Impact of physician-staffed ground emergency medical services-administered pre-hospital trauma care on in-hospital survival outcomes in Japan

PURPOSE

In Japan, the vehicle used in pre-hospital trauma care systems with physician-staffed ground emergency medical services (GEMS) is referred to as a "doctor car". Doctor cars are highly mobile physician-staffed GEMS that can provide complex pre-hospital trauma management using various treatment strategies. The number of doctor car operations for patients with severe trauma has increased. Considering facility factors, the association between doctor cars and patient outcomes remains unclear. Therefore, this study aimed to examine the relationship between doctor cars for patients with severe trauma and survival outcomes in Japan.

METHODS

A nationwide retrospective cohort study was conducted to compare the impact of the doctor car group with the non-physician-staffed GEMS group on in-hospital survival in adult patients with severe trauma. The data were analyzed using multivariable logistic regression models with generalized estimating equations.

RESULTS

This study included 372,365 patients registered in the Japan Trauma Data Bank between April 2009 and March 2019. Of the 49,144 eligible patients, 2361 and 46,783 were classified into the doctor car and non-physician staffed GEMS groups, respectively. The adjusted odds ratio (OR) for survival was significantly higher in the doctor car group than in the non-physician staffed GEMS group (adjusted OR = 1.228 [95% confidence interval 1.065-1.415]).

CONCLUSION

Using nationwide data, this novel study suggests that doctor cars improve the in-hospital survival rate of patients with severe trauma in Japan. Therefore, doctor cars could be an option for trauma strategies.

Gender differences in self-perceived changes among Japanese workers with depression

BACKGROUND

The number of patients living with depression continues to increase in Japan. The economic effects of depression include loss of productivity due to both absenteeism and presenteeism. Gender differences have been reported in prevalence, onset pathways and subjective symptoms of depression.

AIMS

To understand how workers with major depressive disorder (MDD) perceive problems in the workplace and examine gender differences in their self-perceived levels of functioning at work, noticed during the initial stages of depression.

METHODS

This is a cross-sectional study of Japanese workers with MDD. Participants' self-perceived changes in the level of functioning at work were surveyed after the diagnosis during the first visit. The relationship between gender and changes in the level of functioning at work as initially perceived by the participants themselves was analysed using the chi-square test, supplemented by a residual analysis.

RESULTS

We administered the survey to 147 workers with MDD. In terms of gender differences in initial self-perceived changes in the level of functioning at work, the proportion of men reporting reduced work efficiency was significantly higher than that of women, while the proportion of women reporting deterioration in relationships with colleagues and superiors was significantly higher than that of men.

CONCLUSIONS

The findings suggest that greater attention to reduced work efficiency by men and to deterioration in work relationships by women with MDD should be essential components of self-care. Managers need to pay attention to the level of functioning and provide adequate social support for employees.

[Delivery of a Healthy Newborn by the Partner of a Patient with CML Undergoing Treatment with Nilotinib]

A man in his 40s was diagnosed with CML. He and his partner expressed their desire to have a child. We recommended planning the pregnancy after the achievement of major molecular response and completion of TKI therapy because we could not promise complete safety of the fetus, However, he and his partner insisted on starting the TKI therapy immediately and planned the pregnancy during the therapy. The patient was started on nilotinib 600mg/body. CCyR, MMR, and CMR were achieved in 3, 8, and 12 months, respectively. The patient's partner got pregnant when he had been on TKI therapy for 15 months, and she gave birth to a healthy boy. Since many patients with CMLcan live for a long time after receiving TKI therapy, the quality of life of these patients is more important. Even if the percentage of patients with CML who are under 50 years of age is approximately 30%, the safety information of TKI with respect to pregnancy is unsatisfactory. Doctors struggle to address the problems of the patient's wish of childbearing, priority of TKI therapy, and fetal risks of the treatment. Although only a few cases of pregnancy and delivery of the partners of male patients with CML treated with TKI have been reported, all cases showed healthy childbirth and normal child growth. Our experience also showed that the partner of a male patient with CML treated with TKI became pregnant and delivered a healthy baby.

[Refractory multiple myeloma with impaired consciousness accompanied by hyperammonemia and leukoencephalopathy-like findings]

A 81-year-old female was diagnosed with symptomatic multiple myeloma (MM; IgG κ type, D&S: IIB, ISS: 2) in August 2017. Although treatment with lenalidomide and dexamethasone was started, she developed deep venous thrombosis in the lower extremities as a complication; therefore, the treatment was changed to DBd. In February 2018, she required hospitalization due to general weakness and altered consciousness. Her IgG level and κ/λ ratio were elevated at 4,156 mg/dl and 605.56, respectively, revealing that MM was treatment-resistant. A protein-cell dissociation (cell blood count, 0/µl; protein, 100.6 mg/dl) was detected in the cerebrospinal fluid, whereas the ammonia level in serum was high (172 µg/dl). T2-weighted magnetic resonance imaging showed a broad range of high-density area in deep cerebral white matter suggesting leukoencephalopathy, whereas the cerebrospinal fluid was negative for JC virus. No pathological conditions causing secondary hyperammonemia were found. Although the involvement of drug-induced leukoencephalopathy in altered consciousness could not be ruled out since the chromosome with the normal karyotype at the first visit had a complex chromosomal abnormality, an originally minor clone of MM cells with a chromosomal abnormality might have contributed to the ammonia production resulting in altered consciousness.

