Including a diverse set of voices to address biological invasions

Inclusivity is fundamental to progress in understanding and addressing the global phenomena of biological invasions because inclusivity fosters a breadth of perspectives, knowledge, and solutions. Here, we report on how the Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services (IPBES) assessment on invasive alien species (IAS) prioritized inclusivity, the benefits of this approach, and the remaining challenges.

Demonstration of nuclear gamma-ray polarimetry based on a multi-layer CdTe Compton camera

To detect and track structural changes in atomic nuclei, the systematic study of nuclear levels with firm spin-parity assignments is important. While linear polarization measurements have been applied to determine the electromagnetic character of gamma-ray transitions, the applicable range is strongly limited due to the low efficiency of the detection system. The multi-layer Cadmium-Telluride (CdTe) Compton camera can be a state-of-the-art gamma-ray polarimeter for nuclear spectroscopy with the high position sensitivity and the detection efficiency. We demonstrated the capability to operate this detector as a reliable gamma-ray polarimeter by using polarized 847-keV gamma rays produced by the [Formula: see text]([Formula: see text]) reaction. By combining the experimental data and simulated calculations, the modulation curve for the gamma ray was successfully obtained. A remarkably high polarization sensitivity was achieved, compatible with a reasonable detection efficiency. Based on the obtained results, a possible future gamma-ray polarimetery is discussed.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Invasion of the bucco-mandibular space by oral squamous cell carcinoma: histopathological analysis of invasion pattern

Background

This study aimed to determine the patterns of invasion of oral squamous cell carcinoma (OSCC) into the bucco-mandibular space (BMS) using detailed histopathological analysis and to assess clinical outcomes.

Methods

Patients with OSCC who underwent segmental mandibulectomy or hemi-mandibulectomy combined with resection of the BMS between 2012 and 2021 were included. The invasions of the BMS were classified into three patterns. Pattern A was defined as a horizontal invasion, Pattern B as a vertical invasion, and Pattern C as an expansive invasion.

Results

In total, 109 patients were reviewed. Of these 109 patients, the primary tumor affected the lower gingiva in 78 patients, the buccal mucosa in 18 patients, and was a primary intraosseous carcinoma of the mandible in 13 patients. Invasion of the BMS was significantly associated with a higher pathological T stage, positive/close margins, and lower disease-free survival (DFS) rates. The DFS rates were 86.7% and 66.0% in the BMS non-invasion and invasion groups, respectively. The DFS rates for each type of invasion were 82.1% for Pattern A, 67.4% for Pattern B, and 48.0% for Pattern C (P=0.277).

Conclusion

Patients with BMS invasion have a poorer prognosis than those without invasion of the BMS. Therefore, adjuvant therapy is necessary, especially in Patterns B and C. Evaluation of preoperative BMS invasion patterns is important for predicting the prognosis of OSCC.

Role of Stromal Fibroblast-Induced WNT7A Associated with Cancer Cell Migration Through the AKT/CLDN1 Signaling Axis in Oral Squamous Cell Carcinoma

Wnt signaling plays a crucial role in the progression of various cancers, including oral squamous cell carcinoma (OSCC). However, the tumor microenvironment (TME) regulating Wnt signaling has not yet been fully elucidated. In this study, we investigated whether cancer-associated fibroblasts (CAFs), the primary components of the TME, activate Wnt signaling and promote tumor progression in OSCC. We conducted a Transwell coculture assay using human OSCC cell lines and normal human dermal fibroblasts (NHDFs). NHDFs stimulated WNT7A expression in several OSCC cell lines, especially HO-1-N-1 and HSC-5. An immunohistochemical study using 122 human OSCC samples indicated that high WNT7A expression in tumor cells was significantly associated with invasion depth and poor prognosis. Moreover, WNT7A expression in OSCC cells was positively correlated with α-smooth muscle actin expression in CAFs. WNT7A knockdown in OSCC cells demonstrated that OSCC cells cocultured with NHDFs significantly promoted tumor cell migration and invasion, which was dependent on WNT7A expression in OSCC cells. We also isolated HSC-5 cells from the coculture and conducted microarray analysis to investigate the factors that promote tumor progression induced by WNT7A. Among the various differentially expressed genes, we identified a downregulated gene encoding CLDN1 and confirmed that WNT7A negatively regulated CLDN1 expression in OSCC cells and CLDN1 knockdown in OSCC cells promoted their migration. Phosphokinase array analysis showed that WNT7A activates protein kinase B (AKT) phosphorylation. Activating AKT signaling using the SC79 agonist induced CLDN1 downregulation in OSCC cells. In the coculture assay, the AKT inhibitor MK2206 significantly recovered CLDN1 expression downregulated by WNT7A, resulting in OSCC cell migration suppression. These results suggest that CAFs stimulate OSCC cells to produce WNT7A, following CLDN1 expression downregulation by activating AKT signaling, promoting cancer cell migration. These findings highlight the importance of molecular therapies targeting the TME in OSCC.

Personal immune profiles: Diversity and prognostic value for oral tongue squamous cell carcinoma evaluated by comprehensive immune parameter analyses with multiplex immunofluorescence

OBJECTIVES

Understanding the tumor immune microenvironment is becoming increasingly necessary for risk prediction and treatment selection. In particular, oral cancer has various immunosuppressive characteristics in the tumor microenvironment. Therefore, we comprehensively assessed the immune profiles of oral tongue squamous cell carcinoma (OTSCC).

MATERIALS AND METHODS

Multiplex immunofluorescence and tissue imaging analyses were performed to evaluate immune profiles at the invasive tumor front of 60 OTSCC surgical specimens. We analyzed 58 immune parameters including the density and proportion (%) of total leukocytes (Leu) and T cells, six subsets of T and myeloid cells, and the expression of programmed cell death-1 (PD-1) and PD-1 ligand 1 (PD-L1).

RESULTS

The density, proportion, and location of CD45⁺ Leu, three T cell subsets (CD8⁺, Foxp3^-CD4⁺ conventional, and Foxp3⁺CD4⁺ regulatory T cells), CD163^-CD68⁺ M1 and CD163⁺CD68⁺ M2 macrophages, and neutrophils were highly variable at the individual level. The density and proportion of M2 macrophages were significantly lower in the T1 stage group. Risk prediction analyses for recurrence and/or metastasis (R/M) showed that R/M (+) T1 cases had significantly higher M2 density and percentages.

CONCLUSIONS

The immune profiles of OTSCC patients are diverse and cannot be predicted from clinicopathological information alone. The M2 macrophage abundance is a potential candidate biomarker for R/M in the early stage of OTSCC. Personal immune profiling may provide beneficial information for risk prediction and treatment selection.

Comparison of Osteoconductive Ability of Two Types of Cholesterol-Bearing Pullulan (CHP) Nanogel-Hydrogels Impregnated with BMP-2 and RANKL-Binding Peptide: Bone Histomorphometric Study in a Murine Calvarial Defect Model

The receptor activator of NF-κB ligand (RANKL)-binding peptide is known to accelerate bone morphogenetic protein (BMP)-2-induced bone formation. Cholesterol-bearing pullulan (CHP)-OA nanogel-crosslinked PEG gel (CHP-OA nanogel-hydrogel) was shown to release the RANKL-binding peptide sustainably; however, an appropriate scaffold for peptide-accelerated bone formation is not determined yet. This study compares the osteoconductivity of CHP-OA hydrogel and another CHP nanogel, CHP-A nanogel-crosslinked PEG gel (CHP-A nanogel-hydrogel), in the bone formation induced by BMP-2 and the peptide. A calvarial defect model was performed in 5-week-old male mice, and scaffolds were placed in the defect. In vivo μCT was performed every week. Radiological and histological analyses after 4 weeks of scaffold placement revealed that the calcified bone area and the bone formation activity at the defect site in the CHP-OA hydrogel were significantly lower than those in the CHP-A hydrogel when the scaffolds were impregnated with both BMP-2 and the RANKL-binding peptide. The amount of induced bone was similar in both CHP-A and CHP-OA hydrogels when impregnated with BMP-2 alone. In conclusion, CHP-A hydrogel could be an appropriate scaffold compared to the CHP-OA hydrogel when the local bone formation was induced by the combination of RANKL-binding peptide and BMP-2, but not by BMP-2 alone.

