Vancomycin-Induced Neutropenia With Subsequent Perioperative Readministration: A Case Report

Vancomycin (VCM), an essential antibiotic for antimicrobial-resistant Gram-positive cocci, can lead to complications such as neutropenia. Here, we present a case of a 25-year-old male with noncommunicating hydrocephalus due to an intraventricular tumor who developed neutropenia during VCM therapy. Despite the suspected VCM-induced neutropenia, short-term readministration was deemed necessary for perioperative infection prophylaxis. This patient was readministered without neutropenia. A review of the literature revealed an earlier onset of VCM-induced neutropenia than that previously reported, emphasizing the importance of vigilant monitoring. Although readministration of VCM in patients with neutropenia is uncommon, it may be feasible with careful risk assessment, particularly in cases of mild neutropenia and short-term therapy. However, the mechanisms underlying VCM-induced neutropenia remain unclear, necessitating further research on the optimal management strategies.

Peak oxygen uptake in cardiopulmonary exercise testing was associated with left ventricular diastolic dysfunction in patients with preserved ejection fraction

Background

Heart failure with preserved ejection fraction (EF) remains a poor prognosis as same as heart failure with reduced EF. Peak oxygen uptake (VO2) by cardiopulmonary exercise testing (CPET) is a useful parameter for predicting cardiovascular diseases prognosis. Furthermore, though there are some reports that CPET parameters are associated with indicators of diastolic dysfunction, each of these indicators has some limitations. Recently, recommendations for the evaluation of left ventricular diastolic function by echocardiography were reported from the ASE/EACVI. However, no reports have examined the association between exercise tolerance indices and diastolic dysfunction based on these recommended variables.

Purpose

To examine the relationship between peak VO2 and diastolic dysfunction using the recommendation from ASE/EACVI in cardiovascular diseases patients with preserved EF

Methods

We recruited 214 patients who were performed both CPX and echocardiography. EF ≥50% was 99 patients. All patients underwent 0W warm-up and 10W ramp on an upright electrical bicycle ergometer. Diastolic dysfunction was assessed using the recommendations for the evaluation of diastolic function by ASE/EACVI. We used abnormal cutoff values are annular e' velocity: septal e' <7 cm/s, lateral e' <10 cm/s, average E/e' ratio >14, left atrial volume index >34 ml/m2, and peak tricuspid regurgitation (TR) velocity >2.8 m/s. Diastolic dysfunction is present if more than half of the available parameters meet these cutoff values.

Results

Mean age was 57±14 years old, the portion of women was 69%. The portion of diastolic dysfunction was 16%. In univariable logistic regression analysis, age, log BNP, septal e' <7 cm/s or lateral e' <10 cm/s, peak TR velocity >2.8 m/s, and the presence of diastolic dysfunction were significantly associated with peakVO2 <14 ml/min/kg. In multivariable logistic regression analysis, the presence of diastolic dysfunction was an independent risk factor for peak VO2 <14 ml/min/kg (OR 5.03 CI 1.32–19.2, p=0.018). Furthermore, we investigated the association between each variable of diastolic dysfunction and peak VO2 and found that low septal and lateral e'velocity and high TR peak flow velocity were significantly associated with peak VO2 <14 ml/min/kg.

Conclusions

In preserved EF, low peak VO2 was significantly associated with diastolic dysfunction assessed by the recommendations from the ASE/EACVI.

Funding Acknowledgement

Type of funding sources: None.

Oxidative stress was significantly associated with peak oxygen uptake in patients with dilated cardiomyopathy

Background

Systemic oxidative stress is known to be associated with the severity and prognosis in patients with cardiovascular diseases (CVD), including chronic heart failure. On the other hand, exercise tolerance is closely related to the prognosis in heart failure patients. However, no report has examined how oxidative stress is involved in each parameter evaluated by cardiopulmonary exercise testing (CPET) in patients with dilated cardiomyopathy (DCM).

Purpose

To examine the relationship between oxidative stress and CPET parameters such as peak VO2 and VE/VCO2 slope in patients with DCM

Methods

We recruited 214 patients with CVD who were performed CPET and measured brain natriuretic peptide (BNP) and haemoglobin (Hb). Finally, we enrolled 96 patients with DCM who have dilated dimensions of the left ventricular lumen by echocardiography and are diagnosed by endomyocardial biopsy. All patients underwent CPET using 0W warm-up and 10W ramp protocol on an upright electrical bicycle ergometer. We defined low peak VO2 as peak VO2<14 ml/min/kg and high VE/VCO2 slope as VE/VCO2 slope>34. The oxidative stress level was evaluated by a d-ROMs test, in which the amount of organic hydroperoxide converted into radicals oxidizing N, N-diethyl-p-phenylenediamine hydroperoxide is measured. The high level of d-ROMs was defined as d-ROMs≥401 U.CARR.

Results

Mean age was 56±15 years old. Mean ejection fraction, peak VO2 and VE/VCO2 slope were 37±15%, 16.3±5.0 ml/min/kg, and 31.0±11.8, respectively. The percentage of the high level of d-ROMs was 25%. In univariable logistic regression analysis, Hb, log BNP, and the high level of oxidative stress were significantly associated with low peak VO2, whereas, in multivariable logistic regression analysis, age, Hb, and log BNP were significant factors for high VE/VCO2 slope. In multivariable logistic regression analysis, only the high level of d-ROMs was independently associated with low peak VO2 (OR 3.18, CI 1.12–9.04, p=0.030). While, in multivariable logistic regression analysis, Hb (OR 0.51, CI 0.32–0.81, p=0.004) and log BNP (OR 2.77, CI 1.33–5.76, p=0.006) were significantly related to high VE/VCO2 slope.

Conclusions

In patients with DCM, low peak VO2 was associated with the high level of d-ROMs, and high VE/VCO2 slope was associated with BNP. These results suggested that oxidative stress was only related to peak VO2.

Funding Acknowledgement

Type of funding sources: None.

