Case Description:

A previously healthy 51-year-old woman complained of abnormal odor 5 years after TSS for null cell adenoma. A white mass in the sphenoidal sinus was detected on rhinoscopy. Fungal balls were found clustered around the ends of a PVDF suture used for dural closure at the initial surgery. She underwent removal of both the fungal ball and dural suture. The pathological diagnosis was Aspergillus hyphae. It is thought that a dural suture protruding out of the sphenoid sinus mucosa can cause Aspergillus infection even in immunocompetent patients. A rapid and accurate diagnosis followed by surgical removal of the fungal ball and follow-up with oral antimycotic drugs result in good clinical outcomes.

Conclusion:

It is crucial to cut short the suture end and cover it with sphenoid sinus mucosa to avoid such complications.

Antinociceptive effects of the combined use of butorphanol and buprenorphine in mice

Butorphanol and buprenorphine are mixed opioid receptor agonist-antagonist drugs widely used as analgesics in people and animals. There are few reports concerning the interaction of multiple opioids, and their antinociceptive effects, when combined with other opioids, remain unclear. Therefore, we report the preliminary findings of the antinociceptive effects of the combined use of butorphanol and buprenorphine in C57BL/6JJcl mice. Both drugs were administered either simultaneously or in different orders. Compared with the baseline values, the tail-flick and hot-plate test latencies increased regardless of the order of administration. Furthermore, enhanced latencies were observed on administration of butorphanol followed by buprenorphine. Combined use of these drugs may not attenuate analgesic efficacy. Besides, enhancement of these effects can be obtained by changing the order of the administration of these drugs. It is necessary to further investigate the molecular basis of the underlying mechanism in future definitive studies.

Nonalcoholic steatohepatitis in hepatocarcinoma: new insights about its prognostic role in patients treated with lenvatinib

BACKGROUND

Hepatocellular carcinoma (HCC) treatment remains a big challenge in the field of oncology. The liver disease (viral or not viral) underlying HCC turned out to be crucial in determining the biologic behavior of the tumor, including its response to treatment. The aim of this analysis was to investigate the role of the etiology of the underlying liver disease in survival outcomes.

PATIENTS AND METHODS

We conducted a multicenter retrospective study on a large cohort of patients treated with lenvatinib as first-line therapy for advanced HCC from both Eastern and Western institutions. Univariate and multivariate analyses were performed.

RESULTS

Among the 1232 lenvatinib-treated HCC patients, 453 (36.8%) were hepatitis C virus positive, 268 hepatitis B virus positive (21.8%), 236 nonalcoholic steatohepatitis (NASH) correlate (19.2%) and 275 had other etiologies (22.3%). The median progression-free survival (mPFS) was 6.2 months [95% confidence interval (CI) 5.9-6.7 months] and the median overall survival (mOS) was 15.8 months (95% CI 14.9-17.2 months). In the univariate analysis for OS NASH-HCC was associated with longer mOS [22.2 versus 15.1 months; hazard ratio (HR) 0.69; 95% CI 0.56-0.85; P = 0.0006]. In the univariate analysis for PFS NASH-HCC was associated with longer mPFS (7.5 versus 6.5 months; HR 0.84; 95% CI 0.71-0.99; P = 0.0436). The multivariate analysis confirmed NASH-HCC (HR 0.64; 95% CI 0.48-0.86; P = 0.0028) as an independent prognostic factor for OS, along with albumin-bilirubin (ALBI) grade, extrahepatic spread, neutrophil-to-lymphocyte ratio, portal vein thrombosis, Eastern Cooperative Oncology Group (ECOG) performance status and alpha-fetoprotein. An interaction test was performed between sorafenib and lenvatinib cohorts and the results highlighted the positive predictive role of NASH in favor of the lenvatinib arm (P = 0.0047).

CONCLUSION

NASH has been identified as an independent prognostic factor in a large cohort of patients with advanced HCC treated with lenvatinib, thereby suggesting the role of the etiology in the selection of patients for tyrosine kinase treatment. If validated, this result could provide new insights useful to improve the management of these patients.

