Chronic bromine intoxication complicated with Fanconi syndrome: A case report

In this report, we describe a unique case of an 80-year-old woman who developed chronic bromine poisoning due to the prolonged ingestion of over-the-counter (OTC) medication containing bromovalerylurea (BVU), thus leading to the onset of drug-induced partial Fanconi syndrome and resultant osteomalacia. The patient's condition improved following the cessation of bromide intake. This case highlights the potential risks of chronic BVU exposure and the importance of caution regarding the use of OTC medications containing BVU.

The Big Three diagnostic errors through reflections of Japanese internists

OBJECTIVES

To analyze the Big Three diagnostic errors (malignant neoplasms, cardiovascular diseases, and infectious diseases) through internists' self-reflection on their most memorable diagnostic errors.

METHODS

This secondary analysis study, based on a web-based cross-sectional survey, recruited participants from January 21 to 31, 2019. The participants were asked to recall the most memorable diagnostic error cases in which they were primarily involved. We gathered data on internists' demographics, time to error recognition, and error location. Factors causing diagnostic errors included environmental conditions, information processing, and cognitive bias. Participants scored the significance of each contributing factor on a Likert scale (0, unimportant; 10, extremely important).

RESULTS

The Big Three comprised 54.1 % (n=372) of the 687 cases reviewed. The median physician age was 51.5 years (interquartile range, 42-58 years); 65.6 % of physicians worked in hospital settings. Delayed diagnoses were the most common among malignancies (n=64, 46 %). Diagnostic errors related to malignancy were frequent in general outpatient settings on weekdays and in the mornings and were not identified for several months following the event. Environmental factors often contributed to cardiovascular disease-related errors, which were typically identified within days in emergency departments, during night shifts, and on holidays. Information gathering and interpretation significantly impacted infectious disease diagnoses.

CONCLUSIONS

The Big Three accounted for the majority of cases recalled by Japanese internists. The most relevant contributing factors were different for each of the three categories. Addressing these errors may require a unique approach based on the disease associations.

Downregulation of SMOC1 is associated with progression of colorectal traditional serrated adenomas

BACKGROUND

Aberrant DNA methylation is prevalent in colorectal serrated lesions. We previously reported that the CpG island of SMOC1 is frequently methylated in traditional serrated adenomas (TSAs) and colorectal cancers (CRCs) but is rarely methylated in sessile serrated lesions (SSLs). In the present study, we aimed to further characterize the expression of SMOC1 in early colorectal lesions.

METHODS

SMOC1 expression was analyzed immunohistochemically in a series of colorectal tumors (n = 199) and adjacent normal colonic tissues (n = 112).

RESULTS

SMOC1 was abundantly expressed in normal colon and SSLs while it was significantly downregulated in TSAs, advanced adenomas and cancers. Mean immunohistochemistry scores were as follows: normal colon, 24.2; hyperplastic polyp (HP), 18.9; SSL, 23.8; SSL with dysplasia (SSLD)/SSL with early invasive cancer (EIC), 15.8; TSA, 5.4; TSA with high grade dysplasia (HGD)/EIC, 4.7; non-advanced adenoma, 21.4; advanced adenoma, 11.9; EIC, 10.9. Higher levels SMOC1 expression correlated positively with proximal colon locations and flat tumoral morphology, reflecting its abundant expression in SSLs. Among TSAs that contained both flat and protruding components, levels of SMOC1 expression were significantly lower in the protruding components.

CONCLUSION

Our results suggest that reduced expression of SMOC1 is associated with progression of TSAs and conventional adenomas and that SMOC1 expression may be a biomarker for diagnosis of serrated lesions and risk prediction in colorectal tumors.

Three Subtypes of Cutaneous Nerve Entrapment Syndrome: A Narrative Review

Anterior, lateral, and posterior cutaneous nerve entrapment syndromes have been proposed as etiologies of trunk pain. However, while these syndromes are analogous, comprehensive reports contrasting the three subtypes are lacking. We therefore reviewed the literature on anterior, lateral, and posterior cutaneous nerve entrapment syndrome. We searched the PubMed and Cochrane Library databases twice for relevant articles published between March and September 2022. In addition to 16 letters, technical reports, and review articles, a further 62, 6, and 3 articles concerning anterior, lateral, and posterior cutaneous nerve entrapment syndromes, respectively, were included. These syndromes are usually diagnosed based solely on unique history and examination findings; however, the diagnostic process may be prolonged, and multiple re-evaluations are required. The most common first-line treatment is trigger point injection; however, the management of refractory cases remains unclear. Awareness of this disease should be expanded to medical departments other than general medicine.

In-Hospital Onset of Transient Myoclonic State in Older Adults: A Case Report

Background

Transient myoclonic (TM) state in older adults is a neurological condition characterised by short-lived, repetitive myoclonus without consciousness disturbance. First reported in 1992, it predominantly affects older individuals with chronic diseases. Despite its clear symptomatology, TM often remains under-recognised, leading to potential misdiagnoses.

Case description

We report a case of a 68-year-old woman with a history of chronic heart failure who developed TM during hospitalisation following medication adjustment for acute heart failure. The patient, who had no history of intracranial disease or epilepsy, experienced acute involuntary movements of the face and limbs three days after diuretic adjustment. She responded well to intravenous diazepam and oral clonazepam, with no recurrence of symptoms post-treatment.

Discussion

TM presents with bilateral, irregular, and repetitive myoclonus, mostly affecting the head, neck and upper extremities. Diagnosis is clinical, based on symptomatology and normal laboratory results. This case underscores the importance of recognising TM in differential diagnosis, especially in older patients in the acute or recovery phase of infection, or with medication changes. The potential role of fluid volume changes in TM pathophysiology in patients with underlying conditions such as hypertension or chronic heart failure is also highlighted. This case emphasises the need for heightened awareness and knowledge of TM among healthcare professionals.

Conclusions

TM, though rare, requires awareness among clinicians for accurate diagnosis and management. It is crucial to avoid misdiagnosis and unnecessary interventions, and to provide appropriate information during care transitions, particularly in older adults with chronic conditions.

LEARNING POINTS

Transient myoclonic (TM) state is a rare neurological condition in older adults, characterised by brief and repetitive myoclonus, primarily affecting the head, neck and upper extremities.The distinctive clinical diagnostic feature is myoclonus occurring without disturbances in consciousness, without amnesia or paralysis, while retaining the ability to perform directed movements. This condition can manifest at rest, may worsen with posture or movement, and tends to improve during sleep.Management strategies include ensuring smooth care transitions, avoiding misdiagnosis and educating patients and families about the risk of recurrence.

