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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Relationship of Lesion Location to Postoperative Steroid Use in Eosinophilic Chronic Rhinosinusitis

OBJECTIVES

Eosinophilic chronic rhinosinusitis (ECRS) is known to recur after surgery. The treatment choice for recurrent ECRS, such as oral steroids or biological agents, must be chosen carefully, and identifying the lesion location may be useful. This study aimed to evaluate the postoperative course of ECRS patients and assess the relationship between endoscopic lesion location and postoperative oral steroid use.

METHODS

Patients with chronic rhinosinusitis who underwent bilateral endoscopic sinus surgery from April 2018 to March 2020 were divided into two groups based on the presence or absence of oral steroid use after surgery. The primary endpoint was the lesion location on endoscopic findings during surgery: middle turbinate, middle meatus, superior turbinate, superior meatus, nasal septum, and sphenoethmoidal recess. Subjective symptoms, blood tests, and computerized tomography (CT) findings (Lund-Mackay score) were evaluated as secondary endpoints.

RESULTS

Among 264 patients, 88 were diagnosed histologically with ECRS (mean 48.98 ± 1.40 years, 67 males/21 females). Twenty-three patients were steroid-using, 65 were steroid-free, and six stopped attending their appointments. Patients with sphenoethmoidal recess lesions were significantly more likely to require steroids (p = 0.019). There was a significant association between steroid use and younger age (p = 0.041), olfactory dysfunction (p = 0.021), and all sinuses (Frontal sinus: p < 0.001, Anterior ethmoid sinus: p = 0.002, Posterior ethmoid sinus: p = 0.011, Maxillary sinus: p = 0.018, Sphenoid sinus: p = 0.034, Total score: p < 0.001).

CONCLUSION

A sphenoethmoidal recess lesion was a risk factor for requiring postoperative steroids. Young age, olfactory dysfunction, and preoperative severe CT findings were also significant risk factors.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:2511-2516, 2023.

Transcoronary mapping using a guidewire during transcoronary ethanol ablation for ventricular tachycardia with a deep intramural substrate: a case report

Background

Transcoronary ethanol ablation is effective in treating ventricular tachycardia (VT) in the deep myocardium. The selection of the target coronary artery plays an important role in the success of transcoronary ethanol ablation. Transcoronary mapping, using a guidewire, may be effective for identifying the target coronary artery.

Case summary

A 72-year-old man, who had undergone thrombolytic therapy for acute myocardial infarction 40 years ago, was admitted to the emergency department with a chief complaint of syncope. Five years ago, a cardiac resynchronization therapy defibrillator was implanted for a left bundle branch block (QRS duration 153 ms), with New York Heart Association Class Ⅲ and a left ventricular ejection fraction of 30%.Due to VT, he experienced a critical deterioration in his vital parameters, leading to shock. The first VT ablation was performed on the 3rd day of hospitalization. Activation mapping showed that the earliest activation site was located in the mid-anterior septum of the left ventricle. Mapping from the endocardial surface showed no mid-diastolic potential around the VT. Radiofrequency catheter ablation therapy was performed at the targeted site, resulting in transient termination of VT. However, the VT showed recurrence the next day. A transcoronary ethanol ablation was performed on the 10th day of hospitalization. A 0.014 inch guidewire and microcatheter were advanced into the target coronary septal branch, and the myocardial septum was mapped. The guidewire-assisted transcoronary mapping showed a potential 43 ms ahead of QRS onset during VT. The coronary septal artery branch was considered the target artery, and 0.5 mL of ethanol was injected. No further VT was observed for 12 months after the transcoronary ethanol ablation.

Discussion

Transcoronary ethanol ablation is considered in cases where a deep intramural substrate is suspected or when early activation at the interventricular septum is identified. Guidewire-assisted transcoronary mapping allows mapping of VT with deep intramural substrates and may be useful in selecting target coronary arteries while performing transcoronary ethanol ablation.