High-flow bypass using saphenous vein grafts with trapping of ruptured blood blister-like aneurysms of the internal carotid artery: patient series

BACKGROUND

Trapping an aneurysm after the establishment of an extracranial to intracranial high-flow bypass is considered the optimal surgical strategy for ruptured blood blister-like aneurysms (BBAs) of the internal carotid artery (ICA). For high-flow bypass surgeries, a radial artery graft is generally preferred over a saphenous vein graft (SVG). However, SVGs can be advantageous in acute-phase surgeries because of their greater length, easy manipulability, ability to act as high-flow conduits, and reduced risk of vasospasms. In this study, the authors presented five cases of ruptured BBAs treated with high-flow bypass using an SVG followed by BBA trapping, and they reported on surgical outcomes and operative nuances that may help avoid potential pitfalls.

OBSERVATIONS

After the surgeries, there were no ischemic or hemorrhagic complications, including symptomatic vasospasms. In three of the five cases, postoperative modified Rankin scale scores were between 0 and 2 at the 3-month follow-up. In one case, the SVG spontaneously occluded after surgery while the protective superficial temporal artery (STA) to middle cerebral artery (MCA) bypass became dominant, and the patient experienced no ischemic symptoms.

LESSONS

High-flow bypass using an SVG with a protective STA-MCA bypass followed by BBA trapping is a safe and effective treatment strategy.

Novel variant of the glycerol-3-phosphate dehydrogenase-1 Like (GPD1-L) gene in Japanese Brugada syndrome patients

Background

The incidence of Brugada syndrome (BrS) varies among racial groups. Several studies reported Glycerol-3-Phosphate Dehydrogenase 1-Like (GPD1-L) gene is associated with BrS. However, most of these studies were reported from Western countries, so the evidence about GPD1-L mutation is limited especially among Asian BrS patients. This study aimed to search for rare variants in GPD1-L among Japanese BrS patients and to investigate the pathogenicity.

Method

We performed whole-exome sequencing for patients with Brugada type 1 ECG pattern from Japanese multicenter BrS cohort consisting of SCN5A-negative BrS probands (n=288) and controls (n=372). We conducted patch-clamp study in human embryonic kidney (HEK) 293 cells cotransfected with the wild-type sodium channel (SCN5A) and wild-type or mutant GPD1-L expression plasmid.

Results

We identified a rare variant in GPD1-L, p.D262N (c.784g>a) in 2 of 288 BrS probands, which was not identified in 372 controls. The minor allele frequency of the variant is 0.0014% in the Genome Aggregation Database. One proband was a 49-year-old man and the other was 34-year-old man who both developed a ventricular fibrillation. ECGs of both probands showed Brugada Type 1 pattern after administration of the pilsicainide. In functional study, coexpression of D262N GPD1-L with SCN5A in HEK293 cells significantly reduced inward sodium currents compared with wild-type GPD1-L. Additionally, inward sodium currents with D262N were similar to those with A280V GPD1-L, which was associated with BrS in previous reports (Figure). Also, several pathogenicity prediction programs, such as SIFT (score: 0.031) and PolyPhen2 (score: 0.937) predicted deleterious effects of GPD1-L D262N.

Conclusion

We identified a rare variant in GPD1-L at the rate of 0.7% in Japanese BrS patients without SCN5A mutations. GPD1-L, p.D262N reduces inward sodium currents and may be a novel susceptible variant for BrS in the Japanese population.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Current–voltage curve

Role of magnetic resonance vessel wall imaging in detecting and managing ruptured aneurysms among multiple intracranial aneurysms

Background

Wall enhancement of intracranial saccular aneurysms in high-resolution magnetic resonance vessel wall imaging (MR-VWI) might indicate a ruptured aneurysm. Therefore, this study aimed to determine the diagnostic ability of wall enhancement to detect the ruptured aneurysms among multiple aneurysms.

Methods

Patients with subarachnoid hemorrhage (SAH) and multiple intracranial aneurysms who underwent MR-VWI before craniotomy and clipping were included in the study. Three-dimensional T1-weighted fast spin-echo sequences were obtained before and after gadolinium injection. Aneurysm rupture was estimated based on the subarachnoid clot distribution, aneurysmal contours, and MR-VWI findings. We selectively performed surgical clipping and confirmed the rupture site intraoperatively.

Results

Thirteen patients with SAH with 13 ruptured and 17 unruptured aneurysms were treated at out facility. The accuracy rate of rupture site diagnosis using MR-VWI was 69.2% (9/13 cases). Each unruptured aneurysm was equally or more strongly enhanced in the other four cases than the ruptured aneurysms. In three of the four unruptured aneurysms with positive MR-VWI findings, atherosclerosis of the aneurysmal wall was observed during simultaneous or elective clipping surgery. Further, clipping surgery was performed without intraoperative rupture in two cases with the help of MR-VWI findings.

