Tumour-derived exosomes promote the induction of monocytic myeloid-derived suppressor cells from peripheral blood mononuclear cells by delivering miR-106a-5p and miR-146a-5p in multiple myeloma

The shift of the tumour immune microenvironment to a suppressive state promotes not only the development and progression of the disease in multiple myeloma (MM) but also the development of resistance to immunotherapy. We previously demonstrated that myeloma cells can induce monocytic myeloid-derived suppressor cells (M-MDSCs) from healthy peripheral blood mononuclear cells (PBMCs) via the concomitant secretion of CC motif chemokine ligand 5 (CCL5) and macrophage migration inhibitory factor (MIF), but an unknown mediator also promotes M-MDSC induction. This study demonstrates that miR-106a-5p and miR-146a-5p delivered by tumour-derived exosomes (TEXs) from myeloma cells play essential roles in M-MDSC induction in MM. MiR-106a-5p and miR-146a-5p upregulate various immunosuppressive/inflammatory molecules in PBMCs, such as IDO1, CD38, programmed death-ligand 1, CCL5 or MYD88, which are involved in interferon (IFN)-α response, IFN-γ response, inflammatory response, tumour necrosis factor-α signalling and Interleukin-6-JAK-STAT3 signalling. These molecular features mirror the increases in myeloid cellular compartments of PBMCs when co-cultured with myeloma cells. MiR-106a-5p and miR-146a-5p have a compensatory relationship, and these two miRNAs collaborate with CCL5 and MIF to promote M-MDSC induction. Collectively, novel therapeutic candidates may be involved in TEX-mediated sequential cellular and molecular events underlying M-MDSC induction, potentially improving the efficacy of immunotherapy.

Diphenhydramine overdose detected early by integration of toxidrome and electrocardiography and treated with venoarterial extracorporeal membrane oxygenation: a case report

Drug overdose can lead to a range of symptoms, including potentially life-threatening cardiac arrhythmias. However, identifying the specific causative drug upon admission can be challenging in many cases. The toxidrome approach is a method that utilizes toxidromes, which are collections of findings obtained from physical examination and ancillary tests, that may be caused by a specific toxin. In this particular case, a man presented with an unknown drug overdose that caused symptoms indicative of anticholinergic effects and abnormal electrocardiogram (ECG) findings. The ECG revealed an R wave in lead aVR, S waves in leads I and aVL, and wide QRS tachycardia with a Brugada pattern. Shortly after arrival, the patient developed cardiac arrest due to a lethal arrhythmia. Prompt initiation of venoarterial extracorporeal cardiopulmonary membrane oxygenation (VA-ECMO) was performed. Fortunately, the patient achieved full neurological recovery, and the overdosed drug was identified as diphenhydramine. When diagnosing and treating drug overdose caused by an unidentified substance, diphenhydramine toxicity should be considered when an anticholinergic toxidrome is present and a Brugada pattern is observed on the ECG. VA-ECMO demonstrates potential as a viable treatment option when initial interventions prove ineffective.

Clinical Significance of Elevated Xanthine Dehydrogenase Levels and Hyperuricemia in Patients with Sepsis

Patient outcomes for severe sepsis and septic shock remain poor. Excessive oxidative stress accelerates organ dysfunction in severe acute illnesses. Uric acid (UA) is the most abundant antioxidant. We hypothesized that UA and related molecules, which play a critical role in antioxidant activity, might be markers of oxidative stress in sepsis. The study aimed to clarify the clinical significance of UA and the relationship between UA, molecules related to UA, and outcomes by measuring blood UA, xanthine dehydrogenase (XDH), and 8-hydroxy-2-deoxyguanosine (8-OHdG) levels over time. Blood UA levels in septic patients were correlated with the SOFA score (ρ = 0.36, p < 0.0001) and blood XDH levels (ρ = 0.27, p < 0.0001). Blood XDH levels were correlated with the SOFA score (ρ = 0.59, p < 0.0001) and blood 8-OHdG levels (ρ = -0.32, p < 0.0001). Blood XDH levels were persistently high in fatal cases. Blood XDH level (OR 8.84, 95% CI: 1.42-91.2, p = 0.018) was an independent factor of poor outcomes. The cutoff of blood XDH level was 1.38 ng/mL (sensitivity 92.8%, specificity 61.9%), and those 1.38 ng/mL or higher were associated with a significantly reduced survival rate (blood XDH level > 1.38 ng/mL: 23.7%, blood XDH level < 1.38 ng/mL: 96.3%, respectively, p = 0.0007). Elevated UA levels due to elevated blood XDH levels in sepsis cases may reduce oxidative stress. Countermeasures against increased oxidative stress in sepsis may provide new therapeutic strategies.

An Easy-to-Use Prehospital Indicator to Determine the Severity of Suspected Heat-Related Illness: An Observational Study in the Tokyo Metropolitan Area

Rapid hospital arrival decreases mortality risk in heat-related illnesses. We investigated an easy-to-use indicator of life-threatening severity of heat-related illnesses in a community setting to enable quick hospitalization by using data extracted from prehospital transportation records of a database from 2016 that included information on the clinical severity of suspected heat-related illnesses in patients (n = 2528) upon hospital arrival. Patient-related risk factors (adjusted odds ratio, aOR [95% confidence interval, CI]) included age, vital signs, location of the patient, and illness severity, and respiratory rate (3.34 [1.80-6.22]), heart rate (2.88 [1.57-5.29]), axillary body temperature (7.79 [4.02-15.1]), and consciousness level (38.3 [5.22-281.1]) were independent risk factors for heat-related illness severity. On-site blood pressure was not an independent factor for illness severity. Heart rate > 120 beats/min, respiratory rate > 24 breaths/min, and temperature > 38.6 °C (highest areas under the receiver operating characteristic curves [95% CI]: 0.80 [0.75-0.87]; 0.73 [0.67-0.81]; and 0.83 [0.77-0.91], respectively) predicted life-threatening illness severity. Changes in the vital signs of patients with heat-related illnesses, particularly tachycardia and tachypnea, constitute sensitive, easy-to-use indicators that facilitate rapid identification of severity by laypersons and transport of patients before aggravation to a life-threatening situation.

Achievement of Target Glycemic Goal with Simple Basal Insulin Regimen in Women with Gestational Diabetes: A Prospective Cohort Study

There is little evidence concerning the need to treat gestational diabetes (GDM) in the same way as pregestational diabetes. We evaluated the efficacy of the simple insulin injection (SII) regimen for achieving the target glucose goal without increasing adverse perinatal outcomes in singleton pregnant women with GDM. All subjects underwent self-monitoring of blood glucose (SMBG), and insulin therapy was indicated according to the SMBG profile. Insulin was initially started with the SII regimen, in which one daily injection of NPH insulin before breakfast was used, and another NPH injection was added at bedtime, if necessary. We used the target glucose as <95 mg/dL at fasting and <120 mg/dL postprandial and accepted <130 mg/dL for the latter. If the target glucose did not reach with the regimen, we switched to the multiple daily injection (MDI) with additional prandial insulin aspart. We compared the SMBG profile before delivery as well as the perinatal outcomes between the SII and MDI groups. Among 361 women (age 33.7 years, nullipara 41%, prepregnancy body mass index 23.2 kg/m²) with GDM, 59%, 18%, and 23% were in the diet-alone, SII, and MDI groups, respectively. Consequently, regarding women requiring insulin therapy, 43% were treated with the SII regimen throughout pregnancy. The severity of baseline hyperglycemia according to the SMBG data at baseline was the MDI>the SII>the diet group. The rate of achieving target glucose levels before delivery in the SII group at fasting, postprandial < 120 mg/dL and <130 mg/dL were 93%, 54% and 87%, respectively, which were similar to that in the MDI group (93%, 57%, and 93%, respectively), with no significant differences in perinatal outcomes. In conclusion, more than 40% of women with GDM requiring insulin therapy achieved the target glucose goal with this simple insulin regimen without any increase in adverse effects.

"The eyes are the windows of the soul": Portable automated pupillometry to monitor autonomic nervous activity in CO2 narcosis: A case report

RATIONALE

Altered autonomic responses can be observed in patients in the intensive care unit (ICU), and these changes in abnormal autonomic responses are known to be associated with patient prognosis. Therefore, it is important to monitor autonomic nervous system activity in these critically ill patients. While the utility of monitoring critically ill patients using heart rate (HR) variability measurements has been reported, portable automated pupillometers are small, lightweight, and easy-to-operate medical devices that may be more easily evaluated for autonomic nervous system function.

PATIENT CONCERNS

An unconscious 80-year-old female patient with chronic obstructive pulmonary disease was brought to the medical emergency department after a call from her caregiver.

DIAGNOSIS

On arrival, the patient's Glasgow coma scale score was 7, her blood pressure was 140/80 mm Hg, her HR was 114 bpm, and her respiratory rate was 27 breaths/minutes with increased breathing effort. Oxygen saturation was 90% on a venturi mask (3 L of supplemental oxygen). The arterial blood gas analysis showed a pH of 7.196, a partial pressure of carbon dioxide (CO2) of 89.6 mm Hg, a partial pressure of oxygen of 87.5 mm Hg, and a bicarbonate level of 29.4 mmol/L. Other than CO2 narcosis, there were no abnormal findings to induce impaired consciousness. The patient did not respond to support with a bag-valve mask and was intubated. One hour after intubation, her impaired consciousness improved. The patient was extubated 20 hours later and discharged on Day 3.

