Acute Spinal Cord Infarction with Preferential Involvement of Ventral Gray Matter: An Autopsy Report

Herein, we report abdominal aortic thrombosis as a rare cause of acute spinal cord infarction. A 78-year-old man with multiple vascular risk factors developed acute paraplegia with sensory and urinary disturbances and signs of ischemia in both lower limbs. The post-mortem study done 3 days after the onset of symptoms revealed a large coagulum in the abdominal aorta, distal to the renal arteries and extending to bilateral common iliac arteries; in addition, marked atherosclerosis was present in most large blood vessels. Premature incomplete necrotic foci were seen in the ventral gray matter of the spinal cord from T6 through S5; the surrounding white matter and dorsal gray matter were spared. Considering our autopsy case, spinal cord gray matter may be more vulnerable to ischemia than the white matter.

Stimulatory effect of insulin on H+-ATPase in the proximal tubule via the Akt/mTORC2 pathway

Purpose

Acid-base transport in renal proximal tubules (PTs) is mainly sodium-dependent and conducted in coordination by the apical Na+/H+ exchanger (NHE3), vacuolar H+-adenosine triphosphatase (V-ATPase), and the basolateral Na+/HCO3- cotransporter. V-ATPase on PTs is well-known to play an important role in proton excretion. Recently we reported a stimulatory effect of insulin on these transporters. However, it is unclear whether insulin is involved in acid-base balance in PTs. Thus, we assessed the role of insulin in acid-base balance in PTs.

Methods

V-ATPase activity was evaluated using freshly isolated PTs obtained from mice, and specific inhibitors were then used to assess the signaling pathways involved in the observed effects.

Results

V-ATPase activity in PTs was markedly enhanced by insulin, and its activation was completely inhibited by bafilomycin (a V-ATPase-specific inhibitor), Akt inhibitor VIII, and PP242 (an mTORC1/2 inhibitor), but not by rapamycin (an mTORC1 inhibitor). V-ATPase activity was stimulated by 1 nm insulin by approximately 20% above baseline, which was completely suppressed by Akt1/2 inhibitor VIII. PP242 completely suppressed the insulin-mediated V-ATPase stimulation in mouse PTs, whereas rapamycin failed to influence the effect of insulin. Insulin-induced Akt phosphorylation in the mouse renal cortex was completely suppressed by Akt1/2 inhibitor VIII and PP242, but not by rapamycin.

Conclusion

Our results indicate that stimulation of V-ATPase activity by insulin in PTs is mediated via the Akt2/mTORC2 pathway. These results reveal the mechanism underlying the complex signaling in PT acid-base balance, providing treatment targets for renal disease.

Urinary fluorescent metabolite O-aminohippuric acid is a useful biomarker for lung cancer detection

INTRODUCTION

Urine contains diagnostically important metabolites that can act as natural fluorophores. However, whether these fluorescent metabolites can be used in lung cancer diagnosis is unknown.

OBJECTIVES

This study was conducted to determine whether fluorescent urinary metabolites could be useful biomarkers for lung cancer detection.

METHODS

A total of 46 lung cancer patients and 185 volunteers without cancer were evaluated between November 2013 and November 2014. Samples of the first urine of the day were collected from lung cancer patients and diagnosed at the Hamamatsu University School of Medicine and the Hamamatsu Medical Center prior to cancer treatment, and from volunteers without cancer at the Hamamatsu Medical Imaging Center. Fluorescent urinary metabolites were screened by high-performance liquid chromatography and select effective fluorescent substances for distinguishing cancer from non-cancer status.

RESULTS

The fraction of patients at each stage of cancer severity were: 41.3% stage I, 8.7% stage II, 19.6% stage III, and 30.4% stage IV. A robust predictive biomarker for lung cancer was selected by the multivariate logistic analysis of fluorescent metabolites and identified to be O-aminohippuric acid (OAH). The area under the curve (AUC) data for OAH was 0.837 (95% CI 0.769-0.898, P < 0.001).

CONCLUSION

We identified a fluorescent urinary metabolite that can predict lung cancer. OAH exceeds the AUC (0.817) of lung cancer detection by AminoIndex® cancer screening, can be analyzed non-invasively without additional sample processing, and may be a valuable addition to existing lung cancer prediction models.

