Analysis of 25 surgical cases of thymic neuroendocrine tumors and thymic carcinoma

BACKGROUND

The purpose of this study was to evaluate the clinicopathological characteristics of patients who underwent surgical resection for thymic neuroendocrine tumors (TNET) or thymic carcinoma.

METHODS

In this study, we retrospectively evaluated the clinicopathological characteristics of our surgical patients at Fukuoka University Hospital from January 1995 to December 2018.

RESULTS

There were nine cases of TNET and 16 cases of thymic carcinoma. Regarding the pathological type, the TNET group included three atypical carcinoid cases, two large cell neuroendocrine tumor cases, two small cell carcinoma cases, and two other cases. The thymic carcinoma group included 15 squamous carcinoma cases and one case of adenosquamous carcinoma. Based on the Masaoka-Koga staging system, six TNET cases and 11 thymic carcinoma cases were stage III or IV. The complete resection rate was 77% in the TNET group and 81% in the thymic carcinoma group. Additional chemotherapy and/or radiotherapy was performed in five cases of TNET and 11 cases of thymic carcinoma. The five-year survival rate and five-year disease-free survival rate were 87.5% and 75.0% in the TNET group and 58.9% and 57.1% in the thymic carcinoma group, respectively, with no significant difference between the two groups (P = 0.248 and P = 0.894, respectively). In the univariate analysis, complete resection was a statistically significant prognostic factor (P = 0.017).

CONCLUSION

In this study, no difference in prognosis was observed between TNET and thymic carcinomas. To understand the characteristics of these tumors, further case accumulation and multicenter clinical studies are needed. (243words).

Effect of revised organ transplant law in Japan on lung transplantation

PURPOSE

To investigate how revision of the organ transplant law in Japan affected lung transplantation in this country.

METHODS

Lung transplant candidates registered between January, 2000 and December, 2009 were designated as the pre-revision group (n = 396) and those registered between January, 2011 and December, 2020, as the post-revision group (n = 1326). Both groups were analyzed retrospectively using data collected by the Japanese Society of Lung and Heart-Lung Transplantation.

RESULTS

The number of patients who underwent brain-dead donor lung transplantation (BDLT) increased significantly after the law amendment (32.2 vs. 13.8%, p < 0.01). The median waiting time for BDLT was significantly reduced (708 days vs. 1163 days, p < 0.01) and the mortality rate while waiting for BDLT improved significantly after the law amendment (33.1 vs. 42.6%, p < 0.01). In the post-revision group, 18 pediatric patients underwent BDLT. The 5-year survival rates after BDLT were comparable between the groups (73.5% in the pre-revision group vs. 73.2% in the post-revision group, p = 0.32).

CONCLUSIONS

The organ transplant law revision shortened the waiting time for BDLT significantly and decreased the mortality rate while waiting for BDLT. The posttransplant outcomes in Japan remained favorable throughout the study period.

Factors related to post-thoracotomy pain following robotic-assisted thoracic surgery

BACKGROUND

Robotic-assisted thoracic surgery (RATS) is a minimally invasive procedure; however, some patients experience persistent postoperative pain. This study aimed to investigate factors related to postoperative pain following RATS.

METHODS

The data of 145 patients with lung cancer, who underwent RATS with a four-port (one in the sixth intercostal space [ICS] and three in the eighth ICS) lobectomy or segmentectomy between May 2019 and December 2022, were retrospectively analyzed. Factors associated with analgesic use for at least 2 months following postoperative pain (PTP group) were analyzed.

RESULTS

Patients who underwent preoperative pain control for any condition or chest wall resection were excluded. Among the 138 patients, 45 (32.6%) received analgesics for at least 2 months after surgery. Patient height and transverse length of the thorax correlated with PTP in the univariate analysis (non-PTP vs. PTP; height, 166 vs. 160 cm; p < .001; transverse length of the thorax, 270 vs. 260 mm, p = .016). In the multivariate analysis, height was correlated with PTP (p = .009; odds ratio, 0.907; 95% confidence interval, 0.843-0.976). Height correlated with the transverse length of the thorax (r = .407), anteroposterior length of the thorax (r = .294), and width of the eighth ICS in the middle axillary line (r = .210) using Pearson's correlation coefficients. When utilizing a 165-cm cutoff value for height to predict PTP using receiver operating characteristic curve analysis, the area under the curve was 0.69 (95% confidence interval, 0.601-0.779).

CONCLUSION

Short stature is associated with a high risk of postoperative pain following RATS.

Chest wall tuberculosis: precision surgery with indigo carmine in limited cases for safe and intuitive lesion excision

In addition to treatment with antituberculosis drugs, complete surgical excision is important for the cure of chest wall tuberculosis. However, surgery is often challenging to perform due to different factors such as the strong adhesion of tuberculous lesions to the surrounding normal tissue, growth of neovascularization and presence of fragile necrotic tissues. Firm adhesions, bleeding and fragile tissue make it difficult to determine the boundary with normal tissue and completely excide the lesion. Moreover, ingenuity is required. Herein, we report the identification of the boundary between the lesion and normal tissue by injecting indigo carmine into the abscess to completely excide the lesion, which is considered an intuitive and safe method.

Risk factors for surgical site infection following orthopaedic surgery for fracture by trauma: a nested case-control study

BACKGROUND

Surgical site infection (SSI) is associated with higher medical expenses and lower patient quality of life.

AIM

To identify specific modifiable risk factors for SSI after orthopaedic surgery for fractures caused by trauma.

METHODS

This nested case-control study used a nationwide trauma registry, the Japan Trauma Data Bank (JTDB) database. Patient data from 280 hospitals between January 2004 and May 2019 were retrieved from the JTDB. Patients with SSI and identified patients without SSI as control subjects were included, using propensity score matching adjusted for unmodifiable factors. Risk factors associated with SSI after orthopaedic trauma surgery were assessed using multi-level mixed-effects logistic regression models.

FINDINGS

In total, 15,910 patients were included in the analysis. Of these patients, 377 (2.4%) had SSI. After propensity score matching, 258 patients with SSI and 2580 matched patients without SSI were selected. In the multi-level mixed-effects logistic regression analysis, blood transfusion within 24 h (odds ratio (OR): 1.51; 95% confidence interval (CI): 1.06-2.13) was a significant risk factor for SSI following orthopaedic fracture surgery. The OR (95% CI) values for external fixation, transcatheter arterial embolization, and tourniquet for SSI following orthopaedic fracture surgery were 1.40 (0.96-2.03), 1.66 (0.81-3.38), and 2.99 (0.60-14.87), respectively.

CONCLUSION

These findings highlight the necessity of exercising caution when implementing blood transfusion within 24 h as a risk factor associated with SSI following orthopaedic trauma surgery.

Effects of case volume on short- and long-term outcomes following cadaveric lung transplantation in Japan

Background

Despite the low number of lung transplantations (LTs) in Japan, 10 LT facilities are accredited and good outcomes have been reported. A database review was conducted to clarify the impact of case volume at LT facilities in Japan on short- and long-term outcomes.