Conclusion

Correct diagnosis of the rupture site using MR-VWI alone was unreliable due to false positives caused by the wall enhancement of unruptured aneurysms with atherosclerosis. Therefore, ruptured aneurysms should be detected using more information in addition to MR-VWI images. MR-VWI may be advantageous to determine surgical strategies when managing patients with SAH and multiple aneurysms.

P–032 Assessment of embryonic developmental outcome of direct unequal cleavage in patients with non-obstructive azoospermia and/or obstructive azoospermia

Study question

Does direct unequal cleavage (DC) affect embryonic development after ICSI with testicular sperm (TESE-ICSI) in patients with non-obstructive azoospermia (NOA) and/or obstructive azoospermia (OA)?

Summary answer

The incidence of DC at the first cleavage (DC1) was extremely high and DC1 negatively affected embryonic development in NOA patients.

What is known already

It has been reported that the blastocyst development of embryos with direct cleavage (DC) was significantly lower than that without DC, but the clinical pregnancy rate after blastocyst transfer was not different with or without DC. The incidence of DC has been reported to be significantly higher after ICSI with testicular sperm (TESE-ICSI) than ICSI with ejaculated sperm (Ej), but to our knowledge, there are few reports investigating that the embryos with DC after TESE-ICSI affect embryonic development.

Study design, size, duration

We conducted a retrospective cohort study using time-lapse incubators (Geri, Genea Biomedx, Australia) from September 2018 to November 2020. Of 1033 two-pronuclear (2PN) embryos from TESE-ICSI, 486 and 547 embryos were from OA (35.9±5.5 years) and NOA (33.7±5.2 years), respectively. As an age matched control, we chose 581 embryos from ICSI using Ej (36.5±4.4 years).

Participants/materials, setting, methods

DC embryos were classified as DC1 (DC at first cleavage), DC2 (DC at second cleavage), and non-DC (without DC). The incidences of DC1 or DC2 and blastocyst development rates were compared among OA, NOA and Ej groups. In TESE-ICSI group, we compared blastocyst development rates with or without DC between good and poor quality embryos on day 3. Good quality embryos were defined as 8 cells with G3 or more by the Veeck’s classification.

Main results and the role of chance

DC1 incidence was significantly higher in NOA (37.3%) than OA (27.8%) and Ej (22.7%) (P < 0.01), whereas DC2 incidence was not statistically different among three groups; NOA (15.7%), OA (15.0%) and Ej (13.4%). Blastocyst development rates in DC1 were 17.8%, 19.5% and 25.8% for NOA, OA and Ej, respectively, which were significantly lower compared to non-DC in corresponding three groups (65.1%, 67.7%, and 68.5%, respectively, P < 0.01). In TESE-ICSI group, good-quality embryo rate on day 3 was significantly lower in DC1 (34.5%, P < 0.01) than DC2 (60.9%) or non-DC (54.2%). Additionally, blastocyst development rates in DC1 and DC2 were significantly lower than non-DC regardless of embryonic grades on day 3 (35.1%, 51.0%, and 81.6% for good-quality embryos on day 3, 10.1%, 27.0%, and 49.1% for poor-quality embryos on day 3, respectively, P < 0.05). When immotile sperm was used for TESE-ICSI, DC1 incidence was 40.0% (6/15), which did not show statistically differences. When performing single frozen-thawed blastocyst transfers, no pregnancies resulted from either DC1 (n = 13) or DC2 (n = 3) embryos in TESE-ICSI group.

Limitations, reasons for caution

We had a few data about the pregnancy rates after blastocyst transfers with DC, because embryos with DC were seldom transferred due to those lower priority. Although DC might be influenced by the sperm, we did not analyze the incidence of DC by taking the semen factors into account.

Wider implications of the findings: The incidence of DC1 was extremely high and DC1 negatively affected embryonic development in NOA patients. Therefore, it is important to observe embryos using time-lapse incubator in order to recognize embryos with/without pregnancy potential, especially for embryos with DC1 in NOA patients.

Trial registration number

Not applicable

P–019 Sperm parameter and ICSI / IVF outcomes after sperm selection using microfluidic sperm separator and density gradient centrifugation with swim-up in split semen sample

Study question

To analyze whether microfluidic sperm selection (MSS) by ZyMōt™ improves sperm DNA fragmentation rate and embryonic development compared to density gradient centrifugation with swim-up (DGCS).