Performance evaluation of an Indoxyl Sulfate Assay Kit "NIPRO"

Background The relationship between renal disease and cardiovascular disease (CVD) is currently known as cardiorenal syndrome. Indoxyl sulfate (IS) is one of the uremic toxins that accelerates the progression of cardiorenal syndrome. This report presents a new method for measuring IS in a simpler way. Methods We evaluated the analytical performance of an IS Assay Kit "NIPRO" loaded on LABOSPECT 008. The evaluated analytical performances included accuracy, precision, dilution linearity, limit of detection (LOD), limit of quantitation (LOQ), recovery test, interference test and comparison against assays performed by high-performance liquid chromatography (HPLC). Results Total precision showed a <5.3% coefficient of variation at IS concentrations of 3.57-277.73 μmol/L, and satisfactory results were observed in the dilution linearity, LOD, LOQ, recovery and interference tests. The IS Assay Kit "NIPRO" showed a high correlation with the HPLC conventional method (r = 0.993). Conclusions The IS Assay Kit "NIPRO" demonstrated satisfactory analytical performance, and this suggests it could shortly become another common method to measure circulating IS.

Efficacy of a new blood pressure monitor (inflationary non-invasive blood pressure, iNIBP™): a randomised controlled study

The inflationary non-invasive blood pressure monitor (iNIBP™) uses a new measurement method, whereby the cuff is slowly inflated whilst simultaneously sensing oscillations, to determine the diastolic blood pressure first and then the systolic pressure. It may measure blood pressure more quickly than the conventional non-invasive blood pressure monitor. We studied 66 patients undergoing general anaesthesia, comparing the time taken to measure the blood pressure between the two monitors at times when there were marked changes (increases or decreases by 30 mmHg or greater) in the systolic blood pressure. The median (IQR) [range]) time was significantly longer for the non-invasive blood pressure monitor (38.8 (31.5-44.7) [18.0-130.0] s) than for the iNIBP (14.6 (13.7-16.4) [11.5-35.5] s), p = 0.001, 95%CI for difference 22-25 s). We also studied 30 volunteers to evaluate the accuracy of the iNIBP, comparing it with the mercury sphygmomanometer. There was good agreement between the two monitors, with a mean difference of 0 (95% limit of agreement -12 to 11) mmHg for the systolic blood pressure. We also compared the degree of pain during cuff inflation between the automated non-invasive blood pressure and iNIBP monitors. Pain was significantly more for the non-invasive blood pressure monitor (22 of 30 volunteers had less pain with the iNIBP). We have shown that the iNIBP measured the blood pressure quicker than the conventional non-invasive blood pressure monitor and the speed of measurement was not significantly affected by marked changes in the blood pressure.

[Recurrent amylase-producing multiple myeloma responding to pomalidomide and carfilzomib-containing therapies]

A 73-year-old woman diagnosed with symptomatic multiple myeloma (MM; IgG-κ type, D&S: IIIA, ISS: 2) was administered bortezomib plus dexamethasone (BD) therapy. Post BD therapy, although autologous hematopoietic stem cell transplantation and thalidomide, lenalidomide, and melphalan/prednisolone/thalidomide (MPT) therapies were also performed, the patient remained unresponsive. However, the disease relapsed, and she eventually developed pantalgia. Therefore, the patient was admitted to our hospital and was administered pomalidomide and dexamethasone (Pd) therapy. The serum amylase (AMY) and urine AMY levels were 6,329 and 6,098 IU/l, respectively, which were salivary gland-type amylase (S-AMY). Notably, the markedly high levels immediately decreased after the first course of the Pd therapy; additionally, the pantalgia also disappeared. The S-AMY level in the supernatant from cultured bone marrow mononuclear cells was higher than that observed in a normal control. In addition, AMY was high when MM previously relapsed, suggesting the presence of AMY-producing MM. Although AMY-producing MM was first reported by Hata et al. in 1988, few cases have been reported in the new-drug era. In conclusion, AMY-producing MM frequently, including in our case (as the patient was refractory to treatment), is difficult to treat. However, our patient positively responded to the novel next-generation drugs such as pomalidomide and carfilzomib.

