Incidence of phrenic nerve injury during pulmonary vein isolation using different cryoballoons: data from a large prospective ablation registry

AIMS

Phrenic nerve injury (PNI) is the most common complication during cryoballoon ablation. Currently, two cryoballoon systems are available, yet the difference is unclear. We sought to compare the acute procedural efficacy and safety of the two cryoballoons.

METHODS

This prospective observational study consisted of 2,555 consecutive atrial fibrillation (AF) patients undergoing pulmonary vein isolation (PVI) using either conventional (Arctic Front Advance) (AFA-CB) or novel cryoballoons (POLARx) (POLARx-CB) at 19 centers between January 2022 and October 2023.

RESULTS

Among 2,555 patients (68.8 ± 10.9 years, 1,740 men, paroxysmal AF[PAF] 1,670 patients), PVIs were performed by the AFA-CB and POLARx-CB in 1,358 and 1,197 patients, respectively. Touch-up ablation was required in 299(11.7%) patients. The touch-up rate was significantly lower for POLARx-CB than AFA-CB (9.5% vs. 13.6%, p = 0.002), especially for right inferior PVs (RIPVs). The touch-up rate was significantly lower for PAF than non-PAF (8.8% vs. 17.2%, P < 0.001) and was similar between the two cryoballoons in non-PAF patients. Right PNI occurred in 64(2.5%) patients and 22(0.9%) were symptomatic. It occurred during the right superior PV (RSPV) ablation in 39(1.5%) patients. The incidence was significantly higher for POLARx-CB than AFA-CB (3.8% vs. 1.3%, P < 0.001) as was the incidence of symptomatic PNI (1.7% vs. 0.1%, P < 0.001). The difference was significant during RSPV (2.5% vs. 0.7%, P < 0.001) but not RIPV ablation. The PNI recovered more quickly for the AFA-CB than POLARx-CB.

CONCLUSIONS

Our study demonstrated a significantly higher incidence of right PNI and lower touch-up rate for the POLARx-CB than AFA-CB in the real-world clinical practice.

Adjunctive posterior wall isolation for the treatment of persistent and longstanding persistent atrial fibrillation (CORNERSTONE AF) trial: Design and rationale

BACKGROUND

A left atrial posterior wall isolation (LAPWI) is one of the atrial fibrillation (AF) ablation strategies.

HYPOTHESIS

We hypothesized that an additional empirical LAPWI would increase the freedom from recurrent atrial arrhythmias as compared to standard AF ablation in persistent AF patients.

METHODS

The CORNERSTONE AF study is a prospective, randomized, multicenter study investigating patients with AF persisting for >7 days and <3 years undergoing first-time AF ablation. They will be randomized to pulmonary vein isolation (PVI) or PVI + LAPWI in a 1:1 manner. Although PVI can be performed with either radiofrequency catheters or cryoballoons, only radiofrequency catheters will be permitted to achieve LAPWIs. Additional focal ablation targeting non-pulmonary vein triggers will be allowed. A total of 516 patients will be enrolled in 17 centers between August 2022 and February 2024 based on the calculation with 80% power, considering the assumption that 65% and 75% of the PVI and PVI + LAPWI group patients will be free from atrial arrhythmia recurrence 18-months postprocedure (10% of dropout). The primary endpoint is freedom from documented atrial arrhythmias 18 months postsingle procedures. Clinical follow-up will include 7-day ambulatory electrocardiograms and routine outpatient consultations by electrophysiologists at 1, 3, 6, 9, 12, and 18 months postprocedure.

RESULTS

As of August 2023, a total of 331 patients (68 ± 9 years, 270 men, 43 longstanding persistent AF) have been enrolled.

CONCLUSIONS

The CORNERSTONE AF study is a prospective, randomized, multicenter trial designed to evaluate the efficacy and safety of an adjunctive empirical LAPWI following standard AF ablation in persistent AF patients.

Comparative efficacy of ultrasound guidance and fluoroscopy or computed tomography guidance in spinal nerve injections: a systematic review and meta-analysis

PURPOSE

Spinal nerve injections have traditionally been performed under fluoroscopic (FL) and computed tomography (CT) guidance. Recently, ultrasound (US)-guided procedures have provided an alternative guidance approach that does not expose the patient and operator to radiation. The aim of this study was to compare the efficacy and safety of US-guided spinal nerve injections compared with FL- or CT-guided spinal nerve injections.

METHODS

MEDLINE, Cochrane Library, EMBASE, international clinical trials registry platform (ICTRP) and ClinicalTrials.gov database searches for inclusion until February 2023 were independently performed by two authors using predefined criteria. Randomized controlled trials (RCTs) were included. Primary outcomes were change in pain score (numeric rating scale or visual analogue scale) and major adverse events. Secondary outcomes were procedure time, change in functional disability score and minor adverse events. Meta-analysis was performed using random-effect model. We evaluated the certainty of evidence based on the Grading of Recommendations, Assessment and Development (GRADE) approach.

RESULTS

Eight RCTs involving 962 patients were included. There might be little to no difference in the mean score of the pain change between the US-guided methods and the FL- or CT-guided injections (standard mean difference -0.06; 95% confidence interval [CI] -0.26 to 0.15). US guidance probably reduced major adverse events (0.7% [3/433] and 6.5% [28/433], respectively), reduced procedure time (mean difference -4.19 min; 95% CI -5.09 to -3.30), and probably reduced minor adverse events (2.1% [9/433] and 4.2% [18/433], respectively) compared with FL or CT guidance. There was probably little to no difference in the change in functional disability score with either method.

CONCLUSION

US-guided spinal nerve injections remained effective and reduced adverse events compared with conventional FL- or CT-guided spinal nerve injections. Further RCTs are required to verify our results.

STUDY REGISTRATION

Open Science Forum (Available from: https://osf.io/vt92w/ ).

Symptomatic periesophageal vagal nerve injury by different energy sources during atrial fibrillation ablation

Background

Symptomatic gastric hypomotility (SGH) is a rare but major complication of atrial fibrillation (AF) ablation, but data on this are scarce.

Objective

We compared the clinical course of SGH occurring with different energy sources.

Methods

This multicenter study retrospectively collected the characteristics and clinical outcomes of patients with SGH after AF ablation.

Results

The data of 93 patients (67.0 ± 11.2 years, 68 men, 52 paroxysmal AF) with SGH after AF ablation were collected from 23 cardiovascular centers. Left atrial (LA) ablation sets included pulmonary vein isolation (PVI) alone, a PVI plus a roof-line, and an LA posterior wall isolation in 42 (45.2%), 11 (11.8%), and 40 (43.0%) patients, respectively. LA ablation was performed by radiofrequency ablation, cryoballoon ablation, or both in 38 (40.8%), 38 (40.8%), and 17 (18.3%) patients, respectively. SGH diagnoses were confirmed at 2 (1-4) days post-procedure, and 28 (30.1%) patients required re-hospitalizations. Fasting was required in 81 (92.0%) patients for 4 (2.5-5) days; the total hospitalization duration was 11 [7-19.8] days. After conservative treatment, symptoms disappeared in 22.3% of patients at 1 month, 48.9% at 2 months, 57.6% at 3 months, 84.6% at 6 months, and 89.7% at 12 months, however, one patient required surgery after radiofrequency ablation. Symptoms persisted for >1-year post-procedure in 7 patients. The outcomes were similar regardless of the energy source and LA lesion set.

Conclusions

The clinical course of SGH was similar regardless of the energy source. The diagnosis was often delayed, and most recovered within 6 months, yet could persist for over 1 year in 10%.

Quantification of inter-brain coupling: A review of current methods used in haemodynamic and electrophysiological hyperscanning studies

Hyperscanning is a form of neuroimaging experiment where the brains of two or more participants are imaged simultaneously whilst they interact. Within the domain of social neuroscience, hyperscanning is increasingly used to measure inter-brain coupling (IBC) and explore how brain responses change in tandem during social interaction. In addition to cognitive research, some have suggested that quantification of the interplay between interacting participants can be used as a biomarker for a variety of cognitive mechanisms aswell as to investigate mental health and developmental conditions including schizophrenia, social anxiety and autism. However, many different methods have been used to quantify brain coupling and this can lead to questions about comparability across studies and reduce research reproducibility. Here, we review methods for quantifying IBC, and suggest some ways moving forward. Following the PRISMA guidelines, we reviewed 215 hyperscanning studies, across four different brain imaging modalities: functional near-infrared spectroscopy (fNIRS), functional magnetic resonance (fMRI), electroencephalography (EEG) and magnetoencephalography (MEG). Overall, the review identified a total of 27 different methods used to compute IBC. The most common hyperscanning modality is fNIRS, used by 119 studies, 89 of which adopted wavelet coherence. Based on the results of this literature survey, we first report summary statistics of the hyperscanning field, followed by a brief overview of each signal that is obtained from each neuroimaging modality used in hyperscanning. We then discuss the rationale, assumptions and suitability of each method to different modalities which can be used to investigate IBC. Finally, we discuss issues surrounding the interpretation of each method.