Functional Genomics of the Pediatric Obese Asthma Phenotype Reveal Enrichment of Rho-GTPase Pathways

Rationale: Obesity-related asthma disproportionately affects minority children and is associated with nonatopic T-helper type 1 (Th1) cell polarized inflammation that correlates with pulmonary function deficits. Its underlying mechanisms are poorly understood.Objectives: To use functional genomics to identify cellular mechanisms associated with nonatopic inflammation in obese minority children with asthma.Methods: CD4⁺ (cluster of differentiation 4-positive) Th cells from 59 obese Hispanic and African American children with asthma and 61 normal-weight Hispanic and African American children with asthma underwent quantification of the transcriptome and DNA methylome and genotyping. Expression and methylation quantitative trait loci revealed the contribution of genetic variation to transcription and DNA methylation. Adjusting for Th-cell subtype proportions discriminated loci where transcription or methylation differences were driven by differences in subtype proportions from loci that were independently associated with obesity-related asthma.Measurements and Main Results: Obese children with asthma had more memory and fewer naive Th cells than normal-weight children with asthma. Differentially expressed and methylated genes and methylation quantitative trait loci in obese children with asthma, independent of Th-cell subtype proportions, were enriched in Rho-GTPase pathways. Inhibition of CDC42 (cell division cycle 42), one of the Rho-GTPases associated with Th-cell differentiation, was associated with downregulation of the IFNγ, but not the IL-4, gene. Differential expression of the RPS27L (40S ribosomal protein S27-like) gene, part of the p53/mammalian target of rapamycin pathway, was due to nonrandom distribution of expression quantitative trait loci variants between groups. Differentially expressed and/or methylated genes, including RPS27L, were associated with pulmonary function deficits in obese children with asthma.Conclusions: We found enrichment of Rho-GTPase pathways in obese asthmatic Th cells, identifying them as a novel therapeutic target for obesity-related asthma, a disease that is suboptimally responsive to current therapies.

Histopathological study of carcinoma showing thymus-like differentiation (CASTLE)

INTRODUCTION

Carcinoma showing thymus-like differentiation (CASTLE) is a rare tumour that mainly arises from the thyroid gland, or occasionally, from the head and neck. Although the 10-year survival rate of patients with CASTLE is approximately 80%, local recurrence and distant metastasis are observed in some cases. A recent systematic review for CASTLE indicated that the prognostic factors are treatment-dependent, and postoperative radiotherapy significantly improves patient survival.

CASE REPORT

Herein, we describe and compare three cases of CASTLE, including a case with distant metastasis despite administering postoperative chemotherapy. Thus, the mechanisms underlying metastasis of CASTLE are unclear. This case study helps to elucidate the histopathological risk factors of metastasis in CASTLE.

DISCUSSION

We found that prominent lymphovascular invasion and higher proliferative activities might be risk factors of metastasis in CASTLE. In addition, we have summarised the cytological, morphological, and immunohistochemical features of CASTLE for an accurate diagnosis.

Host Species and Body Site Explain the Variation in the Microbiota Associated to Wild Sympatric Mediterranean Teleost Fishes

Microorganisms are an important component in shaping the evolution of hosts and as such, the study of bacterial communities with molecular techniques is shedding light on the complexity of symbioses between bacteria and vertebrates. Teleost fish are a heterogeneous group that live in a wide variety of habitats, and thus a good model group to investigate symbiotic interactions and their influence on host biology and ecology. Here we describe the microbiota of thirteen teleostean species sharing the same environment in the Mediterranean Sea and compare bacterial communities among different species and body sites (external mucus, skin, gills, and intestine). Our results show that Proteobacteria is the dominant phylum present in fish and water. However, the prevalence of other bacterial taxa differs between fish and the surrounding water. Significant differences in bacterial diversity are observed among fish species and body sites, with higher diversity found in the external mucus. No effect of sampling time nor species individual was found. The identification of indicator bacterial taxa further supports that each body site harbors its own characteristic bacterial community. These results improve current knowledge and understanding of symbiotic relationships among bacteria and their fish hosts in the wild since the majority of previous studies focused on captive individuals.

AB0494 CHARACTERISTICS OF THE PATIENTS WITH POLYARTERITIS NODOSA IN JAPAN

Background:

Since the number of polyarteritis nodosa (PAN) patients is small not only in Japan but also in the world, the characteristics of PAN have not been fully clarified and appropriate treatment has not been established.

Objectives:

This study aimed to describe the epidemiological and clinical features and treatment of patients with PAN in Japan.

Methods:

We used the database of the Ministry of Health, Labour and Welfare (MHLW) in 2013 and 2014. Data of 178 patients who fulfilled the diagnostic criteria by MHLW and had registered within a year after onset of PAN was analyzed.

