A case of acquired hemophilia A after pancreaticoduodenectomy for distal cholangiocarcinoma

Acquired hemophilia A (AHA) is a rare disease that results from factor VIII inhibitors causing abnormal coagulation, and certain cases may develop after highly invasive surgery. The present case study reports on a 68-year-old male patient who developed AHA after undergoing a subtotal stomach-preserving pancreatoduodenectomy for distal cholangiocarcinoma. The patient experienced complications after surgery, requiring reoperation on postoperative day (PD) 5 due to rupture of the Braun's enterostomy. On PD 6, angiography was performed after bleeding was detected in the jejunal limb, but hemostasis occurred spontaneously during the examination. Bleeding was observed again on PD 8 and direct surgical ligation was performed. On PD 14, bleeding recurred in the jejunal limb and angiography was performed to embolize the periphery of the second jejunal artery. During the procedure, the prothrombin time was normal, but only the activated partial thromboplastin time was prolonged. A close examination of the coagulation system revealed a decrease in factor VIII levels and the presence of factor VIII inhibitors, resulting in the diagnosis of AHA. Administration of steroids was initiated on PD 15 and, in addition to daily blood transfusions, activated prothrombin complex concentrate was administered to achieve hemostasis. The patient was discharged from the intensive care unit on PD 36 but later developed an intractable labial fistula due to suture failure at the gastrojejunostomy site. As the use of factor VIII inhibitors continued despite the administration of steroids, cyclophosphamide (CPA) pulse therapy was added at PD 58. However, CPA was ineffective and the administration of rituximab was initiated on PD 98. After 12 courses of rituximab, the patient tested negative for factor VIII inhibitors on PD 219. On PD 289, labial fistula closure was performed with continuous replacement of factor VIII and the patient was discharged on PD 342.

Dynamin-related protein 2 interacts with the membrane-associated methyltransferase domain of plantago asiatica mosaic virus replicase and promotes viral replication

Positive-strand RNA viruses replicate their RNA in the viral replication complex, a spherical structure formed by remodeling of host intracellular membranes. This process also requires the interaction between viral membrane-associated replication proteins and host factors. We previously identified the membrane-associated determinant of the replicase of plantago asiatica mosaic virus (PlAMV), a positive-strand RNA virus of the genus Potexvirus, in its methyltransferase (MET) domain, and suggested that its interaction with host factors is required to establish viral replication. Here we identified Nicotiana benthamiana dynamin-related protein 2 (NbDRP2) as an interactor of the MET domain of the PlAMV replicase by co-immunoprecipitation (Co-IP) and mass spectrometry analysis. NbDRP2 is closely related to the DRP2 subfamily proteins in Arabidopsis thaliana, AtDRP2A and AtDRP2B. Confocal microscopy observation and Co-IP confirmed the interaction between the MET domain and NbDRP2. Also, the expression of NbDRP2 was induced by PlAMV infection. PlAMV accumulation was reduced when the expression of NbDRP2 gene was suppressed by virus-induced gene silencing. In addition, PlAMV accumulation was reduced in protoplasts treated with dynamin inhibitor. These results indicate a proviral role of the interaction of NbDRP2 with the MET domain in PlAMV replication.

Evaluation of responses to immunosuppressive therapy in dogs with suspected non-regenerative immune-mediated anaemia: 11 cases (2012-2018)

OBJECTIVES

We aimed to determine the response time to immunosuppressive therapy and time required to achieve a 5% increase in haematocrit among dogs with non-regenerative immune-mediated anaemia.

MATERIALS AND METHODS

Client-owned dogs diagnosed with non-regenerative immune-mediated anaemia in Hokkaido University Veterinary Teaching Hospital between December 2012 and May 2018 were enrolled. The first treatment regimen included prednisolone (2 mg/kg/day) and ciclosporin (up to 10 mg/kg/day) for 8 weeks. Dogs that did not respond to the first regimen proceeded to the second regimen comprising prednisolone and mycophenolate mofetil (15 mg/kg, twice a day). Reticulocyte count and haematocrit were monitored every 1 to 2 weeks. Treatment response was defined as an absolute reticulocyte count more than 60×10³ /μL or increasing haematocrit.

RESULTS

During the study period, 23 dogs fulfilled the inclusion criteria for non-regenerative immune-mediated anaemia. Twelve dogs were excluded from this study for various reasons and response to therapy was evaluated in the remaining 11 dogs. Treatment responses were observed in 8 of 11 dogs, and the median time to response was 39.5 days (range 8 to 92 days). Two responders were unable to continue the first treatment regimen and were switched to the second regimen owing to anorexia and nausea, possibly induced by ciclosporin; withdrawal of ciclosporin improved their symptoms. The time required to achieve a 5% increase in haematocrit was assessed in the other six dogs, with a median of 55.5 days (range 8 to 135 days).

CLINICAL SIGNIFICANCE

Here we report the response to a standardised treatment protocol in dogs with non-regenerative immune-mediated anaemia. Knowledge of potential side effects and expected therapeutic outcomes may be of use for veterinary practitioners treating this condition.

Prognostic value of left atrial stiffness estimated using echocardiography in dogs with myxomatous mitral valve disease

INTRODUCTION

No studies have investigated the prognostic value of left atrial stiffness (LASt) estimated using echocardiography in dogs with myxomatous mitral valve disease (MMVD).

ANIMALS

Seventy-two dogs had MMVD and 46 dogs were healthy dogs.

MATERIALS AND METHODS

Clinical retrospective cohort study. The survival information of MMVD dogs that underwent echocardiographic examination was obtained. The peak velocities of early diastolic transmitral flow (E) and mitral annular motion as determined by pulsed wave Doppler (E') were determined. The left atrial reservoir strain (ε_S) was determined by two-dimensional speckle tracking echocardiography of the left atrium. The LASt was estimated by the formula: E/E'/ε_S. The 95% prediction interval of LASt was computed from the data of the healthy dogs.

RESULTS

Seventeen dogs having MMVD died of cardiac-related causes with 55 MMVD dogs censored. The MMVD dogs with LASt > its 95% upper prediction limit (LASt > 0.56; n = 26; median survival time, 484 days; 95% confidence interval, 283 days-indeterminable) had shorter survival times (P<0.001) than those with LASt ≤ its 95% upper prediction limit (LASt ≤ 0.56; n = 46; median survival time, >1112 days; 95% confidence interval, indeterminable). Multivariable Cox's proportional hazard analysis demonstrated that the ratio of the left atrial dimension to the aortic annulus dimension and LASt were independent predictors of cardiac-related death among conventional echocardiographic indices, ε_S and LASt in MMVD dogs.

CONCLUSIONS

In dogs with MMVD, increased LASt estimated using echocardiography is an independent predictor of cardiac-related death, and LASt can be more useful for prognostication than ε_S.

