Do biologics-naïve patients with rheumatoid arthritis respond better to tocilizumab than patients for whom anti-TNF agents have failed? A retrospective study

OBJECTIVES

To determine responses to tocilizumab between patients with rheumatoid arthritis (RA) who switched to anti-TNF agents and those who are biologics-naïve.

METHODS

This retrospective study investigated 107 patients with RA who were treated with tocilizumab. At baseline, 61 of them had already been treated with anti-TNF agents (switched group; 46 for inefficacy and 15 for adverse events), and 46 were biologics-naïve (naïve group). Treatment responses to tocilizumab at week 12 and 24 were compared between the switched and naïve groups using the disease activity score 28 (DAS28).

RESULTS

Forty-two (91.3%) and 50 (82.0%) patients in the naïve and switched groups, respectively, completed 24 weeks of tocilizumab treatment. The DAS28-ESR and DAS28-CRP values (means±SD) at weeks 12 and 24 compared to baseline decreased significantly for the naïve and switched groups. The DAS28-ESR and DAS28-CRP values at weeks 12 and 24 were significantly decreased in the naïve group, compared to the switched group. Disease activity was improved in the naïve patients compared to the switched patients.

CONCLUSIONS

Tocilizumab was safe, tolerable, and clinically effective for patients with inadequate responses to anti-TNF therapy and for those who were biologics-naïve, and it was more effective among the latter.

How were the high-fever consultation center perceived by the officers who provided it in Kobe City, during swine-origin influenza A (H1N1) outbreak? A qualitative study utilizing SCQRM

BACKGROUND

For the preparation of pandemic influenza, Japan's government requested to set up a high-fever consultation center at each prefectural and city government. During the initial period of pandemic influenza A (H1N1) outbreak in Japan, high-fever consultation centers received a great number of calls. The effectiveness of this system, however, has not been fully evaluated. This study reports the result of a qualitative study, which explored officers who provided the high-fever consultation center during influenza outbreak.

METHODS

A qualitative study, using semi-structured interviews (n=3), was conducted to the officers of a major city government in Japan, who provided the service. Theory construction was conducted with a use of structure construction qualitative research method.

RESULTS

The officers expressed many difficulties during the outbreak. The uncertainty of the disease characteristics, rapidly changing situation, fear of bad outcome of patients due to wrong triage, and miscommunications among health care workers were among the difficulties extracted. While inefficiency was among the problems extracted, lessening anxiety of callers was one of the achievements they felt the high-fever consultation center provided. Development of practical manual made their provision of the service easier.

Association of radiographic and symptomatic knee osteoarthritis with health-related quality of life in a population-based cohort study in Japan: the ROAD study

OBJECTIVE

Knee osteoarthritis (OA) is a major public health issue causing chronic pain and disability. However, there is little information on the impact of this disease on quality of life (QOL) in Japanese men and women. The objective of the present study was to clarify the impact of radiographic and symptomatic knee OA on QOL in Japan.

METHODS

This study examined the association of radiographic and symptomatic knee OA with QOL parameters such as the Medical Outcomes Study Short Form-8 (SF-8), EuroQOL (EQ-5D) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Radiographic knee OA was defined according to Kellgren/Lawrence (KL) grades, and symptomatic knee OA was defined as KL=3 or 4 with knee pain. We also examined the independent association of symptomatic knee OA and grip strength with QOL.

RESULTS

From the 3040 participants in the Research on Osteoarthritis Against Disability (ROAD) study, the present study analyzed 2126 subjects older than 40 years who completed the questionnaires (767 men and 1359 women; mean age, 68.9+/-10.9 years). Subjects with KL=3 or 4 had significantly lower physical QOL as measured by the physical component summary (PCS) score of the SF-8 and pain domains of the WOMAC, whereas mental QOL, as measured by the mental component summary (MCS) score of the SF-8, was higher in subjects with KL=3 or 4 than KL=0 or 1. Symptomatic knee OA was significantly more likely than radiographic knee OA without pain to be associated with physical QOL loss as measured by the PCS score and physical domains of the WOMAC. Symptomatic knee OA and grip strength were independently associated with physical QOL.

CONCLUSION

This cross-sectional study revealed that subjects with symptomatic knee OA had significantly lower physical QOL than subjects without it.