Buccinator muscle invasion is a risk factor for cervical lymph node metastasis in squamous cell carcinoma of the buccal mucosa: A retrospective study

The present study aimed to determine the risk factors associated with cervical lymph node metastasis (CLNM) in patients with buccal mucosa squamous cell carcinoma (BMSCC). This retrospective study included patients with primary BMSCC who underwent surgery at the Department of Oral and Maxillofacial Surgical Oncology of Tokyo Medical and Dental University (Tokyo, Japan) between January 2008 and December 2017. The following data were collected and analyzed: Sex, age, primary lesion subsite, tumor/node/metastasis stage, clinical growth patterns, tumor differentiation, lymphovascular and perineural invasion, mode of invasion, pathological depth of invasion, extent of tumor invasion, and clinical outcome of patients with BMSCC. Multivariate analysis was performed to identify the possible risk factors for CLNM. A total of 75 patients were included in the present study, among whom 30 (40%) were found to have histological CLNM. Of the 33 patients with buccinator muscle infiltration by the tumor, 24 (72.7%) had CLNM. Multiple logistic regression analysis revealed that buccinator muscle invasion was the most significant predictive risk factor for CLNM in BMSCC. The present study found that tumor invasion of the buccinator muscle was the most significant predictive risk factor for CLNM in BMSCC. Therefore, elective neck dissection should be performed if buccinator muscle invasion is identified in patients with BMSCC.

Deep texture representation analysis for histopathological images

Deep texture representations (DTRs) produced from a bilinear convolutional neural network allow objective quantification of tumor histopathology images effectively. They can be used for various analyses, including visualization of morphological correlation between histology images, content-based image retrieval (CBIR), and supervised learning. This protocol describes the simplified workflow to analyze DTRs from data preparation, visualization of the histological profile, and CBIR analysis, to supervised learning model development to predict the profile from histological images. For complete details on the use and execution of this protocol, please refer to Komura et al. (2022).¹.

A rare case of solitary intraoral superficial angiomyxoma arising in the soft palate

Superficial angiomyxomas are myxoid mesenchymal tumors, and intraoral superficial angiomyxoma is extremely rare. This paper reports a novel case of a 41-year-old Japanese male patient with a 32 × 22 mm superficial angiomyxoma in the right soft palate. Tumor resection was performed and a polyglycolic acid sheet was attached. Over a 28-month follow-up, there was no evidence of disease recurrence. This paper also reviewed 11 cases of intraoral superficial angiomyxomas reported in previous literature. The condition was more common among middle-aged men. Surgical resection was the most common treatment, and local recurrence was observed in only one case.

A case of sclerosing odontogenic carcinoma of the mandible with a review of the literature

Sclerosing odontogenic carcinoma (SOC) is a very rare malignant odontogenic tumor characterized by sclerotic stroma and single-file cord-like tumor cell structures. A 38-year-old man presented with extraoral swelling and right mental region paralysis. Panoramic radiography revealed an ill-defined radiolucent lesion extending from the right mandibular ramus to the right lower canine. Magnetic resonance imaging showed tumor invasion into the right inferior alveolar nerve and masseter muscle. Hemimandibulectomy, bilateral neck dissection, and mandibular reconstruction were performed using a rectus abdominis musculocutaneous flap and a titanium plate. Histopathology and immunohistochemistry confirmed SOC diagnosis. No recurrence occurred in the 1-year follow-up. In this paper, a case of SOC with a high Ki-67 labeling index was reported. Since SOC is prone to nerve invasion, treatment is resection with an appropriate surgical margin.

Neurodevelopmental outcome after antenatal therapy for fetal supraventricular tachyarrhythmia: 3-year follow-up of multicenter trial

OBJECTIVES

Although many studies have supported the efficacy of transplacental treatment for fetal supraventricular tachyarrhythmia, the long-term neurodevelopmental outcome after antenatal antiarrhythmic treatment is not well understood. The aim of this study was to investigate the prognosis and neurodevelopmental outcome at 36 months of corrected age and the incidence of tachyarrhythmia after birth, following protocol-defined antenatal therapy for fetal supraventricular tachyarrhythmia.

METHODS

This was a 3-year follow-up study of a multicenter trial that evaluated the efficacy and safety of protocol-defined transplacental treatment for fetal supraventricular tachycardia (SVT) and atrial flutter (AFL). The primary endpoints were mortality and neurodevelopmental impairment (NDI) at 36 months of corrected age. NDI was defined as any of the following outcomes: cerebral palsy, bilateral blindness, bilateral deafness or neurodevelopmental delay. Neurodevelopmental delay was evaluated using appropriate developmental quotient scales, mainly the Kyoto Scale of Psychological Development, or examination by pediatric neurologists. The detection rate of tachyarrhythmia at birth and at 18 and 36 months of corrected age was also evaluated as the secondary endpoint. In addition, the association of NDI at 36 months with perinatal and postnatal factors was analyzed.

RESULTS

Of 50 patients enrolled in the original trial, one withdrew consent and in two there was fetal death, leaving 47 patients available for enrollment in this follow-up study. Of these, 45 cases were available for analysis after two infants were lost to follow-up. The mortality rate was 2.2% (1/45) during a median follow-up of 3.2 (range, 2.1-9.4) years. The infant died at the age of 2.1 years. Another infant had missing neurodevelopmental assessment data. In the remaining 43 infants, at 36 months of corrected age, NDI was detected in 9.3% (4/43) overall and in two of three (66.7%) cases with fetal hydrops with subcutaneous edema. Cerebral palsy was noted in two infants with severe subcutaneous edema or ascites at an early gestational age. Neurodevelopmental delay was found in two infants with severe congenital abnormalities (one with tuberous sclerosis and the other with heterotaxy syndrome). Tachyarrhythmia was present in 31.9% (15/47) cases in the neonatal period and decreased to 8.9% (4/45) and 4.5% (2/44) at 18 and 36 months of corrected age, respectively. The median ventricular rate at diagnosis was significantly higher in infants with NDI compared to those without (265 vs 229 bpm; P = 0.003). In infants with NDI, compared to those without, fetal hydrops with subcutaneous edema at diagnosis was more common (50.0% vs 2.6%; P = 0.019) and the duration of fetal effusion was longer (median, 10.5 vs 0 days; P = 0.013). Postnatal arrhythmia and physical development abnormalities were not associated with NDI.

CONCLUSIONS

This multicenter 3-year follow-up study is the first to demonstrate the long-term mortality and morbidity of infants born following protocol-defined transplacental treatment for fetal SVT and AFL. NDI was associated with the presence of fetal hydrops with subcutaneous edema at diagnosis and longer duration of fetal effusion. Neurodevelopmental delay was detected only in infants with severe congenital abnormalities. Therefore, in infants that have undergone antenatal treatment for fetal tachyarrhythmia and in which there are no comorbidities, the risk of NDI is low. However, in those with fetal hydrops with subcutaneous edema and/or associated severe congenital abnormalities, the risk for long-term neurologic morbidity might be considered somewhat increased. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

IL-1 Generated by Oral Squamous Cell Carcinoma Stimulates Tumor-Induced and RANKL-Induced Osteoclastogenesis: A Possible Mechanism of Bone Resorption Induced by the Infiltration of Oral Squamous Cell Carcinoma

We previously observed a novel osteoclastogenesis system that is induced by oral squamous cell carcinoma (OSCC) cells, which target osteoclast precursor cells (OPC) without upregulation of the master transcriptional factor of osteoclastogenesis, NFATc1. Here, we analyzed inflammatory cytokines that were preferentially expressed in one of the osteoclastogenic OSCC cell lines, namely NEM, compared with the subclone that had lost its osteoclastogenic properties. Based on a gene expression microarray and a protein array analyses, IL-1, IL-6, IL-8, and CXCL1 were chosen as candidates responsible for tumor-induced osteoclastogenesis. From the results of the in vitro osteoclastogenesis assay using OPCs cultured with OSCC cells or their culture supernatants, IL-1 was selected as a stimulator of both OSCC-induced and RANKL-induced osteoclastogenesis. The IL-1 receptor antagonist significantly attenuated osteoclastogenesis induced by NEM cells. The stimulatory effects of IL-1 for OSCC-induced and RANKL-induced osteoclastogenesis were effectively attenuated with cannabidiol and denosumab, respectively. These results suggest that IL-1 secreted from OSCC cells stimulates not only tumor-induced osteoclastogenesis targeting OPCs but also physiological RANKL-induced osteoclastogenesis, and this may be the biological mechanism of bone resorption induced by the infiltration of OSCC. These results also suggest that IL-1 inhibitors are candidates for therapeutic agents against bone resorption induced by OSCC.