INTERVENTIONS

The patient was admitted to the ICU after being intubated, where vital signs and blood gas analysis were monitored every 2 hours, and consciousness was assessed using the Glasgow coma scale. Using a portable automated pupillometer (NeurOptics NPi™-200, Neuroptics Inc., Irvine, CA), pupillary responses, including pupil size or light reflex, were measured every 2 hours during ICU stay.

OUTCOMES

Changes in respiratory rate and partial pressure of CO2 values correlated with pupil size and constriction velocity, but HR changes were contrary.

LESSONS

Pupillary responses exhibited by automated pupillometers observed in patients with CO2 narcosis may be linked to vital signs and allow for autonomic evaluation.

Abstract 2932: Datopotamab deruxtecan (Dato-DXd) enhances antitumor response to PD-1/PD-L1 inhibitors in TROP2-expressing tumors in mice

Background: Trophoblast cell surface antigen 2 (TROP2) is highly expressed in various epithelial tumors, including non-small cell lung cancer (NSCLC) and triple negative breast cancer (TNBC), and correlates with poor prognosis. Datopotamab deruxtecan (Dato-DXd) is an antibody-drug conjugate (ADC) consisting of a humanized anti-TROP2 IgG1 monoclonal antibody covalently linked to a highly potent topoisomerase I (Topo I) inhibitor payload via a stable, tumor-selective, tetrapeptide-based cleavable linker. Dato-DXd has shown encouraging antitumor activity and a manageable safety profile in patients with NSCLC and TNBC as part of the first-in-human, Phase 1 study (NCT03401385). To enhance clinical responses, clinical trials evaluating combination therapy of Dato-DXd with PD-1/PD-L1 inhibitors in NSCLC and TNBC are currently ongoing (e.g. NCT04526691 and NCT03742102). Here we report preclinical evidence for supporting increased antitumor activity of Dato-DXd in combination with PD-1/PD-L1 inhibitors using a syngeneic mouse tumor model and its impact on tumor immunity.

Methods: MC38 mouse colon adenocarcinoma cells stably transfected with human TROP2 (hTROP2_MC38) were inoculated subcutaneously in immunocompetent C57BL6 mice or immunodeficient nude mice and the antitumor activity of Dato-DXd with or without mouse PD-1/PD-L1 inhibitors was evaluated. The tumor infiltrating immune cells in hTROP2_MC38 tumors were analyzed by flow cytometry at 3 days and 10 days after dosing. In addition, the impact of CD8+ T cell depletion on the antitumor activity of Dato-DXd against hTROP2_MC38 tumors in C57BL6 mice was evaluated.

Results: Dato-DXd showed stronger antitumor activity against hTROP2_MC38 tumors in immunocompetent C57BL6 mice than in immunodeficient nude mice, which suggests that immune cells play an important role in the mechanism of action (MoA) of Dato-DXd. The combination of Dato-DXd and mouse PD-1/PD-L1 inhibitors enhanced antitumor activity compared to monotherapy against hTROP2_MC38 tumors in C57BL6 mice. Activation of the dendritic cells in hTROP2_MC38 tumors in C57BL6 mice was observed after Dato-DXd monotherapy or combination therapy with mouse PD-1/PD-L1 inhibitors, which led to the increase of tumor infiltrating CD8+ T cells. Involvement of CD8+ T cells in the MoA of Dato-DXd was also supported by the result that CD8+ T cell depletion in C57BL6 mice decreased the antitumor activity of Dato-DXd against hTROP2_MC38 tumors. In addition, activation of tumor infiltrating NK cells and macrophages was observed after Dato-DXd monotherapy or combination therapy, suggesting the potential effect on innate immunity.

Conclusion: These results suggest that Dato-DXd may stimulate tumor immunity and sensitize tumors to PD-1/PD-L1 inhibitors. The combination of Dato-DXd and PD-1/PD-L1 blockers could be a valuable therapy for patients with TROP2-positive tumors.

Citation Format: Daisuke Okajima, Satoru Yasuda, Takami Suzuki, Michiko Kitamura, Junko Yamaguchi, Takanori Maejima, Tsuyoshi Karibe, Tadashi Toki, Penny Phillips, Toshinori Agatsuma. Datopotamab deruxtecan (Dato-DXd) enhances antitumor response to PD-1/PD-L1 inhibitors in TROP2-expressing tumors in mice [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 2932.

Current status of active cooling, deep body temperature measurement, and face mask wearing in heat stroke and heat exhaustion patients in Japan: a nationwide observational study based on the Heatstroke STUDY 2020 and 2021

Aim

The study aimed to determine the current status of face mask use, deep body temperature measurement, and active cooling in patients suffering from heat stroke and heat exhaustion in Japan.

Methods

This was a prospective, observational, multicenter study using data from the Heatstroke STUDY 2020-2021, a nationwide periodical registry of heat stroke and heat exhaustion patients. Based on the Bouchama heatstroke criteria, we classified the patients into two groups: severe and mild-to-moderate. We compared the outcomes between the two groups and reclassified them into two subgroups according to the severity of the illness, deep body temperature measurements, and face mask use. Cramer's V was used to determine the effect sizes for a comparison between groups.

Results

Almost all patients in this study were categorized as having degree III based on the Japanese Association for Acute Medicine heatstroke criteria (JAAM-HS). However, the severe group was significantly worse than the mild-to-moderate group in outcomes like in-hospital death and modified Rankin Scale scores, when discharged. Heat strokes had significantly higher rates of active cooling and lower mortality rates than heat stroke-like illnesses. Patients using face masks often use them during labor, sports, and other exertions, had less severe conditions, and were less likely to be young male individuals.

Conclusions

It is suggested that severe cases require a more detailed classification of degree III in the JAAM-HS criteria, and not measuring deep body temperature could have been a factor in the nonperformance of active cooling and worse outcomes.

The threat of a new tetanus outbreak due to urban flooding disaster requires vigilance: a narrative review

Vaccines for tetanus prevention have rapidly progressed, and the number of outbreaks, especially the incidence of tetanus in developed countries, has decreased dramatically. However, the mortality rate associated with severe tetanus remains high. Tetanus eradication is difficult owing to the widespread presence of the spores of tetanus bacteria in the environment, but tetanus can be prevented by acquired immunity from vaccines. Older people, intravenous drug users, and migrants are at a high risk of tetanus in developed countries owing to the lack of booster vaccination programs. Natural disasters, especially floods, often cause an increase in the prevalence of tetanus because of the associated injuries. Precautions should be taken to combat the threat of a new tetanus outbreak due to floods in urban areas owing to global warming. In particular, Japan is facing a high risk of urban flooding-induced tetanus, despite its status as a developed country. This review aims to highlight the data on the epidemiology, causes, treatment, and prevention of tetanus and problems associated with tetanus countermeasures during future floods.

Relationship between brain volume reduction during the acute phase of sepsis and activities of daily living in elderly patients: A prospective cohort study

Brain damage in acute sepsis may be associated with poor long-term outcomes that impair reintegration into society. We aimed to clarify whether brain volume reduction occurs during the acute phase of sepsis in patients with acute brain damage. In this prospective, noninterventional observational study, brain volume reduction was evaluated by comparing head computed tomography findings at admission with those obtained during hospitalization. We examined the association between brain volume reduction and performance of the activities of daily living in 85 consecutive patients (mean age, 77 ± 12.7 years) with sepsis or septic shock. The bicaudate ratio increased in 38/58 (65.5%) patients, Evans index increased in 35/58 (60.3%) patients, and brain volume by volumetry decreased in 46/58 (79.3%) patients from the first to the second measurement, with significant increases in the bicaudate ratio (P < 0.0001) and Evans index (P = 0.0005) and a significant decrease in the brain volume by volumetry (P < 0.0001). The change rate for brain volume by volumetry was significantly correlated with the Katz index (ρ = -0.3790, P = 0.0094). In the acute phase of sepsis in this sample of older patients, 60-79% of patients showed decreased brain volumes. This was associated with a decreased capacity for performing activities of daily living.

The Characteristics of Patients with Severe COVID-19 Pneumonia Treated with Direct Hemoperfusion Using Polymyxin B-Immobilized Fiber Column (PMX-DHP)

Purpose

The characteristics of patients with severe COVID-19 pneumonia who underwent direct hemoperfusion using polymyxin B-immobilized fiber column (PMX-DHP), in addition to steroids and immunomodulators, remain unclear.

Patients and Methods

We conducted a retrospective observational study on 31 patients with severe COVID-19 pneumonia treated with PMX-DHP in an intensive care unit (ICU) from December 2020 to September 2021.

Results

Outcomes 28 days after admission to the ICU were 20 in the survival group and 11 in the death group. Parameters significantly different between the survival and death group before PMX-DHP were percentage of invasive mechanical ventilation (25% vs 72.7%, P = 0.0209), PaO₂/F_IO₂ (P/F) ratio (104.5 vs 75, P = 0.0317), and sequential organ failure assessment (SOFA) score (2 vs 3, P = 0.0356). Invasive mechanical ventilation avoidance rate was significantly different between the survival (100%) and death group (0%) (P = 0.0012). P/F ratio, respiratory ratio (RR), and lymphocyte counts improved significantly after PMX-DHP for all patients. The lymphocyte counts changed significantly in the survival (P < 0.0001), but not the death group (P = 0.7927).

Conclusion

PMX-DHP, in addition to steroids and immunomodulators, may improve oxygenation and alleviate tachypnea by modulating the lymphocyte numbers and levels of various mediator against severe COVID-19 pneumonia. It may be better to perform PMX-DHP before multi organ dysfunction and lung injury has progressed. Furthermore, the early increase in lymphocyte counts after PMX-DHP might be an indicate a positive outcome.