Cell death signalling is competitively but coordinately regulated by repressor-type and activator-type ethylene response factors in tobacco (Nicotiana tabacum) plants

Ethylene response factors (ERFs) comprise one of the largest transcription factor families in many plant species. Tobacco (Nicotiana tabacum) ERF3 (NtERF3) and other ERF-associated amphiphilic repression (EAR) motif-containing ERFs are known to function as transcriptional repressors. NtERF3 and several repressor-type ERFs induce cell death in tobacco leaves and are also associated with a defence response against tobacco mosaic virus (TMV). We investigated whether transcriptional activator-type NtERFs function together with NtERF3 in the defence response against TMV infection by performing transient ectopic expression, together with gene expression, chromatin immunoprecipitation (ChIP) and promoter analyses. Transient overexpression of NtERF2 and NtERF4 induced cell death in tobacco leaves, albeit later than that induced by NtERF3. Fusion of the EAR motif to the C-terminal end of NtERF2 and NtERF4 abolished their cell death-inducing ability. The expression of NtERF2 and NtERF4 was upregulated at the early phase of N gene-triggered hypersensitive response (HR) against TMV infection. The cell death phenotype induced by overexpression of wild-type NtERF2 and NtERF4 was suppressed by co-expression of an EAR motif-deficient form of NtERF3. Furthermore, ChIP and promoter analyses suggested that NtERF2, NtERF3 and NtERF4 positively or negatively regulate the expression of NtERF3 by binding to its promoter region. Overall, our results revealed the cell death-inducing abilities of genes encoding activator-type NtERFs, including NtERF2 and NtERF4, suggesting that the HR-cell death signalling via the repressor-type NtERF3 is competitively but coordinately regulated by these NtERFs.

Cytological findings of metastatic poorly differentiated prostate adenocarcinoma to Virchow's node with immunohistochemical positivity for CD10 and negativity for PSA

Metastatic prostate adenocarcinoma (PAC) to the left supraclavicular lymph node is extremely rare. We report a case of metastasis of PAC to the left supraclavicular lymph node (known as Virchow's node), focusing on both cytological and immunohistochemical findings. The patient was a 72-year-old Japanese man who was referred to our hospital after initially noticing a lump in the left supraclavicular lymph node 3 months previously. CT revealed multiple swollen lymph nodes in the left supraclavicular fossa, left axilla, abdominal aorta and the bilateral internal and external iliac arteries, but the primary site was not identified. Fine-needle aspiration cytology was performed, revealing a large sheet of cohesive tumor cells with indistinct cell borders, a high nuclear/cytoplasmic ratio, granular cytoplasm, eccentric oval to round nuclei, and enlarged prominent nucleoli. Immunohistochemical examination of cell block sections revealed that the tumor cells were positive for CK AE1/AE3 and CD10 and negative for PSA. Since additional immunohistochemistry revealed that tumor cells were diffusely positive for both NKX3.1 and PSMA, the cytological diagnosis was suspected metastatic PAC. PET CT and MRI suggested the high probability of PAC. Prostate core biopsy was performed and a histological diagnosis of poorly differentiated PAC was made (Gleason score 9 = 5 + 4). The patient started therapy for PAC and the tumors were observed to have shrunk at the 1-year follow-up evaluation. Familiarity with and recognition of the characteristic cytopathological findings of metastasis of PAC to Virchow's node are important for making a correct diagnosis.

More than the half number of the severe CAD patients without features of metabolic syndrome had hyperlipoprotein(a)-emia

Background

It was reported that insulin suppresses apolipoprotein(a) synthesis in primary cultures of cynomolgus monkey hepatocytes (Neele DM. Diabetologia 1999). Therefore, there is a possibility that inverse association exists between lipoprotein(a); Lp(a) and metabolic syndrome (Mets) with insulin resistance/ hyperinsulinemia for the coronary atherosclerosis.

Purpose

The purpose is to examine the association between Lp(a) and Mets on the CAD patients.

Method

847 male subjects with angiographically demonstrated CAD were enrolled. The subjects were divided into the five groups according to the scored numbers by the counting of Mets components shown below (presence 1, absence 0); 1. BMI ≥25kg/m2, 2. comorbidity of hypertension, 3. triglyceride ≥150mg/dL and/or HDL cholesterol &lt;40mg/dL, 4. fasting plasma glucose ≥110mg/dL and/or comorbidity of diabetes mellitus (Group 0; without any Mets components, Group 4; with all Mets component). The insulin levels (μU/mL) and the prevalence of hyperLp(a)-emia (≥30 mg/dL) were compared between in Group 0 and in Group 4. The blood samples for laboratory tests were collected after an over night fast.

Result

As the scored numbers increased, the insulin levels increased (Group 0; 5.1 μU/mL versus Group 4; 11.4 μU/mL: p&lt;0.0001) and the prevalence of hyperlipoprotein(a)-emia decreased (Group 0; 41.6% versus Group 4; 21.4%: p&lt;0.01). The prevalence of hyperLp(a)-emia increased as the severity of coronary atherosclerosis aggravated (Figure 1; one vessel disease 21.5%, two vessel disease 27.0% three vessel disease 32.1%: one vessel disease versus three vessel disease p&lt;0.01). Especially to limited the three vessel disease subjects (Figure 2), the prevalence of hyperlipoprotein(a)-emia in Group 0 was markedly high (56.7%).

Conclusion

More than the half number of severe CAD patients without features of Mets had hyperLp(a)-emia.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Association of common carotid artery measurements with the incidence of hypertension: a retrospective cohort study

Background

Diameter, intima–media thickness (IMT), and flow parameters, including resistance index (RI) and pulsatility index (PI), in the common carotid artery (CCA) are markers of arterial remodeling, atherosclerosis, and vascular resistance, respectively. These CCA parameters have usually been evaluated as markers of target organ damage. Little is known about whether these parameters predict a new onset of hypertension.

Purpose

In this study, we investigated the association of CCA parameters including IMT, diameter, RI, and PI with the incidence of hypertension.

Methods

This is an observational study involving 1249 participants (656 women, mean age 69.6 years) without hypertension, who underwent carotid artery ultrasonography at baseline. The participants were divided into elderly group (defined as age ≥70 years) and a middle-aged group. We defined obesity as BMI ≥25 kg/m2. CCA diameter was defined as the distance between the adventitia–media interface on the near wall and the media–adventitia interface on the far wall. IMT was defined as the distance between the lumen–intima and media–adventitia interfaces. RI was calculated as [peak systolic velocity (PSV)- end-diastolic velocity (EDV)]/PSV. PI was calculated as (PSV-EDV)/Vmean. Larger CCA diameter, increased IMT, high RI, and high PI were determined based on the optimal cutoff values from ROC curve analysis.

Results

Over a mean 5.1-year follow-up period, 524 participants developed hypertension. Multivariate logistic regression analyses showed that larger CCA diameter and increased IMT were significant predicators for incident hypertension in elderly group, but not in middle-aged group. High RI, and high PI were significant predicators for incident hypertension in both the two groups. CCA diameter, IMT, and RI predicted the incidence of hypertension only in nonobesity group, whereas PI predicted it in both obesity and nonobesity groups (Table).

Conclusion

CCA parameters assessed by ultrasonography are useful markers to estimate the risk of hypertension. In particular, PI is a better predictor for the incidence of hypertension.

Funding Acknowledgement

Type of funding sources: None.

