Antiplatelet drugs may increase the risk for checkpoint inhibitor-related pneumonitis in advanced cancer patients

BACKGROUND

Immune checkpoint inhibitors (ICIs) are indicated for various cancers and are the mainstay of cancer immunotherapy. They are often associated with ICI-related pneumonitis (CIP), however, hindering a favorable clinical course. Recently, non-oncology concomitant drugs have been reported to affect the efficacy and toxicity of ICIs; however, the association between these drugs and the risk for CIP is uncertain. The aim of this study was to assess the impact of baseline concomitant drugs on CIP incidence in ICI-treated advanced cancer patients.

PATIENTS AND METHODS

This was a single-center retrospective study that included a cohort of 511 patients with advanced cancer (melanoma and non-small-cell lung, head and neck, genitourinary, and other types of cancer) treated with ICIs. Univariable analysis was conducted to identify baseline co-medications associated with CIP incidence. A propensity score matching analysis was used to adjust for potential CIP risk factors, and multivariable analysis was carried out to assess the impact of the identified co-medications on CIP risk.

RESULTS

Forty-seven (9.2%) patients developed CIP. In these patients, the organizing pneumonia pattern was the dominant radiological phenotype, and 42.6% had grade ≥3 CIP, including one patient with grade 5. Of the investigated baseline co-medications, the proportion of antiplatelet drugs (n = 50, 9.8%) was higher in patients with CIP (23.4% versus 8.4%). After propensity score matching, the CIP incidence was higher in patients with baseline antiplatelet drugs (22% versus 6%). Finally, baseline antiplatelet drug use was demonstrated to increase the risk for CIP incidence regardless of cancer type (hazard ratio, 3.46; 95% confidence interval 1.21-9.86).

CONCLUSIONS

An association between concomitant antiplatelet drug use at baseline and an increased risk for CIP was seen in our database. This implies the importance of assessing concomitant medications for CIP risk management.

Changes in cerebrovascular disease-related deaths and their location during the COVID-19 pandemic in Japan

Objective

The COVID-19 pandemic placed an enormous strain on healthcare systems and raised concerns for delays in the management of patients with acute cerebrovascular events. In this study, we investigated cerebrovascular excess deaths in Japan.

Study design

Vital mortality statistics from January 2012 to May 2022 were obtained from the Japanese Ministry of Health, Labour and Welfare.

Methods

Using quasi-Poisson regression models, we estimated the expected weekly number of cerebrovascular deaths in Japan from January 2020 through May 2022 by place of death. Estimates were calculated for deaths in all locations, as well as for deaths in hospitals, in geriatric health service facilities, and at home. The age subgroups of ≥75 and <75 years were also considered. Weeks with a statistically significant excess of cerebrovascular deaths were determined when the weekly number of observed deaths exceeded the upper bound of 97.5% prediction interval.

Results

Excess deaths were noted in June 2021 and became more pronounced from February 2022 onwards. The trend was notable among those aged ≥75 years and for those who died in hospitals. With respect to the location of deaths, the excess was significant in geriatric health services facilities from April 2020 to June 2021, while no evidence of excess hospital deaths was observed during the same period.

Conclusions

Beginning in late 2021, excess cerebrovascular deaths coincided with the spread of the Omicron variant and may be associated with increased healthcare burden. In 2020, COVID-19 altered the geography of cerebrovascular deaths, with fewer people dying in hospitals and more dying in geriatric health service facilities and at home.

Aberrant interaction between TEAD1 and Lamin A/C causes cardiomyopathy

Background

Mutations in the LMNA gene encoding Lamin A/C, a major component of the nuclear lamina, cause laminopathies including dilated cardiomyopathy (DCM). DCM patients with LMNA mutations have particularly severe clinical courses such as heart transplantation and death due to heart failure. However, underlying mechanisms of LMNA-induced DCM remains elusive.