Effect of ipragliflozin on carotid intima-media thickness in patients with type 2 diabetes: a multicenter, randomized, controlled trial

AIMS

To examine the effects of a 24-month treatment with ipragliflozin on carotid intima-media thickness (IMT) in type 2 diabetes patients.

METHODS AND RESULTS

In this multicenter, prospective, randomized, open-label, and blinded-endpoint investigator-initiated clinical trial, adults with type 2 diabetes and haemoglobin A1C (HbA1c) of 6.0-10.0% (42-86 mmol/mol) were randomized equally to ipragliflozin (50 mg daily) and non-sodium-glucose cotransporter-2 (SGLT2) inhibitor use of standard-care (control group) for type 2 diabetes and were followed-up to 24 months. The primary endpoint was the change in mean common carotid artery IMT (CCA-IMT) from baseline to 24 months. A total of 482 patients were equally allocated to the ipragliflozin (N = 241) and control (N = 241) groups, and 464 patients (median age 68 years, female 31.7%, median type 2 diabetes duration 8 years, median HbA1c 7.3%) were included in the analyses. For the primary endpoint, the changes in the mean CCA-IMT from baseline to 24 months were 0.0013 [95% confidence interval (CI), -0.0155-0.0182] mm and 0.0015 (95% CI, -0.0155-0.0184) mm in the ipragliflozin and control groups, respectively, with an estimated group difference (ipragliflozin-control) of -0.0001 mm (95% CI, -0.0191-0.0189; P = 0.989). A group difference in HbA1c change at 24 months was also non-significant between the treatment groups [-0.1% (95% CI, -0.2-0.1); P = 0.359].

CONCLUSION

Twenty-four months of ipragliflozin treatment did not affect carotid IMT status in patients with type 2 diabetes recruited in the PROTECT study, relative to the non-SGLT2 inhibitor-use standard care for type 2 diabetes.

Paroxysmal Atrioventricular Block in a Relatively Young Patient with COVID-19

Cardiac involvement has been reported in patients with coronavirus disease 2019 (COVID-19). We herein report a 41-year-old man who presented with recurrent paroxysmal atrioventricular block without showing significant cardiac injuries or comorbidities. The patient was diagnosed with COVID-19 and admitted to our hospital, where he was noted to have paroxysmal atrioventricular block. Cardiac biomarkers, echocardiography, and cardiac magnetic resonance imaging findings were fairly normal. An endomyocardial biopsy performed before the implantation of a permanent pacemaker revealed mild myocardial fibrosis without inflammatory infiltrates. The unusual myocardial involvement of the novel coronavirus was suspected.

POS1487-HPR NEXT-GENERATION ONLINE TELEMEDICINE SYSTEM UTILIZING MIXED REALITY FOR RHEUMATOID ARTHRITIS

Background:

Telemedicine can be performed using a conventional videophone or web conferencing system. Then, joint lesions can only be observed and inferred from two-dimensional images, and it is difficult to perform accurate joint assessments, which is essential for the management of rheumatoid arthritis (RA).

Objectives:

To develop the next-generation online telemedicine system utilizing mixed reality for RA.

Methods:

We have developed a system that can assess joints accurately in three-dimensions images in real-time, using Azure Kinect DK (depth sensor)/ HoloLens 2 (headset), which are mixed reality technologies, and Teams (online interview/chat) provided by Microsoft. Furthermore, by applying artificial intelligence (AI), we plan to implement additionally to this system 1) a function to quickly catch and automatically evaluate the patient’s anxiety and changes in facial expressions at the time of examination, 2) a function to record dialogue with the patient in chronological order, 3) a function to support the detection of swollen joints, and 4) function to automatically analyze the questionnaire.

Results:

This system remotely connects a rheumatologist in the Nagasaki University Hospital (Nagasaki City, urban area) and a patient with RA and a non- rheumatologist in the Goto Central Hospital (Goto Island, rural area). A three-dimensional hologram of the patient’s hand projected in front of a rheumatologist. Using this system, we are able to evaluate joints more accurately than using a conventional videophone or web conferencing system.