Massive low-grade myxoid liposarcoma of the floor of the mouth: A case report and review of literature

BACKGROUND

Oral liposarcoma is an extremely rare lesion that is often clinically misdiagnosed as a benign tumor due to its asymptomatic and indolent clinical course. Here, we report a case of massive low-grade myxoid liposarcoma (MLS) of the floor of the mouth.

CASE SUMMARY

A 71-year-old man presented with a huge mass in the left floor of the mouth. A biopsy was performed, and a diagnosis of a myxoid tumor suspicious for low-grade MLS or myxoma was made. Gadolinium-enhanced T1-weighted magnetic resonance imaging showed an intensely enhanced tumor lesion that occupies the left sublingual space and extends to the submandibular space. Submandibular dissection, tumor resection, and reconstruction with a radial forearm flap were performed. The surgical specimen exhibited histologically low-grade MLS. Fused in sarcoma (FUS, also known as TLS) and DNA damage-inducible transcript 3 (DDIT3, also known as CHOP) break-apart was not detected in the fluorescence in situ hybridization analysis. The tumor was completely encapsulated and did not require additional treatment. Furthermore, no recurrence was reported 40 mo after surgery.

CONCLUSION

We experienced an extremely rare, massive, low-grade MLS emerging from the floor of the mouth. Oftentimes, an MLS of the floor of the mouth lacks significant clinical findings and is often misdiagnosed. Although no FUS-DDIT3 fusion gene was detected, a low-grade MLS was ultimately diagnosed based on the histological findings.

Pioglitazone-incorporated microspheres alleviates cardiac dysfunction through macrophage polarization in a rat myocardial infarction model

 

Inflammatory processes are essential for the repair processes after myocardial infarction. Among inflammatory cells involved in this process, macrophages play a critical role through polarization in pro-inflammatory M1 or reparative M2 subtype. Pioglitazone, known as a treatment drug for diabetes mellitus, is reported to regulate macrophage polarization toward reparative M2 subtype. Poly L-lactic-co-glycolic acid (PLGA) has been widely accepted as the delivery carrier in drug delivery system (DDS).

Here, we aimed to validate the therapeutic effects and investigate the mechanisms of DDS-based treatment using pioglitazone to left ventricular remodeling after myocardial infarction.

Pioglitazone-incorporated PLGA microspheres (PGZ-MS) were prepared and the drug release profile was evaluated. The concentration of interleukin-10 secreted from murine bone marrow derived macrophages incubated with PGZ-MS was quantified in the culture supernatant. To validate the therapeutic potential of PGZ-MS in vivo, Sprague-Dawley rats were subjected to permanent left coronary artery ligation to induce myocardial infarction. Mock-MS (100 μg) or PGZ-MS (100 μg) was injected to the infarct region just after induction (n=9–11/group). Cardiac function and left ventricular size were assessed by echocardiography. At 28-day after surgery, rats were sacrificed, and excised hearts were evaluated histologically.

PGZ-MS released 1.8±0.3% of incorporated PGZ within 24 hours and 29.5±1.2% within 14 days indicating sustained release of PGZ in vitro. PGZ-MS augmented Interleukin-10 release from bone marrow derived macrophages, indicating polarization toward reparative M2 subtype. PGZ-MS significantly ameliorated cardiac function after myocardial infarction (fractional shortening: MI vs MI+Mock-MS vs MI+PGZ-MS, 24.4±1.1 vs 24.3±1.6 vs 32.2±1.4%; P=0.0035) with reverse remodeling (wall thickness: MI vs MI+Mock-MS vs MI+PGZ-MS, 0.69±0.12 vs 0.71±0.13 vs 1.06±0.09; P=0.03). Immunohistochemical analyses revealed that PGZ-MS enhanced macrophage polarization toward reparative M2 subtype (ratio of reparative M2 macrophages: 0.39±0.03 vs 0.42±0.02 vs 0.54±0.02; P=0.0004) and attenuated apoptosis of cardiomyocytes in the ischemic border zone (MI vs MI+Mock-MS vs MI+PGZ-MS, 2.6±0.2 vs 1.9±0.2 vs 1.2±0.2 cells/field; P=0.002).

In the present study, we confirmed that PGZ-MS could realize sustained release of pioglitazone which resulted in sustained effect of macrophage polarization and attenuated left ventricular remodeling accompanied with the amelioration of cardiac dysfunction and cardiomyocytes apoptosis. The strategy of DDS-based macrophage polarization might serve as a promising strategy in cardiac regenerative therapy for ischemic heart disease in the future.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grants-in-Aid for Scientific Research from the Ministry of Education, Science, Sports and Culture of Japan

A medico-legal definition of femicide

Femicide refers to the extreme form of violence against someone belonging to the female gender, i.e. the killing of a woman. Research shows that, to date, gender-based violence remains largely a hidden phenomenon with prevalence often being underestimated by official statistics and data missing in numerous countries. It can be argued that the under-reporting may be suggestive of a legislative gap that needs addressing. This work aims to reach a shared medico-legal definition of femicide stemming from a comprehensive review of the current legislation of countries around the world. In addition, it appraises forensic pathology studies focusing on the murder of women as well as the most relevant documents published by prominent international organizations fighting violence against women. Review of the literature shows a scarcity of national legislations concerning specifically femicide, despite the attention given to this phenomenon by international organizations fighting violence against women. Additionally, a non-homogeneous framing of the term femicide arises from the forensic pathology literature and national laws. Starting from one of the funding principle of medical ethics - autonomy - authors propose to define femicide as a murder perpetrated because of a failure to recognize the victim's right to self-determination. This definition would give the forensic pathologist a central role in identifying femicide cases among the murders of women. A shared forensic approach is needed, ideally employing standardized methodology to compare international data and to standardize scientific research in the field.

Chemical Diagnosis of Calcium Pyrophosphate Deposition Disease of the Temporomandibular Joint: A Case Report

Calcium pyrophosphate dihydrate (CPPD) deposition disease is a benign disorder characterized by acute gouty arthritis-like attacks and first reported by McCarty. CPPD deposition disease rarely occurs in the temporomandibular joint (TMJ), and although confirmation of positive birefringence by polarized light microscopy is important for diagnosis, it is not reliable because other crystals also show birefringence. We reported a case of CPPD deposition disease of the TMJ that was diagnosed by chemical analysis. A 47-year-old man with a chief complaint of persistent pain in the right TMJ and trismus was referred to our department in 2020. Radiographic examination revealed destruction of the head of the mandibular condyle and cranial base with a neoplastic lesion involving calcification tissue. We suspected CPPD deposition disease and performed enucleation of the white, chalky masses. Histopathologically, we confirmed crystal deposition with weak birefringence. SEM/EDS revealed that the light emitting parts of Ca and P corresponded with the bright part of the SEM image. Through X-ray diffraction, almost all peaks were confirmed to be CPPD-derived. Inductively coupled plasma atomic emission spectroscopy revealed a Ca/P ratio of nearly 1. These chemical analyses further support the histological diagnosis of CPPD deposition disease.

Left supraclavicular (Virchow’s) node metastasis detected before primary infradiaphragmatic tumor: a case series

Background

Metastasis of infradiaphragmatic tumors to the left supraclavicular lymph node is reported to be rare. When metastasis is detected in the left supraclavicular node in patients with head and neck carcinoma, locating the primary cancer remains a difficult and time-consuming challenge despite the dramatic development of screening technologies and treatment methods.