Association of adipose tissue insulin resistance and serum free fatty acid levels with the incidence of type 2 diabetes: a retrospective cohort study

Background

Insulin resistance in adipose tissue attenuates the suppression of lipolysis, leading to increased free fatty acid (FFA) release. The excess FFA may be involved in the development of type 2 diabetes.

Purpose

In this study, we investigated the association of adipose tissue insulin resistance and serum free fatty acid levels with the incidence of type 2 diabetes.

Methods

This is an observational study involving 6800 participants (3451 women, mean age 69.2 years) without diabetes who underwent 75-g oral glucose tolerance test (OGTT) at baseline. The participants were divided into the obesity and nonobesity groups on the basis of body mass index of ≥25 and &lt;25 kg/m2, respectively. Serum FFA levels were assessed before and 30, 60, and 120 min after glucose ingestion, and the total area under the FFA curve (AUCFFA) was calculated. Adipose tissue insulin resistance was assessed using adipose insulin resistance index (adipo-IR) calculated based on fasting FFA and insulin concentrations. The homeostasis model assessment of insulin resistance (HOMA-IR), and the Matsuda index were evaluated as measures of insulin resistance in the liver and whole-body, respectively. High adipo-IR, high fasting FFA, great AUCFFA high HOMA-IR, and low Matsuda index were determined based on the optimal cutoff values from ROC curve analysis.

Results

Over a mean 5.3-year follow-up period, 485 participants developed type 2 diabetes. Multivariate logistic regression analyses showed that high adipo-IR was a significant predicator for incident type 2 diabetes in the obesity group, but not in nonobesity group. AUCFFA, HOMA-IR, and Matsuda index were significantly associated with incident type 2 diabetes in both the two groups (Table).

Conclusion

Serum FFA levels after glucose loading predict the incidence of type 2 diabetes. Adipose tissue insulin resistance was associated with the risk of type 2 diabetes in individuals with obesity, but not in individuals without obesity.

Funding Acknowledgement

Type of funding sources: None.

Changes in fears and worries related to COVID-19 during the pandemic among current employees in Japan: a 5-month longitudinal study

Objectives

This study investigates and describes the time course of fears and worries about COVID-19 among current employees during this outbreak.

Study design

This was a longitudinal study.

Methods

This study was a part of the Employee Cohort Study in Japan. The study comprised 4120 individuals from February 2019. A baseline survey in March 2020, a 2-month follow-up survey in May 2020, and a 5-month follow-up survey in August 2020 were conducted. Questions surveyed respondents’ global fear and worry and six items related to COVID-19. A mixed model for repeated measures of an analysis of variance was used.

Results

A total of 1421 respondents completed the baseline survey. At 2- and 5-month follow-ups, 1032 and 1181 respondents completed surveys, respectively. Of those, 64 and 33 individuals who were temporarily laid off or on leave were recorded as missing values. Global fear and worry about COVID-19 significantly increased from March to August 2020. Fears of personal or family infection, limiting one's activities and national and local government policies also significantly increased with time. In contrast, fears of lack of knowledge and difficulty of obtaining hygiene products significantly decreased.

Conclusion

To conduct efficient risk communication during a pandemic, knowing the concerns of the populace, providing correct information and a sufficient supply of products, and setting clear guidelines are essential.

Chronic Kidney Disease, Gut Dysbiosis, and Constipation: A Burdensome Triplet

Gut dysbiosis has been implicated in the progression of chronic kidney disease (CKD). Alterations in the gut environment induced by uremic toxins, the dietary restriction of fiber-rich foods, and multiple drugs may be involved in CKD-related gut dysbiosis. CKD-related gut dysbiosis is considered to be characterized by the expansion of bacterial species producing precursors of harmful uremic toxins, such as indoxyl sulfate and p-cresyl sulfate, and the contraction of species generating beneficial short-chain fatty acids, such as butyrate. Gut-derived uremic toxins cause oxidative stress and pro-inflammatory responses, whereas butyrate exerts anti-inflammatory effects and contributes to gut epithelial integrity. Gut dysbiosis is associated with the disruption of the gut epithelial barrier, which leads to the translocation of endotoxins. Research on CKD-related gut dysbiosis has mainly focused on chronic inflammation and consequent cardiovascular and renal damage. The pathogenic relationship between CKD-related gut dysbiosis and constipation has not yet been investigated in detail. Constipation is highly prevalent in CKD and affects the quality of life of these patients. Under the pathophysiological state of gut dysbiosis, altered bacterial fermentation products may play a prominent role in intestinal dysmotility. In this review, we outline the factors contributing to constipation, such as the gut microbiota and bacterial fermentation; introduce recent findings on the pathogenic link between CKD-related gut dysbiosis and constipation; and discuss potential interventions. This pathogenic link needs to be elucidated in more detail and may contribute to the development of novel treatment options not only for constipation, but also cardiovascular disease in CKD.

Pharmacological inhibition of C-C chemokine receptor 4 aggravates atherosclerosis through prevention of regulatory T cell recruitment to the lesions

Background

Regulatory T cells (Tregs) are demonstrated to play a protective role in the development of atherosclerosis. However, their sites of action in atherosclerosis remain unclear. Although C-C chemokine receptor 4 (CCR4) has been shown to contribute to the accumulation of Tregs in inflamed tissues and prevention of experimental autoimmune diseases, the role of CCR4 in Treg migration to atherosclerotic lesions and suppression of plaque formation remains unknown.

Methods and results

We intraperitoneally injected 8-week-old apolipoprotein E–deficient mice fed a normal diet with vehicle (n=9) or a 4-μg dose of a CCR4 antagonist (n=10) 3 times weekly for 8 weeks and evaluated atherosclerotic lesions at 16 weeks old. Administration of the CCR4 antagonist significantly aggravated atherosclerotic plaque formation (aortic sinus plaque area: 2.91±0.87×104 μm2 versus 5.41±0.98×104 μm2 in control vehicle-treated and CCR4 antagonist-treated mice, respectively; P&lt;0.05), associated with increased accumulation of macrophages and CD4+T cells in the plaques. Flow cytometric analysis revealed a decrease in Foxp3+ Tregs in the para-aortic lymph nodes and thoracoabdominal aortas of CCR4 antagonist-treated mice, along with a tendency toward increase in CD44highCD62Lloweffector T cells in para-aortic lymph nodes, indicating CCR4-dependent migration of Tregs to atherosclerotic lesions and their possible atheroprotective role. We observed no changes in splenic Foxp3+ Tregs and effector T cells following CCR4 antagonist treatment. We also investigated the effect of CCR4 blockade on advanced atherosclerosis using LDL receptor–deficient mice fed a high-cholesterol diet. Although 8-week treatment with the CCR4 antagonist led to a decrease in Foxp3+ Tregs in the atherosclerotic lesions, atherosclerotic lesion formation was not significantly affected, suggesting that CCR4-dependent Treg accumulation in atherosclerotic lesions is not critical for prevention of advanced atherosclerosis.

Conclusions

Our findings indicate an important role for CCR4 in promotion of Treg recruitment into atherosclerotic lesions and subsequent prevention of early atherosclerosis and suggest CCR4 as a novel therapeutic target for atherosclerosis.