Methods and results

We identified LMNA Q353R mutation in a DCM family with severe heart failure. We generated Q353R heterozygous knock-in mice, which showed sarcomere dysplasia and perinatal lethality. Integrative single-cell analyses of the fetal murine hearts and patient-specific induced pluripotent stem cell-derived cardiomyocytes (iPSCMs) revealed that transcriptional regulation of cardiomyocyte maturation/development genes governed by TEAD1 was impaired in LMNA mutant cardiomyocytes. Protein array and immunostaining uncovered increased binding of TEAD1 to mutant Lamin A/C protein and abnormal localization of TEAD1 at the nuclear periphery. Furthermore, TT-10, a Hippo pathway inhibitor, rescued the dysregulation of cardiac developmental genes in LMNA mutant cardiomyocytes. Single-cell RNA-seq of cardiac tissues from DCM patients with the LMNA Q353R mutation confirmed the dysregulated expression of TEAD1 and its target genes. These results demonstrated abnormal interaction between TEAD1 and mutant Lamin A/C impairs structural maturation of cardiomyocytes and suggests that LMNA Q353R-related DCM can be treated through intervention in the Hippo pathway.

Conclusion

TEAD1 trapped by mutant Lamin A/C protein at the nuclear membrane perturbs transcriptional maturation in LMNA Q353R-related DCM.

Funding Acknowledgement

Type of funding sources: None.

Excess deaths from COVID-19 in Japan and 47 prefectures from January through June 2021

Objectives

In Japan, several studies have reported no excess all-cause deaths (the difference between the observed and expected number of deaths) during the coronavirus disease 2019 (COVID-19) pandemic in 2020. This study aimed to estimate the weekly excess deaths in Japan's 47 prefectures for 2021 until June 27.

Study design

Vital statistical data on deaths were obtained from the Ministry of Health, Labour and Welfare of Japan. For this analysis, we used data from January 2012 to June 2021.

Methods

A quasi-Poisson regression was used to estimate the expected weekly number of deaths. Excess deaths were expressed as the range of differences between the observed and expected number of all-cause deaths and the 95% upper bound of the one-sided prediction interval.

Results

Since January 2021, excess deaths were observed for the first time in the week corresponding to April 12–18 and have continued through mid-June, with the highest excess percentage occurring in the week corresponding to May 31–June 6 (excess deaths: 1431–2587; excess percentage: 5.95–10.77%). Similarly, excess deaths were observed in consecutive weeks from April to June 2021 in 18 of 47 prefectures.

Conclusions

For the first time since February 2020, when the first COVID-19 death was reported in Japan, excess deaths possibly related to COVID-19 were observed in April 2021 in Japan, during the fourth wave. This may reflect the deaths of non-infected people owing to the disruption that the pandemic has caused.

Treatment outcomes for infantile spasms in Japanese children with Down syndrome

BACKGROUND

The aim of this study was to assess the treatment response to conventional antiepileptic drugs and low-dose adrenocorticotropic hormone therapy for infantile spasms in children with Down syndrome.

METHODS

We retrospectively investigated the response and relapse rates, electroencephalography findings, patient characteristics during drug withdrawal, and developmental outcome in 10 children with Down syndrome treated for infantile spasms in our hospital.

RESULTS

All patients showed cessation of infantile spasms and achieved electroencephalographic normalization. Spasm relapse occurred in one of 10 patients (10%). Antiepileptic drugs have been withdrawn for seven of 10 patients (70%), none of whom have experienced seizure relapse since drug withdrawal. The median developmental quotient (n = 8) was 20.5, which shows that the developmental outcome was unfavorable. Low-dose adrenocorticotropic hormone therapy achieved a low seizure remission rate of 28.6%.

CONCLUSIONS

Elucidation of the optimal treatment for infantile spasms in children with Down syndrome is needed to reduce the duration of infantile spasms and improve the developmental outcome.

Reversible splenial lesions during febrile illness with or without white matter lesions

OBJECTIVE

Reversible splenium lesions during febrile illness (RESLEF) are found in a spectrum. There are two types of corpus callosum (CC) lesions: CC-only type, with limited lesions and the CC (+) type, with extensive white-matter lesions. This retrospective study aimed to describe the differences in clinical findings between CC-only and CC (+) lesions and the association between onset age and clinico-radiological features in RESLEF.