The Distribution and Effects of Genes Causing F(1) Weakness in ORYZA BREVILIGULATA and O. GLABERRIMA

Weakness of F(1) plants is frequently found in hybrids between strains of Oryza breviligulata (wild) and O. glaberrima (cultivated rice) endemic to West Africa. A set of two complementary dominant weakness genes, W(1) and W(2), was found to control the observed F(1) weakness. Many breviligulata strains had W(1), while most of the glaberrima and semi-wild strains had W(2) or were free of both. In the weak F(1) plants, tissue differentiation in adventitious roots seemed to be disturbed. Modifier genes affecting the expression of the weakness genes appear to be present also.

Analysis of genes controlling f(1) sterility in rice by the use of isogenic lines

In order to look into the genetic basis of intervarietal F(1) sterility in rice (Oryza sativa L.), a series of backcrosses (up to B(13)) was carried out using Taichung 65 (Japonica type) as the recurrent parent and several Indica varieties as donor parents. A number of "isogenic F(1)-sterile lines" were isolated by test-crossing fertile F(2) plants obtained from the selfing of partly pollensterile backcross segregants. Crossing experiments with the isogenic lines confirmed the author's previous hypothesis that there are sets of duplicate gametic lethals (s genes) and that gametes carrying a double recessive combination (s(1)s(2)) of these deteriorate during development, though in the present hypothesis the genes are considered to affect the development of microspores only. Assuming that Taichung 65 has the genotype s(1)/s(1) + (2)/+(2) and a donor parent (like an isogenic F(1)-sterile line derived from it) has +(1)/+(1)s(2)/s(2), pollen grains with +(1)s(2) have shown a higher fertilizing capacity in the genetic background of Taichung 65 than those with s(1) +(2), while those with +(1) +(2) have a lower fertilizing capacity. This certational advantage of alien genes was considered to be an internal mechanism that helped the development of F(1) sterility relationships among rice varieties. The isogenic F(1)-sterile lines derived from different donor parents each had a set of s genes at different loci. Linkage relations were detected between the s loci and three gene markers.

Spin-dependent quantum interference within a single magnetic nanostructure

Quantum interference is a coherent quantum phenomenon that takes place in confined geometries. Using spin-polarized scanning tunneling microscopy, we found that quantum interference of electrons causes spatial modulation of spin polarization within a single magnetic nanostructure. We observed changes in both the sign and magnitude of the spin polarization on a subnanometer scale. A comparison of our experimental results with ab initio calculations shows that at a given energy, the modulation of the spin polarization can be ascribed to the difference between the spatially modulated local density of states of the majority spin and the nonmodulated minority spin contribution.

[Ratio of serum levels of 1,25-dihydroxyvitamin D3 and parathyroid hormone for the diagnosis and treatment of tuberculous peritonitis in a chronic kidney disease patient: a case report]

An 80-year-old man was admitted to our hospital because of exacerbation of preexisting chronic kidney disease (CKD). On admission, he showed elevated levels of serum creatinine (6.37 mg/dL) and corrected calcium (13.7 mg/dL). Although the serum levels of intact parathyroid hormone (I-PTH) and parathyroid hormone-related peptide(PTITH-rP)were low, the serum 1,25-dihydroxyvitamin D3 (1,25 (OH)2D3)levels were high. Computed tomography (CT) revealed ascites, and the ascitic fluid was exudative and serous with predominance of lymphocytes. The levels of adenosine deaminase (ADA) in the ascitic fluid were also elevated, and the results of QuantiFERON-TB2G (QFT-2G)assay were positive, indicating tuberculous peritonitits. Ascites resolved rapidly after initiation of the antituberculosis therapy. The elevated levels of serum calcium and 1,25 (OH) 2D3 returned to below-normal levels; however, serum i-PTH levels increased from 8.9 pg/ mL to 432 pg/mL. Diagnosis of extrapulmonary tuberculosis is often difficult in CKD patients. CKD patients show abnormal vitamin D activation, so these patients usually have low levels of serum 1,25(OH)2D3. On the other hand, in our patient, 1,25(OH)2D3 was extrarenally produced from tuberculous granuloma and therefore, he showed high levels of serum 1,25(OH)2D3 and correspondingly, low levels of serum i-PTH. We observed that the ratio of 1,25 (OH) 2D3:i-PTH decreased due to antituberculosis therapy. This ratio facilitated the diagnosis and evaluation of treatment for this condition.