Development of a risk prediction score and equation for chronic kidney disease: a retrospective cohort study

Background

Chronic kidney disease (CKD) is a risk factor for end-stage renal disease and contributes to increased risk of cardiovascular disease morbidity and mortality. We aimed to develop a risk prediction score and equation for future onset of CKD using large-scale health checkup data.

Methods

This retrospective cohort study included 58,423 participants without baseline CKD who were randomly assigned to Derivation (n=38,948) and Validation cohorts (n=19,475) at a ratio of 2:1. The predictors were anthropometric indices, life style, and blood sampling data. In the Derivation cohort, we performed multivariable logistic regression analysis and obtained the standardized beta coefficient of each factor that was significantly associated with new-onset CKD and assigned scores to each factor. We created a score and an equation to determine the risk of developing CKD after 5 years and applied them to the Validation cohort to assess their reproducibility.

Results

The risk prediction scores ranged from 0 to 16, consisting of the seven indicators, including age, sex, hypertension, dyslipidemia, diabetes, hyperuricemia, and estimated glomerular filtration rate (eGFR). From the receiver operating characteristic (ROC) curve predicting CKD incidence, the area under the curve (AUC) was 0.78. A score of ≥8 showed the highest Youden index in the Derivation cohort, with a sensitivity of 0.90 and specificity of 0.52. The CKD incidence gradually and constantly increased as the score increased from ≤6 to ≥14 (Figure). The risk prediction equation consisted of aforementioned seven indicators: 1/(1 + exp[−(9.4876 + 0.0311×age + 0.2400×sex + 0.3470×hypertension + 0.0893×dyslipidemia + 0.3444×diabetes + 0.0832×hyperuricemia + (−0.1980)×eGFR]). The median probability obtained from the Derivation cohort was 0.018 (interquartile range 0.002–0.084), and the AUC value of the ROC curve for the development of CKD after 5 years was 0.88, with a sensitivity of 0.84 and a specificity of 0.78 at a cutoff value of 0.077. The Validation cohort analysis yielded similar results.

Conclusion

We developed a clinically useful risk score and equation to predict the CKD incidence after 5 years in the general Japanese population. These models have reasonably high predictability and reproducibility.

Funding Acknowledgement

Type of funding sources: None.

A new primate model of hypophyseal dysfunction

For pituitary regenerative medicine, the creation of a hypophyseal model in monkeys is necessary to conduct future preclinical studies; however, previous studies reported that hypophysectomy in monkeys is not always safe or satisfactory. This study aimed to create a hypophyseal dysfunction model in a cynomolgus monkey using a safer surgical technique and establish the protocol of pituitary hormone replacement therapy for this model. Surgical resection of the pituitary gland of a 7.8-year-old healthy adult cynomolgus male monkey weighing 5.45 kg was performed to create a hypophyseal dysfunction model for future regenerative studies. Endoscopic transoral transsphenoidal surgery was used to perform hypophysectomy under navigation support. These procedures were useful for confirming total removal of the pituitary gland without additional bone removal and preventing complications such as cerebrospinal fluid leakage. Total removal was confirmed by pathological examination and computed tomography. Hypopituitarism was verified with endocrinological examinations including stimulation tests. Postoperatively, the monkey's general condition of hypopituitarism was treated with hormone replacement therapy, resulting in long-term survival. The success of a minimally invasive and safe surgical method and long-term survival indicate the creation of a hypophyseal dysfunction model in a cynomolgus monkey; hence, this protocol can be employed in the future.

Gender differences in the effects of weight reduction on future blood pressure elevation in the overweight middle-aged population

Background

The effectiveness of weight loss (WL) to prevent blood pressure (BP) elevation is common knowledge; however, the effect of gender differences on this efficacy is not known. We aimed to investigate whether there were gender differences in the degree of BP increase and the prevalence of hypertension in the future when middle-aged obese participants achieved slight WL.

Methods

We analyzed the annual health checkup data for the general Japanese population collected from January 2001 through December 2015. Middle-aged participants (40–49 years old) with overweight (body mass index [BMI], 25.0–29.9 kg/m2) who had examination data for two follow-up time-points (after 3 and 10 years) were included. The participants with a BMI decrease ≥1.0 kg/m2 in 3 years (WL group) were propensity score (PS)-matched to those with a BMI decrease <1.0 kg/m2 or weight gain (non-WL group) based on the data of the first examination, including age, BMI, smoking and drinking status, eGFR, systolic BP and diastolic BP, and hypertension (defined as SBP ≥140 mmHg and/or DBP ≥90 mmHg). We compared the BMI, systolic BP, and hypertension prevalence after 10 years in both groups.

Results

There were 17,554 individuals, aged 40–49 years, with overweight. After excluding subjects who did not satisfy the inclusion criteria and PS matching, we identified 232 men and 160 women in both WL and non-WL groups. The BMI in the WL group after 3 years was significantly lower than that in the non-WL group (men, 25.2±1.4 kg/m2 vs. 27.1±1.6 kg/m2, P<0.001; women, 24.9±1.4 kg/m2 vs. 27.1±1.5 kg/m2, P<0.001), and the significance persisted even after 10 years among both men and women (men, 25.5±1.8 kg/m2 vs. 26.8±2.1 kg/m2, P<0.001; women, 25.3±2.0 kg/m2 vs. 26.8±2.2 kg/m2, P<0.001). Among women, the systolic BP and hypertension prevalence after 10 years were significantly lower in the WL group than in the non-WL group (systolic BP, 124.8±16.3 mmHg vs. 130.3±19.0 mmHg, P<0.01; hypertension prevalence, 35.0% vs. 48.1%, P<0.05). In contrast, there were no significant differences in the SBP and hypertension prevalence after 10 years among men between the groups (systolic BP, 129.0±17.7 mmHg vs. 129.0±17.5 mmHg, P=0.96; hypertension prevalence, 46.1% vs. 48.7%, P=0.57).

Conclusions

There were gender differences in the effectiveness of WL to prevent future BP elevation in overweight middle-aged participants. WL could prevent future BP elevation and the hypertension onset in women but not in men.