METHODS

Fifty-two episodes of CC-only or CC (+) lesions accompanied by neurological symptoms, e.g., seizures, delirious behavior (DB), and disturbance of consciousness (DC), from January 2008 to October 2019 were included. We analyzed the etiology (pathogen), clinical course, laboratory data, magnetic resonance imaging and electroencephalography findings, therapy, and prognosis.

RESULTS

The rate of DC in the CC (+) was significantly higher than that in the CC-only group (5/6 [83%] vs 7/46 [15%]; p = 0.0016). The median number of seizures in the CC (+) was also significantly higher than that in the CC-only group (4 [0-7] vs 0 [0-7]; p = 0.034). Further, in RESLEF, the median onset age (months) in the seizure was significantly lower than that in the no-seizure group (39 [12-74] vs 83 [28-174]; p = 0.0007). The median onset age (months) in the DB was significantly higher than that in the no-DB group (74.5 [26-174] vs 28 [12-139]; p = 0.003).

CONCLUSIONS

In RESLEF, CC (+) is a more severe neurological symptom than CC-only. Furthermore, the onset age is related to the type of neurological symptoms that appear.

Rapid-onset dystonia-parkinsonism with ATP1A3 mutation and left lower limb paroxysmal dystonia

BACKGROUND

Rapid-onset dystonia-parkinsonism (RDP) is a disease characterized by an abrupt onset of dystonia accompanied by signs of parkinsonism and prominent bulbar symptoms.

CASE REPORT

We describe a case of a female patient, born after normal delivery, but diagnosed with mild intellectual disability at age 7. She presented with an abrupt onset of upper limb dystonia and bradykinesia without tremor in parkinsonism, as well as dysarthria and dysphagia caused by prominent bulbar symptoms, at age 9. She had normal findings on brain magnetic resonance imaging, electroencephalography, and blood examination but was diagnosed with a psychogenic disorder. At age 10, she developed left lower limb paroxysmal stiffness with pain, and at 14, she was hospitalized due to lasting paroxysmal symptoms. Whole-exome sequencing was performed for this index case and her parents, and a de novo missense variant c.829G > A, p.Glu277Lys in ATP1A3 was identified.

DISCUSSION

This RDP case highlights a rare clinical feature of paroxysmal dystonia that affects the lower left limb and develops after the abrupt onset of permanent dystonia. Currently, there are only three reported RDP cases associated with the same missense mutation, and we summarized the clinical features of all cases including ours, such as onset of age, time for stable, RDP score, relapse and exacerbation. Various symptoms owing to ATP1A3 mutation could develop as ATP1A3-related neurological disorders beyond classical phenotypes such as alternating hemiplegia of childhood (AHC) or RDP. Although RDP is extremely rare during childhood, it is important to understand its clinical characteristics in children.

Protective action of the microbial metabolite butyrate against cardiomyocyte hypertrophy

Introduction

Short-chain fatty acids are one of the gut microbial metabolites that may influence host physiology. We previously reported that gut dysbiosis was associated with heart failure, and that the proportions of butyrate-producing bacteria diminished prominently in the gut of patients with heart failure.

Purpose

We investigated the molecular mechanism of butyrate and investigated the protective mechanism against heart failure.

Methods

We searched for G protein-coupled receptors for short-chain fatty acids using single-cell transcriptome analysis of cardiomyocytes and non-cardiomyocytes isolated from murine hearts. In addition, we examined the effects of butyrate on endothelin-1 (ET1) or isoproterenol-induced hypertrophic responses and histone deacetylase (HDAC) activities in cultured neonatal rat cardiomyocytes.

