Unique regioselectivity of the Pd-catalysed cross-dehydrogenative coupling reaction of simple polyaromatic hydrocarbons with polyfluoroarenes

A Pd-catalysed cross-dehydrogenative coupling reaction introduced two polyfluoroarenes into simple polyaromatic hydrocarbons at sterically favourable positions. An investigation of the reaction mechanism revealed that the unique regioselectivity was determined by the reductive elimination step rather than the C-H bond cleavage step.

POS0681 DRUG RETENTION RATE AND EFFECTIVENESS OF JAK INHIBITOR IN PATIENTS WITH DIFFICULT-TO-TREAT RHEUMATOID ARTHRITIS

Background

Recently, the disease activity of rheumatoid arthritis (RA) was improved due to the ‘treat-to-target’ strategy. However, some patients remain various symptoms despite recommended treatment was performed. Then, the term of ‘difficult-to-treat RA (D2TRA)’ is widely recognized. Janus kinase inhibitor (JAKi) might be effective for D2TRA patients, because JAKi can simultaneously block the function of multiple cytokines.

Objectives

The aim of this study was to evaluate drug retention rate and effectiveness of JAKi in patients with D2TRA.

Methods

This study included 220 RA patients (tofacitinib 101, baricitinib 83, upadacitinib 20, peficitinib 14, filgotinib 2) treated with JAKi. Sixty-two patients were treated as first line bDMARDs/JAKi (1st group), 57 patients were treated as second line bDMARDs/ JAKi (2nd group), 101 patients were treated as third and more bDMARDs/ JAKi. In these 101 patients, 25 patients did not met D2TRA criteria (non-D2TRA group) and 76 patients met D2TRA criteria (D2TRA group). Drug retention rate and effectiveness of JAKi were evaluated during 24 weeks in each group.

Results

Usage rate of methotrexate was lower and dosage of glucocorticoid was higher in D2TRA group than in other groups (Table 1). Drug retention rate at 24 weeks was 87.1% (54/62) in 1st group, 80.1% (46/57) in 2nd group, 88% (22/25) in non-D2TRA group, 61.8% (47/76) in D2TRA group. Drug retention rate was lower in D2TRA group compared to 1st group, 2nd group and non-DT2RA group (p<0.01, p=0.03, p=0.01). DAS28-CRP was 4.4, 4.0, 3.9, 4.4 at baseline, 3.0, 3.0, 3.3, 3.5 at 4 weeks, 2.5, 2.9, 2.7, 3.3 at 12 weeks, 2.5, 3.0, 2.9, 3.2 at 24 weeks in 1st group, 2nd group, non-D2TRA group and D2TRA group, respectively. Improvement ratio of DAS28-CRP was 32.9, 27.6, 20.4, 19.3 % at 4 weeks, 40.8, 26.5, 28.1, 19.5 % at 12 weeks, 40.8, 24.6, 18.7, 24.7 % at 24 weeks. DAS28-CRP was improved in all groups. Altough 1st group showed higher improvement ratio of DAS28-CRP at 24 weeks compared to 2nd group, non-DT2RA group and D2TRA group (p<0.01, p<0.01, p<0.01), there was no differences between DT2RA group and 2nd group or non-D2TRA group (p=0.95, p=0.48). SDAI was 22.9, 19.9, 18.3, 23.9 at baseline, 11.8, 11.9, 13.3, 14.4 at 4 weeks, 7.9, 11.3, 8.4, 13.3 at 12 weeks, 8.5, 11.5, 9.7, 12.6 at 24 weeks. CDAI was 21.3, 18.8, 17.6, 21.8 at baseline, 11.3, 11.2, 12.5, 13.9 at 4 weeks, 7.5, 10.9, 8.0, 12.3 at 12 weeks, 8.1, 10.7, 8.6, 12.1 at 24 weeks. HAQ was 1.15, 0.99, 0.89, 1.39 at baseline, 0.84, 0.76, 0.93, 1.22 at 4 weeks, 0.79, 0.84, 0.77, 1.17 at 12 weeks, 0.76, 0.79, 0.76, 1.14 at 24 weeks. Improvement rate of HAQ at 24 weeks were 44.3%, 23.9%, 21.2%, 8.1%.

Table 1.

Baseline characteristics of RA patients

1st group (n=62)2nd group (n=57)non-D2TRA group (n=25)D2TRA group (n=76)Age (years)64.9 ± 14.866.1 ± 11.564.6 ± 16.163.0 ± 15.0Female (%)75.879.096.080.3Disease durations (years)10.4 ± 11.717.6 ± 17.622.6 ± 22.416.3 ± 15.7RF (IU/ml)296.3 ± 1153.8314.9 ± 1037.7262.4 ± 375.9305.9 ± 819.6RF positive ratio (%)81.878.479.275.7Anti CCP antibody (U/ml)221.8 ± 327.2157.8 ± 258.795.9 ± 101.6191.8 ± 250.6Anti CCP antibody positive ratio (%)79.679.672.283.3CRP (U/ml)1.5 ± 2.11.1 ± 2.01.6 ± 1.61.8 ± 2.9MMP-3 (ng/ml)185.7 ± 167.6146.7 ± 122.1190.1 ± 152.6268.0 ± 451.2DAS28-CRP4.3 ± 1.24.1 ± 1.33.9 ± 1.44.4 ± 1.3SDAI21.8 ± 12.221.7 ± 13.118.4 ± 13.023.9 ± 12.8CDAI20.3 ± 11.320.7 ± 12.717.6 ± 12.822.1 ± 12.2HAQ1.1 ± 0.81.2 ± 1.00.9 ± 0.81.4 ± 1.1MTX use (%)69.463.25647.4MTX (mg/day)10.7 ± 3.410.4 ± 3.58.8 ± 3.59.0 ± 4.3Glucocorticoid use (%)29.136.81646.1Glucocorticoid dose (mg/day)3.3 ± 2.13.0 ± 1.53.5 ± 1.95.1 ± 2.8

Conclusion

Drug retention rate of JAKi in treatment of D2TRA group were lower than that of 1st group, 2nd group, and non-D2TRA group. Clinical efficacy of JAKi in D2TRA group were not significantly different to 2nd group and non-D2TRA group. However, HAQ improvement was weak in D2TRA group.

