Factors Associated with Return to Sport After Anterior Cruciate Ligament Reconstruction: A Focus on Athletes Who Desire Preinjury Level of Sport

INTRODUCTION

In most previous studies investigating return to preinjury level of sport (RTPS) after anterior cruciate ligament reconstruction (ACLR), whether patients continue aiming for RTPS not only before but also after ACLR was unclear because environmental and social factors were not considered. Herein, we aimed to evaluate factors associated with RTPS among athletes who desired to achieve RTPS even after ACLR, excluding patients who no longer desire this goal owing to environmental and social factors.

METHODS

Ninety-two patients who underwent primary double-bundle ACLR with a minimum 2-year follow-up and desired to achieve RTPS before surgery were retrospectively enrolled. Twelve (13%) patients who no longer desired to achieve RTPS after ACLR owing to environmental and social factors were excluded. Sixty-nine patients were included in the final cohort. At the final follow-up, the patients were split into two groups: those who achieved (R group) or did not achieve (N group) RTPS based on patient self-assessment. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and Lysholm scores were also determined. The anterior tibial translation in the Lachman test and acceleration and external rotational angular velocity (ERAV) in the pivot shift test were measured at the hardware removal operation.

RESULTS

Significant differences were observed for preinjury level of sports between the groups (P <.05). The rate of RTPS in competitive athletes was lower than that in recreational athletes (20/46: 43%, 16/22: 73%; P =.037). Lysholm score, KOOS symptom, pain, and quality of life showed higher values in the R than in the N group (P <.050). Acceleration was significantly lower in the R than in the N group (P =.028).

CONCLUSION

Competitive level of sports is a risk factor for failure to achieve RTPS. The postoperative functional outcomes in the group that achieved RTPS showed more favorable results. These results provide important information to enable the surgeons to consider the appropriate surgical plan for competitive athletes who desire to achieve RTPS after ACLR.

Rapid growth of primary pulmonary meningioma with hemoptysis

While lung cancer is the predominant neoplasm causing hemoptysis, rare benign neoplasms can also be associated with hemoptysis. A 60-year-old woman presented with cough and hemoptysis. Chest computed tomography revealed an oval-shaped, well-circumscribed solitary mass (10 cm in size) in the right lower lobe, which had grown rapidly over the past year. The presence of intramass air bubbles and a surrounding halo of ground-glass opacities suggested the hemorrhagic rupture of a circumscribed hematoma into the surrounding lung tissue. Subsequent right lower lobectomy revealed a well-demarcated hematoma; its wall consisted of nonatypical spindle tumor cells, which were histologically diagnosed as meningioma. No meningioma was observed in the central nervous system, leading to the diagnosis of primary pulmonary meningioma. This case highlights PPM as a rare benign tumor (World Health Organization grade 1) capable of rapid development due to intratumoral hemorrhage, presenting with hemoptysis.

Impact of lymph node dissection on the efficacy of immune checkpoint inhibitors in patients with postoperative recurrence of non-small cell lung cancer

Background

The effect of lymph node dissection (LND) on the efficacy of immune checkpoint inhibitor (ICI) remains unclear. The purpose of this study was to examine the difference in the effect of ICI between patients with non-small cell lung cancer (NSCLC) according to the extent of LND performed in surgery prior to postoperative recurrence.

Methods

A total of 134 patients with postoperative recurrence (surgery group, n=26) or unresectable advanced lung cancer (non-surgery group, n=108) who were treated with ICIs between January 2016 and December 2022 were included for analysis. In the surgery group, 16 patients underwent systematic LND, whereas the remaining 10 patients underwent selective LND. Progression-free survival with ICI treatment (ICI-PFS) and overall survival (OS) were compared between the surgery and non-surgery groups and between the systematic and selective LND groups using the inverse probability of treatment weighting (IPTW) method to adjust for patient background characteristics.

Results

In the IPTW-adjusted analysis, the 2-year PFS rate with ICI treatment was 31.2% in the surgery group and 27.3% in the non-surgery group (P=0.19); the corresponding 2-year OS rates were 69.6% and 62.2%, respectively (P=0.10). In the surgery group, the 2-year PFS rates under ICI were 20.0% in the systematic LND group and 45.7% in the selective LND group (P=0.03).