Funding Acknowledgement

Type of funding source: None

Fib4 index is a more relevant marker for pulse wave velocity but not for carotid intima-media thickness in a men population

Background

Carotid intima-media thickness (IMT) and pulse wave velocity (PWV) are useful markers for predicting cardiovascular disease not only in patients with cardiovascular disease but also in the general population. On the other hand, liver disease due to obesity has become a problem and has been reported to be associated with the progression of atherosclerosis. Recently, an indicator of liver stiffness, the Fibrosis-4 index (Fib4 index), has been used to detect the pre-stage liver diseases. However, there is no report to investigate the association between atherosclerotic parameters such as IMT and PWV, and Fib4 index. The Fib4 index is a simple index calculated from age and three blood sample data, and it will be useful for screening for an early stage of atherosclerosis if we can show the association between Fib4 index and these parameters.

Purpose

To investigate the association between atherosclerotic parameters such as IMT or PWV and Fib4 index

Methods

We recruited 3, 128 men participants who underwent health checkup. IMT was evaluated by carotid ultrasonography, and branchial-ankle PWV (baPWV) was measured by an automatic device. We analysed the association of IMT or baPWV with Fib4 index and atherosclerotic risk factors such as age, systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C) and fasting blood sugar (FBS). baPWV ≥1,600 cm/s was defined high baPWV and we performed the receiver operating characteristics (ROC) analysis to demonstrate the significance of Fib4 index for baPWV.

Results

Mean Fib4 index was 1.39±0.68. In the univariate linear regression analysis, all factors such as age, SBP, LDL-C, FBS, Fib4 index were significantly associated with IMT or baPWV. On the other hand, in the multivariate linear regression analysis, Fib4 index was an independent factor for baPWV but not for IMT (IMT, p=0.498; baPWV, p=0.023). Figure 1 showed the result of ROC analysis to predict the high baPWV by Fib4 index. The area under curve (AUC) was 0.73, with the highest discriminating sensitivity and specificity at 0.71 and 0.65, respectively at Fib4 index = 1.27.

Conclusions

Fib4 index was significantly related to baPWV and could be the useful screening marker for arterial stiffness in a general men population.

Figure 1. ROC curve analysis

Funding Acknowledgement

Type of funding source: None

Mapping of a New Deformation Region around ^{62}Ti

We performed the first direct mass measurements of neutron-rich scandium, titanium, and vanadium isotopes around the neutron number 40 at the RIKEN RI Beam Factory using the time-of-flight magnetic-rigidity technique. The atomic mass excesses of ^{58-60}Sc, ^{60-62}Ti, and ^{62-64}V were measured for the first time. The experimental results show that the two-neutron separation energies in the vicinity of ^{62}Ti increase compared to neighboring nuclei. This shows that the masses of Ti isotopes near N=40 are affected by the Jahn-Teller effect. Therefore, a development of Jahn-Teller stabilization appears below the Cr isotopes, and the systematics in Sc, Ti, and V isotopes suggest that ^{62}Ti is located close to the peak of the Jahn-Teller effect.

Endoscopic Treatment Strategy for a Disproportionately Large Communicating Fourth Ventricle: Case Series and Literature Review

An isolated fourth ventricle (IFV) is characterized by fourth ventricular dilation due to obstruction of its inlet and outlet. A disproportionately large communicating fourth ventricle (DLCFV) is a rare subtype of IFV, characterized by dilation of the fourth ventricle, regardless of the size of the lateral ventricles, with no apparent obstruction of the cerebral aqueduct. To our knowledge, this is the first case series describing endoscopic diagnosis and treatment strategy for DLCFV. We retrospectively reviewed six cases of DLCFV in which endoscopic surgery was performed at our institution and affiliated facilities between June 2013 and March 2017. DLCFV was diagnosed using radiographic imaging and intraoperative endoscopy. We also conducted a PubMed search and included only original studies related to DLCFV treatment written in English in our review of the literature. Endoscopic third ventriculostomy (ETV) was performed in all patients. Additional endoscope-assisted placement of a fourth ventriculoperitoneal (VP) shunt was performed in two patients who could not be managed with ETV alone because of severe adhesion of the interpeduncular cistern due to subarachnoid hemorrhage (SAH). The patients' symptoms and the size of the fourth ventricle improved with surgical treatment, without complications. Endoscopic surgery for DLCFV appears to be a safe and effective treatment. Based on our treatment strategy, ETV is the first-line treatment for DLCFV. Endoscope-assisted placement of the fourth VP shunt can be treatment for severe adhesion of the interpeduncular cistern.

Damage accrual related to pregnancies before and after diagnosis of systemic lupus erythematosus: a cross-sectional and nested case-control analysis from a lupus registry

OBJECTIVE

The objective of this study was to evaluate the chronic damage associated with pregnancies before and after the diagnosis of systemic lupus erythematosus (SLE).

METHODS

Using childbearing-aged female SLE patient data registered at the Okayama and Showa University Hospitals, a nested case-control analysis was performed to investigate the relationship between pregnancy and chronic damage using the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI).

RESULTS

Pregnancy occurred in 22 patients before and 13 patients after the diagnosis of SLE in 104 eligible patients. Live births occurred in 82% (33/40) and 50% (9/18) of the pregnancies before and after the diagnosis of SLE, respectively. After matching age and disease duration, 33 case patients with chronic damage (SDI ≥ 1) and 33 control patients without chronic damage (SDI = 0) were selected. Hypertension was more frequent in cases than in controls (48% vs. 24%, p = 0.041). Pregnancies before and after the diagnosis of SLE were comparable between cases and controls (before the diagnosis: nine case patients and eight control patients; after the diagnosis: three case patients and five control patients; p = 1.00). Even after adjusting for hypertension using multivariate analysis, the pregnancies before and after the diagnosis were not significant predictors for chronic damage (odds ratio = 1.48 (95% confidence interval 0.33-6.65)), p = 0.60 of the pregnancy before the diagnosis; odds ratio = 0.78 (95% confidence interval 0.13-4.74), p = 0.78 of the pregnancy after the diagnosis).

CONCLUSION

Pregnancies, either before or after the diagnosis of SLE, did not show any differences in chronic damage. Our results help alleviate fears regarding childbearing in female patients with SLE and their families.