Datopotamab Deruxtecan, a Novel TROP2-directed Antibody-drug Conjugate, Demonstrates Potent Antitumor Activity by Efficient Drug Delivery to Tumor Cells

Trophoblast cell surface antigen 2 (TROP2) is highly expressed on various epithelial tumors and correlates with poor prognosis. We developed the novel TROP2-directed antibody-drug conjugate (ADC), datopotamab deruxtecan (Dato-DXd, DS-1062a), with a potent DNA topoisomerase I inhibitor (DXd), and evaluated its antitumor activity and safety profiles in preclinical models.The pharmacologic activity and mechanism of action of Dato-DXd were investigated in several human cancer cell lines and xenograft mouse models including patient-derived xenograft (PDX) models. Safety profiles were also assessed in rats and cynomolgus monkeys.Dato-DXd bound specifically to TROP2 and was internalized into tumor cells followed by intracellular trafficking to lysosome and DXd release, which induced DNA damage and apoptosis in TROP2-expressing tumor cells in vitro. Dato-DXd exhibited in vivo antitumor activity with DNA damage induced by the accumulated DXd in TROP2-expressing xenograft tumors, but neither isotype control IgG-ADC nor anti-TROP2 antibody had this effect. Dato-DXd also showed potent antitumor activity with tumor regression in several TROP2-expressing xenograft tumors including NSCLC PDX models. Safety profiles of Dato-DXd in rats and cynomolgus monkeys were acceptable.Dato-DXd demonstrated potent antitumor activity against TROP2-expressing tumors by efficient payload delivery into tumors and acceptable safety profiles in preclinical models. These results suggest Dato-DXd could be a valuable treatment option for patients with TROP2-expressing tumors in the clinical setting.

Be careful of splenic rupture caused by hit by a pitch during a baseball game: a case report

Background

To the best of our knowledge, splenic rupture caused by hit by a pitch (HBP) has not been previously reported. We present a patient who underwent emergency laparotomy for splenic rupture after being HBP during a baseball game.

Case presentation

A 41-year-old male was HBP in the left abdomen during his first at-bat during a baseball game. During the operation, vascular injury of the splenic hilum and a deeply extending parenchymal injury were observed, and splenectomy was performed. Histologic findings were consistent with splenic rupture.

Conclusions

The patient’s postoperative course was uneventful. Although extremely rare, the possibility of intra-abdominal organ injury should be considered in batters who are hit in the abdomen by a pitched baseball, as illustrated by our patient.

The clinical outcome of fractional flow reserve based coronary revascularization strategy of the patients on hemodialysis

Background

The optimal coronary revascularization strategy for the patients on hemodialysis is yet to be determined. In the real-world practice, we sometimes encounter the rapid deterioration after percutaneous coronary intervention (PCI) to angiographically intermediate but functionally significant stenosis. According to the fractional flow reserve (FFR) based revascularization strategy, the clinical outcome of the deferred lesions is reported to be almost equivalent to that of the lesions received PCI. However, whether the relationship also applies to hemodialysis patients is unclear.

Purpose

To assess the clinical outcome of the lesions for which revascularization strategy was determined by FFR in patients with hemodialysis.

Methods

Consecutive 147 vessels in 120 patients with hemodialysis whose revascularization strategy was decided according to the FFR were enrolled in this study. We compared the clinical outcomes of the deferred group (FFR ≥0.80, 87 vessels, 78 patients) with the PCI group (FFR&lt;0.80, 60 vessels, 42 patients). The primary endpoint of this study was target vessel failure (TVF) defined as a composite of TV revascularization and myocardial infarction evaluated by per-vessel analysis. The secondary endpoint was major adverse cardiovascular events (MACE) defined as all cause death, myocardial infarction, urgent revascularization evaluated by per-patient analysis.

Results

The median follow-up period was 2.3 years (interquartile range, 1.5–4.0 years). The beseline characteristics of the lesions and patients were well balanced between the 2 treatment groups except for the distribution of target vessels and FFR value. The cumulative TVF rate was not significantly different between the deferred group and PCI group (2-year event rate 26.7% vs. 17.7%; Log-rank p=0.23). The risk of MACE was also not significantly different between two groups (2-year event rate 35% vs. 30%; Log-rank p=0.48).

Conclusion

The clinical outcome of the lesions/patients for which received revascularization based on FFR was equivalent to the deferred lesions/patients even in the patients on hemodialysis (2,129/3,000).

Funding Acknowledgement

Type of funding sources: None. Table 1Figure 1

Accidental hypothermia: characteristics, outcomes, and prognostic factors-A nationwide observational study in Japan (Hypothermia study 2018 and 2019)

Aim

This study describes the clinical characteristics and outcomes as well as the prognostic factors of patients with accidental hypothermia (AH) using Japan’s nationwide registry data.

Methods

The Hypothermia study 2018 and 2019, which included patients aged 18 years or older with a body temperature of 35°C or less, was a multicenter registry conducted at 87 and 89 institutions throughout Japan, with data collected from December 2018 to February 2019 and December 2019 to February 2020, respectively.

Results

In total, 1363 patients were enrolled in the registry, of which 1194 were analyzed in this study. The median (interquartile range) age was 79 (68–87) years, and the median (interquartile range) body temperature at the emergency department was 30.8°C (28.4–33.6°C). Forty‐three percent of patients with AH had a mild condition, 35.2% moderate, and 21.9% severe. AH occurred in an indoor setting in 73.4% and was caused by acute medical illness in 49.3% of patients. A total of 101 (8.5%) patients suffered from cardiopulmonary arrest on arrival at the hospital. The overall 30‐day mortality rate was 24.5%, the median (interquartile range) intensive care unit stay was 4 (2–7) days, and the median (interquartile range) hospital stay was 13 (4–27) days. In the multivariable logistic analysis, the prognostic factors were age (≥75 years old), male, activities of daily living (needing total assistance), cause of AH (trauma, alcohol), Glasgow Coma Scale score, and potassium level (>5.5 mEq/L).

Conclusion

The mortality rate of AH was 24.5% in Japan. The prognostic factors developed in this study may be useful for the early prediction, prevention, and awareness of severe AH.

Association between frailty and mortality among patients with accidental hypothermia: a nationwide observational study in Japan

BACKGROUND

Frailty has been associated with a risk of adverse outcomes, and mortality in patients with various conditions. However, there have been few studies on whether or not frailty is associated with mortality in patients with accidental hypothermia (AH). In this study, we aim to determine this association in patients with AH using Japan's nationwide registry data.

METHODS

The data from the Hypothermia STUDY 2018&19, which included patients of ≥18 years of age with a body temperature of ≤35 °C, were obtained from a multicenter registry for AH conducted at 120 institutions throughout Japan, collected from December 2018 to February 2019 and December 2019 to February 2020. The clinical frailty scale (CFS) score was used to determine the presence and degree of frailty. The primary outcome was the comparison of mortality between the frail and non-frail patient groups.

RESULTS

In total, 1363 patients were included in the study, of which 920 were eligible for the analysis. The 920 patients were divided into the frail patient group (N = 221) and non-frail patient group (N = 699). After 30-days of hospitalization, 32.6% of frail patients and 20.6% of non-frail patients had died (p < 0.001). Frail patients had a significantly higher risk of 90-day mortality (Hazard ratio [HR], 1.64; 95% confidence interval [CI], 1.25-2.17; p < 0.001). Based on the Cox proportional hazards analysis using multiple imputation, after adjustment for age, potassium level, lactate level, pH value, sex, CPK level, heart rate, platelet count, location of hypothermia incidence, and rate of tracheal intubation, the HR was 1.69 (95% CI, 1.25-2.29; p < 0.001).

CONCLUSIONS

This study showed that frailty was associated with mortality in patients with AH. Preventive interventions for frailty may help to avoid death caused by AH.

Machine learning-based mortality prediction model for heat-related illness

In this study, we aimed to develop and validate a machine learning-based mortality prediction model for hospitalized heat-related illness patients. After 2393 hospitalized patients were extracted from a multicentered heat-related illness registry in Japan, subjects were divided into the training set for development (n = 1516, data from 2014, 2017–2019) and the test set (n = 877, data from 2020) for validation. Twenty-four variables including characteristics of patients, vital signs, and laboratory test data at hospital arrival were trained as predictor features for machine learning. The outcome was death during hospital stay. In validation, the developed machine learning models (logistic regression, support vector machine, random forest, XGBoost) demonstrated favorable performance for outcome prediction with significantly increased values of the area under the precision-recall curve (AUPR) of 0.415 [95% confidence interval (CI) 0.336–0.494], 0.395 [CI 0.318–0.472], 0.426 [CI 0.346–0.506], and 0.528 [CI 0.442–0.614], respectively, compared to that of the conventional acute physiology and chronic health evaluation (APACHE)-II score of 0.287 [CI 0.222–0.351] as a reference standard. The area under the receiver operating characteristic curve (AUROC) values were also high over 0.92 in all models, although there were no statistical differences compared to APACHE-II. This is the first demonstration of the potential of machine learning-based mortality prediction models for heat-related illnesses.