Disclosure of Interests

None declared

POS0290 THE EFFECTS OF TREATMENT RESPONSE AND RISK FACTOR TO INHIBIT THE CLINICAL RESPONSE IN PATIENTS WITH DIFFICULT-TO-TREAT RHEUMATOID ARTHRITIS TREATED WITH IL-6 RECEPTOR INHIBITOR, ABATACEPT AND JAK INHIBITOR

Background

Recently, the disease activity of rheumatoid arthritis (RA) was improved due to the ‘treat-to-target’ strategy. However, some patients remain various symptoms despite recommended treatment was performed. Then, the term of ‘difficult-to-treat RA (D2TRA)’ is widely recognized. It is unknown how the difference of type of biological disease-modifying anti rheumatic dugs (bDMARDs)/Janus kinase inhibitor (JAKi) will affect clinical efficacy in patients with D2TRA. Moreover, the risk factor to inhibit the clinical response in patients with D2TRA is unknown.

Objectives

The aim of this study was to evaluate the treatment response in patients with D2TRA who were treated with interleukin 6 receptor inhibitor (IL-6Ri), abatacept and JAKi.

Methods

This study used the multicenter database included 673 RA patients treated with bDMARDs/JAKi (tocilizumab 240, sarilumab 67, abatacept 146, tofacitinib 101, baricitinib 83, upadacitinib 20, peficitinib 14, filgotinib 2). Two hundred forty-two patients were treated as first line bDMARDs/JAKi (IL-6Ri 117, abatacept 63, JAKi 62), 211 patients were treated as second line bDMARDs/JAKi (IL-6Ri 117, abatacept 37, JAKi 57), 220 patients were treated as third and more bDMARDs/JAKi. In these 220 patients, 82 patients did not meet D2TRA criteria (IL-6Ri 42, abatacept 15, JAKi 25) and 138 patients met D2TRA criteria (IL-6Ri 31, abatacept 31, JAKi 76). In all patients, we analyzed 138 patients with D2TRA (113 female, mean age was 63.1 ± 13.7 years). Drug retention rate and effectiveness of bDMARDs/JAKi in patients with D2TRA were evaluated for 24 weeks. Multivariate linear regression analysis was performed to clarify the risk factors to inhibit the clinical response.

Results

Drug retention rate of patients with D2TRA at 24 weeks was 67.7% in IL-6Ri group, 74.2% in abatacept group, 61.8% in JAKi group. Drug retention rate in patients with D2TRA was not different between groups (IL-6Ri vs abatacept: p=0.86, IL-6Ri vs JAKi group: p=0.39, abatacept vs JAKi group: p=0.33). DAS28-CRP at 4, 12, 24 weeks decreased in all group (Figure 1). Abatacept showed lower improvement ratio of DAS28-CRP at 24 weeks compared to IL-6Ri group (IL-6Ri vs abatacept: p<0.01, IL-6Ri vs JAKi: p=0.1, abatacept vs JAKi: p=0.07). Good responder (defined as decrease in DAS28-CRP score > 1.2 with a score < 3.2) was 52.4% patients in IL-6Ri, 17.4% patients in abatacept, 29.8% patients in JAKi. SDAI and CDAI at 4, 12, 24 weeks decreased in all group (Figure 1). There were no diferences between the groups in improvement ratio of SDAI (IL-6Ri vs abatacept: p=0.11, IL-6Ri vs JAKi: p=0.81, abatacept vs JAKi: p=0.08) and CDAI (IL-6Ri vs abatacept: p=0.31, IL-6Ri vs JAKi: p=0.82, abatacept vs JAKi: p=0.13) at 24 weeks. HAQ was 1.42, 1.15, 1.39 at baseline, 1.27, 1.07, 1.22 at 4 weeks, 1.17, 1.07, 1.17 at 12 weeks, 1.26, 1.06, 1.14 at 24 weeks in IL-6Ri group, abatacept and JAKi, respectively. Multivariate linear regression analysis revealed that high HAQ (β=0.28, p=0.02) and high dosage of glucocorticoid (β=0.67, p<0.01) inhibited the improvement of DAS28-CRP. Type of bDMARDs/JAKi (β=-0.09, p=0.36) did not affect the DAS28-CRP improvement for 24 weeks.

Table 1.

Multivariate linear regression analysis of risk factor to inhibit the clinical response in patients with D2TRA.

β95% CIpAge (years)-0.037-0.025, 0.0170.74male-0.047-0.788, 0.4860.64Disease durations (years)-0.048-0.028, 0.0170.63RF (IU/ml)-0.082-0.0004, 0.00020.41Anti CCP antibody (U/ml)0.111-0.0005, 0.0020.26DAS28-CRP-0.063-0.265, 0.1420.55HAQ0.2790.059, 0.7170.02MTX (mg/day)0.136-0.018, 0.0810.21Glucocorticoid dose (mg/day)0.6690.174, 0.324< 0.01Type of bDMARDs/JAKi-0.088-0.415, 0.1510.36

Conclusion

Drug retention rate and clinical efficacy of D2TRA patients were not different among IL-6Ri, abatacept and JAKi. DT2RA patient with functional disorder and high dosage of glucocorticoid were risk factor to inhibit the clinical response.