Protecting the primary care physicians' well-being

Seminar participants collaborated as a team to improve their organization, work environment, and labor issues using the Plan-Do-Check-Act (PDCA) cycle. The PDCA cycle helps healthcare providers identify risks and hazards in their work environment and address daily issues. It guides them in planning and executing improvements while enabling progress tracking and encouraging further considerations for implementation.

Diagnostic errors in uncommon conditions: a systematic review of case reports of diagnostic errors

OBJECTIVES

To assess the usefulness of case reports as sources for research on diagnostic errors in uncommon diseases and atypical presentations.

CONTENT

We reviewed 563 case reports of diagnostic error. The commonality of the final diagnoses was classified based on the description in the articles, Orphanet, or epidemiological data on available references; the typicality of presentation was classified based on the description in the articles and the judgment of the physician researchers. Diagnosis Error Evaluation and Research (DEER), Reliable Diagnosis Challenges (RDC), and Generic Diagnostic Pitfalls (GDP) taxonomies were used to assess the factors contributing to diagnostic errors.

SUMMARY AND OUTLOOK

Excluding three cases in that commonality could not be classified, 560 cases were classified into four categories: typical presentations of common diseases (60, 10.7 %), atypical presentations of common diseases (35, 6.2 %), typical presentations of uncommon diseases (276, 49.3 %), and atypical presentations of uncommon diseases (189, 33.8 %). The most important DEER taxonomy was "Failure/delay in considering the diagnosis" among the four categories, whereas the most important RDC and GDP taxonomies varied with the categories. Case reports can be a useful data source for research on the diagnostic errors of uncommon diseases with or without atypical presentations.

Osmotic Demyelination Syndrome in a Patient with Diabetic Ketoacidosis Despite No Rapid Sodium Correction

Osmotic demyelination syndrome (ODS) occurs in patients with diabetes and hyponatremia. We herein report a case of ODS with chorea detected on serial magnetic resonance imaging (MRI), despite no prompt hyponatremia correction. A 74-year-old man with cirrhosis and uncontrolled type 2 diabetes developed an altered mental status and chorea during treatment for diabetic ketoacidosis (DKA). Despite no rapid sodium correction and normal initial brain MRI findings, serial MRI revealed ODS-related abnormalities. Clinicians should consider ODS in patients with DKA and a hyperosmolar hyperglycemic state displaying unconsciousness and neurological manifestations, including chorea, even without substantial changes in serum sodium levels. An MRI re-examination can help capture missing ODS complications.

Usefulness of magnetic resonance imaging for acute abdominal pain in a pregnant woman: A case of idiopathic renal hemorrhage

Acute abdominal pain in pregnant women may complicate the diagnostic process of acute abdominal pain because of anatomical and physiological changes and limitations of computed tomography examinations related to radiation exposure. Here, we present the case of a 35-year-old female in her 10th week of pregnancy who was seen in the emergency department with unilateral abdominal pain and gross hematuria. Ultrasound detected only hydronephrosis and failed to identify ureteral stones, but magnetic resonance imaging revealed a diagnosis of idiopathic renal hemorrhage and intraductal ureteral hematoma, not ureteral stones. Although magnetic resonance imaging for pregnant women has the disadvantages of prolonged scan time and difficulty in image interpretation, no harm or complications to the mother or fetus have been reported. Magnetic resonance imaging may be considered in assessing acute abdominal pain in pregnant women, especially when the diagnosis is uncertain, based on shared decision-making with the patient and assessing the clinical situation and availability.

Rapid-kinetics degron benchmarking reveals off-target activities and mixed agonism-antagonism of MYB inhibitors

Attenuating aberrant transcriptional circuits holds great promise for the treatment of numerous diseases, including cancer. However, development of transcriptional inhibitors is hampered by the lack of a generally accepted functional cellular readout to characterize their target specificity and on-target activity. We benchmarked the direct gene-regulatory signatures of six agents reported as inhibitors of the oncogenic transcription factor MYB against targeted MYB degradation in a nascent transcriptomics assay. The inhibitors demonstrated partial specificity for MYB target genes but displayed significant off-target activity. Unexpectedly, the inhibitors displayed bimodal on-target effects, acting as mixed agonists-antagonists. Our data uncover unforeseen agonist effects of small molecules originally developed as TF inhibitors and argue that rapid-kinetics benchmarking against degron models should be used for functional characterization of transcriptional modulators.

Cervical Angina as a Cause of Non-Cardiac Chest Pain: A Case Report

Cervical angina is a form of non-cardiac chest pain that originates in the cervical spine or cervical cord; it is an under-recognized and easily underdiagnosed condition. Patients with cervical angina often report delayed diagnosis. Here, we report the case of a 62-year-old woman with a history of cervical spondylosis and undiagnosed recurrent chest pain who presented with numbness in the left upper arm and was diagnosed with cervical angina. Although most cases of cervical angina involve uncommon self-limited diseases that improve with conservative treatment, timely diagnosis can reduce patient anxiety and unnecessary office visits and tests. The critical aspect of chest pain evaluation is to rule out fatal disease. Once fatal disease is ruled out, cervical angina should be considered in differential diagnosis if there is a history of cervical spine disease, if the pain radiates to the arm, if it is elicited by cervical spine range of motion or upper extremity movement, or if the chest pain lasts less than a few seconds.

Leukemia core transcriptional circuitry is a sparsely interconnected hierarchy stabilized by incoherent feed-forward loops

Lineage-defining transcription factors form densely interconnected circuits in chromatin occupancy assays, but the functional significance of these networks remains underexplored. We reconstructed the functional topology of a leukemia cell transcription network from the direct gene-regulatory programs of eight core transcriptional regulators established in pre-steady state assays coupling targeted protein degradation with nascent transcriptomics. The core regulators displayed narrow, largely non-overlapping direct transcriptional programs, forming a sparsely interconnected functional hierarchy stabilized by incoherent feed-forward loops. BET bromodomain and CDK7 inhibitors disrupted the core regulators' direct programs, acting as mixed agonists/antagonists. The network is predictive of dynamic gene expression behaviors in time-resolved assays and clinically relevant pathway activity in patient populations.

