Efficacy of primary treatment with immunoglobulin plus ciclosporin for prevention of coronary artery abnormalities in patients with Kawasaki disease predicted to be at increased risk of non-response to intravenous immunoglobulin (KAICA): a randomised controlled, open-label, blinded-endpoints, phase 3 trial

BACKGROUND

Genetic studies have indicated possible involvement of the upregulated calcium-nuclear factor of activated T cells pathway in the pathogenesis of Kawasaki disease. We aimed to assess safety and efficacy of ciclosporin, an immunosuppressant targeting this pathway, for protection of patients with Kawasaki disease against coronary artery abnormalities.

METHODS

We did a randomised, open-label, blinded endpoints trial involving 22 hospitals in Japan between May 29, 2014, and Dec 27, 2016. Eligible patients predicted to be at higher risk for intravenous immunoglobulin (IVIG) resistance were randomly assigned to IVIG plus ciclosporin (5 mg/kg per day for 5 days; study treatment) or IVIG (conventional treatment) groups, stratified by risk score, age, and sex. The primary endpoint was incidence of coronary artery abnormalities using Japanese criteria during the 12-week trial, assessed in participants who received at least one dose of study drug and who visited the study institution at least once during treatment. This trial is registered to Center for Clinical Trials, Japan Medical Association, number JMA-IIA00174.

FINDINGS

We enrolled 175 participants. One patient withdrew consent after enrolment and was excluded and one patient (in the study treatment group) was excluded from analysis because of lost echocardiography data. Incidence of coronary artery abnormalities was lower in the study treatment group than in the conventional treatment group (12 [14%] of 86 patients vs 27 [31%] of 87 patients; risk ratio 0·46; 95% CI 0·25-0·86; p=0·010). No difference was found in the incidence of adverse events between the groups (9% vs 7%; p=0·78).

INTERPRETATION

Combined primary therapy with IVIG and ciclosporin was safe and effective for favourable coronary artery outcomes in Kawasaki disease patients who were predicted to be unresponsive to IVIG.

FUNDING

Japan Agency for Medical Research and Development (grant CCT-B-2503).

Muscle oxygenation and fascicle length during passive muscle stretching in ballet-trained subjects

Muscle stretching transiently decreases muscle-blood flow corresponding to a muscle extension. It may disturb a balance between muscular oxygen demand and oxygen supply to muscles and reduce muscle oxygenation. However, muscle-stretching training may improve blood circulatory condition, resulting in the maintained muscle oxygenation during muscle stretching. The aim of this study was to investigate changes in muscle-blood volume (tHb) and tissue oxygenation index (TOI) during muscle stretching determined by using near-infrared spectroscopy (NIRS) in ballet-trained (BT) and untrained (C) subjects. 11 BT women who regularly perform muscle stretching and 11 C women participated in this study. Fascicle lengths, tHb and TOI in the tibialis anterior muscle were measured during passive plantar flexion from ankle joint angles of 120° (baseline) to 140°, 160°, the maximal comfortable position without pain (CP), and the maximal position (MP). At 160°, the % fascicle-length change from baseline was significantly lower in the BT than the C group, however, for the changes in tHb and TOI the significant interaction effect between the 2 groups was not detected. On the other hand, although the increases in the fascicle length from baseline to CP and MP were greater in BT than C, the tHb and TOI reductions were comparable between groups. We concluded that it appears that BT can extend their muscles without excessive reduction in muscle-blood volume and muscle oxygenation at relatively same but absolutely greater muscle-stretching levels than C. The attenuation in these indices during high-level muscle stretching may be associated with the repetitive muscle stretching of long-term ballet training.

[Efficacy of simultaneous bolus injection of lidocaine with propofol on pain caused by propofol injection]

To investigate the effect of simultaneous bolus injection of 2% lidocaine 2 ml on preventing the pain on propofol injection, 80 patients were randomly assigned to one of four study groups; Group I received simultaneous bolus injection of 2% lidocaine 2 ml with infusion of propofol; Group II received bolus injection of saline 2 ml, 10 s before the start of infusion of propofol-lidocaine mixture; Groups III and IV received bolus injections of lidocaine and saline, separately 10 s before starting propofol infusion. Incidence of propofol-induced pain was significantly more frequent (P < 0.001) in Group IV (70%) than in the other groups (20% each). Number of patients who were satisfied with this anesthetic induction and requested for the same induction method in the next anesthesia was significantly larger in the groups receiving lidocaine (P < 0.05). Simultaneous bolus injection of lidocaine with propofol showed a similar clinical efficacy compared with both preadministration and premixing of lidocaine in preventing the propofol-induced pain.

