[Epstein-Barr virus-associated gastritis with perigastric lymphadenopathy accompanied by infectious mononucleosis:a case report]

A 28-year-old female patient with no particular medical history had a sore throat seven days before admission. Subsequently, she developed malaise, right abdominal pain, and a fever of 38°C and visited our hospital. A blood test revealed a mild inflammatory response and elevated liver enzymes, and she was admitted to the hospital for detailed examination and acute liver injury treatment. Various viral tests and autoantibody measurements revealed elevated Epstein-Barr virus (EBV) immunoglobulin M and negative EB nuclear antigen antibodies. Therefore, she was diagnosed with primary infectious mononucleosis-associated EB viral hepatitis. Abdominal computed tomography upon admission revealed swollen lymph nodes around the stomach;thus, esophagogastroduodenoscopy (EGD) was performed. A histopathological examination revealed severe lymphocytic infiltration, and EB encoding region in situ hybridization demonstrated that 10-20% of the lymphocytes were EBV-infected. Drip and rest treatment improved the patient's liver enzymes, and her symptoms resolved. Repeat EGD after two months revealed improved gastric erosions. Here, we report a case of EBV-associated gastritis that was discovered due to perigastric lymphadenopathy accompanied by infectious mononucleosis. This report includes a review of the literature because a few studies reported EBV-associated gastritis.

A Novel Hemostatic Peptide Solution for Common Acute Gastrointestinal Bleeding Diseases: First Case Series Study on the Treatment Results of Endoscopic Hemostasis by Nonexpert Endoscopists

INTRODUCTION

We investigated the hemostatic effect and safety of a hemostatic peptide solution for the treatment of gastrointestinal bleeding requiring emergency endoscopy.

METHODS

We retrospectively examined the patient backgrounds, hemostatic results, and procedural safety in patients who were treated with a hemostatic peptide solution for hemostasis during emergency endoscopies for gastrointestinal bleeding. All hemostatic procedures were performed by nonexpert physicians with less than 10 years of endoscopic experience. All of the cases were treated at a single institution over the months from January 2022 to January 2023.

RESULTS

Twenty-six consecutive patients (17 males and 9 females) with a median age of 74 (45-95) years were included. Their conditions requiring emergency endoscopy were melena in 8 patients, hematochezia in 2, hematemesis in 8, anemia in 6, and bleeding during esophagogastroduodenoscopy in 2. The sites of bleeding were the esophagus in 3 patients, the stomach in 17, the duodenum in 3, the small intestine in 2, and the colon in 1. Hemostasis was obtained with another hemostasis device used in conjunction with the hemostatic peptide solution in 13 cases and with the hemostatic peptide solution alone in 13 cases. The hemostasis success rate was 100%, with no complications. Rebleeding occurred within 1 week in 4 cases.

CONCLUSION

Hemostasis with the hemostatic peptide solution was safe and provided a temporary high hemostatic effect in emergency gastrointestinal endoscopy.

Imaging findings of arrested pneumatisation and differentiation from other skull base lesions

OBJECTIVES

Arrested pneumatisation (AP) is an anatomic variant of the sphenoid sinus. Since AP remains underrecognised, otolaryngologists and radiologists may mistake AP for a lesion and perform follow-up imaging studies. We investigated the imaging findings of CT, MRI, and F-18 fludeoxyglucose (FDG)-positron emission tomography (PET) for AP, and discussed the differences between AP and other skull base lesions.

METHODS

We reviewed multidetector low CT imaging of 442 patients (285 men and 157 women; age range, 19-93 years; mean age, 67.8 years) who underwent FDG-PET/CT for head and neck tumours between January 2019 and December 2019. The imaging findings of AP were reviewed on CT, MRI, FDG-PET/CT, and compared with those of fibrous dysplasia, chordoma, chondrosarcoma, multiple myeloma, and bone invasion of nasopharyngeal carcinoma.

RESULTS

AP was identified in 22 patients (14 men and 8 women; age range, 24-93 years; mean age, 67.0 years) based on criteria from previous reports. AP manifested with well-circumscribed sclerotic margins on CT, without evidence of expansion. AP showed high-signal intensity on T1-/T2 weighted MRI. FDG-PET revealed non-significant uptake [maximum standardised uptake value (SUVmax): 0.85 (range, 0.4-1.27)] in AP. Contrastingly, skull base lesions showed expansion, poorly circumscribed boundaries without osteosclerotic margins, and moderate-to-severe FDG uptake (SUVmax: 1.8-8.4).

CONCLUSIONS

The characteristic imaging findings of AP, namely non-expansile on CT and non-uptake on FDG-PET, may aid in its differentiation from other skull base lesions.

A resonant sextuplet of sub-Neptunes transiting the bright star HD 110067

Planets with radii between that of the Earth and Neptune (hereafter referred to as 'sub-Neptunes') are found in close-in orbits around more than half of all Sun-like stars1,2. However, their composition, formation and evolution remain poorly understood3. The study of multiplanetary systems offers an opportunity to investigate the outcomes of planet formation and evolution while controlling for initial conditions and environment. Those in resonance (with their orbital periods related by a ratio of small integers) are particularly valuable because they imply a system architecture practically unchanged since its birth. Here we present the observations of six transiting planets around the bright nearby star HD 110067. We find that the planets follow a chain of resonant orbits. A dynamical study of the innermost planet triplet allowed the prediction and later confirmation of the orbits of the rest of the planets in the system. The six planets are found to be sub-Neptunes with radii ranging from 1.94R⊕ to 2.85R⊕. Three of the planets have measured masses, yielding low bulk densities that suggest the presence of large hydrogen-dominated atmospheres.

Multiple ulcerative colitis-associated aseptic abscesses successfully treated with infliximab: a case report

Aseptic abscesses are rare extraintestinal manifestations of inflammatory bowel disease. Herein, we present the case of a 69-year-old female patient with ulcerative colitis in whom multiple aseptic abscesses were successfully treated with infliximab. Aseptic abscesses associated with ulcerative colitis are difficult to differentiate from infectious abscesses. In the present case, we reached a diagnosis of aseptic abscesses associated with ulcerative colitis as antibiotics were ineffective and repeated Gram stains and cultures of blood and abscess were negative. Aseptic abscesses are commonly found in the spleen, lymph nodes, liver, and skin; however, in the present case, the periosteum was the major site. Prednisolone is often effective for aseptic abscesses; however, the present patient was initially treated with a combination of 40 mg/day of prednisolone and granulocyte and monocyte adsorption apheresis, with inadequate effect. Infliximab was administered as the patient was steroid-resistant, with strong effect. Subsequently, infliximab treatment has been continued, with no recurrence after 2 years. However, as there have been reports of cases of recurrence even after remission with treatment, careful follow-up in the future is therefore necessary.