Results:

The analysis included 75 males and 103 females, with a mean age of 64.5 ± 20.3 years. PAN was diagnosed by clinical symptoms in 27.6% of the patients, 11.5% of the patients by pathological findings, and the rest of the patients by both. Pathological examination was performed in 71.3% of the patients, of whom 11.2% had evidence of necrotizing vasculitis of the small and medium arteries. As a systemic symptom, fever was observed in 55.2% of cases. As organ symptoms, muscle and joint symptoms (74.7%), skin symptoms (73.0%), neuropsychiatric symptoms (50.0%), respiratory symptoms (32.6%), and renal symptoms (19.7%) were common. Patients aged 65 or older had a higher rate of systemic, renal and respiratory symptoms, and lower rate of skin symptoms compared with the patients younger than 65. Patients with renal symptoms had a high prevalence of respiratory, cardiac and ocular symptoms, while those with respiratory symptoms had a high prevalence of systemic and cardiac symptoms. Laboratory findings showed that MPO- and/or p-ANCA positive rate was 30.5% and PR3- and/or c-ANCA positive rate was 11.0%. The Hepatitis B antigen positive rate was 3.9%. Angiography was performed in 20.7%, among which 27.0% were found to have multiple small aneurysms, wall irregularities and stenosis at the abdominal aortic branches. Glucocorticoids were used for treatment in all cases with an average maximum prednisolone dose of 32.5 mg/day. Concomitant immunosuppressants were used in 28.7%, half of which was cyclophosphamide. In other cases, azathioprine or methotrexate was used. Immunosuppressants have been used more frequently in patients with systemic symptoms and nasal and ear symptoms. Among the immunosuppressants, cyclophosphamide tends to be used for patients with higher CRP or patients with respiratory symptoms, and the maximum dose of glucocorticoids was significantly higher in patients who used cyclophosphamide compared to those who used other immunosuppressants.

Conclusion:

PAN developed in middle-aged and elderly people and exhibited various clinical symptoms. We found that common symptoms varied with age, and treatment options were determined depending on the types of organ symptoms and severity. Hepatitis B virus infection was rare in patients with PAN in Japan.

References:

None.

Disclosure of Interests: :

Mai Kawazoe: None declared, Toshihiro Nanki Grant/research support from: Chugai Pharmaceutical Co., Eisai Co., Ltd., Teijin Pharma Ltd., Eli Lilly Japan K.K., Bristol-Myers K.K., Ono Pharmaceutical Co., Ltd., Novartis Pharma K.K., Asahikasei Pharma Corp., Mitsubishi-Tanabe Pharma Co., Astellas Pharma Inc., Ayumi Pharmaceutical Co., Pfizer Japan Inc., Daiichi Sankyo Co., Ltd., Shionogi & Co., Ltd., Sanofi K.K., Nippon Kayaku Co., Ltd., Yutoku Pharmaceutical Ind. Co., Ltd., UCB Japan Co. Ltd., Nihon Pharmaceutical Co., Ltd., and Bayer Yakuhin, Ltd., Consultant of: UCB Japan Co., Ltd., Eisai Co., Ltd., and Chugai Pharmaceutical Co., Speakers bureau: Mitsubishi-Tanabe Pharma Co., Chugai Pharmaceutical Co., Eisai Co., Ltd., Astellas Pharma Inc., Janssen Pharmaceutical K.K., Ayumi Pharmaceutical Co., Pfizer Japan Inc., Asahikasei Pharma Corp., Sanofi K.K., Novartis Pharma K.K., Eli Lilly Japan K.K., Nippon Kayaku Co., Ltd., Teijin Pharma Ltd., Takeda Pharmaceutical Co., Nippon Boehringer Ingelheim Co., Ltd., and AbbVie GK., Noboru Hagino: None declared, Noriko Iketani: None declared, Satoshi Ito Speakers bureau: Abbvie,Eisai, Masanari Kodera: None declared, Naoko Nakano: None declared, Miki Suzuki: None declared, Shin-ya Kaname: None declared, masayoshi harigai Grant/research support from: AbbVie Japan GK, Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Eisai Co., Ltd., Mitsubishi Tanabe Pharma Co., Nippon Kayaku Co., Ltd., and Teijin Pharma Ltd. MH has received speaker’s fee from AbbVie Japan GK, Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Kissei Pharmaceutical Co., Ltd., Oxford Immuotec, Pfizer Japan Inc., and Teijin Pharma Ltd. MH is a consultant for AbbVie, Boehringer-ingelheim, Kissei Pharmaceutical Co., Ltd. and Teijin Pharma.

A Cellular Stress Response Induced by the CRISPR-dCas9 Activation System Is Not Heritable Through Cell Divisions

The CRISPR-Cas9 system can be modified to perform "epigenetic editing" by utilizing the catalytically inactive (dead) Cas9 (dCas9) to recruit regulatory proteins to specific genomic locations. In prior studies, epigenetic editing with multimers of the transactivator VP16 and guide RNAs (gRNAs) was found to cause adverse cellular responses. These side effects may confound studies inducing new cellular properties, especially if the cellular responses are maintained through cell divisions-an epigenetic regulatory property. Here, we show how distinct components of this CRISPR-dCas9 activation system, particularly dCas9 with untargeted gRNAs, upregulate genes associated with transcriptional stress, defense response, and regulation of cell death. Our results highlight a previously undetected acute stress response to CRISPR-dCas9 components in human cells, which is transient and not maintained through cell divisions.