Funding Acknowledgement

Type of funding source: None

Delayed hyperenhancement obtained by non-contrast computed tomography following coronary angiography in patients of extracorporeal cardiopulmonary resuscitation

Background/Introduction

Extracorporeal cardiopulmonary resuscitation (ECPR) has been reported to improve survival and neurologic outcome as compared to conventional CPR in refractory cardiac arrest. Although prognostic factors of these patients have been reported, predicting of outcome is difficult in real world. Recently, early evaluation of myocardial viability in acute myocardial infarction by non-contrast computed tomography (CT) post coronary angiography (CAG) has been reported. And myocardial contrast delayed enhancement obtained by this method related to higher risk of cardiac events. However, few studies have reported delayed enhancement on left ventricular wall findings in non-contrast CT after CAG in terms of patients performed ECPR.

Purpose

To investigate the impact of delayed hyperenhancement obtained by non-contrast CT following CAG in patients performed ECPR.

Methods

We investigated 79 patients treated by ECPR for refractory cardiac arrest regardless of whether in-hospital or out-hospital in our institute from Apr 2009 to Feb 2018. Thirty-two in these patients received non-contrast CT following CAG with ECPR were enrolled. All ECPR cases underwent VA-ECMO in the catheter laboratory using percutaneous procedure while maintaining conventional CPR. Non-ECG-gated and non-contrast CT was performed using a 64-row multidetector CT scanner.

Results

Survival rate was 18.8% in this cohort. There was no significant difference between survive and in-hospital death group in terms of patient characteristics, clinical time courses, initial blood samples and procedure characteristics. Only delayed hyperenhancement showed significant difference between 2 groups (p=0.04). All delayed hyperenhancements were detected in only in-hospital death group. Delayed hyperenhancement was detected in 12 cases (37.5%). Initial shockable rhythm was less common in cases with delayed hyperenhancement. Cardiac death tended to be more frequent in patients with delayed hyperenhancement. The major causes of death were bleeding (41.7%) and heart failure (33%).

Conclusion(s)

Delayed hyperenhancement in patients treated ECPR was strong predictor of in-hospital death.

Image of delayed hyperenhancement

Funding Acknowledgement

Type of funding source: None

FRI0497 THERAPEUTIC STRATEGIES AND LONG-TERM OUTCOME IN PATIENTS WITH INTERSTITIAL PNEUMONIA WITH AUTOIMMUNE FEATURES: A SINGLE CENTER LARGE-SCALE OBSERVATIONAL COHORT STUDY

Background:

Patients with idiopathic interstitial pneumonia (IIP) may have features of connective tissue diseases (CTDs). The term interstitial pneumonia with autoimmune features (IPAF) has been recently proposed for such patients [1]. To date, only few studies have comprehensively described outcomes over a long-term period and choices of treatment [2-4].

Objectives:

The aim of this study was to investigate the therapeutic strategies and long-term outcome among patients with IPAF, IIP, and CTD-ILD.

Methods:

Six hundreds- and seventy-two patients who had visited our department between April 2009 and March 2019 and were evaluated by chest HRCT scan. They were clinically and radiologically diagnosed as having interstitial lung disease (ILD), including IIP, CTD-ILD, undifferentiated connective tissue diseases associated ILD or other ILD. Then, we applied IPAF criteria to these patients, 68 patients were diagnosed as IPAF. We extracted the treated patients from IPAF patients. Then, the treated patients were divided into two groups, which were treated with monotherapy (glucocorticoid: GC) and with combination therapy (GC and immunosuppressant: IS). Clinical, laboratory and imaging data were collected from medical records and statistically analyzed.

Results:

Proportion of treatment received patients with IPAF, IIP, or CTD-ILD was 44.1%, 28.1%, and 88.0%, respectively. Then we compared long-term outcomes among patients with IPAF, IIP, and CTD-ILD, 5-year non-exacerbation rate in IPAF patients, IIP patients, and CTD-ILD patients was 53.7%, 28.3%, and 59.5%, respectively (Figure 1.). No significant difference between IPAF and CTD-ILD group was found (P=0.71). Next, we focused on IPAF and compared characteristics at diagnosis between the treatment group (n=30) and non-treatment group (n=38) in patients with IPAF. Interestingly, treatment group was significantly associated with signs of mechanic’s hands, arthritis, anti-SS-A antibody positivity, and anti-ARS antibody positivity (P=0.009, 0.05, 0.05, and 0.007). Among the treatment group, GC monotherapy was received in 46.7% (n=14), whereas GC+IS combination therapy group was 50% (n=15). When we compared long-term outcomes between two groups, 3-year non-exacerbation rate was 70.1%, 43.5%, and 83.3% (Figure 2.). No significant difference was not seen between two different treatment groups (P=0.24).

Conclusion:

Our large-scale cross-sectional cohort study identified that the prognosis of IPAF patients was poor as same as that of CTD patients, and even though GC mono or GC+IS combination treatment was applied for IPAF patients, prognosis was still poor and thus new intervention for IPAF should be needed to improve their prognosis.

References:

[1]Eur Respir J. 2016; 47:1622–1624,

[2]J Rheumatol. 2013; 40:640-646,

[3]Respirology. 2019 Aug 6,

[4]Autoimmun Rev. 2019 Dec 12

Disclosure of Interests:

Okinori Murata: None declared, Katsuya Suzuki: None declared, Nobuhito Sasaki: None declared, Tsutomu Takeuchi Grant/research support from: Eisai Co., Ltd, Astellas Pharma Inc., AbbVie GK, Asahi Kasei Pharma Corporation, Nippon Kayaku Co., Ltd, Takeda Pharmaceutical Company Ltd, UCB Pharma, Shionogi & Co., Ltd., Mitsubishi-Tanabe Pharma Corp., Daiichi Sankyo Co., Ltd., Chugai Pharmaceutical Co. Ltd., Consultant of: Chugai Pharmaceutical Co Ltd, Astellas Pharma Inc., Eli Lilly Japan KK, Speakers bureau: AbbVie GK, Eisai Co., Ltd, Mitsubishi-Tanabe Pharma Corporation, Chugai Pharmaceutical Co Ltd, Bristol-Myers Squibb Company, AYUMI Pharmaceutical Corp., Eisai Co., Ltd, Daiichi Sankyo Co., Ltd., Gilead Sciences, Inc., Novartis Pharma K.K., Pfizer Japan Inc., Sanofi K.K., Dainippon Sumitomo Co., Ltd., Makoto Maemondo: None declared

Predictors of Cerebral Aneurysm Rupture after Coil Embolization: Single-Center Experience with Recanalized Aneurysms

BACKGROUND AND PURPOSE

Recanalization after coil embolization is widely studied. However, there are limited data on how recanalized aneurysms rupture. Herein, we describe our experience with the rupture of recanalized aneurysms and discuss the type of recanalized aneurysms at greatest rupture risk.

MATERIALS AND METHODS

A total of 426 unruptured aneurysms and 169 ruptured aneurysms underwent coil embolization in our institution between January 2009 and December 2017. Recanalization occurred in 38 (8.9%) of 426 unruptured aneurysms (unruptured group) and 37 (21.9%) of 169 ruptured aneurysms (ruptured group). The Modified Raymond-Roy classification on DSA was used to categorize the recanalization type. Follow-up DSA was scheduled until 6 months after treatment, and follow-up MRA was scheduled yearly. If recanalization was suspected on MRA, DSA was performed.