The effectiveness of strict low-density lipoprotein cholesterol management in secondary prevention of Japanese patients

Background

In Japanese guidelines, target value of low-density lipoprotein cholesterol (LDL-C) <100mg/dL is recommended as standard management for secondary prevention of coronary artery disease. On the other hand, the guidelines also state that LDL-C targeting <70mg/dL should be considered in high-risk patients. However, the effectiveness of strict LDL-C management in the prevention of long-term coronary event recurrence in Japanese patients remains unclear.

Purpose

The purpose of the present study was to evaluate whether the strict management of LDL-C targeting <70 mg/dL was effective to prevent recurrence of acute coronary syndrome (ACS) than standard management in patients with previous percutaneous coronary intervention (PCI).

Methods

From January 2007 to August 2020, we performed coronary angiography in 359 patients with previous PCI who were suspected of having signs of recurrent cardiac ischemia. Patients were stratified into three groups according to achieved LDL-C value; <70mg/dL (n=57), 70 to <100mg/dL (n=135) and ≥100mg/dL (n=167). In addition, patients who had previous ACS and/or diabetes mellitus were defined as high-risk group, and sub-analysis by their achieved LDL-C values was performed in high-risk group and non-high-risk group. Endpoint was recurrence of ACS. Moreover, risk factors associated with recurrent-ACS were examined in patients with LDL-C <100 mg/dL.

Results

After follow-up (median 6.1 years), 99 patients (28%) had recurrent-ACS. Recurrent-ACS was significantly lower in patients with LDL-C <70mg/dL than LDL-C 70 to <100mg/dL and LDL-C ≥100mg/dL (p<0.01 and p<0.001, respectively). In sub-analysis, high-risk group with LDL-C <70 mg/dL had lower incidence of recurrent-ACS than LDL-C 70 to <100 mg/dL (p=0.03). Similar tendency was found in non-high-risk group (p=0.08). There was no difference of recurrent-ACS between high-risk group and non-high-risk group in patients with LDL-C <70mg/dL (p=0.41). Moreover, in patients with achieved LDL-C <100mg/dL (n=192), multivariate analysis identified that LDL-C (HR: 1.032, p<0.01) and HbA1c (HR: 1.330, p<0.01) were independent predictors of recurrent-ACS. In these patients, whether or not they were in the high-risk group was not a significant predictor (p=0.61).

Conclusions

Strict management of LDL-C targeting <70 mg/dL should be considered for a wider range of Japanese patients as well as for Westerners to prevent recurrence of ACS in secondary prevention.

Funding Acknowledgement

Type of funding sources: None. Probability of freedom from ACS

CD133 prevents colon cancer cell death induced by serum deprivation through activation of Akt-mediated protein synthesis and inhibition of apoptosis

During the early phase of tumorigenesis, primary malignant cells survive within a low nutrition environment caused by a poorly organized vascular system. Here, we sought to determine the functional significance of CD133 in the survival of cancer cells under nutrient‐poor conditions. Knockdown and overexpression experiments demonstrated that CD133 suppresses colon cancer cell death induced by serum deprivation through activation of Akt‐mediated anti‐apoptosis and protein synthesis pathways. Furthermore, serum deprivation increased the amount of endogenous CD133 protein, which was regulated at least in part by phosphoinositide 3‐kinase. Thus, it is highly likely that CD133 contributes to the acquisition/maintenance of the resistance to stress arising from nutrient deficiency in early avascular tumor tissues.

Long-year follow-up of acute myocardial infarction with preserved initial LVEF: prognostic impact of progressively reduced LVEF

Background

Severely reduced left ventricular ejection fraction (LVEF ≤35%) is commonly seen in approximately 5% of the myocardial infarction (MI) survivors in its acute-phase, which is recognized as a risk factor of post-MI cardiac death. However, clinical incidence and risk factor of the progressively reduced LVEF in the chronic-phase after MI has not been clarified.

Purpose

To evaluate clinical incidence and risk factor of the progressively reduced LVEF in the chronic-phase after MI by serial echocardiography.

Method

We evaluated 1144 consecutive patients with acute MI with preserved LVEF (≥50%) in acute-phase. Primary outcome was severely reduced LVEF (<35%) in the chronic-pahse. We analyzed the predictive factor using multivariate analysis.

Result

During follow-up (median:1097 days), severely reduced LVEF newly developed in 8.6% of AMI survivors. Kaplan-meier curve is shown in the Figure. Multivariate analysis showed that men, eGFR <30, AMI of LAD and absence of renin-angiotensin system blocking drugs was an independent predictor of severely reduced LVEF.

Conclusions

Progressively reduced LVEF during chronic-phase occurred 8.6% in acute MI survivors with preserved initial LVEF. Especially patients with these risk factors, careful long-term follow-up after MI should be needed to identify possible candidate for the implantable cardioverter-defibrillator.

Figure 1

Funding Acknowledgement

Type of funding source: None

Effectiveness of more strict managements after achievement of standard target value of low-density lipoprotein cholesterol in secondary prevention of Japanese patients

Background

In secondary prevention of coronary artery disease, target value of low-density lipoprotein cholesterol (LDL-C) <100 mg/dL is recommended as standard management in Japanese guideline. The guideline also stated that strict management of LDL-C targeting <70 mg/dL is considered in some high risk patients. However, in Japanese patients, effectiveness of more strict management of LDL-C lowering therapy for prevention of long-term cardiovascular events remains unclear.

Purpose

The purpose of the present study was to evaluate whether the strict management of LDL-C targeting <70 mg/dL was effective to prevent recurrence of long-term coronary events than standard management in patients with previous percutaneous coronary intervention (PCI).

Methods

We investigated 344 patients with previous PCI who underwent late coronary angiography to examine recurrence of cardiac ischemia beyond the early phase of restenosis from January 2007 to August 2019. Patients were stratified into three groups according to achieved LDL-C value; LDL-C <70mg/dL (n=53), 70 to <100mg/dL (n=130) and ≥100mg/dL (n=161). Endpoints of this study were recurrence of cardiac ischemia presenting as acute coronary syndrome (recurrence-ACS) and any late coronary revascularization.