AB0619 PROGNOSTIC FACTORS OF PATIENTS WITH ANTI-MDA5 ANTIBODY-POSITIVE DERMATOMYOSITIS COMPLICATED WITH INTERSTITIAL PNEUMONIA -A JAPANESE SINGLE CENTER STUDY-

Background:

Anti-melanoma differentiation-associated gene 5 antibody (anti-MDA5 Ab)-positive dermatomyositis (DM) is frequently associated with rapidly progressive interstitial pneumonia (RPIP), whose prognosis is assumed to be poor[1]. Although outcome of DM-RPIP has been reported to be improved by early immunosuppressive therapy, we still experience the cases with severe outcome. Only several reports mentioned the prognostic factors and they have not been fully elucidated.

Objectives:

To identify the predictors of prognosis in patients with anti-MDA5 Ab-positive DM associated with interstitial pneumonia (DM-IP).

Methods:

Anti-MDA5 Ab-positive DM-IP patients admitted to Fujita Health University Hospital between January 2010 and October 2019 were consecutively included and stratified into 2 groups, the survived and the deceased groups. DM was diagnosed according to the criteria proposed by Bohan and Peter[2]. Clinically amyopathic DM was diagnosed according to the criteria proposed by Sontheimer [3]. Diagnosis of IP was based on findings of high resolution CT scan (HRCT). The definition of RPIP was rapid exacerbation of hypoxemia or HRCT findings in a period of days to one month after the onset. Clinical features and prognosis of the patients were collected retrospectively and compared between groups. Candidates of predictors are extracted by the univariable analysis using Fisher’s exact test for dichotic parameters and Wilcoxon signed-rank test for continuous parameters and multivariable analysis using logistic regression analysis. Receiver operating characteristic (ROC) curve analysis was examined to obtain the cut-off level. Survival was examined using Kaplan-Meier method and Log-rank test.

Results:

Twenty-one patients were involved. Eight were deceased and 13 were survived. The deceased group had a higher ratio of male (75% versus 25%, p= 0.018). All deceased cases were with RPIP and 67 % in the survived cases. Levels of serum ferritin (4490 versus 646 ng/mL, p = 0.0026), CRP (2.1 versus 0.9 mg/dL, p = 0.0490), CK (1150 versus 290 U/L, p = 0.017), AST (194 versus 108 U/L, p = 0.025) and LDH (674 versus 368 U/L, p = 0.011) were higher in the deceased group. Interestingly, skin ulcers were tended to be more frequent (12.5% versus 87.5%, p= 0.0587), and anti-SS-A antibody was also more frequently detected (14.3% versus 85.7%, p=0.0072) in the survived group. Using ROC analysis cut-off values were 963 ng/mL for serum ferritin level (sensitivity 100%, specificity 83%), 0.7 mg/dL for CRP (sensitivity 75%, specificity 69%), 308 U/L for CK (sensitivity 88%, specificity 77%), 62 U/L for ALT (sensitivity 100%, specificity 62%), and 454 U/L for LDH (sensitivity 88%, specificity 77%). Patients were divided into two groups based on these cut-offs or based on dichotic parameters and survival was examined between 2 groups. Except CRP and anti-SS-A antibody, survival was significantly worse in parameter-positive or higher groups. Interestingly, anti-SS-A antibody-positive group had better outcome compared with those without.

Conclusion:

In our analysis, novel candidates such as serum CK, AST, and LDH levels were newly extracted and parameters previously reported was also included and those were also associated with the clinical outcome. In addition, anti-SS-A antibody was identified as a novel protective factor associated with a good outcome.

References:

[1]Nakashima R, Hosono Y, Mimori T. Clinical significance and new detection system of autoantibodies in myositis with interstitial lung disease. Lupus 2016;25:925-33.

[2]Bohan A, Peter JB. Polymyositis and dermatomyositis. N Eng J Med 1975;292:344-7.

[3]Sontheimer RD. Dermatomyositis: an overview of recent progress with emphasis on dermatologic aspects. Dermatol Clin 2000;20:387-408.

Disclosure of Interests:

None declared

SAT0122 HIGHER DOSES OF METHOTREXATE ASSOCIATED WITH DISCONTINUATION OF ORAL GLUCOCORTICOIDS AFTER INITIATION OF BIOLOGICAL DMARDS: A RETROSPECTIVE OBSERVATIONAL STUDY BASED ON DATA FROM A JAPANESE MULTICENTER REGISTRY STUDY

Background:

Glucocorticoids exert anti-inflammatory effects and are important drugs used to treat rheumatoid arthritis(1). We recommend glucocorticoid discontinuation as soon as possible because glucocorticoid caused several side effects, but many patients continue to take oral glucocorticoids long-term in daily clinical practice. The frequency of use of glucocorticoid has gradually declined, and there are several reports on discontinuation of glucocorticoid due to the initiation of biological disease-modifying antirheumatic drugs (bDMARDs)(2). However, there is no report showing the relation between discontinuation of glucocorticoid and MTX dose.