[A methotrexate-associated lympholiferative disorder patient with gastrointestinal perforation]

A 70-year-old woman was diagnosed with chronic rheumatoid arthritis and treated with methotrexate and prednisolone. She visited our hospital to determine the cause of her continuous fatigue and fever for the past three weeks. She consumed no food orally and was provided antibiotics because free air was found on computed tomography (CT). Intraperitoneal small lymphadenopathy and swelling of both adrenal glands was also found on CT, and MTX-associated lymphoproliferative disorder (MTX-LPD) was suspected. Am adrenal gland biopsy showed diffuse large B-cell lymphoma (DLBCL) associated with MTX-LPD. The causes of gastrointestinal perforation with collagen diseases have been reported to be functional gastrointestinal disorders with collagen diseases like amyloidosis, gastrointestinal infections in immunocompromised patients, and side effects of medication, such as steroids or NSAIDs and MTX. MTX-LPD is an uncommon side effect of methotrexate. To ensure its appropriate diagnosis and treatment, it is important to improve the degree of recognition of MTX-LPD, and a prompt response is needed.

Low-dose immunoglobulin G is not associated with mortality in patients with sepsis and septic shock

Background

The administration of low-dose intravenous immunoglobulin G (IVIgG) (5 g/day for 3 days; approximate total 0.3 g/kg) is widely used as an adjunctive treatment for patients with sepsis in Japan, but its efficacy in the reduction of mortality has not been evaluated. We investigated whether the administration of low-dose IVIgG is associated with clinically important outcomes including intensive care unit (ICU) and in-hospital mortality.

Methods

This is a post-hoc subgroup analysis of data from a retrospective cohort study, the Japan Septic Disseminated Intravascular Coagulation (JSEPTIC DIC) study. The JSEPTIC DIC study was conducted in 42 ICUs in 40 institutions throughout Japan, and it investigated associations between sepsis-related coagulopathy, anticoagulation therapies, and clinical outcomes of 3195 adult patients with sepsis and septic shock admitted to ICUs from January 2011 through December 2013. To investigate associations between low-dose IVIgG administration and mortalities, propensity score-based matching analysis was used.

Results

IVIgG was administered to 960 patients (30.8%). Patients who received IVIgG were more severely ill than those who did not (Acute Physiology and Chronic Health Evaluation (APACHE) II score 24.2 ± 8.8 vs 22.6 ± 8.7, p < 0.001). They had higher ICU mortality (22.8% vs 17.4%, p < 0.001), but similar in-hospital mortality (34.4% vs 31.0%, p = 0.066). In propensity score-matched analysis, 653 pairs were created. Both ICU mortality and in-hospital mortality were similar between the two groups (21.0% vs 18.1%, p = 0.185, and 32.9% vs 28.6%, p = 0.093, respectively) using generalized estimating equations fitted with logistic regression models adjusted for other therapeutic interventions. The administration of IVIgG was not associated with ICU or in-hospital mortality (odds ratio (OR) 0.883; 95% confidence interval (CI) 0.655–1.192, p = 0.417, and OR 0.957, 95% CI, 0.724–1.265, p = 0.758, respectively).

Conclusions

In this analysis of a large cohort of patients with sepsis and septic shock, the administration of low-dose IVIgG as an adjunctive therapy was not associated with a decrease in ICU or in-hospital mortality.

Trial registration

University Hospital Medical Information Network Individual Clinical Trials Registry, UMIN-CTR000012543. Registered on 10 December 2013.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1764-4) contains supplementary material, which is available to authorized users.

[Successful Prophylactic Minocycline Treatment for Recurrent Helicobacter Cinaedi Sepsis during Chemotherapy in a Patient with Follicular Lymphoma]

A 63-year-old man with follicular lymphoma was administered standard R-CHOP chemotherapy. Six days after the second course of chemotherapy, the patient developed fever and chills. Blood cultures yielded rod-shaped gram-negative bacteria, but no further identification was obtained. High fever and chills returned on the fifth and sixth days after the third and fourth courses of R-CHOP, respectively. These blood cultures were also positive. Since we detected spiral-shaped gram-negative rods, we performed a prolonged culture during the febrile period after the fourth course of R-CHOP. This revealed the formation of characteristic film-like colonies, and Helicobacter cinaedi(H. cinaedi)bacteria was identified. After final identification, the patient was administered prophylactic minocycline treatment. Subsequent blood cultures were negative, fever did not recur, and we were able to complete 6 courses of R-CHOP. Although H. cinaedi has been reported to be a cause of sepsis in immunocompromised patients, standard correlation has not been established. Our case suggests that H. cinaedi should be considered when recurrent fever is observed after chemotherapy. Prophylactic antibiotic treatment with minocycline may prevent sepsis, as observed in our case.

Totally implantable central venous device-associated blood stream infection in elderly malignant disease patients

AIM

We investigated the rate of bloodstream infections in elderly malignant disease patients whose totally implantable central venous device (CV ports) had been removed for any reason at our hospital.

METHODS

We evaluated 22 elderly malignant disease patients who had had their CV ports removed for any reason between May 2014 to April 2015.

