Mouse Models for HTLV-1 Infection and Adult T Cell Leukemia

Adult T cell leukemia (ATL) is an aggressive hematologic disease caused by human T cell leukemia virus type 1 (HTLV-1) infection. Various animal models of HTLV-1 infection/ATL have been established to elucidate the pathogenesis of ATL and develop appropriate treatments. For analyses employing murine models, transgenic and immunodeficient mice are used because of the low infectivity of HTLV-1 in mice. Each mouse model has different characteristics that must be considered before use for different HTLV-1 research purposes. HTLV-1 Tax and HBZ transgenic mice spontaneously develop tumors, and the roles of both Tax and HBZ in cell transformation and tumor growth have been established. Severely immunodeficient mice were able to be engrafted with ATL cell lines and have been used in preclinical studies of candidate molecules for the treatment of ATL. HTLV-1-infected humanized mice with an established human immune system are a suitable model to characterize cells in the early stages of HTLV-1 infection. This review outlines the characteristics of mouse models of HTLV-1 infection/ATL and describes progress made in elucidating the pathogenesis of ATL and developing related therapies using these mice.

Thymocyte Development of Humanized Mice Is Promoted by Interactions with Human-Derived Antigen Presenting Cells upon Immunization

Immune responses in humanized mice are generally inefficient without co-transplantation of human thymus or HLA transgenes. Previously, we generated humanized mice via the intra-bone marrow injection of CD133+ cord blood cells into irradiated adult immunodeficient mice (IBMI-huNSG mice), which could mount functional immune responses against HTLV-1, although the underlying mechanisms were still unknown. Here, we investigated thymocyte development in IBMI-huNSG mice, focusing on the roles of human and mouse MHC restriction. IBMI-huNSG mice had normal developmental profiles but aberrant thymic structures. Surprisingly, the thymic medulla-like regions expanded after immunization due to enhanced thymocyte expansion in association with the increase in HLA-DR+ cells, including CD205⁺ dendritic cells (DCs). The organ culture of thymus from immunized IBMI-huNSG mice with a neutralizing antibody to HLA-DR showed the HLA-DR-dependent expansion of CD4 single positive thymocytes. Mature peripheral T-cells exhibited alloreactive proliferation when co-cultured with human peripheral blood mononuclear cells. Live imaging of the thymus from immunized IBMI-huNSG mice revealed dynamic adhesive contacts of human-derived thymocytes and DCs accompanied by Rap1 activation. These findings demonstrate that an increase in HLA-DR+ cells by immunization promotes HLA-restricted thymocyte expansion in humanized mice, offering a unique opportunity to generate humanized mice with ease.

Vaccination with short-term-cultured autologous PBMCs efficiently activated STLV-1-specific CTLs in naturally STLV-1-infected Japanese monkeys with impaired CTL responses

A small proportion of human T-cell leukemia virus type-1 (HTLV-1)-infected individuals develop adult T-cell leukemia/lymphoma, a chemotherapy-resistant lymphoproliferative disease with a poor prognosis. HTLV-1-specific cytotoxic T lymphocytes (CTLs), potential anti-tumor/virus effectors, are impaired in adult T-cell leukemia/lymphoma patients. Here, using Japanese monkeys naturally infected with simian T-cell leukemia/T-lymphotropic virus type-1 (STLV-1) as a model, we demonstrate that short-term-cultured autologous peripheral blood mononuclear cells (PBMCs) can serve as a therapeutic vaccine to activate such CTLs. In a screening test, STLV-1-specific CTL activity was detectable in 8/10 naturally STLV-1-infected monkeys. We conducted a vaccine study in the remaining two monkeys with impaired CTL responses. The short-term-cultured PBMCs of these monkeys spontaneously expressed viral antigens, in a similar way to PBMCs from human HTLV-1 carriers. The first monkey was subcutaneously inoculated with three-day-cultured and mitomycin C (MMC)-treated autologous PBMCs, and then boosted with MMC-treated autologous STLV-1-infected cell line cells. The second monkey was inoculated with autologous PBMC-vaccine alone twice. In addition, a third monkey that originally showed a weak STLV-1-specific CTL response was inoculated with similar autologous PBMC-vaccines. In all three vaccinated monkeys, marked activation of STLV-1-specific CTLs and a mild reduction in the STLV-1 proviral load were observed. Follow-up analyses on the two monkeys vaccinated with PBMCs alone indicated that STLV-1-specific CTL responses peaked at 3-4 months after vaccination, and then diminished but remained detectable for more than one year. The significant reduction in the proviral load and the control of viral expression were associated with CTL activation but also diminished 6 and 12 months after vaccination, respectively, suggesting the requirement for a booster. The vaccine-induced CTLs in these monkeys recognized epitopes in the STLV-1 Tax and/or Envelope proteins, and efficiently killed autologous STLV-1-infected cells in vitro. These findings indicated that the autologous PBMC-based vaccine could induce functional STLV-1-specific CTLs in vivo.