Peel-off resection of the pituitary gland for functional pituitary adenomas: pathological significance and impact on pituitary function

PURPOSE

Functional pituitary adenomas (FPAs) lacking a well-defined pseudocapsule can invade the adjacent pituitary gland. In such situations, peel-off resection of the adjacent pituitary gland after selective adenomectomy might lead to complete tumor removal, resulting in optimal endocrinological outcomes. Here, we present the significance of peel-off resection of the pituitary gland in patients with FPA in whom complete extracapsular tumor removal cannot be achieved.

METHODS

We performed a retrospective review of 21 patients with FPA who underwent transsphenoidal surgery (TSS). After selective adenomectomy, peel-off resection of the adjacent pituitary gland was performed in 13 patients because complete extracapsular resection could not be achieved, while peel-off resection was not performed in the remaining 8 patients because complete extracapsular resection was accomplished. The clinical outcomes of these groups were compared. The pituitary tissues obtained by peel-off resection were pathologically examined for tumor cells.

RESULTS

Early postoperative biochemical remission was achieved in 20 patients (95.2%). Anterior pituitary functions were not aggravated postoperatively in any patient: however, transient diabetes insipidus (DI) occurred in 2 patients. There were no statistically significant differences in the clinical outcomes of the two groups. A pseudocapsule was pathologically detected in the adjacent anterior pituitary even in patients in whom no pseudocapsule was intraoperatively detected. Tumor cells were pathologically detected in 7 (58.3%) of 12 pituitary tissues examined.

CONCLUSIONS

Peel-off resection of the pituitary gland, which can remove a small tumor cell remnant in the adjacent pituitary, might maximize the effectiveness of TSS with minimal impact on postoperative pituitary function.

Removal of the Medial Wall of the Cavernous Sinus for Functional Pituitary Adenomas: A Technical Report and Pathologic Significance

BACKGROUND

Removal of the medial wall of the cavernous sinus (MW) is challenging for neurosurgeons. We describe a practical method of endoscopic MW removal via endonasal transsphenoidal approach to minimalize intraoperative blood loss and postoperative morbidities. We also present the pathologic significance of this technique for functional pituitary adenomas (FPAs).

METHODS

We performed MW removal in patients with FPA with no well-defined pseudocapsule and a tumor in direct contact with the MW. The MW was judged to have tumor invasion based on the intraoperative appearance, and it was removed regardless of the appearance of MW involvement. Intraoperative findings and postoperative clinical, endocrinologic, and pathologic outcomes were retrospectively reviewed.

RESULTS

Fourteen patients underwent MW removal for FPA, including 12 patients with acromegaly and 2 with Cushing disease. Mean intraoperative blood loss was 170 mL (range, 32-400 mL), and none of the patients required blood transfusion. Among the 7 patients without intraoperative apparent MW involvement, 4 (57.1%) had pathologically confirmed tumor invasion into the MW (occult invasion). Biochemical remission by surgery alone was achieved in 13 patients (92.9%). Transient oculomotor palsy occurred in 1 patient (7.1%).

CONCLUSIONS

Occult tumor invasion into the MW was often detected in patients with FPA without a well-defined pseudocapsule but in direct contact with the MW. Our technique can enhance the effectiveness of surgery with minimal postoperative morbidities.

Dominance of Tensor Correlations in High-Momentum Nucleon Pairs Studied by (p,pd) Reaction

The isospin character of p-n pairs at large relative momentum has been observed for the first time in the ^{16}O ground state. A strong population of the J,T=1,0 state and a very weak population of the J,T=0,1 state were observed in the neutron pickup domain of ^{16}O(p,pd) at 392 MeV. This strong isospin dependence at large momentum transfer is not reproduced by the distorted-wave impulse approximation calculations with known spectroscopic amplitudes. The results indicate the presence of high-momentum protons and neutrons induced by the tensor interactions in the ground state of ^{16}O.

Progressive reduction of serum complement levels: a risk factor for relapse in patients with hypocomplementemia in systemic lupus erythematosus

Objective

Serologically active clinically quiescent (SACQ)-SLE is a subtype of systemic lupus erythematosus (SLE); most SACQ-SLE patients relapse. Although complement and/or anti-dsDNA level fluctuations during SACQ status are reportedly not useful for predicting relapse, they might be useful in specific clinical settings. We aimed to assess the correlation between future relapse and progressive reductions in serum complement levels following remission in patients with hypocomplementemia .

Methods

We retrospectively reviewed patients aged ≥15 years who were treated with ≥20 mg/day of prednisolone for remission induction. After achieving remission, the patients treated with prednisolone tapered to ≤15 mg/day without relapse and followed by hypocomplementemia (first hypocomplementemia point) were analyzed. The primary outcome was the relapse during the first 24 months.

Results

Seventy-six patients were enrolled; 31 (40.8%) relapsed. A ≥10% reduction after the first hypocomplementemia point in serum C3, C4, and CH50 levels was found in 10, 21, and 16 patients, respectively. Hazard ratios (95% confidence intervals) for relapse were 2.32 (0.92–5.12) for serum C3 levels and 2.46 (1.18–5.01) for serum C4 levels. Progressive reductions in serum C3 and C4 levels had relatively high specificity (93.3% and 82.2%) but limited sensitivity (22.6% and 41.9%) for predicting relapse. However, simultaneous progressive reduction in C3 levels and increase in anti-dsDNA antibody levels had the highest specificity (97.8%), and simultaneous progressive reduction in C4 levels or increase in anti-dsDNA antibody levels had the highest sensitivity (71.0%).

Conclusion

Simultaneous progressive reductions in complement levels and increases in anti-dsDNA antibody levels may indicate future relapse SACQ-SLE patients.