RESULTS

In the unruptured group, the median follow-up term was 74.0 months. Retreatment for recanalization was performed in 18 aneurysms. Four of 20 untreated recanalized aneurysms (0.94% of total coiled aneurysms) ruptured. In untreated recanalized aneurysms, class IIIb aneurysms ruptured significantly more frequently than class II and IIIa (P = .025). In the ruptured group, the median follow-up term was 28.0 months. Retreatment for recanalization was performed in 16 aneurysms. Four of 21 untreated recanalized aneurysms (2.37% of total coiled aneurysms) ruptured. Class IIIb aneurysms ruptured significantly more frequently than class II and IIIa (P = .02).

CONCLUSIONS

The types of recanalization after coil embolization may be predictors of rupture. Coiled aneurysms with class IIIb recanalization should undergo early retreatment because of an increased rupture risk.

Claspin overexpression is associated with high-grade histology and poor prognosis in renal cell carcinoma

Renal cell carcinoma (RCC) is one of the most common human cancers. We previously reported that claspin is a key regulator in the progression of gastric cancer, and it likely plays an important role in cancer stem cells of gastric cancer. However, the significance of claspin in RCC has not been examined. First, we analyzed the expression and distribution of claspin in 95 RCC cases by immunohistochemistry. In the nonneoplastic kidney, the staining of claspin was either weak or absent, whereas RCC tissue showed nuclear staining. In total, claspin expression was detected in 45 (47%) of 95 RCC cases. The claspin staining appeared relatively stronger in high nuclear grade RCC than in low nuclear grade RCC. Claspin-positive RCC cases were associated with higher T grade, tumor stage, nuclear grade, vein invasion, and poorer prognosis. CLSPN siRNA treatment decreased RCC cell proliferation. The levels of phosphorylated Erk and Akt were lower in CLSPN siRNA-transfected RCC cells than in control cells. In addition, claspin was coexpressed with CD44, epidermal growth factor receptor, p53, and programmed death ligand-1. These results suggest that claspin plays an important role in tumor progression in RCC and might be a prognostic marker and novel therapeutic target molecule.

P4403Sleep quality is associated with visit-to-visit blood pressure variability in elderly people

Background

The proportion of people suffering from poor sleep quality increases with age. Several studies reported that poor sleep quality is involved in elevation of blood pressure (BP) level and the development of hypertension. However, it is unclear whether sleep quality is associated with visit-to-visit BP variability, which is related to the incident cardiovascular disease independent of mean BP.

Purpose

In this study, we investigated the association between sleep quality and visit-to-visit BP variability in elderly people.

Methods

This is an observational study involving 3313 participants without atrial fibrillation, aged 68 years or older, who underwent assessment of sleep quality at general health examination between October 2014 and September 2015, and had more than four visits during the first 3 years following the assessment. Of these, 1951 participants (59%) had hypertension, 488 (17%) had diabetes, 432 (13%) had dyslipidemia, and 333 (10%) were on treatment for, or with a history of, cardiac disease. Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI), which yields seven component scores (0, 1, 2, or 3 is given for each component). A sum of the seven scores was used to calculate the global PSQI score which ranged from 0 to 21. Higher scores indicated poorer sleep quality. Visit-to-visit BP variability for each individual was evaluated by coefficient of variation (CV, defined as standard deviation/mean).

Results

The mean global PSQI score was 5.2±3.2. The mean CV of SBP and CV of DBP was 6.9±3.0, and 8.0±3.5, respectively. The global PSQI score was significantly associated with CV of SBP (ρ= 0.039, P=0.025), and CV of DBP (ρ= 0.039, P=0.024) in Spearman's rank correlation coefficient test. Multiple regression analyses showed that the global PSQI score was a significant contributor to CV of SBP, and CV of DBP, after adjusting for variables with P values <0.1 in Spearman's test (Table).

Table 1. Multiple regression analysis for blood pressure variability (n=3313) Variables CV of SBP CV of DBP β P β P Age 0.131 <0.001 0.140 <0.001 Female −0.017 0.338 0.023 0.186 Hypertension 0.037 0.032 0.031 0.073 Cardiac disease 0.045 0.009 0.038 0.030 Global PSQI score 0.035 0.042 0.047 0.007

Conclusion

Sleep quality is associated with visit-to-visit BP variability in elderly people.

1436Overexpression of Cytotoxic T-Lymphocyte Associated Antigen-4 suppresses aortic immunoinflammatory responses and prevents angiotensin II-induced abdominal aortic aneurysm formation in mice

Aims

Vascular inflammation via T-cell-mediated immune responses has been shown to be critically involved in the pathogenesis of abdominal aortic aneurysm (AAA). T-cell coinhibitory molecule cytotoxic T-lymphocyte–associated antigen-4 (CTLA-4) is known to act as a potent negative regulator of immune responses. However, the role of this molecule in the development of AAA remains completely unknown. In the present study, we determined the effects of CTLA-4 overexpression on experimental AAA.

Methods and results

We continuously infused 12-week-old CTLA-4 transgenic (CTLA-4-Tg)/apolipoprotein E–deficient (Apoe−/−) mice (n=35) or control Apoe−/− mice (n=40) fed a high-cholesterol diet with angiotensin II by implanting osmotic mini-pumps and evaluated the development of AAA. Ninety percent of angiotensin II-infused mice developed AAA, with 50% mortality because of aneurysm rupture. Overexpression of CTLA-4 significantly reduced the incidence (66%), mortality (26%), and diameter (18%) of AAA (incidence: P=0.0104; mortality: P=0.031; diameter: P=0.011). These protective effects were associated with a decreased number of effector CD4+ T cells and the downregulated expression of costimulatory molecules CD80 and CD86, ligands for CTLA-4, on CD11c+ dendritic cells in lymphoid tissues. In addition, by performing in situ zymography of the abdominal aortic aneurysm lesions, we observed a trend toward a decrease in MMP activity in the aneurysmal lesion following overexpression of CTLA-4. Finally, CTLA-4-Tg/Apoe−/− mice had reduced macrophage and CD4+ T cell accumulation and MMP activity in the aneurysmal lesion, leading to attenuated aortic inflammation, preserved vessel integrity, and decreased susceptibility to AAA and aortic rupture.

Conclusion

Our findings suggest that CTLA-4 protects against AAA by suppressing immunoinflammatory responses and could be an attractive therapeutic target for AAA.

P6366High blood pressure cut-off by 130/80 mmHg in middle-ages may be valid for predicting heart failure in ages of seventies

Background

ESC/ESH Guidelines (2018) recommended that treated BP values should be targeted to 130/80 mmHg or lower in most patients. However, it remains unclear whether this target in middle-aged population is associated with future development of heart failure.

Purpose

We conducted a retrospective analysis to determine whether high blood pressure cut-off by 130/80 mmHg in the middle-age predicts the risk of heart failure, detected by high N-terminal pro-brain natriuretic peptide (NT-proBNP) level, in the elderly in a cohort in which longitudinal blood pressure records exist.