RESULTS

The patients were 12 males and 10 females between 62 and 86 years of age with a median age of 75.5 years. The catheter tip cultures were positive in 6 out of 22 cases (27.3%). Gram-positive cocci were detected in 5 cases, and gram-positive bacilli were detected in 1 case. Five of these 6 cases (83%) found to have positive catheter tip cultures were cultured at the time of death. In addition, 5 of the 13 catheters removed at the time of death resulted in positive culture results (38%). The positive culture ratio correlated well with the ratio of death and the age in cases of hematopoietic tumors.

CONCLUSION

In cancer patients, the CV port is frequently used for the delivery of anti-cancer medicines. However, CV port infections are underestimated and typically not recognized in a timely manner. Patients suspected of having a CV port infection should be closely observed and the catheter removed immediately. However, it is very difficult to decide to discontinue a CV port, since its removal may render patients more susceptible to blood stream infections due to their poor general health and old age. CV port use should be considered in such cases to prevent future blood stream infections.

Intraarterial Occlusion by Radiofrequency

Arterial occlusion using radiofrequency energy was performed. The length of the noninsulated part of the guidewire was 10 mm and the duration of radiofrequency supply was 20 s. Animal experiments were carried out in 17 canine arteries; 4 out of 6 arteries less than 2.3 mm in diameter were completely occluded during the 20 s radiofrequency supply. A clinical application was also successfully performed without any complications. Arterial occlusion with radiofrequency can be applied to vessels less than about 2 mm in diameter.

A new liquid embolic material for liver tumors: An animal experimental study using Onyx

Purpose: To evaluate the feasibility of a new liquid embolic material, Onyx, for treating liver tumors.

Material and Methods: Onyx is a mixture of 6% (w/v) ethylene-vinyl-alcohol copolymer dissolved in anhydrous dimethyl sulfoxide (DMSO) with 28% (w/v) tantalum powder. In addition to 6% Onyx, we also tried 4%, 2% and 1% solutions, prepared by adjusting the amount of DMSO. We used 15 white rabbits with liver tumors created by percutaneous injection of VX2 tumor cells. In 4 groups with 3 rabbits in each, the liver arteries were embolized with 6%, 4%, 2% and 1% Onyx, respectively, and in 3 rabbits DMSO alone was injected. The injections were performed just proximal to the bifurcation of the proper hepatic artery, followed by celiac arteriography. Post mortem, the livers were examined by soft-tissue radiography, and liver-tissue section microscopy.

Results: The maximum number of arterial branching points passed by embolic material in either the right or left hepatic arteries was 11, 15 and 16, for 6%, 4% and 2% Onyx, respectively, but was non-measurable for 1% Onyx. Minimum diameters of arteries reached by 6%, 4%, 2% and 1% Onyx in tumorous areas were 40 μm, 35 μm, 20 μm and 10 μm, respectively, and in non-tumorous areas 35 μm, 5 μm, 5 μm and 5 μm, respectively.

Conclusion: This study suggests that Onyx may be feasible for treatment of hepatic tumors.

Characteristics, treatments, and outcomes of severe sepsis of 3195 ICU-treated adult patients throughout Japan during 2011-2013

Severe sepsis is a major concern in the intensive care unit (ICU), although there is very little epidemiological information regarding severe sepsis in Japan. This study evaluated 3195 patients with severe sepsis in 42 ICUs throughout Japan. The patients with severe sepsis had a mean age of 70 ± 15 years and a mean Acute Physiology and Chronic Health Evaluation II score of 23 ± 9. The estimated survival rates at 28 and 90 days after ICU admission were 73.6 and 56.3 %, respectively.

Control of the wetting properties of ^{4}He crystals in superfluid

To investigate whether it is possible to control the wetting of ^{4}He crystals on a wall in superfluid, the contact angles of ^{4}He crystals were measured on rough and smooth walls at very low temperatures. A rough wall was prepared in a simple manner in which a commercially available coating agent for car mirrors, which makes the glass surface superhydrophobic, was used to coat a glass plate. The contact angles of ^{4}He crystals were increased by approximately 10^{∘} on the rough wall coated with the agent. Therefore, the increase in the repellency of ^{4}He crystals in superfluid was demonstrated to be possible on a very rough surface. The enhancement of the contact angles and a scanning electron microscopy image of the coated surface both suggest that a Cassie-Baxter state of ^{4}He crystals was realized on the surface; the crystals did not have full contact with the wall, but entrapped superfluid was present beneath the crystals in the hollow parts of the rough wall.

[Successful treatment of venous thromboembolism with a Factor Xa inhibitor, edoxaban, in patients with lenalidomide-treated multiple myeloma]

Two multiple myeloma (MM) patients developed venous thromboembolism (VTE) while being treated with lenalidomide and low-dose dexamethasone. Aspirin is recommended for VTE prophylaxis when using lenalidomide/dexamethasone for MM patients with a standard risk of VTE. Despite aspirin administration, however, these two patients experienced VTE. Following VTE development, warfarin and then a Factor Xa inhibitor, edoxaban, were administered. The edoxaban treatment, especially, resulted in favorable and effective control of VTE. Considering these observations, Factor Xa inhibitors may in future become a preferred option for prevention and treatment of VTE when managing MM patients.