Results

Single-cell transcriptome analysis and co-expression network analysis revealed that G protein-coupled receptors for short-chain fatty acid receptors were not expressed in cardiomyocytes and that Olfr78 was expressed in vascular smooth muscle cells in the heart. Treatment with butyrate inhibited ET1-induced hypertrophic growth and up-regulation of the genes such as Nppa, Acta1, and Myh7 in cultured rat neonatal cardiomyocytes. Moreover, butyrate increased the acetylation levels of histone H3, indicating that butyrate has an inhibitory effect on HDAC in cardiomyocytes. In addition, treatment with butyrate caused up-regulation of Inpp5f, encoding inositol polyphosphate-5-phosphatase f, which was associated with a significant decrease in the phosphorylation levels of Akt. These results suggest that butyrate may act as HDAC inhibitor to increase Inpp5f gene expression, leading to the activation of Akt-glycogen synthase kinase 3beta (Gsk3beta) pathway, and thereby protect against hypertrophic responses.

Conclusion

There was no known GPCR for short-chain fatty acid expressed in cardiomyocytes. However, butyrate suppressed cardiomyocyte hypertrophy through epigenetic modification of gene expression. Our results may uncover a potential role of the dysbiosis of intestinal microbiota in the pathogenesis of cardiac hypertrophy and failure.

Funding Acknowledgement

Type of funding source: None

Trend change of the transmission route of COVID-19-related symptoms in Japan

OBJECTIVES

The Japanese prime minister declared a state of emergency on April 7 2020 to combat the outbreak of coronavirus disease 2019 (COVID-19). This declaration was unique in the sense that it was essentially driven by the voluntary restraint of the residents. We examined the change of the infection route by investigating contact experiences with COVID-19-positive cases.

STUDY DESIGN

This study is a population-level questionnaire-based study using a social networking service (SNS).

METHODS

To assess the impact of the declaration, this study used population-level questionnaire data collected from an SNS with 121,375 respondents (between March 27 and May 5) to assess the change in transmission routes over the study period, which was measured by investigating the association between COVID-19-related symptoms and (self-reported) contact with COVID-19-infected individuals.

RESULTS

The results of this study show that the declaration prevented infections in the workplace, but increased domestic infections as people stayed at home. However, after April 24, workplace infections started to increase again, driven by the increase in community-acquired infections.

CONCLUSIONS

While careful interpretation is necessary because our data are self-reported from voluntary SNS users, these findings indicate the impact of the declaration on the change in transmission routes of COVID-19 over time in Japan.

Human papillomavirus vaccine effectiveness within a cervical cancer screening programme: cohort study

OBJECTIVE

To assess the effectiveness of an HPV vaccination programme in reducing the risk of cervical abnormalities identified at subsequent screening.

DESIGN

Retrospective cohort study using administrative health data.

SETTING

General population of Ferrara Province, Italy.

POPULATION

Female residents born in 1986-1993 and participating in the organized cervical screening programme in 2011-2018, who were eligible for HPV vaccination in catch-up cohorts.

METHODS

Logistic regression to evaluate the potential association between abnormal cervical cytology and one, two, three or at least one dose of HPV vaccine.

MAIN OUTCOME MEASURES

Cervical abnormalities, as predicted by low-grade or high-grade cytology, by number of vaccine doses, stratified by age.

RESULTS

The sample consisted of 7785 women (mean age 27.5 years, SD 2.3). Overall, 391 (5.0%) were vaccinated with ≥1 dose and 893 (11.5%) had abnormal cytology. Women receiving at least one vaccine dose were significantly less likely to have an abnormal cytology (adjusted odds ratio 0.52; 95% confidence interval 0.34-0.79). Similar results were observed for women receiving a single dose, for both bivalent and quadrivalent vaccines, and applying buffer periods (excluding cytological outcomes within 1 month, 6 months and 1 year of the first dose).

CONCLUSIONS

In the context of an organised cervical screening programme in Italy, catch-up HPV vaccination almost halved the risk of cytological abnormalities.

TWEETABLE ABSTRACT

Among Ferrara women, vaccination against human papillomavirus halved the risk of screening cervical abnormalities.