Disclosure of Interests

None declared

AB0405 JAK INHIBITORS IMPROVE PATIENT-REPORTED OUTCOMES SUCH AS PAIN AND HAQ EARLIER THAN ANTI-IL-6 INHIBITORS

Background

Clinical feature of Janus kinase (JAK) inhibitor is recognized as not only suppress inflammation but also improve patient-reported outcomes (PRO) such as pain and health assessment questioner (HAQ) in patients with rheumatoid arthritis (RA). This representative clinical feature was known as a results of phase 3 trial compared to TNF inhibitor. One of the mechanisms of JAK in RA is to suppresses interleikin-6 (IL-6). However, the effect for PRO in JAK inhibitor compared to IL-6 inhibitor have not been known.

Objectives

We investigated the effect for patient-reported outcomes such as pain and HAQ in patients with RA treated with JAK inhibitor compared to IL-6 inhibitor.

Methods

This study was analysed a multicenter database included RA patients treated with biological disease-modifying anti rheumatic dugs (bDMARDs) and JAK inhibitors. In 307 patients treated with IL-6 inhibitor (tocilizumab 240 and sarilumab 67) and 220 patients with JAK inhibitor (tofacitinib 101, baricitinib 83, upadacitinib 20, peficitinib 14 and filgotinib 2), 155 patients were treated as first-line bDMARDs/JAK inhibitor (IL-6R inhibitor 104 and JAK inhibitor 51). In this first-line patients, patients treated with IL-6R inhibitor and JAK inhibitor were matched using the propensity score adjusted for gender, age, RA disease duration, baseline charactristics of disease activity, CRP level, and MMP-3 level. The beaseline data and the change of clinical and laboratory data at 4, 12 and 24 weeks were compared between IL-6 inhibitor and JAK inhibitor.

Results

Thirty-six patients in each group were matched and analyzed. The average age was 62.4 and 62.6 years and the average disease duration of RA was 13.2 and 10.1 years in IL-6 inhibitor and JAK inhibitor. The baseline characteristics were not significantly different in both groups. At week 4, tender joint count (TJC) was significantly improved in JAK inhibitor than IL-6 (IL-6: -1.86 vs JAK: -4.12, p= 0.036) and HAQ was significantly improved in JAK inhibitor than IL-6 (IL-6: -0.04 vs JAK: -0.27, p= 0.041). Moreover, Clinical Disease Activity Index (CDAI) was also improved in JAK inhibitor than IL-6 (IL-6: -6.6 vs JAK: -10.9, p= 0.026) at week 4. However, pain VAS and patient global VAS were not significantly different in each group in week4. TJC, HAQ and CDAI was not different in both groups at week 12 and week 24. On the other hand, ESR was significantly decreased in IL-6 inhibitor than JAK inhibitor at week 4, 12 and 24 (IL-6: -26.6 vs JAK: -14.1, p=0.018 at week 4, IL-6: -32.7 vs JAK: -16.5 p=0.004 at week 12, IL-6: -31.3vs JAK: -17.7 p=0.014 at week 24).

Conclusion

In a comparison between IL-6 inhibitor and JAK inhibitor as a first-line molecular-targeted drug matched baseline charactristics of disease activity, TJC and HAQ was improved in JAK inhibitor earlier than IL-6 inhibitors. JAK inhibitor suppress multi cytokine that might be the reason why JAK inhibitor improve pain. Improvement of patient reported outcome in JAK inhibitor was found also in comparison with IL-6 inhibitor.

References

[1]Taylor PC, Keystone EC, van der Heijde D, et al. Baricitinib versus Placebo or Adalimumab in Rheumatoid Arthritis. N Engl J Med. 2017;376:652-62.

[2]Fleischmann R, Pangan AL, Song IH, et al. Upadacitinib Versus Placebo or Adalimumab in Patients with Rheumatoid Arthritis and an Inadequate Response to Methotrexate: Results of a Phase III, Double-Blind, Randomized Controlled Trial. Arthritis Rheumatol. 2019;71:1788-1800.

Acknowledgements

We wish to thank Atsuko Kamiyama and Tomoko Nishimura for clinical assistant, and all member of Team RA.

Disclosure of Interests

Tadashi Okano Speakers bureau: Asahi Kasei, Astellas, Abbvie, Amgen, Ayumi, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead Sciences, Janssen, Kyowa Kirin, Mitsubishi Tanabe, Novartis, Ono, Pfizer, Sanofi, Takeda, UCB, Grant/research support from: Asahi Kasei, Abbvie, Chugai, Eisai, Mitsubishi Tanabe, Tatsuya Koike Speakers bureau: Takeda Pharmaceutical, Mitsubishi Tanabe Pharma Corporation, Chugai Pharmaceutical, Eisai, Abbott Japan, Teijin Pharma, Banyu Pharmaceutical and Ono Pharmaceutical, Kentaro Inui Speakers bureau: Daiichi Sankyo Co. Ltd., Mitsubishi Tanabe Pharma, Janssen Pharmaceutical K.K., Astellas Pharma Inc., Takeda Pharmaceutical Co. Ltd., Ono Pharmaceutical Co. Ltd., Abbvie GK, Pfizer Inc., Eisai Co.,Ltd., Chugai Pharmaceutical Co., Ltd., Grant/research support from: Janssen Pharmaceutical K.K., Astellas Pharma Inc., Sanofi K.K., Abbvie GK, Takeda Pharmaceutical Co. Ltd., QOL RD Co. Ltd., Mitsubishi Tanabe Pharma, Ono Pharmaceutical Co. Ltd., Eisai Co.,Ltd., Masahiro Tada: None declared, Kenji Mamoto: None declared, Yutaro Yamada: None declared, kazuki Orita: None declared, Koji Mandai: None declared, Shohei Anno: None declared, Takahiro Iida: None declared, Hiroaki Nakamura: None declared