Identification and characterization of a novel enhancer in the HTLV-1 proviral genome

Human T-cell leukemia virus type 1 (HTLV-1) is a retrovirus that causes adult T-cell leukemia/lymphoma (ATL), a cancer of infected CD4⁺ T-cells. There is both sense and antisense transcription from the integrated provirus. Sense transcription tends to be suppressed, but antisense transcription is constitutively active. Various efforts have been made to elucidate the regulatory mechanism of HTLV-1 provirus for several decades; however, it remains unknown how HTLV-1 antisense transcription is maintained. Here, using proviral DNA-capture sequencing, we found a previously unidentified viral enhancer in the middle of the HTLV-1 provirus. The transcription factors, SRF and ELK-1, play a pivotal role in the activity of this enhancer. Aberrant transcription of genes in the proximity of integration sites was observed in freshly isolated ATL cells. This finding resolves certain long-standing questions concerning HTLV-1 persistence and pathogenesis. We anticipate that the DNA-capture-seq approach can be applied to analyze the regulatory mechanisms of other oncogenic viruses integrated into the host cellular genome.

Human T-cell leukemia virus type 1 (HTLV-1) is an oncogenic virus with constantly active antisense transcription from the proviral genome. Here, Matsuo et al. perform proviral DNA-capture followed by high-throughput sequencing and identify a yet unknown viral enhancer in the middle of the HTLV-1 provirus.

Erratum: Using Diffuse Scattering to Observe X-Ray-Driven Nonthermal Melting [Phys. Rev. Lett. 126, 015703 (2021)]

This corrects the article DOI: 10.1103/PhysRevLett.126.015703.

Chemoradiation induces upregulation of immunogenic cell death-related molecules together with increased expression of PD-L1 and galectin-9 in gastric cancer

Surgery alone or combined with chemo- and/or radiation therapy remains the primary treatment for gastric cancer (GC) to date and immunotherapeutic tools such as monoclonal antibodies are only slowly being implemented. This is partly due to the fact that the immune microenvironment in GC during chemoradiation and other treatment modalities is still poorly understood. 7 gastric cancer (GC) cell lines were tested for their response to chemoradiation using 5-FU in combination with X-ray irradiation. We conducted flow cytometric analysis to determine the cells’ ability to undergo immunogenic cell death (ICD) and their expression of the two immunosuppressive proteins programmed death-ligand 1 (PD-L1) and galectin-9 (Gal-9). We evaluated the overall immunogenicity of two cell lines (MKN7, MKN74) in co-culture experiments with human monocyte-derived dendritic cells (Mo-DCs). Chemoradiation induces distinct responses in different GC cell lines. We observe ICD in vitro in all tested GC cell lines in the form of calreticulin (CRT) translocation to the plasma membrane. As a resistance mechanism, these cells also upregulated Gal-9 and PD-L1. Mo-DC maturation experiments showed that GCs provoked the maturation of Mo-DCs after chemoradiation in vitro. The addition of α-PD-L1 blocking antibody further enhanced the immunogenicity of these cells while improving DC viability. Blocking Tim-3, as the main receptor for Gal-9, had no such effect. Our findings suggest that the benefits of chemoradiation can substantially depend on tumor subtype and these benefits can be offset by induced immune evasion in GC. Combination treatment using checkpoint inhibitors could potentially lead to enhanced immune responses and yield better patient outcomes.

AB0391 LOW SERUM COMPLEMENT C3 LEVEL AS A RISK FACTOR FOR RELAPSE OF ANTINEUTROPHIL CYTOPLASMIC ANTIBODY-ASSOCIATED VASCULITIS: A RETROSPECTIVE COHORT STUDY

Background:

The alternative pathway of complement activation has recently been recognized as a key pathogenic event in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). Some previous studies have reported that low serum complement C3 level in AAV patients is associated with more severe renal disease, worse renal prognosis, or higher mortality. However, the correlation between low serum C3 level and AAV relapse remains unclear.

Objectives:

To analyze the clinical characteristics and outcomes of AAV patients with low serum C3 levels at the time of diagnosis.