Conclusions

IPTW-adjusted analysis indicated no difference in prognosis between patients with postoperative recurrence and those with advanced unresectable lung cancer. However, in patients with postoperative recurrence, the extent of LND was a significant predictor of ICI-PFS. These findings suggest that systematic LND may reduce the efficacy of ICI, indicating that preoperative ICI administration may be warranted.

Simplified drug efficacy evaluation system for vasopressin neurodegenerative disease using mouse disease-specific induced pluripotent stem cells

Familial neurohypophyseal diabetes insipidus (FNDI) is a degenerative disorder in which vasopressin-secreting neurons degenerate over time due to the production of mutant proteins. We have demonstrated therapeutic effects of chemical chaperones in an FNDI mouse model, but the complexity and length of this evaluation were problematic. In this study, we established disease-specific mouse induced pluripotent stem cells (iPSCs) from FNDI-model mice and differentiated vasopressin neurons that produced mutant proteins. Fluorescence immunostaining showed that chemical chaperones appeared to protect vasopressin neurons generated from iPSCs derived from FNDI-model mice. Although KCL stimulation released vasopressin hormone from vasopressin neurons generated from FNDI-derived iPSCs, vasopressin hormone levels did not differ significantly between baseline and chaperone-added culture. Semi-quantification of vasopressin carrier protein and mutant protein volumes in vasopressin neurons confirmed that chaperones exerted a therapeutic effect. This research provides fundamental technology for creating in vitro disease models using human iPSCs and can be applied to therapeutic evaluation of various degenerative diseases that produce abnormal proteins.

Reverse Posterior Interosseous Artery Flap for Human Bite Injury to the Hand

Bite injuries frequently occur on human hands. Human bite injuries to the hand may lead to an infection because of limited soft tissue protection and wound contamination. However, no studies have reported severe bite injuries on hands treated by flaps. We report a case of an 80-year-old woman diagnosed with a major neurocognitive disorder. The patient accidentally had a self-bite injury accompanied with an open metacarpal fracture. Debridement and fixation of the first metacarpal fracture were performed. Afterward, skin necrosis occurred gradually on the dorsum of the hand. Therefore, a reverse posterior interosseous artery (PIA) flap was used, and the postoperative course was uneventful. Given the high risk of infection, human bite injuries, particularly hand bites, should be treated immediately. Delayed treatment for such injuries may lead to extensive soft tissue defects requiring reconstruction with flaps.

Outcomes of spring-locking plate fixation method using locking mesh plate/box plate for posterior wall fractures of the acetabulum: a retrospective single-centre study

INTRODUCTION

This retrospective study evaluated the outcomes of variable-angle locking compression plate, mesh plate, or footplate box fixation for posterior acetabular wall fractures.

PATIENTS AND METHODS

The study included nine patients with unstable posterior acetabular wall fractures who underwent internal fixation with the "spring-locking plate fixation method" between January 2015 and December 2019. Patient demographics, fracture classifications, surgical details, radiological and clinical evaluations, and complications were collected from electronic medical records. Statistical analyses were performed to assess the relationship between preoperative and postoperative dislocations.

RESULTS

The mean age of the patients was 46 years, and the majority were men (88.9%). Fracture types included posterior wall fractures and posterior column plus posterior wall fractures. The mean operative time was 246 min and the mean blood loss was 663 mL. The surgical approaches included the Kocher-Langenbeck, Ganz trochanteric flip, and transtrochanteric approaches. Variable-angle locking compression plate mesh plates and footplate box type implants were used for fixation. The mean preoperative dislocation was 23 mm, which was significantly reduced to 1 mm immediately post-operation and at the final observation. The bone fusion rate was 100% and radiological and clinical evaluations revealed favourable outcomes. Complications were minimal, with mild heterotopic ossification observed in four patients.

CONCLUSION

The spring-locking plate fixation method demonstrated satisfactory outcomes for the treatment of posterior acetabular wall fractures. This technique provides rigid fixation. Furthermore, the use of variable-angle locking screws minimizes the risk of intra-articular perforations. Despite limitations such as a small sample size and the absence of a control group, the results suggest that the spring-locking plate fixation method may be valuable in managing these fractures.