PMX-DHP Therapy for Dyspnea and Deoxygenation in Severe COVID-19 Pneumonia: A Case Series

Hypercytokinemia induced by coronavirus disease-19 (COVID-19) is associated with severe pulmonary involvement, which may lead to respiratory failure. These conditions play an important role in the worsening of clinical symptoms in patients with severe COVID-19. There is no established treatment for hypercytokinemia. We report on two patients whose clinical symptoms improved after direct hemoperfusion using polymyxin B-immobilized fiber column (PMX-DHP), following the administration of the anti-inflammatory agent tocilizumab. Case A was a 70-year-old man diagnosed with COVID-19 pneumonia. Despite treatment with ciclesonide and favipiravir, supplemental oxygen was administered due to the worsening of dyspnea with tachypnea. Although tocilizumab was started on day 6, the patient deteriorated into deoxygenation, presenting with the PaO₂/F_IO₂ (P/F) ratio of 92. On days 8 and 10, the patient received PMX-DHP therapy. On day 11, his dyspnea improved. On day 13, his P/F ratio began to improve, and oxygen therapy was discontinued on day 18. The patient recovered without requiring mechanical ventilation. Case B was a 70-year-old man diagnosed with COVID-19 pneumonia and treated with favipiravir, starting on day 0. Despite starting ciclesonide inhalation and tocilizumab on day 2, his P/F ratio was 53. On day 5, he received PMX-DHP therapy. On day 6, his dyspnea improved, as did his P/F ratio, reaching 81 on day 8. Finally, his clinical symptoms resolved, and he was discharged from the intensive care unit without requiring mechanical ventilation. These cases indicate that PMX-DHP therapy might be a suitable treatment option for dyspnea and deoxygenation in COVID-19 pneumonia, especially in cases where an anti-inflammatory agent, such as tocilizumab, has failed to achieve the desired effect.

Ultrasonographic evaluation of the caudal vena cava in dogs with right-sided heart disease

INTRODUCTION/OBJECTIVES

In humans with impaired right-sided cardiac function, the caudal vena cava (CVC) diameter serves as a marker of venous congestion. This study aimed to investigate whether ultrasonographic CVC variables could identify the presence of right-sided congestive heart failure (R-CHF) in dogs with right-sided heart disease (RHD).

ANIMALS

Fifty client-owned control dogs and 67 dogs with RHD were enrolled. The dogs with RHD were subdivided into the non-R-CHF (n = 43) and R-CHF (n = 24) groups.

MATERIALS AND METHODS

We measured and compared the ultrasonographic CVC variables and echocardiographic variables among the groups. Receiver operating characteristic (ROC) curve analysis was performed to calculate the sensitivity and specificity of the variables at optimal cutoff values.

RESULTS

We obtained the highest accuracies of the ratio of the shortest diameter (SD) of the minimal CVC area to the aorta diameter (Ao) during inspiration [SD(min)/Ao] and of the ratio of SD(min) to the longest diameter of the minimal CVC area during inspiration [LD(min),SD/LD(min)], with high sensitivities, specificities, and an area under the ROC curve greater than 0.925.

CONCLUSIONS

In addition to the echocardiographic assessment of right-sided cardiac function, the CVC variables in this study, especially SD(min)/Ao and SD/LD(min), would be useful diagnostic indices for identifying R-CHF in dogs with RHD.

Aggressive lipid lowering therapy with pitavastatin and ezetimibe improve cardiovascular outcomes in patients with ST segment elevation myocardial infarction: insights from the HIJ-PROPER Study

Aims

The purpose of this study was to evaluate the effect of aggressive lipid-lowering therapy with pitavastatin and ezetimibe in patients with ST-segment elevation myocardial infarction (STEMI) as compared with those with other classification of an acute coronary syndrome (ACS) including non-STEMI (NSTEMI) and unstable angina pectoris (UA).

Methods

This is a post hoc sub-analysis of the HIJ-PROPER study. In the original study, ACS patients with dyslipidemia were randomized to either pitavastatin + ezetimibe therapy or pitavastatin monotherapy. In the present analysis, we divided HIJ-PROPER participants into the STEMI group (n=880) and NSTEMI + UA group (n=841). Cardiovascular events were analyzed between the two groups. The primary endpoint was a composite of major advanced cardiovascular events (MACE; all-cause death, non-fatal myocardial infarction, non-fatal stroke, unstable angina pectoris, and ischemia-driven revascularization)

Result

During median follow-up period of 3.4 years, the cumulative incidence of the primary endpoint in STEMI group was 31.9% in the pitavastatin+ezetimibe therapy, compared with 39.7% in the pitavastatin-monotherapy (HR, 0.77; 95% CI, 0.62–0.97; p=0.02). However, there was no effect of pitavastatin+ezetimibe therapy on the primary endpoint in the NSTEMI + UA group. Concerning the individual components of the primary endpoint in STEMI group, the percentage of occurrence of all-cause death was significantly lower in the pitavastatin+ezetimibe therapy compared to pitavastatin mono-therapy (14 patients (3.2%) vs. 31 patients (6.9%), respectively; HR, 0.45; 95% CI, 0.23–1.84, p=0.01). Multivariate analysis revealed that use of ezetimibe and prevalence of diabetes mellitus at baseline were independent predictors of primary endpoints in STEMI group (HR, 0.79; 95% CI, 0.63–0.99; p=0.04 for use of ezetimibe, HR 1.54; 95% CI, 1.22–1.94, p=0.0003 for diabetes mellitus).

Conclusion

Patients with pitavastatin+ezetimibe therapy as compared with pitavastatin-monotherapy had lower cardiovascular event in patients with ST-segment elevation myocardial infarction.

Kaplan-Meier curves for primary endpoint

Funding Acknowledgement

Type of funding source: None

Impact of comprehensive management on clinical outcomes in hypertensive patients with coronary artery disease: HIJ-CREATE sub-study

Background

There are limited data on the effects of blood pressure (BP) control and lipid lowering in secondary prevention of coronary artery disease (CAD) patients. We report a secondary analysis of the effects of BP control and lipid management in participants of the HIJ-CREATE, a prospective randomized trial.

Methods

HIJ-CREATE was a multicenter, prospective, randomized, controlled trial that compared the effects of candesartan-based therapy with those of non-ARB-based standard therapy on major adverse cardiac events (MACE; a composite of cardiovascular death, non-fatal myocardial infarction, unstable angina, heart failure, stroke, and other cardiovascular events requiring hospitalization) in 2,049 hypertensive patients with angiographically documented CAD. In both groups, titration of antihypertensive agents was performed to reach the target BP of &lt;130/85 mmHg. The primary endpoint was the time to first MACE. Incidence of endpoint events in addition to biochemistry tests and office BP was determined during the scheduled 6, 12, 24, 36, 48, and 60-month visits. Achieved systolic BP and LDL-Cholesterol (LDL-C) level were defined as the mean values of these measurements in patients who did not develop MACEs and as the mean values of them prior to MACEs in those who developed MACEs during follow-up.

Results

During a median follow-up of 4.2 years (follow-up rate of 99.6%), the primary outcome occurred in 304 patients (30.3%). Among HIJ-CREATE participants, 905 (44.2%) were prescribed statins on enrollment. Kaplan–Meier curves for the primary outcome revealed that there was no relationship between statin therapy and MACEs in hypertensive patients with CAD. The original HIJ-CREATE population was divided into 9 groups based on equal tertiles based on mean achieved BP and LDL-C during follow-up. For the analysis of subgroups, estimates of relative risk and the associated 95% CIs were generated with a Cox proportional-hazards model (Figure 1). The relation between LDL cholesterol level and hazard ratios for MACEs was nonlinear, with a significant increase of MACEs only in the patients with inadequate controlled LDL-C level even in the patients with tightly controlled BP.

Conclusions

The results of the post-hoc analysis of the HIJ-CREATE suggest that clinicians should pay careful attention to conduct comprehensive management of lipid lowering even in the contemporary BP lowering for the secondary prevention in hypertensive patients with CAD.

Figure 1

Funding Acknowledgement

Type of funding source: None

Lower levels of high-density lipoprotein cholesterol are associated with increased cardiovascular events in patients with acute coronary syndrome receiving contemporary lipid-lowering therapy

Background

This study aimed to elucidate whether high-density lipoprotein cholesterol (HDL-C) at 3-month follow-up for patients receiving contemporary lipid-lowering therapy after acute coronary syndrome (ACS) could predict cardiac events.

Methods

The HIJ-PROPER study was a multicenter, prospective, randomized trial comparing intensive lipid-lowering therapy (pitavastatin + ezetimibe) and conventional lipid-lowering therapy (pitavastatin monotherapy) after ACS. For the present analysis, the entire cohort was divided into three groups according to HDL-C levels at 3-month follow-up (Group 1, HDL-C ≤43 mg/dL; Group 2, 43–53.6 mg/dL; Group 3; HDL-C ≥53.6 mg/dL). Baseline characteristics and the incidence of the primary endpoint (a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, unstable angina pectoris, or ischemia-driven revascularization) were compared among the three groups.

Results

The primary endpoint was reported in 34.8%, 30.1%, and 24.6% of patients in Groups 1, 2, and 3, respectively. The incidence of the primary endpoint was significantly higher in Group 1 than in Group 3 (hazard ratio [HR], 1.5; 95% confidence interval [CI], 1.19–1.9; p=0.001). Irrespective of the treatment regimen, Group 1 had a significantly higher rate of the primary endpoint than Group 3 (pitavastatin + ezetimibe therapy: HR, 1.6; 95% CI, 1.12–2.22; p=0.01 and pitavastatin monotherapy: HR, 1.4; 95% CI, 1.05–1.98; p=0.02). These trends remained even after adjustment for baseline characteristics and lipid profiles.