Objectives:

The present study aimed to explore factors associated with glucocorticoid discontinuation at 52 weeks after initiating bDMARDs.

Methods:

We established the large observational cohort, the Nagoya University orthopedic facility multicenter study (TBCR), and a total of 3119 patients used bDMARD and examined the status of oral glucocorticoid use at 52 weeks after initiating the 1stbDMARD. In predictive analyses, the outcome variable was glucocorticoid discontinuation at 52 weeks after bDMARD initiation. Factors associated with baseline characteristics at bDMARD initiation were assessed with univariate and stepwise forward multivariate logistic regression analyses. This cohort study was not randomized. Propensity score (PS) matching was used to align patient backgrounds to avoid selection bias.

Results:

Subjects were 564 patients administered glucocorticoids and methotrexate (MTX) following initiation of the 1stbDMARD (Figure 1). Mean DAS28-CRP at bDMARD initiation was 4.70 ± 1.16. Percentages of patients with low, moderate, and high disease activity as evaluated by DAS28-CRP at bDMARD initiation were 4.7%, 23.5%, and 71.8%, respectively. By 52 weeks after bDMARD initiation, 164 patients (29.1%) discontinued glucocorticoids. Multivariate analysis identified age (odds ratio (OR), 0.98), MTX dose (OR, 1.11), and glucocorticoid dose (OR, 0.87) as factors independently associated with glucocorticoid discontinuation at the time of bDMARD initiation (Table 1). After adjusting for baseline characteristics using propensity score matching among patient groups administered MTX ≤ 8 mg/week and MTX > 8 mg/week, 105 pairs remained. Among patients administered MTX > 8 mg/week, 41.0% discontinued glucocorticoids. Among those administered MTX ≤ 8 mg/week, 22.9% discontinued glucocorticoids, with a significant difference between the two groups (Figure 2, P=0.007).

Table 1.

Factors associated with baseline characteristics at bDMARD initiation

Continuation(n=400)Discontinuation(n=164)UnivariateOdds ratio (95% CI)MultivariateOdds ratio (95% CI)Age, years58.4 ± 12.954.3 ± 14.30.98 (0.97-0.99)*0.98 (0.97-0.99)*Disease duration, years9.4 ± 9.47.5 ± 8.50.98 (0.95-0.99)*–Female, %80.381.11.06 (0.67-1.68)–DAS28-CRP4.78 ± 1.154.50 ± 1.160.81 (0.69-0.96)*–Seropositivity, %90.086.10.69 (0.38-1.25)–MTX dose, mg/week7.7 ± 2.58.8 ± 3.01.16 (1.09-1.24)*1.11 (1.03-1.21)*Glucocorticoid dose, mg/day4.9 ± 2.14.3 ± 2.10.86 (0.78-0.95)*0.87 (0.78-0.97)*TNF inhibitor use, %88.885.40.74 (0.43-1.26)-

Data are presented as mean ± standard deviation.

Conclusion:

Data from the TBCR revealed that, from a clinical perspective, glucocorticoid use decreased among RA patients treated with bDMARDs. Higher doses of MTX (> 8 mg/week) at the time of bDMARD initiation were found to be associated with glucocorticoid discontinuation in patients treated with bDMARDs. In addition, we found that aggressive use of MTX was sufficient to fulfill the Treat-to-Target approach, demonstrating that glucocorticoid discontinuation is a viable option.

References:

[1]Smolen JS. Ann Rheum Dis. 2014;73(3):492-509.

[2]Shimizu Y. Mod Rheumatol. 2018;28(3):461-7.

Disclosure of Interests:

Mochihito Suzuki Speakers bureau: Bristol-Myers Squibb, Eisai, and Asahi Kasei, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, Shuji Asai Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Janssen, Takeda, and UCB Japan, Kenya Terabe: None declared, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama

0141 A Novel, Orally Available Orexin 2 Receptor-Selective Agonist, TAK-994, Shows Wake-Promoting Effects Following Chronic Dosing in an Orexin-Deficient Narcolepsy Mouse Model

Introduction

The use of an orexin 2 receptor (OX2R) agonist may be a promising approach for the treatment of narcolepsy type 1. TAK-994 is a novel, orally available OX2R-selective agonist with &gt;700-fold selectivity against orexin 1 receptor. Single administration of TAK-994 ameliorates narcolepsy-like symptoms such as fragmentation of wakefulness and cataplexy-like episodes in orexin/ataxin-3 mice, a narcolepsy mouse model with orexin deficiency. In this study, we evaluated the effect of chronic dosing with TAK-994 on sleep/wakefulness states in orexin/ataxin-3 mice.