Three types of dural suturing for closure of CSF leak after endoscopic transsphenoidal surgery

OBJECTIVE: Transsphenoidal surgery (TSS) is commonly used for anterior skull base surgery, especially in the sella turcica (sellar) region. However, because of its anatomical position, CSF leakage is a major complication of this approach. The authors introduced a new grading reconstruction strategy for anterior skull base surgery with continuous dural suturing in 2013. In this paper the authors report on their methods and results. METHODS: All patients with sellar or anterior skull base lesions that were removed with TSS or extended TSS by a single neurosurgeon between April 2013 and March 2017 at Nagoya University Hospital and several cooperating hospitals were retrospectively identified. Three methods of suturing dura were considered, depending on the dural defect. RESULTS: There were 176 TSS cases (141 conventional TSS cases and 35 extended endoscopic TSS cases) and 76 cases of Esposito's grade 2 or 3 intradural high-flow CSF leakage. In the high-flow CSF leak group, there were 3 cases of CSF leakage after the operation. The rates of CSF leakage after surgery corresponding to grades 2 and 3 were 2.9% (1/34) and 4.7% (2/42), respectively. CONCLUSIONS: Dural suturing is a basic and key method for reconstruction of the skull base, and continuous suturing is the most effective approach. Using this approach, the frequency of cases requiring a nasoseptal flap and lumbar drainage can be reduced.

Magic Nature of Neutrons in ^{54}Ca: First Mass Measurements of ^{55-57}Ca

We perform the first direct mass measurements of neutron-rich calcium isotopes beyond neutron number 34 at the RIKEN Radioactive Isotope Beam Factory by using the time-of-flight magnetic-rigidity technique. The atomic mass excesses of ^{55-57}Ca are determined for the first time to be -18650(160), -13510(250), and -7370(990)  keV, respectively. We examine the emergence of neutron magicity at N=34 based on the new atomic masses. The new masses provide experimental evidence for the appearance of a sizable energy gap between the neutron 2p_{1/2} and 1f_{5/2} orbitals in ^{54}Ca, comparable to the gap between the neutron 2p_{3/2} and 2p_{1/2} orbitals in ^{52}Ca. For the ^{56}Ca nucleus, an open-shell property in neutrons is suggested.

Distribution of gene segments of the pandemic A(H1N1) 2009 virus lineage in pig populations

Swine influenza viruses (SIVs) are important not only for pig farming, but also for public health. In fact, pandemic A(H1N1) 2009 viruses [A(H1N1)pdm09] were derived from SIVs. Therefore, timely characterization of locally circulating SIVs is necessary for understanding the global status of SIVs. To genetically characterize SIVs circulating in Japanese pig populations, we isolated 24 SIVs of three subtypes (17 H1N1, four H1N2 and three H3N2 strains) from 14 pig farms in Japan from 2013 to 2016. Genetic analyses revealed that the haemagglutinin (HA) and neuraminidase (NA) genes of the 17 H1N1 and the HA gene of one H1N2, A/swine/Aichi/02/2016 (H1N2), SIVs belonged to the A(H1N1)pdm09 lineage. More importantly, all of the remaining six gene segments (i.e., PB1, PB1, PA, NP, M and NS) of the 24 SIVs, regardless of the HA and NA subtype, were also classified as belonging to the A(H1N1)pdm09 lineage. These results indicate that gene segments of A(H1N1)pdm09 lineage are widely distributed in SIVs circulating in Japanese pig populations In addition, the NA gene of A/swine/Aichi/02/2016 (H1N2) shared less than 88.5% nucleotide identity with that of the closest relative A/swine/Miyagi/5/2003 (H1N2), which was isolated in Japan in 2003. These results indicate the sustained circulation of classical H1N2-derived SIVs with remarkable diversity in the NA genes in Japanese pig populations. These findings highlight the necessity of both intensive biosecurity systems and active SIV surveillance in pig populations worldwide for both animal and public health.

Excitation of the Isovector Spin Monopole Resonance via the Exothermic ^{90}Zr(^{12}N,^{12}C) Reaction at 175 MeV/u

The (^{12}N, ^{12}C) charge-exchange reaction at 175  MeV/u was developed as a novel probe for studying the isovector spin giant monopole resonance (IVSMR), whose properties are important for better understanding the bulk properties of nuclei and asymmetric nuclear matter. This probe, now available through the production of ^{12}N as a secondary rare-isotope beam, is exothermic, is strongly absorbed at the surface of the target nucleus, and provides selectivity for spin-transfer excitations. All three properties enhance the excitation of the IVSMR compared to other, primarily light-ion, probes, which have been used to study the IVSMR thus far. The ^{90}Zr(^{12}N,^{12}C) reaction was measured and the excitation energy spectra up to about 70 MeV for both the spin-transfer and non-spin-transfer channels were deduced separately by tagging the decay by γ emission from the ^{12}C ejectile. Besides the well-known Gamow-Teller and isobaric analog transitions, a clear signature of the IVSMR was identified. By comparing with the results from light-ion reactions on the same target nucleus and theoretical predictions, the suitability of this new probe for studying the IVSMR was confirmed.

Evidence for prevalent Z = 6 magic number in neutron-rich carbon isotopes

The nuclear shell structure, which originates in the nearly independent motion of nucleons in an average potential, provides an important guide for our understanding of nuclear structure and the underlying nuclear forces. Its most remarkable fingerprint is the existence of the so-called magic numbers of protons and neutrons associated with extra stability. Although the introduction of a phenomenological spin-orbit (SO) coupling force in 1949 helped in explaining the magic numbers, its origins are still open questions. Here, we present experimental evidence for the smallest SO-originated magic number (subshell closure) at the proton number six in 13-20C obtained from systematic analysis of point-proton distribution radii, electromagnetic transition rates and atomic masses of light nuclei. Performing ab initio calculations on 14,15C, we show that the observed proton distribution radii and subshell closure can be explained by the state-of-the-art nuclear theory with chiral nucleon-nucleon and three-nucleon forces, which are rooted in the quantum chromodynamics.

Refractory neuromyelitis optica spectrum disorder in systemic lupus erythematosus successfully treated with rituximab

We present a case of a woman with systemic lupus erythematosus (SLE) who had refractory episodes of neuromyelitis optica spectrum disorder (NMOSD) and was successfully treated with rituximab. She was positive for anti-aquaporin-4 (AQP4) antibody and had typical cranial and longitudinally extended spinal lesions but no optic nerve involvement. There is no established treatment for NMOSD/SLE overlap cases. Our experience suggests that rituximab may be effective for patients with combined SLE and anti-AQP4 antibody-positive NMOSD.