Conclusions

Lower levels of HDL-C at 3-month follow-up are associated with higher incidence of the cardiovascular events in patients with acute coronary syndrome receiving contemporary lipid-lowering therapy.

HDL-C levels and Cardiovascular events

Funding Acknowledgement

Type of funding source: None

Effects of PCSK9 inhibitor on adverse limb outcomes in patients with critical limb ischemia

Background

The proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9-I), evolocumab, reduced the risk of cardiovascular event in patients with peripheral artery disease in FOURIER trial. However, the effects of evolocumab on favorable limb outcomes in patients with critical limb ischemia (CLI) is still unclear.

Purpose

The aim of this study was to evaluate the impacts of evolocumab on favorable limb outcomes and lipid profile in patients with CLI.

Methods

This was a single center, prospective observational study. A total of 39 patients with CLI were enrolled between November 2016 to May 2019. The subjects were divided into 2 groups based on evolocumab administration: evolocumab-treated group: E group (mean 69.4±11.7 years, n=14) and evolocumab non-treated group: Non-E group (mean 74.0±8.8 years, n=25). Baseline characteristics were assessed at admission. Lipid profile was evaluated at admission, 1, 3, 6, 12 and 18 months. The primary outcome was defined 18-month amputation-free survival (AFS). The secondary outcomes were defined 18-month overall survival (OS) and wound-free limb salvage. Mean follow-up period was 18±11 months.

Results

The patients in E group had greater reduction in levels of LDL cholesterol and non-HDL cholesterol than those in Non-E group over time. The reduction in MDA-LDL level was maintained at 1, 3, 6, 12 months, respectively. The 18-month AFS rate in the E-group was significantly higher than those in the Non-E group (log-rank p=0.02). The patients receiving evolocumab had a lower hazard regarding AFS (hazard ratio, 0.12; 95% confidence interval, 0.02–0.94; P=0.043) and a higher proportion of wound-free limb salvage at 12 months (E group [92%] vs Non-E group [57%], P=0.034) and 18 months (92% vs 52%, P=0.03). Otherwise, evolocumab administration was not associated with 18-month OS (log-rank p=0.053).

Conclusions

Evolocumab administration may be associated with the favorable outcome of 18-month AFS in the patients with CLI. Additionally, long-term administration of evolocumab over 12 months may improve wound-free limb salvage.

Effects of evolocumab on limb outcomes

Funding Acknowledgement

Type of funding source: None

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

Background

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Figure 1

Funding Acknowledgement

Type of funding source: None

EWSR1 overexpression is a pro-oncogenic event in multiple myeloma

Multiple myeloma (MM) is cytogenetically, genetically and molecularly heterogenous even among subclones in one patient, therefore, it is essential to identify both frequent and patient-specific drivers of molecular abnormality. Following previous molecular investigations, we in this study investigated the expression patterns and function of the Ewing sarcoma breakpoint region 1 (EWSR1) gene in MM. The EWSR1 transcriptional level in CD138-positive myeloma cells was higher in 36.4% of monoclonal gammopathy of undetermined significance, in 67.4% of MM patients compared with normal plasma cells, and significantly higher in ten human myeloma-derived cell lines (HMCLs) examined. EWSR1 gene knockdown caused growth inhibition with an increase of apoptotic cells in NCI-H929 and KMS-12-BM cells. Gene expression profiling using microarray analysis suggested EWSR1 gene knockdown caused transcriptional modulation of several genes associated with processes such as cell proliferation, cell motility, cell metabolism, and gene expression. Of particular, EWSR1 gene knockdown caused upregulation of let-7c and downregulation of its known targets K-RAS and AKT. Finally, our analysis using community database suggested that high EWSR1 expression positively associates with poor prognosis and advanced disease stage in MM. These findings suggest that EWSR1 overexpression is a pro-oncogenic molecular abnormality that may participate in MM progression.

Moraxella lacunata infection accompanied by acute glomerulonephritis

Moraxella lacunata (M. lacunata) is a Gram-negative bacterium, which rarely causes serious infection. This is a rare case report of acute glomerulonephritis diagnosed by pathological findings in a child accompanied by M. lacunata infection. The patient showed hematuria, proteinuria and hyperkalemia requiring emergency hemodialysis. After hospitalization, M. lacunata bacteremia became apparent. Pathological findings showed an increase in glomerulus inflammatory cells and glomerular C3 deposition was observed in the renal tissue biopsy. Final diagnosis was endocapillary proliferative glomerulonephritis. Clinical reports of M. lacunata infection requiring emergency hemodialysis in children are rare. Previous reports have suggested that lowered immune competency with chronic kidney disease may be a risk factor associated with serious invasive cases of M. lacunata infection. However, detailed clinical laboratory data and pathological findings have not been identified in previous case reports. Our case directly indicated complement activity and acute glomerulonephritis with M. lacunata infection. Although there are various causes for acute glomerulonephritis, infection-related glomerulonephritis (IRGN) is an important concept. M. lacunata infection might have a potential risk for IRGN with dysregulation of complement activity leading to serious and invasive clinical conditions than previously considered.

Successful de-escalation antibiotic therapy using cephamycins for sepsis caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae bacteremia: A sequential 25-case series

Carbapenems are frequently used to treat infections caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E), but carbapenem-resistant Enterobacteriaceae bacteria are a clinical concern. Although cephamycins (cefmetazole; CMZ) have been shown to be effective against mild cases of ESBL-E infection, data on their use for severe ESBL-E infections with sepsis or septic shock remain scarce. Herein, we discuss a de-escalation therapy to CMZ that could be used after empiric antibiotic therapy in ICU patients with sepsis or septic shock caused by ESBL-E bacteremia. A sequence of 25 cases diagnosed with sepsis or septic shock caused by ESBL-E bacteria was evaluated. The attending infectious disease specialist physicians selected the antibiotics and decided the de-escalation timing. The median SOFA (Sequential Organ Failure Assessment) and APACHE II (Acute Physiology and Chronic Health Evaluation II) severity scores were 8 and 30; the rate of septic shock was 60%. Infections originated most frequently with urinary tract infection (UTI) (56%) and Escherichia coli (85%). Eleven patients were de-escalated to CMZ after vital signs were stable, and all survived. No patients died of UTI regardless of with or without de-escalation. The median timing of de-escalation antibiotic therapy after admission was 4 days (range, 3–6 days). At the time of de-escalation, the median SOFA score fell from 8 to 5, the median APACHE II score from 28 to 22, and the rate of septic shock from 55% to 0%. We conclude that for sepsis in UTI caused by ESBL-E bacteremia, de-escalation therapy from broad-spectrum antibiotics to CMZ is a potential treatment option when vital signs are stable.

Aberrant BUB1 Overexpression Promotes Mitotic Segregation Errors and Chromosomal Instability in Multiple Myeloma

Chromosome instability (CIN), the hallmarks of cancer, reflects ongoing chromosomal changes caused by chromosome segregation errors and results in whole chromosomal or segmental aneuploidy. In multiple myeloma (MM), CIN contributes to the acquisition of tumor heterogeneity, and thereby, to disease progression, drug resistance, and eventual treatment failure; however, the underlying mechanism of CIN in MM remains unclear. Faithful chromosomal segregation is tightly regulated by a series of mitotic checkpoint proteins, such as budding uninhibited by benzimidazoles 1 (BUB1). In this study, we found that BUB1 was overexpressed in patient-derived myeloma cells, and BUB1 expression was significantly higher in patients in an advanced stage compared to those in an early stage. This suggested the involvement of aberrant BUB1 overexpression in disease progression. In human myeloma-derived cell lines (HMCLs), BUB1 knockdown reduced the frequency of chromosome segregation errors in mitotic cells. In line with this, partial knockdown of BUB1 showed reduced variations in chromosome number compared to parent cells in HMCLs. Finally, BUB1 overexpression was found to promote the clonogenic potency of HMCLs. Collectively, these results suggested that enhanced BUB1 expression caused an increase in mitotic segregation errors and the resultant emergence of subclones with altered chromosome numbers and, thus, was involved in CIN in MM.

Lenalidomide and pomalidomide potently interfere with induction of myeloid-derived suppressor cells in multiple myeloma

An increase in immunosuppressive myeloid-derived suppressor cells (MDSCs) is associated with disease progression and treatment resistance in multiple myeloma (MM). We investigated the mechanisms underlying MDSC induction, and sought to discover a strategy for prevention of MDSC induction in MM. Using a transwell co-culture system, four of nine examined human myeloma-derived cell lines (HMCLs) were potent in inducing monocytic (M)-MDSCs from normal peripheral blood mononuclear cells (PBMCs). As the results, we identified that secretion of C-C motif chemokine ligand 5 (CCL5) and macrophage migration inhibitory factor (MIF) by myeloma cells is a prerequisite for induction of MDSCs in MM. The immunomodulatory drug (IMiD) compounds, such as lenalidomide (LEN) and pomalidomide (POM), were identified as potent inhibitors of MDSC induction through bidirectional molecular effects of cereblon (CRBN)-dependent and -independent downregulation of CCL5 and MIF in myeloma cells; and downregulation of C-C motif chemokine receptor 5, a receptor for CCL5, and induction of interferon regulatory factor 8, a critical transcription factor for monocytic differentiation, in PBMCs. In the present study of the molecular mechanisms underlying MDSC induction, we identified a novel effect of LEN and POM of inhibiting MDSC induction via overlapping regulatory effects in myeloma cells and normal PBMCs.