Summary answer

MSS by ZyMōt™ selects sperm for clinical use with less DNA damage significantly compared to DGCS.

What is known already

Conventional sperm preparation methods, such as density gradient centrifugation and the swim-up method utilize centrifugation during processing, may damage the sperm. MSS may allow for improved selection of normal sperm compared with conventional sperm preparation as it yields sperm with a lower DNA fragmentation rate. However, there are few clinical studies by sibling oocytes study compared to DGCS.

Study design, size, duration

This prospective study was performed between March 2020 and May 2020 at a reproductive center. All patients involved gave written consent, and institutional review board approval was granted. A total of 575 metaphase II oocytes were collected from 49 cycles. Wife’s age was 34.7 ± 3.9 years old. Raw sperm concentration and motile sperm concentration was 63.1 ± 78.7M/mL, and 41.6 ± 67.7M/mL, respectively.

Participants/materials, setting, methods

Patients who performed ART for the first or second time were divided into two groups according to MSS and DGCS. Sperm DNA fragmentation rate (SDFR) and motile sperm concentration were compered between MSS and DGCS. SDFR was measured by sperm chromatin structure assay (SCSA) using a flow cytometer. Sibling oocytes were randomized into MSS-IVF, DGCS-IVF, MSS-ICSI, and DGCS-ICSI. Rate of two pronuclear (2PN) oocytes, blastocysts development, and good-quality blastocysts were compared between each group.

Main results and the role of chance

SDFR was 13.5 ± 11.8% for raw semen. SDFR was significantly lower after MSS (3.6 ± 4.1%) than that for raw semen and after DGCS (17.4 ± 14.8%) (P < 0.01). Motile sperm concentration after MSS (19.0 ± 28.3M/mL) was significantly higher after than after DGCS (15.4 ± 15.3M/mL) (P < 0.01). The number of IVF performed was 145 for MSS and 132 for DGCS. IVF results (MSS vs DGCS) were 2PN rate (73.1% vs 72.0%), blastocysts development rate (65.3% vs 55.4%), and good quality blastocysts rate (43.2% vs 34.9%). The number of ICSI performed was 149 for MSS and 149 for DGCS. ICSI results (MSS vs DGCS) were 2PN rate (77.9% vs 79.2%), blastocysts development rate (68.8% vs 65.8%), and good quality blastocysts rate (35.8% vs 30.6%). No significant difference was observed between MSS and DGCS for each parameter both IVF and ICSI.

Limitations, reasons for caution

The participants were limited to those who collected semen of 2mL or more and motile sperm concentration of above 1M/mL, because semen sample needed to be divided to MSS and DGCS.

Wider implications of the findings: This is the first study to conducted in sibling oosytes study with MSS and DGCS, in both IVF and ICSI. MSS is effective in collecting sperm with less DNA damage compared to DGCS. Motile sperm concentration after using MSS is sufficient to perform IVF as well as DGCS.

Trial registration number

Not applicable

Results of surgical treatment after Gamma Knife radiosurgery for cerebral arteriovenous malformations: patient series

BACKGROUND

Gamma Knife radiosurgery (GKRS) is a safe and effective treatment, but it has a risk of bleeding. Herein, the authors describe their experience with some patients who required surgical removal of cerebral arteriovenous malformations (AVMs) located mainly in eloquent areas of the brain after GKRS, and they consider the advantages of surgical removal after GKRS.

OBSERVATIONS

Twelve patients who had undergone surgical removal of AVMs after GKRS at Tokyo Women’s Medical University between April 2013 and July 2019 were selected for analysis. All participants underwent GKRS as first-line therapy for AVMs located in an eloquent region or if requested by the patient. Complete obliteration was achieved in 7 patients, and the size of the nidus decreased in 3 patients during the follow-up period. The Spetzler-Martin grade decreased in 11 patients. Three patients experienced symptomatic intracerebral hemorrhage before and after confirmation of complete obliteration of the nidus via GKRS, and 7 patients experienced some neurological deficits because of an encapsulated expanding hematoma. All patients underwent resection of the nidus without complications. The preoperative neurological deficits improved in 6 patients and remained unchanged in 6 patients.

LESSONS

This report indicates that performing GKRS before surgery may be useful for future multimodal therapy.