Refractory neuromyelitis optica spectrum disorder in systemic lupus erythematosus successfully treated with rituximab

We present a case of a woman with systemic lupus erythematosus (SLE) who had refractory episodes of neuromyelitis optica spectrum disorder (NMOSD) and was successfully treated with rituximab. She was positive for anti-aquaporin-4 (AQP4) antibody and had typical cranial and longitudinally extended spinal lesions but no optic nerve involvement. There is no established treatment for NMOSD/SLE overlap cases. Our experience suggests that rituximab may be effective for patients with combined SLE and anti-AQP4 antibody-positive NMOSD.

Tumor Volume Decrease via Feeder Occlusion for Treating a Large, Firm Trigone Meningioma

Trigone meningiomas are considered a surgical challenge, as they tend to be considerably large and hypervascularized at the time of presentation. We experienced a case of a large and very hard trigone meningioma that was effectively treated using initial microsurgical feeder occlusion followed by surgery in stages. A 19-year-old woman who presented with loss of consciousness was referred to our hospital for surgical treatment of a brain tumor. Radiological findings were compatible with a left ventricular trigone meningioma extending laterally in proximity to the Sylvian fissure. At initial surgery using the transsylvian approach, main feeders originating from the anterior and lateral posterior choroidal arteries were occluded at the inferior horn; however, only a small section of the tumor could initially be removed because of its firmness. Over time, feeder occlusion resulted in tumor necrosis and a 20% decrease in its diameter; the mass effect was alleviated within 1 year. The residual meningioma was then totally excised in staged surgical procedures after resection became more feasible owing to ischemia-induced partial softening of the tumor. When a trigone meningioma is large and very hard, initial microsurgical feeder occlusion in the inferior horn can be a safe and effective option, and can lead to necrosis, volume decrease, and partial softening of the residual tumor to allow for its staged surgical excision.

A Novel Dissection Method Using a Flexible Neuroendoscope for Resection of Tumors Around the Aqueduct of Sylvius

BACKGROUND

Flexible endoscopes have both a wide range of movement and a wide field of view and are therefore widely used for endoscopic third ventriculostomy and biopsy. However, tumor resection around the aqueduct of Sylvius using flexible endoscopes has scarcely been reported.

CASE DESCRIPTION

We report 2 cases of tumor resection around the aqueduct of Sylvius. The first case is a 38-year-old man presenting with progressive headache, nausea, and diplopia. Magnetic resonance imaging (MRI) revealed a 1.4 cm nonenhancing mass at the entry of the aqueduct of Sylvius and occlusive hydrocephalus. We performed tumor resection and endoscopic third ventriculostomy (ETV) simultaneously. His symptoms disappeared after the operation. Final pathologic diagnosis was ancient schwannoma. The second case is a 78-year-old woman presenting with progressive disturbance of consciousness (coma). MRI showed 0.7 cm nonenhancing mass at the entry of the aqueduct of Sylvius and occlusive hydrocephalus. We performed tumor resection and ETV similarly. Her consciousness improved after the operation. Final tumor diagnosis was cavernous malformation. In both cases there was no additional neurologic deficit after the surgery.

CONCLUSIONS

By using a flexible endoscope for tumor dissection, resection of a tumor without a neck, which cannot be removed through aspiration alone, becomes possible. To our knowledge, the presented cases are the first to describe the effectiveness of complete resection of a tumor in the third ventricle using flexible endoscopy.

A novel rare variant R292H in RTN4R affects growth cone formation and possibly contributes to schizophrenia susceptibility

Reticulon 4 receptor (RTN4R) plays an essential role in regulating axonal regeneration and plasticity in the central nervous system through the activation of rho kinase, and is located within chromosome 22q11.2, a region that is known to be a hotspot for schizophrenia (SCZ) and autism spectrum disorder (ASD). Recently, rare variants such as copy-number variants and single-nucleotide variants have been a focus of research because of their large effect size associated with increased susceptibility to SCZ and ASD and the possibility of elucidating the pathophysiology of mental disorder through functional analysis of the discovered rare variants. To discover rare variants with large effect size and to evaluate their role in the etiopathophysiology of SCZ and ASD, we sequenced the RTN4R coding exons with a sample comprising 370 SCZ and 192 ASD patients, and association analysis using a large number of unrelated individuals (1716 SCZ, 382 ASD and 4009 controls). Through this mutation screening, we discovered four rare (minor allele frequency <1%) missense mutations (R68H, D259N, R292H and V363M) of RTN4R. Among these discovered rare mutations, R292H was found to be significantly associated with SCZ (P=0.048). Furthermore, in vitro functional assays showed that the R292H mutation affected the formation of growth cones. This study strengthens the evidence for association between rare variants within RTN4R and SCZ, and may shed light on the molecular mechanisms underlying the neurodevelopmental disorder.

Rare genetic variants in CX3CR1 and their contribution to the increased risk of schizophrenia and autism spectrum disorders

CX3CR1, a G protein-coupled receptor solely expressed by microglia in the brain, has been repeatedly reported to be associated with neurodevelopmental disorders including schizophrenia (SCZ) and autism spectrum disorders (ASD) in transcriptomic and animal studies but not in genetic studies. To address the impacts of variants in CX3CR1 on neurodevelopmental disorders, we conducted coding exon-targeted resequencing of CX3CR1 in 370 Japanese SCZ and 192 ASD patients using next-generation sequencing technology, followed by a genetic association study in a sample comprising 7054 unrelated individuals (2653 SCZ, 574 ASD and 3827 controls). We then performed in silico three-dimensional (3D) structural modeling and in vivo disruption of Akt phosphorylation to determine the impact of the detected variant on CX3CR1-dependent signal transduction. We detected a statistically significant association between the variant Ala55Thr in CX3CR1 with SCZ and ASD phenotypes (odds ratio=8.3, P=0.020). A 3D structural model indicated that Ala55Thr could destabilize the conformation of the CX3CR1 helix 8 and affect its interaction with a heterotrimeric G protein. In vitro functional analysis showed that the CX3CR1-Ala55Thr mutation inhibited cell signaling induced by fractalkine, the ligand for CX3CR1. The combined data suggested that the variant Ala55Thr in CX3CR1 might result in the disruption of CX3CR1 signaling. Our results strengthen the association between microglia-specific genes and neurodevelopmental disorders.