Case presentation

We report three cases of malignant infradiaphragmatic tumor diagnosed following an initial finding of left supraclavicular node metastasis after surgery for tongue squamous cell carcinoma (follow-up period, range 18–62 months). In these cases, adenocarcinoma was diagnosed based on left supraclavicular node biopsies, and a second primary tumor was found, in a 78-year-old Japanese woman with a diagnosis of cholangiocarcinoma, a 64-year-old Japanese man with a diagnosis of bladder carcinoma, and a 61-year-old Japanese man with a diagnosis of prostate carcinoma. In the cholangiocarcinoma case, carbohydrate antigen 19-9 and alpha-fetoprotein levels helped to diagnose cholangiocarcinoma. Palliative care only was given, with survival for 11 months after diagnosis of lymph node metastasis. In the bladder carcinoma case, pathological analysis of fine-needle aspiration biopsy specimen of the metastatic cervical lymph node showed atypical cells with slight squamous differentiation. Hematoxylin–eosin staining of the bladder lesion did not identify a clear glandular or squamous component, and we could not make a definitive diagnosis of whether the lesion was poorly differentiated squamous cell carcinoma, adenocarcinoma, or high-grade urothelial carcinoma. GATA3 staining aided in the diagnosis of urothelial bladder cancer with left supraclavicular node metastasis. He survived for 2 months after diagnosis of left supraclavicular lymph node metastasis. In the prostate carcinoma case, ¹⁸F‐fluorodeoxyglucose uptake was weak. Prostate-specific antigen levels and magnetic resonance imaging findings aided the diagnostic process. This patient underwent bilateral orchiectomy and adjuvant hormonal therapy and survived for 47 months after diagnosis of left supraclavicular node metastasis.

Conclusions

Pathological diagnosis on the basis of immunohistochemistry and specific diagnosis methods such as radiological and serological assessments are important for providing rapid diagnosis and appropriate treatment.

Epithelial-Myoepithelial Carcinoma of the Minor Salivary Glands: Case Series with Comprehensive Review

Epithelial-myoepithelial carcinoma (EMC) is a rare salivary gland tumor that is histologically characterized by biphasic tubular structures composed of inner ductal and outer clear myoepithelial cells, which is especially uncommon in the minor salivary glands (MSG). Because of its histologic variety, complexity, and heterogeneity, it is sometimes challenging to make the accurate diagnosis. Here, we report a literature review of EMC of the MSGs with our experience of two cases. Incisional biopsy was suggestive of pleomorphic adenoma in Case 1 and pleomorphic adenoma or a low-grade salivary gland carcinoma in Case 2. Both cases were performed intraoral tumor resection, and they have good postoperative courses and are alive with no evidence of local recurrence or metastasis at 31 and 16 months, respectively. Considering that the anatomy, structure, and size of salivary glands are quite different from MSGs, it might be difficult to predict EMCs of the MSG similarly to EMCs of the major salivary glands. This comprehensive review also reports the features of EMC of the MSG cases and the trends of diagnosis and discusses treatment strategy.

Multicenter retrospective analysis of clinicopathological features and prognosis of oral tongue squamous cell carcinoma in adolescent and young adult patients

ABSTRACT

The aim of this study is to report the differences in clinicopathological features of oral tongue squamous cell carcinoma (OTSCC) and survival between adolescent and young adult (AYA) patients and elderly patients and to find the prognosticators. The medical records of 101 AYA patients and 175 control patients with OTSCC who underwent surgery were reviewed. Variables related to prognosis and their clinicopathological associations were analyzed. The 5-year overall survival (5y-OS) rates of AYA and control patients with stage I and II OTSCC were 94.4% and 89.6% (P = .353), respectively, and their 5-year disease-free survival (5y-DFS) rates were 82.0% and 76.6%, respectively (P = .476). The 5y-OS rates of patients with stages III and IV OTSCC were 83.3% and 66.7% (P = .333), respectively, and their 5y-DFS rates were 75.0% and 57.1% (P = .335), respectively. Logistic regression analysis revealed that there was no significant clinicopathological difference in AYA and control group. Furthermore, there was no significant difference in 5y-OS rates between patients who underwent elective neck dissection (END) and those who underwent therapeutic neck dissection (TND) in both group (P = 0.717 and 0.688). Overall, the present study revealed the clinicopathological features and prognosis of OTSCC were similar in AYA patients and elderly patients. Moreover, as there was no significant difference in OS between patients who underwent END and those who underwent TND in AYA and control groups, our results suggest that the indication for END in AYA patients with clinical N0 OTSCC is similar to that for elderly patients.

Significance of mitral L wave to predict late recurrence of atrial fibrillation after radiofrequency catheter ablation

Background

Mitral L wave, prominent mid-diastolic filling wave in echocardiographic examinations, is associated with severe left ventricular diastolic dysfunction, and that has been reported to predict recurrent atrial fibrillation (AF) after cardioversion. However, association between mitral L wave and the outcome of AF after radiofrequency catheter ablation (RFCA) has not been established.

Objective

The aim of this study is to evaluate the predictive value of mitral L wave on AF recurrence after RFCA.

Methods

250 patients including 164 paroxysmal AF (65.6%) and 86 non-paroxysmal AF (34.4%) who received RFCA in single center from January 2015 to December 2016 were enrolled consecutively. Echocardiographic examinations before RFCA were recorded, and the mitral L wave was defined as a distinct mid-diastolic flow velocity with a peak velocity ≥20 cm/s following the E wave. Systematic follow-up was conducted after RFCA. Univariate and multivariate analyses were carried out to determine the factors predicting late recurrence of AF (LRAF) which means AF recurrence after 3 months. Enrolled patients were divided into groups with the L wave (L-group; n=57) or without the L wave (NL-group; n=193) based on the findings of echocardiographic examinations.

Results

During a follow-up of 35.0±17.6 months, the ratio of LRAF in the L-group was significantly higher than that in the NL-group (32 (56.1%) vs. 41 (21.2%), Hazard ratio [HR]: 3.55, 95% confidence interval [CI]: 2.33 - 5.42, p&lt;0.001). Among the clinical factors, presence of mitral L wave, BNP value, non-paroxysmal AF and moderate-severe mitral regurgitation were related to LRAF. A multivariate analysis using a Cox proportional hazard model found that presence of mitral L wave (HR: 2.67, 95% CI: 1.30 - 5.48, p=0.007) was significantly associated with LRAF.

Conclusion

This study revealed that mitral L wave predicts late recurrence of AF after RFCA.

Funding Acknowledgement

Type of funding sources: None.

Detection of novel fusion genes by next-generation sequencing-based targeted RNA sequencing analysis in adenoid cystic carcinoma of head and neck

OBJECTIVE

Adenoid cystic carcinoma (AdCC) is a rare, indolent salivary gland tumor that is reported to be driven by fusion genes. However, MYB/MYBL1-NFIB fusions have been detected in <60% of all AdCC cases and the oncogenic driver mutations in approximately 40% of AdCC remain unknown. Our aim was to identify novel gene fusions in AdCC.

STUDY DESIGN

We investigated 20 AdCC cases using a targeted RNA sequencing panel to identify gene fusions and performed quantitative real-time reverse transcription polymerase chain reaction to assess MYB, MYBL1, and NFIB expression levels.

RESULTS

A total of 36 fusion transcripts in 15 cases were detected and validated by Sanger sequencing. The MYB-NFIB and MYBL1-NFIB fusion genes were detected in 9 and 3 cases, respectively, in a mutually exclusive manner. Furthermore, novel gene fusions, namely, NFIB-EPB41L2, MAP7-NFIB, NFIB-MCMDC2, MYBL1-C8orf34, C8orf34-NFIB, and NFIB-CASC20, were identified. Among them, NFIB-EPB41L2 and NFIB-MCMDC2 are thought to activate MYB and MYBL1 expression, respectively, through the insertion of a genomic segment in proximity to MYB and MYBL1 genes, respectively.

CONCLUSION

Six novel gene fusions other than MYB/MYBL1-NFIB were identified. The detection of novel fusion genes and investigation of the molecular mechanism will contribute to the development of novel molecular targeted therapies for this disease.

Comparison of Clinicopathological Characteristics Between the Anterior and Posterior Type of Squamous Cell Carcinoma of the Floor of the Mouth: The Anterior Type Is a Risk Factor for Multiple Primary Cancer

Background

Floor of the mouth (FOM) squamous cell carcinoma (SCC) accounts for approximately 10% of all oral SCCs. FOM SCC can be classified into the anterior and posterior types according to their site of origin, but few studies have compared these types. This study sought to clarify differences in clinicopathological characteristics between these two types.

Methods

A total of 1,220 patients with oral SCC were treated at our department from January 2001 to December 2015. Among these patients, 62 had FOM SCC. The FOM SCCs were classified into two groups: the anterior type and the posterior type. The anterior and posterior types were defined by the boundary connecting the spaces between the canine and the first premolar bilaterally. We retrospectively compared the sex, age, smoking and drinking history, clinical stage, treatment, histopathological diagnosis, multiple primary cancers, and outcomes of the two groups.