Clinical characteristics, prognostic factors, and outcomes of heat-related illness (Heatstroke Study 2017-2018)

Aim

Heat‐related illness is common, but its epidemiology and pathological mechanism remain unclear. The aim of this study was to report current clinical characteristics, prognostic factors, and outcomes of heat‐related illness in Japan.

Methods

We undertook a prospective multicenter observational study in Japan. Only hospitalized patients with heat‐related illness were enrolled from 1 July to 30 September 2017 and 1 July to 30 September 2018.

Results

A total of 763 patients were enrolled in the study. Median age was 68 years (interquartile range, 49–82 years) and median body temperature on admission was 38.2°C (interquartile range, 36.8–39.8°C). Non‐exertional cause was 56.9% and exertional cause was 40.0%. The hospital mortality was 4.6%. The median Japanese Association for Acute Medicine disseminated intravascular coagulation (JAAM DIC), Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores on admission were 1 (0–2), 4 (2–6), and 13 (8–22), respectively. To predict hospital mortality, areas under the receiver operating characteristic curves were 0.776 (JAAM DIC score), 0.825 (SOFA), and 0.878 (APACHE II). There were 632 cases defined as heatstroke by JAAM heat‐related illness criteria, 73 cases diagnosed as having DIC. A total of 16.6% patients had poor neurological outcome (modified Rankin Scale ≥ 4) at hospital discharge. In the multivariate analysis, Glasgow Coma Scale and platelets were independent predictors of mortality. Type of heatstroke, Glasgow Coma Scale, and platelets were independent predictors of poor neurological outcome. Body temperature was not associated with mortality or poor neurological outcome.

Conclusions

In this study, hospital mortality of heat‐related illness was <5%, one‐sixth of the patients had poor neurological outcome. The APACHE II, SOFA, and JAAM DIC scores predicted hospital mortality. Body temperature was not associated with mortality or poor neurological outcome.

Serine-227 in the N-terminal kinase domain of RSK2 is a potential therapeutic target for mantle cell lymphoma

RSK2 is a serine/threonine kinase downstream signaling mediator in the RAS/ERK signaling pathway and may be a therapeutic target in mantle cell lymphoma (MCL), an almost incurable disease subtype of non‐Hodgkin lymphoma. In this study, serine‐227 (RSK2^Ser227) in the N‐terminal kinase domain (NTKD) of RSK2 was found to be ubiquitously active in five MCL‐derived cell lines and in tumor tissues derived from five MCL patients. BI‐D1870, an inhibitor specific to RSK2‐NTKD, caused RSK2^Ser227 dephosphorylation, and thereby, induced dose‐dependent growth inhibition via G₂/M cell cycle blockade and apoptosis in four of the five cell lines, while one cell line showed only modest sensitivity. In addition, RSK2 gene knockdown caused growth inhibition in the four BI‐D1870‐sensitive cell lines. Comparative gene expression profiling of the MCL‐derived cell lines showed that inhibition of RSK2^Ser227 by BI‐D1870 caused downregulation of oncogenes, such as c‐MYC and MYB; anti‐apoptosis genes, such as BCL2 and BCL2L1; genes for B cell development, including IKZF1, IKZF3, and PAX5; and genes constituting the B cell receptor signaling pathway, such as CD19, CD79B, and BLNK. These findings show that targeting of RSK2^Ser227 enables concomitant blockade of pathways that are critically important in B cell tumorigenesis. In addition, we found favorable combinatory growth inhibitory effects of BI‐D1870 with inhibitors of BTK (ibrutinib), AKT (ipatasertib), and BCL2 (venetoclax) in cell characteristic‐dependent manners. These results provide a rationale for RSK2^Ser227 in the NTKD as a potential therapeutic target in MCL and for future development of a novel bioavailable RSK2 NTKD‐specific inhibitor.

Parameters Influencing Brain Oxygen Measurement by Regional Oxygen Saturation in Postcardiac Arrest Patients with Targeted Temperature Management

In several studies, regional cerebral oxygen saturation (rSO₂) has been measured in patients with postcardiac arrest syndrome (PCAS) to analyze the brain's metabolic status. However, the significance of rSO₂ in PCAS patients remains unclear. In the present study, we investigated the relationship between rSO₂ and physiological parameters. Comatose survivors of out-of-hospital PCAS with targeted temperature management (TTM) at 34°C for 24 hours were included. All patients were monitored for their rSO₂ and additional parameters (arterial oxygen saturation [SaO₂], hemoglobin [Hb], mean arterial pressure [MAP], arterial carbon dioxide pressure [PaCO₂], and body temperature]) measured at the start of monitoring and 24 and 48 hours after return of spontaneous circulation (ROSC). Patients were divided into favorable and unfavorable groups, and the correlation between rSO₂ and these physiological parameters was evaluated by multiple regression analysis. Forty-nine patients were included in the study, with 15 in the favorable group and 34 in the unfavorable group. There was no significant difference in the rSO₂ value between the two groups at any time point. The multiple regression analysis of the favorable group revealed a moderate correlation between rSO₂ and SaO₂, Hb, and PaCO₂ only at 24 hours (coefficients: 0.482, 0.422, and 0.531, respectively), whereas that of the unfavorable group revealed moderate correlations between rSO₂ and Hb values at all time points, PaCO₂ at 24 hours and MAP at 24 and 48 hours. rSO₂ was moderately correlated to MAP in unfavorable patients. To optimize brain oxygen metabolic balance for PCAS patients with TTM measuring rSO₂, we suggest total evaluation of each parameters of SaO₂, Hb, MAP, and PaCO₂.

Abstract C026: DS-1062a, a novel TROP2-targeting antibody-drug conjugate with a novel DNA topoisomerase I inhibitor DXd, demonstrates potent antitumor activity in preclinical models

Background: A trophoblast cell surface antigen 2 (TROP2) is a 36-kDa single-pass transmembrane protein overexpressed in various epithelial tumors including non-small cell lung cancer (NSCLC) with relatively low and restricted expression in normal tissues, and is associated with aggressive tumor behavior. Therefore, TROP2 could be an attractive target for cancer therapy. We created DS-1062a, TROP2-targeting antibody-drug conjugate (ADC) with Daiichi Sankyo DXd technology using a novel DNA topoisomerase I inhibitor DXd. In this study, the pharmacological activity and the mechanism of action of DS-1062a were evaluated in preclinical in vitro and in vivo models. Methods: In vitro cell growth inhibitory and in vivo antitumor activities of DS-1062a were evaluated using TROP2-high and -low tumor cell lines and xenograft mouse models. Internalization and intracellular trafficking of DS-1062a in tumor cells were analyzed by immunofluorescence microscopy. Induction of DNA damage and apoptosis to tumor cells by DXd payload released from DS-1062a were assessed by western blot and immunohistochemistry. Pharmacokinetic profiles of DS-1062a were also analyzed in xenograft mouse model. Results: DS-1062a showed in vitro cell growth inhibitory activity to TROP2-high tumor cells, but not to TROP2-low tumor cells. It was observed with confocal microscopy that DS-1062a was co-localized with a lysosomal marker LAMP-2 after internalizing into TROP2-high tumor cells. The amount of DXd payload released from TROP2-high tumor cells after the in vitro treatment with DS-1062a was higher than that of TROP2-low tumor cells. DNA damage and apoptosis were induced in TROP2-high tumor cells after the in vitro treatment with DXd and DS-1062a, but not with isotype control IgG ADC. Similarly, DS-1062a exhibited strong antitumor activity with tumor regression in several TROP2-high tumors including NSCLC and DXd accumulation and DNA damage in TROP2-high tumors were observed in DS-1062a-treated tumors, but not in isotype control IgG ADC-treated tumors. Pharmacokinetic profiles of DS-1062a in xenograft mouse model were preferable. Conclusion: Based on these preclinical results, DS-1062a could provide a valuable therapy with a potential benefit in TROP2-expressing cancers in the clinical setting. A first-in-human phase 1 study in patients with advanced solid tumors is in progress (NCT03401385).

Citation Format: Daisuke Okajima, Junko Yamaguchi, Michiko Kitamura, Reiko Kamei, Takanori Maejima, Tomoko Shibutani, Satoru Yasuda, Tadashi Toki, Tsuyoshi Karibe, Tomomichi Fujitani, Takashi Nakada, Riki Goto, Yutaka Noguchi, Yuki Abe, Toshinori Agatsuma. DS-1062a, a novel TROP2-targeting antibody-drug conjugate with a novel DNA topoisomerase I inhibitor DXd, demonstrates potent antitumor activity in preclinical models [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference on Molecular Targets and Cancer Therapeutics; 2019 Oct 26-30; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2019;18(12 Suppl):Abstract nr C026. doi:10.1158/1535-7163.TARG-19-C026

Abstract A027: Combination of TROP2 and SLFN11 as the sensitivity biomarkers for DS-1062a, a novel TROP2-targeting antibody-drug conjugate with a novel DNA topoisomerase I inhibitor DXd