Sodium temperature/wind lidar based on laser-diode-pumped Nd:YAG lasers deployed at Tromsø, Norway (69.6°N, 19.2°E)

An Nd:YAG laser-based sodium temperature/wind lidar was developed for the measurement of the northern polar mesosphere and lower thermosphere at Tromsø (69.6N, 19.2E), Norway. Coherent light at 589 nm is produced by sum frequency generation of 1064 nm and 1319 nm from two diode laser end-pumped pulsed Nd:YAG lasers. The output power is as high as 4W, with 4 mJ/pulse at 1000 Hz repetition rate. Five tilting Cassegrain telescopes enable us to make five-direction (zenith, north, south, east, west) observation for temperature and wind simultaneously. This highly stable laser system is first of its kind to operate virtually maintenance-free during the observation season (from late September to March) since 2010.

Time-Reversal Measurement of the p-Wave Cross Sections of the ^{7}Be(n,α)^{4}He Reaction for the Cosmological Li Problem

The cross sections of the ^{7}Be(n,α)^{4}He reaction for p-wave neutrons were experimentally determined at E_{c.m.}=0.20-0.81  MeV slightly above the big bang nucleosynthesis (BBN) energy window for the first time on the basis of the detailed balance principle by measuring the time-reverse reaction. The obtained cross sections are much larger than the cross sections for s-wave neutrons inferred from the recent measurement at the n_TOF facility in CERN, but significantly smaller than the theoretical estimation widely used in the BBN calculations. The present results suggest the ^{7}Be(n,α)^{4}He reaction rate is not large enough to solve the cosmological lithium problem, and this conclusion agrees with the recent result from the direct measurement of the s-wave cross sections using a low-energy neutron beam and the evaluated nuclear data library ENDF/B-VII.1.

Polymorphisms in PTCH1 Affect the Risk of Ameloblastoma

Ameloblastoma is the most common odontogenic tumor, but the genetic nature of the changes in the tumor cells has been unclear. Mutations of CTNNB1 or PTCH1 are observed in many human tumors. Both CTNNB1 and PTCH1 are important in tooth development and are expressed in ameloblastoma. The aim of this study was to investigate whether genetic alterations of CTNNB1 and PTCH1 are present in ameloblastoma. We investigated 14 cases of ameloblastoma. The polymorphisms found in the ameloblastoma patients were further examined in a subsequent case-control study. We found a CTNNB1 mutation in one case of plexiform-type ameloblastoma. CGG triplet repeat-number polymorphism (CGG7/CGG8) in the 5′-untranslated region of PTCH1 was observed. The proportion of CGG8 alleles was significantly higher in the ameloblastoma group. The results of this study indicate a possible relationship between the CGG8 allele in PTCH1 and the risk for ameloblastoma.

Candidate Resonant Tetraneutron State Populated by the ^{4}He(^{8}He,^{8}Be) Reaction

A candidate resonant tetraneutron state is found in the missing-mass spectrum obtained in the double-charge-exchange reaction ^{4}He(^{8}He,^{8}Be) at 186  MeV/u. The energy of the state is 0.83±0.65(stat)±1.25(syst)  MeV above the threshold of four-neutron decay with a significance level of 4.9σ. Utilizing the large positive Q value of the (^{8}He,^{8}Be) reaction, an almost recoilless condition of the four-neutron system was achieved so as to obtain a weakly interacting four-neutron system efficiently.

Fungal Internal Carotid Artery Aneurysm Treated by Trapping and High-Flow Bypass: A Case Report and Literature Review

We report a case of unruptured fungal internal carotid artery (ICA) aneurysm and review the pertinent literature. A 79-year-old man presented with decreased visual acuity on the right side, and he was diagnosed with retrobulbar optic neuritis. Medical treatment with steroids resulted in Aspergillus meningoencephalitis spreading to the bottom of bilateral frontal lobes, caused by an intracranial extension of sphenoid sinusitis. Magnetic resonance imaging (MRI) performed 26 days after the start of antifungal therapy showed a denovo right ICA aneurysm projecting anteriorly into the sphenoid sinus. As the aneurysm grew rapidly, it was trapped surgically after establishing a high-flow bypass from the external carotid artery to the middle cerebral artery. The patient's postoperative course was uneventful. Anti-fungal medication was continued until plasma concentrations of beta-D-glucan decreased to within normal limits. Although fungal ICA aneurysm carries a high mortality rate, early detection and prompt treatment by trapping and high-flow bypass can lead to good clinical outcome.

Nonquenched Isoscalar Spin-M1 Excitations in sd-Shell Nuclei

Differential cross sections of isoscalar and isovector spin-M1 (0(+)→1(+)) transitions are measured using high-energy-resolution proton inelastic scattering at E(p)=295  MeV on (24)Mg, (28)Si, (32)S, and (36)Ar at 0°-14°. The squared spin-M1 nuclear transition matrix elements are deduced from the measured differential cross sections by applying empirically determined unit cross sections based on the assumption of isospin symmetry. The ratios of the squared nuclear matrix elements accumulated up to E(x)=16  MeV compared to a shell-model prediction are 1.01(9) for isoscalar and 0.61(6) for isovector spin-M1 transitions, respectively. Thus, no quenching is observed for isoscalar spin-M1 transitions, while the matrix elements for isovector spin-M1 transitions are quenched by an amount comparable with the analogous Gamow-Teller transitions on those target nuclei.

The efficacy of add-on tacrolimus for minor flare in patients with systemic lupus erythematosus: a retrospective study

Objective

We have assessed the effectiveness of tacrolimus for minor flares in systemic lupus erythematosus (SLE) patients.