Results

During average 7.1 years follow-up, 200 patients (58%) underwent any late coronary revascularization. In 94 of those patients, recurrence-ACS was observed. The incidence of recurrence-ACS was significantly lower in patients with achieved LDL-C <70mg/dL than in those with LDL-C 70 to <100mg/dL and LDL-C ≥100mg/dL (p=0.009 and p=0.001, respectively), however, there was no difference between patients with LDL-C 70 to <100mg/dL and LDL-C ≥100mg/dL (p=0.140). Any late revascularization was significantly lower in patients with achieved LDL-C <70mg/dL and in those with LDL-C 70 to <100mg/dL than in those with LDL-C ≥100mg/dL (p=0.002 and p<0.001, respectively), however, no difference was found between patients with LDL-C <70mg/dL and LDL-C 70 to <100mg/dL (p=0.119). Moreover, in patients with achieved LDL-C <100mg/dL (n=183), multivariate analysis identified that LDL-C (HR 1.035, p=0.007) and HbA1c (HR 1.338, p=0.001) were independent predictors of recurrence-ACS. In contrast, only using statins (HR 0.461, p=0.009) was an independent predictor of recurrence-ACS in patients with achieved LDL-C ≥100mg/dL.

Conclusions

LDL-C was the important residual risk of recurrence-ACS even after recommended standard LDL-C lowering management had been achieved. More strict management of LDL-C targeting to <70mg/dL should be considered to prevent recurrence-ACS for wider range of Japanese patients in secondary prevention.

Incidence of late coronary events

Funding Acknowledgement

Type of funding source: None

Prognostic impact of initial serum albumin for newly developing heart failure after acute myocardial infarction

Background/Introduction

Previous studies have shown that poor nutritional status relate to the clinical outcomes in patients with heart failure (HF). However, relationships between initial serum albumin and newly developing HF after acute myocardial infarction (AMI) remain unclear.

Methods

We evaluated 2289 consecutive patients with AMI in our hospital. Primary outcome was HF hospitalization after AMI. We analyzed the predictive impact of initial serum albumin using multivariate analysis, both in all AMI patients and subgroup of AMI patient without known risk factors of HF (LMT, peak CK >8000, eGFR <30, and LVEF <35%).

Result

In the remote-phase(median follow-up: 754 days), 5.4% of all AMI patients were hospitalized due to HF. Multivariate analysis showed that low albumin (<4.0g/dl) was an independent predictor of HF hospitalization after AMI in all patients, as well as other known risk factors. Interestingly, low albumin still showed the predictive value even in the no-HF risk subgroup. Kaplan-meier curve of no-HF risk group is shown in the Figure.

Conclusions

Low initial albumin level would be an useful predictor of newly developing HF in the remote-phase after AMI.

Figure 1

Funding Acknowledgement

Type of funding source: None

Catheter ablation of atrial fibrillation benefits the patients with heart failure and preserved ejection fraction as well as those with heart failure and reduced ejection fraction

Background

Although catheter ablation of atrial fibrillation (AF) has recently been shown to improve the cardiac function and even mortality in patients with heart failure (HF) and reduced ejection fraction (HFrEF), few studies have examined the outcomes of AF catheter ablation in patients with HF with preserved ejection fraction (HFpEF).

Purpose

To verify the impact of AF catheter ablation on the cardiac function and HF status in patients with HFpEF.

Methods

We studied 306 patients with HF who had a history of an HF hospitalization and/or preprocedural serum BNP levels >100pg/ml (age, 68.9±8.2 years old; male, 66.3%; non-paroxysmal AF, 63.1%, left atrial diameter [LAD], 42.5±6.3 mm; left ventricular ejection fraction [LVEF], 60.6±12.0%) out of 596 consecutive patients who underwent pulmonary vein isolation-based catheter ablation of AF. The patients with an LVEF ≥50% were defined as having HFpEF (n=262; age, 69.0±8.2 years old; male, 64.5%; non-paroxysmal AF, 61.8%, LAD, 42.1±5.9 mm; left LVEF, 64.0±8.2%) and the remaining patients with an LVEF <50% were defined as having HFrEF (n=44, age, 67.9±8.7 years old; male, 77.0%; non-paroxysmal AF, 70.5%, LAD, 44.9±8.2 mm; LVEF, 40.1±10.2%). The patients received periodic follow-ups for 12 months after the catheter ablation. The cardiac function parameters including the echocardiographic findings and HF functional status of the patients were compared between baseline and 12 months, stratified by the HF subgroup.

Results

AF recurred in 60 patients with HFpEF (22.9%) and in 14 with HFrEF (31.8%) during the 12 month follow-up (p=0.27), however, sinus rhythm was maintained at 12 months in most of the patients (253 patients with HFpEF [96.6%] and 42 patients with HFrEF [95.5%]) (p=0.71). Figure 1 compares the changes in the cardiac function parameters and NYHA functional class from baseline to the 12-month follow-up stratified by the HF subgroup. Both the patients with HFpEF and HFrEF had significant improvements in the serum BNP levels, chest thorax ratio, and LVEF determined by echocardiography. LA reverse remodeling as shown by a significant reduction in the LAD was observed in both HF subgroups, however, the E/E', an index of the LV diastolic function, did not significantly change in either of the subgroups. Similar to the patients with HFrEF, an improvement in the NYHA functional class was seen in those with HFpEF.

Conclusions

Catheter ablation of AF may benefit patients with HFpEF as well as those with HFrEF. Sinus rhythm maintenance achieved by AF catheter ablation in patients with HFpEF may lead to LA reverse remodeling and a better LV systolic function, thereby improving the NYHA functional class. It is unclear whether changes in the LV diastolic function may contribute to this favorable process.

Funding Acknowledgement

Type of funding source: None

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

0634 Volume-Assured Pressure Support is Effective Treatment for Obstructive Sleep Apnea Patients Who Failed CPAP Titration

Introduction

Obstructive sleep apnea (OSA) is a common disease, often treated using continuous positive airway pressure (CPAP). In many cases, patients fail an attended CPAP titration study, often due to inadequate control of AHI, and treatment-emergent central apneas as CPAP is increased. Here, we report our experience using volume-assured pressure support (VAPS) for these patients.

Methods

We retrospectively reviewed records of 45 adults who had OSA diagnosed on polysomnography (PSG) in whom CPAP titration had failed. In these patients, VAPS-AE (adjustable expiratory pressure) titrations were performed. Patients with central sleep apnea on baseline PSG were excluded.

Results

Reasons for CPAP titration failure included: treatment emergent central apneas (25), failure of maximum CPAP pressure to treat OSA (18), and persistent hypoxia (2). Average age was 57.9±13.1, BMI was 40.2±8.7, 26 males, Epworth sleepiness score was 10.7±7.9. The following significant changes from baseline PSG to VAPS titration were observed: AHI: 65.3±29.3 to 22.3 ±16.1 (p<.001) events/hour. Time < 88% saturation: 63.7 (median) to 6.9 (median) min (p<.001). The number of patients with AHI<15 was 0 on PSG and 16 (36%) on VAPS-AE, while the number of patients with AHI<30 was 7 (16%) on PSG and 32 (71%) on VAPS-AE. Improvement in AHI was not related to gender, age, or narcotic use, but was correlated with BMI: ΔAHI = 12.2 - (1.4 * BMI); p=.05. VAPS resulted in improved sleep architecture: slow wave sleep increased (medians: 1.4% to 19.6% total sleep time (TST)) (p<.001), REM sleep increased (medians 6.4% to 13.6% TST) (p<.01).