Results

Among the 62 patients, 32 had the anterior type, while 30 had the posterior type. The anterior type was found more significantly in men (p = 0.01) and individuals with a smoking history than the posterior type (p = 0.04). pN2–3 cervical lymph node metastasis was significantly more common in the anterior type than in the posterior type (p = 0.01). The median depth of invasion in the anterior type was 4 mm. Multivariate analysis showed that the anterior type was an independent risk factor for multiple primary cancer development in FOM SCC (p = 0.02). The cumulative 10-year disease-specific survival rates of the anterior and posterior types were 92.8 and 95.0%, respectively, while the overall survival rates were 65.4 and 95.0%, respectively. In the anterior type FOM SCC, a lower overall survival rate was associated with multiple primary cancers and smoking-related diseases.

Conclusion

Smoking cessation and adequate systemic screening for multiple primary cancers are needed to improve the prognosis of FOM SCC, particularly the anterior type.

DNAJA1 promotes cancer metastasis through interaction with mutant p53

Accumulation of mutant p53 (mutp53) is crucial for its oncogenic gain of function activity. DNAJA1, a member of J-domain containing proteins or heat shock protein 40, is shown to prevent unfolded mutp53 from proteasomal degradation. However, the biological function of DNAJA1 remains largely unknown. Here we show that DNAJA1 promotes tumor metastasis by accumulating unfolded mutp53. Levels of DNAJA1 in head and neck squamous cell carcinoma (HNSCC) tissues were higher than those in normal tissues. Knockdown of DNAJA1 in HNSCC cell lines carrying unfolded mutp53 significantly decreased the levels of mutp53, filopodia/lamellipodia formation, migratory potential, and active forms of CDC42/RAC1, which were not observed in HNSCC cells with DNA contact mutp53, wild-type p53, or p53 null. Such mutp53-dependent functions of DNAJA1 were supported by the observation that DNAJA1 selectively bound to unfolded mutp53. Moreover, DNAJA1 knockdown in HNSCC cells carrying unfolded mutp53 inhibited primary tumor growth and metastases to the lymph nodes and lungs. Our study suggests that DNAJA1 promotes HNSCC metastasis mainly in a manner dependent on mutp53 status, suggesting DNAJA1 as a potential therapeutic target for HNSCC harboring unfolded mutp53.

Metastatic tumors in the oral region: a retrospective chart review of clinical characteristics and prognosis

OBJECTIVE

The study aimed to evaluate the clinical characteristics and outcomes of patients with metastatic tumors in the oral region.

STUDY DESIGN

We conducted a retrospective study of 14 patients (11 men and 3 women; median age, 70.5 years) with metastatic tumors in the oral region diagnosed between 2005 and 2018.

RESULTS

The primary tumors were located in the lung (n = 7), kidney (n = 3), renal pelvis (n = 1), thyroid (n = 1), stomach (n = 1), and bladder (n = 1). The most common histologic type of the tumor was adenocarcinoma (n = 6). The metastatic sites were the mandible (n = 7), tongue (n = 4), upper gingiva (n = 2), and maxilla (n = 1). In 6 patients, metastatic tumors were found in the oral region before the primary tumors were detected. The primary tumors were detected by positron emission tomography/computed tomography in 5 patients and by computed tomography alone in one patient. Seven patients received treatment for metastatic tumors in the oral region. The overall 1- and 5-year survival rates were 35.7% and 10.7%, respectively.

CONCLUSIONS

It is important to detect metastatic tumors in the oral region and primary tumors as early as possible. Radical or palliative treatment should be performed if possible, considering the condition of the primary tumor and its metastasis to other organs.

Deceleration area and capacity during labour-like umbilical cord occlusions identify evolving hypotension: a controlled study in fetal sheep

OBJECTIVE

Cardiotocography is widely used to assess fetal well-being during labour. The positive predictive value of current clinical algorithms to identify hypoxia-ischaemia is poor. In experimental studies, fetal hypotension is the strongest predictor of hypoxic-ischaemic injury. Cohort studies suggest that deceleration area and deceleration capacity of the fetal heart rate trace correlate with fetal acidaemia, but it is not known whether they are indices of fetal arterial hypotension.

DESIGN

Prospective, controlled study.

SETTING

Laboratory.

SAMPLE

Near-term fetal sheep.

METHODS

One minute of complete umbilical cord occlusions (UCOs) every 5 minutes (1:5 min, n = 6) or every 2.5 minutes (1:2.5 min, n = 12) for 4 hours or until fetal mean arterial blood pressure fell <20 mmHg.

MAIN OUTCOME MEASURES

Deceleration area and capacity during the UCO series were related to evolving hypotension.

RESULTS

The 1:5 min group developed only mild metabolic acidaemia, without hypotension. By contrast, 10/12 fetuses in the 1:2.5-min group progressively developed severe metabolic acidaemia and hypotension, reaching 16.8 ± 0.9 mmHg after 71.2 ± 6.7 UCOs. Deceleration area and capacity remained unchanged throughout the UCO series in the 1:5-min group, but progressively increased in the 1:2.5-min group. The severity of hypotension was closely correlated with both deceleration area (P < 0.001, R²  = 0.66, n = 18) and capacity (P < 0.001, R²  = 0.67, n = 18). Deceleration area and capacity predicted development of hypotension at a median of 103 and 123 minutes before the final occlusion, respectively.

CONCLUSIONS

Both deceleration area and capacity were strongly associated with developing fetal hypotension, supporting their potential to improve identification of fetuses at risk of hypotension leading to hypoxic-ischaemic injury during labour.

TWEETABLE ABSTRACT

Deceleration area and capacity of fetal heart rate identify developing hypotension during labour-like hypoxia.

Case Report: Hidden Oral Squamous Cell Carcinoma in Oral Somatic Symptom Disorder

Background: Burning mouth syndrome (BMS) is a common condition of predominant oral pain without evident cause, that maxillofacial surgeons and otolaryngologists often refer to psychiatrists as somatic symptom disorder. In very rare cases, its typical burning symptom mimics those of other diseases in which serious fatal comorbidities may be missed. We encountered three rare cases of oral squamous cell carcinoma (OSCC) with the first symptom of burning tongue. Case Presentation: Case 1: A 68-year-old woman had burning pain on the left lingual margin for 8 years. Antidepressant treatment was not efficacious. Cytology and biopsy revealed OSCC. Case 2: A 70-year-old man had burning sensation and paralysis of the tongue for 6 months. Magnetic resonance imaging (MRI) revealed a 37 × 23-mm mass under the floor of the mouth and enlargement of lymph nodes on both sides. Case 3: A 90-year-old man had burning sensation of the tongue for 1 year. MRI revealed a 12 × 12-mm mass on the mandible with bone absorption. Conclusion: This case series suggests that psychiatrists must always be careful in regarding BMS as somatic symptom disorder and be cautious of the possibility of OSCC, especially in elderly patients.

Sequential variation of super periodic structures emerged in Bi-layered perovskite pillar-matrix epitaxial nanocomposite films with spinel ferrites

The phase stability of Aurivillius bismuth-layer structured Bi5Ti3FeO15 (BTFO15) has been investigated in an epitaxial pillar-matrix nanocomposite system with spinel ferrites.

Homeobox transcription factor engrailed homeobox 1 is a possible diagnostic marker for adenoid cystic carcinoma and polymorphous adenocarcinoma

Diagnostic utility of a homeobox transcription factor, engrailed homeobox 1 (En1) in the histopathology of salivary gland neoplasms was studied. The expression of En1 was immunohistochemically examined in 51 cases of adenoid cystic carcinoma (AdCC) and 143 cases of other salivary gland neoplasms. In all 51 AdCCs, En1 was expressed in 30-100% of tumor cells. In eight of nine polymorphous adenocarcinomas (PACs), En1 was expressed in 40-100% of tumor cells. Less than 5% of tumor cells expressed En1 in three of 12 epithelial-myoepithelial carcinomas, one of 17 basal cell adenomas (BCAs), and one of 34 pleomorphic adenomas (PAs). Among 55 other carcinoma cases, 1-30% of tumor cells expressed En1 in three salivary duct carcinomas (SDCs) ex PA. None of the myoepitheliomas and Warthin tumors expressed En1. When the cut-off value of the percentage of En1-expressing cells was set to 25%, all 51 AdCCs, eight of nine PACs and one SDC ex PA were En1-positive and the others were En1-negative. En1 is expressed consistently in AdCCs, frequently in PACs, but rarely in other salivary gland neoplasms. En1 is a possible diagnostic marker for AdCC and PAC in the histopathology of salivary gland neoplasms.