Neurological Analysis Based on the Terminal End of the Spinal Cord and the Narrowest Level of Injured Spine in Thoracolumbar Spinal Injuries

This study aimed to clarify neurological differences among the epiconus, conus medullaris, and cauda equina syndromes. Eighty-seven patients who underwent surgery for acute thoracolumbar spinal injuries were assessed. We defined the epiconus as the region from the terminal end of the spinal cord to the proximal 1.0 to 2.25 vertebral bodies, the conus medullaris as the region proximal to < 1.0 vertebral bodies, and the cauda equina as the distal part of the nerve roots originating from the spinal cord. On the basis of the distance from the terminal end of the spinal cord to the narrowest level of the spinal canal, the narrowest levels were ordered as follows: the epiconus followed by the conus medullaris and cauda equina. The narrowest levels were the epiconus in 22 patients, conus medullaris in 37 patients, and cauda equina in 25 patients. On admission, significantly more patients had a narrowed epiconus of Frankel grades A-C than a narrowed cauda equina. At the final follow-up, there were no significant differences in neurological recovery among those with epiconus, conus medullaris, or cauda equina syndrome. Anatomically classifying the narrowest lesion is useful for clarifying the differences and similarities among these three syndromes.

The Outcomes of Neoadjuvant Chemoradiotherapy Using Moderately Hypofractionated Intensity Modulated Radiotherapy for Borderline Resectable Pancreatic Cancer

PURPOSE/OBJECTIVE(S)

Complete resection of borderline resectable pancreatic cancer (BRPC) is difficult because of its invasion to the vital vessels. Although neoadjuvant therapy is recommended for BRPC, its optimal regimens remain unclear. Neoadjuvant chemoradiotherapy using moderately hypofractionated intensity-modulated radiotherapy (NAC-MH-IMRT) has potentials to improve the treatment outcomes with shorter treatment periods. Therefore, we evaluated the outcomes for BRPC patients treated with NAC-MH-IMRT.

MATERIALS/METHODS

Between February 2013 and June 2021, patients with BRPC treated with NAC-MH-IMRT at our institution were evaluated. All patients were classified as BRPC-A and BRPC-V according to NCCN guidelines. Information regarding patient status, tumor and treatment characteristics, margin-negative resection (R0) rates, histological effects assessed by Evans classification, and outcomes were obtained from the clinical records. Overall survival (OS) and progression-free survival (PFS) were calculated by the Kaplan-Meier method from the start date of any first treatment for BRPC. Toxicity was evaluated by CTCAE version 5.0.

RESULTS

Sixty-eight patients were included in this study (Table). All patients underwent induction chemotherapy, and 67 were treated with IMRT at 42 Gy in 15 fractions with concurrent gemcitabine (for 65) or S-1 (for 2). All patients achieved completion of radiotherapy. Fifty-seven of the 68 patients (83.8%) underwent surgical exploration, and 48 patients (70.6%) had a resection. The R0 resection was achieved in 44 patients, and the R0 resection rate was 91.7% in resected patients. Therapeutic effects by Evans classification showed as below: Grade 1/2a/2b/3/4 = 6 (12.5%)/17 (35.4%)/17 (35.4%)/7 (14.6%)/1 (2.1%). Adjuvant chemotherapy was performed for 41 patients, and S-1 and gemcitabine were used for 40 and 1 patient(s), respectively. The median follow-up time and median survival time (MST) were 23.6 months and 42.7 months, and 2-year OS and PFS were 67.3% and 30.2%, respectively. Recurrence was observed in 54 patients (79.4%), and the first recurrence pattern was as follows: 7 (13.0%)/42 (77.8%)/5 (9.3%) patients had local recurrence, distant metastases, and both of them, respectively. Regarding ≥ Grade 3 gastrointestinal toxicity related NAC-MH-IMRT, grade 3 ileus was observed in 1 patient.

CONCLUSION

NAC-MH-IMRT for BRPC showed preferable outcomes and acceptable toxicities with high completion rate.

Peri-procedural anticoagulation in patients with end-stage kidney disease undergoing atrial fibrillation ablation: results from the multicentre end-stage kidney disease-atrial fibrillation ablation registry

AIMS

The optimal anticoagulation regimen in patients with end-stage kidney disease (ESKD) undergoing atrial fibrillation (AF) catheter ablation is unknown. We sought to describe the real-world practice of peri-procedural anticoagulation management in patients with ESKD undergoing AF ablation.

METHODS AND RESULTS

Patients with ESKD on haemodialysis undergoing catheter ablation for AF in 12 referral centres in Japan were included. The international normalized ratio (INR) before and 1 and 3 months after ablation was collected. Peri-procedural major haemorrhagic events as defined by the International Society on Thrombosis and Haemostasis, as well as thromboembolic events, were adjudicated.  A total of 347 procedures in 307 patients (67 ±9 years, 40% female) were included. Overall, INR values were grossly subtherapeutic [1.58 (interquartile range: 1.20-2.00) before ablation, 1.54 (1.22-2.02) at 1 month, and 1.22 (1.01-1.71) at 3 months]. Thirty-five patients (10%) suffered major complications, the majority of which was major bleeding (19 patients; 5.4%), including 11 cardiac tamponade (3.2%). There were two peri-procedural deaths (0.6%), both related to bleeding events. A pre-procedural INR value of 2.0 or higher was the only independent predictor of major bleeding [odds ratio, 3.3 (1.2-8.7), P = 0.018]. No cerebral or systemic thromboembolism occurred.

CONCLUSION

Despite most patients with ESKD undergoing AF ablation showing undertreatment with warfarin, major bleeding events are common while thromboembolic events are rare.

Clinical characteristics and outcomes of pheochromocytoma crisis: a literature review of 200 cases

PURPOSE

Pheochromocytoma crisis is a life-threatening endocrine emergency that requires prompt diagnosis and treatment. Because of its rarity, sudden onset, and lack of internationally uniform and validated diagnostic criteria, pheochromocytoma crisis remains to be fully clarified. Therefore, we aimed to describe the clinical characteristics and outcomes of pheochromocytoma crisis through a literature review.

METHODS

We performed a systematic literature search of PubMed/MEDLINE database, Igaku-Chuo-Zasshi (Japanese database), and Google Scholar to identify case reports of pheochromocytoma crisis published until February 5, 2021. Information was extracted and analyzed from the literature that reported adequate individual patient data of pheochromocytoma crisis in English or Japanese. Cases were also termed as pheochromocytoma multisystem crisis (PMC) if patients had signs of hyperthermia, multiple organ failure, encephalopathy, and labile blood pressure.

RESULTS

In the 200 cases of pheochromocytoma crisis identified from 187 articles, the mean patient age was 43.8 ± 15.5 years. The most common symptom was headache (39.5%). The heart was the most commonly damaged organ resulting from a complication of a pheochromocytoma crisis (99.0%), followed by the lungs (44.0%) and the kidney (21.5%). PMC accounted for 19.0% of all pheochromocytoma crisis cases. After excluding 12 cases with unknown survival statuses, the mortality rate was 13.8% (26/188 cases). Multivariable logistic regression analysis revealed that nausea and vomiting were significantly associated with a higher mortality rate.

CONCLUSION

Pheochromocytoma can present with different symptomatology, affecting different organ systems. Clinicians should be aware that patients with nausea or vomiting are at a higher risk of death because of pheochromocytoma crisis.

Association of the bioimpedance phase angle and quality of life in postmenopausal osteoporosis

OBJECTIVES

Osteoporosis patients with fragility fractures and vertebral deformities have impaired quality of life (QOL). The phase angle is an index calculated from bioelectrical impedance analysis (BIA) measurements that has been reported to be related to clinical outcomes, mortality, and QOL in various diseases. The aim was to investigate the relationship between the phase angle and QOL in patients with postmenopausal osteoporosis.

METHODS

A total of 81 female patients treated for postmenopausal osteoporosis from September 2019 to March 2020 underwent measurement of bone mineral density (BMD) by dual-energy X-ray absorptiometry, body composition by BIA, and QOL by the 36-Item Short-Form Health Survey (SF-36).

RESULTS

The phase angle showed significant positive correlations with the physical functioning (PF) (r = 0.270, p = 0.015) and physical component summary (PCS) (r = 0.251, p = 0.024) of SF-36. The phase angle showed significant positive correlations with appendicular skeletal muscle index (ASMI) (r = 0.456, p < 0.001) lumbar spine BMD (r = 0.241, p = 0.030), and femoral neck BMD (r = 0.26, p = 0.021), and a significant negative correlation with age (r = -0.526, p < 0.001). Multiple regression analysis of the factors potentially associated with SF-36 PCS showed that the phase angle (r = 7.506, p = 0.012) was the significant contributor to PCS (R2 = 0.184).

CONCLUSION

The phase angle in postmenopausal osteoporotic patients was significantly related to QOL after adjusting for age, BMI, ASMI, and BMD. Because the phase angle is a parameter that can be measured easily and non-invasively, it might be a useful aid for QOL assessment in osteoporotic patients.

Vascular endothelial factor C and D in patients with heart failure with preserved, mildly reduced, and reduced ejection fraction: the PREHOSP-CHF study

Background

The lymphatic system has been suggested to play an important role in cardiovascular diseases including heart failure (HF). Vascular endothelial growth factor C (VEGF-C) and D (VEGF-D) are key regulators of lymphangiogenesis, and we recently reported the association of low VEGF-C with the risk of all-cause death and high VEGF-D with the risk of HF hospitalization in patients with HF.