Methods

Orexin/ataxin-3 mice were grouped into two cohorts: a control group and a 14-day treatment group. In the control group, vehicle was administered orally to mice three times a day: zeitgeber time 12 (ZT12), ZT15 and ZT18, for 14 days. In the 14-day treatment group, TAK-994 was administered orally to mice at ZT12, ZT15 and ZT18 for 14 days. Electroencephalogram/electromyogram analysis was performed on day 1 and day 14 (ZT12-ZT21), and the subsequent sleep phase (ZT0-ZT10).

Results

On day 1, TAK-994 significantly increased wakefulness time, accompanied by a decrease in non-rapid eye movement (NREM) sleep time and rapid eye movement (REM) sleep time, in orexin/ataxin-3 mice compared with the control group. On day 14, TAK-994 also significantly increased wakefulness time, and decreased NREM sleep time and REM sleep time in orexin/ataxin-3 mice. There were no changes in the time spent in wakefulness, NREM sleep and REM sleep during the subsequent sleep phase after chronic dosing with TAK-994.

Conclusion

Wake-promoting effects of TAK-994 were observed following chronic dosing for up to 14 days in orexin/ataxin-3 mice with no rebound of sleep. Overall, there was no clear difference in efficacy between the single and repeated administration of TAK-994 in orexin/ataxin-3 mice.

Support

This work was conducted by Takeda Pharmaceutical Company Limited.

Prevalence of human papillomavirus in oral gargles and tonsillar washings

OBJECTIVES

Human papillomavirus (HPV) infection drives carcinogenesis in the oropharynx. No standard sampling or HPV detection methods for evaluating oropharyngeal HPV infection exist. The prevalence of oral HPV infection in Japan is unknown.

MATERIALS AND METHODS

We examined 435 healthy Japanese individuals to address whether adding tonsillar washing to oral gargling would improve HPV detection. We compared HPV assessment using GENOSEARCH HPV31 versus nested PCR and direct sequencing. Associations between HPV infection and demographic and behavioral characteristics were examined.

RESULTS

Most participants who were HPV-positive based on oral gargles were also HPV-positive based on tonsillar washings: 11 (64.7%) of 17 on nested PCR and 12 (70.6%) of 17 on GENOSEARCH HPV31. Although HPV infection was more prevalent in oral gargles followed by tonsillar washings than in oral gargles alone, the difference was not statistically significant (nested PCR, 4.8% vs. 3.9%, P = 0.46; GENOSEARCH HPV31, 5.3% vs. 3.9%, P = 0.33). The overall agreement between nested PCR and GENOSEARCH HPV31 was 98.6%, with 76.0% positive agreement. The overall prevalence of oral HPV infection in Japan was 5.7% (95% confidence interval, 3.9-8.3%). Men had a significantly higher prevalence of oral HPV infection than women (8.3% vs. 2.6%, P = 0.02). Infection increased with number of lifetime sexual partners (P < 0.001 for trend).

CONCLUSION

The oropharynx is probably the major source of HPV-infected cells in oral gargles. Oral gargling could be a standard sampling method for evaluating oropharyngeal HPV infection. GENOSEARCH HPV31 could be an option for oral HPV detection.

Spatial clustering of suicide mortality and associated community characteristics in Kanagawa prefecture, Japan, 2011-2017

BACKGROUND

Suicide mortality is high in Japan and early interventional strategies to solve that problem are needed. An accurate evaluation of the regional status of current suicide mortality would be useful for community interventions. A few studies in Kanagawa prefecture, located next to Tokyo and with the second largest population in Japan, have identified spatial clusters of suicide mortality at regional levels. This study examined spatial clustering and clustering over time of such events using spatial data from regional statistics on suicide deaths.

METHODS

Data were obtained from regional statistics (58 regions in Kanagawa prefecture) of the National Vital Statistics of Japan from 2011 to 2017. The standardized mortality ratio (SMR) and Empirical Bayes estimator for the SMR (EBSMR) were used as measures. Spatial clusters were examined by Kulldorff's circular spatial scan statistic, Tango-Takahashi's flexible spatial scan statistic and Tango's test. Linear regression and conditional autoregressive (CAR) models were used not only to adjust for covariates but also to estimate regional effects. The analyses were conducted for each year, inclusive.