Methods

All cadaveric LT cases treated between 2000 and 2021 in Japan were analyzed using the database of the Japanese Society of Lung and Heart-Lung Transplantation (JSLHT). The nine institutions represented were categorized into the low-volume (LV; <80 cumulative LT cases, <8 LTs/year, n=5) and high-volume (HV; ≥80 cumulative LT cases, ≥8 LTs/year, n=4) centers. Ninety-day and 1-year mortality, as well as 5- and 10-year survival data were evaluated.

Results

A total of 658 cadaveric LTs were performed at the nine institutions. The 90-day rates of mortality at the HV and LV centers were 3.5% and 3.9%, respectively (P=0.801), while the 1-year mortality rates were 9.2% and 11.5%, respectively (P=0.199). Additionally, log-rank analysis of Kaplan-Meier curves showing case volume did not reveal a significant difference in long-term survival between the HV and LV centers (P=0.272), though the LV centers had wide differences for long-term outcomes (P=0.030).

Conclusions

Case volume did not have effects on short- or long-term outcomes following LT in Japan, while there were large variations in long-term outcomes among the LV centers compared to those of the HV centers.

Relationship between ankle-foot-complex mobility during static loading and frontal moment impulses of knee and hip joints during the stance phase

BACKGROUND

Ankle-foot-complex mobility impairments, which can be assessed by the difference between the sitting and standing positions, are related to an increase in the load on the knee and hip joints during the stance phase of the gait.

RESEARCH QUESTION

What is the relationship between the ankle-foot-complex mobility during static weight bearing and the mechanical stresses on the knee and hip joints throughout the stance phase?

METHODS

Ankle-foot-complex mobility and gait data were collected from 26 healthy adults. The complex mobility was established by comparing the foot indices, measured using a three-dimensional foot scanner, in sitting and standing positions. The gait data were acquired using eight cameras (recording at 100 Hz) and three force plates (recording at 1000 Hz). Stance phase data were collected via ground reaction forces. The stance phase was dissected into shock absorption and propulsion phases, during which the external knee and hip adduction moment impulses (KAMi, HAMi) were recorded. The correlation between the ankle-foot-complex mobility during static weight bearing and KAMi and HAMi during the stance phase was examined using Pearson's product-moment correlation coefficients.

RESULTS

This study revealed that KAMi correlated with medial malleolus mobility (r = -0.44) throughout the stance phase. Furthermore, in the propulsive phase, KAMi correlated with calcaneus (r = 0.51) and navicular (r = -0.50) mobilities, whereas HAMi correlated with calcaneus mobility (r = -0.40).

SIGNIFICANCE

The study provides insights into the relationship between the static mobility of the ankle-foot complex in healthy individuals and mechanical stress during the stance phase. Calcaneus and navicular mobilities were related to efficient push-off in the propulsive phase. Medial malleolus mobility was related to the control of the lateral tilt of the lower limb and ankle dorsiflexion motion throughout the stance phase.

Efficacy and safety of add-on mirogabalin to conventional therapy for the treatment of peripheral neuropathic pain after thoracic surgery: the multicenter, randomized, open-label ADMIT-NeP study

BACKGROUND

For chronic pain after thoracic surgery, optimal timing of its diagnosis and effective treatment remains unresolved, although several treatment options are currently available. We examined the efficacy and safety of mirogabalin, in combination with conventional pain therapy (nonsteroidal anti-inflammatory drugs and/or acetaminophen), for treating peripheral neuropathic pain (NeP) after thoracic surgery.

METHODS

In this multicenter, randomized, open-label, parallel-group study, patients with peripheral NeP were randomly assigned 1:1 to mirogabalin as add-on to conventional therapy or conventional treatment alone.

RESULTS

Of 131 patients of consent obtained, 128 were randomized (mirogabalin add-on group, 63 patients; conventional treatment group, 65 patients). The least squares mean changes (95% confidence interval [CI]) in Visual Analogue Scale (VAS) score for pain intensity at rest from baseline to Week 8 (primary endpoint) were - 51.3 (- 54.9, - 47.7) mm in the mirogabalin add-on group and - 47.7 (- 51.2, - 44.2) mm in the conventional group (between-group difference: - 3.6 [95% CI: - 8.7, 1.5], P = 0.161). However, in patients with Self-administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) score (used for the screening of NeP) ≥ 12 at baseline, the greater the S-LANSS score at baseline, the greater the decrease in VAS score in the mirogabalin add-on group, while no such trend was observed in the conventional treatment group (post hoc analysis). This between-group difference in trends was statistically significant (interaction P value = 0.014). Chronic pain was recorded in 7.9% vs. 16.9% of patients (P = 0.171) at Week 12 in the mirogabalin add-on vs. conventional treatment groups, respectively. Regarding activities of daily living (ADL) and quality of life (QOL), changes in Pain Disability Assessment Scale score and the EQ-5D-5L index value from baseline to Week 8 showed significant improvement in the mirogabalin add-on group vs. conventional treatment group (P < 0.001). The most common adverse events (AEs) in the mirogabalin add-on group were dizziness (12.7%), somnolence (7.9%), and urticaria (3.2%). Most AEs were mild or moderate in severity.

CONCLUSIONS

Addition of mirogabalin to conventional therapy did not result in significant improvement in pain intensity based on VAS scores, but did result in significant improvement in ADL and QOL in patients with peripheral NeP after thoracic surgery.

TRIAL REGISTRATION

Japan Registry of Clinical Trials jRCTs071200053 (registered 17/11/2020).

[11C] Methionine-PET Imaging as a Cancer Biomarker for Methionine Addiction and Sensitivity to Methionine-restriction-based Combination Chemotherapy

BACKGROUND/AIM

Methionine addiction is a fundamental and universal hallmark of cancer, termed the Hoffman effect. Methionine addiction of cancer is greater than glucose addiction, termed the Warburg effect, as shown by the comparison of PET imaging with [11C]methionine and [18F]fluorodeoxyglucose. The aim of the present study was to determine whether [11C]methionine PET (MET-PET) images could be a biomarker of methionine addiction of cancer and potential response to methionine-restriction-based combination chemotherapy.

PATIENTS AND METHODS

In the present study a patient with invasive lobular carcinoma of the breast metastatic to axillary lymph nodes was imaged by both MET-PET and [18F]fluorodeoxyglucose PET (FDG-PET) before and after combination treatment with methionine restriction, comprising a low-methionine diet and methioninase, along with first-line chemotherapy.

RESULTS

MET-PET gave a much stronger and precise image of the patient's metastatic axillary lymph nodes than FDG-PET. The patient had a complete response to methionine restriction-based chemotherapy as shown by MET-PET.

CONCLUSION

MET-PET imaging is a biomarker of methionine-addicted cancer and potential response to methionine-restriction-based chemotherapy.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Iodine contrast volume reduction in preoperative transcatheter aortic valve implantation computed tomography: Comparison with 64- and 256-multidetector row computed tomography

INTRODUCTION

This study aimed to compare the vascular enhancement and radiation dose in preoperative transcatheter aortic valve implantation (TAVI) computed tomography (CT) with a reduced contrast medium (CM) using volume scans in 256-multidetector row CT (MDCT) with a standard CM using 64-MDCT.

METHODS

This study included 78 patients with preoperative TAVI CT with either 64- or 256-MDCT. The CM was injected at 1.5 mL/kg in the 64-MDCT group and 1.0 mL/kg in the 256-MDCT group. We compared vascular enhancement of the aortic root and access routes, image quality (IQ) scores, and radiation dose in both groups.