Conclusion

For OSA patients for whom CPAP titration failed, titration with VAPS-AE was an effective treatment for many patients.

Support

N/A

0633 Volume Assured Pressure Support is an Effective Treatment in Patients with Central Sleep Apnea Syndrome

Introduction

Central sleep apnea syndrome (CSA) is commonly found in patients with congestive heart failure, brainstem disorders, and narcotic use. Various treatment modalities have been used with varied effectiveness in reducing the apnea-hypopnea index (AHI) and improving ventilation in patients with CSA. This study assessed whether Volume Assured Pressure Support (VAPS), a BiLevel mode of ventilation, is effective in treating CSA.

Methods

We performed a retrospective review of polysomnography (PSG) and VAPS titration studies on 11 patients at our institution: 7 patients had CSA with Cheyne-Stokes Respiration, 2 patients had CSA attributed to narcotic use, and 2 patients had primary CSA. CSA was diagnosed if more than 50% of the disordered breathing events were central. Five patients had failed a Continuous Positive Airway Pressure (CPAP) titration and then proceeded to VAPS while in 6 patients, VAPS was the initial treatment modality tried. We examined the effectiveness of VAPS in reducing AHI, improving oxygenation, and improving sleep architecture.

Results

Among the 11 patients, age was 63.0±12.1 yo, BMI was 33.7 ±4.5, 7 were males, Epworth sleepiness score was 9.3±4.9. The following significant changes from baseline PSG to VAPS titration were observed: AHI: 59.1± 8.0 to 27.2 ± 9.9 (p<.01); Time ≤ 88% O2 saturation (min): 48.1±14.5 to 15.4±6.1 (p<.05). Improvement in AHI was not related to gender, body mass index, narcotic use, or age. No significant changes in sleep architecture between the two studies were found. Ten (91%) patients had AHI > 30 on initial PSG. In 6 (55%) patients AHI was reduced to <15 with VAPS use. An additional patient had AHI reduced to 22.2, while 4 (36%) patients did not achieve an AHI < 30 with VAPS.

Conclusion

VAPS is an effective mode of treating CSA in the majority of patients.

Support

NA

P762 Preserved mitral apparatus dynamics predict the improvement of acute ischemic mitral regurgitation: four-dimensional quantitative echocardiographic study

Background

We sought to evaluate the predictive value of acute stage mitral apparatus geometry and dynamics for the reduction of ischemic mitral regurgitation (IMR) in the remote phase after successful primary percutaneous coronary intervention (pPCI) by using real-time 3D-transthoracic echocardiography (3D-TTE).

Methods

We performed 2D and 3D-TTE in consecutive 44 first acute MI patients with more than mild IMR within 3 days after successful pPCI. 3DTTE of left ventricle (LV) volumes and mitral apparatus dynamics through the cardiac cycle were quantified offline. We compared the 3D geometric and dynamic parameters in the acute phase between 1)20 remained MR group and 2)24 improved MR group in 6-to-12 months after MI onset.

Results

Ejection fraction (EF) was preserved in the improved MR group compared to the remained MR group (49.0 ± 11.2 vs. 56.5 ± 7.0%, p = 0.013). Mitral valve annulus area, leaflet tenting length and papillary muscles spatial position had no significant difference between the two groups (all p > 0.05) throughout cardiac cycle. In contrast, mitral annulus saddle shape was preserved in the improved MR group than the remained MR group (p = 0.010) and annular area changed dynamically through early- to late-systole in the improved MR group (phasic p = 0.017) despite it was adynamic in remained MR group (phasic p = 0.201). Conclusions: IMR improvement in the remote phase after AMI associated with preserved EF, mitral annulus saddle shape and dynamics during systole in the acute phase of MI. 4D dynamics of the mitral apparatus can be clinically useful predictor of the improvement in acute IMR and may contribute to the clinical decision making including surgical or percutaneous intervention for IMR.

P292 The risk of adverse outcome with ischemic mitral regurgitation at 6-month after myocardial infarction: possible benefit of early intervention by transcatheter mitral-valve repair

Background

The latest study has demonstrated the better outcomes of transcatheter mitral-valve repair in patients with decompensated heart failure (HF) and left ventricular (LV) dysfunction. However, it is unknown whether earlier intervention for mitral regurgitation (MR) can improve the outcome of myocardial infarction (MI).

Purpose

The aim of this study was to investigate the prognostic value of ischemic MR (IMR) at 6-month after MI for the later incidence of HF and death.

Methods

We retrospectively examined 723 MI patients who were admitted to our hospital. 95.5% of the patients were treated by primary coronary intervention. Patients were clinically followed-up at 6-month after the onset of MI, and divided into 3 groups according to the degree of IMR, i.e. No/Trivial IMR group (n = 528), Mild IMR group (n= 154) and ≥Moderate IMR group (n= 41). We compared the later incidence of hospitalization for HF and all-cause death at 3-year for each group.

Results

The studied population had preserved ejection fraction (EF) (56.9 ± 10.7%, average) and mostly asymptomatic at 6-month after MI. All-cause mortality within 3-year was higher in patients with ≥Moderate IMR (p < 0.001), and the incidence of hospitalization for HF was significantly higher depends on the degree of IMR at 6-month (p < 0.001). Multivariate analysis showed EF and the degree of IMR were the independent predictor for the hospitalization for HF.

Conclusions

IMR at 6-month after MI was associated with the later adverse events despite relatively preserved LV contraction without heart failure symptoms at the index examination. Early intervention for IMR potentially benefit for the better outcome.

Abstract P292 Figure. Caplan-Meier estimates on adverse events

P1520 Aortic flow reversal caused by aortic regurgitation deteriorates renal function

Background

Chronic kidney disease is a growing public health problem. Renal dysfunction is known as a strong risk factor for cardiovascular disease and end-stage renal failure. The presence of pan-diastolic flow reversal in the abdominal aorta is a very specific sign of severe aortic regurgitation (AR). A higher aortic reverse/forward flow ratio is associated with lower intrarenal forward flow. However, the influence of AR on renal function has been poorly understood. We hypothesized that the aortic flow reversal reduces the renal artery forward flow and accordingly leads to renal dysfunction in patients with severe AR.