Conclusion:

It is expected that this system will enable remote medical care specializing in rheumatology, which is standardized at a high level even in areas without rheumatologists such as remote islands and remote areas. This system remotely connects Nagasaki City and Goto Island, but due to the performance of the system, it is not limited to these areas and it is possible to connect rheumatologists to any area that can be connected to the network. It is also effective for the purpose of avoiding the risk of infection during long-distance hospital visits under the epidemic of COVID-19 infection.

References:

[1]Mov Disord. 2020;35:1719-1720.

Disclosure of Interests:

Shin-ya Kawashiri Speakers bureau: Speaker fees from AbbVie, Asahi Kasei, Astellas, Chugai, Eisai, Eli Lilly, Mitsubishi Tanabe, Novartis, and ONO., Grant/research support from: Research grants from Pfizer., Fumiaki Nonaka: None declared, Shinji Chiba: None declared, Tomoyuki Honda: None declared, Tomohiko Nakajima: None declared, Tomoyuki Ishikawa: None declared, Atsushi Kawakami Speakers bureau: Speaker fees from AbbVie, Actelion, Asahi Kasei, Astellas, Boehringer Ingelheim, Celltrion, Chugai, Daiichi Sankyo, Eisai, Eli Lilly, GSK, Janssen, Kowa, MedPeer, Mitsubishi Tanabe, Novartis, ONO, Pfizer, Taisho, and Takeda., Grant/research support from: Grants and research support from AbbVie, Actelion, Asahi Kasei, Astellas, AYUMI, Boehringer Ingelheim, Bristol-Myers Squibb, Celltrion, Chugai, Daiichi Sankyo, Eisai, Eli Lilly, Kyowa Hakko Kirin, MSD, Neopharma, Novartis, ONO, Sanofi, Taisho, Takeda Science Foundation, and Teijin

The description of the excitation energy sharing in nuclear fission within the Langevin approach

We apply the four-dimensional Langevin approach to the description of fission of 235U by neutrons and calculate the dependence of the excitation energy of fission fragments on their mass number. For this we run the Langevin equations until the compound nucleus splits into two separated fragments. This is possible since the we used in this work two-center shell model shape parametrization that describes well both compact and separated shapes. The excitation energies of each fragment are calculated assuming that the temperatures of both fragments are the same. The deformation energy of the fragment immediately after scission is added to its excitation energy. The saw-tooth structure of the dependence neutron multiplicity on the fragment’s mass number in reaction 235U + n at En = 5 Mev is qualitatively reproduced.

0700 Prediction Of Surgical Outcome Using Respiratory Pattern Clafification

Introduction: Introduction

A diagnosis of the surgical indication is important in Sleep surgery. In otolaryngology regions, it is usually considered that a site of occlusion diagnosis by DISE. However, for OSA patients with aging, heart failure and neurologic disease, the effect with the surgical treatment is still low. In these OSA patients, it is a reason that a functional factor is associated as well as an anatomical factor. Similarly, without clear complications including Aging etc, there are a lot of the OSA patients whom a functional factor is associated with. OSA is multi-factorial disease according to Wellman model, OSA is associated with the functional factor including loop gain and the ability of the upper airway to dilate associated with ventilatory drive, arousal threshold only other than the anatomical factor of the upper airway. By normal PSG, the respiratory event is classified as obstructive, mixed and central. However, there are a lot of events that a functional factor is associated with, even if it is a respiratory event to be diagnosed as an obstructive respiratory event. An effect of sleep surgery is expected only for an anatomical factor. Therefore, in the case of sleep surgery, we must diagnose a pure obstructive respiratory event precisely. Purpose of this study: To clarify a respiratory pattern to influence surgical success.