RESULTS

Despite the reduced CM (by 33 %) in the 256-MDCT group, the mean vascular enhancement of the right and left subclavian arteries was significantly higher than that in the 64-MDCT group [284 and 267 Hounsfield units (HU) vs. 376 and 359 HU; p < 0.05]; however, no significant differences in the mean vascular enhancement in the ascending aorta, abdominal aorta at the celiac level, and bilateral common femoral arteries were observed between the two groups (p > 0.05 for all). The median IQ scores at the aortic root were higher in the 256-MDCT group than in the 64-MDCT group (3 vs. 4; p < 0.05), and those at the femoral access routes were comparable (4 vs. 4; p = 0.33). The mean effective dose was significantly reduced by 30 % in the 256-MDCT group (23.6 vs. 16.3 mSv; p < 0.05).

CONCLUSION

In preoperative TAVI CT, volume scans using 256-MDCT provide comparable or better vascular enhancement and IQ with a 30 % reduction in CM and radiation dose than those using 64-MDCT.

IMPLICATIONS FOR PRACTICE

Volume scan using 256-MDCT for preoperative TAVI CT may reduce CM and radiation dose in TAVI patients with renal dysfunction.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Impact of a pneumatic surgical robot with haptic feedback function on surgical manipulation

Although robotic-assisted surgery has the advantages of low patient burden and high precision without unsteady hand movements, the lack of tactile sensations may result in unexpected iatrogenic organ damage. The Saroa (Riverfield Inc., Tokyo, Japan) is a pneumatically driven robot that provides real-time haptic feedback to the surgeon. Using the Saroa robot, six examinees performed puffed rice transfer and four of them performed pig lung resection tasks with the feedback function turned on and off. The puffed rice transfer task consisted of transferring 20 grains of puffed rice from the left to the right compartment in the training box. The mean grasping forces during the puffed rice transfer task with the haptic feedback function turned off and on were 2.14 N and 0.63 N, respectively (P = 0.003). The mean grasping forces during the pig lung resection task were lower with the feedback turned on than turned off. The force that the forceps exerted on the grasping object was weaker in both tasks when the haptic feedback function was turned on, suggesting that the feedback function allows gentler handling of tissues, improving patient safety during robotic surgery.

Antiferromagnetic topological insulator with selectively gapped Dirac cones

Antiferromagnetic (AF) topological materials offer a fertile ground to explore a variety of quantum phenomena such as axion magnetoelectric dynamics and chiral Majorana fermions. To realize such intriguing states, it is essential to establish a direct link between electronic states and topology in the AF phase, whereas this has been challenging because of the lack of a suitable materials platform. Here we report the experimental realization of the AF topological-insulator phase in NdBi. By using micro-focused angle-resolved photoemission spectroscopy, we discovered contrasting surface electronic states for two types of AF domains; the surface having the out-of-plane component in the AF-ordering vector displays Dirac-cone states with a gigantic energy gap, whereas the surface parallel to the AF-ordering vector hosts gapless Dirac states despite the time-reversal-symmetry breaking. The present results establish an essential role of combined symmetry to protect massless Dirac fermions under the presence of AF order and widen opportunities to realize exotic phenomena utilizing AF topological materials.

A case of sacrococcygeal teratoma associated with antenatally acquired urethrovaginal fistula and hydrocolpos

BACKGROUND

Sacrococcygeal teratomas (SCTs) are known to cause urological complications, but urethrovaginal (UV) fistula as a complication of SCT is rare. We herein report a case of SCT with UV fistula and hydrocolpos.

CASE PRESENTATION

A 1-day-old female neonate presented to our department with prominent swelling in the sacrococcygeal region. She was born at 37 gestational weeks via spontaneous vaginal delivery from a 39-year-old woman. The weight of the baby was 2965 g, and her Apgar scores were 4/10 (at 1 and 5 min). An MRI examination confirmed an 11 × 11 cm Altman classification typeII SCT associated with hydrocolpos, a dilated urinary bladder, and bilateral hydronephrosis. When she was 5 days, the SCT was excised totally and a coccygectomy was performed. After the operation, as her urinary output appeared unstable, a cystoscopic examination was performed on the third postoperative day. This revealed that the UV fistula was located approximately 1 cm from the urethral opening. In addition, the proximal urethra was unobstructed and connected to the bladder. The cystoscope allowed for the passage of a urinary catheter through the urethra. After 1 month of catheter placement, she was discharged from the hospital at 57 days of age. Follow-up was uneventful, with neither urinary infection nor retention.

CONCLUSIONS

SCTs are associated with not only trouble with rectal function and lower extremity movement but also urinary complications. The pathogenesis of this UV fistula is thought to be the rapid growth of the SCT that developed in the fetal period, resulting in obstruction of the urethra by the tumor and the pubic bone, which in turn caused urinary retention and the formation of a fistula as an escape route for the pressure. Because SCTs can cause a variety of complications depending on the course of the disease, careful examination and follow-up are necessary.

Prognostic factors in patients with high-risk stage II colon cancer after curative resection: a post hoc analysis of the JFMC46-1201 trial

PURPOSE

The goal of the current study was to identify prognostic factors for disease-free survival (DFS) and overall survival (OS) in high-risk stage II colon cancer.

METHODS

The subjects were patients with histologically confirmed stage II colon cancer undergoing R0 resection who met at least one of the following criteria: T4, perforation/penetration, poorly differentiated adenocarcinoma, mucinous carcinoma, and < 12 examined lymph nodes. Patients self-selected surgery alone or a 6-month oral uracil and tegafur plus leucovorin (UFT/LV) regimen. Serum CEA mRNA at ≥ 24 h after surgery and < 2 weeks after registration was also examined as a potential prognostic factor for stage II colon cancer. This study is registered with UMIN-CTR (protocol ID: UMIN000007783).

RESULTS

1880 were included in the analysis to identify prognostic factors for DFS and OS in patients with high-risk stage II colon cancer. In multivariate analyses, gender, depth of tumor invasion, extent of lymph node dissection, number of examined lymph nodes, and postoperative adjuvant chemotherapy (POAC) emerged as significant independent prognostic factors for DFS. Similarly, multivariate analysis showed that age, gender, depth of tumor invasion, perforation/penetration, extent of lymph node dissection, number of examined lymph nodes, and POAC were significant independent prognostic factors for OS. Univariate analyses showed no significant difference in DFS or OS for CEA mRNA-positive and mRNA-negative cases.

CONCLUSION

This study showed that gender, depth of tumor invasion, extent of lymph node dissection, number of examined lymph nodes, and lack of use of POAC were significant independent prognostic factors in stage II colon cancer.

Prognostic factors for lung transplant recipients focusing on age and gender: the Japanese lung transplantation report 2022

PURPOSE

To clarify the impact of donor and recipient characteristics on the survival of recipients before and after lung transplantation in the Japanese population.

METHODS

Patients' data were collected for retrospective analysis from all authorized lung transplant centers in Japan. We included 1963 patients listed for lung transplantation by the end of December 2021, comprised of 658 deceased-donor and 270 living-donor lung transplants.