Methods:

We conducted a retrospective observational cohort study including 83 consecutive patients diagnosed with AAV in our hospital from January 1999 to December 2020. Serum C3 levels were measured at diagnosis. AAV included microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA), and eosinophilic granulomatosis with polyangiitis (EGPA); patients with ANCA-negative AAV were excluded. Patients were divided into low- and high-C3 groups (C3 < 100 and ≥ 100 mg/dL, respectively). We compared the clinical characteristics, and relapse-free and overall survival rates, of the two groups, and identified predictors of AAV relapse.

Results:

Of the 83 patients (MPA, n = 61; GPA, n = 18; EGPA, n = 4), 20 (24%) were in the low-C3 group. We found no significant group difference in sex, body mass index, disease type, ANCA subtype, Birmingham Vasculitis Activity Score (BVAS), or treatment. The low-C3 group patients were older (p=0.01), and had a higher Five Factor Score (FFS) (p=0.01) and a lower remission rate (p=0.02), than the high-C3 group. The generalized Wilcoxon test revealed that the relapse-free survival time was significantly shorter in the low-C3 group (29 months; 95% confidence interval [CI]: 15–49) than in the high-C3 group (82 months; 95% CI: 61–NA; p=0.01) (Figure 1A). The overall survival was also shorter in the low-C3 group (83 months; 95% CI: 8-121) than in the high-C3 group (112 months; 95% CI: 77-NA; p=0.03) (Figure 1B). In the Cox proportional hazards model, a low C3 level (< 100 mg/dL) (hazard ratio [HR], 3.01; 95% CI: 1.29–7.04], p=0.01) and GPA (HR, 3.04; 95% CI: 1.32–7.01; p=0.01) were independent predictors of AAV relapse.

Figure 1.

Kaplan-Meier estimates of the relapse-free (A) and overall (B) survival rates of AAV patients by baseline serum C3 levels. Eight patients who did not show remission were excluded in the relapse-free survival analysis. Black line: high-C3 group (≥ 100 mg/dL); red line: low-C3 group (< 100 mg/dL).

Conclusion:

AAV patients with low C3 levels at diagnosis were at higher risk of relapse. Larger prospective studies are required to confirm these findings.

Disclosure of Interests:

None declared

Using Diffuse Scattering to Observe X-Ray-Driven Nonthermal Melting

We present results from the SPring-8 Angstrom Compact free electron LAser facility, where we used a high intensity (∼10^{20}  W/cm^{2}) x-ray pump x-ray probe scheme to observe changes in the ionic structure of silicon induced by x-ray heating of the electrons. By avoiding Laue spots in the scattering signal from a single crystalline sample, we observe a rapid rise in diffuse scattering and a transition to a disordered, liquidlike state with a structure significantly different from liquid silicon. The disordering occurs within 100 fs of irradiation, a timescale that agrees well with first principles simulations, and is faster than that predicted by purely inertial behavior, suggesting that both the phase change and disordered state reached are dominated by Coulomb forces. This method is capable of observing liquid scattering without masking signal from the ambient solid, allowing the liquid structure to be measured throughout and beyond the phase change.

Impact of east Japan earthquake disaster with massive tsunami for prevalence of Takotsubo syndrome – a multicenter regional registry before and after east Japan earthquake disaster

Background

Previous studies demonstrated Takotsubo syndrome (TS) was easy provoked by earthquake disaster. However, a previous other regional report demonstrated TS was not increased after 2011 east Japan earthquake disaster. The purpose of this study was to clarify incidence of TS after the earthquake disaster in Iwate prefecture during long term period.

Method

Consecutive hospitalized TS patients were registered during 8 years between 2009 and 2016 in our medical university and five Iwate prefecture hospitals. Moreover, patients were divided into two groups, i.e., those with the inland and those with tsunami-stricken area groups. Prevalence of TS were calculated by standard incidence ratio (SIR) before and after the earthquake disaster. Moreover, long-term prognosis in the both groups was compared using Kaplan-Meier analysis.

Results

A total of 112 TS (male 25 and female 87) were registered from acute coronary syndrome registry in each hospital (n=4,163). Averaged age was 75.3 year-old. A total number of TS just after the two months of the earthquake (March and April 2011) was nine and significance monthly variation was observed comparing with the other months (p=0.029). SIR before and after the disaster is as following Figure. There were no significant differences for long-term prognosis between the two groups (p=0.20).