Methods

The study consisted of 21 consecutive patients (mean age 69 ± 11 years) with severe AR who underwent aortic valve replacement (AVR). We compared echocardiographic indices and the glomerular filtration rate (GFR) before and 603 ± 541 days after AVR.

Results

Blood pressure was 122 ± 16/54 ± 8 mmHg before AVR and 123 ± 16/76 ± 11 mmHg after AVR. After AVR, left ventricular (LV) end-diastolic dimension decreased from 57 ± 9 to 44 ± 5 mm and LV ejection fraction increased from 58 ± 12 to 60 ± 11 %. Estimated GFR significantly increased from 62.9 ± 18.9 to 71.8 ± 18.1 mL/min per 1.73 m2 after AVR (p = 0.003).

Conclusions An increase in aortic flow reversal caused by severe AR reduces forward flow into the kidney and thereby deteriorates renal function. This study demonstrated a key mediating role of central hemodynamic factors, particularly an exaggerated aortic flow reversal in renal dysfunction and severe AR.

mDia1/3-dependent actin polymerization spatiotemporally controls LAT phosphorylation by Zap70 at the immune synapse

The mechanism by which the cytosolic protein Zap70 physically interacts with and phosphorylates its substrate, the transmembrane protein LAT, upon T cell receptor (TCR) stimulation remains largely obscure. In this study, we found that the pharmacological inhibition of formins, a major class of actin nucleators, suppressed LAT phosphorylation by Zap70, despite TCR stimulation-dependent phosphorylation of Zap70 remaining intact. High-resolution imaging and three-dimensional image reconstruction revealed that localization of phosphorylated Zap70 to the immune synapse (IS) and subsequent LAT phosphorylation are critically dependent on formin-mediated actin polymerization. Using knockout mice, we identify mDia1 and mDia3, which are highly expressed in T cells and which localize to the IS upon TCR activation, as the critical formins mediating this process. Our findings therefore describe previously unsuspected roles for mDia1 and mDia3 in the spatiotemporal control of Zap70-dependent LAT phosphorylation at the IS through regulation of filamentous actin, and underscore their physiological importance in TCR signaling.

1182 Clinical evidence of the mitral valve leaflet remodeling after st-elevation acute myocardial infarction: longitudinal observation using real-time 3D echocardiography

Background

Mitral valve (MV) leaflet remodeling after acute myocardial infarction (AMI) has been proposed as biological and physiological reaction under the ischemic environment mainly by animal experiments. Clinical evidence of leaflet growth after AMI is lacking.

Purpose

We aimed to assess the clinical evidence of the mitral valve leaflet remodeling after acute myocardial infarction by serial 2D/3D transthoracic echocardiography.

Methods

Sixty-six patients with first-onset ST-elevation MI (33 anterior and 33 inferior) were serially examined by 2D/3D-transthoracic echocardiography. MV complex geometry including leaflet surface area and leaflet thickness was quantitatively analyzed in acute phase and 6-month follow-up.

Results

3D-leaflet surface area was significantly increased in 6-month follow-up (anterior MI; 5.58 [4.93-6.00] versus 5.98 [5.68-6.40] cm²/m²; P < 0.001, inferior MI; 5.48 [4.69-6.07] versus 5.79 [4.74-6.37] cm²/m²; P < 0.001). In anterior MI, both anterior and posterior leaflet lengths significantly increased (anterior leaflet; 12.78 [11.55-13.55] versus 13.63 [12.52-14.15] mm/m²; P = 0.001, posterior leaflet; 9.61 [8.73-10.77] versus 9.84 [8.94-10.96] mm/m²; P = 0.037). In inferior MI, posterior leaflet length significantly increased (9.18 [8.50-10.38] versus 10.00 [8.56-10.85] mm/m²; P = 0.029), while there was no significant change in anterior leaflet length (12.54 [11.61-13.56] versus 12.56 [12.08-14.06] mm/m²; P = 0.214). Leaflet thickness was found to become greater in both groups in 6-month follow-up (anterior MI; 1.08 [0.92-1.21] versus 1.32 [1.25-1.45] mm; P < 0.001, inferior MI; 1.14 [0.98-1.25] versus 1.32 [1.21-1.49] mm; P < 0.001) (Figure).

Conclusions

In six months from the onset of AMI, MV enlarged in area and increased in thickness. Anterior leaflet mainly enlarged in anterior MI, while posterior leaflet enlarged in inferior MI. This is the first clinical evidence of the MV remodeling after AMI, and long-year follow-up should contribute to assess the course of valve growth with relation to ischemic mitral regurgitation.

Abstract 1182 Figure. 3D analysis of the mitral valve

Polymer gel with a flexible and highly ordered three-dimensional network synthesized via bond percolation

Gels are a soft elastic material consisting of a three-dimensional polymer network with nanometer-sized pores and are used in a variety of applications. However, gel networks typically have a substantial level of defects because the network formation reaction proceeds stochastically. In this study, we present a general scheme to fabricate gels with extremely low levels of defects by applying geometric constraints into pregel solution based on the "bond percolation" concept. In the formed gel, stationary laser speckles, which are an indicator of spatial defects, were not observed at all. In addition, we found that the concentration fluctuations of the polymer chains were ergodic across the whole gel network. In such a homogeneous gel, both the spatial and temporal correlations of polymer chains are the same before and after gelation.

P3619Incidence of progressively reduced LVEF during long-year follow-up after myocardial infarction: impact for mid-term outcomes

Background

Severely reduced left ventricular ejection fraction (LVEF≤35%) is commonly seen in approximately 5% of the myocardial infarction (MI) survivors in its acute-phase, which is recognized as a risk factor of post-MI cardiac death. However, clinical impact of the progressively reduced LVEF in the chronic-phase after MI has not been clarified.

Purpose

To evaluate clinical impact of the progressively reduced LVEF in the chronic-phase after MI.

Method

We evaluated 1659 consecutive patients with acute MI by serial echocardiography. Primary outcome was severely reduced LVEF. And secondary outcome was all cause death and cardiac death.

Result

During follow-up (median: 1097 days), severely reduced LVEF newly developed in 8.6% of AMI survivors. These patients had significantly higher incidence of all cause death (20.7% vs. 4.4%, p<0.01) and cardiac death (10.6% vs. 1.2%, p<0.01) than those with LVEF>35%. Severely reduced LVEF progressed in the chronic-phase associated with all cause death and cardiac death as well as those with severely reduced EF in the acute-phase.

Figure 1

Conclusions

Progressively reduced LVEF during chronic-phase occurred 8.6% per 10-year in MI survivors. Careful long-term follow-up after MI should be needed to identify possible candidate for the implantable cardioverter-defibrillator.