Purpose

To investigate the association of VEGF-C and VEGF-D with prognosis in patients with HF with preserved ejection fraction (EF) (HFpEF: EF≥50%), mildly reduced EF (HFmrEF: EF, 40–49%), and reduced EF (HFrEF: EF&lt;40%).

Methods

The PREHOSP-CHF study is a multicenter prospective cohort study to determine the predictive value of angiogenesis-related biomarkers in HF. A total of 1,024 patients (mean age 75.5±12.6 years; 58.7% male) admitted to acute decompensated HF were included in the analyses. Serum levels of VEGF-C and VEGF-D, as well as N-terminal pro B-type natriuretic peptide (NT-proBNP), high sensitivity cardiac troponin-I (hs-cTnI), high sensitivity C reactive protein, were measured at the time of discharge. Patients were followed-up over two years.

Results

The numbers of HFpEF, HFmrEF, and HFrEF were 429 (41.9%), 186 (18.2%), and 409 (39.9%), respectively. HFpEF patients were older, more likely to be female, and had more hypertension, atrial fibrillation, and anemia, but less coronary artery disease. NT-proBNP and hs-cTnI levels increased with decreasing EF. VEGF-C levels decreased with increasing EF (median [interquartile range]: HFpEF, 4508 [3318–5919] pg/ml; HFmrEF, 4719 [3663–6203] pg/ml; HFrEF, 5023 [3804–6382] pg/ml), whereas VEGF-D levels were comparable among the three EF groups (HFpEF, 404.6 [293.1–560.3] pg/ml; HFmrEF, 386.0 [298.5–556.3] pg/ml; HFrEF, 414.2 [296.1–557.3] pg/ml). In multivariate stepwise logistic regression analyses, anemia and high NT-proBNP were independently associated with low VEGF-C levels, and high NT-proBNP was independently associated with high VEGF-D levels, across all the EF groups. During the follow-up, incidences of all-cause death and HF hospitalizations were similar among the three EF groups (log-rank P=0.6 for all-cause death, and log-rank P=0.3 for HF hospitalization). On multivariate Cox proportional hazard analyses including established risk factors and cardiovascular biomarkers, VEGF-C levels tended to be inversely associated with the incidence of all-cause death in patients with HFpEF and HFrEF (Figure). On the contrary, VEGF-D levels were significantly and positively associated with the incidence of HF hospitalization in patients with HFpEF, and tended to be positively associated with it in patients with HFmrEF and HFrEF (Figure).

Conclusions

Low VEGF-C was associated with the risk of all-cause death in patients with HFpEF and HFrEF, while high VEGF-D was associated with the risk of HF hospitalization especially in HFpEF.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Grant-in-Aid for Clinical Research from the National Hospital Organization

Gata2, Nkx2-2 and Skor2 form a transcription factor network regulating development of a midbrain GABAergic neuron subtype with characteristics of REM-sleep regulatory neurons

The midbrain reticular formation (MRF) is a mosaic of diverse GABAergic and glutamatergic neurons that have been associated with a variety of functions, including sleep regulation. However, the molecular characteristics and development of MRF neurons are poorly understood. As the transcription factor, Gata2 is required for the development of all GABAergic neurons derived from the embryonic mouse midbrain, we hypothesized that the genes expressed downstream of Gata2 could contribute to the diversification of GABAergic neuron subtypes in this brain region. Here, we show that Gata2 is required for the expression of several GABAergic lineage-specific transcription factors, including Nkx2-2 and Skor2, which are co-expressed in a restricted group of post-mitotic GABAergic precursors in the MRF. Both Gata2 and Nkx2-2 function is required for Skor2 expression in GABAergic precursors. In the adult mouse and rat midbrain, Nkx2-2-and Skor2-expressing GABAergic neurons locate at the boundary of the ventrolateral periaqueductal gray and the MRF, an area containing REM-off neurons regulating REM sleep. In addition to the characteristic localization, Skor2+ cells increase their activity upon REM-sleep inhibition, send projections to the dorsolateral pons, a region associated with sleep control, and are responsive to orexins, consistent with the known properties of midbrain REM-off neurons.

Five-Year Impacts of Antithrombotic Therapy Based on 10-Year Clinical Outcomes of Cypher™ Stent Implantation

Introduction

Few researchers have investigated the optimal long-term antithrombotic therapy regimen, especially after first-generation drug-eluting stent (DES) use. This study aimed to evaluate the impact of mid-term antithrombotic therapy on long-term outcomes in patients treated with the first sirolimus-eluting coronary stent (Cypher™).

Methods

Between 2004 and 2009, 1021 patients underwent Cypher™ implantation at our institute; among them, 567 patients had available data on antithrombotic therapy at year 5. We assessed patients’ antithrombotic therapy at year 5 post Cypher™ implantation and examined their association with adverse events from year 5 to year 10 post Cypher™ implantation.

Results

Patients with dual-antiplatelet therapy (DAPT) at year 5 had significantly lower risk of stent thrombosis (ST) than those with single-antiplatelet therapy (SAPT) (hazard ratio [HR] 0.24, p = 0.034). The HR of major bleeding in DAPT, compared to SAPT, was high, but the difference was not significant (HR 1.72, p = 0.26). Risk of major bleeding was significantly higher in patients on oral anticoagulants (OAC) than in those in other groups (OAC/SAPT; HR 5.31, p = 0.0048, OAC/DAPT; HR 3.08, p = 0.022), without significant reduction in the risk of cardiovascular events.

Conclusions

The incidence of ST after Cypher™ implantation in patients with DAPT at year 5 was significantly lower than that in SAPT. However, the risk of bleeding was higher with DAPT than with SAPT. Moreover, the risk of major bleeding was significantly higher in patients on anticoagulant therapy than in other patients. New options for the use of antithrombotic drugs after percutaneous coronary intervention warrant further studies on the optimal antithrombotic therapy for first-generation DES.

AB0343 LONG-TERM TOCILIZUMAB TREATMENT IN PATIENTS WITH RHEUMATOID ARTHRITIS IN DAILY CLINICAL PRACTICE

Background

Tocilizumab (TCZ) is a humanized anti-IL-6 receptor monoclonal antibody that improves the signs and symptoms of rheumatoid arthritis (RA). In previous clinical trials, long-term outcomes have been increasingly evaluated in daily clinical practice. We report the five-year outcomes of TCZ treatment at our institute.

Objectives

This retrospective study determined the long-term trends in TCZ use in clinical practice.

Methods

Data from the Toyohashi RA database (TRAD) were used. The TRAD is single-center retrospective data. Last observation carried forward was used as a complementary method for missing data. Participants were 59 RA patients in whom TCZ therapy was started at our institute from September 2009 to May 2016. Subsequent items, baseline patient characteristics, disease activity, treatment continuation rates of TCZ using the Kaplan-Meier method, reasons for stopping TCZ, concomitant use of methotrexate (MTX) and prednisolone (PSL) were investigated.

Results

Baseline characteristics at the start of TCZ treatment were 17 men and 42 women with a mean age of 58.6 years (30–81). The mean RA duration was 8.7 years (0–31). The mean SDAI score was 27.9 ± 11.6; the mean DAS28-CRP was 5.0 ± 1.0. CRP was 4.1 ± 3.0 mg/dl and MMP-3 388.3 ± 311.5 ng/ml. Methotrexate (MTX) was administered in 37 patients (62.7%, mean 6.0 mg, mean MTX dose administered in cases, 9.6 mg/week). Prednisolone (PSL) was administered in 37 patients (62.7%, mean 3.6 mg; the mean PSL dose administered in cases 5.7 mg/day).

Regarding disease activity, the mean SDAI was 27.9 at baseline; 12.3 at three months; 8.1 at one year; 7.3 at two years; 6.5 at three years; 46.7 at four years; 5.6 at five years, and 5.2 at final observation. The SDAI significantly improved after two years compared to baseline. Remission and low disease activity also significantly improved at one year and gradually improved after one year (Figure 1). The remission rate at the final observation was 55.2%, with an SDAI ≦3.3.

TCZ continuation rates were 86.9% at one year, 78.7％ at three years, and 68.9% at five years (Figure 2). TCZ was discontinued due to adverse events in 11 cases (18%), and inadequate efficacy occurred in 9 (14.8%). The adverse events were respiratory infection (5), purulent arthritis (1), infectious endocarditis (1), subarachnoid hemorrhage (1), breast cancer (1), pruritis (1), and skin ulcer (1). Other reasons for discontinuation were dialysis (2), suspension of hospital visits (2), kidney transplant (1), and financial difficulties (1). Concomitant use from baseline to final observation declined from 62.7% to 15.3% for MTX and from 62.7% to 23.7% for PSL.

Conclusion

Long-term treatment with TCZ was acceptable. We found that with TCZ therapy, the remission and low disease activity rates significantly improved at one year and continued to improve after one year. Treatment persistence was high, but careful monitoring for infection is necessary.