Conclusion

Incidence of TS was increased in acute phase after east Japan earthquake disaster. However, significance increases were maintained during long-term period, although number of TS was decreased after acute phase. TS is increased not only acute but also chronic phase after the serious earthquake disaster.

Standard incidence ratio

Funding Acknowledgement

Type of funding source: None

Single-blind randomized clinical trial of transinguinal preperitoneal repair using self-expanding mesh patch vs. Lichtenstein repair for adult male patients with primary unilateral inguinal hernia

PURPOSE

The aim of the study was to compare proportions of chronic postoperative inguinal pain (CPIP) and other surgical outcomes between transinguinal preperitoneal repair with modified Kugel patch (MK) and Lichtenstein repair (LR).

METHODS

Two-hundred adult male patients with primary unilateral inguinal hernia were randomized into MK or LR groups. The primary endpoint was CPIP, pain at 6 months after surgery. Secondary outcomes included recurrence rate, incidence of postoperative complications, time until return to activities, inguinal pain and sensory disturbances assessed at 1 week, 1 month, 3, 6, and 12 months after the operation using an 11-point numerical rating scale (NRS). The study was an intention-to-treat analysis.

RESULTS

In comparison of MK (n = 100) and LR (n = 100) with similar backgrounds, proportions of CPIP were similar (7.2 vs. 11.1%, p = 0.3452). Favorable outcomes for MK were duration of operation (32 vs. 40 min, p < 0.0001), NRS of foreign body sensation at 1 year (0 [0-1] vs. 0 [0-2], p = 0.0067), and NRS of numbness at 1 month (0 [0-1] vs. 0 [0-3], p = 0.0078) after the operation.

CONCLUSIONS

In regard to CPIP, the short-term results of MK and LR were similar.

Fat-specific protein 27α inhibits autophagy-dependent lipid droplet breakdown in white adipocytes

AIMS/INTRODUCTION

Fat-specific protein 27 (FSP27) α is the major isoform of FSP27 in white adipose tissue (WAT), and is essential for large unilocular lipid droplet (LD) formation in white adipocytes. In contrast, FSP27β is abundantly expressed in brown adipose tissue (BAT), and plays an important role in small multilocular LD formation. In FSP27 KO mice in which FSP27α and β are both depleted, WAT is characterized by multilocular LD formation, and by increased mitochondrial abundance and energy expenditure, whereas BAT conversely manifests large oligolocular LDs and reduced energy expenditure.

MATERIALS AND METHODS

We investigated the effects of autophagy in WAT and BAT of wild type (WT) and FSP27 knockout (KO) mice. In addition, we examined the effects of FSP27α and FSP27β to the induction of autophagy in COS cells.

RESULTS

Food deprivation induced autophagy in BAT of WT mice, as well as in WAT of FSP27 KO mice, suggesting that enhanced autophagy is characteristic of adipocytes with small multilocular LDs. Pharmacological inhibition of autophagy attenuated the fasting-induced loss of LD area in adipocytes with small multilocular LDs (BAT of WT mice and WAT of FSP27 KO mice), without affecting that in adipocytes with large unilocular or oligolocular LDs (WAT of WT mice or in BAT of FSP27 KO mice). Overexpression of FSP27α inhibited autophagy induction by serum deprivation in COS cells, whereas that of FSP27β had no such effect.

CONCLUSIONS

The present results thus showed that FSP27α inhibits autophagy and might thereby contribute to the energy-storage function of WAT.

P1761Distal transradial approach for primary percutaneous coronary intervention for patients with acute myocardial infarction: a multicentre study

Background

The distal transradial approach (dTRA) for coronary catheterisation is a newly introduced alternative to the conventional transradial approach. This technique is expected to decrease the incidence of haemorrhagic complications and improve patient comfort. However, limited data are available regarding the application of this technique in patients with acute myocardial infarction (AMI). This study investigated the feasibility and safety of the dTRA for primary percutaneous coronary intervention (PCI) in patients with AMI.

Methods

This study included patients with AMI who underwent primary PCI via the distal radial artery across 3 Japanese hospitals between January 2018 and January 2019. Patients' background, procedural characteristics, and clinical outcomes including the incidence of haemorrhagic complications were analysed.

Results

This study enrolled 95 consecutive patients with AMI, including 68 patients (71.6%) with ST-segment elevation myocardial infarction (STEMI), in whom distal radial artery puncture was attempted for primary PCI. The patients included 70 men (73.7%), and the mean age was 72.2±12.4 years. Among these patients, cannulation was successfully performed in 89 patients (93.7%). A 5-, 6-, or 7-French sheath (conventional or slender) was used in this study. Cannulation was performed using a forearm radial artery approach in patients in whom dTRA failed.