Effect of neutrophil elastase inhibitor (sivelestat sodium) in the treatment of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS): a systematic review and meta-analysis

INTRODUCTION

Sivelestat is neutrophil elastase inhibitor, which is widely used in Japan for the treatment of acute lung injury. However, the clinical efficacy of the medication has not been convincingly demonstrated.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials on sivelestat for the treatment of acute lung injury and acute respiratory distress syndrome. Studies were identified using MEDLINE, EMBASE, Cochrane library, conference proceedings, and references of included studies. Authors were contacted if necessary. ICHUSHI, the Japanese database for medical literature and conference proceedings was also used for the search, since many studies on sivelestat were published in Japanese language and not registered in major databases such as MEDLINE. The primary outcome was mortality within 28-30 days after randomization. Relative risks were pooled with the random effect model.

RESULTS

8 trials were included in the analysis. There was no difference in mortality within 28-30 days after randomization (relative risk 0.95, 95% confidence interval 0.72 to 1.26). Subgroup analysis conducted only on studies conducted in Japan showed the same result (0.59, 0.28 to 1.28). There was no difference in mechanical ventilation days (standardized mean difference -0.43, -1.12 to 0.27), but sivelestat was associated with a better short term PaO(2)/FiO(2) ratio (0.30, 0.05 to 0.56). Heterogeneity was not significant for the main analysis and funnel plot did not suggest publication bias.

CONCLUSION

Sivelestat was not associated with decreased mortality, even when including studies published in Japanese language.

Epidemiology of lumbar osteoporosis and osteoarthritis and their causal relationship--is osteoarthritis a predictor for osteoporosis or vice versa?: the Miyama study

SUMMARY

In a 10-year follow-up of a population-based cohort of Japanese subjects, incidences of and causal relationships between osteoporosis (OP) and osteoarthritis (OA) at the lumbar spine were clarified. OP might reduce the risk of subsequent OA at the spine in women, but not in men.

INTRODUCTION

The aim of this study is to clarify the contribution of osteoarthritis (OA) to osteoporosis (OP) and vice versa.

METHODS

A population-based, epidemiological study was conducted in a Japanese rural community. From 1,543 participants aged 40-79 years, 200 men and 200 women were selected and followed up for 10 years. Bone mineral density measurements were repeated after 3, 7, and 10 years, and X-rays were repeated after 10 years.

RESULTS

The incidence of lumbar OP per 10,000 person-years for persons in their 40s, 50s, 60s, and 70s was 0, 0, 109.5, and 151.1 for men and 124.2, 384.0, 227.3, and 239.5 for women, respectively. The cumulative incidence of lumbar OA over 10 years aged 40-79 years was 25.8% in men and 45.2% in women. Cox's proportional hazards model showed no significant relationship between the presence of lumbar OA at the baseline and incidence of lumbar and femoral neck OP in both genders. A significant relationship was demonstrated between the presence of lumbar OP, not femoral neck OP, at the baseline and cumulative incidence of lumbar OA in women (odds ratio, 0.20; 95% confidence interval, 0.05-0.80; P = 0.02).

CONCLUSION

OP in women appears to reduce the future incidence of OA at the lumbar spine.

Long-term outcomes of idiopathic membranous nephropathy in Japanese patients treated with low-dose cyclophosphamide and prednisolone

BACKGROUND

Treatment with cyclophosphamide and steroids for idiopathic membranous nephropathy (IMN) is effective in Caucasian patients, but the cumulative cyclophosphamide dosage exceeds 10 g and includes steroid pulse therapy. Adverse effects and difficulties with repeating treatment are major limitations. We studied the long-term outcomes of low-dose cyclophosphamide and prednisolone therapy in Japanese patients, who were thought to have relatively benign IMN compared with Caucasian patients.

METHODS

This is a prospective cohort study of 103 consecutive Japanese patients with IMN and nephrotic syndrome. Patients were treated with cyclophosphamide (50 mg/day for the first 3 months and 25 mg/day for the next 3 months) and prednisolone (30 mg/day for the first week and the dosage was gradually tapered to withdraw by 2 years). Additional therapies were allowed for initial treatment failure or relapse.