AB0141 MYCOPHENOLATE MOFETIL, INHIBITOR OF INOSINE-5’-MONOPHOSPHATE DEHYDROGENASE, REGULATES DIFFERENTIATION, MATURATION AND FUNCTION OF HUMAN DENDRITIC CELL SUBSETS

Background:

Systemic lupus erythematosus (SLE) is a heterogeneous disease in which excessive inflammation, autoantibodies, and complement activation lead to multisystem tissue damage. Plasmacytoid dendritc cells (pDCs) play a central role in the pathogenesis of SLE through dysregulated type I IFN production, together with activated myeloid DCs (mDCs), amplifying vicious spiral of autoimmune disorders(1). Therefore, control of the aberrant DC activation may provide an alternative treatment strategy against SLE.

Objectives:

Mycophenolate mofetil (MMF), which has been used to treat lupus nephritis, specifically blocks proliferation of B and T lymphocytes by inhibition of inosine-5-monophosphate dehydrogenase (IMPDH). In addition, although there is evidence indicating the immunosuppressive effects of MMF on human monocyte-derived dendritic cells(2.3), there are no reports showing its effects on human blood DC subsets. Here we focused on the effects of MMF on the functions of the blood pDCs and mDCs.

Methods:

We isolated human blood DCs from healthy donors using cell sorting(4) and examined the function of mycophenolic acid (MPA), which is metabolic products of MMF, on DC subsets in response to TLR-ligands and serum from patients with active SLE. Written informed consent was obtained from all healthy adult donors and SLE patients.

Results:

We found that therapeutic plasma concentration range of MPA down-regulated expression of CD40, CD80 and CD86 dose-dependently on mDCs and pDCs without inducing apoptosis, in response to R848(TLR7/8 agonist) and CpG2216(TLR9 agonist), respectively. Of note, MPA profoundly suppressed IL-12 production and STAT4 expression in the mDCs and IFN-α production and IRF7 expression in the pDCs(Fig 1). We also obserbed inhibition of nuclear translocation of IRF-7 in pDCs treated with MPA by confocal microscopy(Fig 2). Furthermore,we identified that MPA had an inhibitory effect on SLE serum-induced IFN-α production by human PBMCs.

Conclusion:

Our data suggest that MMF can drive a wedge into the vicious spiral of autoimmune disorders through regulating the function of not only lymphocyte but also DC subsets. Thus, we unveiled a part mechanism of the therapeutic ability of MMF against SLE.

References:

[1]A Plasmacytoid Dendritic Cells-Type I Interferon Axis is Critically Implicated in the Pathogenesis of Systemic Lupus Erythematosus. Int. J. Mol. Sci. 2015: 16, 14158-14170.

[2]Mycophenolate mofetil inhibits differentiation, maturation and allostimulatory function of human monocyte-derived dendritic cells. Clin Exp Immunol. 2003;134:63-69.

[3]Mycophenolic acid inhibits maturation and function of human dendritic cells and B cells. Human Immunol. 2009;70: 692–700.

[4]Miyamoto et al. Arthritis Research & Therapy 2010, 12:R87.

Disclosure of Interests:

None declared

FRI0550 CAN CYTOKINE GENE POLYMORPHISMS BE USEFUL FOR THE THERAPEUTIC CHOICE IN JAPANESE PATIENTS WITH RHEUMATOID ARTHRITIS?

Background:

Rheumatoid arthritis (RA) is a common autoimmune disease. It is characterized by systemic synovitis with bone erosion and joint cartilage degradation(1). Production of autoantibody is important for autoimmune disease. Cytokines play crucial roles in its pathogenesis(2). SNP distribution varies between races. Few studies have examined SNP targeted at Japanese patients. The analysis of cytokine gene polymorphisms is important factor of pathophysiology and treatment.

Objectives:

This analysis was aimed to investigate the association between cytokine gene polymorphisms and autoantibody and therapeutic response in Japanese RA patients.

Methods:

This study subjects consisted of 100 RA patients and 50 healthy controls. We extracted data on patient sex, age, disease duration, rheumatoid factor (RF), anti cyclic citrullinated peptide (anti-CCP) antibody and therapeutic response including methotrexate (MTX) and biological DMARDs. Genomic DNA was isolated from peripheral blood, these were genotyped for TNFα, TGFβ1, IL-6, IL-10 and IFNγ polymorphisms. We analyzed these data using a chi-square test.