RESULTS

Among male suicide deaths, being unemployed (50%) was most frequently related to suicide while among female health problem (50%) were frequent. Spatial clusters with significance detected by FlexScan, SatScan and Tango's test were few and varied somewhat according to the method used. Spatial clusters were detected in some regions including Kawasaki ward after adjustment by covariates. By the linear regression models, selected variables with significance were different between the sexes. For males, unemployment, family size, and proportion of higher education were detected for several of the years studied while for females, family size and divorce rate were detected over this period. These variables were also observed by the CAR model with 5 covariates. Regional effects were much clearer by considering the spatial parameter for both males and females and especially, Kawasaki ward was detected as a high risk region in many years.

CONCLUSION

The present results detected some spatial clustering of suicide deaths within certain regions. Factors related to suicide deaths were also indicated. These results would provide important information in policy making for suicide prevention.

Chronotherapy of Non-Steroidal Anti-Inflammatory Drugs May Enhance Postoperative Recovery

Postoperative pain relief is crucial for full recovery. With the ongoing opioid epidemic and the insufficient effect of acetaminophen on severe pain; non-steroidal anti-inflammatory drugs (NSAIDs) are heavily used to alleviate this pain. However, NSAIDs are known to inhibit postoperative healing of connective tissues by inhibiting prostaglandin signaling. Pain intensity, inflammatory mediators associated with wound healing and the pharmacological action of NSAIDs vary throughout the day due to the circadian rhythm regulated by the clock genes. According to this rhythm, most of wound healing mediators and connective tissue formation occurs during the resting phase, while pain, inflammation and tissue resorption occur during the active period of the day. Here we show, in a murine tibia fracture surgical model, that NSAIDs are most effective in managing postoperative pain, healing and recovery when drug administration is limited to the active phase of the circadian rhythm. Limiting NSAID treatment to the active phase of the circadian rhythm resulted in overexpression of circadian clock genes, such as Period 2 (Per2) at the healing callus, and increased serum levels of anti-inflammatory cytokines interleukin-13 (IL-13), interleukin-4 (IL-4) and vascular endothelial growth factor. By contrast, NSAID administration during the resting phase resulted in severe bone healing impairment.

P1480 A case of triple left ventricular aneurysms diagnosed by CT and echocardiography

【Background】

Left ventricular aneurysms is complication of myocardial infarction (MI) that can lead to death or serious morbidity. False aneurysm is rare complications of myocardial infarction or iatrogenic perforation and represent a contained myocardial rupture. False aneurysm does not contain all the three layers of the myocardium and is frequently lined by pericardium and mural thrombus. Definitive diagnosis is achieved by echocardiography, computed tomography (CT), angiography, or magnetic resonance imaging. Coexistence of true and false aneurysms is rare.

【Case】 A 58 years old man with a history of hypertension and MI was referred to our hospital for aneurysmectomy. During the course of prior MI, he got fever and pericardial effusion.

CT revealed that three left ventricular aneurysms were present. Also, three aneurysms were connected by narrow ducts each other. Transthoracic echocardiography (TTE) revealed that three ventricular aneurysms were connected via acceleration blood flow which swirling in the spherical aneurysm. We determined that this triple ventricular aneurysms were at high risk for rupture, so we performed surgery.

The postoperative course was good and he was discharged without any complications.

【Discussion】

False aneurysms occur after hemorrhagic dissection into an area of transmural infarction and most commonly result in free intrapericardial rupture of the heart, cardiac tamponade, and death. Rarely, if the overlying pericardium becomes adherent to the epicardium along the surface of the infarct, it can contain the rupture.

We were able to evaluate the mechanism of development with triple left ventricular aneurysms using CT and TTE. We could know about spatial comprehension of triple aneurysms using CT. False aneurysms were restricted enlargement due to stiff pericardium because of complicating Dressler syndrome. We hypothesis that aneurysms were enlarging in the direction of the base of heart in the adhered pericardium space.

We were able to evaluate the thickness of aneurysms and blood flow condition using TTE. TTE revealed that the wall of aneurysm was fragile. Multimodality imaging like TTE or cardiac CT are useful diagnostic methods in this case.

Abstract P1480 Figure. Triple aneurysms

1638 A case of capturing changes in interatrial blood flow and anatomical structure during percutaneous PFO closure with platypnea orthodeoxia syndrome using intra-cardiac echocardiography

Background

Platypnea–orthodeoxia syndrome (POS) is an uncommon condition characterized by positional dyspnea and hypoxemia due to intracardiac right-to-left shunting through a patent foramen ovale (PFO). The most commonly associated conditions included pneumonectomy, ascending aortic dilation, and arch surgery, as previously reported. Percutaneous closure of PFO is useful treatment for POS.

Case

A 76 year old man used home oxygen therapy because of unexplained hypoxemia. A decrease in blood oxygen saturation was observed in sitting and standing positions. The patient was diagnosed as "POS" because a shunt blood flow with PFO and atrial septal aneurysm (ASA) and eustachian valve was observed at transesophageal echocardiography. He was admitted for the purpose of percutaneous PFO closure.