AB0387 THE RELATIONSHIP BETWEEN JAK INHIBITORS AND CREATINE KINASE ELEVATION IN PATIENTS WITH RHEUMATOID ARTHRITIS: A REAL-WORLD CLINICAL STUDY

Background

Some cases of creatine kinase (CK) elevation caused by Janus kinase (JAK) inhibitor treatment for rheumatoid arthritis (RA) have been reported in clinical trials1. However, the frequency and patients’ background characteristics in clinical practice are unknown.

Objectives

The correlation between JAK inhibitor treatment for RA and changes in CK levels in clinical practice were investigated using a multicenter database.

Methods

The multicenter database of JAK inhibitors was used, and 103 (tofacitinib 46, baricitinib 44, upadacitinib 11, peficitinib 1, filgotinib 1) of 265 RA patients were followed up at 24 weeks, and their CK levels were evaluated. The time-dependent change of CK was evaluated by sex and analyzed by the Wilcoxon signed-rank test. The percentage abnormal from the standard titer was calculated. The factors related to an elevated CK at 24 weeks were investigated using patients’ background characteristics at the time of starting JAK inhibitors by univariate analysis.

Results

Women accounted for 85.4% of the patients, the median age was 68 years, disease duration was 15 years, and the mean DAS28ESR was 5.00. The CK levels of both men and women were significantly elevated at 4 weeks and maintained until 24 weeks (men, women: 63, 62 (0 weeks), 101, 95 (4 weeks), 119, 96 (12 weeks), 155, 99 (24 weeks), U/L, P<0.001) (Figure 1). The percentage abnormal was also significantly increased at 4 weeks and maintained until 24 weeks (5.8% (0 weeks), 20.7% (4 weeks), 26.3% (12 weeks), 24.3% (24 weeks), P=0.002). The factors significantly positively related to elevated CK levels at 24 weeks were male, CK, creatinine, and lactate dehydrogenase (LDH), and stage, class, modified health assessment questionnaire, estimated glomerular filtration rate (eGFR), and glucocorticoid use were significantly negatively correlated (Table 1). There were no significant differences in CK elevation among the agents.

Table 1.

Characteristics at the time of starting JAK inhibitors related to elevated creatine kinase levels at 24 weeks

UnivariateData at stating JAK inhibitorsR valueP valueCreatine kinase0.653<0.001Gender, men0.2470.012Steinbrocker stage-0.2150.039Steinbrocker class-0.2770.008modified health assessment questionnaire-0.2680.008Creatinine0.2890.003eGFR-0.2310.019LDH0.2010.041Glucocorticoid use-0.4090.008

Analyzed by Spearman rank correlation coefficient

Figure 1.

Time-dependent changes of CK in all RA patients

Conclusion

CK was significantly elevated at 4 weeks and maintained until 24 weeks. However, no patients complained of muscle pain and stopped JAK inhibitors. Patients with high CK, low eGFR, high LDH, or maintained activities of daily living at the time of starting JAK inhibitors tended to have high CK levels at 24 weeks.

References

[1]Fleischmann, R. et al. Upadacitinib Versus Placebo or Adalimumab in Patients With Rheumatoid Arthritis and an Inadequate Response to Methotrexate: Results of a Phase III, Double-Blind, Randomized Controlled Trial. Arthritis & rheumatology (Hoboken, N.J.) 71, 1788-1800, doi:10.1002/art.41032 (2019).

Disclosure of Interests

None declared

POS1146 ROMOSOZUMAB INCREASE BONE MINERAL DENSITY AT LUMBAR AND FEMORAL IRRESPECTIVE OF PREOSTEOPOROSIS TREATMENT, HISTORY OF FRAGILITY FRACTURE AND COMBINATION OF VITAMIN D

Background

Romosozumab, a monoclonal antibody that binds sclerostin, increases bone formation and decreases bone resorption. Romosozumab has an excellent therapeutic effect on patients with osteoporosis. However, there are few reports investigated the efficacy and the effect of various factors relative to osteoporosis in real-world.

Objectives

We evaluated bone mineral density (BMD) and bone metabolism marker (BMM) change in osteoporosis patients treated with romosozumab, and assessed the effect of various factors, such as preosteoporosis treatment, history of fragility fracture and combination of vitamin D.

Methods

This study included 141 osteoporosis patients (132 female, mean age: 78.8 ± 7.5 years, mean hight: 151.1 ± 7.5 cm, mean weight: 50.9 ± 8.9 kg) treated with romosozumab. BMD measurements using dual energy X-ray absorptiometry (DXA) and BMM measurements using N-terminal propeptide of type 1 collagen (P1NP) were evaluated at 0, 4, 6, and 12 months after treatment. DXA were performed at the lumbar spine (n=92), at proximal femoral and femoral neck (n=92), and at distal third radius (n=49). We evaluated the influence of preosteoporosis treatment, history of fragility fracture and combination of vitamin D for BMD change.