PCI was successfully performed in all patients. The meantime to achieve haemostasis was 6.3±5.3 hours, and no major bleeding complications occurred. Based on The Early Discharge After Transradial Stenting of Coronary Arteries trial haematoma scale, grade I, II, and III subcutaneous haemorrhages were observed in 16 (16.8%), 4 (4.2%), and 1 patient (1.1%), respectively. No patient developed a haematoma > grade IV.

In patients with STEMI, the mean door-to-balloon time was 39.4±31.9 min, and the mean puncture-to-balloon time was 19.7±14.2 min.

Conclusions

The distal radial approach is feasible and safefor primary PCI in selected patients with AMI.The application of the dTRA may serve as a less invasive strategy for the treatment of patients with AMI.

P1671Subclinical persistent hemolysis may affect late renal function deterioration after HeartMateII implantation

Background

Late renal function dysfunction is an increasingly recognized complication in continuous flow left ventricular assist device (CF-LVAD) patients. Although hemolysis is prevalent in CF-LVAD patients and hemolysis may deteriorate renal function, the influence of persistent hemolysis on renal function in CF-LVAD patients remains to be investigated.

Purpose

To investigate the influence of persistent hemolysis on renal function in CF-LVAD patients, using lactate dehydrogenase (LDH) as a sensitive marker of hemolysis.

Methods

Excluding patients who died or underwent pump exchange for pump thrombosis, we retrospectively reviewed 65 consecutive adults who underwent HeartMateII implantation in our center from May 2011 to October 2017. Patient characteristics, chronotropic change of estimated glomerular filtration rate (eGFR) and LDH values weekly for 4 weeks and every 4 weeks between 4 and 48 weeks after implantation were collected. Then, calculating mean LDH during 48 weeks after implantation, study population was divided into low and high mean LDH groups at the median value of mean LDH.

Results

The median value of mean LDH was 304 U/l. Compared with low LDH patients, though high LDH patients were more likely female and had smaller body surface area, there were no significant difference in pre-operative eGFR between the groups (66.0±23.7 vs. 70.2±25.7 ml/min/1.73m2, p=0.495). After 40 weeks after implantation, high LDH patients had significantly lower eGFR than low LDH patients (71.0±23.7 vs. 87.1±31.4 ml/min/1.73m2, p=0.024). In multivariate linear regression analysis, mean LDH [parameter estimate: −0.10 (95% CI: −0.17 to −0.04), p=0.003] and post-operative pulse pressure [parameter estimate: 0.71 (95% CI: 0.05 to 1.37), p=0.036] were significantly associated with eGFR change during 48 weeks after HeartMateII implantation.

Univariate and multivariate linear regression analysis for eGFR change Univariate parameter estimate 95% CI p value Multivariate parameter estimate 95% CI p value Bilirubin, mg/dl 9.97 3.82 to 16.13 0.002 6.55 −0.43 to 13.53 0.065 BNP, pg/ml 0.01 0.00 to 0.02 0.044 0.00 −0.01 to 0.01 0.528 Mean LDH during 4 to 48 weeks, U/l −0.11 −0.18 to −0.05 <0.001 −0.10 −0.17 to −0.04 0.003 Pre-operative right atrial pressure, mmHg 1.43 0.35 to 2.51 0.010 −0.06 −1.52 to 1.40 0.935 Post-operative pulse pressure, mmHg 0.77 0.03 to 1.52 0.042 0.71 0.05 to 1.37 0.036

Conclusions

High mean LDH and low pulse pressure were associated with a significant decrease in eGFR late after HeartMateII implantation. Subclinical persistent hemolysis may be associated with late renal function deterioration in CF-LVAD patients.

Current-feedback-stabilized laser system for quantum simulation experiments using Yb clock transition at 578 nm

We developed a laser system for the spectroscopy of the clock transition in ytterbium (Yb) atoms at 578 nm based on an interference-filter stabilized external-cavity diode laser (IFDL) emitting at 1156 nm. Owing to the improved frequency-to-current response of the laser-diode chip and the less sensitivity of the IFDL to mechanical perturbations, we succeeded in stabilizing the frequency to a high-finesse ultra-low-expansion glass cavity with a simple current feedback system. Using this laser system, we performed high-resolution clock spectroscopy of Yb and found that the linewidth of the stabilized laser was less than 320 Hz.