Selection of approach and bypass for fetal-type posterior cerebral artery aneurysm: illustrative cases

BACKGROUND

Unlike in aneurysms of the adult-type posterior cerebral artery (PCA), in aneurysms of the fetal-type PCA, parent artery occlusion (PAO) results in vascular insufficiency and major ischemic strokes. Preservation or reconstruction of fetal-type PCAs is necessary to prevent these complications. Furthermore, it is necessary to select an appropriate bypass method and approach for revascularization of the PCA.

OBSERVATIONS

The authors report 2 cases of aneurysms of fetal-type PCAs that were successfully treated with PAO with revascularization. A 38-year-old man with a large unruptured right PCA aneurysm at the postcommunicating (P2) segment underwent trapping with superficial temporal artery–PCA bypass via the anterior temporal and subtemporal approaches. In addition, a 45-year-old woman with a left PCA aneurysm at the quadrigeminal (P3)–cortical (P4) segments resulting in subarachnoid hemorrhage underwent proximal clipping of the P3 segment via the occipital interhemispheric approach with an occipital artery–PCA bypass. Although she had perforator infarction, major ischemic stroke was prevented, and aneurysm occlusion was accomplished in both cases.

LESSONS

Aneurysms of fetal-type PCAs pose a risk of ischemia due to PAO. The combined use of bypass and revascularization should be considered to prevent major ischemic stroke after occlusion of the fetal-type PCA. However, perforator infarction is a concern.

POS1487-HPR NEXT-GENERATION ONLINE TELEMEDICINE SYSTEM UTILIZING MIXED REALITY FOR RHEUMATOID ARTHRITIS

Background:

Telemedicine can be performed using a conventional videophone or web conferencing system. Then, joint lesions can only be observed and inferred from two-dimensional images, and it is difficult to perform accurate joint assessments, which is essential for the management of rheumatoid arthritis (RA).

Objectives:

To develop the next-generation online telemedicine system utilizing mixed reality for RA.

Methods:

We have developed a system that can assess joints accurately in three-dimensions images in real-time, using Azure Kinect DK (depth sensor)/ HoloLens 2 (headset), which are mixed reality technologies, and Teams (online interview/chat) provided by Microsoft. Furthermore, by applying artificial intelligence (AI), we plan to implement additionally to this system 1) a function to quickly catch and automatically evaluate the patient’s anxiety and changes in facial expressions at the time of examination, 2) a function to record dialogue with the patient in chronological order, 3) a function to support the detection of swollen joints, and 4) function to automatically analyze the questionnaire.

Results:

This system remotely connects a rheumatologist in the Nagasaki University Hospital (Nagasaki City, urban area) and a patient with RA and a non- rheumatologist in the Goto Central Hospital (Goto Island, rural area). A three-dimensional hologram of the patient’s hand projected in front of a rheumatologist. Using this system, we are able to evaluate joints more accurately than using a conventional videophone or web conferencing system.

Conclusion:

It is expected that this system will enable remote medical care specializing in rheumatology, which is standardized at a high level even in areas without rheumatologists such as remote islands and remote areas. This system remotely connects Nagasaki City and Goto Island, but due to the performance of the system, it is not limited to these areas and it is possible to connect rheumatologists to any area that can be connected to the network. It is also effective for the purpose of avoiding the risk of infection during long-distance hospital visits under the epidemic of COVID-19 infection.

References:

[1]Mov Disord. 2020;35:1719-1720.

Disclosure of Interests:

Shin-ya Kawashiri Speakers bureau: Speaker fees from AbbVie, Asahi Kasei, Astellas, Chugai, Eisai, Eli Lilly, Mitsubishi Tanabe, Novartis, and ONO., Grant/research support from: Research grants from Pfizer., Fumiaki Nonaka: None declared, Shinji Chiba: None declared, Tomoyuki Honda: None declared, Tomohiko Nakajima: None declared, Tomoyuki Ishikawa: None declared, Atsushi Kawakami Speakers bureau: Speaker fees from AbbVie, Actelion, Asahi Kasei, Astellas, Boehringer Ingelheim, Celltrion, Chugai, Daiichi Sankyo, Eisai, Eli Lilly, GSK, Janssen, Kowa, MedPeer, Mitsubishi Tanabe, Novartis, ONO, Pfizer, Taisho, and Takeda., Grant/research support from: Grants and research support from AbbVie, Actelion, Asahi Kasei, Astellas, AYUMI, Boehringer Ingelheim, Bristol-Myers Squibb, Celltrion, Chugai, Daiichi Sankyo, Eisai, Eli Lilly, Kyowa Hakko Kirin, MSD, Neopharma, Novartis, ONO, Sanofi, Taisho, Takeda Science Foundation, and Teijin

Antihypersensitivity effect of betanin (red beetroot extract) via modulation of microglial activation in a mouse model of neuropathic pain

BACKGROUND

Neuropathic pain (NeP) medications have several side effects that affect NeP patients' quality of life. Betanin, the most common betacyanin pigment, has been shown to have potent antioxidant and anti-inflammatory properties in vivo; thus, it has potential as a healthcare treatment. In this study, we focused on betanin (red beetroot extract) as a potential therapy for NeP.