Results

BMD at lumbar spine (5.2%: p<0.01, 9.2%: p<0.01, 10.8%: p<0.01), proximal femoral (1.3%: p=0.02, 2.8%: p<0.01, 4.5%: p<0.01) and femoral neck (2.0%: p=0.03, 2.7%: p=0.06, 5.0%: p=0.01) were significantly increased at 4, 8, 12 months after treatment. BMD at distal third radius (-1.5%: p<0.01, -0.8%: p=0.17, -1.0%: p=0.13) were not increased at 4, 8, 12 months after treatment. P1NP chane were 63% (p<0.01), 6.4% (p=0.55), -2.3% (p=0.2) at 4, 8, 12 months after treatment. There were no significant differences in 1 year improvement ratio of BMD at lumbar spine, proximal femoral and femoral neck between 38 patients with pretreatment of osteoporosis and 54 patients without pretreatment of osteoporpsis (13.5 vs 9.5%: p=0.1, 4.9 vs 4.4%: p=0.7, 6.1 vs 4.6%: p=0.67), between 33 patients with a history of fragility fracture and 59 patients without a history of fragility fracture (7.3 vs 11.7%: p=0.42, 0.8 vs 5.5%: p=0.08, -0.7 vs 6.6%: p=0.14), between 50 patients with romosozumab alone and 42 patients with romosozumab plus vitamin D (11.3 vs 10.0%: p=0.93, 4.1 vs 5.3%: p=0.59, 6.8 vs 2.3%: p=0.47). There were no significant differences in 1 year improvement ratio of BMD at distal third radius between 33 patients with pretreatment of osteoporosis and 16 patients without pretreatment of osteoporpsis (-1.1 vs -0.9%: p=0.63), between 31 patients with a history of fragility fracture and 18 patients without a history of fragility fracture (-1.5 vs -0.5%: p=0.3).

Conclusion

Romosozumab improved BMD at lumbar and femoral independently regardless of preosteoporosis treatment, history of fragility fracture and combination of vitamin D.

References

[1]Felicia Cosman et al. Romosozumab Treatment in Postmenopausal Women with Osteoporosis. N Engl J Med 2016; 375:1532-1543, DOI: 10.1056/NEJMoa1607948

Disclosure of Interests

None declared

Examination of the acute efficacy and safety about aggressive use of tolvaptan for early rising after admission in super-elder patients with congestive heart failure

Background

From August 2015, for shortening of hospitalization period through efficient medical care in acute phase, we had introduced a unique clinical pathway (PATH) for congestive heart failure (CHF) cases. In PATH, since immediate taking of Tolvaptan, which is an strong oral diuretic and approver for use in the treatment of CHF cases since 2010 in Japan, after admission is specified, early diuresis makes it possible to achieve early rising from bed and streamline each medical care such as oxygen inhalation, continuous infusion, and urethral catheterization. Early rising from bed is particularly important for super-elder CHF patients who merge often frail. On the other hand, for super-elder CHF patients, it is feared that aggressive use of Tolvaptan may frequently cause dehydration, renal damage caused by it, or hypernatremia, which is a peculiar side effect about the drug.

Purpose

In this study, we examined the usefulness and safety of active use of Tolvaptan by introducing PATH in patients with super-elder CHF patients.

Methods

We set up three groups, NE group consist of 37 CHF cases (90 years old or over) who admitted in our hospital before (without) introduction of PATH between April 2014 and July 2015, PE group consist of 130 CHF cases (90 years old or over) and PY group consist of 466 CHF cases (under 90 years old) who ware admitted with introduction of PATH between August 2015 and July 2020. And in each group, we investigated various medical conditions in their acute phase after admission and the incidence of adverse events related to oral administration of tolvaptan, and examined the differences between three groups.

Results

Between NE group and PE group, there were no significant differences in mean age, pre-hospital living status, or clinical status at admission (Figure 1). But due to lean and efficient CHF care, the average length of hospitalization period was significantly shorter in PE group. And, in PE group, each medical care was performed as efficiently as in PY group, but the progression of renal damage or hypernatremia that required unscheduled discontinuation of tolvaptan use occurred more frequently in PE group (Figure 2).

Conclusions

Aggressive Tolvaptan use through our unique clinical pathway for congestive heart failure cases seemed to be useful even in super-elder patients. Although we thought that the safety of active use of tolvaptan for super-elder patients was well tolerated considering the results of this study, the incidence of adverse events such as hypernatremia was clearly higher in super-elder patients than in non-super-elder patients. It seemed that we should pay close attention to the clinical data of super-elder patients after introduction of tolvaptan.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Examination about more realistic prognosis evaluation method, how long the patients with congestive heart failure can spend at home

Background

From August 2015, for efficient medical care in congestive heart failure (CHF) cases, we had introduced a unique clinical pathway (PATH) provided the immediate use of Tolvaptan and comprehensive education by multi-disciplinary staff after admission. And by introduction of PATH, we confirmed the shortening effect of hospitalization period with CHF and the suppressive effect of readmission with CHF after discharge. But since almost CHF patients repeat hospitalization and discharge due to change of their medical condition, the investigation for only first readmission rate after discharge is not enough to assess the entire long clinical course of CHF. Recently we found one report about evaluation method for CHF clinical prognosis, how long CHF patients can stay healthy at their own home after discharge within a certain period. This evaluation method is considered to take into account the long clinical course of CHF.

Purpose

We investigated whether the CHF patients introduced PATH on admission could stay longer at their home than CHF patients without PATH.

Methods

Between April 2014 and July 2019, 471 CHF cases, who ware admitted in our hospital at first and could be followed up for at least 1 month after discharge, ware enrolled. We divided them to two groups, PATH- group before introducing PATH (until July 2015, 142 cases), and PATH+ group applied PATH (after August 2015, 329 cases). Between both groups, we investigated the readmission rate (RR) with CHF and the total period (TP) that patients could spend at home within1, 3, 6 and 12month after discharge.