Methods: Methods

26 surgical patients with Pharyngeal surgeries diagnosed as OSA by PSG + Pes measurements were enrolled. We distinguish respiratory event as Pure obstructive event or not, using Pes signal pattern and EEG arousal timing.

Results: Results

Rate of pure obstructive event of all respiratory event varied by an individual patient. Mean rate of pure obstructive event is 57.3%. We find significant difference of AHI improvement rate between two groups which Rate of pure obstructive event shows more than 55% or less than 55%.

Conclusion: Conclusion

Breathing pattern is variety and pure obstructive event is few than ever considered. Respiratory pattern influence surgical success.

Support

Non

0903 Screening Of Pediatric Obstructive Sleep Apnea Using Video Monitoring

Introduction

In Japan, the many of the patients are not able to access the specialized sleep medical facilities for overnight polysomnography(PSG) due to less availability and cost issues. Purpose of the study is to examine whether combination of video monitoring and other clinical examinations can reliably predict the severity of pediatric OSA compared with PSG.

Methods

Between April 1, 2012 and March 31, 2019, total of 175 children (3-12 years of age, boy 122, girl 53) with SDB were enrolled in this individual prospective-cohort study. In-laboratory based PSG were performed for all patients and sleep stages and respiratory events were manually scored. Video monitoring was performed during PSG. Modified video-recording test scoring system (based on Sivan et al 1996), were scored by laboratory technicians. Other clinical examinations were extracted from each PSG with ENT examinations, cephalogram, and rhinomanometry for all patient

Results

Multiple linear regression analyses was performed with a forward stepwise approach in which independent predictors that were significantly related to severity of OSA (AHI: 5/hr and 10/hr). Applying the multiple logistic regression analysis, the independent predictors for AHI 5/hr were ODI 3% &gt;3/hr, rhinomanometry (NR&gt;0.5 Pa/cm3/sec), enlargement of tonsils (Brodsky classification more than 2), two video monitoring items and total score, with an accuracy of predictive statistic model was 88.0% (sensitivity 78.3%, and specificity 93.0%). For the severity above AHI 10/hr, the independent predictors were Cephalogram parameter (Fx&gt;84°), Oximetry (ODI 3% &gt;5/hr) and BMI&lt;15 with the video monitoring parameters of whole night inspiratory noise (loud) and chest retraction contribute to predict with the sensitivity 91.5%, the specificity 82.6% and the accuracy 88.0%.

Conclusion

Video monitor scoring parameters contributed to predict both AHI 5/hr and 10/hr with good overall sensitivity, specificity and overall accuracy compare with the combination of objective results alone. Instead of PSG, the combination of video scoring system and multiple clinical examinations could potentially provide reliable diagnostic approach for pediatric OSA with high accuracy. These results will support to establish more efficient diagnostic strategy for both patients and physicians

Support

N/A

0618 What are the Benefits of Remote Monitoring Polysomnography

Introduction

The use of information and communication technology (ICT) for sleep testing is mainly aimed at improving the accuracy of out-of-center sleep testing (OCST) by remote monitoring. In this study, as the first achievement in Japan, we report the results of our sleep medical clinic and hospital unit. For the diagnosis of sleep disorders, monitoring polysomnography (PSG) attending sleep technologist is the gold standard and is positioned as Type I. On the other hand, diagnosis using OCST has become acceptable because many patients can be diagnosed quickly and cost can be reduced.When using Type II devices that measure electroencephalogram at home, the measurement accuracy is inevitable, including poor recording, because it is performed in a non-monitoring situation. As an attempt to improve this situation, our clinic and hospital unit have established a remote monitoring PSG system that can be upgraded from Type II to Type I level by remote monitoring by a sleep technologist to ensure recording accuracy.

Methods

During the period from April 2004 to December 2017, a total of 286 remote monitoring PSGs were performed by dedicated sleep technologists at the Ota Memorial Sleep Center for patients admitted to a private room at Ota General Hospital.