Five strategies on writing research papers for beginners and young general medicine doctors

We propose five important strategies for young generalists to write original research and papers. We hope that even beginners will understand and practice these five strategies, and help young generalist to write research papers based on clinical questions that arise in their daily practice.

Medical Malpractice and Diagnostic Errors in Japanese Emergency Departments

INTRODUCTION

Emergency departments (ED) are unpredictable and prone to diagnostic errors. In addition, non-emergency specialists often provide emergency care in Japan due to a lack of certified emergency specialists, making diagnostic errors and associated medical malpractice more likely. While several studies have investigated the medical malpractice related to diagnostic errors in EDs, only a few have focused on the conditions in Japan. This study examines diagnostic error-related medical malpractice lawsuits in Japanese EDs to understand how various factors contribute to diagnostic errors.

METHODS

We retrospectively examined data on medical lawsuits from 1961-2017 to identify types of diagnostic errors and initial and final diagnoses from non-trauma and trauma cases.

RESULTS

We evaluated 108 cases, of which 74 (68.5%) were diagnostic error cases. Twenty-eight of the diagnostic errors were trauma-related (37.8%). In 86.5% of these diagnostic error cases, the relevant errors were categorized as either missed or diagnosed incorrectly; the others were attributable to diagnostic delay. Cognitive factors (including faulty perception, cognitive biases, and failed heuristics) were associated with 91.7% of errors. Intracranial hemorrhage was the most common final diagnosis of trauma-related errors (42.9%), and the most common initial diagnoses of non-trauma-related errors were upper respiratory tract infection (21.7%), non-bleeding digestive tract disease (15.2%), and primary headache (10.9%).

CONCLUSION

In this study, the first to examine medical malpractice errors in Japanese EDs, we found that such claims are often developed from initial diagnoses of common diseases, such as upper respiratory tract infection, non-hemorrhagic gastrointestinal diseases, and headaches.

Serum amyloid A1 recruits neutrophils to the invasive front of T1 colorectal cancers

BACKGROUND AND AIM

The tumor microenvironment plays an essential role in the development and progression of colorectal cancer (CRC). We recently reported that crosstalk between CRC cells and tumor-associated macrophages (TAMs) via serum amyloid A1 (SAA1) promotes invasion by T1 CRCs. In the present study, we aimed to clarify the role of neutrophils in early CRCs.

METHODS

Immunohistochemical analysis of CD66b, chemokine CXC motif ligand 8 (CXCL8 or interleukin-8, IL-8) and matrix metalloproteinase-9 (MMP-9) was performed using primary T1 CRCs (n = 49). The HL-60 human promyelocytic leukemia cell line and THP-1 human monocytic leukemia cell line were used to obtain neutrophil-like and macrophage-like cells, respectively. Boyden chamber assays were used to analyze cell migration and invasion, and quantitative RT-PCR was used to analyze gene expression.

RESULTS

Immunohistochemical analysis revealed accumulation of neutrophils at the SAA1-positive invasive front of T1 CRCs. Experiments using HL-60 cells suggested that treatment with SAA1 induced neutrophil migration and expression of CXCL8 and MMP-9 in neutrophils and that neutrophils promote CRC cell migration and invasion. Immunohistochemistry confirmed accumulation of CXCL8- or MMP-9-positive neutrophils at the SAA1-positive invasive front of T1 CRCs. Moreover, co-culture experiments using CRC, THP-1 and HL-60 cells suggested that CRC cells activated by macrophages upregulate CXCL8 and MMP-9 in neutrophils.

CONCLUSIONS

Our results suggest that interplay between macrophages and CRC cells leads to recruitment of neutrophils to the invasive front of T1 CRCs and that SAA1 secreted by CRC cells activate neutrophils to promote invasion.

Deprescribing antacids after the diagnosis of Clostridioides difficile infection: A single-center observational study

Overuse of antacids is associated with the development and recurrence of Clostridioides difficile infection (CDI). Discontinuation of unnecessary antacids for CDI management is advocated; however, the clinical pervasiveness on the discontinuation of antacids remains unclear. We conducted a single-center retrospective observational study to determine the rate of antacid discontinuation following CDI diagnosis. Among 51 patients (58 infections; median age 76.5 years, range 69-82; 53.5% women) treated with antimicrobials against C. difficile, 41 had been treated with antacids, and of these, 18 exhibited no indication for antacid administration. However, none had discontinued antacid use. While CDI provides an opportunity for antacid stewardship, it is not implemented in clinical practice. In addition to the efforts of individual clinicians, the dissemination of knowledge of the indications and side effects of antacids, establishment of a multidisciplinary support system, and creation and implementation of a clinical stewardship pathway are necessary to increase the deprescription of antacids in patients with CDI.

Effectiveness of patient and staff cohorting to reduce the risk of vancomycin-resistant enterococcus (VRE) acquisition: a retrospective cohort study during a VRE outbreak in Japan

BACKGROUND

Patient and staff cohorting is part of a bundle approach in the response to multi-drug-resistant organisms, but its effectiveness is not fully clarified. This study compared the risks of acquiring vancomycin-resistant Enterococcus faecium (VREfm) at a hospital during a VREfm outbreak based on contact characteristics in order to better understand the effectiveness of cohorting.

METHODS

Exposure came from contact with patients with VREfm (infectors), including existing patients with VREfm and patients who acquired VREfm during the study period. Contact was defined as length of contact time, degree of sharing space, and care by the same nurses as those caring for infectors between January and March 2018. The outcome was VREfm acquisition as determined through monthly stool or rectal screening cultures. Incidence rates were calculated based on contact patterns, and incidence rate ratios (IRRs) were compared.

FINDINGS

Among 272 inpatients (4038 patient-days), 43 patients acquired VREfm with the same or similar pulsotype. Incidence rates were 8.45 per 1000 patient-days when susceptible inpatients were on the same ward as an infector but cared for by different nurses (reference), 16.96 when susceptible inpatients were on the same ward as an infector and cared for by the same nurses [IRR 2.01, 95% confidence interval (CI) 0.62-10.28], and 52.91 when susceptible inpatients shared a room with an infector (IRR 6.26, 95% CI 1.61-35.40).

CONCLUSION

Compared with susceptible inpatients in a different room from infectors and not being cared for by the same nurses, the risk of VREfm acquisition could be six times higher for susceptible inpatients who are in the same room as infectors, and could be double for susceptible inpatients cared for by the same nurses as infectors.