Methods

The cohort consists of health check examinee who consulted the examination institute between 2015 and 2018 (n=8513), aged 70 years or older, and had previous institution-visit record at least once from 50 to 69 years old. We measured serum NT-proBNP level in the all examinee and defined the group of high NT-proBNP as ≥144 pg/ml [defined as the highest quartile, n=2135 (25%)]. The number of participants whose previous blood pressure records exists was 8123 (95%) for 65–69 years old, 6980 (82%) for 60–64 years old, 5233 (61%) for 55–59 years old, and 3018 (35%) for 50–54 years old, respectively. The each generation subgroups were divided into the three gradual categories according to the blood pressure records: SBP ≥140 and/or DBP ≥90, SBP130–139 and/or DBP80–89, and SBP <130 and DBP <80 mmHg.

Results

Categorization to high NT-proBNP group in ages of 70 or more was significantly associated with the categorization to high blood pressure, which was not only the SBP ≥140 and/or DBP ≥90 mmHg but also the SBP130–139 and/or DBP80–89 mmHg at any time points of previous blood pressure measurements. The multivariable adjusted odds ratios for having high NT-proBNP level in the elderly against the two high blood pressure categories based on the previous blood pressure measurements were shown in the Table.

Table 1. Multivariable adjusted OR for high NT-proBNP level in elderly Age N SBP 130–139 and/or DBP 80–89 SBP ≥140 and/or DBP ≥90 OR P OR P 65–69 8123 1.30 <0.001 1.68 <0.001 60–64 6980 1.26 0.002 1.55 <0.001 55–59 5233 1.25 0.013 1.41 <0.001 50–54 3018 1.32 0.023 1.58 <0.001 Model included age, gender, BMI, serum creatinine, hemoglobin, and presence of antihypertensive medications, and cardiac disease.

Conclusion

High blood pressure cut-off by 130/80 mmHg in the middle-age may be valid to predict the risk of heart failure in the elderly.

Epidemiology of massive hepatocellular carcinoma in dogs: A 4-year retrospective study

Hepatocellular carcinoma (HCC) is the most common primary liver tumour in dogs. However, the clinical features and risk factors of HCC have not been confirmed. The objective of this study was to investigate the clinical features and risk factors for canine HCC. Medical records of 44 dogs diagnosed with HCC at Hokkaido University Veterinary Teaching Hospital between 2013 and 2017 were retrospectively reviewed. All dogs evaluated at the teaching hospital during the study period were used as the reference population for breed, age, sex predispositions or possible related factors for HCC, including concurrent disorders. Clinical characteristics of HCC were determined using propensity score matching analysis. The prevalence of HCC diagnosis was 0.96%. Multivariate analysis revealed that dogs diagnosed with HCC were significantly older (odds ratio [OR], 1.20; 95% confidence intervals [CI], 1.07-1.33) than the reference population. Welsh Corgis (OR, 3.68; 95% CI, 1.56-8.67) and Beagles (OR, 4.33; 95% CI, 1.58-11.90) were significantly predisposed to HCC. Twenty-seven of 44 dogs with HCC had at least one concurrent disorder. The most common concurrent disorder was hyperadrenocorticism (n = 10), and the adjusted odds of hyperadrenocorticism in dogs with HCC were 4.13 higher than those of the reference population (95% CI, 1.95-8.76). Propensity score matching analysis revealed that thrombocytosis (n = 30/43), increased alanine aminotransferase (n = 41/44), increased alkaline phosphatase (n = 42/44), and hypercalcemia (n = 13/32) were significantly associated with HCC diagnosis. The results of this study suggest that Welsh Corgis and Beagles are breeds with a predisposition for HCC and that hyperadrenocorticism might be a potential risk factor.

The Repeatability and Left Atrial Strain Analysis Obtained via Speckle Tracking Echocardiography in healthy Dogs

INTRODUCTION

In left atrial (LA) strain-derived two-dimensional speckle tracking echocardiography, the reference intervals in healthy dogs can provide useful information to evaluate the LA function in dogs with heart disease.

ANIMALS

Six laboratory beagles and 120 privately owned dogs without cardiac diseases were recruited.

MATERIALS AND METHODS

The LA strain and strain rate (SR) and echocardiographic indices were obtained in dogs who underwent standard echocardiography and offline analysis for LA strain and SR measurement by speckle tracking echocardiography.

RESULTS

The intra-observer within-day variations of strain variables showed adequate repeatability (coefficient of variation <20%). The mean values of strain were 25.37 for the LA reservoir function, 11.06 for the LA conduit function, and 14.17 for the LA booster-pump function; the strain was significantly correlated with the LA fractional volume change at each phasic function. The left atrial longitudinal strain during early ventricular diastole showed moderate correlation with the peak velocity of early diastolic transmitral flow (r = 0.5560) and ratio of peak velocity of early diastolic transmitral flow to peak velocity of late transmitral flow (r = 0.5515). In multiple regression analysis, only age was significantly related to the strain/SR and volumetric change indices, indicating conduit function.

CONCLUSIONS

Left atrial speckle tracking echocardiographic analysis provided useful information to assess the LA function in healthy dogs. The influencing factors on strain and SR variables including the age, body weight, and heart rate should be considered in interpretation of these parameters in a clinical setting.

Endoscopic submucosal dissection followed by chemoradiotherapy for superficial esophageal cancer: choice of new approach

Background

The standard treatment for superficial esophageal cancer (SEC) involving muscularis mucosal (T1a-MM) or submucosal (T1b) invasion has been the surgical resection of the esophagus. However, esophagectomy with extended lymph node dissection is highly invasive. Recent reports have shown that endoscopic submucosal dissection (ESD) followed by chemoradiotherapy (CRT) has promising results and might become a new therapeutic approach. This retrospective study aimed to elucidate the efficacy and safety of this new treatment.

Methods

Patients with clinical stage T1b tumor without apparent metastasis treated with ESD followed by CRT from 2014 to 2017 (the CRT group) were included. The outcomes on disease-free survival (DFS) of this group were compared with those of consecutive patients in a historical control group who underwent ESD followed by esophagectomy (the esophagectomy group) between 2008 and 2015.

Results

Of 32 patients analyzed, 16 were in the CRT group and 16 with similar stage cancer were in the esophagectomy group. Radiotherapy was completed in all patients, and the incidence of grade ≥ 3 nonhematologic adverse events was 6%. The 2-year overall survival rates were 100%, and locoregional control was achieved in all patients in the CRT group, and the 2-year DFS rates were 88 and 100% for the CRT and esophagectomy groups, respectively, without significant differences.

Conclusions

Our data confirmed our new approach as being safe and effective for locoregional control and may provide a nonsurgical treatment option for patients with clinical stage T1b tumors.