Invasive raccoon management systems and challenges in regions with active control

BACKGROUND

The raccoon (Procyon lotor) is an invasive, non-native species in Japan. Throughout the country, it causes significant agricultural damage and negatively affects native biodiversity. Most of the responsibility for raccoon management lies with local government, and there are still many challenges to be overcome. Although raccoon populations have not been eradicated, intensive control campaigns such as focus on the early stages of invasion have controlled raccoons in some regions. To improve the national management of raccoons, we conducted a survey on raccoon management systems in local government departments considered to solve the challenges recognized in many areas. During 2014 and 2015, we surveyed three different municipal departments about raccoon management measures. The semi-structured interview survey covered two topics: (1) the situation leading up to the current management system; (2) the current management system.

RESULTS

Our results describe the scope and methods used in raccoon management. The government staff managed raccoons using monitoring, employing a variety of methods, a range of budgets, and various role divisions. The management practices are similar in that they share a sense of taking precautions, collaborating with stakeholders, understanding that adequate methods must be used, and obtaining support from experts.

CONCLUSIONS

Our case studies reveal the challenges in raccoon management faced by local government officers in regions with active control. The management systems and methods that we surveyed seemed to be effective in solving problems in both developed and undeveloped areas.

Long-term outcomes of Japan-specific dosage of rivaroxaban in high-risk patients with non-valvular atrial fibrillation: analysis from the XAPASS

Background

XAPASS is a real-world, prospective, single-arm, observational study conducted as a post-marketing surveillance mandated by the health authority in Japan. Nowadays, direct oral anticoagulant therapy using factor Xa or thrombin inhibitor has been the standard of care for patients with non-valvular atrial fibrillation (NVAF) to prevent ischemic stroke. However, the clinical impact of reduced dosage (approved dose of 15 or 10 mg once daily in Japan is relatively reduced compared to global dosage) factor Xa inhibitor rivaroxaban in high-risk patients remains unclear.

Purpose

The present sub-analysis of XAPASS was carried out to assess long-term safety and effectiveness of reduced-dose rivaroxaban in high-risk NVAF patients for bleeding and thromboembolism.

Methods

All patients with NVAF who were newly started on rivaroxaban were eligible for surveillance. The principal safety outcome was a composite of major and non-major bleeding events, and the primary effectiveness outcome was a composite of ischaemic stroke, haemorrhagic stroke, non-central nervous system systemic embolism (non-CNS SE), and myocardial infarction (MI). In this present sub-analysis, high-risk patients were defined as those who had two of the following three risk factors: elderly (≥75 years old), low body weight (≤50 kg), and renal impairment (CrCl &lt;50 mL/min).

Results

In total, 11,308 patients were enrolled between April 2012 and June 2014 from 1,419 hospitals, and overall data were analysed from 10,664 patients from whom data were collected. Among them, 3,694 patients matched the criteria for the high-risk patients defined in this sub-analysis, and 6,970 patients did not match the criteria (non-high-risk patients). The mean treatment duration was 791±673 days in the high-risk patients and 944±709 days in the non-high-risk patients. Mean patient age was 80.9±5.5 years and 69.0±9.0 years at baseline, respectively. Mean CHADS2 score was 2.8 and 1.8, and CHA2DS2-VASc score was 4.4 and 2.9, respectively. The rates of CHADS2 component comorbidities were lower in the non-high-risk patients except for diabetes mellitus. The incidence rates of any bleeding, major bleeding, and the primary effectiveness outcomes were 4.8, 1.6, and 2.1%/patient-year in the high-risk patients. The incidence rates of these clinical events in the non-high-risk patients were 3.3, 0.9, and 1.0%/patient-year, respectively.

Conclusions

Incidence rates of long-term bleeding and thromboembolism were higher in the high-risk patients than in the non-high-risk patients. However, the rates of these outcomes using the Japan-specific reduced dose were not so high. Furthermore, the balance between safety and effectiveness outcomes was within an acceptable range. The present study provides useful information for physicians to stratify high-risk patients using the reduced dose in daily clinical practice.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Bayer Yakuhin Ltd.

Electrocardiographic evaluation of depolarization and repolarization abnormalities in breast cancer patients with HER2-inhibitor related cardiac dysfunction

Background

The arrhythmic substrates of the myocardium such as depolarization and repolarization abnormalities are thought to reflect cardiac dysfunction prior to the morphologic left ventricular dysfunction. Activation time (AT), recovery time (RT) and T wave peek-end interval dispersion (Tpe-dispersion) are useful indicators of the arrhythmic substrate. We examined the appearance of depolarization and repolarization abnormalities in patients with cancer therapeutics-related cardiac dysfunction (CTRCD) using AT, RT and Tpe-dispersion.

Methods

We conducted a standardized case-control study of CTRCD with 40 patients who developed breast cancer and treated with trastuzumab (13 cases and 27 controls). We assessed the relation between electrocardiographic indexes, including AT, RT and corrected Tpe-dispersion, and CTRCD. QT intervals were measured by Fridericia method, and QT observer 3 software were used for the measurement of all electrocardiographic indexes.

Results

LVEF in case and control group were 45.7±8% and 69.2±6%, respectively. AT in aVR lead was significantly higher in case group compared with control (28.8±7ms vs 22.8±5ms, P=0.02). corrected Tpe-dispersion tended to be higher in case group than that of control group (43.2±19ms vs 31.9±10ms, P=0.06). QT dispersion and RT dispersion were not different between case and control group.

Conclusions

Our study demonstrated that AT in aVR may predict cardiac dysfunction in breast cancer patients with HER2-inhibitor related cardiac dysfunction. More detailed studies using other modalities which can detect depolarization and repolarization abnormalities, including ventricular late potentials and T wave alternans, are needed.

Funding Acknowledgement

Type of funding source: None

Assessment of the 2015 cardiopulmonary resuscitation guidelines for patients with out-of-hospital cardiac arrest: results from the All-Japan Utstein registry

Background

The 2015 cardiopulmonary resuscitation (CPR) guidelines have stressed that high-quality CPR improves survival from cardiac arrest (CA). In particular, the guidelines recommended that it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120/min in adult CA patients. However, it is unknown whether the 2015 guidelines contributed to favorable neurological outcome in adult CA patients. The present study aimed to clarify the effects of the 2015 guidelines in adult CA patients, using the data of the All-Japan Utstein Registry, a prospective, nationwide, population-based registry of out-of-hospital CA (OHCA).

Methods

From the data of this registry between 2011 and 2016, we included adult witnessed OHCA patients due to cardiac etiology, who had non-shockable rhythm as an initial rhythm. We excluded patients who received prehospital care in 2015 because it was difficult to distinguish prehospital care based on either 2010 CPR guidelines or 2015 CPR guidelines. We also excluded patients who received bystander CPR by citizens because we cannot assess the quality of bystander CPR in this registry. Study patients were divided into five groups based on different years (figure). The endpoint was the favorable neurological outcome at 30 days after OHCA. Potential confounding factors based on biological plausibility and previous studies were included in the multivariable logistic regression analysis. These variables included the age, sex (male, female), advanced airway or not, the administration of adrenaline or not, the administration of saline or not, instructed by dispatcher or not, and time interval from call EMS to scene.

Results

The figure showed favorable neurological outcomes at 30 days. In the multivariate analysis, the adjusted odds ratio for 30-day favorable neurological outcome in OHCA patients in 2016 as compared to in 2011 was 1.32 (95% CI: 1.04–1.68, p=0.022). On the other hands, there were no significant differences from 2011 to 2014.

Conclusion

In the OHCA patients with non-shockable rhythm, the 2015 guidelines were superior to the 2010 guidelines, in terms of neurological benefits.

Figure 1

Funding Acknowledgement

Type of funding source: None

Transplantation of clinical-grade human induced pluripotent stem cell derived cardiac tissues contributes to functional recovery in a rat myocardial infarction model

Background

Clinical-grade human induced pluripotent stem cells (iPSCs) established from a healthy volunteer are currently being considered as a quality controlled cell source for regenerative therapy. Transplantation of three-dimensional bioengineered cardiac tissues composed of human iPSC-derived cardiovascular cell lineages is reported to hold potential for cardiac functional recovery.