Results:

IL-10 (-819 C/T and -592 C/A) revealed that there were significant decrease in the frequency of IL-10 (-819) CC genotype and (-592) CC genotype as compared to controls in RA patients. Genotyping of IL-10 showed that there was significant decrease ACC/ACC genotype (Table 1).

IFNγ (+874 A/T) revealed that there was significant decrease in the frequency of TT genotype as compared to controls (Table 1).

No significant differences in TNFα, TGFβ1and IL-6 genotypes and alleles frequency were observed between RA patients and control.

TGFβ1(+869 A/T) in patients with anti-CCP antibody positive revealed that there was significant decrease in the frequency of TT genotype as compared to patients with anti-CCP antibody negative (Table 2).

No significant association between RF and any cytokine gene polymorphism.

Analyzing cytokine gene polymorphisms could be useful for treatment with MTX and biological DMARDs.

Table 1.

Table 2.

Conclusion:

IL-10 (-819 C/T, -592 C/A) and IFNγ (+874 A/T) polymorphism might be related to RA in Japanese population. In addition, TGFβ1(+869 A/T) polymorphism might be associated with the production of anti-CCP antibody. These results suggest that the analyzing cytokine gene polymorphisms may offer promise as useful factors in the choice of treatment for Japanese RA patients.

References:

[1] Scott DL, Wolfe F, Huizinga TW. Rheumatoid arthritis. Lancet. 2010; 376: 1094–108.

[2] McInnes IB, Schett G. Cytokines in the pathogenesis of rheumatoid arthritis. Nat Rev Immunol. 2007 Jun;7(6):429-42.

Disclosure of Interests:

None declared

Clinical findings in patients with febrile seizure after 5 years of age: A retrospective study

OBJECTIVE

Febrile seizures (FSs) typically occur in infants and children between 6 and 60 months of age. Rarely, FS can occur in late childhood (late FS [LFS]; >5 years of age); however, the clinical features of LFS remain unclear. We aimed to clarify the clinical features of LFS.

METHODS

We retrospectively analyzed data from patients with LFS who visited Hirakata City Hospital between January 2004 and December 2014. We defined LFS as a seizure accompanied by fever (temperature ≥38 °C) occurring after 5 years of age, without a central nervous system infection.

RESULTS

A total of 505 patients (349 boys, 156 girls: 5-14 years old) were included. A history of FS before 60 months of age was observed in 319 of 460 patients (69.3%) with sufficient information about previous FS history among the 505 patients enrolled. LFS was more likely to occur in males (69.1%). Seizure duration was ≤15 min in 87.4% of cases. A family history of FS in first-degree relatives was observed in 103/327 cases (31.5%). Among LFS cases, 45% occurred at 5 years of age, and 92.1% experienced only one seizure after 5 years of age. The number of seizure episodes gradually lessened with age, decreasing drastically to 5.6% of cases older than 9 years.

CONCLUSIONS

Our findings suggest that sex differences, seizure duration, and family history were similar for LFS and FS. Over 90% patients with LFS experienced no recurrence after 5 years of age. Further study is needed to verify the recurrence rate of LFS.

The relationship between fever rate and telework implementation as a social distancing measure against the COVID-19 pandemic in Japan

Objectives

On March 28, the Japanese government decided on the “Basic Policies for Novel Coronavirus Disease Control” and called on the public to thoroughly implement social distancing measures (i.e., behavioral restrictions to limit the frequency and intensity of human contact), especially telework.

Methods

We used population-level questionnaire data from a social networking service (SNS), with 275,560 respondents from March 5 to April 6, to evaluate the relationship between telework implementation and the presence of a fever (body temperature higher than 37.5 °C) within 1 month as a surrogate indicator of COVID-19 infection, by occupation type and age-group.

Results

Among company employees, statistical significance was identified in the 15- to 29-year and 30- to 59-year age-groups, showing higher fever rates in the non-teleworker group (for the 15- to 29-year age-group, non-teleworkers: 7.64%; teleworkers: 6.45%; P = 0.02; for the 30- to 59-year age-group, non-teleworkers: 3.46%; teleworkers: 3.14%; P = 0.02).