Caspase-1 initiates apoptosis in the absence of gasdermin D

Caspase-1 activated in inflammasomes triggers a programmed necrosis called pyroptosis, which is mediated by gasdermin D (GSDMD). However, GSDMD-deficient cells are still susceptible to caspase-1-mediated cell death. Therefore, here, we investigate the mechanism of caspase-1-initiated cell death in GSDMD-deficient cells. Inflammasome stimuli induce apoptosis accompanied by caspase-3 activation in GSDMD-deficient macrophages, which largely relies on caspase-1. Chemical dimerization of caspase-1 induces pyroptosis in GSDMD-sufficient cells, but apoptosis in GSDMD-deficient cells. Caspase-1-induced apoptosis involves the Bid-caspase-9-caspase-3 axis, which can be followed by GSDME-dependent secondary necrosis/pyroptosis. However, Bid ablation does not completely abolish the cell death, suggesting the existence of an additional mechanism. Furthermore, cortical neurons and mast cells exhibit little or low GSDMD expression and undergo apoptosis after oxygen glucose deprivation and nigericin stimulation, respectively, in a caspase-1- and Bid-dependent manner. This study clarifies the molecular mechanism and biological roles of caspase-1-induced apoptosis in GSDMD-low/null cell types.

In inflammasomes, caspase-1 activation leads to pyroptosis mediated by gasdermin D, but cells lacking gasdermin-D still initiate caspase-dependent cell death. Here, Tsuchiya et al. show that these cells undergo Bid- and caspase-3-dependent apoptosis.

Effects of exenatide and liraglutide on postchallenge glucose disposal in individuals with normal glucose tolerance

PURPOSE

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are categorized as short- or long-acting types, but information regarding differences in the effects of these two types on postprandial glucose disposal has been limited. We have now investigated the effects of exenatide and liraglutide (short- and long-acting GLP-1RAs, respectively) on glucose disposal during an oral glucose tolerance test (OGTT).

METHODS

Fourteen healthy volunteers with normal glucose tolerance underwent three OGTTs, which were performed without pharmacological intervention or after a single administration of exenatide or liraglutide at 30 min and 10 h, respectively, before test initiation. The three OGTTs were performed with intervals of at least 7 days between successive tests and within a period of 2 months.

RESULTS

Exenatide, but not liraglutide, markedly decelerated the peak of both plasma glucose and serum insulin levels during the OGTT, with the peaks of both glucose and insulin concentrations occurring at 150 min after test initiation with exenatide compared with 30 min in the control condition or with liraglutide. Exenatide and liraglutide reduced the area under the curve for plasma glucose levels during the OGTT by similar extents, whereas that for serum insulin levels was reduced only by exenatide.

CONCLUSIONS

Our results suggest that exenatide decelerates the increase in plasma glucose levels through inhibition of glucose absorption and that it exerts an insulin-sparing action after glucose challenge.

Terminal Ileac Ulcers Mimicked Post-transplantation Lymphoproliferative Disorder in a Heart Recipient Treated With Everolimus: A Case Report

Post-transplant lymphoproliferative disorder (PTLD) is a well-recognized and potentially fatal complication of cardiac transplantation that commonly involves the gastrointestinal tract. Herein, we report a case of life-threatening gastrointestinal bleeding from recurrent terminal ileac ulcers mimicking PTLD in a heart recipient treated with everolimus (EVL). A 40-year-old man underwent heart transplantation for dilated cardiomyopathy 3 years prior to the current admission and was treated with tacrolimus and EVL. He was admitted to a local hospital because of fever, abdominal pain, and diarrhea. His symptoms persisted and, 3 weeks later, hematochezia occurred; thus, he was transferred to our hospital. As computed tomography and ¹⁸F-fluorodeoxyglucose positron emission tomography showed bowel-wall thickening of the terminal ileum, gastrointestinal PTLD was initially suspected. However, although colonoscopy- performed after switching EVL to mycophenolate mofetil (MMF)-showed terminal ileac ulcers, the histologic examination revealed no findings corresponding to PTLD. As EVL may delay ulcer healing, MMF was maintained for 3 months. After repeated colonoscopy showed ulcer healing, MMF was switched back to EVL for cardiac allograft vasculopathy prevention. Three weeks later, he was emergently admitted to a local hospital for life-threatening gastrointestinal bleeding from a recurrent terminal ileal ulcer, which required hemostatic forceps hemostasis. As EVL is suspected to be associated with recurrent ileal ulcers, EVL was again switched back to MMF. The ileal ulcers resolved, without recurrence in 3 months of clinical follow-up. This case demonstrates that cases of life-threatening gastrointestinal bleeding from recurrent terminal ileac ulcers can mimic PTLD in a heart recipient treated with EVL.