Efficacy of all-inside devices in reducing gap and step-off in knee extension for ramp lesion repair: A cadaveric study

PURPOSE

The aim of this study is to assess the dynamics of the tear site of meniscal ramp lesions, particularly considering knee flexion angles, and validate anchor fixation using an all-inside device.

METHODS

Eight Thiel-embalmed paired cadaveric knees with their whole bodies were used in this study. The ramp lesions were created arthroscopically, and ramp lesion dynamics were evaluated by gradually extending the knee from 90° of knee flexion. Changes in the gap and step-off (0: no step-off; 1: cross-sectional overlap exists; and 2: tibial articular surface exposed) were evaluated at 90°, 60°, 30°, and 10° of knee flexion. After dynamic evaluation, all-inside repairs of the ramp lesions using all-inside devices were conducted. Dissection was performed to confirm the position of anchor fixation.

RESULTS

As the knee was extended, the gap significantly decreased at all knee flexion angles. Similarly, the step-off grade decreased as the knee was extended, and the step-off completely disappeared in all cases when the knee was extended from 30° to 10°. The average knee flexion angle at which the gap and step-off completely disappeared was 22.5°. After suturing the ramp lesion, arthroscopic evaluation showed that the gap had disappeared and the step-off had been repaired in all cases. Anchor fixation locations were not found within the joint but were fixed to the semimembranosus tendon or its surrounding articular capsule. Overall, 31% (5/16) anchors were fixed to the attachment site of the semimembranosus tendon, whereas the remaining were fixed to the articular capsule, located peripherally to the semimembranosus tendon.

CONCLUSION

Suturing with an all-inside device for ramp lesions is a good option, and the repair in knee extension was found to be reasonable, considering the dynamics of ramp lesions in this study.

LEVEL OF EVIDENCE

Level IV.

Factors Associated With Residual Pivot Shift After ACL Reconstruction: A Quantitative Evaluation of the Pivot-Shift Test Preoperatively and at Minimum 12-Month Follow-up

Background

Postoperative residual rotatory laxity remains despite improvement in surgical techniques for anterior cruciate ligament (ACL) reconstruction (ACLR).

Purpose

To evaluate factors associated with residual pivot shift after ACLR by quantitative measurement of the pivot shift before and after surgery.

Study Design

Case-control study; Level of evidence, 3.

Methods

A total of 97 patients who underwent primary double-bundle ACLR between June 2016 and March 2021 and underwent surgery to remove staples, with at least 12 months of follow-up evaluation, were enrolled. Quantitative measurements were performed under general anesthesia immediately before ACLR (preoperatively), after temporary fixation of the ACL graft (intraoperatively), and immediately before staple removal (postoperatively). The laxity of pivot shift was assessed using inertial sensors to measure acceleration and external rotational angular velocity (ERAV). Descriptive data were assessed for associations with postoperative acceleration and ERAV in a univariate analysis. A multiple linear regression analysis was performed to identify factors associated with postoperative acceleration and ERAV.

Results

Anterior tibial translation, acceleration, and ERAV increased from intra- to postoperatively (P < .05). Factors significantly associated with postoperative acceleration were age (β = -0.238; P = .021), lateral posterior tibial slope (PTS) (β = 0.194; P = .048), and preoperative acceleration (β = 0.261; P = .008). Factors significantly affecting postoperative ERAV were age (β = -0.222; P = .029), ramp lesions (β = 0.212; P = .027), and preoperative ERAV (β = 0.323; P = .001).

Conclusion

Greater preoperative laxity in the pivot shift was the factor having the most significant association with residual pivot shift after ACLR using quantitative measurements under general anesthesia. Younger age, higher lateral PTS, and concomitant ramp lesions were significant predictors of residual pivot shift. These findings can help pre- and intraoperative decision-making regarding whether an anterolateral structure augmentation should be added.