Clinicopathological significance of claspin overexpression and its association with spheroid formation in gastric cancer

Gastric cancer (GC) is one of the leading causes of cancer-related death worldwide. Spheroid colony formation is a useful method to identify cancer stem cells (CSCs). The aim of this study was to identify a novel prognostic marker or therapeutic target for GC using a method to identify CSCs. We analyzed the microarray data in spheroid body-forming and parental cells and focused on the CLSPN gene because it is overexpressed in the spheroid body-forming cells in both the GC cell lines MKN-45 and MKN-74. Quantitative reverse-transcription polymerase chain reaction analysis revealed that CLSPN messenger RNA expression was up-regulated in GC cell lines MKN-45, MKN-74, and TMK-1. Immunohistochemistry of claspin showed that 94 (47%) of 203 GC cases were positive. Claspin-positive GC cases were associated with higher T and N grades, tumor stage, lymphatic invasion, and poor prognosis. In addition, claspin expression was coexpressed with CD44, human epidermal growth factor receptor type 2, and p53. CLSPN small interfering RNA treatment decreased GC cell proliferation and invasion. These results indicate that the expression of claspin might be a key regulator in the progression of GC and might play an important role in CSCs of GC.

Comparison of radiation dermatitis between hypofractionated and conventionally fractionated postoperative radiotherapy: objective, longitudinal assessment of skin color

This study aimed to quantitatively compare radiation dermatitis due to hypofractionated (Hypo) and conventionally fractionated (Conv) external-beam radiotherapy in patients who underwent postoperative radiotherapy after breast-conserving surgery. Skin color changes, in terms of L* (brightness, white-black), a* (red-green), and b* (yellow-blue) values, due to external-beam radiotherapy were examined at alternate fractions using an objective method. Twenty-six patients were included in the Hypo group (42.56 Gy/16 fractions) and 46 in the Conv group (50 Gy/25 fractions). Radiotherapy decreased the L* value (darker) and increased the a* value (redder) gradually. These color alterations progressed linearly according to elapsed fractions and were similar between Hypo and Conv per fraction. The Hypo group showed significantly milder alterations in L* and a* values than the Conv group. The maximal dosage was significantly correlated to alterations in L* and a* values. Common Terminology Criteria for Adverse Events v4 assessment did not show a statistically significant difference between the Hypo (Grade 0:1:2 = 2:24:1) and Conv (1:39:6, p = 0.25) groups. The results of our objective analysis revealed that patients undergoing Hypo show milder color alteration than those undergoing Conv and that the maximal dosage is a useful predicator of color alteration.

Palliative Reirradiation for Painful Bone Metastases: Clinical Cases and Literature Review

Reirradiation to previously irradiated peripheral bone metastases for pain has been shown to be safe and effective, but no specific trial has been completed to define the indications for reirradiation of patients with recurrent symptoms of metastatic bone disease. Thus, we aimed to assess the effectiveness and prognostic factors of reirradiation for painful bone metastases. To do so, we reviewed the cases of 14 patients with painful bone metastases who had undergone reirradiation at our hospital. A favorable pain response after reirradiation was achieved in 50% (7/14) of the patients. An interval from initial radiotherapy >6 months was a significant prog nostic factor for pain response (p = 0.03). Performance status was correlated with pain response, with borderline significance (p = 0.06). No severe adverse events were reported. We conclude that reirradiation of painful bone metastases is effective in providing pain relief, especially for patients with a long interval from initial radiation and good performance status.

Pharmacological and Model-based Interpretation of Neuronal Dynamics Transitions during Sleep-Waking Cycle

Power spectral analysis has been applied to spontaneous single neuronal activities during the sleep-waking cycle in various regions of the cat’s central nervous system. During slow-wave sleep (SWS), the spontaneous activities of many neurons had a white noise-like power-spectral density profile in a very low frequency range (0.01-1.0 Hz) whereas, during rapid-eye-movement sleep (REMS), they showed a 1/f-like spectral pattern. This spectral transition between SWS and REMS was hypothesized to depend on the influence of serotonergic and cholinergic neuronal activity which is considered to modulate various brain functions. According to both pharmacological experiments and simulation studies with a neural network model, it was concluded that the serotonergic system may have a function to eliminate slow fluctuations in neuronal activity in wide areas, from the reticulothalamo-neocortical to the limbic systems. Consequently, simple signal processing of spontaneous neuronal activity has elucidated an important neurophysiological fact, which may lead to a principle of the basic brain function and its mechanism.

Long-term Outcomes of a Dose-reduction Trial to Decrease Late Gastrointestinal Toxicity in Patients with Prostate Cancer Receiving Soft Tissue-matched Image-guided Intensity-modulated Radiotherapy

BACKGROUND/AIM

We experienced an unexpected high incidence of gastrointestinal (GI) toxicity in patients undergoing image-guided intensity-modulated radiotherapy (IG-IMRT) using helical tomotherapy in our initial 2.2 Gy/fraction schedule for prostate cancer; hence, a dose-reduction trial from 2.2 Gy to 2 Gy/fraction was conducted using modified planning target volume (PTV) contouring.

PATIENTS AND METHODS

We compared 130 patients treated using 2.2 Gy/fraction (Group A) and 144 treated using the 2 Gy/fraction (Group B) with modified PTV (excluding rectal volume) with a median follow-up period of 62 months. Prescribed dose was 72.6-74.8 Gy in 33-34 fractions (Group A) and 72-74 Gy in 36-37 fractions (Group B).

RESULTS

Patients in Group B had a reduced rectal and bladder V10-V70 and were irradiated at the maximal dose. Their cumulative incidence of grade ≤2 GI toxicity at 5 years improved from 10.1% [95% confidence interval (CI), 4.9-15.3%] to 1.4% (0-3.3%). Grade 2≤ urinary toxicity also decreased from 5.5% (1.5-9.4%) in Group A to 1.4% (0-3.3%, p=0.0167) in Group B. The biochemical failure-free 5-year survival rate was 89.1% (95%CI=83.6-95.4%) and 87.5% (82.0-92.9%, p=0.75) in groups A and B, respectively.

CONCLUSION

The reduced dose fraction schedule decreased the incidence of late GI toxicity without compromising prostate-specific antigen control. Careful target volume definition and fraction size are important even for IG-IMRT.

Small amounts of ethanol attenuate folic acid stability in acidic beverages during storage

Folic acid (FA) is an essential compound involved in important biochemical processes and is used to fortify various food products. FA in fortified acidic beverages decomposes during storage due to H+ attack. FA stability in acidic beverages is a serious problem as food fortification should guarantee labeled FA concentrations until the expiry date. In this study, we investigated the influence of ethanol (EtOH) on FA depletion using a model acidic beverage and observed that small amounts of EtOH, derived from added flavor, promoted FA depletion. FA depletion was promoted by only small amounts of EtOH, but not by acetonitrile. This suggested that FA decomposition might be accelerated by EtOH, which surrounds FA molecules in solution due to selective solvation. In the development of FA-fortified beverages, EtOH content should be decreased or removed altogether, to prevent accelerating FA decomposition.

Transcranial Doppler Ultrasound Examination in Dogs with Suspected Intracranial Hypertension Caused by Neurologic Diseases

Background

Transcranial Doppler ultrasound examination (TCD) is a rapid, noninvasive technique used to evaluate cerebral blood flow and is useful for the detection of intracranial hypertension in humans. However, the clinical usefulness of TCD in diagnosing intracranial hypertension has not been demonstrated for intracranial diseases in dogs.