Results

The breakdown of the reasons for requesting remote monitoring tests is about 30% of patients scheduled to undergo surgerysuch as palatine tonsillectomy or soft palate plastic surgery the next day, and 24% of hospitalized patients with risky complications %, 17% of patients expected to have a high probability of nighttime seizures and abnormal behavior, and 15% were physically disabled or paralyzed.

Conclusion

Our remote monitoring PSG system is effectively used in the clinic for the general hospital for patients who need nighttime safety management and nursing management.

Support

non

Outcome of maintenance systemic chemotherapy with drug-free interval for metastatic urothelial carcinoma

OBJECTIVE

Aiming to achieve long-term disease control, maintenance systemic chemotherapy (MSC) with a 1-3-month drug-free interval is continued in selected patients. We report our experience of MSC for metastatic urothelial carcinoma (UC).

METHODS

Of 228 metastatic UC patients treated with systemic chemotherapy, 40 (17.5%, 40/228) had continuously undergone MSC. Data on the regimen, cycle number, and reason for the discontinuation of MSC were also collected. We analyzed OS from the initiation of MSC until death or the last follow-up, using the log-rank test to assess the significance of differences.

RESULTS

The median number of cycles of chemotherapy was 6, and the responses were CR in 6, PR in 20, SD in 13, and PD in 1 before MSC. Gemcitabine plus CDDP or carboplatin was mainly performed as MSC (70%, 28/40). MSC was repeated quarterly in 30 (75%, 30/40), every two months in 8 (20%, 8/40), and with other intervals in 2 (5%, 2/40). Overall, a median of 3.5 cycles (range: 1-29) of MSC was performed. The reason for the discontinuation of MSC was PD in 24 (60%, 24/40), favorable disease control in 9 (22.5%, 9/40), and myelosuppression in 3 (7.5%, 3/40), and for other reasons in 2 (5%, 2/40). MSC was ongoing in 2 (5%, 2/40). The median OS was 27 months from the initiation of MSC. PS0 (P = 0.0169), the absence of lung metastasis (P = 0.0387), and resection of the primary site (P = 0.0495) were associated with long-term survival after MSC.

CONCLUSIONS

In selected patients, long-term systemic chemotherapy could be performed with a drug-free interval. Our maintenance strategy with cytotoxic drugs may become one of the treatment options for long-term disease control.

The 4-dimensional Langevin approach to low energy nuclear fission

We applied the four-dimensional Langevin approach to the description of fission of 235U by neutrons and calculated the dependence of the excitation energy of fission fragments on their mass number. For this we have fitted the compact just-before-scission configuration obtained by the Langevin calculations by the two separated fragments and calculated the intrinsic excitation and the deformation energy of each fragment accurately taking into account the shell and pairing effects and their dependence on the temperature and mass of the fragments. For the sharing of energy between the fission fragments we have used the simplest and most reliable assumption - the temperature of each fragment immediately after the neck rupture is the same as the temperature of mother nucleus just before scission. The calculated excitation energy of fission fragments clearly demonstrates the saw-tooth structure in the dependence on fragment mass number.

Role of Multichance Fission in the Description of Fission-Fragment Mass Distributions at High Energies

Fission-fragment mass distributions were measured for ^{237-240}U, ^{239-242}Np, and ^{241-244}Pu populated in the excitation-energy range from 10 to 60 MeV by multinucleon transfer channels in the reaction ^{18}O+^{238}U at the Japan Atomic Energy Agency tandem facility. Among them, the data for ^{240}U and ^{240,241,242}Np were observed for the first time. It was found that the mass distributions for all the studied nuclides maintain a double-humped shape up to the highest measured energy in contrast to expectations of predominantly symmetric fission due to the washing out of nuclear shell effects. From a comparison with the dynamical calculation based on the fluctuation-dissipation model, this behavior of the mass distributions was unambiguously attributed to the effect of multichance fission.