Non-Episodic Angioedema Associated with Eosinophilia after COVID-19

Introduction

Non-episodic angioedema associated with eosinophilia (NEAE) has been reported primarily in young East Asian women and is characterized by a single episode of persistent limb oedema, peripheral eosinophilia, and transient joint pain. Although there are reports of eosinophilia disease after coronavirus disease 2019 (COVID-19), the occurrence of NEAE has not been previously reported.

Case description

A 29-year-old Japanese woman, with a history of allergic rhinitis and atopic dermatitis, sought a medical consultation for persisting oedema of the extremities, which developed about 2 weeks after she contracted COVID-19. Physical examination revealed symmetrical non-pitting oedema with peripheral predominance. Laboratory examination revealed a blood eosinophil count of 7536/μl. The patient was diagnosed with NEAE and a 7-day course of prednisolone (15 mg/day) was initiated, with rapid improvement in the oedema and no recurrence on follow-up.

Discussion

The exact aetiology of NEAE is unknown, but it may develop after infection or drug exposure. Eosinophilic disease after COVID-19 infection has been reported and, therefore, eosinophilic angioedema should be considered in the differential diagnosis of non-pitting oedema of the extremities after a COVID-19 infection. Early diagnosis of NEAE is important as rapid improvement can be achieved with low-dose steroid treatment.

Conclusion

NEAE can develop after COVID-19 and should be considered in the differential diagnosis of non-pitting oedema of the extremities.

LEARNING POINTS

Non-episodic angioedema associated with eosinophilia (NEAE) is characterized by a single episode of symmetrical non-pitting oedema with distal limb predominance.The case presented indicates that NEAE can occur after COVID-19 infection.Therefore, eosinophilic angioedema should be considered in the differential diagnosis of non-pitting oedema of the extremities in a patient with a positive COVID-19 history.

Factors associated with delayed diagnosis of appendicitis in adults: A single-center, retrospective, observational study

Appendicitis is one of the most common causes of acute abdominal pain; yet the risk of delayed diagnosis remains despite recent advances in abdominal imaging. Understanding the factors associated with delayed diagnosis can lower the risk of diagnostic errors for acute appendicitis. These factors, including physicians’ specialty as a generalist or non-generalist, were evaluated through a retrospective, observational study of adult acute appendicitis cases at a single center, between April 1, 2014, and March 31, 2021. The main outcome was timely diagnosis, defined as "diagnosis at the first visit if the facility had computed tomography (CT) capability" or "referral to an appropriate medical institution promptly after the first visit for a facility without CT capability," with all other cases defined as delayed diagnosis. The frequency of delayed diagnosis was calculated and associated factors evaluated through multivariate and exploratory analyses. The overall rate of delayed diagnosis was 26.2% (200/763 cases). Multivariate analysis showed that tenderness in the right lower abdominal region, absence of diarrhea, a consultation of ≤6 h after symptom onset, and consultation with a generalist were associated with a decreased risk of delayed diagnosis of acute appendicitis. Exploratory analysis found that generalists performed more physical findings related to acute appendicitis, suggesting that this diagnostic approach may be associated with timely diagnosis. Future studies should adjust for other potential confounding factors, including patient complexity, consultation environment, number of physicians, diagnostic modality, and physician specialties.

Long-COVID and long-term cancer survivorship-Shared lessons and opportunities

As of 2022, close to 90 million persons in the United States, 243 million persons in Europe and 585 million worldwide have been infected with the novel SARS‐CoV‐2 (COVID‐19) virus and survived. Estimates vary but suggest that up to 50% may experience long‐term sequelae, termed ‘Long‐COVID’. While Long‐COVID is a new condition, the phenomenon of disabling long‐term effects following an illness requiring ongoing surveillance and management is not. In this commentary, we discuss how Long‐COVID parallels the experiences of long‐term cancer survivors, highlight shared challenges and offer opportunities to improve research and clinical care for both growing populations of patients as well as other long‐term chronic, disabling conditions.

Two Cases of Acute Urinary Retention Associated With Acute Sarcopenia in Older Women

Acute urinary retention during hospitalization is a poor prognostic predictor. Therefore, prevention of the same is important. Herein, we describe two cases of acute urinary retention in older women admitted to the hospital for acute illness, with severe sarcopenia being the only predisposing cause. Both women developed urinary problems shortly after admission. In both, acute urinary retention was preceded by an in-hospital period of poor nutritional intake and a lack of progress in rehabilitation. There was no evidence of genitourinary disorder, neurological disease, drug-induced dysuria, bone fracture, or pain. Both patients presented with severe sarcopenia and severe frailty.Although the loss of mass in the voiding muscles is difficult to detect, the possibility of dysuria as one of the complications of acute and severe sarcopenia was indicated in our patients. Of note, however, is that many patients with severe sarcopenia do not develop dysuria. Therefore, accumulating evidence on the possible association between severe sarcopenia and dysuria is needed to inform prevention.

Evaluation of the usefulness of costovertebral angle tenderness in patients with suspected ureteral stone

Background

The usefulness of costovertebral angle (CVA) tenderness for the diagnosis of a suspected ureteral stone remains controversial.

Methods

This single-center, retrospective, observational study included patients aged 16-64 years with acute-onset unilateral lower back pain or abdominal pain. The diagnostic accuracy of CVA tenderness was investigated.

Results

In total, 132 patients met the criteria; 80 were diagnosed with ureteral stones. The sensitivity and specificity of CVA tenderness were 0.65 and 0.50, respectively; positive and negative likelihood ratios were 1.3 and 0.7, respectively.

Conclusions

CVA tenderness cannot be used as a single diagnostic indicator to confirm or exclude ureteral stone diagnosis.

Transcriptional Plasticity Drives Leukemia Immune Escape

Relapse of acute myeloid leukemia (AML) after allogeneic bone marrow transplantation has been linked to immune evasion due to reduced expression of major histocompatibility complex class II (MHCII) genes through unknown mechanisms. In this work, we developed CORENODE, a computational algorithm for genome-wide transcription network decomposition that identified a transcription factor (TF) tetrad consisting of IRF8, MYB, MEF2C, and MEIS1, regulating MHCII expression in AML cells. We show that reduced MHCII expression at relapse is transcriptionally driven by combinatorial changes in the expression of these TFs, where MYB and IRF8 play major opposing roles, acting independently of the IFNγ/CIITA pathway. Beyond the MHCII genes, MYB and IRF8 antagonistically regulate a broad genetic program responsible for cytokine signaling and T-cell stimulation that displays reduced expression at relapse. A small number of cells with altered TF abundance and silenced MHCII expression are present at the time of initial leukemia diagnosis, likely contributing to eventual relapse.