METHODS

Mice model of NeP were made by chronic constriction injury (CCI), and the development of mechanical hypersensitivity was confirmed using the von Frey test. Motor coordination and locomotor activity were assessed using open field tests and rotarod tests, respectively. The expression level of glial markers in the spinal cords was analyzed by immunostaining. The direct effects of betanin on microglial cells were investigated using primary cultured microglial cells.

RESULTS

In CCI model mice, repeated betanin treatment, both intraperitoneally and orally, attenuated developing mechanical hypersensitivity in a dose-dependent manner without impairing motor coordination. Betanin treatment also attenuated mechanical hypersensitivity that had developed and prevented the onset of mechanical hypersensitivity in CCI mice. Microglial activation in the spinal cord is known to play a key role in the development of NeP; betanin treatment reduced CCI-induced microglial activation in the spinal cord of model mice. Moreover, in primary microglia cultured cells, the activation of microglia by lipopolysaccharide application was suppressed by betanin treatment.

CONCLUSION

Betanin treatment appears to ameliorate mechanical hypersensitivity related to CCI-induced NeP in mice by inhibiting microglial activation.

SIGNIFICANCE

This article supports findings of the effect of betanin on NeP and provides a potential therapeutic candidate for NeP. Furthermore, elucidating the underlying mechanism of the effect of betanin on microglial activation could assist the development of new treatments for chronic pain.

In Pursuit of Adult Progenitors of Thymic Epithelial Cells

Peripheral T cells capable of discriminating between self and non-self antigens are major components of a robust adaptive immune system. The development of self-tolerant T cells is orchestrated by thymic epithelial cells (TECs), which are localized in the thymic cortex (cortical TECs, cTECs) and medulla (medullary TECs, mTECs). cTECs and mTECs are essential for differentiation, proliferation, and positive and negative selection of thymocytes. Recent advances in single-cell RNA-sequencing technology have revealed a previously unknown degree of TEC heterogeneity, but we still lack a clear picture of the identity of TEC progenitors in the adult thymus. In this review, we describe both earlier and recent findings that shed light on features of these elusive adult progenitors in the context of tissue homeostasis, as well as recovery from stress-induced thymic atrophy.

The heptamer sgRNA targeting the human OCT4 mRNA can upregulate the OCT4 expression

TRUE gene silencing is one of the gene suppression technologies. This technology exploits the enzymatic property of the tRNA 3' processing endoribonuclease tRNase Z^L, which is that it can cleave a target RNA under the direction of a small guide RNA (sgRNA). We have been working on the development of therapeutic sgRNAs for hematological malignancies. In the course of an experiment to examine the ability of the heptamer-type sgRNA H15792 targeting the OCT4 mRNA to differentiate human amnion stem cells, we observed unexpectedly that the amnion cells exhibited a morphology resembling initialized cells. Here we investigated the effect of H15792 on human HL60 leukemia cells, and found that H15792 can upregulate the OCT4 expression and the expression of alkaline phosphatase in the cells.

Heptamer-type small guide RNA that can shift macrophages toward the M1 state

Multiple myeloma is a refractory cancer of plasma cells. Although treatment strategies for multiple myeloma are getting improved year by year, in most cases patients relapse due to the emergence of drug-resistant mutations in the myeloma cells. The interplay between myeloma cells and tumor-associated macrophages (TAM) is important for the pathology. We thought that some heptamer-type sgRNAs for TRUE gene silencing would be able to transform TAM toward the M1 state and might become therapeutic drugs for myeloma. Here, we searched for heptamer-type sgRNAs that can shift macrophages toward the M1 state. We screened a heptamer-type sgRNA library for the ability to up-regulate IL-12b gene expression in human macrophage-like cell lines, and found three such sgRNAs. One of the sgRNAs, H12960, which also showed such ability in human fresh macrophages and mouse macrophage-like cell lines, efficiently suppressed human myeloma cell growth in SCID/NOD mice.