Spin-dependent acoustic response in the nonunitary A1 and A2 phases of superfluid 3He under high magnetic fields

The transverse acoustic impedance of superfluid ^{3}He was measured in the A1 and A2 phases up to 13 T to investigate the surface states in nonunitary superfluids. The temperature dependence of the impedance was much larger in the A1 phase than in the A2 phase. This nonsymmetric behavior indicates that momentum exchange with walls for spin-down surface states is quite different from that for spin-up surface states. The spin-dependent response might be a reflection of an essential feature of the nonunitary states where gap amplitudes depend on spin states. Weak-coupling theories ignore any spin-dependent processes and do not account for the nonsymmetric behavior.

Effect of cricoid pressure on placement of the I-gel™ : a randomised study

We studied 40 adult patients to see if cricoid pressure affected placement of the I-gel(™). In a randomised crossover design, the i-gel was placed with and without cricoid pressure, and we compared the success rate of adequate ventilation through the i-gel, time to placement and the rate of optimal position of the device between the two circumstances. Cricoid pressure significantly decreased the success rate of adequate ventilation through the i-gel (40 vs 34 patients) (p = 0.041, 95% CI for difference 4-26%), and significantly decreased the rate of the optimal position (39 vs 17 patients) (p < 0.001). The time to achieve adequate ventilation was significantly longer (p < 0.001) with cricoid pressure than without (median difference 8 s; 95% CI for median difference 3-12 s). Cricoid pressure significantly decreases the success rate of ventilation through the i-gel, but the success rate of ventilation through the i-gel is reasonably high.

Serum undercarboxylated osteocalcin level increases with 48 weeks of teriparatide treatment in pre-treated elderly rheumatoid arthritis patients who use anti-resorptive drugs

AIM

The serum undercarboxylated osteocalcin (ucOC) level, a biochemical bone marker of vitamin K insufficiency, is often affected by anti-osteoporosis drugs. There have been no reports regarding the relationship between ucOC and teriparatide.

SUBJECTS AND METHODS

We conducted a prospective observational study of 26 female rheumatoid arthritis (RA) patients. The patients were divided into 3 groups: those who underwent a direct switch from anti-resorptive drugs to teriparatide (12 cases), those who started teriparatide without pre-treatment (5 cases), and the control patients (9 cases). The median age (interquartile range) of the patients in each group was 75 (67-77), 82 (78-84), and 69 (62-80) yr, respectively. All patients, except controls, received 48-week treatments of teriparatide. We analyzed the median 48-week changes from baseline of the serum ucOC levels with the Steel-Dwass method.

RESULTS

The median change from baseline in the direct switch group was higher than that in other groups (p<0.05).

CONCLUSIONS

The serum ucOC levels increased with treatment of teriparatide in elderly RA patients, especially when the patients received pre-treatment.

Surface Andreev bound states of superfluid 3He and Majorana fermions

Superfluid (3)He is an intensively investigated and well characterized p-wave superfluid. In the bulk Balian-Werthamer state, which is commonly called the (3)He B phase, the superfluid gap is opened isotropically but near a flat boundary such as a wall of a container it can harbor interesting quasi-particle states inside the gap. These states are called surface Andreev bound states, and have not been experimentally explored in detail. Transverse acoustic impedance measurement has revealed their existence and provided spectroscopic details of the dispersion of the bound states. Recent theoretical arguments claim that the surface Andreev bound states of the superfluid (3)He B phase can be recognized as the edge states of the topological superfluid and be regarded as a Majorana fermion, a fancy particle which has not been confirmed in elementary particle physics. In this review, we present up-to-date knowledge on the surface Andreev bound states of the (3)He B phase revealed by acoustic spectroscopy and the possible realization of a Majorana fermion, along with related studies on this topic.

Post-menopausal women with rheumatoid arthritis who are treated with raloxifene or alendronate or glucocorticoids have lower serum undercarboxylated osteocalcin levels

BACKGROUND

Serum undercarboxylated osteocalcin (ucOC) is a biochemical bone marker of vitamin K insufficiency. It had been reported that bone resorption inhibitors tend to decrease the serum ucOC level in patients with primary osteoporosis. In rheumatoid arthritis (RA) patients, these results have never been reported.

AIM

We investigated risk factors which could change serum ucOC level in post-menopausal women with RA (no.=100).

SUBJECTS AND METHODS

Twenty patients received no bone resorption inhibitor (control), 30 received raloxifene (RLX), while 50 received alendronate (ALN). This cross-sectional study was limited to patients with low RA disease activity (Disease Activity Score-28 ≤3.2). We measured serum ucOC, and the data were analyzed by multivariable analysis, including ucOC and the other variables.