SIGNIFICANCE

Our findings point to an adaptive transcriptional mechanism of AML evolution after allogeneic transplantation whereby combinatorial fluctuations of TF expression under immune pressure result in the selection of cells with a silenced T-cell stimulation program. This article is highlighted in the In This Issue feature, p. 369.

Cognitive biases encountered by physicians in the emergency room

Background

Diagnostic errors constitute an important medical safety problem that needs improvement, and their frequency and severity are high in emergency room settings. Previous studies have suggested that diagnostic errors occur in 0.6-12% of first-time patients in the emergency room and that one or more cognitive factors are involved in 96% of these cases. This study aimed to identify the types of cognitive biases experienced by physicians in emergency rooms in Japan.

Methods

We conducted a questionnaire survey using Nikkei Medical Online (Internet) from January 21 to January 31, 2019. Of the 159,519 physicians registered with Nikkei Medical Online when the survey was administered, those who volunteered their most memorable diagnostic error cases in the emergency room participated in the study. EZR was used for the statistical analyses.

Results

A total of 387 physicians were included. The most common cognitive biases were overconfidence (22.5%), confirmation (21.2%), availability (12.4%), and anchoring (11.4%). Of the error cases, the top five most common initial diagnoses were upper gastrointestinal disease (22.7%), trauma (14.7%), cardiovascular disease (10.9%), respiratory disease (7.5%), and primary headache (6.5%). The corresponding final diagnoses for these errors were intestinal obstruction or peritonitis (27.3%), overlooked traumas (47.4%), other cardiovascular diseases (66.7%), cardiovascular disease (41.4%), and stroke (80%), respectively.

Conclusions

A comparison of the initial and final diagnoses of cases with diagnostic errors shows that there were more cases with diagnostic errors caused by overlooking another disease in the same organ or a disease in a closely related organ.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00708-3.

Increasing the Status of Hospital General Medicine Departments with Emphasis on Outpatient Care in Japan

Demand is increasing for general medicine services in Japan, a super-aged society. The new medical specialty system introduced in 2019 obligates physicians to obtain a qualified specialty from among 19 basic specialty fields, including general medicine, before obtaining more advanced qualified subspecialties. The role of the department of general medicine in Japan varies in each hospital. Remuneration for medical services obtained by general medicine departments that mainly provide outpatient care is relatively low, making it difficult to fill positions in this department within a hospital. We conducted a narrative review and discussed ways to increase the status of hospital general medicine departments that mainly provide outpatient care. We consider the following four points to be important: improvement of diagnostic capabilities in the outpatient setting; playing a central role in education for medical students and residents; active involvement with patients who have diagnostic difficulties or social problems; and branding and promotion of the general medicine department. We envision that adopting an active approach to these points will increase the status of general medicine departments that mainly provide outpatient care within the hospital, allowing such newly established departments to start easily in Japanese hospitals in the future.

Relationship Between the Use of Preprinted Physician Orders for Hospital-Acquired Fever and Time to Blood Culture Collection: A Single-Center Retrospective Cross-Sectional Study

Purpose

Fever is relatively common in patients admitted to general wards. There is no standardized approach, and little is known about how physicians respond to fever. Additionally, preprinted physician orders are routinely used clinically in hospital medicine, and it is not clear how preprinted physician orders for fever affect the care of patients with fever. Therefore, we aimed to determine whether preprinted physician orders for inpatients have an effect on the time from fever measurement to blood culture collection.

Patients and Methods

This was a single-center, retrospective, cross-sectional study of patients with bacteremia. Between January 1, 2015 and December 31, 2019, 137 hospitalized febrile patients diagnosed with bacteremia by blood culture prepared from blood collected 72 h after hospitalization were included.

Results

Preprinted physician orders with instructions to call the physician if the patient has a fever were present for 59 patients. For preprinted physician orders with instructions to notify the physician about fever onset, 62.7% of the blood cultures were collected within 1 h of fever observation; when preprinted orders were not used, only 23.1% met the 1-h collection criterion. Multivariate analysis showed that preprinted physician orders were significantly associated with blood culture collection within 1 h from the reporting of fever (odds ratio, 4.94; 95% confidence interval, 2.27–10.70).

Conclusion

Preprinted physician orders with instructions to notify the physician about fever onset were present for only 40% of our sample, and this was related to the time of blood culture collection.

AB0382 COMPARISON OF ADVERSE EVENTS (AEs) RELATED TO MAJOR ANTI-RHEUMATIC DRUGS, REPORTED TO THE OFFICIAL JAPANESE ADVERSE DRUG EVENT REPORT DATABASE (JADER)

Background

Currently, many disease-modifying anti-rheumatic drugs (DMARDs) are available for the treatment of rheumatoid arthritis (RA). Among them, methotrexate (MTX), biologic DMARDs (bDMARDs) and Janus kinase inhibitors (JAKi) are the major options. AEs related to these are major concerns. In Japan, the AEs data spontaneously reported to and summarized by Pharmaceuticals and Medical Devices Agency (PMDA) are freely accessible.

Objectives

The major AEs relating to MTX, bDMARDs, and JAKi observed in the real world were compared.

Methods

The number of AEs listed by JADER from 2014 to 2020 was collected. The AEs were classified by System Organ Class (SOC) of Medical Dictionary for Regulatory Activities (MedDRA) and compared using the chi-square test. The bDMARDs included were etanercept (ETN), adalimumab (ADA), golimumab (GOL), tocilizumab (TCZ), and abatacept (ABT), and JAKi was tofacitinib (TOF) and baricitinib (BAR).

Results

The total number of AEs was 27,604. The number was significantly increasing in total and MTX, GOL, TOF during these years, although the number of cases that have each DMARD is not known in this study. The proportion of SOCs among each DMARD was similar throughout the period.

The most frequent was infections/infestations in all DMARDs except for MTX, in which neoplasms were the most. The primary cause of infection was bacterial, including pneumonia. Varicella-zoster virus infection in JAKi, and tuberculosis in ADA and GOL were conspicuous.