Background: DS-1062a is a TROP2-targeting antibody-drug conjugate with Daiichi-Sankyo DXd technology. DS-1062a is expected to deliver DXd, a derivative of Exatecan, to TROP2 highly expressed tumors such as epithelial cancers with stronger anti-tumor effect and safer profile than the systemic chemotherapy. SLFN11 has been reported as a sensitivity biomarkers of DNA topoisomerase I inhibitors in several cancers. In this research, we elucidated the potency of combination of TROP2 and SLFN11 as a sensitive biomarkers of DS-1062a sensitivity using in vitro and in vivo preclinical models. Materials and Methods: Growth inhibition effect of DS-1062a and DXd were tested using 39 cell lines of various cancer types and correlation between DS-1062a efficacy and both TROP2 and SLFN11 mRNA level was elucidated. To confirm the contribution of SLFN11 expression to DS-1062a sensitivity, SLFN11 was knocked down in 5 of TROP2 and SLFN11 expressed cell lines and changes of growth inhibition effects of DS-1062a and DXd were evaluated. DS-1062a efficacy were also evaluated in 25 PDX (Patient-derived xenograft) models which express various levels of TROP2 and SLFN11 and relationship of sensitivity of each tumor to DS-1062a and TROP2 and SLFN11 mRNA levels was analyzed. Results: In vitro tumor cell growth inhibition effect of DS-1062a was observed in the most of TROP2 highly expressed cell lines. However, DS-1062a showed weak efficacy in some cell lines with high TROP2 expression, which have relatively low sensitivity to DXd. Correlation analysis between DXd efficacy and gene expression suggested cell lines with low sensitivity tend to express limited level of SLFN11. Knock down of SLFN11 weakened in vitro tumor cell growth inhibition effect of both DS-1062a and DXd in cell lines with high expression of SLFN11 level. Furthermore, in vivo study with 25 PDX models, strong drug efficacy of DS-1062a was frequently observed in both TROP2 and SLFN11 expressed tumor. Conclusion: We revealed that SLFN11 is one of the sensitivity biomarkers other than TROP2 expression levels against DS-1062a. This finding suggests combination of TROP2 and SLFN11 could be a promising biomarker to predict antitumor effect of DS-1062a.

Citation Format: Satoru Yasuda, Daisuke Okajima, Tadashi Toki, Junko Yamaguchi, Tsuyoshi Karibe, Tomomichi Fujitani, Takashi Nakada, Yutaka Noguchi, Masato Murakami. Combination of TROP2 and SLFN11 as the sensitivity biomarkers for DS-1062a, a novel TROP2-targeting antibody-drug conjugate with a novel DNA topoisomerase I inhibitor DXd [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference on Molecular Targets and Cancer Therapeutics; 2019 Oct 26-30; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2019;18(12 Suppl):Abstract nr A027. doi:10.1158/1535-7163.TARG-19-A027

Correction to: Sepsis patients with complication of hypoglycemia and hypoalbuminemia are an early and easy identification of high mortality risk

In the original article, there were errors in Unit of serum albumin level and the Cases numbers in Table 4.

P824The clinical impact of polyunsaturated fatty acid on clinical outcomes in acute coronary syndrome with dyslipidemia: HIJ-PROPER sub-analysis

Background

Polyunsaturated fatty acids, especially omega-3 and -6 series, are key essential nutrients that play an important role in humans to maintain cell membranes and function. A recent randomized trial reported that adding eicosapentaenoic acid (EPA) to statins was beneficial to cardiovascular disease patients who had a residual risk factor. Further, several studies have reported that the low baseline value for EPA to arachidonic acid (AA) ratio is related to worse clinical outcome and plaque vulnerability in coronary artery disease patients. However, effects of baseline EPA/AA ratio on clinical outcomes in ACS patients have not been thoroughly evaluated.

Objectives

This study aimed to examine the impact of baseline eicosapentaenoic acid to arachidonic acid (EPA/AA) ratio on clinical outcomes of acute coronary syndrome (ACS) patients and how lipid-lowering therapy affects serum EPA/AA levels in these patients.

Methods

This is a sub-analysis of HIJ-PROPER assessing the effect of aggressive low-density lipoprotein cholesterol (LDL-C)-lowering treatment with pitavastatin+ezetimibe in 1,734 ACS patients with dyslipidemia. Patients were divided into two groups based on EPA/AA level on admission (cut-off: 0.34 μg/mL; median of baseline EPA/AA level) and clinical outcomes were examined.

Results

Percent reduction of LDL-C from baseline to follow-up and mean LDL-C level during follow-up were similar regardless of baseline EPA/AA ratio. In the low EPA/AA group, the Kaplan–Meier estimate for the primary endpoint at 3 years was 27.2% in the pitavastatin+ezetimibe group, compared with 36.6% in the pitavastatin-monotherapy group [hazard ratio (HR), 0.69; 95% confidence interval (CI), 0.52–0.93; P=0.015). However, in the high EPA/AA group, there was no significant reduction in the primary endpoint by pitavastatin+ezetimibe therapy (HR, 0.92; 95% CI, 0.70–1.20; P=0.52).

Conclusions

Aggressive lipid-lowering therapy with ezetimibe had a positive effect on clinical outcomes in the low EPA/AA group of ACS patients with dyslipidemia, but not in the high EPA/AA group. This effect was independent of LDL-C reduction and suggests that EPA/AA measurement on admission in ACS patients contributes to a “personalized” lipid-lowering approach.

P830Differences in the usefulness of aggressive lipid-lowering therapy among single-vessel and multi-vessel coronary artery disease patients: HIJ-PROPER sub-study

Background

Acute coronary syndrome (ACS) patients with multi-vessel disease (MVD) are at high risk of recurrent cardiovascular events. Previous study, examining stable atherosclerotic cardiac disease, reported that aggressive lipid-lowering therapy was more beneficial in MVD patients than in single-vessel disease (SVD) patients. However, no report has investigated the effects of aggressive lipid-lowering treatment according to the number of diseased coronary arteries in ACS patients.

Purpose

The purpose of the present study was to elucidate the efficacy of aggressive lipid-lowering therapy in ACS patients with MVD and SVD in modern early invasive strategy era.

Methods

The study population was derived from the HIJ-PROPER study, in which, ACS patients with dyslipidemia were randomized to pitavastatin + ezetimibe therapy (targeting LDL-C less than 70mg/dl) or pitavastatin-monotherapy (targeting LDL-C less than 90mg/dl). In the present study, the treatment efficacy was compared between patients with MVD and SVD. The primary end point was a composite of major advanced cardiovascular events (MACEs), including all-cause death, non-fatal myocardial infarction, non-fatal stroke, and ischemia driven revascularization.

Results

We identified 1702 eligible patients (mean age, 65.6 years; male, 75.6%); 869 patients (51.1%) had MVD and 833 (48.9%) patients had SVD. The rate of acute revascularization was 96.2%. The incidence of MACEs was significantly higher in MVD group compared to SVD group (43.7% vs 25.9%, hazard ratio 1.95, 95% confidence interval 1.65–2.31, p<0.001). In MVD group, there was no significant difference in MACEs between pitavastatin + ezetimibe therapy and pitavastatin-monotherapy group. (43.5% vs. 43.9%, 1.0, 0.82–1.23; p=0.95). However, in SVD group, pitavastatin + ezetimibe therapy showed significantly fewer MACEs than pitavastatin-monotherapy (34.6% vs. 47.4%, 0.72, 0.55–0.94, p=0.02). (Figure)

Conclusion

This study showed that ACS patients with SVD enjoyed significantly greater benefits from pitavastatin + ezetimibe therapy compared with pitavastatin monotherapy, whereas the patients with MVD did not. High rate of revascularization in acute phase of ACS might affect the efficacy of aggressive lipid-lowering therapy and our results in the present study suggest different treatment approach would be necessary in ACS patients with MVD in modern early invasive strategy era.

P6339Sequential organ failure assessment score on admission predicts long-time mortality of the patients with acute heart failure

Background

Despite the remarkable advances in the treatment options of acute heart failure (HF), prognosis assessment remains an ongoing challenge. Previous studies revealed only a moderate accuracy of models predicting mortality. Sequential Organ Failure Assessment (SOFA) Score are widely used in the intensive care unit (ICU) to predict outcome and predicted higher long-time mortality in unselected patients in cardiac ICU. In addition, the American Heart Association Get With the Guidelines–Heart Failure (GWTG-HF) risk score allows for risk stratification of 30-day outcome for patients hospitalized with HF. The purpose of this study was to evaluate whether SOFA score on admission is useful for long-time mortality prediction in acute HF patients and also to assess the discriminative performance as compared with GWTG-HF risk score.

Methods

This was a single-centre, retrospective cohort study. Between January 2007 and December 2016, we screened eligible 661 consecutive patients with acute HF administered at our hospital. SOFA score on admission of 294 patients was able to calculate retrospectively. We enrolled 269 patients who could complete follow up evaluation for more than 1 year. Endpoint was all-cause mortality after admission. Additive information of SOFA score was evaluated by area under the curve (AUC), net reclassification improvement (NRI), integrated discrimination improvement (IDI) and decision curve analysis (DCA).

Results

The 269 patients were included in this study (78.5±10.9 years; 136 men; left ventricular ejection fraction [EF], 49.8±16.6%) during a mean follow-up of 32.1±22.3 months. Patients with all-cause death had higher SOFA score (4.2±2.3 versus 2.8±1.8, p<0.001; AUC, 0.689) and GWTG-HF risk score (44.0±7.6 versus 38.1±7.9, P<0.001, AUC, 0.692).

Kaplan-Meier survival analysis demonstrated higher SOFA scores (P<0.001) and GWTG-HF risk scores (P<0.001) appears to be related to increase probabilities of all cause death. A multivariate Cox proportional hazard model were made with adjustment for SOFA score, GWTG-HF risk score, age, gender and ejection fraction. As a result, SOFA score (hazard ratio [HR] 1.227; 95% confidence interval [CI], 1.130 to 1.326; P<0.001), GWTG-HF (HR, 1.054; 95% CI, 1.029 to 1.078; P<0.001) and age (HR, 1.069; 95% CI 1.048 to 1.092; P<0.001) were independent predictors of all cause death and HR of SOFA score was the highest in these parameters. Incorporating SOFA score into GWTG-HF score yielded a significant NRI (0.528 (95% CI 0.291 to 0.765) and IDI (0.046 (95% CI 0.020 to 0.072). In DCA, compared with the reference model, the net benefit for SOFA score model was greater across the range of threshold probabilities.