RESULTS

Scheffe's F test demonstrated a significant difference in serum ucOC levels between controls and the RLX group (p<0.01), and between controls and the ALN group (p<0.01). Serum ucOC levels were low in both treated groups. An adjusted multivariate analysis was performed for the variables: bone resorption inhibitor use, serum alkaline phosphatase, glucocorticoid dose, age, estimated glomerular filtration rate and matrix metalloproteinase 3. As a result, serum ucOC inversely correlated with bone resorption inhibitor use (p<0.01) and oral glucocorticoid dose (p<0.01), which were independent risk factors of lowering ucOC.

CONCLUSIONS

Bone resorption inhibitors and glucocorticoids were independent risk factors for lowering serum ucOC levels in post-menopausal RA patients.

The action of D-dopachrome tautomerase as an adipokine in adipocyte lipid metabolism

Adipose tissue is a critical exchange center for complex energy transactions involving triacylglycerol storage and release. It also has an active endocrine role, releasing various adipose-derived cytokines (adipokines) that participate in complex pathways to maintain metabolic and vascular health. Here, we found D-dopachrome tautomerase (DDT) as an adipokine secreted from human adipocytes by a proteomic approach. DDT mRNA levels in human adipocytes were negatively correlated with obesity-related clinical parameters such as BMI, and visceral and subcutaneous fat areas. Experiments using SGBS cells, a human preadipocyte cell line, revealed that DDT mRNA levels were increased in an adipocyte differentiation-dependent manner and DDT was secreted from adipocytes. In DDT knockdown adipocytes differentiated from SGBS cells that were infected with the adenovirus expressing shRNA against the DDT gene, mRNA levels of genes involved in both lipolysis and lipogenesis were slightly but significantly increased. Furthermore, we investigated AMP-activated protein kinase (AMPK) signaling, which phosphorylates and inactivates enzymes involved in lipid metabolism, including hormone-sensitive lipase (HSL) and acetyl-CoA carboxylase (ACC), in DDT knockdown adipocytes. The AMPK phosphorylation of HSL Ser-565 and ACC Ser-79 was inhibited in DDT knockdown cells and recovered in the cells treated with recombinant DDT (rDDT), suggesting that down-regulated DDT in adipocytes brings about a state of active lipid metabolism. Furthermore, administration of rDDT in db/db mice improved glucose intolerance and decreased serum free fatty acids levels. In the adipose tissue from rDDT-treated db/db mice, not only increased levels of HSL phosphorylated by AMPK, but also decreased levels of HSL phosphorylated by protein kinase A (PKA), which phosphorylates HSL to promote its activity, were observed. These results suggested that DDT acts on adipocytes to regulate lipid metabolism through AMPK and/or PKA pathway(s) and improves glucose intolerance caused by obesity.

Strong suppression of the Kosterlitz-Thouless transition in a 4He film under high pressure

We have found that the surface specularity for 3He quasiparticle scattering is closely related to the superfluidity and the Kosterlitz-Thouless (KT) transition of 4He film adsorbed on the surface. The specularity is determined by measurements of the transverse acoustic impedance of bulk liquid 3He. The unique point of our system is that we can control the correlation among 4He atoms in the film by changing the pressure of the bulk 3He. The observed KT transition temperature is significantly suppressed by increasing the pressure, which suggests a strong correlation effect on KT transition.

[Activities for laboratory medicine support after the Great East Japan Earthquake by the Japanese Society of Laboratory Medicine]

The Great East Japan Earthquake caused a tragic tsunami and resulted in serious damage to north region of Japan on March 11, 2011. The Japanese Society of Laboratory Medicine, JSLM launched an ad hoc Committee to support Laboratory Medicine affairs in the affected area. We expected that laboratory testing demands would increase during the weeks following the disaster. We decided to support the use of Point-of-Care Testing. Many POCT devices use battery-powered analyzers. This is definite advantage for their use in areas with limited access to power and water supplies. We contacted many companies about the possibility of providing POCT devices, IVD reagents and/or any laboratory supplies including disposable materials. Finally, forty companies agreed to support this project and we received list of reagents materials for more than one hundred IVD tests. We entered this information on our web site and continued to update it as additional support was received. Once a request of support was received, communication were made to confirm the amount of material, the method of shipping/receipt and if any specific training that would be required for its use at the testing site. Also, we dispatched volunteer Medical Technologists for eight weeks to assist in the laboratory work. Some of the crucial points in recruiting volunteer laboratory professions are expenses and accommodations. We prepared not only accommodations but also transportation methods and covered all expenses including insurance and meals. Our relief activities have shown that Laboratory Medicine and Medical Technologists are useful in disaster-affected area.

Porcine circovirus type 2 potentiates morbidity of Salmonella enterica serovar Choleraesuis in Cesarean-derived, colostrum-deprived pigs

PROBLEM ADDRESSED

Porcine circovirus type 2 (PCV2) and Salmonella enterica subspecies enterica serovar Choleraesuis (S. Choleraesuis) are two leading causes of economic loss in the swine industry. Although S. Choleraesuis infection occurs concurrently with PCV2-associated disease in many swine herds, the pathogenesis of concurrent infection with PCV2 and S. Choleraesuis remains largely undefined.