Depth profiles of volatile halogenated hydrocarbons in seawater in the Bay of Bengal

Measurements were made of bromocarbons (CHBr3 and CH2Br2), iodocarbons (CH2I2 and CH2ClI), and dimethylsulfide (DMS, CH3SCH3) in seawater collected from the Bay of Bengal under tropical stratified conditions. These compounds showed different depth profiles, characteristic of each group. CH2I2 and CH2ClI showed very similar depth profiles to chlorophyll-a, suggesting their production by phytoplankton followed by rapid decay in seawater. The CH2I2 maximum at a depth a little below the CH2ClI maximum was consistent with its more significant photolytic decay. The bromocarbons were less localized in their distributions than were the iodocarbons, suggesting their longer residence time in seawater after their release from phytoplankton. Both of these profiles were different from the pattern of DMS, which had its maxima above the chlorophyll-a maximum layer near the surface.

Accumulative characteristics of pesticide residues in organs of bivalves (Anodonta woodiana and Corbicula leana) under natural conditions

Accumulative characteristics of pesticide residues in the gill, midgut gland, gonad, and the remaining tissues of the bivalve mollusks Anodonta woodiana and Corbicula leana were examined during the rice planting seasons of 1992 and 1994. Although seven pesticides, except thiobencarb, were accumulated all at ppb levels in the midgut gland (liver) and gonad of both bivalves during their application period, thiobencarb was accumulated in C. leana at extremely high levels of 15.70 microg g(-1) in 1992 and 12.45 microg g(-1) in 1994 in the midgut gland and 15.80 microg g(-1) in 1992 and 16.40 microg g(-1) in 1994 in the gonad, respectively. These levels were about 100 times higher than those in A. woodiana. Thiobencarb and molinate in A. woodiana and chlornitrofen (CNP) and molinate in C. leana remained in the gonad and midgut gland longer than in the gill and remaining tissues, while thiobencarb in organs of C. leana remained at ppm levels until the end of the experiments. The present study suggests that these interspecies differences can be attributed to differences between the two species in their ability to eliminate pesticides.

Electrospray ionization mass spectrometric analysis of microcystins, cyclic heptapeptide hepatotoxins: modulation of charge states and [M + H]+ to [M + Na]+ ratio

Electrospray ionization mass spectrometry was used to develop a rapid, sensitive, and accurate method for determination and identification of hepatotoxic microcystins, cyanobacterial cyclic heptapeptides. To optimize the electrospray ionization conditions, factors affecting charge state distribution, such as amino acid components of sample, proton affinity of the additives, and additive concentration, were investigated in detail and a method for controlling charge states was developed to provide molecular-related ions for assignment of molecular weight and reasonably abundant precursor ions for MS/MS analysis. A procedure for identification of microcystins consisting of known amino acids was proposed: for microcystins giving abundant [M + 2H]2+ ions, the addition of nitrogen-containing bases to the aqueous sample solution is effective to obtain an increased intensity of [M + H]+ ions, whereas the addition of Lewis acids containing nitrogen can produce increased abundances of [M + 2H]2+ ions for microcystins giving weak [M + 2H]2+ ions. Microcystins possessing no arginine residue always give sodium adduct ions [M + Na]+ as the base peak, and these are difficult to fragment via low energy collision-induced dissociation to yield structurally informative products; the addition of oxalic acid increases [M + H]+ ion abundances, and these fragment readily.