RESULTS

With a mean observation period of 8.5 years, 90 patients (87.4%) achieved proteinuria of <1 g/day and 78 (75.7%) achieved complete remission. A total of 27 patients did not respond to initial treatment and 30 patients had relapses after remission. Of these patients, 39 received additional therapies. At the last observation, 12 patients had developed renal insufficiency (S-Cr >1.5 mg/dL) but only 2 patients had reached renal death. Multivariate analysis revealed that the duration without remission was the strongest risk factor for renal prognosis. There were 14 deaths, and 8 patients developed cancers during the observation period.

CONCLUSION

Treating nephrotic IMN in Japanese patients with low-dose cyclophosphamide and prednisolone is beneficial for long-term renal prognosis with relatively few adverse effects.

Computerized quantification of psoriasis lesions with colour calibration: preliminary results

An evaluation was made of a fully automated index of psoriasis, termed Computer-assisted Area and Severity Index (CASI). This method requires taking digital photographs of the target skin area(s) with a colour reference marker, Casmatch. The CASI evaluates the severity of the psoriasis from the size and redness of the lesion(s). In five patients with mild psoriasis vulgaris mainly observed on their trunk, 18 photographs of the trunk were taken every 2 weeks. Three of the five patients [Psoriasis Area and Severity Index (PASI) of 3.0, 3.6 and 10.1, respectively] were treated with oral cyclosporin 3 mg/kg/day for 4 weeks. The mean +/- SD area of lesion selected by a dermatologist was 2.3 +/- 1.3% of the total skin area. This method achieved extraction performance for psoriasis of 72.1 +/- 19.4% for sensitivity and 97.4 +/- 2.0% for specificity. CASI correlated strongly with PASI (r = 0.92), but not with Skindex16 (r = 0.35). Although only erythema was evaluated, our preliminary results indicate that this method is capable of quantifying psoriasis lesions.

Familial lecithin: cholesterol acyltransferase deficiency complicated with unconjugated hyperbilirubinemia and peripheral neuropathy. The first reported cases in the Far East

Three Japanese patients with lecithin: cholesterol acyltransferase (LCAT) deficiency, the offspring of a consanguineous marriage, are described. In addition to the characteristic clinical and laboratory findings of the disease, our patients had hitherto unreported manifestations, namely unconjugated hyperbilirubinemia, peripheral neuropathy and marked hypocholesterolemia. Although the mechanism of the unconjugated hyperbilirubinemia is not clear, the role of impaired hepatic bilirubin uridine-diphosphate-glucuronyl transferase activity combined with another unknown factor(s) was postulated. Non-random assortment was observed between LCAT deficiency and haptoglobin types, as previously reported. The discovery of Japanese patients with LCAT deficiency indicates that the distribution of this hereditary metabolic disorder is not confined to the Western hemisphere.

[A case of lymphocytic interstitial pneumonia complicated with primary Sjögren's syndrome followed by chest CT scanning for thirteen years]

We encountered a rare case of lymphocytic interstitial pneumonia (LIP) complicated with primary Sjögren's syndrome (SjS), followed by chest CT scanning for a long period of time. A 54-year-old man with hemoptysis was admitted to our hospital in December, 2001. A diagnosis of SjS was made based on elevation of anti-SS-B/La antibody titer in serum in combination with diagnosis of keratoconjunctivitis sicca and xerostomia on a Schirmer test and a lip biopsy, respectively. Subsequent histopathological diagnosis by open lung biopsy showed LIP. Chest CT in September, 1995 at previous hospital revealed ground-glassed opacity (GGO), small nodules, thickened bronchovascular bundles and cyst formation in lungs. Chest CT was performed every year until 2008, when remarkable progression from thickened bronchovascular bundles accompanied by nodular opacities to an air-space consolidation in the right lower lobe was observed. Also, appearance of cyst formation in the right middle lobe, nodular lesions and GGO in the left lower lobe were noticed. Although the nodular opacities and GGO improved after an administration of corticosteroid (PSL 0.5 mg/kg/day), little improvement in the consolidations and cyst formation was demonstrated. In conclusion, it was suggested that differences among CT findings of LIP may be important for evaluating of efficacy of treatment by steroid agents for LIP associated with SjS.

Bony tunnel formation in the middle meningeal groove: an anatomic study for safer pterional craniotomy

OBJECTIVE

When the bone flap is removed in a pterional craniotomy, the middle meningeal artery (MMA) should be gently dissected to minimize blood loss. However, when the MMA pierces a bony tunnel in the middle meningeal groove it is easily damaged upon bone flap elevation. We have performed an anatomic study of this tunnel to render pterional craniotomy safer.