P642What is the most important residual risk after achievement of appropriate low-density lipoprotein cholesterol lowering therapy in secondary prevention of Japanese patients?

Background

In secondary prevention of coronary artery disease, target value of low-density lipoprotein cholesterol (LDL-C) <100mg/dL with using statins is recommended as standard therapy in Japanese guideline. However, impact of residual risks after achievement of standard LDL-C lowering therapy was not fully examined. Furthermore, there is little information whether more strict management of LDL-C lowering is effective to prevent long-term cardiovascular events than standard management.

Purpose

The purpose of this study was to evaluate the relationship between residual risks after achievement of standard LDL-C lowering therapy and long-term coronary events in secondary prevention of Japanese patients.

Methods

From January 2007 to August 2018, 333 patients with previous percutaneous coronary intervention underwent late coronary angiography to examine recurrence of cardiac ischemia beyond the early phase of restenosis. We defined appropriate LDL-C lowering therapy as achieved LDL-C <100mg/dL with using statins. Patients whose achieved LDL-C was <100mg/dL with using statins were classified as Appropriate-group (n=139), and patients who were not using statins or whose achieved LDL-C was ≥100mg/dL were classified as Inappropriate-group (n=194). Endpoints of the study were recurrence of cardiac ischemia as acute coronary syndrome (recurrence-ACS) and any late coronary revascularization.

Results

During average 7.1 years follow-up, 195 patients (59%) underwent any late coronary revascularization. In 91 of those patients, clinical presentation of recurrence-ACS was observed. Kaplan-Meier curve analysis revealed that the incidence of recurrence-ACS and any late coronary revascularization were significantly lower in Appropriate-group than in Inappropriate-group (p=0.017 and p<0.001, respectively). In Appropriate-group, recurrence-ACS was significantly lower in patients with achieved LDL-C <70mg/dL than in those with LDL-C 70 to <100mg/dL (p=0.042), however, any late revascularization was not different between the two groups. On the other hand, in Inappropriate-group, recurrence-ACS was significantly lower in patients with using statins than in those without using statins (p=0.038), and any late revascularization was less frequent in patients with achieved LDL-C <100mg/dL than in those with LDL-C ≥100mg/dL (p=0.035). Moreover, multivariate analysis identified that only LDL-C was an independent predictor of recurrence-ACS in Appropriate-group (HR: 1.047, p=0.006), in contrast, LDL-C (HR: 1.008, p=0.020), using statins (HR: 0.555, p=0.034) and triglyceride (HR: 1.003, p=0.038) were independent predictors of recurrence-ACS in Inappropriate-group.

Conclusions

LDL-C was the most important residual risk of recurrence-ACS even after recommended standard therapy has been achieved. More strict management of LDL-C targeting to <70mg/dL should be considered in secondary prevention of Japanese patients.

P3604Gender difference in Low-BMI patients with acute myocardial infarction makes an impact on mid-term outcomes

Background/Introduction

There are some reports about impact of low body-mass-index (BMI) on patients with acute myocardial infarction (MI), suggesting an obesity paradox. However, the differential impact of gender between low-BMI and mid-term outcome remains unclear.

Purpose

To evaluate the differential impact of gender between low-BMI patients with acute MI and mid-term outcome.

Methods

We evaluated 3038 consecutive patients with acute MI in Miyazaki medical association hospital. Patients were stratified low-BMI group (BMI≤20) from other-BMI group (BMI>20), and compared. BMI was measured at admission of acute MI. Primary outcome was cardiac death. We also analyzed each gender, using Kaplan-meier curve with long-rank test.

Result

Among all patients, low-BMI patient was 8.6%. Median follow-up was 1085 days, and cardiac death was significantly higher rate in low-BMI group (14.5% vs 7.7%, p<0.001). Male patient with low-BMI was significantly higher event rate, compared with other-BMI group (11.0% vs 5.5%, p<0.001). However, female patient group had no significant difference of outcomes between low-BMI and other-BMI (12.6% vs 10.3%, p=0.315). Event rate is shown in the Figure.

Gender

Conclusions

Low BMI was associated with mid-term outcomes in acute MI patients. Impact of low-BMI on mid-term outcome seems to be gender dependent in acute MI patients.

P1038Device implantation after catheter ablation of paroxysmal atrial fibrillation with coexisting sick sinus syndrome: Insights from the Kansai Plus Atrial Fibrillation (KPAF) study

Background

Sick sinus syndrome (SSS) and atrial fibrillation (AF) frequently coexist and interact to initiate and perpetuate each other. Several retrospective or small cohort studies have suggested that successful catheter ablation of AF may help to waive device implantations in patients with paroxysmal AF plus SSS, however, no prospective large studies are so far available on this scenario.

Purpose

We aimed to elucidate the device implantation-free survival after catheter ablation of paroxysmal AF with coexisting SSS in a prospective large-scale registry. We also determined the risk factors for device implantations after catheter ablation of paroxysmal AF.

Methods

The Kansai Plus Atrial Fibrillation (KPAF) study is a multi-center prospective registry that enrolled 5,019 consecutive patients that underwent an initial pulmonary vein isolation-based radiofrequency catheter ablation of AF. This study was comprised of 3,226 patients with paroxysmal AF registered in the KPAF study (age, 64.8±10.5 years old; female, n=999 [31.0%]; left atrial diameter [LAD], 37.5±8.0 mm; left ventricular ejection fraction [LVEF], 65.3±8.4%, CHADS2 score, 1.09±1.05). The atrial tachyarrhythmia-free and device-free survivals after catheter ablation were compared between patients with SSS (n=368; tachy-brady syndrome, 88%) and without SSS (control; n=2,858).

Results

The atrial tachyarrhythmia-free survival was almost identical between the two groups both after the first ablation session (Fig.1A) and after the last procedure with an average of 1.3±0.5 sessions. At baseline, the devices had already been implanted in 53 (14.4%) SSS and 36 (1.3%) control patients. In the remaining patients, devices were newly implanted in 54 (17.1%) SSS and 62 (2.2%) control patients during the follow-up of 3 years after the catheter ablation (Figure 1B). In the SSS group, devices were implanted predominantly within 6 months after the catheter ablation, and atrial tachyarrhythmia recurrence preceded the device implantation in 48 (89%) patients. Multivariate predictors of device implantations after the paroxysmal AF ablation included: SSS (hazard ratio [HR] 6.85, 95% confidence interval [CI] 4.61–10.19, p<0.001), an age>75 years old (HR 1.69, 95% CI 1.08–2.64, p=0.019), a female gender (HR 2.16, 95% CI 1.44–3.24, p<0.001), the LAD (mm) (HR 1.05, 95% CI 1.02–1.08, p=0.006), and the LVEF (%) (95% CI 0.96, 95% CI 0.94–0.98, p<0.001).