Identification of cell-type-specific mutations in nodal T-cell lymphomas

Recent genetic analysis has identified frequent mutations in ten-eleven translocation 2 (TET2), DNA methyltransferase 3A (DNMT3A), isocitrate dehydrogenase 2 (IDH2) and ras homolog family member A (RHOA) in nodal T-cell lymphomas, including angioimmunoblastic T-cell lymphoma and peripheral T-cell lymphoma, not otherwise specified. We examined the distribution of mutations in these subtypes of mature T-/natural killer cell neoplasms to determine their clonal architecture. Targeted sequencing was performed for 71 genes in tumor-derived DNA of 87 cases. The mutations were then analyzed in a programmed death-1 (PD1)-positive population enriched with tumor cells and CD20-positive B cells purified by laser microdissection from 19 cases. TET2 and DNMT3A mutations were identified in both the PD1+ cells and the CD20+ cells in 15/16 and 4/7 cases, respectively. All the RHOA and IDH2 mutations were confined to the PD1+ cells, indicating that some, including RHOA and IDH2 mutations, being specific events in tumor cells. Notably, we found that all NOTCH1 mutations were detected only in the CD20+ cells. In conclusion, we identified both B- as well as T-cell-specific mutations, and mutations common to both T and B cells. These findings indicate the expansion of a clone after multistep and multilineal acquisition of gene mutations.

High transmission Ni compound refractive lens for high energy X-rays

We present a new planar Ni compound refractive lens for high energy X-rays (116 keV). The lens is composed of identical plano-concave elements with longitudinal parabolic grooves manufactured by a punch technique. In order to increase the lens transmission, the thickness of the single lens at the parabolic groove vertex was reduced to less than 5 μm and the radius of curvature was reduced to about 20 μm. The small radius of curvature allowed us to reduce the number of single elements needed to get the focal length of 3 m to 54 single lenses. The gain parameter has been significantly improved compared to the previous lenses due to higher transmission, but the focused beam size and its gain are not as good as expected, mostly due to the aberrations caused by the lens shape imperfections.

Therapeutic implication of genetic variants of IL13 and STAT4 in airway remodelling with bronchial asthma

BACKGROUND

Several gene variants identified in bronchial asthmatic patients are associated with a decrease in pulmonary function. The effects of this intervention on pulmonary function have not been fully researched.

OBJECTIVE

We determined the effects of high-dose inhaled corticosteroids (ICSs) on decreased pulmonary function in asthmatic Japanese patients with variants of IL13 and STAT4 during long-term treatments with low to mild doses of ICS.

METHODS

In this study, 411 patients with bronchial asthma who were receiving ICSs and living in Japan were recruited, were genotyped, and underwent pulmonary function tests and fibreoptic examinations. The effects of 2 years of high-dose ICSs administered to asthmatic patients who were homozygous for IL13 AA of rs20541 or STAT4 TT of rs925847 and who progressed to airway remodelling were investigated.

RESULTS

High-dose ICS treatment increased the pulmonary function of patients homozygous for IL13 AA of rs20541 but not of patients homozygous for STAT4 TT of rs925847. The increased concentrations of the mediators IL23, IL11, GMCSF, hyaluronic acid, IL24, and CCL8 in bronchial lavage fluid (BLF) were diminished after high-dose ICS treatment in patients homozygous for IL13 AA of rs20541.

CONCLUSION AND CLINICAL RELEVANCE

IL13 AA of rs20541 and STAT4 TT of rs925847 are potential genomic biomarkers for predicting lower pulmonary function. The administration of high-dose ICSs to asthmatic patients with genetic variants of IL13 AA may inhibit the advancement of airway remodelling. The genetic variants of STAT4 TT did not respond to high-dose ICSs. Therefore, using medications other than ICSs must be considered even during the initial treatment of bronchial asthma. These genetic variants may aid in the realization of personalized and phenotype-specific therapies for bronchial asthma.