Disclosure of Interests

None declared

AB0368 EFFECTS OF SWITCHING FROM ETANERCEPT ORIGINATOR TO ETANERCEPT BIOSIMILAR ON DISEASE ACTIVITY, PHYSICAL FUNCTION, AND PATIENT-REPORTED OUTCOME REGARDING A SELF-INJECTION DEVICE IN PATIENTS WITH WELL-CONTROLLED RHEUMATOID ARTHRITIS

Background

Although biological drugs have dramatically changed and improved the outcome of patients with rheumatoid arthritis (RA), a lot of unresolved problems still exist. Although comorbidity by which enough treatment drugs cannot be prescribed or RA patients refractory to biological agents are representatives, financial difficulty is another representative. There are RA patients who hesitate biological treatment or treatment with Janus-kinase inhibitor due to financial difficulty. Although biosimilar disease-modifying anti-rheumatic drugs (DMARDs) are promising treatment options for such patients, real-world clinical experiences are still lacking in respect to exchanging from biological originator DMARDs to biosimilar DMARDs.

Objectives

This retrospective study investigated the effects of switching from etanercept originator (ETN-OR) to ETN biosimilar (ETN-BS: LBEC0101 developed by LG Chem) on disease activity, physical function, and patient reported outcome (PRO) regarding a self-injection device in patients with well-controlled RA.

Methods

Data from the Toyohashi RA Database (TRAD) was used, which is a collection of single-center retrospective data. We retrospectively investigated disease activity, modified health assessment questionnaire (mHAQ), and patient characteristics in 42 RA patients that switched from ETN-OR to ETN-BS at least 6 months prior. Patients were also requested to answer the Toyohashi Self-Injection Assessment Questionnaire (T-SAQ), originally designed to assess PRO. T-SAQ consisted of 18 questions about self-injection device such as burden, learning, pain, convenience, handling and so on. Best was 0 and worst was 4 in each question and mean score of 18 questions was called total T-SAQ score.　

Results

All the patients were female. The mean age, RA duration, and ETN-OR treatment duration were 63.1 years, 18.3 years, and 3107 days, respectively. Mean disease activity and mean mHAQ after switching were as follows (baseline-3 months-6): DAS28-CRP (1.86-2.00-2.03), SDAI (4.3-5.0-5.3), and mHAQ (0.43-0.44-0.46). SDAI after 6 months was significantly elevated compare to baseline. Among each parameter, tender joints count at 3 months and patients’ global assessment at 6 months after switching are significantly increased compared to baseline (Table 1). Other parameters such as swollen joint counts, physician global assessment and CRP were not significantly changed. Total T-SAQ scores before and after switching were 1.3 and 1.1 (p < 0.01), respectively. Ease of use, mental tension, and pain were especially improved after switching to ETN-BS.

Conclusion

Switching from ETN-OR to ETN-BS worsened disease activity in well-controlled RA patients in our real-world clinical practice due to not objective findings, but subjective complaints by RA patient. We thought that nocebo effect was one of the reasons to explain the results. On the other hand, the PRO regarding the injection device was improved. This improvement may be due to Finer needle of ETN-BS (ETN-OR: 27G, ETN-OR: 29G).

Disclosure of Interests

None declared

AB1016 ROMOSOZUMAB AS A TREATMENT FOR OSTEOPOROSIS: PREDICTORS OF EFFICACY AT 12 MONTHS

Background

Romosozumab (ROMO) is an antisclerostin antibody that is used in the treatment of severe osteoporosis (OP). In March 2019, ROMO was approved for use in Japan for treating severe OP in clinical practice, causing an increase in its prescription in our institute. Although efficacy data for ROMO have been presented in clinical trials, there is a lack of real-world data. In our experience, ROMO treatment results in significant bone mineral density (BMD) gain in some patients, but not all. Therefore, understanding the predictors that enhance the efficacy of ROMO treatments to achieve BMD gain is essential.

Objectives

This study investigated the efficacy of a 12-month ROMO treatment in patients with OP and explored the efficacy predictors of increased BMD.

Methods

Our study included 52 patients with OP, who were started on ROMO treatment between June 2019 and August 2020. The following information was collected: 1) baseline characteristics, 2) time-course of BMD (lumbar spine [LS] and total hip [TH]) and bone turnover markers (BTM; bone-specific alkaline phosphatase [BAP], type I procollagen-N-propeptide [P1NP], type I procollagen-N-propeptide[NTX], and tartrate-resistant acid phosphatase-5b [TRACP-5b]), 3) multiple regression analysis results following Spearman’s correlation analysis of increased BMD values (%) at 12 months and BL characteristics, including BTM change (%) at one month, to investigate the efficacy predictors of ROMO.

Results

1) The mean age of the participants was 72.9 years (48 female and four male). Of the 52 understudied patients, 78.8% had past insufficiency fractures, whereas 21.2% had been treated with concomitant prednisolone. Furthermore, 21 patients had primary OP, 20 had rheumatoid arthritis, nine had glucocorticoid-induced OP, and two had other conditions. Pretreatments for OP were bisphosphonate (33 patients), vitamin D (6), none (5), selective estrogen receptor modulator (4), and denosumab (3).

2) Both mean LS- and TH-BMD significantly increased in the patients for whom ROMO administration was continued for 12 months. The average percentage changes of LS- and TH-BMD were 7.1% and 1.6% at six months and 11.7% and 3.0% at 12 months, respectively (Figure 1). However, BAP and P1NP increased steeply at one month, followed by a gradual decrease. As observed, the average percentage changes of BAP and P1NP were +70.1% and +166.8% at one month, +50.3% and +91.7% at six months, and +24.4% and +41.5% at 12 months, respectively. The results also showed that TRACP-5b decreased from one to 12 months, with the average percentage changes being −22.9% at one month, −13.8% at six months, and −17.7% at 12 months. Moreover, NTX, a bone-resorptive marker, was slightly increased during ROMO treatment.

3) Multiple regression analysis results revealed that the baseline BAP and percentage calcium changes at 12 months were significant factors positively correlated with the percentage change of LS-BMD at 12 months. As observed, the baseline T-score of LS-BMD was a significant factor negatively correlated with the percentage change of LS-BMD at 12 months. The standardized partial regression coefficient values were +0.68, +0.26, and −0.40, respectively. Moreover, the multiple regression analysis results revealed no significant factor that was correlated with the percentage changes of TH-BMD at 12 months.

Figure 1.

Conclusion

ROMO treatments rapidly increased BMD, especially LS-BMD, and changed BTM after one month. Baseline BAP were correlated with increased LS-BMD but not with TH-BMD. The factors correlated with increased BMD may differ between LS-BMD and TH-BMD.

Disclosure of Interests

None declared

POS1143 FIVE-YEAR TREATMENT OUTCOME OF DENOSUMAB ON OSTEOPOROSIS IN PATIENTS WITH RHEUMATOID ARTHRITIS, IN CLINICAL PRACTICE

Background

Osteoporosis (OP) is a frequent complication identified in patients with rheumatoid arthritis (RA). Effective treatment must be provided to treat OP in RA (RAOP). Denosumab (DMB) is a promising drug, currently being used for the treatment of RAOP. Although DMB was determined to be effective in a long-term FREEDOM extension trial [1] for treating postmenopausal OP, its efficacy in the treatment of RAOP in real-world is not be fully evaluated.

Objectives

This retrospective study assessed the five-year treatment outcome of DMB in Japanese patients with RAOP.

Methods

Data from the Toyohashi RA Database (TRAD) was used, which is a collection of single-center retrospective data. Our study included 65 female patients with RAOP for whom DMB treatment was initiated between October 2013 and May 2016. The following information was collected: 1) baseline characteristics, 2) DMB continuation rates using the Kaplan–Meier method and reasons for stopping DMB, 3) fracture occurrence during DMB treatment, and 4) time-course of bone mineral density (BMD) [lumbar spine (LS) and total hip (TH)] and bone turnover markers (BTM) [bone-specific alkaline phosphatase (BAP), type I procollagen-N-propeptide (P1NP), type I procollagen-N-propeptide (NTX), and tartrate-resistant acid phosphatase-5b (TRACP-5b)] in 38 patients who underwent DMB treatment over a period of five years.

Results

1) The mean age and RA duration were 69.4 years (46–86) and 17.2 years (1–49), respectively. Prednisolone and biologics were administered in 21 (32.3%) and 20 (30.8%) patients, respectively. Twenty-seven patients (41.5%) had a history of fragility fractures, and 24 patients (36.9%) had a history of vertebral fractures. Pretreatment drugs for OP were as follows: bisphosphonate in 22 patients; teriparatide, 17; none, 16; activated vitamin D, 7; and selective estrogen receptor modulator, 3.

2) Continuation rates of DMB were 96.9% at one year, 95.4% at two years, 85.8% at three years, 79.4% at four years, and 71.1% at five years. DMB treatment was terminated in 24 patients due to lack of efficacy in nine patients, death in seven patients (unknown reason in four, pneumonia in two, and senile decay in one), adverse events except death in five patients (worsening of dementia in two, brain hemorrhage in one, necrosis of jaw in one, and pneumonia in one), and other reasons in three patients.

3) Nine patients (13.8%) experienced fractures during DMB treatment; vertebral and non-vertebral fractures occurred in three and four patients, respectively. Two cases of fractures remained undefined.