Reversible Cerebral Vasoconstriction Syndrome After Heart Transplantation: A Case Report

BACKGROUND

Reversible cerebral vasoconstriction syndrome (RCVS) is a transient cerebrovascular disorder putatively caused by some immunosuppressive agents.

CASE REPORT

We recently encountered a 47-year-old female patient diagnosed with dilated cardiomyopathy who developed RCVS after heart transplantation. A triple-drug regimen consisting of tacrolimus, mycophenolate mofetil, and a corticosteroid was started after surgery. On postoperative day (POD) 11, the patient developed a severe headache, although computed tomography of the head demonstrated no signs of hemorrhage or infarction. At first, both a painkiller and migraine drugs were regularly administered to the patient. On POD 21, however, she developed an unbearable headache with a visual field defect and mild hemiparesis of the right hand. Magnetic resonance imaging (MRI) of the brain revealed a cerebral infarction in the left occipital lobe with diffuse vasoconstriction of both the middle and posterior cerebral arteries. A diagnosis of RCVS was made and tacrolimus, a drug suspected to cause RCVS, was discontinued. In its place, two doses of basiliximab followed by everolimus, both of which are alternatives for tacrolimus, were given. The corticosteroid dose was also increased. Furthermore, to release vasoconstriction, both verapamil and diltiazem were administered. On POD 27, cerebrovascular constrictions were shown to be relieved on brain MRI and the patient's neurological symptoms subsequently almost completely diminished.

CONCLUSION

RCVS should always be considered as a cause of headache in heart transplant recipients because tacrolimus, an immunosuppressive agent, may trigger RCVS. This will allow rapid intervention that is essential for avoiding irreversible neurological deficits.

Characterization of Innate and Adaptive Immune Responses in PYNOD-Deficient Mice

PYNOD (also called NLRP10) is a member of the nucleotide-binding domain and leucine-rich repeat containing family. Many members of this family play important roles in the activation and/or regulation of immune and inflammatory responses. We previously showed that PYNOD inhibits the IL-1β secretion in response to microbial infection in PYNOD-transgenic mice. In this study, we generated PYNOD-knockout (KO) mice and further investigated PYNOD's role in the innate and adaptive immune responses. Similar to wild-type macrophages, PYNOD-KO macrophages produced IL-1β and induced pyroptosis, a caspase-1-dependent programmed cell death, in response to various inflammasome activators and microbial infection. In addition, the PYNOD deficiency did not significantly affect the proliferation or cytokine production of T cells, the delayed-type hypersensitivity responses, the anti-tumor immunity, the Ag-specific Ab production, the cytotoxicity of NK cells, or the maturation, Ag-presenting capacity, or elicited migration of dendritic cells. Furthermore, the steady-state skin self-antigen transport to regional lymph nodes was not impaired in PYNOD-KO mice, suggesting that PYNOD is dispensable for steady-state dendritic cell migration. These results suggested that PYNOD is dispensable for the regulation of innate and adaptive immune responses in mice, unless PYNOD's expression is highly induced under certain conditions.

Effects of Cytokines on Oxygen Radical Production by Peripheral Blood Monocytes and Alveolar Macrophages in Patients with Lung Cancer

The effects of cytokines (interleukin-2, tumor necrosis factor-alpha and interferon-gamma) on the ability of peripheral blood monocytes and alveolar macrophages to produce oxygen radicals were examined by the chemiluminescence assay in patients with lung cancer. Oxygen radical production by peripheral blood monocytes before stimulation with cytokines was lower in the lung cancer group than in healthy controls, suggesting reduced immune function in lung cancer patients. However, the activity in the lung cancer group was elevated to the control level when the monocytes were stimulated by any of the three aforementioned cytokines. Oxygen radical production by alveolar macrophages did not differ significantly between nonstimulated monocytes from lung cancer patients and those from healthy controls. In the lung cancer group, stimulation of the macrophages with any of the three cytokines elevated their ability to produce oxygen radicals to the same extent as in the control group. The results suggest that stimulation of macrophages by interleukin-2, tumor necrosis factor-alpha or interferon-gamma can exert an antitumor action in patients with lung cancer.