Objectives

To determine the association between the TCD variables and intracranial hypertension in dogs with intracranial diseases.

Animals

Fifty client‐owned dogs with neurologic signs.

Methods

Cross‐sectional study. All dogs underwent TCD of the basilar artery under isoflurane anesthesia after magnetic resonance imaging (MRI). Dogs were classified into 3 groups based on MRI findings: no structural diseases (group I), structural disease without MRI evidence of intracranial hypertension (group II), and structural disease with MRI evidence of intracranial hypertension (group III). The TCD vascular resistance variables (resistive index [RI], pulsatility index [PI], and the ratio of systolic to diastolic mean velocity [Sm/Dm]) were measured.

Results

Fifteen, 22, and 13 dogs were classified into groups I, II, and III, respectively. Dogs in group III had significantly higher Sm/Dm (median, 1.78; range, 1.44–2.58) than those in group I (median, 1.63; range, 1.43–1.75) and group II (median, 1.62; range, 1.27–2.10). No significant differences in RI and PI were identified among groups.

Conclusions and Clinical Importance

Our findings suggest that increased Sm/Dm is associated with MRI findings of suspected intracranial hypertension in dogs with intracranial diseases and that TCD could be a useful tool to help to diagnose intracranial hypertension.

Local field radiotherapy without elective nodal irradiation for postoperative loco-regional recurrence of esophageal cancer

Background

Radiotherapy is an effective treatment for the postoperative loco-regional recurrence of esophageal cancer; however, the optimal treatment field remains controversial. This study aims to evaluate the outcome of local field radiotherapy without elective nodal irradiation for postoperative loco-regional recurrence of esophageal cancer.

Methods

We retrospectively investigated 35 patients treated for a postoperative loco-regional recurrence of esophageal cancer with local field radiotherapy between December 2008 and March 2016. The median irradiation dose was 60 Gy (range: 50-67.5 Gy). Thirty-one (88.6%) patients received concurrent chemotherapy.

Results

The median follow-up period was 18 months (range: 5-94 months). The 2-year overall survival was 55.7%, with a median survival time of 29.9 months. In the univariate analysis, the maximal diameter ≤20 mm (P = 0.0383), solitary lesion (P = 0.0352), and the complete remission after treatment (P = 0.00411) had a significantly better prognosis. A total of 27 of 35 patients (77.1%) had progressive disease (loco-regional failure [n = 9], distant metastasis [n = 7], and both loco-regional failure and distant metastasis [n = 11]). No patients had Grade 3 or greater mucositis.

Conclusion

Local field radiotherapy is a considerable treatment option for postoperative loco-regional recurrence of esophageal cancer.

Clinical Usefulness of the Platelet-to Lymphocyte Ratio in Patients with Angiosarcoma of the Face and Scalp

Angiosarcoma of the face and scalp (ASFS) is an extremely aggressive tumor that frequently metastasizes, often leading to death. The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR) are inflammatory markers that predict outcome of various cancers. We aimed to examine the relationship between pretreatment inflammatory markers and ASFS outcome. We included 17 patients with ASFS and a control group of 56 age- and gender-matched healthy individuals. Total white blood counts, neutrophil, lymphocyte, monocyte, and platelet counts were recorded; NLR, PLR, and LMR were calculated. Kaplan–Meier curves were used to calculate overall survival (OS) and distant metastasis-free survival (DMFS). Optimal cut-off values for each inflammatory marker were calculated using receiver operating curve analysis. Median follow-up was 22 months (range, 6–75). There was a statistically significant difference in absolute neutrophil counts and NLR between patient and control groups. Two-year OS and DMFS rates were 41% and 35%, respectively. In patients with tumors < 10 cm, PLR was highly correlated with DMFS, with the 2-year DMFS for those with a high PLR being 50% compared with 100% for those with a low PLR (p = 0.06). This study suggests that PLR is superior to NLR and LMR, and is a clinically useful marker in patients with ASFS with small tumors.

Interfractional Rectal Displacement Requiring Repeated Precaution Did Not Correlate to Biochemical Control and Rectal Toxicity in Patients with Prostate Cancer Treated with Image-guided Intensity-modulated Radiation Therapy

AIM

To investigate the correlation between frequency of action level of interfractional rectal displacement requiring repeated precaution in patients with prostate cancer and late toxicity from image-guided intensity-modulated radiation therapy (IG-IMRT) using helical tomotherapy.

PATIENTS AND METHODS

We examined 264 patients who underwent IG-IMRT during 2007-2011. Megavoltage computed tomographic (MVCT) images were acquired before radiation therapy and was examined with soft-tissue matching by comparing treatment planning images within 9,345 fractions. Displacement of the anterior rectal region larger than 5 mm, requiring repeated precaution, was defined as the level of rectal displacement requiring action (ARD).

RESULTS

ARD was identified in 815 (7.7%) out of 9,345 fractions and at least once in 82% (216/264) of patients. The highest incidence of ARD (11%) was found during the initial week of treatment (first five and next five fractions), after which the incidence decreased to 6% (p<0.0001). Patients with lean body (lower body mass index (BMI) tended to have a higher incidence of ARD. We identified 16 (6%) cases of gastrointestinal toxicity and 12 (4.5%) genitourinary toxicities as a late adverse reaction (3 months or later after IG-IMRT). There was no correlation between ARD and late toxicity. Prostate-specific antigen (PSA) control was also similar (p=0.12) between those with ARD (96% at 5 year) and those without ARD (88%).

CONCLUSION

ARD occurred predominantly in lean patients, during the initial week of treatment and became less likely over time. ARD was not correlated to late toxicity and PSA control, therefore, IG-IMRT technique was able to adequately control error due to interfractional prostate and rectal motion.

Measurement of exhaled nitric oxide and serum surfactant protein D levels for monitoring radiation pneumonitis following thoracic radiotherapy

The present study aimed to examine the role of exhaled nitric oxide (eNO) and serum surfactant protein D (SP-D) level in the determination of radiation pneumonitis (RP) after thoracic radiotherapy (RT). The study included 34 treatments for 33 patients, including 16 three-dimensional conformal and 18 stereotactic body RT treatments. eNO levels were measured prior to RT, immediately subsequent to RT, every week during the RT course and at 1, 3, 6, 9 and 12 months following the treatment. The therapy reduced the eNO from 24.3±12.8 ppb prior to RT to 19.0±10.4 ppb immediately subsequent to RT (P=0.04). A total of 5 patients (14%) developed symptomatic RP of grade 2 or higher 3–5 months later, and exhibited an eNO elevation of 2.1±0.68-fold the minimum value, whereas the RP- group exhibited 1.4±0.6-fold elevation (P=0.02). The sensitivity of a cut-off of a 1.4-fold increase in the eNO ratio at the onset of RP was 100%; however, the specificity was 52%, and no predictive alterations to eNO levels were observed prior to the onset of RP. RT was associated with an elevated serum SP-D level at 3–6 months after RT. There was a statistically significant difference in the initial serum SP-D level between RP+ and RP- patients. In conclusion, obtaining the eNO ratio was a useful RP monitoring tool but did not predict RP occurrence in the present setting, whereas serum SP-D level may be a potential predictor for the detection of RP risk.