Conclusions

Telework remains a controversial topic in Japan as the government called for emergency measures. Although caution is warranted in interpreting our findings because our data are limited to the voluntary SNS users, they will be essential to push forward with more measures to promote social distancing measures in the midst of Japan's current tense political climate.

Serum high-mobility group box 1 is correlated with interferon-α and may predict disease activity in patients with systemic lupus erythematosus

Sensing self-nucleic acids through toll-like receptors in plasmacytoid dendritic cells (pDCs), and the dysregulated type I IFN production, represent pathogenic events in the development of the autoimmune responses in systemic lupus erythematosus (SLE). Production of high-mobility group box-1 protein (HMGB1) promotes type I IFN response in pDCs. To better understand the active pathogenic mechanism of SLE, we measured serum levels of HMGB1, thrombomodulin, and cytokines (IL-1β, IL-2, IL-4, IL-5, IL-6, IL-10, IL-13, IL-17A, IL-17F, IFNα, IFNγ, TNFα) in 35 patients with SLE. Serum HMGB1 and IFNα were significantly higher in patients with active SLE (SLE Disease Activity Index (SLEDAI) score ≥ 6) compared with healthy donors or patients with inactive SLE. Furthermore, the HMGB1 levels were significantly correlated with IFNα levels. By qualitative analysis, the detection of serum IFNα or HMGB1 suggests active SLE and the presence of SLE-related arthritis, fever, and urinary abnormality out of SLEDAI manifestations. Collectively, HMGB1 and IFNα levels are biomarkers reflecting disease activity, and qualitative analysis of IFNα or HMGB1 is a useful screening test to estimate SLE severity and manifestations. Our results suggest the clinical significance of type I IFNs and HMGB1 as key molecules promoting the autoimmune process in SLE.

Benefits and Harms of Gastric Cancer Screening and Prevention in Japan: A Microsimulation Modeling Analysis

Background: In 2016, gastric cancer is the second leading cause of cancer mortality worldwide. Globally, Japan and Korea are the only two countries implementing national screening program for gastric cancer. South Korea launched a biennial national -endoscopic screening program in 1999, which demonstrated a 47% reduction in gastric cancer mortality compared with no screening. In 2015, endoscopic screening was recommended by the Japanese Guideline for Gastric Cancer Screening. Currently, Japan's screening policy recommends endoscopic screening every 2 to 3 years for individuals aged 50 or above. Aim: This study aims to quantify the potential impacts of Japan's current national endoscopic screening policy and other alternative endoscopic screening options, and to identify a set of efficient endoscopic screening strategies for the current population of Japan. Methods: A microsimulation model of intestinal-type noncardia gastric adenocarcinoma was developed to simulate a virtual population with similar risk profile and life expectancy to the actual population of Japan. The model was calibrated and validated to the nationally-representative data from vital statistics and population-based cancer registries. The baseline scenario was modeled to project the current trend of gastric cancer. Variations among age of initiation (40, 45, 50, and 55), age of termination (75, 80, and 85), and screening interval (2, 5, 10, and 15 years) resulted in 39 unique endoscopic screening strategies for evaluation. In addition, the following three existing screening scenarios were included for analysis: the current screening program in Japan (screening every two or three years from age 50 years, with no termination) and Korea (biennial screening from age 40 years, with no termination). In total, 42 unique endoscopic screening strategies were simulated. Full adherence for all screening scenarios were assumed. Results: In comparison with baseline scenario, endoscopic screening strategies provided 43 to 203 life-years gained per 1000 individuals. The number of lifetime endoscopies per 1000 individuals ranged from 2281 to 28,635. The complications caused by screening were from 6 to 77 per 1000 individuals. The lifetime number of false-positive results ranged from 381 to 4941 per 1000 individuals. Scenarios simulating the current national endoscopic screening program in Japan and Korea fell below the efficient frontier. Under full adherence assumption, the most advantageous endoscopic screening strategy among evaluated scenarios is screening from age 40 to 80 years every 5 year. Conclusion: In this microsimulation modeling study with full adherence assumption, the findings suggest that the current national endoscopic screening program for gastric cancer in Japan might not be the most efficient screening option under benefit-to-harm consideration. The finding underpins the need for further investigation to bring up an efficient and cost-effective endoscopic screening program in Japan.