4) Both mean LS-BMD and TH-BMD significantly increased in 38 patients for whom DMB administration was continued for five years. Average percent changes of LS-BMD and TH-BMD were 3.9% and 3.0% at six months, 5.5% and 3.8% at one year, 7.6% and 4.1% at two years, 9.8% and 5.7% at three years, 10.8% and 6.5% at four years, and 12.9% and 6.8% at five years (Figure 1). Four BTMs, BAP, P1NP, NTX, and TRACP-5b, significantly decreased from six months to five years when compared to baseline values, with average changes at 5 years equaling −38.4%, −37.8%, −23.8%, and −24.6%, respectively.

Conclusion

DMB treatment of RAOP proved effective and reasonably safe, and it increased BMD by a percentage similar to that observed in the FREEDOM extension trial. However, DMB administration was ceased in 13.8% of cases due to fractures and lack of efficacy. Although DMB is recommended for the treatment of RAOP, future evaluations should be conducted to predict its efficacy and determine alternative treatment strategies.

References

[1]Bone HG et al. Lancet Diabetes Endocrinol. 2017.

Disclosure of Interests

None declared

Real-time Diagnosis of Micro Powder Injection Molding Using Integrated Ultrasonic Sensors

Real-time diagnostics of ceramic powder injection molding using a commercial micromolding machine was performed using ultrasound. Miniature ultrasonic sensors were integrated onto the mold insert. Melt front, solidification, temperature variation and part detachment of the feedstock inside the mold cavity were observed. It has been demonstrated that ultrasonic velocity in feedstock inside the mold cavity, the ultrasonic contact duration during which the part and mold are in contact, and holding pressure can be used to assist with optimization of injection and cooling parameters to minimize energy consumption and maximize process efficiency.

Chronic atlantoaxial rotatory fixation with neurofibromatosis type I: A case report

Background:

Atlantoaxial rotatory fixation (AARF) can be caused by infection, rheumatoid arthritis, surgery of head and neck, and congenital diseases. Type 1 neurofibromatosis (NF-1) is often associated with various musculoskeletal diseases, but few reports have described AARF with NF-1. Here, we report the success of a closed reduction and halo fixation utilized to treat chronic AARF with NF-1 in a 7-year-old female.

Case Description:

A 7-year-old female with NF-1 presented with a 2-month history of torticollis and neck pain. C2 facet deformity had previously been identified on computed tomography (CT) before the onset of neck pain. Cervical radiography and CT showed AARF classified Fielding’s Type I and Ishii’s Grade II. Following 2 weeks of cervical traction, a closed reduction was followed by halo fixation that was utilized for 2 months. The patient fully recovered cervical range of motion following halo vest removal 4 months later. Further, the follow-up CT documented a normal atlantoaxial joint despite residual C2 facet deformity. In addition, no recurrence was evident 2 years later.

Conclusion:

Halo fixation for chronic AARF with NF-1 proved effective. C2 facet deformity associated with NF-1 might have contributed to the onset of AARF.

Elucidation of host diversity of the VanD-carrying genomic islands in enterococci and anaerobes

Background

VanD is a rare type of vancomycin resistance worldwide. However, the host diversity of the vanD gene cluster and the structural similarity of their genomic islands are not well understood.

Methods

Three VanD-type Enterococcus faecium strains (AA620, AA622 and AA624) isolated from a Japanese patient who underwent vancomycin treatment in 2017 were analysed. This study utilized WGS analysis to characterize the three VanD-type E. faecium strains and describes the diversity of hosts possessing VanD-carrying genomic islands.

Results

The three isolates exhibited variable MICs of vancomycin. In the relatively vancomycin-resistant AA620, mutations were identified in vanS_D and ddl. The strains AA622 and AA624 had intact ddl and harboured two vanD gene clusters. qRT-PCR results revealed the ddl mutation to be a factor affecting the high vancomycin resistance range of AA620. WGS data showed the 155 kb and 185 kb genomic islands harbouring the vanD gene cluster inserted in the coding region of the lysS gene, located in the chromosome in AA620 and AA622/624, respectively. Comparing the VanD-carrying genomic islands to available sequences of other enterococci and enteric anaerobes revealed how the genomic islands of these organisms isolated worldwide shared similar core genes and backbones. These anaerobes belonged to various genera within the order Eubacteriales. The phylogenetic cluster of the genomic island core genome alignment did not correlate with the host-species lineage, indicating horizontal gene transfer in the gut microbiota.

Conclusions

By horizontal gene transfer, various bacteria forming the gut microbiota maintain VanD-carrying genomic islands.

Distinct association of VEGF-C and VEGF-D with prognosis in patients with chronic heart failure: the PREHOSP-CHF study

Background

The lymphatic system has been suggested to play an important role in cardiovascular (CV) diseases including heart failure (HF). Vascular endothelial growth factor C (VEGF-C) and VEGF-D are key regulators of lymphoangiogenesis.

Purpose

To investigate the association of VEGF-C and VEGF-D with prognosis in patients with chronic HF (CHF).

Methods

The PREHOSP-CHF study is a multicenter prospective cohort study to determine the predictive value of angiogenesis-related biomarkers in CHF. A total of 1,024 patients (mean age, 75.5±12.6 years; male, 58.7%) admitted to acute decompensated HF were included in the analyses. The primary outcome was MACE defined as a composite of CV death or HF hospitalization. The secondary outcomes were all-cause death, CV death, and HF hospitalizations. Serum levels of VEGF-C and VEGF-D, as well as N-terminal pro B-type natriuretic peptide (NT-proBNP), high sensitivity cardiac troponin-I (hs-cTnI), high sensitive C reactive protein (hs-CRP), VEGF, and soluble VEGF receptor-2 (sVEGFR-2) were measured at the time of discharge. Patients were followed-up over two years.

Results

Median [interquartile range] of VEGF-C and VEGF-D levels were 4821 [3633–6131] pg/ml and 404 [296–559] pg/ml, respectively. In multivariate stepwise regression analysis, independent determinants of VEGF-C levels were younger age, female gender, absence of prior HF hospitalization, chronic kidney disease, and anemia, lower ejection fraction, lower NT-proBNP levels, higher VEGF levels, and higher sVEGFR-2 levels, while those of VEGF-D levels were lower body mass index, presence of diabetes and atrial fibrillation, and higher NT-proBNP levels. During the follow-up, a total of 209 (20.4%) all-cause deaths, 112 (10.9%) CV deaths, and 309 (30.2%) HF hospitalizations occurred. After adjusting for established risk factors and CV biomarkers, VEGF-C levels were significantly and inversely associated with the incidence of MACE and non-CV death (Fig.1, model 4). On the other hand, VEGF-D levels were significantly and positively associated with the incidence of HF hospitalization (Fig. 1, model 4). When we divided the patients into 4 groups based on the median of VEGF-C and VEGF-D levels, patients with low VEGF-C and high VEGF-D showed significantly higher incidence of MACE, all-cause death, CV death, and HF hospitalization compared to those with high VEGF-C and low VEGF-D (Fig. 2).

Conclusions

Among patients with CHF, VEGF-C and VEGF-D had different characteristic and association with the incidence of adverse events. VEGF-C levels were inversely associated with the incidence of MACE and non-CV death, and VEGF-D levels were positively associated with the incidence of HF hospitalization. These results suggests different effects of VEGF-C and VEGF-D in CHF. Combination of VEGF-C and VEGF-D enables us to make good risk stratification in patients with CHF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant-in-Aid for Clinical Research from the National Hospital Organization Figure 1Figure 2

Fragmented QRS on far-field intracardiac electrograms as a predictor of arrhythmic events

BACKGROUND

Studies suggest that fragmented QRS (fQRS) can predict arrhythmic events in various cardiac diseases. However, the association between fQRS recordings on intracardiac electrogram (EGM) and ventricular arrhythmic events remains unknown.

METHODS

We enrolled 51 patients (age, 62 ± 12 years; 40 men) with an implantable cardioverter-defibrillator (ICD) and structural heart disease and evaluated surface electrocardiogram (ECG) and EGM measurement of fQRS and the association between fQRS and arrhythmic events.

RESULTS

fQRS was detected on surface ECG and ICD-EGM in 12 (23.5%) and 15 (29.4%) patients, respectively. fQRS was detected more frequently on ICD-EGM in patients with fQRS on surface ECG than in patients without fQRS (7/12 [58.3%] vs 8/39 patients [20.5%], P = .01). Appropriate ICD therapies were documented in 16 patients. Among these patients, fQRS was detected more frequently on surface ECG and ICD-EGM in patients with appropriate ICD therapies (8/16, 50.0%; P = .001 and 11/16, 68.9%; P < .001). Nonsustained ventricular tachycardia was significantly more frequent in patients with appropriate ICD therapies (15/16, 93.8%; P = .04). Multiple logistic regression analysis showed that fQRS on ICD-EGM was a predictor of arrhythmic events (P = .03). Kaplan-Meier survival analysis revealed that ICD therapies were significantly more frequent among patients with fQRS on both surface ECG and ICD-EGM than among those without fQRS (66.7% vs 6.6%, P < .001).

CONCLUSION

The presence of fQRS on ICD-EGM can be a predictor of arrhythmic events in ICD patients. Surface ECG and ICD-EGM measurement may help predict ventricular arrhythmic events.