Establishment of a sampling strategy for the use of blue mussels as an indicator of organotin contamination in the coastal environment

The application of the Mussel Watch concept to the assessment of chemical contamination in the coastal environment is still premature, since the relationship between the physiological and ecological aspects of blue mussels and the accumulation of contaminants in their soft tissues remains unclear. We cannot yet directly estimate with known confidence the degree of chemical contamination from the levels of contaminants in the soft tissues of mussels. An understanding of the source and range of variability in the tissue concentrations of contaminants is essential, and the establishment of a biomonitoring sampling strategy to minimize the effect of identified sources of variability is required. The present study was conducted to clarify the characteristics of organotin accumulation in blue mussels under various conditions in Tokyo Bay, and to establish an optimized sampling strategy of mussels as exposure indicators of organotin contamination in Japan. It was clear that the sample number, individual size, spawning activity and vertical habitat were factors causing a variation of tissue concentration. Based on a quantitative estimation of the variability of organotin concentration in mussel tissues under various physiological and natural conditions, we suggest that a composite sample of 30 mussels (3-5 cm in shell length), collected from the infralittoral zone prior to their spawning season, is essential to reduce the variability between individuals and to obtain reproducible analytical values at a sampling site. For monitoring sites where natural blue mussels cannot be collected, an alternative method of transplanting blue mussels from a relatively clean area would be required.

Low-energy collisionally activated decomposition and structural characterization of cyclic heptapeptide microcystins by electrospray ionization mass spectrometry

Characteristics of electrospray ionization mass spectrometry/collision-induced dissociation (ESIMS/CID) mass spectra of microcystins, cyanobacterial cyclic heptapeptide hepatoxins, were examined. The collision conditions showed remarkable effects on the quality of the CID mass spectra, which were divided into three patterns according to the number of Arg residues. A characteristic cleavage reaction and neutral losses of MeOH, NH3 and guanidine group(s) from the (2S,3S,8S,9S)-3-amino-9-methoxy-2,6,8-trimethyl-10-phenyldeca-4 E,6E-dienoic acid (Adda) and Arg residues were observed in the ESI and ESIMS/CID mass spectra, suggesting the most probable protonation sites in [M + H]+ and [M + 2H]2+ ions of microcystins. Microcystins with no Arg residue showed only [M + H]+ ions with a proton reacting at the methoxyl group in the Adda residue, and the ESIMS/CID/MS data revealed their structures unambiguously. The protonation site in [M + H]+ ions of microcystins with Arg residue(s) was the guanidine group. The [M + 2H]2+ ions of microcystins possessing one Arg residue had one proton on the Arg residue and probably another proton on the Adda residue, while the [M + 2H]2+ ions of microcystins having two Arg residues showed protonation at both Arg residues and the ESIMS/CID/MS data assigned their sequences. Structures of microcystins possessing one Arg residue can be assigned by ESIMS/CID/MS of [M + H]+ ions combined with those of [M + 2H]2+ ions.

Seven new microcystins possessing two L-glutamic acid units, isolated from Anabaena sp. strain 186

Electrospray ionization mass spectrometry has been applied to the structure assignment of seven new microcystins (1-7), obtained from cultured Anabaena sp. strain 186. The seven new microcystins contain the dehydroalanine (Dha) or L-Ser unit instead of the N-methyldehydroalanine unit and the L-Glu and/or its delta-methyl ester [E(OMe)] units at the two variable L-amino acid units, and the structures were assigned as [Dha7]microcystin-E(OMe)E(OMe) (1), [D-Asp3,Dha7]microcystin-E(OMe)E(OMe) (2), [L-Ser7]microcystin-E(OMe)E(OMe) (3), [D-Asp3,L-Ser7]microcystin-E(OMe)E(OMe) (4), [Dha7]microcystin-EE(OMe) (5), [D-Asp3,Dha7]microcystin-EE(OMe) (6), and [L-Ser7]microcystin-EE(OMe) (7). These microcystins are the first examples containing dicarboxylic amino acids at the two variable L-amino acid units in microcystins.

Effect of pretreatment with ethanol containing fluoride on etched enamel surface as evaluated by scanning electron microscopy, optical microscopy, and tensile bond strength measurement

The effects of pretreatment with a fluoride-containing ethanol solution on etched enamel surfaces before application of sealant were examined using scanning electron microscopy, optical microscopy, and tensile bond strength determinations. The results suggested that when etched enamel surfaces are treated with ethanol containing no more than 250 ppm fluorine in potassium fluoride, there is no interference with the bonding of the sealant to the treated, etched anamel surface.