Results

There were no significant differences in mean age, pre-hospital living status, or clinical status at admission between the two groups. On the other hand, due to efficient CHF care, the average length of hospital stay was significantly shorter (figure1). RR within 1, 3, 6 and 12 months after discharge ware all lower in PATH+ group. And TP within 1, 3, 6 and 12 months after discharge ware all longer in PATH+ group (figure2).

Conclusion

By introducing our unique clinical pathway for congestive heart failure cases requiring hospitalization, we could confirm not only the improvement of their conventional clinical prognosis index but also the improvement of their new and more realistic clinical prognosis index after discharge.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Short- and Long-Term Outcomes of Live Donor Renal Allografts From Older and Younger Donors

BACKGROUND

The rising demand for living renal donors has led to the recruitment of older donors. Findings vary, but these grafts appear to survive as long as grafts from standard criteria deceased and expanded criteria deceased donors. We investigated the effects of donor age ≥65 years and the presence or absence of donor antihypertensive therapy on patient condition 1 year after transplantation, and retrospectively examined 1-year (273 patients), 3-year (217 patients), and 5-year (140 patients) patient and graft survival.

METHODS

We divided 273 donor-recipient pairs into Group Y (donor age <65 years, n = 224) and Group O (donor age ≥65 years, n = 49). Group O was subdivided into donors receiving treatment for hypertension (subgroup O-1, n = 16) and those not receiving treatment for hypertension (subgroup O-2, n = 33). We compared results of 1 hour post-transplant biopsies and looked at a small number of 1 year post-transplant biopsies.

RESULTS

Although a significantly larger percentage of recipients from younger donors were undergoing preemptive transplantation, and the incidence of arteriosclerosis was significantly higher in the Group O kidneys, there were no significant differences between the 2 groups in terms of patient or graft survival at 1, 3, or 5 years; serum creatinine levels; or number of episodes of acute rejection. The presence or absence of donor antihypertensive treatment had no effect.

CONCLUSIONS

We found that donor age ≥65, with or without antihypertensive treatment, had no effect on graft or patient survival.

Effective Treatment With Daclatasvir and Asunaprevir in Kidney Transplant Patients Infected With Hepatitis C Virus: A Report of Two Cases

BACKGROUND

Hepatitis C virus (HCV) infection is known to affect long-term patient and graft survivals after kidney transplantation (KT). Recently, combination therapy with the use of 2 oral direct-acting antivirals, daclatasvir (DCV) and asunaprevir (ASV) reportedly showed a high rate of HCV eradication. We report the safety and efficacy of DCV and ASV therapy in 2 KT patients.

METHODS

The safety and viral responses were investigated in a prospective study of KT patients infected with HCV genotype 1. Two patients received 60 mg DCV once daily plus 100 mg ASV twice daily for 24 weeks.

RESULTS

A 69-year-old woman and a 57-year-old man underwent DCV and ASV therapy for 24 weeks. In both cases, the HCV genotype was 1b. Case 1 had undergone KT twice and had received treatment with pegylated interferon and ribavirin. She received DCV and ASV therapy 12 years after the 2nd KT, and had undetectable virus after only 6 weeks of treatment and at 24 weeks after the end of treatment (SVR24). The post-transplantation immunosuppressive therapy at that time comprised tacrolimus, mycophenolate mofetil, and prednisolone. The other case, after failure of interferon treatment, received DCV and ASV therapy 27 years after his KT and achieved SVR24. His immunosuppressive regimen at that time was mizoribine and prednisolone. DCV and ASV therapy did not affect renal graft function or tacrolimus blood concentrations.

CONCLUSIONS

DCV and ASV therapy had high antiviral effect and a low rate of adverse events in KT patients.

Living Donor Kidney Transplantation After Brachytherapy for Prostate Cancer: Case Report

INTRODUCTION

There is no obvious criterion about kidney transplantation for patients with pretransplant malignancy. Minimum tumor-free waiting periods differ according to type of cancer, staging, site of occurrence, response to therapy, and risk of cancer recurrence. We report a case of living donor kidney transplantation (LDKT) in a patient after brachytherapy for prostate cancer.

CASE REPORT

The patient was a 65-year-old man with chronic kidney disease due to chronic glomerular nephritis. He received hemodialysis 3 times a week. His prostate-specific antigen level (PSA) was high (6.57 ng/mL), and he was diagnosed with prostate cancer (T1cN0M0, Gleason Score 3 + 4 = 7, 3/10) by needle biopsy in urology. He was treated with maximum androgen blockade (MAB) therapy and brachytherapy in May 2014. He underwent LDKT from a spousal donor at our department in December 2015, because urologists concluded that the prostate cancer was completely cured. Immunosuppression consisted of induction with basiliximab and maintenance with tacrolimus, mizoribine, and steroids. The postoperative course was uneventful. He discharged at postoperative day 29 with a serum creatinine level of 1.30 mg/dL. Three months after LDKT, his PSA level was 0.477 ng/mL, and there was no evidence of prostate cancer recurrence.

CONCLUSION

This is the first case of LDKT for patients with prostate cancer after brachytherapy in combination with MAB. There is no recurrence of prostate cancer so far; however, careful follow-up including PSA is necessary and important.