Pigmented Villonodular Synovitis Around the Elbow Joint That Required Upper Arm Amputation

Pigmented villonodular synovitis (PVNS) is a relatively rare benign proliferative disorder of the synovium, and it commonly occurs in the knee joint. A unique case of huge PVNS originating around the elbow joint that required upper arm amputation is reported. A 74-year-old woman had a 5-month history of right elbow pain and noticed a mass measuring 8 × 5 cm on the olecranon side. She had a past history of undergoing tumor resection and flap surgery 9 years earlier, diagnosed as a giant cell tumor involving the right elbow region. She had chronic renal failure, with a shunt on the right forearm. On magnetic resonance imaging, the tumor around the elbow joint showed low signal intensity on T1-weighted images and low to high intensity on T2-weighted images. It was thought that it was difficult to preserve the limb because of the size of the tumor and the shunt blood vessel. Therefore, upper arm amputation was performed. The histological diagnosis was PVNS. There was no recurrence of PVNS postoperatively. In the treatment of PVNS, initial surgery with complete resection of the synovial membrane and careful postoperative follow-up are considered important.

Relationship between Shear Velocities Recorded by Microtremor Observations and Seismic Cone Penetration Test Results

This research proposes a relationship between two methods such as a numerical approach by conducting a microtremor array observation and field survey by using the seismic cone penetration test unit (SCPTu). A database of shear-wave velocity (Vs) measurements was established using the microtremor array technique and seismic cone penetration test unit (SCPTu) on high-quality samples of rock and soft soil in Padang city, Indonesia. The study also demonstrates that the Vs values obtained from the different methods are consistent with the microtremor array technique. This technique may thus be deemed a valuable tool, as it can be used in engineering practice with confidence. Comparison of the Vs for different soils at the first layer between the microtremor array observation results and the SCPTu results exhibited the microtremor array method is unable to determine the Vs  at the layer where its Vs changes dramatically, such as at the same layer as station UNP at 2 to 3.5m deep.

Staging laparoscopy for pancreatic cancer using intraoperative ultrasonography and fluorescence imaging: the SLING trial

This prospective trial revealed the additional diagnostic value of staging laparoscopy with contrast-enhanced intraoperative ultrasonography and indocyanine green-fluorescence imaging, detecting radiologically occult liver metastases and other occult metastases effectively for patients with high-risk resectable or borderline resectable pancreatic cancer. The 2-year survival rate of patients without occult metastasis was significantly better than that of patients with occult metastasis. These favourable results for patients without occult metastasis indicate that an enhanced screening strategy and modern multidisciplinary treatment may improve the outcome even of patients affected by high-risk advanced pancreatic cancer.

State-of-the-art staging worth the effort

Incidence of outflow tract ventricular tachycardia long after surgical aortic valve replacement

BACKGROUND

The peri-outflow tract region could be the origin of ventricular tachycardia (VT) after aortic valve replacement (AVR). However, the clinical characteristics of outflow tract ventricular tachycardias (OTVTs) after AVR are yet to be clarified. This study investigated the incidence, risk factors, and clinical characteristics of patients with OTVTs after AVR.

METHODS

We retrospectively analyzed the clinical course of 120 patients who had undergone surgical AVR (SAVR) between April 1980 and October 2018. The patients had no ischemic or diagnosed cardiomyopathies other than primary aortic valve diseases.

RESULTS

Six patients (5.0%) developed OTVTs after SAVR. The average onset was at 10.8 ± 5.7 years after SAVR. All cases of VT arose from the inferior axis and included left and right bundle branch block configuration. Two patients who underwent cardiac magnetic resonance imaging (MRI) had late gadolinium enhancement (LGE) in the midlayer of the left ventricle basal anteroseptal wall. Patients with periaortic VTs had significantly larger left ventricular (LV) diameter at systole, lower LV ejection fraction, higher positive rates of signal-averaged electrocardiogram (SAECG), and nonsustained VTs on Holter monitoring. On ablation, local fragmented potentials with low voltage zones were observed in accordance with the LGE distribution. Multiple VTs originating from the periaortic region were provoked in the sessions.

CONCLUSIONS

Acute OTVT was found in 5% of patients after SAVR. Arrhythmia risk stratification by SAECG, Holter ECG, and cardiac MRI should be considered for a long period in patients after SAVR.

Sesame lignans suppress age-related disorders of the kidney in mice

OBJECTIVE

Sesamin is a functional ingredient in sesame (Sesamum indicum) seeds and has many physiological effects. This study investigated whether sesame lignans, sesamin and episesamin (1:1), can suppress age-related disorders of the kidney.

MATERIALS AND METHODS

Twenty-month-old mice were divided into three groups, and each group received a regular diet (O-C), diet containing sesame lignans (O-SE), and diet containing sesame lignans and α-tocopherol (VE; O-SE+VE), respectively, for 5 months. Six-month-old young mice (Y-C) were compared to the older mice.

RESULTS

Renal lipofuscin deposition was increased in the O-C group compared to that in the Y-C group and its deposition with aging was significantly decreased in both O-SE and O-SE+VE groups. Plasma blood urea nitrogen levels in the O-C group increased compared to those in the Y-C group; however, those in both O-SE and O-SE+VE groups did not differ from those in the Y-C group. The number of podocytes in the O-C group decreased compared to that in the Y-C group and this effect was attenuated in the O-SE and O-SE+VE groups. The effect was strongest in the O-SE+VE group. Histological examinations showed that glomerular hypertrophy accompanied by mesangial hyperplasia and renal tubular degeneration was less severe in the O-SE and O-SE+VE groups than in the O-C group. Moreover, age-related increases in the mRNA expression of NADPH oxidase- and inflammation-related genes, including p67phox, p40phox, TNFα, and IL-6, in the kidney were suppressed in the O-SE and O-SE+VE groups.

CONCLUSIONS

Sesame lignans might be useful to suppress age-related kidney disorders, and these effects could be enhanced with VE.

Evaluation of factors affecting the occurrence of second atypical fracture after bone union of the first atypical fracture

PURPOSE

Teriparatide is sometimes used in the treatment of atypical femoral fracture (AFF). Even if bone union is achieved, orthopedic physicians must consider the risk of relapse. This study aimed to investigate the factors affecting AFF recurrence, and to determine the appropriate treatment for osteoporosis after bone union.

METHODS

One hundred thirty-one consecutive AFFs in 113 Japanese patients were included. Eleven patients had AFF in the unaffected limb (9 patients) after the first AFF or re-fracture at the original fracture site (2 patients) after bone union of the first AFF was confirmed. We divided all patients into two groups: the second fracture group (22 AFFs in 11 patients) and non-second fracture group (109 AFFs in 102 patients). We compared clinical information between the 2 groups and investigated the factors affecting AFF recurrence using the Student t-, Welch t-, and chi-square tests.

RESULTS

Although there was no significant difference in clinical characteristics between the 2 groups, multivariate analysis of factors associated with AFF recurrence identified short duration of treatment with teriparatide and active vitamin D₃ (p = 0.0408 and 0.0366, respectively) as risk factors. Even in the analysis excluding subtrochanteric AFF, short periods of teriparatide and active vitamin D₃ administration were observed as risk factors (p = 0.0484 and 0.0346, respectively).

CONCLUSION

The administration of teriparatide for as long as possible after occurrence first AFF and the use of active vitamin D₃ after completion of teriparatide therapy may be the most effective strategy to prevent the recurrence of AFF.

Assignment Design and its Effects on Japanese College Freshmen’s Motivation in L2 Emergency Online Courses: A Qualitative Study

Unlike conventional distance learning, the COVID-19-induced emergency online learning environment has resulted in students experiencing prolonged social isolation and anxiety, thereby creating additional barriers to their motivation to learn. Studying under these conditions influences students’ motivation to complete and turn in course-related assignments, especially newly enrolled students taking the English reading online courses as second language learners (L2). The aim of this qualitative study is to examine various factors influencing Japanese college freshmen’s (n = 80) motivation when completing graded online assignments as part of asynchronous English reading courses held during the COVID-19 pandemic. The post-course survey of students from three separate classes was used to capture a detailed panorama of learner motivation. Results from an inductive content analysis of responses indicated that higher levels of motivation were strongly associated with assignments that facilitated learner autonomy, social interaction, personal interest, and practical utility of the task. Conversely, decreased motivation appears to be strongly associated with assignments reinforcing the perception of high difficulty, personal inefficacy, and cognitive overload. These findings are consistent with studies examining online learners’ motivation in the pre-pandemic period. This study found that intrinsic motivation plays an explicit role in enhancing learners’ engagement with instructional materials. Researchers recommend that, especially during emergencies such as a pandemic or major crisis, teachers should deliberately and extensively employ strategies to enhance the motivational appeal of instructional materials and assignments. When designing online assignments for freshman courses, special attention must be paid to psychological (autonomy, utility, relevance), cognitive (information overload), social (relatedness, interaction), and environmental (an emergency, uncertainty, isolation) conditions of learning.

Evaluation of the Nature and Etiologies of Risk Factors for Diaphyseal Atypical Femoral Fractures

OBJECTIVES

Differences in mechanisms of subtrochanteric and diaphyseal atypical femoral fractures (AFFs) are speculated in studies that analyzed differences in the patients' background. However, the etiologies of each type of AFF have not been studied in detail. This study aimed to investigate the nature and etiologies of the risk factors for diaphyseal AFFs.