RESULTS

Primary disease had a significant impact on the mortality of patients waiting for transplantation. The indications for transplant significantly affected the post-transplant survival rate of deceased-donor lung transplant recipients. The recipient's age also significantly affected the post-transplant survival rate of the deceased-donor and living-donor lung transplant recipients. The recipients of grafts transplanted from donors aged 61 years or older showed a worse post-transplant survival rate (≧60 years old). The survival rate for the combination of a female donor to a male recipient among the deceased-donor lung transplant recipients was the worst among the four combinations.

CONCLUSION

The donor and recipient characteristics significantly impacted the survival of recipients after lung transplantation. The underlying mechanism of the negative impact of the gender mismatch of female donor to male recipient on post-transplant survival needs to be investigated further.

Targeted Pubic Neoantigen Immunotherapy Using Encapsulated Nanoparticles, Directed by Radiation

PURPOSE/OBJECTIVE(S)

We tested a treatment combining radiotherapy with pubic neoantigen nanoparticles of CAND1 and ADGRF5-II (120 ± 56 nm) in nanocapsules detectable by computed tomography (CT) (545± 24 nm) with IFN γ or PD-L1 antibody (Ab), which released their contents upon radiation exposure. We performed two radiotherapy sessions: 1) induction of MHC-I and II in tumor cells and dendritic cells (DC) by the first round of radiation with concurrently released IFN γ from nanoparticles; 2) targeted neoantigen immunotherapy with PD-L1 blockade by the second round of radiation, elicited by CAND1-specific CD8+T-cell and ADGRF5-II-specific CD4+T-cell, related to induced MHC-I and MHC-II in session 1, respectively.

MATERIALS/METHODS

For session one, nanocapsules were generated by mixing iopamiron and 15 mg IFN γ with a 1.0 mL solution containing 4.0% alginate, 3.0% hyaluronate, and 1 μg/mL P-selectin. This mixture was sprayed into 0.5 mmol/l FeCl2 supplemented with 1 µg/mL anti-VEGFR-1/2 Ab. For session two, Mixture of 110 fmol CAND1 and fmol ADGRF5-II, were encapsulated into poly lactic-co-Glycolic acid (PLGA) particle, using nanoprecitation method. Those particles were encapsulated by mixing into above alginate-hyaluronate cocktail with 400 mg PD-L1 antibody (Ab), then sprayed into 0.5 mmol/l FeCl2 supplemented with P-selectin Ab. In session one, 1 × 1010 nanocapsules were intravenously injected into BALB/c mice exhibiting primary 4TI mammary carcinoma in the left hind leg and lung metastases. Tumor accumulation was monitored by CT. Subsequently, 10 or 20 Gy 60Co γ-radiation was administered to primary tumors and lung metastasis. In session two, 1 × 1010 nanocapsules were injected i.v. and allowed to interact with P-selectin for 24 h; a further 10 or 20 Gy 60Co γ-radiation was administered to tumors and lung metastasis.

RESULTS

In session one, CT imaged the accumulation of anti-VEGFR-1/2 nanocapsules around primary and metastatic tumors, which helped determine the timing of the first radiation. The nanocapsules released P-selectin and IFN γ in response to first radiation. P-selectin was deposited on tumor vessels. Radiation and released IFN γ elicited MHC-I and II on tumor cells and DCs. In session two, released CAND1 and ADGRF5-II from PLGA particle, which were emitted from nanocapsules upon second radiation, were loaded onto MHC-I and II. Subsequently, two kinds of tertiary complex were formed on tumor cells and DC: 1) MHC-I-CAND1-CD8+T-cell receptor (TCR); and 2) MHC-II- ADGRF5-II-CD4+TCR, which destroyed tumor cells, in collaboration with released PD-L1 Ab. Those T-cell mediated cell killing was magnified via enhanced DC-mediated T-cell priming by the two kinds of tertiary complex on DC. Those treatments resulted in EF 1.5 and 86% reduction of new metastasis formation.

CONCLUSION

Our encapsulated pubic neoantigen particle will lead to quick and effective neoantigen immunotherapy.

The history of Japanese lung transplantation: the unique pathway to establishing the program and its initial success

Japan is a unique country in terms of organ transplantation. Despite the impressive progress in transplant medicine achieved during the late 20th century in many Western countries, Japan was unable to implement a program for organ transplants from brain-dead donors due to persistent public distrust regarding the ethical understanding of "brain death as human death". In 1997, the Japanese Organ Transplant Law was enacted, and organ transplantation from brain-dead donors was finally legalized. However, this law was strongly opposed by religious leaders, philosophers, politicians, and even medical personnel who did not accept the idea that brain death is human death, so transplant physicians had to start performing transplants in the face of strong social resistance. The Japanese National Lung Transplant System was established based on the following three philosophies: (I) an institutional certification system based on strict standards; (II) a rigorous central monitoring system for transplant results; and (III) a third-party review system to determine eligibility for patient registration. The purpose of these policies was to avoid ethical issues at lung transplant institutes, and to achieve high-quality transplant results. The actual progress of Japanese lung transplantation has been quite unusual compared to other countries. The number of brain-dead organ donations was extremely limited at first, so more than 60% of lung transplants were performed as living-donor transplants during the first 9 years [1998-2006]. The number of brain-dead donations subsequently increased, particularly after the revision of the Organ Transplant Law in 2010 such that the majority of lung transplants are now performed as brain-dead transplantations. Regarding the results of lung transplants, the most recent national registry report indicated that a total of 668 lung transplants including 447 from brain-dead donors and 221 from living donors, had been performed as of 2018. The 5- and 10-year survival rates for brain-dead donor lung transplantation were 71.9% and 57.8%, respectively, with no significant difference between the living-donor and brain-dead-donor groups. These results are comparable with the outcome of preceding programs in the US and European countries.

Perioperative outcomes of minimally invasive surgery for large malignant thymic epithelial tumors and for total thymectomy

PURPOSE

Minimally invasive surgery (MIS) for thymic tumors is now accepted widely, in line with improved surgical techniques; however, we occasionally encounter complicated cases of large tumors or of total thymectomy requiring prolonged operative duration or conversion to an open procedure (OP). We reviewed patients registered in a nationwide database to identify the technical feasibility of MIS for thymic epithelial tumors.

METHODS

Data on patients treated surgically between 2017 and 2019 were extracted from the National Clinical Database of Japan. Clinical factors and operative outcomes were calculated by tumor diameter using trend analyses. Perioperative outcomes of MIS for non-invasive thymoma were investigated using propensity score-matched analyses.

RESULTS

MIS was performed in 46.2% of the patients. The operative duration and conversion rate increased with the tumor diameter (p < .001). After propensity score-matching, operative duration and postoperative hospital stay were shorter (p < .001), and the transfusion rate was lower (p = .007) in patients who underwent MIS than in those who underwent OP for thymomas ≥ 5 cm. Among patients who underwent total thymectomy, blood loss was less (p < .001) and the postoperative hospital stay was shorter (p < .001) in those who underwent MIS than in those who underwent OP. There were no significant differences in postoperative complications and mortality.

CONCLUSIONS

MIS is technically feasible even for large non-invasive thymomas or for total thymectomy, although the operative duration and open conversion rate increase with the tumor diameter.