Intestinal amoebiasis in a patient with acute graft-versus-host disease after allogeneic bone marrow transplantation successfully treated by metronidazole

Amoebiasis has rarely been reported in patients undergoing hematopoietic stem cell transplantation, although it is a world-wide infection and extremely common. We present a case of intestinal amoebiasis unexpectedly revealed by colonoscopy after allogeneic bone marrow transplantation from a human leukocyte antigen-mismatched unrelated donor for acute myeloid leukemia arising from chronic myelomonocytic leukemia and successfully treated by metronidazole.

First-line treatment and outcome of elderly patients with primary central nervous system lymphoma (PCNSL)--a systematic review and individual patient data meta-analysis

BACKGROUND

To investigate prognosis and effects of first-line therapy in elderly primary central nervous system lymphoma (PCNSL) patients.

PATIENTS AND METHODS

A systematic review of studies about first-line therapy in immunocompetent patients ≥60 years with PCNSL until 2014 and a meta-analysis of individual patient data from eligible studies and international collaborators were carried out.

RESULTS

We identified 20 eligible studies; from 13 studies, we obtained individual data of 405 patients, which were pooled with data of 378 additional patients (N = 783). Median age and Karnofsky Performance Score (KPS) was 68 years (range: 60-90 years) and 60% (range: 10%-100%), respectively. Treatments varied greatly, 573 (73%) patients received high-dose methotrexate (HD-MTX)-based therapy. A total of 276 patients received whole-brain radiotherapy (median 36 Gy, range 28.5-70 Gy). KPS ≥ 70% was the strongest prognostic factor for mortality [hazard ratio (HR) 0.50, 95% confidence interval (CI) 0.41-0.62]. After a median follow-up of 40 months, HD-MTX-based therapy was associated with improved survival (HR 0.70, 95% CI 0.53-0.93). There was no difference between HD-MTX plus oral chemotherapy and more aggressive HD-MTX-based therapies (HR 1.39, 95% CI 0.90-2.15). Radiotherapy was associated with an improved survival, but correlated with an increased risk for neurological side-effects (odds ratio 5.23, 95% CI 2.33-11.74).

CONCLUSIONS

Elderly PCNSL patients benefit from HD-MTX-based therapy, especially if combined with oral alkylating agents. More aggressive HD-MTX protocols do not seem to improve outcome. WBRT may improve outcome, but is associated with increased risk for neurological side-effects. Prospective trials for elderly PCNSL patients are warranted.

Synchronous marine pelagic regime shifts in the Northern Hemisphere

Regime shifts are characterized by sudden, substantial and temporally persistent changes in the state of an ecosystem. They involve major biological modifications and often have important implications for exploited living resources. In this study, we examine whether regime shifts observed in 11 marine systems from two oceans and three regional seas in the Northern Hemisphere (NH) are synchronous, applying the same methodology to all. We primarily infer marine pelagic regime shifts from abrupt shifts in zooplankton assemblages, with the exception of the East Pacific where ecosystem changes are inferred from fish. Our analyses provide evidence for quasi-synchronicity of marine pelagic regime shifts both within and between ocean basins, although these shifts lie embedded within considerable regional variability at both year-to-year and lower-frequency time scales. In particular, a regime shift was detected in the late 1980s in many studied marine regions, although the exact year of the observed shift varied somewhat from one basin to another. Another regime shift was also identified in the mid- to late 1970s but concerned less marine regions. We subsequently analyse the main biological signals in relation to changes in NH temperature and pressure anomalies. The results suggest that the main factor synchronizing regime shifts on large scales is NH temperature; however, changes in atmospheric circulation also appear important. We propose that this quasi-synchronous shift could represent the variably lagged biological response in each ecosystem to a large-scale, NH change of the climatic system, involving both an increase in NH temperature and a strongly positive phase of the Arctic Oscillation. Further investigation is needed to determine the relative roles of changes in temperature and atmospheric pressure patterns and their resultant teleconnections in synchronizing regime shifts at large scales.