Neoplasms were the second major in many DMARDs. Lymphoproliferative disorders were most common in MTX-related neoplasms, whereas solid tumors were more in other DMARDs like ABT or BAR.

Other SOCs include all other categories such as the musculoskeletal, nervous system, cardiac, and vascular disorders. Among them, major adverse cardiovascular events (MACE, including cardiovascular death, myocardial infarction and stroke) and venous thromboembolism (VTE) were both reported in small numbers. However, more MACE was noted in BAR and GOL, and more VTE was in BAR and TOF compared to other DMARDs.

Conclusion

The number of AEs cases related to DMARDs was increasing. Significant difference among AEs related to DMARDs was noted in the JADER database, especially regarding MTX and JAKi.

References

[1]S. Inokuma. Expert Open Drug Saf. 2021 Nov 11. Online ahead of print.

Table 1.

Total case numbers and proportion of adverse events related to each DMARD.

DMARDs (year of launch)TotalMTX (1999)ETN (2005)ADA (2008)GOL (2011)TCZ (2008)ABT (2010)TOF (2013)BAR (2017)Number of AEs2760411636297419591302424517093065714Blood/lymphatic system disorders5.89.92.03.22.64.00.92.83.5Gastrointestinal disorders5.04.13.47.55.97.73.95.24.2General disorders/administration site reactions4.63.211.34.12.23.04.07.62.5Infections/infestations28.020.321.332.234.236.537.137.049.2 Pneumonia (bacterial)6.64.06.15.210.97.712.59.415.1 Other bacterial infection9.15.95.612.39.517.69.19.810.6 Herpes zoster2.11.10.41.41.21.01.28.211.2 Tuberculosis1.40.91.96.03.50.60.60.31.0Investigations5.04.95.52.32.65.72.28.32.8Neoplasms benign, malignant, unspecified21.134.811.013.512.77.415.610.815.4 Lymphoproliferative diseases14.329.82.84.14.02.24.52.12.2 Solid tumors5.63.87.37.87.54.09.97.310.5Respiratory, thoracic, mediastinal disorders7.16.88.38.49.56.57.46.26.7Other System Organ Class23.315.937.328.830.229.228.922.215.7 Major adverse cardiovascular events1.10.41.11.62.51.51.61.32.9 Venous thromboembolism0.40.10.40.50.60.30.21.11.4

Background colors indicate: comparing to the total cases, higher with p<0.05, light pink; higher with p<0.00001, dark pink; higher with p<1E-10, red. Lower with p<0.05, light blue; lower with p<0.00001, blue; lower with p<1E-10, dark blue, using chi-square test. Yellow indicates System Organ Classes.

Figure 1.

Total number of adverse events reported from 2014 to 2020.

Linear regression is shown only for DMARDs with increasing numbers of AEs.

Disclosure of Interests

None declared

Missed Opportunities for Diagnosing Vertebral Osteomyelitis Caused by Influential Cognitive Biases

Patient: Male, 83-year-old

Final Diagnosis: Vertebral osteomyelitis

Symptoms: Back pain • fever

Medication: —

Clinical Procedure: —

Specialty: Infectious Diseases

Feasibility and safety of endoscopic submucosal dissection for lesions in proximity to a colonic diverticulum

Background/Aims

Endoscopic submucosal dissection (ESD) for diverticulum-associated colorectal lesions is generally contraindicated because of the high risk of perforation. Several studies on patients with such lesions treated with ESD have been reported recently. However, the feasibility and safety of ESD for lesions in proximity to a colonic diverticulum (D-ESD) have not been fully clarified. The aim of this study was to evaluate the feasibility and safety of D-ESD.

Methods

D-ESD was defined as ESD for lesions within approximately 3 mm of a diverticulum. Twenty-six consecutive patients who underwent D-ESD were included. Two strategic approaches were used depending on whether submucosal dissection of the diverticulum-related part was required (strategy B) or not (strategy A). Treatment outcomes and adverse events associated with each strategy were analyzed.

Results

The en bloc resection rate was 96.2%. The rates of R0 and curative resection in strategies A and B were 80.8%, 73.1%, 84.6%, and 70.6%, respectively. Two cases of intraoperative perforation and one case of delayed perforation occurred. The delayed perforation case required emergency surgery, but the other cases were managed conservatively.

Conclusions

D-ESD may be a feasible treatment option. However, it should be performed in a high-volume center by expert hands because it requires highly skilled endoscopic techniques.

Hypoxic, glycolytic metabolism is a vulnerability of B-acute lymphoblastic leukemia-initiating cells

High-risk forms of B-acute lymphoblastic leukemia (B-ALL) remain a therapeutic challenge. Leukemia-initiating cells (LICs) self-renew and spark relapse and therefore have been the subject of intensive investigation; however, the properties of LICs in high-risk B-ALL are not well understood. Here, we use single-cell transcriptomics and quantitative xenotransplantation to understand LICs in MLL-rearranged (MLL-r) B-ALL. Compared with reported LIC frequencies in acute myeloid leukemia (AML), engraftable LICs in MLL-r B-ALL are abundant. Although we find that multipotent, self-renewing LICs are enriched among phenotypically undifferentiated B-ALL cells, LICs with the capacity to replenish the leukemic cellular diversity can emerge from more mature fractions. While inhibiting oxidative phosphorylation blunts blast proliferation, this intervention promotes LIC emergence. Conversely, inhibiting hypoxia and glycolysis impairs MLL-r B-ALL LICs, providing a therapeutic benefit in xenotransplantation systems. These findings provide insight into the aggressive nature of MLL-r B-ALL and provide a rationale for therapeutic targeting of hypoxia and glycolysis.

Morris et al. use single-cell transcriptomics to identify a candidate-initiating cell in B-acute lymphoblastic leukemia (B-ALL) with rearrangement of the KMT2A/MLL1 locus (MLL-r), finding that this population is plastic and exists in a hypoxic state that can be pharmacologically targeted.

A distinct core regulatory module enforces oncogene expression in KMT2A-rearranged leukemia

In this study, Harada et al. identified the transcription factors MEF2D and IRF8 as selective transcriptional dependencies of KMT2A-rearranged AML, where MEF2D displays partially redundant functions with its paralog, MEF2C. This study illustrates a mechanism of context-specific transcriptional addiction whereby a specific AML subclass depends on a highly specialized core regulatory module to directly enforce expression of common leukemia oncogenes.