Whole-genome sequencing analysis of molecular epidemiology and silent transmissions causing meticillin-resistant Staphylococcus aureus bloodstream infections in a university hospital

BACKGROUND

The emergence of novel genomic-type clones, such as community-associated meticillin-resistant Staphylococcus aureus (MRSA) and livestock-associated MRSA, and their invasion into hospitals have become major concerns worldwide; however, little information is available regarding the prevalence of MRSA in Japan. Whole-genome sequencing (WGS) has been conducted to analyse various pathogens worldwide. Therefore, it is important to establish a genome database of clinical MRSA isolates available in Japan.

AIM

A molecular epidemiological analysis of MRSA strains isolated from bloodstream-infected patients in a Japanese university hospital was conducted using WGS and single-nucleotide polymorphism (SNP) analysis. Additionally, through a review of patients' clinical characteristics, the effectiveness of SNP analysis as a tool for detecting silent nosocomial transmission that may be missed by other methods was evaluated in diverse settings and various time points of detection.

METHODS

Polymerase-chain-reaction-based staphylococcal cassette chromosome mec (SCCmec) typing was performed using 135 isolates obtained between 2014 and 2018, and WGS was performed using 88 isolates obtained between 2015 and 2017.

FINDINGS

SCCmec type II strains, prevalent in 2014, became rare in 2018, whereas the prevalence of SCCmec type IV strains increased from 18.75% to 83.87% of the population, and became the dominant clones. Clonal complex (CC) 5 CC8 and CC1 were detected between 2015 and 2017, with CC1 being dominant. In 88 cases, SNP analyses revealed nosocomial transmissions among 20 patients which involved highly homologous strains.

CONCLUSIONS

Routine monitoring of MRSA by whole-genome analysis is effective not only for gaining knowledge regarding molecular epidemiology, but also for detecting silent nosocomial transmission.

Data-driven cascade control system: Response estimation and controller design

In this study, we propose a data-driven design method for a cascade control system with inner and outer control loops. First, the input-output response of a controlled plant, which varies with the controller parameters of a fixed-structure inner-outer control law, is estimated directly from open-loop input-output data. Next, based on the estimated response, the controller parameters are optimized to minimize the difference between a reference model with a controlled closed-loop system. In the proposed method, the response of a fictitious reference input, which varies with the controller parameters, is estimated, and then the closed-loop response is estimated. Therefore, a closed-loop input-output data is not required, and the controller parameters are determined directly from an open-loop input-output data. Furthermore, the time constant of a reference model is also optimized so as to reduce the control error. The proposed method is compared with both conventional single-loop and cascade data-driven methods by means of numerical examples.

Anterior mediastinal tracheostomy for severe tracheal stenosis in a child with severe motor and intellectual disabilities: a case report

BACKGROUND

Owing to recurrent aspiration pneumonia and airway stenosis secondary to thoracic deformities, tracheostomy or laryngotracheal separation are often necessary in children with severe motor and intellectual disabilities. However, these procedures are associated with the risks of tracheal stenosis due to tracheal granulation and tracheoinnominate artery fistula formation. We report a case of a child with severe motor and intellectual disabilities treated with an anterior mediastinal tracheostomy.

CASE PRESENTATION

The patient was a 15-year-old boy with severe motor and intellectual disabilities due to intractable epilepsy. Due to thoracic deformity and tracheomalacia, the patient had a flattened and narrowed trachea. Accordingly, laryngotracheal separation was performed 4 months before admission to avoid aspiration pneumonia. Due to a common cold, the patient required frequent sputum suctioning, which exacerbated the tracheal stenosis. Bronchoscopy revealed tracheal stenosis 4-5 cm caudal to the tracheostomy site, tracheal mucosal ulcers, and pulsation of the innominate artery on the anterior wall of the trachea. We performed an anterior mediastinum tracheostomy to release the tracheal stenosis and prevent tracheoinnominate artery fistula formation.

CONCLUSIONS

Anterior mediastinal tracheostomy has several advantages. Including sufficient release of bony compression, release of tracheal hyperextension, and relief of tracheal and innominate artery contact ensures a cannula-free tracheostomy, and there is no need to dissect the brachiocephalic artery. It is the procedure of choice in cases of head and neck malignancies requiring extensive tracheal resection and could be a good surgical option for severe tracheal stenosis and tracheoinnominate artery fistula in children with severe motor and intellectual disabilities.

GC-MS analysis of exhaled gas for fine detection of inflammatory diseases

Exhaled gas analysis is a non-invasive test ideal for continuous monitoring of biological metabolic information. We analyzed the exhaled gas of patients with inflammatory diseases for trace gas components that could serve as biomarkers that enable early detection of inflammatory diseases and assessment of treatment efficacy. Furthermore, we examined the clinical potential of this method. We enrolled 34 patients with inflammatory disease and 69 healthy participants. Volatile components from exhaled gas were collected and analyzed by a gas chromatography-mass spectrometry system, and the data were examined for gender, age, inflammatory markers, and changes in markers before and after treatment. The data were tested for statistical significance through discriminant analysis by Volcano plot, Analysis of variance test, principal component analysis, and cluster analysis comparing healthy and patient groups. There were no significant differences in the trace components of exhaled gas by gender or age. However, we found differences in some components of the exhaled gas between healthy and untreated patients. In addition, after treatment, gas patterns including the patient-specific components changed to a state closer to the inflammation-free status. We identified trace components in the exhaled gas of patients with inflammatory diseases and found that some of these regressed after treatment.

Optimal bowel resection margin in colon cancer surgery: prospective multicentre cohort study with lymph node and feeding artery mapping

Background

There are no standardised criteria for the 'regional' pericolic node in colon cancer, which represents a major cause of the international uncertainty regarding the optimal bowel resection margin. This study aimed to determine 'regional' pericolic nodes based on prospective lymph node (LN) mapping.

Methods

According to preplanned in vivo measurements of the bowel, the anatomical distributions of the feeding artery and LNs were determined in 2996 stages I-III colon cancer patients who underwent colectomy with resection margin >10 cm at 25 institutions in Japan.

Findings

The mean number of retrieved pericolic nodes was 20.9 (standard deviation, 10.8) per patient. In all patients except seven (0.2%), the primary feeding artery was distributed within 10 cm of the primary tumour. The metastatic pericolic node most distant from the primary tumour was within 3 cm in 837 patients, 3-5 cm in 130 patients, 5-7 cm in 39 patients and 7-10 cm in 34 patients. Only four patients (0.1%) had pericolic lymphatic spread beyond 10 cm; all of whom had T3/4 tumours accompanying extensive mesenteric lymphatic spread. The location of metastatic pericolic node did not differ by the feeding artery's distribution. Postoperatively, none of the 2996 patients developed recurrence in the remaining pericolic nodes.

Interpretation

The pericolic nodes designated as 'regional' were those located within 10 cm of the primary tumours, which should be fully considered when determining the bowel resection margin, even in the era of complete mesocolic excision.

Funding

Japanese Society for Cancer of the Colon and Rectum.

Search for the Pair Production of Dark Particles X with K_{L}^{0}→XX, X→γγ

We present the first search for the pair production of dark particles X via K_{L}^{0}→XX with X decaying into two photons using the data collected by the KOTO experiment. No signal was observed in the mass range of 40-110  MeV/c^{2} and 210-240  MeV/c^{2}. This sets upper limits on the branching fractions as B(K_{L}^{0}→XX)<(1-4)×10^{-7} and B(K_{L}^{0}→XX)<(1-2)×10^{-6} at the 90% confidence level for the two mass regions, respectively.