Hes1 suppresses acute myeloid leukemia development through FLT3 repression

In leukemogenesis, Notch signaling can be up and downregulated in a context-dependent manner. The transcription factor hairy and enhancer of split-1 (Hes1) is well-characterized as a downstream target of Notch signaling. Hes1 encodes a basic helix-loop-helix-type protein, and represses target gene expression. Here, we report that deletion of the Hes1 gene in mice promotes acute myeloid leukemia (AML) development induced by the MLL-AF9 fusion protein. We then found that Hes1 directly bound to the promoter region of the FMS-like tyrosine kinase 3 (FLT3) gene and downregulated the promoter activity. FLT3 was consequently upregulated in MLL-AF9-expressing immortalized and leukemia cells with a Hes1- or RBPJ-null background. MLL-AF9-expressing Hes1-null AML cells showed enhanced proliferation and ERK phosphorylation following FLT3 ligand stimulation. FLT3 inhibition efficiently abrogated proliferation of MLL-AF9-induced Hes1-null AML cells. Furthermore, an agonistic anti-Notch2 antibody induced apoptosis of MLL-AF9-induced AML cells in a Hes1-wild type but not a Hes1-null background. We also accessed two independent databases containing messenger RNA (mRNA) expression profiles and found that the expression level of FLT3 mRNA was negatively correlated with those of HES1 in patient AML samples. These observations demonstrate that Hes1 mediates tumor suppressive roles of Notch signaling in AML development, probably by downregulating FLT3 expression.

Forensic identification using multiple lot numbers of an implanted device

We report a case in which identification of a deceased individual was established using multiple lot numbers printed on a body implantable device. Autopsy of an unknown woman revealed an intramedullary nail inserted within her right femur. The device manufacturer was identified from the configuration of the intramedullary nail, and the "use history" was traced from lot numbers printed on the device's multiple parts. The deceased individual was thus identified as a woman who had attempted suicide by jumping from a height about a year previously and had been transported to a hospital and undergone surgery that included implantation of the intramedullary nail. The main factor contributing to the rapid identification was the manufacturer's and distributor's record of the use history (traceability) of the product, because of their accountability for purposes of quality control. A second contributing factor was multiple lot numbers, resulting in extremely low probability of the same combination of lot numbers being present in multiple individuals. This case confirmed the utility of multiple lot numbers of body implantable devices in forensic identification.

Proteasome inhibitors exert cytotoxicity and increase chemosensitivity via transcriptional repression of Notch1 in T-cell acute lymphoblastic leukemia

The Notch signaling pathway has been recognized as a key factor for the pathogenesis of T-cell acute lymphoblastic leukemia (T-ALL), because of the high incidence of activating mutations of Notch1. Notch inhibition could serve as a new treatment strategy for T-ALL; however, the attempts to perturb Notch signaling pathways have been unsuccessful so far. In this study, we found that proteasome inhibitors exert cytotoxic effects on T-ALL cells with constitutive activation of Notch1 to a similar extent as myeloma cells. The proteasome inhibitor bortezomib repressed the transcription of Notch1 and downstream effectors including Hes1, GATA3, RUNX3 and nuclear factor-κB (NF-κB) (p65 and p50), coincided with downregulation of the major transactivator Sp1 and its dissociation from Notch1 promoter. Overexpression of the Notch1 intracellular domain (NICD) significantly ameliorated bortezomib-induced cytotoxicity against T-ALL cells. Drug combination studies revealed that bortezomib showed synergistic or additive effects with key drugs for the treatment of T-ALL such as dexamethasone (DEX), doxorubicin and cyclophosphamide, which were readily abolished by NICD overexpression. The synergy of bortezomib and DEX was confirmed in vivo using a murine xenograft model. Our findings provide a molecular basis and rationale for the inclusion of proteasome inhibitors in treatment strategies for T-ALL.