MATERIALS AND METHODS

Eighty consecutive Japanese patients with 91 diaphyseal AFFs (AFF group) and 110 age-matched women with osteoporosis (non-AFF control group) were included. Their clinical data were compared; factors affecting AFFs were investigated, and the etiologies of the risk factors for diaphyseal AFFs were examined.

RESULTS

Multivariate analysis revealed that femoral serrated changes, bisphosphonate or denosumab usage, and lateral and anterior femoral curvatures were risk factors for diaphyseal AFFs (p < 0.0011, p = 0.0137, and p < 0.0001, respectively). Multivariate analyses revealed that serrated changes and low serum 25(OH)D levels affected the lateral curvature (p = 0.0088 and 0.0205, respectively), while serrated changes affected the anterior curvature (p = 0.0006), each significantly affected the femoral curvature. High serum calcium (Ca) levels, lateral femoral curvature, and anterior femoral curvature were predictors of serrated changes (p = 0.0146, 0.0002, and 0.0098, respectively).

CONCLUSION

Risk factors for diaphyseal AFFs were bone resorption inhibitor usage, a strong femoral curvature, and serrated changes. Low serum 25(OH)D levels and serrated changes are risk factors for lateral curvature, while a high serum Ca level is a risk factor for serrated changes.

Locomotive Syndrome Is Associated with Health-Related Quality of Life and Low Back Pain in the Elderly, Including Individuals More Than 80 Years Old

Objectives:

The extent to which locomotive syndrome is associated with low back pain (LBP), health-related quality of life (HRQOL), and impairment of activities of daily living among elderly men and women remains poorly documented. This study evaluated associations between locomotive syndrome and both HRQOL and LBP as assessed using a questionnaire completed by elderly individuals, including some >80 years old.

Methods:

We conducted a survey assessing locomotive syndrome using the loco-check, HRQOL using the Short-Form 36 questionnaire (SF-36), and LBP using the Roland-Morris Disability Questionnaire (RDQ) among individuals >60 years old. SF-36 and RDQ scores were compared between 253 subjects with and without locomotive syndrome.

Results:

Fifty-seven men (48%) and 71 women (53%) were diagnosed with locomotive syndrome. Subjects of both sexes with locomotive syndrome scored significantly lower for eight items from SF-36. Physical and mental component summary scores were significantly worse in women with locomotive syndrome in their 60s and 70s. RDQ scores were significantly higher in participants with locomotive syndrome for men in their 60s and for both men and women in their 70s.

Conclusions:

Locomotive syndrome was associated with impaired HRQOL and worse LBP among men and women >60 years old. Differences in HRQOL and LBP between subjects with and without locomotive syndrome were significant for both men and women in their 60s and 70s, but not in their 80s. Locomotive syndrome should be prevented to maintain HRQOL, particularly for men and women in their 60s and 70s.

Implementation of evacuation measures during natural disasters under conditions of the novel coronavirus (COVID-19) pandemic based on a review of previous responses to complex disasters in Japan

We aimed to investigate how evacuation measures could be effectively implemented in the event of multiple disasters caused by natural hazards under conditions of the novel coronavirus infection (COVID-19) pandemic, which is rapidly spreading worldwide. We conducted a review of literature focusing on complex disasters, entailing natural disasters in combination of outbreaks or endemics of infectious diseases. Using the Google Scholar search engine, we identified and reviewed 24 papers sourced from academia, governments, and concerned organizations, and associated data on such disasters, commencing with the Great Hanshin-Awaji Earthquake, which occurred in 1995. In light of our review, we developed a summary of correspondences and problems linked to compound disasters involving conjunctions of outbreaks/endemics and natural disasters that could offer insights for developing measures to deal with natural disasters that occur in the context of the COVID-19 pandemic. We subsequently attempted to differentiate the characteristics of evacuation measures relating to COVID-19 from those relating to other infectious diseases using three sets of extracted keywords: (1) surveillance and information sharing, (2) evacuation center environment and stockpiled supplies, and (3) community disaster risk reduction and community leadership. We identified issues relating to evacuation measures that would need to be explored further to improve disaster management and preparedness in the future.

Growing Rod Surgery for Early-Onset Scoliosis in an Osteogenesis Imperfecta Patient

BACKGROUND

Osteogenesis imperfecta (OI) is characterized by bone fragility and is often accompanied by spinal deformity. Surgical treatment for early-onset scoliosis in patients with OI is hazardous and difficult due to the bone fragility and rigidity of the deformity. A case of early-onset scoliosis with OI that was treated using growing-rod surgery is presented.

CASE DESCRIPTION

The patient was an 11-year-old girl with type 4 OI. At the age of 4 years, she was noted to have scoliosis. Preoperative radiographs showed that the Cobb angle, thoracic kyphosis angle, and T1-S1 height were 94°, 77°, and 258 mm, respectively. One year before the operation, she underwent cyclic intravenous pamidronate disodium treatment. Three months after the pedicle screws were inserted, the growing rods were placed with pedicle screws and sublaminar polyethylene tape. The patient had intraoperative traction for correction. At 13 years and 11 months, the patients underwent posterior instrumentation and spinal fusion. Postoperative radiographs showed that the Cobb angle, thoracic kyphosis angle, and T1-S1 height were 29°, 29°, and 405 mm, respectively. Three months after the operation, she was well, and there have been no spine-related problems.

CONCLUSIONS

This case demonstrates the successful use of the growing rod for early-onset scoliosis in patients with OI. The treatment strategy, which included pedicle screw insertion as anchors to create the foundations in advance, sublaminar tape, intraoperative traction, and preoperative bisphosphonate administration, might have led to the good outcome.

Sesamin suppresses aging phenotypes in adult muscular and nervous systems and intestines in a Drosophila senescence-accelerated model

OBJECTIVE

Sesamin is a major lignan constituent of sesame and possesses various health-promoting effects. Previous studies have demonstrated that sesamin extends the lifespan of Drosophila and Caenorhabditis elegans and corrects oxidative damage-related tissue dysfunction in mammals. To understand its anti-aging effects, we aimed to determine whether sesamin restores tissue function hampered by oxidative damage and suppresses several aging-related phenotypes using Drosophila senescence-accelerated models.

MATERIALS AND METHODS

We elucidated the anti-aging effects of sesamin on several aging-related phenotypes in the muscle, brain and midgut using the senescence-accelerated models (Sod1n1 mutant and Sod1-depleted flies) by immunostaining experiments. We determined the expression levels of several anti-oxidative and DNA repair genes using quantitative Real Time-Polymerase Chain Reaction (qRT-PCR). We also identified the metabolite of sesamin in Drosophila by LC-MS/MS.

RESULTS

We confirmed that sesamin (0.35 and 2 mg/ml) extended the lifespan of the fly models. As observed in mammals, it can be absorbed and metabolized by Drosophila adults. The sesamin feeding suppressed the age-dependent impairment of locomotor activity and inhibited the accumulation of reactive oxygen species (ROS) in their bodies. Sesamin delayed the age-dependent accumulation of damaged proteins in the muscle, partially suppressed the loss of dopaminergic neurons in adult brains displaying ROS accumulation, and suppressed the accumulation of DNA damage and hyperproliferation of intestinal stem cells. Four antioxidative genes and two DNA repair genes were simultaneously upregulated in sesamin-fed adults.  CONCLUSIONS: These observations represent the first direct evidence of the anti-aging effects of sesamin at the individual level. We propose that sesamin exerts anti-aging effects in the muscles, brain and midgut by inducing antioxidative and DNA repair genes, resulting in extended lifespan in flies.

Learning Promotes Subfield-Specific Synaptic Diversity in Hippocampal CA1 Neurons

The hippocampus is functionally heterogeneous between the dorsal and ventral subfields with left–right asymmetry. To determine the possible location of contextual memory, we performed an inhibitory avoidance task to analyze synaptic plasticity using slice patch-clamp technique. The training bilaterally increased the AMPA/NMDA ratio at dorsal CA3–CA1 synapses, whereas the training did not affect the ratio at ventral CA3–CA1 synapses regardless of the hemisphere. Moreover, sequential recording of miniature excitatory postsynaptic currents and miniature inhibitory postsynaptic currents from the same CA1 neuron clearly showed learning-induced synaptic plasticity. In dorsal CA1 neurons, the training dramatically strengthened both excitatory and inhibitory postsynaptic responses in both hemispheres, whereas the training did not promote the plasticity in either hemisphere in ventral CA1 neurons. Nonstationary fluctuation analysis further revealed that the training bilaterally increased the number of AMPA or GABA_A receptor channels at dorsal CA1 synapses, but not at ventral CA1 synapses, suggesting functional heterogeneity of learning-induced receptor mobility. Finally, the performance clearly impaired by the bilateral microinjection of plasticity blockers in dorsal, but not ventral CA1 subfields, suggesting a crucial role for contextual learning. The quantification of synaptic diversity in specified CA1 subfields may help us to diagnose and evaluate cognitive disorders at the information level.