The interrelationship between three-dimensional foot mobility and bodyweight bearing

[Purpose] To clarify the three-dimensional nature of foot mobility and its interrelationships within the foot due to bodyweight bearing. [Participants and Methods] Data regarding left foot mobility due to body weight bearing were collected from 31 healthy adults. Foot shape differences while sitting and standing, and their interrelationship were examined. The same examiner reapplied the landmark stickers when misaligned during measurement position changes. [Results] The foot length, heel width, forefoot width, hallux valgus angle, and calcaneus eversion angle were significantly larger in the standing than in sitting position. The digitus minimus varus angle was significantly smaller in the standing than in sitting position. The medial and lateral malleoli, navicular, and dorsum of the foot were displaced medially and inferiorly; the other indices, except for the midfoot, were displaced anteriorly. The interrelationships within the foot showed a positive correlation between the calcaneus eversion angle and the medial displacement of the medial and lateral malleoli, navicular, and dorsum of the foot points. There was a negative correlation between the calcaneus eversion angle and inferior displacement of the medial malleolus, navicular, and dorsum of the foot. [Conclusion] The intra-foot coordination relationship in response to bodyweight bearing was clarified.

Final analysis of a prospective controlled trial of the efficacy of uracil and tegafur/leucovorin for stage II colon cancer with risk factors for recurrence using propensity score-based methods (JFMC46-1201)

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Background: The usefulness of adjuvant chemotherapy for stage II colon cancer with high-risk factors for recurrence has not been established. Methods: This was a prospective, non-randomized controlled study based on patients’ selection of treatment options, including randomized therapeutic decision-making. High-risk factors were defined as having at least one of the following factors: T4, perforation/penetration, poorly differentiated adenocarcinoma/mucinous carcinoma, and < 12 dissected lymph nodes. UFT (300 mg/m2/day) plus LV (75 mg/day) were orally administered for 6 months after surgery. The primary endpoint was disease-free survival (DFS) after adjusting for risk factors using propensity sore matching (1:2) and inverse probability of treatment weighting (IPTW) in the non-randomized arm. The secondary endpoints were overall survival (OS) and safety. Results: 1902 (98%) and 36 (2%) patients were enrolled in the non-randomized and randomized arms, respectively between May 2012 and April 2016. There were too few patients in the randomized arm and these were therefore excluded from the analysis. Eligible patients were divided into two groups: A, patients who selected surgery alone (n = 641); B, patients who selected UFT/LV treatment (n = 1239). Of the eligible patients, 402 in group A and 804 in group B were propensity score-matched. The 5-year DFS rate (95% confidence interval) was significantly higher in group B (76.3% [73.1-79.1]) than in group A (68.8% [63.9-73.2]) {hazard ratio [HR] 0.66 [0.51–0.84, P = 0.0008]}. The 5-year OS rates were not significantly different between group B and group A [HR 0.74 (95% CI 0.50–1.10, P = 0.1391)]. Using IPTW, significantly higher 5-year DFS [HR 0.71 (95% CI 0.59–0.86, P = 0.0006)] and overall survival [HR 0.66 (95% CI 0.49–0.90, P = 0.0122)] rates were observed in group B compared with group A. Multivariate analysis revealed that male sex, over 70 years old, T4, < 12 dissected lymph nodes, and no adjuvant chemotherapy were significant risk factors for recurrence. Conclusions: Adjuvant chemotherapy with UFT/LV significantly improves DFS. Oral UFT/LV as adjuvant chemotherapy shows efficacy with an acceptable safety profile for stage II colon cancer with risk factors. Clinical trial information: UMIN000007783 .

Chylothorax following transsternal total thymectomy: a case report

Herein, we report a case of chylothorax following total thymectomy. A 46-year-old woman having an anterior mediastinal tumor underwent a thymectomy via median sternotomy. Seven days after surgery, there was no massive pleural effusion. However, on post-operative day 17, a right massive pleural effusion was detected, and it was diagnosed as chylothorax. She was successfully treated with conservative therapy. Chylothorax following thymectomy is a very rare complication.

[Intraoperative Margin Assessment during Thoracoscopic Sublobar Resection Using Radiofrequency Identification Microchip]

We developed a novel wireless localization technique with radiofrequency identification( RFID) markers to enable precise localization of deeply located small lung lesions. Electromagnetic navigational bronchoscopy was used to place RFID markers as close to tumors as possible. Without palpating the lung, operators located the marker using a detection probe, following tone changes in accordance with the marker-probe distance. In this section, we present a novel wireless localization technique using an RFID marker for accurate localization of small lung lesions.

Giant spin polarization and a pair of antiparallel spins in a chiral superconductor

Chiral molecules can exhibit spin-selective charge emission, which is known as chirality-induced spin selectivity^1,2. Despite the constituent light elements of the molecules, their spin polarization can approach or even exceed that of typical ferromagnets. This powerful capability may lead to applications in the chiral spintronics² field. Although the origin of spin selectivity is elusive, two microscopic phenomena have been suggested based on experimental results: effective enhancement of spin-orbit interactions³ and chirality represented by a pair of oppositely polarized spins^4,5. However, the hypotheses remain to be verified. Here we report the simultaneous observation of these two phenomena in an organic chiral superconductor by magnetoresistance measurements in the vicinity of the superconducting transition temperature. A pair of oppositely polarized spins is demonstrated by spatially mapping the spin polarity in an electric alternating current excitation. The obtained spin polarization exceeds that of the Edelstein effect^6-10 by several orders of magnitude, which indicates an effective enhancement of the spin-orbit interaction. Our results demonstrate a solid-state analogue of spin accumulations assumed for chiral molecules, and may provide clues to the origin of their molecular counterparts. In addition, the innovative capability of spin-current sourcing will invigorate superconducting spintronics research¹¹.

Electromagnetic navigation bronchoscopy-guided radiofrequency identification marking in wedge resection for fluoroscopically invisible small lung lesions

OBJECTIVES

We developed a novel wireless localization technique after electromagnetic navigation bronchoscopy-guided radiofrequency identification marker placement for fluoroscopically invisible small lung lesions. We conducted an observational study to investigate the feasibility of this technique and retrospectively compared 2 marking approaches with or without cone-beam computed tomography (CBCT).

METHODS

Consecutive patients from January 2021 to March 2022 in our institution were enrolled. Markers were placed central to the lesions either in a bronchoscopic suite under intravenous anaesthesia or a hybrid operation theatre with CBCT under general anaesthesia. The efficacy of the 2 marking methods was compared using an inverse probability of treatment weighting adjusted analysis.

RESULTS

Totally 80 markers were placed (45 under CBCT and 35 under fluoroscopy) for 74 patients with 80 lesions [mean size: 6.9 mm (interquartile range: 5.1-8.4) at a median depth from the pleura of 14.0 mm (interquartile range: 8.5-19.5)]. The median distance from marker to lesion was 9.1 mm, with a pleural depth of 15.5 mm. The tumour resection rate was 97.5% (78/80) with the median surgical margin of 10.0 mm (interquartile range: 8.0-11.0). Although the bronchoscopy time was longer using CBCT because of the need for 2.8 scans per lesion, the distance from the marker to the lesion was shorter for marking using CBCT than marking using fluoroscopy (adjusted difference: -4.56, 95% confidence interval: -6.51 to -2.61, P < 0.001).