Acute myeloid leukemia with KMT2A (MLL) rearrangements is characterized by specific patterns of gene expression and enhancer architecture, implying unique core transcriptional regulatory circuitry. Here, we identified the transcription factors MEF2D and IRF8 as selective transcriptional dependencies of KMT2A-rearranged AML, where MEF2D displays partially redundant functions with its paralog, MEF2C. Rapid transcription factor degradation followed by measurements of genome-wide transcription rates and superresolution microscopy revealed that MEF2D and IRF8 form a distinct core regulatory module with a narrow direct transcriptional program that includes activation of the key oncogenes MYC, HOXA9, and BCL2. Our study illustrates a mechanism of context-specific transcriptional addiction whereby a specific AML subclass depends on a highly specialized core regulatory module to directly enforce expression of common leukemia oncogenes.

Precise Measurement of Differential Cross Sections of the Σ^{-}p→Λn Reaction in Momentum Range 470-650 MeV/c

The differential cross sections of the Σ^{-}p→Λn reaction were measured accurately for the Σ^{-} momentum (p_{Σ}) ranging from 470 to 650  MeV/c at the J-PARC Hadron Experimental Facility. Precise angular information about the Σ^{-}p→Λn reaction was obtained for the first time by detecting approximately 100 reaction events at each angular step of Δcosθ=0.1. The obtained differential cross sections show a slightly forward-peaking structure in the measured momentum regions. The cross sections integrated for -0.7≤cosθ≤1.0 were obtained as 22.5±0.68 [statistical error(stat.)] ±0.65 [systematic error(syst.)] mb and 15.8±0.83(stat)±0.52(syst)  mb for 470<p_{Σ}(MeV/c)<550 and 550<p_{Σ}(MeV/c)<650, respectively. These results show a drastic improvement compared with past measurements of the hyperon-proton scattering experiments. They will play essential roles in updating the theoretical models of the baryon-baryon interactions.

Misdiagnosis Due to False-Positive Detection of Pneumococcal Urinary Antigen

Introduction: The detection of pneumococcal antigens in urine is an alternative to gram staining, and their culture is central to the diagnosis of pneumococcal pneumonia. We present a case of the false-positive detection of urinary Streptococcus species pneumococcal antigen with a BinaxNOW test. This resulted in delayed diagnosis of a liver abscess. Case description: A 70-year-old woman presented to the emergency department with a 1-day history of chills and difficulty walking. She had a fever and her physical examination was normal. Non-contrast chest computed tomography (CT) revealed a slight ground-glass opacity in the left lower lobe. Laboratory tests revealed liver injury and elevated C-reactive protein levels. A urinary pneumococcal antigen test was positive, and she was diagnosed with acute bronchopneumonia caused by Streptococcus pneumoniae. She was treated with ceftriaxone. However, abdominal contrast-enhanced CT performed the next day revealed portal vein thrombus and a left lobe liver abscess. Streptococcus constellatus was detected in a puncture specimen of the liver abscess. It was concluded that the positive urinary pneumococcal antigen test was a false-positive owing to Streptococcus infection. Discussion: False-positive results might be explained by the presence of C-polysaccharide antigens in the cell wall of S. pneumoniae. The positive urinary antigen test together with the finding of slight ground-glass opacity in the left lung on chest CT initially led to misdiagnosis. False positives may result in misdiagnosis and unnecessary antimicrobial therapy. Conclusion: The overuse of the pneumococcal urinary antigen tests can lead to false positives and misdiagnosis.

Two-dimensional echocardiographic scoring system of the left ventricular filling pressure and clinical outcomes in heart failure with preserved ejection fraction

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Japan Society for the Promotion of Science (JSPS)

Introduction

Elevated left ventricular (LV) filling pressure in non-decompensated state is a powerful indicator of worse clinical outcomes in heart failure regardless of LV ejection fraction. However, its detection is often challenging in heart failure with preserved ejection fraction (HFpEF).

Purpose

This study aimed to elucidate the predictive value of recently proposed echocardiographic parameter of LV filling pressure, Visually assessed time difference between the Mitral valve and Tricuspid valve opening (VMT) score in HFpEF.

Methods

We retrospectively analyzed 310 well-differentiated HFpEF patients in stable conditions. Using two-dimensional echocardiographic images, time sequence of opening of mitral valve and tricuspid valve was visually assessed in the apical four-chamber view and scored to 0 to 2 (0: tricuspid valve first, 1: simultaneous, 2: mitral valve first). When the inferior vena cava diameter was dilated, 1 point was added and VMT score was calculated as four grades from 0 to 3. Based on the previous study, VMT≥2 was regarded as a sign of elevated LV filling pressure (Figure 1). LV diastolic function was graded according to the guidelines. The primary endpoint was defined as a composite of cardiac death and heart failure hospitalisation during the two years after echocardiographic examination.

Results

During the follow-up period, 55 events (18%) occurred, including four cardiac deaths and 51 heart failure hospitalisations. Kaplan-Meier curves demonstrated that VMT≥2 (n = 54) was associated with worse outcomes compared to patients showing VMT ≤ 1 (n = 256) (log-rank test P &lt;0.001). Furthermore, VMT≥2 was associated with worse outcomes when tested in 100 HFpEF patients with atrial fibrillation (log-rank test P = 0.026) (Figure 2). In the adjusted model including age, systolic blood pressure, serum albumin level, and the LV diastolic function grading, VMT≥2 was independently associated with the primary outcome (hazard ratio: 2.23; 95% confidence interval: 1.17 to 4.24, P = 0.014). Additionally, the nested regression model showed that VMT scoring provided an incremental prognostic value over clinically relevant variables (age, sex, the plasma brain natriuretic peptide level, atrial fibrillation) and LV diastolic function grading (chi-square 10.8 vs 16.3, P = 0.035).

Conclusions

In patients with HFpEF, the VMT score was independently and incrementally associated with adverse clinical outcomes. Moreover, it discriminated worse clinical outcome even in HFpEF patients with atrial fibrillation. Abstract Figure. VMT scoring  Abstract Figure. Kaplan-Meier analysis

Single‐center observation of direct impact of the Tokyo 2020 Games on ambulance emergency response

The burden of the 2020 Tokyo Olympic and Paralympic Games on the local emergency medical system was limited. In addition to the Games were held without spectators, this was due to advance preparation by various organizations and the efforts of local staff, including primary care physicians.