Methods

The medical records of 313 patients were retrospectively reviewed over a period of seven years, from 2006 to 2013. We enrolled patients with minor flare treated with add-on tacrolimus, without glucocorticoid (GC) intensification (tacrolimus group). Minor flare was defined as a ≥1-point increase in a total score between 3 and 11 in the SLE Disease Activity Index (SLEDAI). We enrolled as controls patients who were administered increased doses of GC for minor flare (GC group). All patients were followed for one year. The primary outcome measure was the proportion of responders.

Results

There were 14 eligible patients in the tacrolimus group and 20 eligible patients in the GC group. The mean SLEDAI at flare tended to be higher in the tacrolimus group than in the GC group (7.5 vs. 6.2, p = 0.085). A mean dose of 1.6 mg tacrolimus/day was administered for flare, while the mean GC dose was 13.7 mg/day in the GC group. The proportion of responders was 86% (12/14) in the tacrolimus group and 75% (15/20) in the GC group ( p = 0.67). The mean dose of GC at 12 months was higher in the GC group than in the tacrolimus group (9.7 mg/day vs. 7.1 mg/day, p < 0.05). Only one patient discontinued tacrolimus because of fatigue after three months.

Conclusion

Adding tacrolimus without increasing the GC dose may provide an effective treatment option for minor flares in patients with SLE.

Genetic diversity of highly pathogenic H5N8 avian influenza viruses at a single overwintering site of migratory birds in Japan, 2014/15

We isolated eight highly pathogenic H5N8 avian influenza viruses (H5N8 HPAIVs) in the 2014/15 winter season at an overwintering site of migratory birds in Japan. Genetic analyses revealed that these isolates were divided into three groups, indicating the co-circulation of three genetic groups of H5N8 HPAIV among these migratory birds. These results also imply the possibility of global redistribution of the H5N8 HPAIVs via the migration of these birds next winter.

Identification of the β+ isovector spin monopole resonance via the 208Pb and 90Zr(t,3He) reactions at 300 MeV/u

The double-differential cross sections for the (208)Pb and (90)Zr(t,(3)He) reactions at 300 MeV/u have been measured at the RI Beam Factory at RIKEN. This was the first physics experiment with the SHARAQ magnetic spectrometer. The combined analysis of the present (t,(3)He) data and previous (n,p) data provides the clearest identification for the β(+) isovector spin monopole resonance both in the (208)Tl and (90)Y nuclei, and puts the observations of this giant resonance on a firm foundation. The measured distributions of the (t,(3)He) monopole cross sections were well reproduced by the distorted-wave Born approximation calculation, where the target transition density was calculated with the self-consistent Hartree-Fock plus random-phase approximation using the T43 Skyrme interaction. A major part of the expected β(+) isovector spin monopole strength was found in the measured cross section spectra.

Separation of pygmy dipole and M1 resonances in 90Zr by a high-resolution inelastic proton scattering near 0°

A high-resolution measurement of inelastic proton scattering off (90)Zr near 0° was performed at 295 MeV with a focus on a pronounced strength previously reported in the low-energy tail of giant dipole resonance. A forest of fine structure was observed in the excitation energy region 7-12 MeV. A multipole decomposition analysis of the angular distribution for the forest was carried out using the ECIS95 distorted-wave Born approximation code with the Hartree-Fock plus random-phase approximation model of E1 and M1 transition densities and inclusion of E1 Coulomb excitation. The analysis separated pygmy dipole and M1 resonances in the forest at E(PDR)=9.15±0.18 MeV with Γ(PDR)=2.91±0.64 MeV and at E(M1)=9.53±0.06 MeV with Γ(M1)=2.70±0.17 MeV in the Lorentzian function, respectively. The B(E1)↑ value for pygmy dipole resonance over 7-11 MeV is 0.75±0.08 e(2)fm(2), which corresponds to 2.1±0.2% of the Thomas-Reiche-Kuhn sum rule.

Hindered proton collectivity in 16(28)S12: possible magic number at Z=16

The reduced transition probability B(E2;0(gs)(+)→2(1)(+)) for (28)S was obtained experimentally using Coulomb excitation at 53 MeV/nucleon. The resultant B(E2) value 181(31) e(2)fm(4) is smaller than the expectation based on empirical B(E2) systematics. The double ratio |M(n)/M(p)|/(N/Z) of the 0(gs)(+)→2(1)(+) transition in (28)S was determined to be 1.9(2) by evaluating the M(n) value from the known B(E2) value of the mirror nucleus (28)Mg, showing the hindrance of proton collectivity relative to that of neutrons. These results indicate the emergence of the magic number Z=16 in the |T(z)|=2 nucleus (28)S.

Laparoendoscopic single-site surgery for urachal remnants

INTRODUCTION

Urachal remnants are relatively rare but may potentially cause various symptoms and an increased risk for developing adenocarcinoma. Open or laparoscopic surgery is usually used for their resection. Laparoendoscopic single-site surgery has been recently applied in several surgical procedures. This report describes two cases of vesicourachal diverticulum treated by resection using laparoendoscopic single-site surgery.

MATERIALS AND SURGICAL TECHNIQUE

In each case, laparoendoscopic single-site surgery was performed transperitoneally via one port at a subumbilical semicircular incision. Except for a flexible camera and SILS Port, traditional, non-flexible laparoscopic instruments were used. After the induction of general anesthesia, the patient was placed in a supine position (or lithotomy position). A 2.0-cm incision was made semicircumferentially following the natural subumbilical folds. After the umbilical ligament was cut under direct vision, a SILS Port was placed at the incision. The urachus was liberated distally down to the roof of the urinary bladder using 0° 5-mm flexible camera. Vesicourachal diverticulum with a bladder cuff was completely excised under the supporting view of cystoscopy. Both patients' perioperative days were uneventful.

DISCUSSION

Our findings suggest that the laparoendoscopic single-site surgery procedure is safe, minimally invasive and cosmetically acceptable. Therefore, this procedure is an excellent option for the radical resection of urachal remnants.