Paradoxical Reaction of Tuberculosis in a Heart Transplant Recipient During Antituberculosis Therapy: A Case Report

INTRODUCTION

Tuberculous paradoxical reactions (PRs) are excessive immune reactions occurring after antituberculosis (TB) treatment and are commonly observed in immunocompromised hosts such as patients infected with the human immunodeficiency virus.

CASE REPORT

We recently encountered a 63-year-old male heart transplant recipient who developed tuberculous PR after treatment for miliary TB. The patient had been receiving immunosuppressive therapy with cyclosporine and mycophenolate mofetil for over 15 years. The diagnosis of miliary TB was made based on the presence of intermittent fever and fatigue; thus, anti-TB treatments (isoniazid, levofloxacin, ethambutol, and pyrazinamide) were started, which led to rapid defervescence and regression of the granular shadow and pleural effusion. However, a new persistent fever and confused state developed 1 month after the anti-TB therapy was started. After excluding possible etiologies of the patient's symptom, a PR was suspected, and anti-TB drugs were continued; corticosteroids were added as anti-inflammatory agents. After that, he has shown a favorable course with long-term anti-TB chemotherapy.

CONCLUSION

A PR should always be considered when the patients' symptoms of tuberculosis re-exacerbate after an appropriate anti-TB therapy. A PR commonly occurs in patients with various immunologic conditions including heart transplant recipients.

Clinical Outcomes of Patients With the HeartMate II Left Ventricular Assist Device: A Single-center Experience From Japan

BACKGROUND

Left ventricular assist device (LVAD) therapy is the "gold standard" alternative therapy for patients with advanced heart failure. However, LVAD therapy is still uncommon in the Asia-Pacific region. Therefore, we aimed to elucidate the clinical outcomes of patients from Japan supported with the HeartMate II (HM-II) LVAD at our institution.

METHODS

Ninety-two patients (mean 44.3 ± 12.1 years, 68 men, average body mass index 1.65 ± 0.28 m²; 81 with nonischemic cardiomyopathy) who underwent HM-II implantation for bridge to transplantation (n = 91) or for destination therapy in a clinical study (n = 1) at the National Cerebral and Cardiovascular Center between April 2013 and October 2017 were enrolled in this analysis. Preoperatively, most patients (n = 73, 79%) had an INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) profile of between level 2 and 4. Postoperatively, the average pump speed was 8602 ± 258 rpm and the hemodynamics were well compensated.

RESULTS

Adverse events consisted of 38 (41.3%) hemolysis, 30 (32.6%) major infection, 27 (29.3%) major bleeding (6 [6.5%] with gastrointestinal bleeding), and 18 (19.6%) neurologic dysfunction events. Eighteen patients underwent heart transplantation (HTx) after an average of 32.9 ± 8.9 months of VAD support, and overall survival at both 6 months and 3 years was 96.3%.

CONCLUSION

Clinical outcome among patients with HM-II at our institution is satisfactory for both survival and adverse events. The HM-II can provide effective hemodynamic support during the extremely long waiting period for HTx in Japan.

The analgesic effect of rescue administration of intravenous acetaminophen in cancer patients may be associated with sex and opioid dose, and the effect would appear to patients administered under 45 mg/day opioid (oral morphine equivalents)

There have been no investigations examining the analgesic effect of rescue administration of intravenous acetaminophen (IV APAP) for pain in cancer patients. Fifty cancer patients who received IV APAP for pain at Ashiya Municipal Hospital (Hyogo, Japan) between January 2014 and July 2016 were retrospectively evaluated. The degree of pain was evaluated using a 4-point verbal rating scale. Pain intensity differences ≥ 1 defined the IV APAP effective group, and the patient' characteristics were compared by a medical chart review. Variables were extracted from medical records for logistic regression analyses of factors associated with analgesic effect. The cut-off value of opioid dose (oral morphine equivalent) was determined using receiver operator characteristic (ROC) curve analysis. Thirty eight (76%) patients experienced an analgesic effect of rescue administration of IV APAP. Sex (odds ratio [OR] 5.4014; p = 0.0397) and opioid dose used for pain control (OR 0.9901; p = 0.0147) were found to be associated with the efficacy of rescue administration of IV APAP. The cut-off value of opioid dose (oral morphine equivalent), which may be difficult to match the analgesic effect of IV APAP, was calculated to be more than 45 mg/day. This study demonstrated the efficacy of a rescue administration of IV APAP for pain in cancer patients, and revealed that sex and opioid dose may be associated with the analgesic effect. Furthermore, this study also proposes a criterion for the analgesic effect.