METHODS

We examined 78 sides from 39 adult skulls for the presence and length of the tunnel, the distance between the lateral border of the superior orbital fissure and the proximal part of the tunnel, and examined the relationship between the MMA piercing the tunnel to a surface landmark, i.e., the junction of the sphenoparietal, sphenosquamosal, and squamosal sutures.

RESULTS

We found 59 tunnels on 78 sides (75.6%); 2 were at the branching of the MMA on one side. The tunnels were located on the temporal side of the lesser wing of the sphenoid bone. The length of the tunnel and the distance from the superior orbital fissure were 3-23 mm (mean: 12.2 mm) and 11-33 mm (mean: 18.9 mm), respectively. Most tunnels (86.4%) were bilateral; in 67.8% of the specimens the MMA piercing the tunnel was just beneath the surface landmark.

CONCLUSION

As we found a high incidence of bony tunnel formation in the middle meningeal groove, actual findings can be different from the accepted nomenclature. If a tunnel exists, the MMA is easily damaged upon cracking of the lesser wing during bone flap elevation. Recognition of this anatomy may render pterional craniotomy safer.

Fully automatic quantification of knee osteoarthritis severity on plain radiographs

OBJECTIVE

Although knee osteoarthritis (OA) is a major public health issue causing chronic disability, there is no objective or accurate method for measurement of the structural severity in general clinical practice. Here we have established a fully automatic program KOACAD (knee OA computer-aided diagnosis) to quantify the major OA parameters on plain knee radiographs, validated the reproducibility and reliability, and investigated the association of the parameters with knee pain.

METHODS

KOACAD was programmed to measure joint space narrowing at medial and lateral sides, osteophyte formation, and joint angulation. Anteroposterior radiographs of 1979 knees of a large-scale cohort population were analyzed by KOACAD and conventional categorical grading systems.

RESULTS

KOACAD automatically measured all parameters in less than 1s without intra- or interobserver variability. All parameters, especially medial joint space narrowing, were significantly correlated with the conventional gradings. In the parameters, osteophyte formation was associated with none of the joint space parameters, suggesting different etiologic mechanisms between them. Multivariate logistic regression analysis after adjustment for age and confounding factors revealed that medial joint space narrowing and varus angulation of knee joints were risk factors for the presence of pain (594/1979 knees), while neither lateral joint space nor osteophyte area was.

CONCLUSION

KOACAD was shown to be useful for objective, accurate, simple and easy evaluation of the radiographic knee OA severity in daily clinical practice. This system may also serve as a surrogate measure for the development of disease-modifying drugs for OA, just as bone mineral density does in osteoporosis.

Prevalence of radiographic lumbar spondylosis and its association with low back pain in elderly subjects of population-based cohorts: the ROAD study

OBJECTIVES

Although lumbar spondylosis is a major cause of low back pain and disability in elderly people, few epidemiological studies have been performed. The prevalence of radiographic lumbar spondylosis was investigated in a large-scale population study and the association with low back pain was examined.

METHODS

From a nationwide cohort study (Research on Osteoarthritis Against Disability; ROAD), 2288 participants aged > or =60 years (818 men and 1470 women) living in urban, mountainous and coastal communities were analysed. The radiographic severity at lumbar intervertebral levels from L1/2 to L5/S was determined by Kellgren/Lawrence (KL) grading.

RESULTS

In the overall population the prevalence of radiographic spondylosis with KL> or =2 and > or =3 at the severest intervertebral level was 75.8% and 50.4%, respectively, and that of low back pain was 28.8%. Although KL> or =2 spondylosis was more prevalent in men, KL> or =3 spondylosis and low back pain were more prevalent in women. Age and body mass index were risk factors for both KL > or =2 and KL> or =3 spondylosis. Although KL = 2 spondylosis was not significantly associated with low back pain compared with KL = 0 or 1, KL> or =3 spondylosis was related to the pain only in women.

CONCLUSIONS

This cross-sectional study in a large population revealed a high prevalence of radiographic lumbar spondylosis in elderly subjects. Gender seems to be distinctly associated with KL> or =2 and KL> or =3 lumbar spondylosis, and disc space narrowing with or without osteophytosis in women may be a risk factor for low back pain.