Figure 1

Conclusions

Device implantations could be waived in >80% of patients with SSS at 3 years of follow-up after the catheter ablation of paroxysmal AF in this real world all comer prospective registry. In addition to coexisting SSS, predictors of device implantations after paroxysmal AF ablation included: the elderly, a female gender, a large LA, and a reduced LVEF.

Acknowledgement/Funding

None

Oral administration of whole dihomo-γ-linolenic acid-producing yeast suppresses allergic contact dermatitis in mice

Dihomo-γ-linolenic acid (DGLA, C20: 3n-6) is known to have an anti-inflammatory activity, but its range of effects was not well studied because of its limited natural sources. We addressed these issues by constructing an yeast Saccharomyces cerevisiae strain having a complete metabolic pathway for DGLA synthesis by introducing two desaturase and one elongase genes to convert endogenous oleic acid to DGLA. Taking advantage of well-known safety of S. cerevisiae, we previously investigated the efficacy of heat-killed whole DGLA-producing yeast cells on irritant contact dermatitis, and showed that oral intake of this yeast significantly suppressed inflammatory reactions, whereas no such suppression was observed by the intake of 25 times the amount of purified DGLA. Since this method is considered to be a simple and efficient way to suppress inflammation, we examined its effectiveness against allergic contact dermatitis (ACD) in this study and showed that this method was also effective against ACD.

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.

Role of filamentous fungi in migration of radioactive cesium in the Fukushima forest soil environment

The fate of radioactive Cs deposited after the Fukushima nuclear power plant accident and its associated radiological impacts are largely dependent on its mobility from surface soils to forest ecosystems. We measured the accumulation of radioactive Cs in the fruit bodies of wild fungi in a forest at Iitate, Fukushima, Japan. The transfer factors (TFs) of radioactive Cs from soil to the fruit bodies of wild fungi were between 10-2 and 102, a range similar to that reported for the fruit bodies collected in Europe after the Chernobyl accident and in parts of Japan contaminated by the nuclear bomb test fallout. Comparison of the TFs of wild mushroom and those of fungal hyphae of 704 stock strains grown on agar medium containing nutrients and 137Cs showed that the TFs of wild mushroom were lower. The TF was less than 0.1 after the addition of the minerals zeolite, vermiculite, phlogopite, smectite, or illite of 1.0% weight to the agar medium. These results indicate that the presence of minerals decreases Cs uptake by fungi grown on the agar medium, and filamentous fungi still accumulate radioactive Cs even when minerals are present in the medium.

Abstract 838: Epigenetic reprogramming of different cancer-related pathways at the single cell level after low-dose DNA demethylation therapy

The efficacy of DNA demethylation therapy is highly dependent on the dosing regimen. Administration of a drug at a dose much lower than the maximum tolerated dose (MTD) for a prolonged period shows a high therapeutic efficacy, despite its small demethylating effect. However, the mechanisms underlying the high therapeutic efficacy of low-dose treatment are still unclear. In this study, we aimed to reveal the mechanisms by analyzing decitabine (DAC)-treated individual cancer cells. To reveal the epigenetic reprogramming at the single cell level and its functional consequences, individual DAC-treated HCT116 cells (H3 clones) were cloned from DAC-treated bulk HCT116 cells. Genome-wide DNA methylation was analyzed using InfiniumHuman450 beadChip. In bulk cells, only partial reduction of DNA methylation levels was observed, and no genes were completely demethylated. In contrast, in cloned cells, a much larger reduction of DNA methylation levels was observed, depending upon genes. Promoter CpG islands of 233-470 genes of 1,188 hypermethylated genes in HCT116 were completely demethylated (Δβ ≥ 0.6) in some of the clones analyzed. Demethylated genes were highly variable among individual clones, and different cancer-related genes, such as those involved in the p53 pathway, WNT pathway, and cell cycle regulation, were completely demethylated, depending upon clones. For example, CDKN2A (p16) was completely demethylated only in a H3-32 clone, and this clone showed slower cell growth rate (14.6% of untreated cells), and aneuploid cells were detected possibly due to cellular senescence. These results showed that epigenetic reprogramming at the single cell level involves diverse cancer-related pathways, and this mechanism is likely to underlie the high efficacy of low-dose DNA demethylation therapy.

Citation Format: Hideyuki Takeshima, Yukie Yoda, Naoko Watanabe, Mika Wakabayashi, Toshikazu Ushijima. Epigenetic reprogramming of different cancer-related pathways at the single cell level after low-dose DNA demethylation therapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 838.

Effects of forefoot arthroplasty on plantar pressure, pain, gait and disability in rheumatoid arthritis

Objectives: The purpose of this study was to clarify the effect of forefoot arthroplasty on plantar pressure, pain, gait, and disability within 1 year after arthroplasty in patients with RA.Methods: Eleven patients with RA who underwent forefoot arthroplasty completed this quasi-experimental study. Outcome measures were in-shoe plantar pressure, visual analog scale (VAS) for pain, temporal gait parameters, and modified Health Assessment Questionnaire (mHAQ), obtained preoperatively and at 4 and 12 months postoperatively.Results: The average peak plantar pressure under the 2nd metatarsal head decreased at 4 months postoperatively, compared to preoperative values (p < .05) and the decreased plantar pressure was sustained at 12 months postoperatively. Similar changes were observed under the 3rd to 5th metatarsal heads. The median VAS for foot pain decreased from 25 mm preoperatively to 1 mm at 4 months postoperatively and the lower score was sustained at 12 months postoperatively (p < .05). The median mHAQ score remained lower (<1.0) at all measurement points. Regarding gait, there were no significant differences from the preoperative assessment to postoperative follow-up.Conclusion: Plantar pressure and forefoot pain decreased at 4 and 12 months after forefoot arthroplasty in patients with RA. No adverse effects on gait parameters or disability were observed.

Continuous cell culture monitoring using a compact microplate reader with a silicone optical technology-based spatial filter

Continuous cell monitoring is very important for the maintenance and control of cell multiplication and differentiation. This paper presents a compact microplate reader that is able to continuously measure a 24-well microplate (6 × 4 wells) using the optical absorption measurement method. The 24-channel plate reader consisted of a spatial filter, light emitting diode light source, and color sensors and was similarly sized with the cell culture microwell plates. A spatial filter was previously fabricated by our group using silicone optical technology (SOT). This SOT-based spatial filter has an excellent noise reduction effect. Light reflection at the optical path interface can be absorbed and only forward light can be transmitted; accordingly, a larger S/N ratio than that of conventional optical systems is expected. The fabricated 24-channel plate reader permits real-time cell monitoring during cultivation on the clean bench and in cell culture conditions by incorporating the SOT spatial filter. Using the device, it was possible to continuously evaluate the concentration and pH of reagents in the 24 wells in real time. Moreover, cell activity and protein production were detectable using the device. These results suggest that the newly fabricated device is a promising tool for the evaluation of cell behaviors for cell management.