CONCLUSIONS

Electromagnetic navigation bronchoscopy-guided radiofrequency identification marking provided a high tumour resection rate with sufficient surgical margins.

Expected resolution limits of x-ray free-electron laser single-particle imaging for realistic source and detector properties

The unprecedented intensity of x-ray free-electron laser sources has enabled single-particle x-ray diffraction imaging (SPI) of various biological specimens in both two-dimensional projection and three dimensions (3D). The potential of studying protein dynamics in their native conditions, without crystallization or chemical staining, has encouraged researchers to aim for increasingly higher resolutions with this technique. The currently achievable resolution of SPI is limited to the sub-10 nanometer range, mainly due to background effects, such as instrumental noise and parasitic scattering from the carrier gas used for sample delivery. Recent theoretical studies have quantified the effects of x-ray pulse parameters, as well as the required number of diffraction patterns to achieve a certain resolution, in a 3D reconstruction, although the effects of detector noise and the random particle orientation in each diffraction snapshot were not taken into account. In this work, we show these shortcomings and address limitations on achievable image resolution imposed by the adaptive gain integrating pixel detector noise.

Teaching Control during the COVID-19 Pandemic

This paper aims to analyze some different solutions that were adopted in control education activities during the pandemic. The authors of this paper are educators in the control education field from different countries on all the continents, who have developed a questionnaire with the idea of collecting data about the COVID-19 pandemic impact on the control education activities. The main objective is to study the diverse alternatives that were used worldwide to perform the online educational activities during that period, such as methodologies, tools, learning management systems (LMS), theoretical exercises, laboratory experiments, types of exams, simulators, software for online lecturing, etc. As a result, comparisons between pre-and during-pandemic educational resources and methods are performed, where useful ideas and discussions are given for the control education community.

Nuclear accumulation of MLKL induces necroptosis in cardiomyocytes: potential implication in Doxorubicin-induced cardiotoxicity

Background

The treatment with doxorubicin, a powerful chemotherapeutic agent, has been shown to be associated with an increased risk of lethal heart failure. Although various types of cell death pathway such as apoptosis and ferroptosis have been shown to be involved in the development of doxorubicin-induced cardiotoxicity, DIC, the involvement of necroptosis, a novel programmed necrosis induced by translocation of activated mixed lineage kinase domain-like protein, MLKL, to plasma membrane, remains unclear.

Purpose

The aim of this study was to determine whether necroptosis is involved in the development of DIC.

Methods and results

DIC was induced in C57BL/6J mice by intraperitoneal injection of doxorubicin at a dose of 10 mg/kg 3 times for a week. Eight days after the commencement of injection, echocardiographic analyses showed that left ventricular ejection fraction assessed by echocardiography was significantly lower in the doxorubicin-treated mice than in the vehicle-treated mice (44.0±13.7 vs. 70.5±3.7%), indicating the development of DIC. Immunoblot analysis showed that MLKL protein level was higher by 1.6 fold in the doxorubicin-treated mice than in the vehicle-treated mice. Interestingly, immunohistochemical analysis showed that signals of phospho-Ser345-MLKL, an activated form of MLKL, was found in the nuclei in addition to cytosol and intercalated discs of cardiomyocytes in the doxorubicin-treated mice. To get novel insight into significance of nuclear MLKL accumulation, a leucine-rich nuclear export signal (NES) spanning amino acids 280–284 of rat MLKL was identified by site-directed mutation analyses, and H9c2 cells, cultured rat cardiomyoblasts, were transfected with expression constructs for nucleus-directed MLKL (FLAG-mtNES-MLKL) or its wild type (FLAG-WT-MLKL). Percentage of FLAG-positive cells stained with Zombie Red, a fluorescent dye that is non-permeant to live cells, was higher in FLAG-mtNES-MLKL-transfected cells than in FLAG-WT-MLKL-transfected cells (80.0±3.5% vs. 6.3±1.3%, p&lt;0.05), whereas percentage of cells immunostained with cleaved caspase-3 to FLAG-positive cells was similar in the two groups. The effect of the MLKL mutant on necroptosis was attenuated by treatment with GppNHp, an inhibitor of Ran-mediated nuclear protein import.

Conclusion

Nuclear accumulation of MLKL induces necroptosis in cardiomyocytes, which may contribute to progression of DIC.

Funding Acknowledgement

Type of funding sources: None.

Clinical trajectory and outcomes of patients with heart failure with preserved ejection fraction with normal or indeterminate diastolic function

Background

Heart failure (HF) with preserved ejection fraction (HFpEF) is a chronic and progressive disease, but limited therapeutic strategies are currently available. Although left ventricular diastolic dysfunction (DD) is a prominent mechanism of HFpEF, a certain number of patients with HFpEF have a normal diastolic function (ND) or indeterminate diastolic function (ID). With the progressive nature of HFpEF, diastolic function may change over time. However, the change of diastolic function, its predictor and prognosis in patients with clinically established HFpEF remains unknown.

Purpose

To investigate the clinical trajectory and outcomes of patients with HFpEF with ND or ID and to identify factors associated with progression from ND or ID at discharge to DD at 1-year follow-up.

Methods

Using data from a prospective multicenter observational study of patients with HFpEF, we extracted 289 patients with HFpEF with ND or ID at discharge who had echocardiographic data at 1-year follow-up for the re-evaluation of diastolic function. Diastolic function was assessed according to the 2016 American Society of Echocardiography recommendations. Patients were classified according to the absence or presence of progression from ND or ID to DD at 1 year. The primary endpoint was a composite of all-cause death and HF rehospitalization.

Results

Median age was 81 years, and 138 (47.8%) patients were female. At 1 year, 107 (37%) patients progressed to DD. During a median follow-up of 709 days, the composite endpoint occurred in 90 (31.1%) patients. Compared to patients without progression to DD, those with progression to DD had a significantly higher cumulative incidence rate of the composite endpoint (incidence rate: 11.7/100 person-year versus 23.3/100 person-year, P&lt;0.001). Progression to DD (adjusted HR: 2.014, 95% CI: 1.239–3.273, P=0.005) was independently associated with the composite endpoint. Age (adjusted OR: 1.046, 95% CI: 1.008–1.087, P=0.018), body mass index (BMI) (adjusted OR: 1.107, 95% CI: 1.029–1.192, P=0.006), and serum albumin (adjusted OR: 0.459, 95% CI: 0.216–0.974, P=0.042) were independently associated with progression from ND or ID to DD at 1 year.

Conclusion

More than one-third of patients with HFpEF with ND or ID progressed to DD at 1 year and had poor clinical outcomes. Age, BMI, and serum albumin were independently associated with this progression.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by grants from Japan Society for the Promotion of Science KAKENHI (No. JP 17K09496) and Japan Agency for Medical Research and Development (No. JP16lk1010013).