Purpose

The aims of this study were to evaluate tissue conformation and cellular viability of human iPSC-derived cardiac tissues (HiCTs) generated from clinical-grade cells and to validate functional efficacy of HiCT transplantation.

Methods

Clinical-grade human iPSC lines were simultaneously differentiated into cardiovascular cell lineages by a high-density monolayer culture. The differentiation efficacy was analyzed by flow cytometry. We seeded the cells on temperature responsive culture dishes to form cell sheets. HiCTs are generated by stacking 5 cell sheets with insertion of gelatin hydrogel microspheres (GHMs) between each sheet to promote oxygen and nutrition supply. Characteristics of the HiCTs are histologically and immunohistochemically evaluated. The HiCTs were transplanted onto an athymic nude rat myocardial infarction (MI) model. Cardiac function was evaluated by echocardiography and cardiac magnetic resonance imaging (MRI) until 4 weeks after surgery, and compared to those in animals with sham operation and with cell sheet stacks without GHMs [GHM(−)].

Results

Flow cytometry at differentiation day15 revealed cellular components as follows: 52.5±1.4% of cardiomyocytes (cardiac isoform of troponin-T+), 9.8±0.7% of vascular endothelial cells (VE-cadherin+), 14.8±1.8% of vascular mural cells (PDGFRβ+) and 0.2±0.1% of undifferentiated cells (TRA-1-60+). HiCTs were significantly thicker [GHM(−) vs HiCT: 357.3±81.5 vs 723.0±84.0μm, p&lt;0.05], composed of higher area of cardiomyocytes (27.7±7.9 vs 71.9±15.5mm2, p&lt;0.05) and endothelial cells (CD31+) (1.6±0.7 vs 9.2±1.5mm2, p&lt;0.05), free from hypoxia (HIF-1α+) (3.1±0.1 vs 0.8±0.2%, p&lt;0.05) and cell death (TUNEL+) (3.2±0.1 vs 1.4±0.3%, p&lt;0.05) after 7 days of in vitro culture. Echocardiography revealed significantly lower left ventricular end diastolic volume (LVEDV) and higher left ventricular ejection fraction (LVEF) in HiCT group [sham (n=27) vs GHM(−) (n=12) vs HiCT (n=12): LVEDV; 1.4±0.1 vs 1.3±0.1 vs 0.9±0.1mL, p&lt;0.0001/LVEF; 55.3±1.1 vs 58.2±2.3 vs 78.2±1.5%, p&lt;0.0001]. Cardiac MRI showed lower LVEDV and higher LVEF as well [sham (n=8) vs GHM(−) (n=6) vs HiCT (n=6): LVEDV; 0.7±0.03 vs 0.7±0.03 vs 0.6±0.02mL, p&lt;0.01 / LVEF; 39.2±2.1 vs 43.8±1.4 vs 54.0±2.8%, p&lt;0.001].

Conclusions

We conclude that HiCTs generated from clinical-grade cells hold sufficient viability and tissue conformation suitable for functional recovery validated by a rat MI model. Clinical-grade human iPSCs potentially serve as a reasonable cell source for stem cell-derived product transplantation therapy with foreseeable clinical applications.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Japan Agency for Medical Research and Development (AMED), Invited Research Project of Institute for Advancement of Clinical Transnational Science, Kyoto University Hospital

Clinical usefulness of Lipoprotein(a) for the prevalence and severity of peripheral artery disease among patients with acute coronary syndrome

Background

Lipoprotein(a) [LP(a)] is known to be a robust lipid marker associated with cardiovascular events. Though coronary artery disease and peripheral artery disease (PAD) are often coexist, little is known about the relationship between LP(a) and PAD among patients with acute coronary syndrome (ACS).

Purpose

The purpose of this study is to examine if LP(a) is of predictive value for PAD among ACS patients in Japanese population.

Methods

Of consecutive 238 ACS patient who received successful primary PCI, a total of 175 patients were enrolled in the current study. We excluded the patients who received hemodialysis (n=10), required multidisciplinary treatment (n=36) and incomplete data (n=17). PAD was diagnosed as ankle brachial index &lt;0.9. Multiple lipid biomarkers [LP(a), low-density lipoprotein (LDL-C), high-density lipoprotein (HDL-C), malondialdehyde-modified LDL (MDA-LDL), docosahexaenoic acid and arachidonic acid] were compared between patients with PAD (n=21) and without PAD (n=154). Further, multivariable logistic regression models were used to assess if LP(a) was associated with PAD. In addition, serum LP(a) level were compared between 3 groups according to pattern of PAD [none (n=154), unilateral (n=10) and bilateral PAD (n=11), respectively].

Results

Compared to patients without PAD, those with PAD were older (74.4 vs. 65.4 years, p=0.003), and had a higher prevalence of chronic kidney disease (CKD) (61.9% vs. 20.1%, p&lt;0.001), diabetes mellitus (DM) (66.7% vs. 27.3%, p&lt;0.001). Serum LP(a) level was significantly higher in patients with PAD (36.4 vs. 18.5 mg/dl, p&lt;0.001), whereas LDL-C and MDA-LDL were significantly lower in PAD (92.0 vs. 109.5 mg/dl, p=0.015 and 98.6 vs. 119.5 mg/dl, p=0.046, respectively). After adjusting for LDL-C and MDA-LDL, LP(a) &gt;30 mg/dl was independently associated with a presence of PAD (OR 5.67, 95% CI 2.09–15.4, p=0.0006). When adjusting for CKD and DM in a different model, LP(a) &gt;30 mg/dl was similarly associated with PAD (OR 4.98, 95% CI 1.66–14.9, p=0.004). Serum LP(a) levels were significantly higher in bilateral PAD group compared to none PAD group (Figure).

Conclusion

LP(a) was a useful lipid biomarker for the prevalence and severity of PAD among patients with ACS in Japanese population.

Funding Acknowledgement

Type of funding source: None

Primordial odontogenic tumor occurred in the maxilla with unique calcifications and its crucial points for differential diagnosis

Primordial odontogenic tumor (POT) is a newly classified, mixed epithelial and mesenchymal odontogenic tumor, with only 17 reported cases to date. Herein, we report a case of POT that occurred in the right maxilla of a 10-year-old boy and reveal unique features in comparison with those previously reported. Radiologically, the lesion presented as a well-defined, unilocular radiolucency with notable radiopaque foci on the periphery. Microscopically, the tumor was mainly composed of dental papilla-like myxoid fibrous connective tissue, largely surrounded by non-keratinized squamous epithelium with numerous calcified particles, and partly enclosed by inner enamel epithelium-like columnar cells and enamel organ-like structures accompanied with cuboidal and/or stellate reticulum-like cells. Immunohistochemically, the epithelium tested positive for cytokeratin 14 and 19. Moreover, amelogenin and ameloblastin, matrix proteins relating to enamel formation, were positive in the covering epithelium. The tumor was enucleated as a whole, and no recurrence was recorded thereafter. Although the presence of numerous calcified particles was unique, we diagnosed this lesion as POT based on the above-described features. Furthermore, we emphasize the importance of the differential diagnosis of POT and other odontogenic tumors that resemble corresponding tooth germ components.

Renal cell carcinoma metastasis to the maxillary bone successfully treated with surgery after vascular embolization: a case report

Background

Metastasis of renal cell carcinoma to the oral cavity is rare. Renal cell carcinoma metastases are regarded as radioresistant tumors and surgery is recommended. However, since metastatic renal cell carcinoma has poor prognosis and is composed of abundant blood vessels, it is sometimes difficult for clinicians to choose surgical therapy. Here, we report a case of a patient with renal cell carcinoma metastasis to the maxillary bone, which was successfully controlled by surgical therapy after vascular embolization, and provide a detailed literature review regarding the treatments and outcomes of renal cell carcinoma metastasis to the oral cavity.

Case presentation

An 89-year-old Japanese man presented with an 8 × 8-mm granulomatous tumor with palpable pulsation in the left upper gingiva, which had been clinically suspected as an arteriovenous malformation or neoplastic lesion with rich blood vessels. Our patient had undergone left nephrectomy for clear cell carcinoma 7 years prior. Pulmonary metastasis had appeared 3 years later. After intravascular embolization, our patient underwent tumor resection of the maxilla with little intraoperative blood loss. The tumor was diagnosed on histopathology as a metastasis of clear cell renal cell carcinoma to the maxillary bone. Seventeen months after surgery, he died because of pulmonary metastasis without evidence of recurrence in the oral cavity.