Thrombomodulin Attenuates Inflammatory Damage Due to Liver Ischemia and Reperfusion Injury in Mice in Toll-Like Receptor 4-Dependent Manner

Liver ischemia reperfusion injury (IRI) is an important problem in liver transplantation. Thrombomodulin (TM), an effective drug for disseminated intravascular coagulation, is also known to exhibit an anti-inflammatory effect through binding to the high-mobility group box 1 protein (HMGB-1) known as a proinflammatory mediator. We examined the effect of recombinant human TM (rTM) on a partial warm hepatic IRI model in wild-type (WT) and toll-like receptor 4 (TLR-4) KO mice focusing on the HMGB-1/TLR-4 axis. As in vitro experiments, peritoneal macrophages were stimulated with recombinant HMGB-1 protein. The rTM showed a protective effect on liver IRI. The rTM diminished the downstream signals of TLR-4 and also HMGB-1 expression in liver cells, as well as release of HMGB-1 from the liver. Interestingly, neither rTM treatment in vivo nor HMGB-1 treatment in vitro showed any effect on TLR-4 KO mice. Parallel in vitro studies have confirmed that rTM interfered with the interaction between HMGB-1 and TLR-4. Furthermore, the recombinant N-terminal lectin-like domain 1 (D1) subunit of TM (rTMD1) also ameliorated liver IRI to the same extent as whole rTM. Not only rTM but also rTMD1 might be a novel and useful medicine for liver transplantation. This is the first report clarifying that rTM ameliorates inflammation such as IRI in a TLR-4 pathway-dependent manner.

Coil Embolization for Intracranial Aneurysm by Direct Puncture of the Carotid Artery in Elderly Patients

Seven aneurysms in elderly patients (average 78 year-old) were treated by intra-aneurysmal coil embolization. The 19 gage elastic needle or 4.0Fr. sheath introducer was placed into the carotid artery, and 3.0Fr. microcatheter was advanced into the aneurysm.

An operative difficulty to approach to the aneurysm due to arteriosclerosis was ameliorated by this method. Mobility related to this procedure was a local hematoma at the puncture site in one case.

HSV vector-mediated GAD67 suppresses neuropathic pain induced by perineural HIV gp120 in rats through inhibition of ROS and Wnt5a

Human immunodeficiency virus (HIV)-related neuropathic pain is a debilitating chronic condition that is severe and unrelenting. Despite the extensive research, the exact neuropathological mechanisms remain unknown, which hinders our ability to develop effective treatments. Loss of GABAergic tone may play an important role in the neuropathic pain state. Glutamic acid decarboxylase 67 (GAD67) is one of isoforms that catalyze GABA synthesis. Here, we used recombinant herpes simplex virus (HSV-1) vectors that encode gad1 gene to evaluate the therapeutic potential of GAD67 in peripheral HIV gp120-induced neuropathic pain in rats. We found that 1) subcutaneous inoculation of the HSV vectors expressing GAD67 attenuated mechanical allodynia in the model of HIV gp120-induced neuropathic pain, 2) the anti-allodynic effect of GAD67 was reduced by GABA-A and-B receptors antagonists, 3) HSV vectors expressing GAD67 reversed the lowered GABA-IR expression, and 4) the HSV vectors expressing GAD67 suppressed the upregulated mitochondrial superoxide and Wnt5a in the spinal dorsal horn. Taken together, our studies support the concept that recovering GABAergic tone by the HSV vectors may reverse HIV-associated neuropathic pain through suppressing mitochondrial superoxide and Wnt5a. Our studies provide validation of HSV-mediated GAD67 gene therapy in the treatment of HIV-related neuropathic pain.

Vascularized anal autotransplantation model in rats: preliminary report

Ostomy has served as an effective surgery for various anorectal disfunctions. However, it must also be noted that those patients suffered greatly from stresses caused by their stoma. Many alternative therapies have been developed, but none have solved this critical issue. Meanwhile, due to the improvements in operative methods and immunosuppressive therapy, allotranplantation has gained great popularity in recent years. Therefore, we began development of an anal transplantation model. The operation was performed in six adult Wistar rats that were divided into two groups. Group 1 underwent vascular anastomoses, while group 2 did not Group 1 grafts survived, fully recovering anal function. However, many of the group 2 grafts did not survive; those that did survive showed major defects in their anus, never recovering anal function. We succeeded in establishing the rat anal transplantation model utilizing super-microsurgery. While research in anal transplantation was behind compared to that in other fields, we hope that this model will bring significant possibilities for the future.

Search for nucleon decay via n→ν[over ¯]π0 and p→ν[over ¯]π+ in Super-Kamiokande

We present the results of searches for nucleon decay via n→ν[over ¯]π0 and p→ν[over ¯]π+ using data from a combined 172.8  kt·yr exposure of Super-Kamiokande-I,-II, and-III. We set lower limits on the partial lifetime for each of these modes: τn→ν[over ¯]π0>1.1×10(33) years and τp→ν[over ¯]π+>3.9×10(32) years at a 90% confidence level.

Lymphaticovenular anastomosis to prevent cellulitis associated with lymphoedema

BACKGROUND

One of the complications of lymphoedema is recurrent cellulitis. The aim was to determine whether lymphaticovenous anastomosis (LVA) was effective at reducing cellulitis in patients with lymphoedema.

METHODS

This was a retrospective review of patients with arm/leg lymphoedema who underwent LVA. The frequency of cellulitis was compared before and after surgery. The diagnostic criteria for cellulitis were a fever of 38·5°C or higher, and warmth/redness in the affected limb(s).

RESULTS

A total of 95 patients were included. The mean number of episodes of cellulitis in the year preceding surgery was 1·46, compared with 0·18 in the year after surgery (P < 0·001).

CONCLUSION

LVA reduced the rate of cellulitis in these patients with lymphoedema.