Impact of right ventricular reserve on exercise capacity and quality of life in patients with left ventricular assist device

Background

Right heart failure following left ventricular assist device (LVAD) implantation is a major complication which significantly impairs functional capacity and quality of life (QoL). Right ventricular (RV) reserve function may limit exercise capacity and QoL in LVAD patients; however, most patients show normal RV haemodynamics at rest.

Purpose

The aim of this study was to investigate whether RV reserve assessed by the changes of RV function during exercise is correlated with exercise capacity and QoL in patients with LVAD.

Methods

We prospectively examined 20 consecutive LVAD patients who were admitted to our university hospital between June 2020 and November 2021 after excluding those who were unable to perform exercise (n=8). All patients underwent invasive exercise right heart catheterisation with simultaneous echocardiography in the supine position. RV stroke work index (RVSWI) was calculated as 0.0136 × stroke volume index × (mean pulmonary artery pressure [mPAP] − right atrial pressure [RAP]) at rest and during exercise. Exercise capacity and QoL were assessed by 6-minute walk distance (6MWD) and peak oxygen consumption (VO2) in cardiopulmonary exercise testing, and the EuroQol visual analogue scale (EQ-VAS), respectively. The patients were divided into two groups according to the median ΔRVSWI (RVSWI change from rest to peak exercise) of 1.45 (interquartile range [IQR] −0.31 to 8.25) g/m2.

Results

Patients were predominantly male (75%) and the median age was 47 (IQR 38–60) years. Patients with lower ΔRVSWI had significantly higher change on RAP (P=0.019), but significantly lower change on mPAP (P&lt;0.001) compared to those with higher ΔRVSWI. There were no significant differences in age, gender, primary aetiology of heart failure, type of LVAD devices, or echocardiographic parameters including tricuspid annular plane systolic excursion, and RVSWI at rest between the groups. ΔRVSWI during exercise were positively correlated with 6MWD (R=0.69, P&lt;0.01) and peak VO2 (R=0.66, P&lt;0.01) (Figure A). In addition, ΔRVSWI during exercise were positively correlated with the EQ-VAS (R=0.48, P=0.031). On the other hand, there was no significant correlation between RVSWI at rest and 6MWD (R=−0.11, P=0.63) and peak VO2 (R=0.13, P=0.95), and the EQ-VAS (R=0.11, P=0.61). During a median follow-up period of 312 (IQR 176–369) days, adverse events occurred in 3 patients (15%), including 1 death and 2 hospitalisations for major bleeding and right heart failure. Kaplan-Meier analysis revealed that the adverse events more frequently occurred in patients with lower ΔRVSWI compared to those with higher ΔRVSWI (Figure B).

Conclusions

ΔRVSWI was positively correlated with 6MWD, peak VO2 and EQ-VAS irrespective of RV function at rest. Our findings suggest that the assessment of RV reserve function using ΔRVSWI would be useful for risk stratification in patients with LVAD.

Funding Acknowledgement

Type of funding sources: None.

Premature atrial contraction on Holter electrocardiogram predicts the recurrence of atrial fibrillation after catheter ablation

Introduction

It is important to detect the recurrence of atrial fibrillation (AF) after catheter ablation (CA) early, but the method of detection has not been established. The purpose of this study is to determine whether 24-h Holter electrocardiogram (ECG) can predict the recurrence of AF after CA.

Methods

We studied 336 patients of 497 patients enrolled in EARNEST-PVI trial to investigate whether the total number of premature atrial contraction (PAC) and the maximum number of PAC run by 24-h Holter ECG at 6 months after CA predicted AF recurrence after 6 months. We excluded 86 patients with recurrence by 6 months after CA and 75 patients without Holter ECG at 6 months after CA.

Results

Median age was 66 years, male were 77% and median follow-up period was 1138 days. Receiver operating characteristic curve analysis identified the total number of PAC ≥270 beats and the maximum number of PAC run ≥8 beats as the optimal cutoff for prediction of AF recurrence. Kaplan-Meier analysis showed patients with the total number of PAC ≥270 beats had more frequent AF recurrence than those without (Kaplan-Meier estimated 3-year AF recurrence rate 34% vs. 17%, Log-rank P=0.001) and patients with the maximum number of PAC run ≥8 beats had more frequent AF recurrence than those without (Kaplan-Meier estimated 3-year AF recurrence rate 33% vs. 20%, Log-rank P=0.006). Multivariate analysis revealed that the total number of PAC ≥270 beats and the maximum number of PAC run were significantly associated with AF recurrence (hazard ratio [95% confidence interval] 1.83 [1.16–2.91], P=0.01 and 1.01 [1.01–1.02], P=0.001, respectively)

Conclusion

The total number of PAC and the maximum number of PAC run on the Holter ECG may be useful in predicting AF recurrence after CA.

Funding Acknowledgement

Type of funding sources: None.

Evaluation of the direct protective effects of Canagliflozin on the Isoproterenol-induced cell injury in rat cardiomyocytes

Background

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are agents that act by inhibiting glucose and sodium reabsorption in the proximal renal tubule which promotes urinary glucose excretion. More recently, significant benefit data of SGLT2 inhibitors in patients with heart failure, independent of the presence of type 2 diabetes has been reported. We have previously demonstrated that Canagliflozin (Cana), a SGLT2 inhibitor, reduced the ventricular effective refractory period in isoproterenol (ISP)-induced myocardial injury rat model accompanied with the suppression of reactive oxygen species and the elevation of ketone bodies, suggesting the effect of Cana on electrical cardiac remodeling. The direct effect of Cana to the cardiomyocytes and its underlying molecular mechanism was remained to be clarified. We therefore established an ISP-induced neonatal rat ventricular cardiomyocyte (NRVCM) in vitro model, pretreated with Cana and/or ketone bodies.

Methods

Primary NRVCM were isolated from Wistar rats, were pretreated by Cana with or without βOHB (the most abundant ketone body in circulation), followed by a stimulation of ISP (10μM). Cells without drug or ketone body pretreatment were used as control. We then analyzed its effect on cell viability, apoptosis, and mitochondrial membrane potential using MTT assay, TUNEL assay, and mitochondrial membrane potential assay, respectively. MTT assay was also performed with or without PI3k inhibitor, LY294002. The end-labeling of DNA fragmentation were labelled with FITC, followed by the nuclei counterstain with DAPI and were observed with confocal microscope. The apoptotic index was defined as the percentage of TUNEL positive cells / total nuclei.

Results

Cana rescued the reduction of NRVCM cell viability induced by ISP stimulation for 24 hours which was inhibited by LY294002 compared to cells without pretreatment. Interestingly, pretreatment of βOHB with or without Cana improved also the NRCVM cell viability whereas there was no significant difference between these two conditions or with cells treated with Cana only, suggesting the direct protective effect of Cana. In 48 hours of ISP stimulation, the apoptotic index intends to decrease in Cana and/or βOHB compared to cells without pretreatment (Figure 1). Although the mitochondrial function was maintained in Cana-pretreated cells compared to cells without pretreatment, there was no significant difference in βOHB-pretreated cells.

Conclusions

Cana has a direct protective effect on cardiomyocytes cell viability, apoptosis as well as the mitochondrial function impaired by ISP through the cell survival signaling PI3K/Akt pathway. This brings a new insight to the therapeutic target of cardiovascular disease.

Funding Acknowledgement

Type of funding sources: None.