Conclusions

The SOFA score, simple and validated mortality risk score can predict long-term all-cause mortality in patients with acute HF. Discriminative performance metrics such as NRI, IDI and DCA were improved on incorporation of the SOFA score for prediction of mortality.

P5577Preoperative transaortic pressure gradient predicts renal functional improvement after transcatheter aortic valve implantation in patients with chronic kidney disease

Introduction

Transcatheter aortic valve implantation (TAVI) theoretically increases renal blood flow through increasing cardiac output by relieving aortic valvular obstruction of blood flow from left ventricle, resulting in a renal functional recovery in patients with severe aortic valve stenosis (AS). However, procedural steps of TAVI including contrast use potentially damages renal medulla and may deteriorate renal function.

Purpose

The aim of this study was to investigate renal functional change and clarify preoperative predictors for renal functional improvement after TAVI in chronic kidney disease (CKD) patients with severe AS.

Methods

A total of 88 consecutive severe AS patients with CKD (grade >3) who underwent TAVI from 2015 to 2018 was enrolled in this observational study. They were divided into two groups depending on their renal functional improvement after TAVI that was defined as more than 10% increase in estimated glomerular filtration rate (eGFR) at discharge from their preoperative level.

Results

Among the whole candidates, 49 patients (55.7%) were improved their renal function. Patients with the lowest preoperative eGFR achieved the highest increase in eGFR after TAVI (CKD grade >4: +22.7±23.7%, Figure). Patients in the Improved group had lower hemoglobin level, higher mean transaortic pressure gradient (TAPG), and higher aortic valve gradient before TAVI, compared to those in the Non-improved group. However, contrast volume during the procedure was not significantly different between the groups. Multivariate logistic regression analysis revealed that high mean TAPG and low left ventricular ejection fraction (LVEF) before TAVI were independent predictors for the improvement of renal function (odds ratio (OR): 1.04, 95% confidence interval (CI): 1.00–1.08; OR: 0.94, 95% CI: 0.89–0.99, respectively), even after the adjustment of baseline eGFR level and hemoglobin level that were statistically significant on univariate logistic regression analysis. Receiver Operating Characteristic (ROC) curve showed the cut-off level of preoperative mean TAPG in renal functional improvement after TAVI as 47.0 mmHg (Sensitivity: 47.9%, Specificity: 79.5%, area under the curve: 0.62).

Correlation between CKDgrade and ΔeGFR

Conclusions

Preoperative high mean TAPG may predict renal functional improvement after TAVI in patients with deteriorated renal function. This non-invasive predictor may help clinicians to consider to perform TAVI in a challenging case with severe CKD.

Benign hilar bile duct strictures resected as perihilar cholangiocarcinoma

BACKGROUND

Differentiation between perihilar cholangiocarcinoma (PHCC) and benign strictures is frequently difficult. The aim of this study was to investigate the incidence and long-term outcome of patients with tumours resected because of suspicion of PHCC, which ultimately turned out to be benign (malignancy masquerade).

METHODS

Patients who underwent surgical resection with a diagnosis of PHCC between 2001 and 2016 were reviewed retrospectively.

RESULTS

Among 707 consecutive patients, 685 had PHCC and the remaining 22 (3·1 per cent) had benign biliary stricture. All patients with benign disease underwent major hepatectomy, with no deaths. Preoperative histological assessment using bile duct biopsy or aspiration cytology had a high specificity (90 per cent), low sensitivity (62 per cent) and unsatisfactory accuracy (63 per cent). Despite the increasing use of histological assessment, the incidence of benign strictures resected did not decrease over time, being 0·9 per cent in 2001-2004, 4·0 per cent in 2005-2008, 3·8 per cent in 2009-2012 and 2·9 per cent in 2013-2016. The final pathology of benign strictures included IgG4-related sclerosing cholangitis (9 patients), hepatolithiasis (4), granulomatous cholangitis (3), non-specific chronic cholangitis (3), benign strictures after cholecystectomy (2), and a benign stricture possibly caused by parasitic infection (1). The 10-year overall survival rate for the 22 patients with benign stricture was 87 per cent, without recurrence of biliary stricture.

CONCLUSION

The incidence of benign strictures resected as PHCC as a proportion of all resections was relatively low, at 3·1 per cent. Currently, unnecessary surgery for suspected PHCC is unavoidable.

Amplitude-Integrated Electroencephalography and Brain Oxygenation for Postcardiac Arrest Patients with Targeted Temperature Management

Brain injury is the most common cause of death postcardiac arrest. Amplitude-integrated electroencephalography (aEEG) is suggested to be useful in the prognostication in cases of postcardiac arrest brain injury. However, combined monitoring with aEEG and regional oxygen saturation (rSO₂) for postcardiac arrest syndrome (PCAS) patients to improve accuracy has not been reported. The purpose of this prospective observational study is to assess the usefulness of aEEG and rSO₂ for PCAS patients with targeted temperature management (TTM) to predict neurological outcome and possibly identify the pathophysiology of postcardiac arrest brain injury. PCAS patients with TTM at 34°C were monitored by aEEG and rSO₂ immediately after admission to the intensive care unit and evaluated at the start of monitoring, and 24 and 48 hours after return of spontaneous circulation (ROSC). Patients were divided into two groups according to electroencephalography (EEG) pattern: a continuous EEG (C) pattern group and a noncontinuous EEG (NC) pattern group. Patients with C pattern had a significantly more favorable neurologic outcome compared with patients with an NC pattern at each point in time. No significant difference in rSO₂ values was observed between the C pattern and the NC pattern at any time point. Variation coefficient at rSO₂ in the NC group was significantly greater than that in the C group from the start of the monitoring to 24 hours. aEEG is useful in predicting outcome for PCAS patients whereas rSO₂ is not.

Prediction of delayed platelet engraftment after autologous stem cell transplantation for B-cell non-Hodgkin lymphoma

Delayed platelet engraftment (DPE) is occasionally observed despite prompt neutrophil engraftment after autologous peripheral blood stem cell transplantation (auto-PBSCT). To identify risk factors for DPE and to develop a simple and clinically applicable system for predicting the time required for platelet recovery, we conducted a multi-institutional retrospective study in 144 patients with B-cell non-Hodgkin lymphoma who underwent auto-PBSCT. In a median observation period of 930 days (range: 25-5272 days), 139 patients successfully achieved platelet engraftment (≥50.0 × 10⁹/L). The median duration for platelet engraftment was 19 days, and 130 patients had platelet engraftment within 40 days after auto-PBSCT; however, the other 14 patients failed to achieve platelet engraftment within 60 days. These 14 patients with DPE required a significantly greater number of apheresis procedures and had a lower pre-apheresis absolute lymphocyte count (PA-ALC) compared to those without DPE. Importantly, multivariate analysis revealed that the number of transplanted CD34⁺ cells (≤2.0 × 10⁶/kg), number of required apheresis procedures (≥3 days), and PA-ALC (≤1.0 × 10⁹/L) were independently associated with a longer time for platelet engraftment after auto-PBSCT. By incorporating these three independent factors as variables, we generated a new scoring system for prediction of the time and probability for platelet engraftment after auto-PBSCT.

Treatment rationale and design of a phase II study of narrow-band ultraviolet B phototherapy for cutaneous steroid-refractory acute graft-vs-host disease following allogenic stem-cell transplantation

BACKGROUND

Acute graft-vs-host disease (aGVHD) is a common complication of allogenic hematopoietic stem-cell transplantation (allo-HSCT) and skin is the most common and often the 1st site at which aGVHD develops. Cutaneous aGVHD is usually treated with oral and/or topical corticosteroids as the 1st-line treatment; however, steroid-refractory aGVHD not only impairs patients' quality of life but also causes significant morbidity and mortality after allo-HSCT. Narrow-band ultraviolet B (NB-UVB) phototherapy has been utilized for a wide range of immunologic inflammatory skin diseases, but there is limited information on the efficacy, safety, and biomarkers for response prediction of NB-UVB for cutaneous aGVHD.

AIMS

The purpose of this study is to investigate the efficacy and safety of NB-UVB phototherapy for steroid-refractory cutaneous aGVHD.

PATIENTS AND METHODS

A total of 40 subjects aged from 16 to 70 years with steroid-refractory cutaneous aGVHD after allo-HSCT will be included in the trial. Patients with worse than stage 2 intestine/liver aGVHD will be excluded. Eligible patients will undergo NB-UVB phototherapy until resolution or further worsening of rash or occurrence of an unmanageable adverse event. The primary endpoint is the overall response rate. The secondary outcomes include rates for complete response, partial response, stable disease, progressive disease, duration of response, sparing effect on calcineurin inhibitors and/or corticosteroids, safety, and predictive biomarkers for treatment response.

ETHICS AND DISSEMINATION

The protocol has been approved by the institutional Clinical Research Review Board of Kyoto Prefectural University of Medicine. Written informed consent will be obtained from all patients before registration, in accordance with the Declaration of Helsinki. Results of the study will be disseminated via publications in peer-reviewed journals.

TRIAL REGISTRATION

Trial registration numbers UMIN000032426 and jRCTs052180005.