Search for dinucleon decay into kaons in Super-Kamiokande

A search for the dinucleon decay pp → K+ K+ has been performed using 91.6  kton·yr data from Super-Kamiokande-I. This decay provides a sensitive probe of the R-parity-violating parameter λ112''. A boosted decision tree analysis found no signal candidates in the data. The expected background was 0.28±0.19 atmospheric neutrino induced events and the estimated signal detection efficiency was 12.6%±3.2%. A lower limit of 1.7×10(32)  years has been placed on the partial lifetime of the decay O16 → C14K+ K+ at 90% C.L. A corresponding upper limit of 7.8×10(-9) has been placed on the parameter λ112''.

Two-year results of intravitreal ranibizumab for polypoidal choroidal vasculopathy with recurrent or residual exudation

AIM

To clarify the 2-year efficacy of ranibizumab for patients with polypoidal choroidal vasculopathy (PCV) with recurrent or residual exudation from branching vascular networks after previous photodynamic therapy (PDT).

METHODS

We retrospectively reviewed 26 eyes of 26 Japanese patients (22 men, 4 women) in this pilot study. All eyes had PCV with complete regression of polypoidal lesions resulting from PDT detected by indocyanine green angiography (ICGA), but recurrent or residual leakage from branching vascular networks on fluorescein angiography and evidence of persistent fluid on optical coherence tomography (OCT). Three consecutive intravitreal injections of ranibizumab (0.5 mg/0.05 ml) were administered to all eyes.

RESULTS

The mean logarithm of the minimum angle of resolution best-corrected visual acuity (BCVA) improved significantly from 0.55 at baseline to 0.35 at 12 months (P<0.0001) and 0.43 at 24 months (P=0.0012). The mean increases in the BCVA 12 and 24 months after baseline were 1.95 and 1.23 lines, respectively. The mean central retinal thickness significantly decreased from 295 μm at baseline to 189 μm at 12 months (P<0.0038) and 163 μm at 24 months (P<0.001). The mean numbers of intravitreal ranibizumab (IVR) injections at months 12 and 24, including the initial treatments, were 5.8 and 8.8, respectively. Five (19.2%) eyes had recurrent polypoidal lesions on ICGA at a mean of 15.7 months after baseline. At month 24, OCT showed no exudation in 17 (65.4%) of the 26 eyes. No adverse events developed.

CONCLUSIONS

IVR injections maintained or improved the VA and retinal thickness at 24 months in eyes with PCV with recurrent or residual exudation from branching vascular networks after previous PDT.

Evidence for the appearance of atmospheric tau neutrinos in super-Kamiokande

Super-Kamiokande atmospheric neutrino data were fit with an unbinned maximum likelihood method to search for the appearance of tau leptons resulting from the interactions of oscillation-generated tau neutrinos in the detector. Relative to the expectation of unity, the tau normalization is found to be 1.42 ± 0.35(stat)(-0.12)(+0.14)(syst) excluding the no-tau-appearance hypothesis, for which the normalization would be zero, at the 3.8σ level. We estimate that 180.1 ± 44.3(stat)(-15.2)(+17.8) (syst) tau leptons were produced in the 22.5 kton fiducial volume of the detector by tau neutrinos during the 2806 day running period. In future analyses, this large sample of selected tau events will allow the study of charged current tau neutrino interaction physics with oscillation produced tau neutrinos.

Development of a new aortoscope system for the use of endovascular intervention

"Balloon aortoscopy" is a technique for viewing inner wall of aorta and used in clinics. By this method, endoluminal aortic surface could be clearly monitored, however, during this period, the aortic blood flow is blocked off by the inflated balloon. To solve this clinical problem, we have been developing a prototype aortoscope system without blocking off aortic flow aiming for the use of an assistive technique for endovascular interventions such as stent-graft placement for aortic aneurysm and have been evaluating through in vitro and in vivo tests. The technique introduced for this purpose was the use of intermittent and instantaneous saline jet controlled by a high-speed electromagnetic valve synchronized to heart beat (diastolic phase). In the previous study, we designed an endoscope with two channels (one for saline discharge and the other for forceps insertion), and confirmed the validity of this method by in vitro and in vivo tests. Based on these findings, in this study, we have newly designed a conventional and low price endoscope system aiming for wide clinical use. From the results of in vitro tests using a mock circulation system, it was confirmed that the newly designed system was capable of visualizing a target installed on an inner surface of the mock system suggesting an availability of the system for an aortoscope without blocking off aortic flow.

Pediatric liver transplantation using reduced and hyper-reduced left lateral segment grafts: a 10-year single-center experience

Few studies have examined the long-term outcomes and prognostic factors associated with pediatric living living-donor liver transplantation (LDLT) using reduced and hyper-reduced left lateral segment grafts. We conducted a retrospective, single-center assessment of the outcomes of this procedure, as well as clinical factors that influenced graft and patient survival. Between September 2000 and December 2009, 49 patients (median age: 7 months, weight: 5.45 kg) underwent LDLT using reduced (partial left lateral segment; n = 5, monosegment; n = 26), or hyper-reduced (reduced monosegment grafts; n = 18) left lateral segment grafts. In all cases, the estimated graft-to-recipient body weight ratio of the left lateral segment was more than 4%, as assessed by preoperative computed tomography volumetry, and therefore further reduction was required. A hepatic artery thrombosis occurred in two patients (4.1%). Portal venous complications occurred in eight patients (16.3%). The overall patient survival rate at 1, 3 and 10 years after LDLT were 83.7%, 81.4% and 78.9%, respectively. Multivariate analysis revealed that recipient age of less than 2 months and warm ischemic time of more than 40 min affected patient survival. Pediatric LDLT using reduced and hyper-reduced left lateral segment grafts appears to be a feasible option with acceptable graft survival and vascular complication rates.