Sex-specific differences in transcriptomic profiles and cellular characteristics of oligodendrocyte precursor cells

The susceptibility to neurological and psychiatric disorders reveals sexual dimorphism in the structure and function of human brains. Recent evidence has also demonstrated the sex-related differences in cellular components of the brain, including neurons, microglia, astrocytes, and endothelial cells. Oligodendrocyte precursor cells (OPCs) regulate the neuronal system in various ways and play crucial roles in brain homeostasis beyond their well-known role as a reservoir for mature oligodendrocytes. Although recent studies have shown regional diversities and heterogeneities of OPCs, sex-related differences in OPCs are largely unknown. Here, we revealed transcriptomic differences in OPCs isolated from male and female neonatal rat brains. Furthermore, we demonstrated sex-dependent differences in OPCs regarding proliferation, migration, differentiation, tolerance against ischemic stress, energy metabolism, and the ability to regulate the blood-brain barrier integrity.

Sesame lignans increase sympathetic nerve activity and blood flow in rat skeletal muscles

Beneficial effects of sesame lignans, especially antioxidative effects, have been widely reported; however, its potential effects on autonomic nerves have not yet been investigated. Therefore, the current study aimed to investigate the effect of sesame lignans on the autonomic nervous system. The sympathetic nerve activity in rat skeletal muscle was measured using electrophysiological approaches, with blood flow determined using the laser Doppler method. Sesame lignans were administered intragastrically at 2 and 20 mg/kg, and after 60 min, the sympathetic nerve activity was observed to increase by 45.2% and 66.1%, respectively. A significant increase in blood flow (39.6%) was also observed for the 20-mg/kg dose when measured at 55 min after administration. These sympathomimetic effects were completely prevented by subdiaphragmatic vagotomy, and the increase in blood flow was eliminated in the presence of the beta2-adrenergic receptor inhibitor butoxamine. Thus, it is proposed that sesame lignans can increase the blood flow of skeletal muscle, possibly by exciting sympathetic nerve activity through the afferent vagal nerve.

Regional pancreatoduodenectomy versus standard pancreatoduodenectomy with portal vein resection for pancreatic ductal adenocarcinoma with portal vein invasion

Background

Pancreatoduodenectomy (PD) with portal vein resection (PVR) is a standard operation for pancreatic ductal adenocarcinoma (PDAC) with portal vein (PV) invasion, but positive margin rates remain high. It was hypothesized that regional pancreatoduodenectomy (RPD), in which soft tissue around the PV is resected en bloc, could enhance oncological clearance and survival.

Methods

This retrospective study included consecutive patients who underwent PD with PVR between January 2005 and December 2016 in a single high‐volume centre. In standard PD (SPD) with PVR, the PV was skeletonized and the surrounding soft tissue dissected. In RPD, the retropancreatic segment of the PV was resected en bloc with its surrounding soft tissue. The extent of lymphadenectomy was similar between the procedures.

Results

A total of 268 patients were included (177 SPD, 91 RPD). Tumours were more often resectable in patients undergoing SPD (60·5 per cent versus 38 per cent in those having RPD; P = 0·014), and consequently they received neoadjuvant therapy less often (7·9 versus 25 per cent respectively; P < 0·001). R0 resection was achieved in 73 patients (80 per cent) in the RPD group, compared with 117 (66·1 per cent) of those in the SPD group (P = 0·016), although perioperative outcomes were comparable between the groups. Median recurrence‐free (RFS) and overall (OS) survival were 17 and 32 months respectively in patients who had RPD, compared with 11 and 21 months in those who had SPD (RFS: P = 0·003; OS: P = 0·004).

Conclusion

RPD is as safe and feasible as SPD, and may increase the survival of patients with PDAC with PV invasion.

Diagnosis of Presarcopenia Using Body Height and Arm Span for Postmenopausal Osteoporosis

Purpose

Sarcopenia and osteoporosis are both serious health problems in postmenopausal women. The Asia Working Group for Sarcopenia recommends using the skeletal muscle index (SMI), which is height-adjusted appendicular skeletal muscle mass (ASMM). However, loss of height has been shown to be a common clinical finding in patients with osteoporosis. This study examined the prevalence of presarcopenia using height and arm span, which is a predictor of height, and investigated the diagnostic accuracy for presarcopenia.

Methods

A total of 55 post-menopausal osteoporotic patients aged 62-95 years underwent bioelectrical impedance analysis (BIA) for ASMM measurement and dual-energy X-ray absorptiometry (DXA) scan for bone mineral density (BMD). Anthropometric measurements, including height, weight, and arm span were taken, and body mass index (BMI), SMI, and arm span-adjusted SMI (Arm span SMI) were calculated. Presarcopenia was defined as SMI or Arm span SMI <5.7 kg/m² in this study.

Results

The prevalence of presarcopenia was 27.3% and 38.2% evaluated by SMI and Arm span SMI, respectively. The prevalence of presarcopenia was higher when evaluated by Arm span SMI than by SMI. In the presarcopenia group diagnosed only by Arm span SMI (n=11), the arm span-height difference was significantly higher (p<0.001) and the percentage of young adult mean (YAM) femoral neck-BMD was significantly lower (p=0.013) compared to the normal group diagnosed by both SMI and Arm span-SMI (n=29).

Conclusion

These results indicated that Arm span SMI might be useful for the diagnosis of sarcopenia in patients with severe osteoporosis and kyphosis.

Sesame lignans reduce LDL oxidative susceptibility by downregulating the platelet-activating factor acetylhydrolase

OBJECTIVE

Low-density lipoprotein (LDL) oxidative susceptibility is recognized as a risk factor for atherosclerosis. We previously reported that the ingestion of a supplement containing sesame lignans (sesamin/episesamin) for 4 weeks reduced LDL oxidative susceptibility in humans.

MATERIALS AND METHODS

To elucidate the mechanisms underlying this observation, 12-week-old New Zealand White rabbits were fed a fat/cholesterol-enriched diet (100 g/day) for 6 weeks followed by oral administration of vehicle (control) or sesame lignans (50 mg/kg) for 4 weeks with the fat/cholesterol-enriched diet.

RESULTS

The results showed that the ingestion of sesame lignans prolonged LDL oxidation lag time, regardless of the existence of the anti-oxidative catechol metabolite of sesamin/episesamin in LDL. Plasma platelet-activating factor acetylhydrolase (PAF-AH) activity was significantly reduced by sesame lignans. The prolongation of LDL oxidation lag time was abolished by the addition of a PAF-AH inhibitor. The expression level of pro-inflammatory cytokines and macrophage infiltration observed in the liver following the feeding of the fat/cholesterol-enriched diet were also significantly reduced by sesame lignans.

CONCLUSIONS

These results indicate that sesame lignans reduce LDL oxidative susceptibility by downregulating plasma PAF-AH activity via the reduction of inflammation in the liver induced by fat/cholesterol-enriched diets.

Effects of bazedoxifene and low-intensity aerobic exercise on bone and fat parameters in ovariectomized rats

INTRODUCTION

Postmenopausal osteoporosis and dyslipidemia are well-known skeletal and metabolic changes in middle-aged women. We investigated the effects of combined treatments with a selective estrogen receptor modulator (SERM) and exercise on bone and fat parameters in ovariectomized (OVX) rats.

MATERIALS AND METHODS

Sixteen-week-old female Sprague-Dawley rats underwent bilateral ovariectomy, and rats were randomized to BZA (bazedoxifene at 0.3 mg/kg/day), Exe (treadmill exercise at 12-15 m/min, 60 min/day, 5 days/week), Comb (BZA and Exe), and Cont (control treated with vehicle and no exercise) groups 8 weeks after ovariectomy. After 4 or 8 weeks of treatment, bone mineral density (BMD) of the total femur and lumbar spine and whole-body percentage fat mass were determined by dual-energy X-ray absorptiometry, and mechanical testing of the femoral shaft, and bone and fat histomorphometric analyses of the proximal tibia were performed.

RESULTS

Treadmill exercise had decreased bone marrow adipocytes from 4 weeks of treatment and whole-body percentage fat mass at 8 weeks. BZA increased BMD at the lumbar spine and decreased the whole-body percentage fat mass from 4 weeks and bone marrow adipocytes at 8 weeks. Combination therapy increased BMD for the lumbar spine and decreased bone marrow adipocytes and whole-body percentage fat mass from 4 weeks.

CONCLUSION

Combination therapy with BZA and exercise appears effective to improve bone and fat parameters in OVX rats.

L1CAM Is a Marker for Enriching Corticospinal Motor Neurons in the Developing Brain

The cerebral cortical tissue of murine embryo and pluripotent stem cell-derived neurons can survive in the adult brain and extend axons to the spinal cord. These features suggest that cell transplantation can be a strategy to reconstruct the corticospinal tract (CST). It is unknown, however, which cell population makes for safe and effective donor cells. To address this issue, we grafted the cerebral cortex of E14.5 mouse to the brain of adult mice and found that the cells in the graft extending axons along the CST expressed CTIP2. By using CTIP2:GFP knock-in mouse embryonic stem cells (mESCs), we identified L1CAM as a cell surface marker to enrich CTIP2⁺ cells. We sorted L1CAM⁺ cells from E14.5 mouse brain and confirmed that they extended a larger number of axons along the CST compared to L1CAM⁻ cells. Our results suggest that sorting L1CAM⁺ cells from the embryonic cerebral cortex enriches subcortical projection neurons to reconstruct the CST.