OBJECTIVE

We investigated the interactions between PCV2 and S. Choleraesuis in 20 Cesarean-derived, colostrum-deprived (CDCD) pigs randomly assigned to 4 groups (n=5 per group).

METHODS AND APPROACH

Pigs in the dual-infected and PCV2-infected groups were inoculated intranasally with PCV2 at 5 weeks of age, and pigs in the dual-infected and S. Choleraesuis-infected groups were inoculated intranasally with S. Choleraesuis at 7 weeks of age. Pigs in the control group served as uninfected controls.

RESULTS

After S. Choleraesuis inoculation, severe clinical signs, reduction of weight gain, and severe microscopic lung lesions were observed in dual-infected pigs compared to those in other groups. In addition, the pigs in the dual-infected group shed significantly (P=0.002) higher quantities of S. Choleraesuis in feces 12 days after S. Choleraesuis inoculation, and S. Choleraesuis was recovered from more tissues in this group 14 days after S. Choleraesuis inoculation.

CONCLUSIONS

These results indicate that prior PCV2 infection potentiates the severity of clinical signs, lung lesions, and fecal shedding and tissue dissemination of S. Choleraesuis in infected pigs. Therefore, dual infection of pigs with PCV2 and S. Choleraesuis may increase clinical effects of salmonellosis in the field.

Activity of retreatment with sorafenib for metastatic renal cell carcinoma

404

Background: Treatment options for metastatic renal cell carcinoma (mRCC) have increased. Complete remission is, however, rarely seen and patients are treated with multiple sequential therapies. We assessed clinical activity of sorafenib rechallenge after progressing on other therapies.

Methods: Patients with mRCC who received a second course of sorafenib therapy after failure of prior sorafenib and other agents were retrospectively identified. RECIST-defined objective response rate and progression-free survival (PFS) and toxicity were analyzed.

Results: Fourteen patients with mRCC who were retreated with sorafenib were identified and twelve patients were assessable for this study. 92% were male. Median age at first systemic therapy was 63 years. Prior nephrectomy was performed in 92% of patients. 42% of patients had favorable or intermediate risk, 17% poor, and the rest not available per MSKCC criteria. Eighty-three percent of patients were treated with other agents before initial sorafenib therapy, including 75% interferon-alpha (IFN-alpha), 50% interleukin-2 (IL-2), and 17% sunitinib. First sorafenib therapy began a median of 9.0 months after the diagnosis of mRCC and produced a clinical benefit (PR + SD) rate of 75% and a median PFS of 5.0 months. 67% of patients discontinued initial sorafenib for disease progression and 33% for adverse events. Interval between discontinuation of initial sorafenib and rechallenge was a median of 7.6 months. During the intervening period, 50% of patients were treated with sunitinib, 33% with everolimus, 25% with VEGFR1 vaccine, and others. Clinical benefit rate of 67% and a median PFS of 4.3 months were obtained on sorafenib rechallenge. There was no significant difference in outcome to sorafenib rechallenge based on duration between sorafenib treatments or number or type of intervening treatments. No new severe toxicity was observed during rechallenge.

Conclusions: Sorafenib rechallenge has potential to achieve clinical benefits, is well-tolerated, and may be considered after multiple sequential therapies in select mRCC patients.

No significant financial relationships to disclose.

[Serum indoxyl sulfate is a useful predictor for progression of chronic kidney disease]

BACKGROUND

Indoxyl sulfate, an endogenous metabolite of tryptophan is normally excreted into urine. In patients with chronic kidney disease (CKD), however, the reduced indoxyl sulfate renal clearance leads to elevated indoxyl sulfate serum level. In this study we determined whether the serum levels of indoxyl sulfate are related to the progression rate of CKD stage in CKD patient.

METHODS

The association between indoxyl sulfate and progression of CKD stage was studied in 47 CKD patients (19 male, 28 female). Serum levels of IS were measured by using high performance liquid chromatography and the measured values of the study cohort were divided into quintiles.

RESULTS

The mean serum amount indoxyl sulfate in the healthy subject was 0.06 +/- 0.04 mg/dL (mean +/- SD). Those with indoxyl sulfate serum levels of > or = 0.3 mg/dL had a significantly progression of CKD than with <0.3 mg/dL. Especially, those patients with indoxyl sulfate serum levels of 0.47 mg/dL had the highest CKD progression.

CONCLUSION

High serum levels of indoxyl sulfate are related with a progression of CKD stage in CKD patients. Thus, serum indoxyl sulfate is one of the clinical factors that affect CKD progression.