Major hepatectomy with or without pancreatoduodenectomy for advanced gallbladder cancer

BACKGROUND

The indications for major hepatectomy for gallbladder cancer either with or without pancreatoduodenectomy remain controversial. The clinical value of these extended procedures was evaluated in this study.

METHODS

Patients who underwent major hepatectomy for gallbladder cancer between 1996 and 2016 were identified from a prospectively compiled database. Postoperative outcomes and overall survival were compared between patients undergoing major hepatectomy alone or combined with pancreatoduodenectomy (HPD).

RESULTS

Seventy-nine patients underwent major hepatectomy alone and 38 patients had HPD. The patients who underwent HPD were more likely to have T4 disease (P < 0·001), nodal metastasis (P = 0·015) and periaortic nodal metastasis (P = 0·006), but were less likely to receive adjuvant therapy (P = 0·006). HPD was associated with a high incidence of grade III or higher complications (P = 0·002) and death (P = 0·037). Overall survival was longer in patients who underwent major hepatectomy alone than in patients who underwent HPD (median survival time 32 versus 10 months; P < 0·001). In multivariable analysis, surgery in the early period (1996-2006) (P = 0·002), pathological T4 disease (P = 0·005) and distant metastasis (P < 0·001) were associated with shorter overall survival, and cystic duct tumour (P = 0·002) with longer overall survival.

CONCLUSION

Major hepatectomy alone for gallbladder cancer contributes to favourable overall survival with low morbidity and mortality, whereas HPD is associated with poor overall survival and high morbidity and mortality rates. HPD may eradicate locally spreading gallbladder cancer; however, the indication for the procedure is questioned from an oncological viewpoint.

Recombinant Human Soluble Thrombomodulin Delivers Bounded Thrombin to Antithrombin III: Thrombomodulin Associates with Free Thrombin and Is Recycled to Activate Protein C

Recombinant human soluble thrombomodulin (rhs-TM), having no transmembrane domain or chondroitin sulfate, was expressed in Chinese hamster ovary cells. Interactions between rhs-TM, thrombin (Th), protein C (PC) and antithrombin III (ATIII) were studied. Equilibrium between rhs-TM and Th had no detectable time lag in clotting inhibition (K d = 26 nM) or PC activation (K d = 22 nM), while ATIII inhibited Th at a bimolecular rate constant = 5,200 M-1s-1 (K d <0.2 nM). A mixture of ATIII, Th and rhs-TM showed that ATIII reacted with Th slower than rhs-TM, whose presence did not affect the reaction between ATIII and Th. In a mixture of rhs-TM, ATIII and PC, the repeated addition of Th caused the repeated activation of PC; which was consistent with the Simulation based on the assumption that rhs-TM is recycled as a Th cofactor. From these results, we concluded that upon inhibition of the rhs-TM-Th complex by ATIII, rhs-TM is released to recombine with free Th and begins to activate PC, while the Th-ATIII complex does not affect rhs-TM-Th equilibrium.

Analysis of the Disappearance Curve of Labelled Fibrinogen at the Time of Hyperfibrinogenemia in Rabbits with Acute or Chronic Intravascular Coagulation

In order to study fibrinogen metabolism, the disappearance curve of 125I-labelled homologous fibrinogen was investigated in the rabbits with experimentally induced acute or chronic intravascular coagulation by injection of Lycopodium spores or thromboplastin. The results obtained were as follows.

1. Using haemolysate, an intermediate phase with upward convexity was clearly recognized between the early rapid-decay phase and the late slow phase in each radioactivity decay curve obtained in groups of rabbits. This convexity was most marked with acute intravascular coagulation induced by injection of Lycopodium spores, and was less marked, although higher, with chronic intravascular coagulation induced by injection of thromboplastin than that in the normal control.

2. The disappearance curve with the intermediate phase could be expressed, in approximation, as a sum of 2 equations - the initial exponential decay equation and the late parabolic one.

3. From the results obtained by separate examinations of the disappearance curve of plasma, fibrin clots and serum in rabbits with acute intravascular coagulation induced by injection of Lycopodium spores, the intermediate phase appears to be influenced more by the secondary increase of labelled non-clottable part than recirculation of the labelled fibrinogen.

4. The half time (27.4 hours) of the radioactivity in fibrin clots at the late phase observed in the group of rabbits with acute intravascular coagulation induced by injection of Lycopodium spores was shorter than that in the normal rabbits (50.2 hours). This fact may indicate that the increase of fibrinogen in the group of rabbits with acute intravascular coagulation induced by the injection of Lycopodium spores is due to overproduction of fibrinogen.

5. The half time of labelled fibrinogen should be calculated from disappearance curve of fibrin clots, instead from that of haemolysate or plasma.

Post-acute Rehabilitation for Ataxia Associated with Acute Lithium Toxicity: A Case Report

Background

Acute lithium intoxication is associated with neurological manifestations such as tremor, ataxia, dysarthria, seizures, and in more severe cases encephalopathy and coma; patients experiencing such manifestations require rehabilitation. The authors present a patient who received post-acute rehabilitation for lithium toxicity-associated ataxia.

Case

The patient was a man aged 30 years who had been diagnosed with bipolar disorder more than 10 years ago and had been prescribed lithium carbonate by a psychiatrist. The patient was admitted to the hospital with disturbance of consciousness, and physical therapy began on day 6 of hospitalization. Occupational therapy and speech therapy began on day 15. Physical therapy interventions focused on improving balance and coordination, and occupational therapy focused on improving stability while sitting, upper extremity control, and activities of daily living to improve the Functional Independence Measure motor subscale score. Speech therapy focused on dysarthria. On day 27 of hospitalization, the patient was able to walk 5 m with two Lofstrand crutches and could feed himself without assistance. From day 15 to day 30 of hospitalization, the Scale for the Assessment and Rating of Ataxia score improved from 28 to 19, and the Functional Independence Measure score increased from 25 to 77. On day 31, the patient was discharged to a convalescent rehabilitation hospital.

Discussion

Post-acute rehabilitation for ataxia caused by acute lithium toxicity may improve ataxia and the ability to perform activities of daily living, and therefore may be of benefit.