He was treated with intra-cardiac echocardiography (ICE) guidance under local anesthesia because of poor lung function.

PFO closure was performed successfully with 30mm AMPLATZER Cribriform. The ICE findings prior to PFO closure showed a right-to-left shunt blood flow through the PFO in the sitting position but almost disappeared after closure. Furthermore, it was observed that the aortic artery compression was stronger in the sitting position than in the supine position with right-to-left shunt blood flow. After PFO closure, hypoxia associated with postural change improved and patient’s symptom as shortness of breath also significantly improved.

Discussion

POS is a position-dependent condition of dyspnea and hypoxemia due to right-to-left shunting. It often remains unrecognized in clinical practice, possibly because of its complex underlying pathophysiology. It is considered that the cause of POS in this patient was multiple factors such as ASA, aortic displacement, and venous valve remnant. In addition, being able to observe the change of the atrium due to compression from the aortic artery using ICE during the operation was very significant to explain the mechanism of POS.

Abstract 1638 Figure. Intra-cardiac echocardiography

P1713 A case of quadricuspid aortic valve complicated with infective endocarditis diagnosed by 3D transesophageal echocardiography

Background

Quadricuspid aortic valve (QAV) is a rare congenital heart disease with an estimated incidence of 0.008% to 1.46%. The functional status of QAV is predominantly a pure aortic regurgitation. The extensive use of echocardiography has allowed an early and accurate diagnosis of this malformation. In many cases, the transthoracic echocardiography (TTE) is suitable for the diagnosis but, transesophageal echocardiography (TEE), especially 3-dimensional (3D) TEE, is a tool for the accurate definition of the valve anatomy.

Clinical case

A 60-year-old female underwent a head CT for intermittent headaches for one month ago. She was admitted to neurosurgery in our hospital diagnosed of subarachnoid hemorrhage. Four mm aneurysm was found on the periphery of the right middle cerebral artery on CT examination, and a cerebral aneurysm coil embolization was performed with a catheter in emergency. The possibility of infectious cerebral aneurysm was pointed out, and we examined in cardiovascular internal medicine. TTE revealed moderate aortic regurgitation. The ventricular septum exhibits sigmoid septum. A mobile mass was found near the left ventricular outflow tract in the sigmoid septum. TEE revealed a hypoplasia cusp (accessory cusp) is found between non coronary cusp and right coronary cusp. Aortic valve leaflets have become thickened and regurgitation from the central part of the cusps. 3DTEE was able to more accurately visualize that only the accessory cusp was hypoplastic, and the size of the other three leaflets appears almost the same. Similarly, vegetation on the left ventricular outflow tract were clearly revealed by 3DTEE.

Based on the above, it was diagnosed that quadricuspid aortic valve complicated with infective endocarditis (IE) with aortic valve regurgitation. After treatment with antibiotics according to IE, surgical treatment was scheduled.

Discussion

QAV is a rare congenital heart disease, and TTE is an important imaging tool for accurate diagnosis. Furthermore, TEE, especially 3DTEE, was a more appropriate diagnostic method in QAV and IE.

Abstract P1713 Figure. 3DTEE

[Time-sparing screening method for mild cognitive impairment and early Alzheimer's disease: Self- and family reports using the TMIG index of competence]

AIM

To verify the clinical utility of instrumental activities of daily life evaluated using the Tokyo Metropolitan Institute of Gerontology index of competence (TMIG-IC) as a screening tool for patients with early-phase cognitive impairment, including mild cognitive impairment (MCI) and early Alzheimer's disease (AD).

METHODS

We recruited healthy subjects from our community-based cohort and consecutive subjects with MCI and AD from our clinic. The TMIG-IC was investigated in all participants and their family members. The total and subscale scores were compared among all groups. We then statistically determined the accuracy of the differentiation of MCI and AD.

RESULTS

We registered 187 normal controls (NC), 39 participants with MCI, 50 AD patients with functional assessment staging (FAST) 4, and 19 AD patients with ≥5 FAST. The family-report score was significantly lower in MCI patients than in others, followed by AD patients. The total score was able to differentiate MCI and AD with a sensitivity of 85.7% and a specificity of 90.9% (area under the curve [AUC]=0.913). Differentiation of MCI alone had a low accuracy (AUC=0.787). However, the AUC was 0.847 when only the items with inconsistent responses between self and family reports were used as indices.

CONCLUSIONS

The TMIG-IC is a useful tool for evaluating the severity of AD, including early AD. These findings suggest that family-report scores can differentiate MCI and AD from cognitive normal aging with a sufficient degree of accuracy. It was also suggested that inconsistencies between self and family reports were higher when differentiating MCI than the self- and family-reports.