Conclusions

Our literature review reveals that oral metastatic lesions of renal cancer often exhibit rapid enlargement and cause severe symptoms, such as dysphagia and bleeding. Although oral metastasis of renal cell carcinoma has a poor prognosis due to the presence of concurrent disseminated metastases, surgical therapy may be recommended because of its high local control rate and ability to maintain quality of life. Preoperative vascular embolization is considered to be effective to reduce intraoperative hemorrhage, which leads to safe surgery.

Susceptibility of patients receiving chemotherapy for haematological malignancies to scabies

BACKGROUND

Scabies is a contagious dermatosis. The risk factors for its transmission remain unclear. A scabies outbreak, involving patients who were receiving chemotherapy for haematological malignancies, occurred at our hospital.

METHODS

The outbreak population was analysed to determine whether the incidence of scabies was higher among contact patients receiving chemotherapy for haematological malignancies.

RESULTS

A patient with crusted scabies was the index case, and 18 of 78 contact healthcare workers (HCWs) and 22 of 135 contact patients were diagnosed with classical scabies. Ten of 17 contact patients with haematological malignancies and 12 of 118 contact patients with other diseases were infected with scabies. The incidence rate was significantly higher among the patients with haematological malignancies (P<0.001). The patients with haematological malignancies had a significantly lower mean minimum neutrophil count than those with other diseases (1159/μL vs 3761/μL, P=0.0012). Most haematological patients did not require special nursing assistance, suggesting that the higher incidence of scabies among these patients resulted from their immunodeficiency rather than greater skin-to-skin contact with infected HCWs.

CONCLUSION

Our study suggests that patients receiving chemotherapy for haematological malignancies are more susceptible to scabies than patients with other diseases, and require stricter protection.

Secretory carcinoma around Stensen's duct misdiagnosed as salivary duct cyst

Secretory carcinoma (SC) of the salivary gland was identified in 2010, and it is characterized by a specific ETV6 gene arrangement. The most common primary site for SC is the parotid gland; however, SC around the Stensen's duct is rare. Here we describe a rare case of a SC around the Stensen's duct that was initially misdiagnosed as a salivary duct cyst. A 59-year-old woman presented with a mass in the region of the left parotid papilla. Magnetic resonance imaging (MRI) revealed a well-circumscribed lesion and enhancement with a rim and an inner wall-like part that appeared in the late phase. Based on the initial clinical and imaging findings, a salivary duct cyst of the parotid gland was diagnosed. However, the lesion was histopathologically diagnosed as a SC based on immunohistochemical findings. The tumor cells showed diffuse positive staining for AE1/AE3, vimentin, and mammaglobin and focal positive staining for S-100 protein, SOX-10, and DOG-1. Fluorescence in-situ hybridization revealed ETV6 gene rearrangement in the tumor. In cases of cystic lesions around the Stensen's duct, clinicians should bear in mind that the possibility that they could be minor salivary gland cancers, such as SC.

AB0988 CLINICAL FEATURES AND ANALYSIS OF MEFV GENE IN 31 PATIENTS WITH FAMILIAL MEDITERRANEAN FEVER (FMF)

Background:

FMF is recessive systemic autoinflammatory disorder characterized by recurrent fever, peritonitis, pleuritis, pericarditis and arthritis accompanied with headache and abdominal pain. Mutation of MEFV gene encoding pyrin resulted in inflammasome activation and the uncontrolled production of IL-1β. Overview of pathogenesis, clinical features and management in Japanese patients with FMF had been reported. However, the differences of clinical features between mutated and non-mutated of MEFV still remain unclear.

Objectives:

We have analyzed 31 Japanese patients with FMF in Gifu district to clarify the association between various clinical features and mutation ofMEFV.

Methods:

Genomic DNA were purified from white blood cells in 31 FMF patients, and mutated MEFV has been explored. We have analyzedMEFV, TNFRSF1A, MVK and NLRP3 genesin 31 patients with FMF except for 1 patient. Therefore, we excluded another autoinflammatory diseases such as TNF receptor-associated syndrome (TRAPS), mevalonate kinase deficiency and cryopyrin-associated periodic syndrome. Clinical symptoms and laboratory data were analyzed around onset time. Each patient had been treated with colchicine (0.5-2 mg).

Results:

Characteristics of Patients with FMF (22 female/9 male) were as follows; Onset time were 0-56 years-old (21.4 ±11.8), and Frequencies of clinical symptoms such as periodic fever, headache, abdominal pain, arthralgia, chest pain, cervical lymph nodes swelling, and myalgia were 31/31, 9/31, 8/31, 6/31, 5/31, 3/31 and 1/31, respectively (double symptoms were observed). Patients with FMF were divided into 3 groups as follows; Patients with typical compound heterozygous mutations of MEFV (E148Q /M694I) which indicated exon 10 mutation, were 5 cases (G1). Patients with atypical mutations, except for exon 10, such as 133G>A in 3UTR, exon 1 (E84K), 2 (L110P, E148Q), 3(R202Q, P257L, G304R, P369S, R408Q), 5(S503C) and 9(I591M) were 13 cases (G2). Patients with no mutations in MEFV gene were 12 cases (G3). There were no significant differences of age at first visiting hospital (FV)and onset age of fever attack (O) (FV: 29.0 ± 15.6, 27.1 ± 12.5 years-old (yo) and 34.7 ± 12.7 yo, O: 21.0 ± 17.6 yo, 17.8 ± 12.1 yo and 25.2 ± 6.5). But significant differences in duration of fever attack (D) and frequency of fever attack (FF) between G1 and G2 or G3 were observed as follows; (D: 2.2 ± 0.4 days vs 5.5 ± 3.1 days, P<0.05, and 3.8 ± 1.7 days), FF: 0.72 ± 0.3/month (M), 1.24 ± 1.1/M, and 1.5 ± 0.7/M vs group1, P<0.05), respectively. Laboratory examinations such as WBC, CRP and serum amyloid A (SAA)at fever attack were not significantly different between 3 groups. All of those patients were effective for colchicine treatment except for 2 patients in group 1 because of loss of hair, severe diarrhea and liver dysfunction due to side effects of colchicine. Finally, 4 patients in G1and G2 received canakinumab treatment. Patients withMEFVmutations have no family histories. Mutations of E148Q were found in 12 patients (40%).

Conclusion:

We have examined association between clinical features and mutations of MEFV in 31 patients in Gifu district, suggesting that duration of fever attacks and frequency of fever attacks in G1 are significantly shorter than G2 and G3, respectively in Japanese patients with FMF. Mutations of E148Q in exon 2 were observed in 16-23 % of normal Japanese patients, indicating that E148Q is the polymorphism or accelerating factor.

Disclosure of Interests:

None declared

Alteration in faecal bile acids, gut microbial composition and diversity after laparoscopic sleeve gastrectomy

Background

Laparoscopic sleeve gastrectomy (LSG) is a well established treatment for severe obesity and type 2 diabetes. Although the gut microbiota is linked to the efficacy of LSG, the underlying mechanisms remain elusive. The effect of LSG for morbid obesity on the gut microbiota and bile acids was assessed here.

Methods

Severely obese subjects who were candidates for LSG were included and followed until 6 months after surgery. The composition and abundance of the microbiota and bile acids in faeces were assessed by 16S ribosomal RNA sequencing, quantitative PCR and liquid chromatography–mass spectrometry.

Results

In total, 28 patients with a mean(s.d.) BMI of 44·2(6·6) kg/m2 were enrolled. These patients had achieved excess weight loss of 53·2(19·0) per cent and showed improvement in metabolic diseases by 6 months after LSG, accompanied by an alteration in the faecal microbial community. The increase in α-diversity and abundance of specific taxa, such as Rikenellaceae and Christensenellaceae, was strongly associated with reduced faecal bile acid levels. These changes had a significant positive association with excess weight loss and metabolic alterations. However, the total number of faecal bacteria was lower in patients before (mean(s.d.) 10·26(0·36) log10 cells per g faeces) and after (10·39(0·29) log10 cells per g faeces) operation than in healthy subjects (10·83(0·27) log10 cells per g faeces).

Conclusion

LSG is associated with a reduction in faecal bile acids and greater abundance of specific bacterial taxa and α-diversity that may contribute to the metabolic changes.