Increases in discontinuous rib cartilage and fused carpal bone in rat fetuses exposed to the teratogens, busulfan, acetazolamide, vitamin A, and ketoconazole

Skeletal changes induced by treatment of pregnant rats with four potent teratogens, busulfan, acetazolamide, vitamin A palmitate, and ketoconazole, were evaluated using Alizarin Red S and Alcian Blue double-staining to investigate the relationship between drug-induced skeletal malformations and cartilaginous changes in the fetuses. Pregnant rats (N = 8/group) were treated once or twice between gestation days (GDs) 10 to 13 with busulfan at doses of 3, 10, or 30 mg/kg; acetazolamide at 200, 400, or 800 mg/kg; vitamin A palmitate at 100,000, 300,000, or 1,000,000 IU/kg; or ketoconazole at doses of 10, 30, or 100 mg/kg. Uterine evaluations and fetal external and skeletal examinations were conducted on GD 20. Marked skeletal abnormalities in ribs and hand/forelimb bones such as absent/ short/bent ribs, fused rib cartilage, absent/fused forepaw phalanx, and misshapen carpal bones were induced at the mid- and high-doses of busulfan and acetazolamide and at the high-dose of vitamin A palmitate and ketoconazole. Increased incidences of discontinuous rib cartilage (DRC) and fused carpal bone (FCB) were observed from the low- or mid-dose in the busulfan and acetazolamide groups, and incidences of FCB were increased from the mid-dose in the vitamin A palmitate and ketoconazole groups. Therefore, DRC and FCB were detected at lower doses than those at which ribs and hand/forelimb malformations were observed in the four potent teratogens.

New anomaly in the transverse acoustic impedance of superfluid 3He-B with a wall coated by several layers of 4He

We measured the transverse acoustic impedance of superfluid 3He-B with a wall coated by several layers of 4He. The coating is known to enhance the specularity in quasiparticle scattering by the wall. We found a new anomaly, a bump and a peak, in the temperature dependence of the transverse acoustic impedance. This agrees with a theoretical calculation using a partially specular wall boundary condition. The new anomaly is shown to arise from a change in the surface density of states by coating and the scattering of thermally occupied surface bound states to other states. The change is towards the density of states of Majorana cone in the specular limit.

[Comparison of intravenous fentanyl analgesia and epidural analgesia for postoperative pain relief]

BACKGROUND

Epidural analgesia is available for postoperative pain relief except for the patients with bleeding tendency or under anticoagulation. Intravenous fentanyl analgesia can be applied for such patients but its effect has not been evaluated enough. We compared these two methods after abdominal surgery.

METHODS

In the intravenous fentanyl analgesia group (group iv, n = 15), 0.7 microg x kg(-1) x hr(-1) fentanyl infusion was started during operation and decreased to 0.5 microg x kg(-1) x hr(-1) on the next morning. In the epidural analgesia group (group e, n = 15), 0.4 microg x kg(-1) x hr(-1) fentanyl and 5 ml x hr(-1) 1% mepivacaine infusion was started during operation. The VAS pain score (at rest and at coughing), the level of consciousness, respiratory and cardiovascular depression, nausea and vomiting were evaluated for 3 days.

RESULTS

The VAS scores at rest were similar in two groups but the VAS scores at coughing were similar or lower in the group iv. In the group iv, five patients suffered from nausea and one patient had somnolence. In the group e, only one patient had nausea but two patients had hypotension.

CONCLUSIONS

Intravenous fentanyl analgesia is safe and possibly more effective than epidural analgesia.

A new formulation for orally disintegrating tablets using a suspension spray-coating method

The aim of this study was to design a new orally disintegrating tablet (ODT) that has high tablet hardness and a fast oral disintegration rate using a new preparation method. To obtain rapid disintegration granules (RDGs), a saccharide, such as trehalose, mannitol, or lactose, was spray-coated with a suspension of corn starch using a fluidized-bed granulator (suspension method). As an additional disintegrant, crospovidone, light anhydrous silicic acid, or hydroxypropyl starch was also included in the suspension. The RDGs obtained possessed extremely large surface areas, narrow particle size distribution, and numerous micro-pores. When tabletting these RDGs, it was found that the RDGs increased tablet hardness by decreasing plastic deformation and increasing the contact frequency between granules. In all tablets, a linear relationship was observed between tablet hardness and oral disintegration time. From each linear correlation line, a slope (D/H value) and an intercept (D/H(0) value) were calculated. Tablets with small D/H and D/H(0) values could disintegrate immediately in the oral cavity regardless of the tablet hardness and were considered to be appropriate for ODTs. Therefore, these values were used as key parameters to select better ODTs. Of all the RDGs prepared in this study, mannitol spray-coated with a suspension of corn starch and crospovidone (2.5:1 w/w ratio) showed most appropriate properties for ODTs; fast in vivo oral disintegration time, and high tablet hardness. In conclusion, this simple method to prepare superior formulations for new ODTs was established by spray-coating mannitol with a suspension of appropriate disintegrants.

Comparative analysis of a CFo ATP synthase subunit II homologue derived from marine and fresh-water algae

Comparative analysis was performed with a CFo ATP synthase subunit II homologue (CFo-II) derived from marine or fresh-water algae. The marine algae-derived CFo-II-transformed Escherichia coli grew and accumulated ATP more vigorously in NaCl or Cadmium containing medium, suggesting that this gene was useful for the development of stress-tolerant plant.