The efficacy of adrenocorticotropic hormone in a girl with anti-N-methyl-D-aspartate receptor encephalitis

BACKGROUND

Immunomodulatory therapy has shown some therapeutic benefits in patients with anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis. In this report, we describe the use of adrenocorticotropic hormone (ACTH) immunotherapy with good outcome in a patient with anti-NMDAR encephalitis.

SUBJECT AND METHODS

A 4-year-old girl developed convulsions in her right arm and leg without impaired consciousness. These convulsions occurred frequently in clusters of 10-20 events of 10-20 s duration. She was admitted to our hospital on the 6th day following her initial series of convulsions. Flaccid paralysis of the right hand and leg was also found. Interictal electroencephalography showed high-amplitude slow waves. No abnormal findings were shown on MRI. ^99mTc-ECD brain SPECT on the 14th day showed hyperperfusion in the left hemisphere, including the left basal ganglia. The convulsions ceased following the oral administration of valproic acid on the 10th day; however, paralysis associated with choreic dyskinesia of the right arm and leg remained. ACTH immunotherapy was then performed on the 15th day. We identified the presence of N-methyl-D-aspartate receptor antibody in CSF samples taken on the 6th day. After ACTH therapy, the patient fully recovered from the paralysis associated with choreic dyskinesia of the right arm and leg. She has not had a relapse and has not required medication for over a year.

CONCLUSION

ACTH immunotherapy may be a useful treatment option for patients with anti-NMDAR encephalitis, although further evaluation is required.

Prognostic factors in the early phase of acute encephalopathy

BACKGROUND

Neurological sequelae occur in 40% of patients with acute encephalopathy (AE). The early prediction of poor outcomes is critical to the initiation of appropriate treatment. The aim of the present study was therefore to elucidate prognostic factors that can be quickly and feasibly evaluated on hospital admission in patients with AE.

METHODS

We analyzed data from 51 AE patients admitted to Hirakata City Hospital between January 2005 and December 2014. Age at onset, sex, underlying disease, status epilepticus (SE), presence of benzodiazepine-resistant SE (BZD-resistant SE), and basic blood serum parameters on admission were evaluated in relation to each patient's outcome.

RESULTS

On univariate analysis age at onset, BZD-resistant SE, and serum aspartate aminotransferase (AST), alanine aminotransferase, lactate dehydrogenase, and platelet count varied significantly according to outcome. On multivariate analysis age at onset (≤21 months), presence of BZD-resistant SE, and AST (≥46 IU/L) were identified as independent variables associated with poor outcome.

CONCLUSION

Age at onset, presence of BZD-resistant SE, and AST are associated with a poor prognosis in AE.

Gaze stabilization exercises derive sensory reweighting of vestibular for postural control

[Purpose] The aim of this study was to investigate whether gaze stabilization exercise derives sensory reweighting of vestibular for upright postural control. [Subjects and Methods] Twenty-three healthy volunteers participated in this study. The center of pressure of the total trajectory length was measured before (pre), immediately after (post), and 10 min after (post10) gaze stabilization exercise, in the static standing position, with the eyes open or closed, on the floor or on foam rubber. The sensory contribution values of the visual, somatosensory, and vestibular systems were calculated using center of pressure of the total trajectory length value in these measuring conditions. [Results] The center of pressure of the total trajectory length on foam rubber in post and post10 were significantly lower than that in the pre. The sensory contribution values of vestibular in post10 stages were significantly higher than that in pre-stage. [Conclusion] Gaze stabilization exercise can improve the static body balance in a condition that particularly requires vestibular function. The possible mechanism involves increasing sensory contribution of the vestibular system for postural control by the gaze stabilization exercise, which may be useful to derive sensory reweighting of the vestibular system for rehabilitation.