Diagnostic error rates and associated factors for lower gastrointestinal perforation

Lower gastrointestinal perforation is rare and challenging to diagnose in patients presenting with an acute abdomen. However, no study has examined the frequency and associated factors of diagnostic errors related to lower gastrointestinal perforation. This large-scale multicenter retrospective study investigated the frequency of diagnostic errors and identified the associated factors. Factors at the level of the patient, symptoms, situation, and physician were included in the analysis. Data were collected from nine institutions, between January 1, 2015 and December 31, 2019. Timely diagnosis was defined as diagnosis at the first visit in computed tomography (CT)-capable facilities or referral to an appropriate medical institution immediately following the first visit to a non-CT-capable facility. Cases not meeting this definition were defined as diagnostic errors that resulted in delayed diagnosis. Of the 439 cases of lower gastrointestinal perforation identified, delayed diagnosis occurred in 138 cases (31.4%). Multivariate logistic regression analysis revealed a significant association between examination by a non-generalist and delayed diagnosis. Other factors showing a tendency with delayed diagnosis included presence of fever, absence of abdominal tenderness, and unavailability of urgent radiology reports. Initial misdiagnoses were mainly gastroenteritis, constipation, and small bowel obstruction. In conclusion, diagnostic errors occurred in about one-third of patients with a lower gastrointestinal perforation.

Lateral tongue bite in patient with transient loss of consciousness

The finding of a tongue bite is infrequent since it is a physical finding that is often overlooked, but it has a very high diagnostic value. It is important to check for tongue bites when examining any patient with a transient loss of consciousness.

Recent progress and future prospects of hyperon nucleon scattering experiment

A new hyperon-proton scattering experiment, dubbed J-PARC E40, was performed to measure differential cross sections of the Σ+p, Σ−p elastic scatterings and the Σ−p → Λn scattering by identifying a lot of Σ particles in the momentum ranging from 0.4 to 0.8 GeV/c produced by the π±p → K+Σ± reactions. We successfully measured the differential cross sections of these three channels with a drastically improved accuracy with a fine angular step. These new data will become important experimental constraints to improve the theories of the two-body baryon-baryon interactions. Following this success, we proposed a new experiment to measure the differential cross sections and spin observables by using a highly polarized Λ beam for providing quantitative information on the ΛN interaction. The results of three Σp channels and future prospects of the Λp scattering experiment are described.

Fitz-Hugh-Curtis syndrome without salpingitis: Should contrast-enhanced computed tomography be a routine diagnostic procedure?

Fitz-Hugh-Curtis syndrome should be suspected in sexually active young women presenting with acute right upper quadrant pain even in the absence of lower abdominal pain. The risk of radiation exposure associated with computed tomography should also be considered while making a diagnosis of abdominal pain in young patients.

Vertebral Artery Dissection after Exposure to Levofloxacin: A Report of Two Cases

Exposure to quinolones is known to be an independent risk factor for aortic dissection; however, the association with vertebral artery dissection remains unclear. We report two cases of vertebral artery dissection that occurred 4 and 8 days after exposure to levofloxacin, respectively. Both patients had risk factors for vertebral artery dissection, and quinolone use could have been avoided. These two cases indicate that quinolone exposure can be a risk factor for vertebral artery dissection. Considering the possible mechanism, it is better to avoid the prescription of quinolones to patients who have insufficient connective tissues to avoid vertebral artery dissection.

Delayed treatment of bacteremia during the COVID-19 pandemic

OBJECTIVES

Coronavirus disease (COVID-19) blindness, that is, the excessive consideration of the disease in diagnosis, has reportedly led to delayed diagnosis of some diseases. We compared several clinical measures between patients admitted for bacteremia during the two months of the COVID-19 pandemic and those admitted during the same period in 2019. We hypothesized that the pandemic has led to delayed treatment of bacteremia.

METHODS

This retrospective observational study compared several measures undertaken for patients who visited the emergency unit in two hospitals between March 1 and May 31, 2020, during the COVID-19 pandemic and whose blood cultures tested positive for bacteremia with those for corresponding patients treated during the same period in 2019. The primary measure was time from consultation to blood culture/antimicrobials.

RESULTS

We included 29 eligible patients from 2020 and 26 from 2019. In 2020, the time from consultation to antimicrobial administration was significantly longer than in 2019 (mean [range], 222 [145-309] min vs. 139 [102-179] min, p=0.002). The frequency of chest computed tomography (CT) was significantly higher in 2020 (96.6 vs. 73.1%, p=0.021). Significant differences were not observed in the time to blood culture or chest CT preceding the blood culture between the two periods.

CONCLUSIONS

Our findings suggested that due to the COVID-19 epidemic/pandemic, focusing on the exclusion of its infection using CT scans leads to an overall delay in the diagnosis and treatment of bacteremia. Medical providers must be aware of COVID-19 blindness and evaluate patients objectively based on rational criteria and take appropriate action.

Activated macrophages promote invasion by early colorectal cancer via an interleukin 1β-serum amyloid A1 axis

Submucosal invasion and lymph node metastasis are important issues affecting treatment options for early colorectal cancer (CRC). In this study, we aimed to unravel the molecular mechanism underlying the invasiveness of early CRCs. We performed RNA‐sequencing (RNA‐seq) with poorly differentiated components (PORs) and their normal counterparts isolated from T1 CRC tissues and detected significant upregulation of serum amyloid A1 (SAA1) in PORs. Immunohistochemical analysis revealed that SAA1 was specifically expressed in PORs at the invasive front of T1b CRCs. Upregulation of SAA1 in CRC cells promoted cell migration and invasion. Coculture experiments using CRC cell lines and THP‐1 cells suggested that interleukin 1β (IL‐1β) produced by macrophages induces SAA1 expression in CRC cells. Induction of SAA1 and promotion of CRC cell migration and invasion by macrophages were inhibited by blocking IL‐1β. These findings were supported by immunohistochemical analysis of primary T1 CRCs showing accumulation of M1‐like/M2‐like macrophages at SAA1‐positive invasive front regions. Moreover, SAA1 produced by CRC cells stimulated upregulation of matrix metalloproteinase‐9 in macrophages. Our data suggest that tumor‐associated macrophages at the invasive front of early CRCs promote cancer cell migration and invasion through induction of SAA1 and that SAA1 may be a predictive biomarker and a useful therapeutic target.