Improved glycemic control after the use of flash glucose monitoring accompanied by improved treatment satisfaction in patients with non-insulin-treated type 2 diabetes: A post-hoc analysis of a randomized controlled trial

AIMS

In our previously reported randomized controlled trial in patients with noninsulin-treated type 2 diabetes, the use of flash glucose monitoring (FGM) improved glycated hemoglobin (HbA1c), and the improvement was sustained after the cessation of glucose monitoring. In this post-hoc analysis, we examined data from our trial to identify the factors that influenced FGM efficacy.

METHODS

We analyzed data for 48 of 49 participants of the FGM group who completed the trial to clarify the changes in various parameters and factors related to HbA1c improvement with the use of FGM.

RESULTS

Analyses of the FGM data during the 12-week FGM provision period showed that the weekly mean blood glucose levels considerably decreased as early as at 1 week compared with the baseline values, and this decline continued for 12 weeks. An enhancement in the Diabetes Treatment Satisfaction Questionnaire regarding "willingness to continue the current treatment" score was significantly associated with the improvement in HbA1c at 12 (p = 0.009) and 24 weeks (p = 0.012).

CONCLUSIONS

Glycemic control was improved soon after FGM initiation, accompanied by improved satisfaction with continuation of the current treatment in patients with noninsulin-treated type 2 diabetes.

Transforming Growth Factor-β Induces Interleukin-6 Secretion from Human Ligamentum Flavum-Derived Cells through Partial Activation of p38 and p44/42 Mitogen-Activated Protein Kinases

STUDY DESIGN

This experimental study was performed using human ligamentum flavum-derived cells (HFCs).

PURPOSE

To investigate the intracellular signaling mechanism of interleukin-6 (IL-6) secretion in transforming growth factor-β (TGF- β)-stimulated HFCs.

OVERVIEW OF LITERATURE

Lumbar spinal stenosis (LSS) is a prevalent disease among the elderly, characterized by debilitating pain in the lower extremities. Although the number of patients with LSS has increased in recent years, the underlying pathomechanism remains unclear. Clinical examinations typically rely on magnetic resonance imaging to diagnose patients, revealing ligamentum flavum hypertrophy. Some studies have suggested an association between ligamentum flavum hypertrophy and inflammation/fibrosis, and expression of TGF-β and IL-6 has been observed in surgically obtained ligamentum flavum samples. However, direct evidence linking TGF-β and IL-6 expression in HFCs is lacking.

METHODS

HFCs were obtained from patients with LSS who had undergone decompression surgery. The cells were stimulated with TGF-β and pretreated with either the p38 mitogen-activated protein (MAP) kinase inhibitor SB203580 or the p44/42 MAP kinase inhibitor FR180204. IL-6 secretion in the cell culture medium and IL-6 messenger RNA (mRNA) expression levels were analyzed using an enzyme-linked immunoassay and real-time polymerase chain reaction, respectively.

RESULTS

TGF-β administration resulted in a dose- and time-dependent stimulation of IL-6 release. Treatment with SB203580 and FR180204 markedly suppressed TGF-β-induced IL-6 secretion from HFCs. Moreover, these inhibitors suppressed IL-6 mRNA expression in response to TGF-β stimulation.

CONCLUSIONS

Our findings indicate that TGF-β induces IL-6 protein secretion and gene expression in HFCs through the activation of p38 or p44/42 MAP kinases. These results suggest a potential association between IL-6-mediated inflammatory response and tissue hypertrophy in LSS, and we provide insights into molecular targets for therapeutic interventions targeting LSS-related inflammation through our analysis of the MAP kinase pathway using HFCs.

Generation and purification of ACTH-secreting hPSC-derived pituitary cells for effective transplantation

Pituitary organoids are promising graft sources for transplantation in treatment of hypopituitarism. Building on development of self-organizing culture to generate pituitary-hypothalamic organoids (PHOs) using human pluripotent stem cells (hPSCs), we established techniques to generate PHOs using feeder-free hPSCs and to purify pituitary cells. The PHOs were uniformly and reliably generated through preconditioning of undifferentiated hPSCs and modulation of Wnt and TGF-β signaling after differentiation. Cell sorting using EpCAM, a pituitary cell-surface marker, successfully purified pituitary cells, reducing off-target cell numbers. EpCAM-expressing purified pituitary cells reaggregated to form three-dimensional pituitary spheres (3D-pituitaries). These exhibited high adrenocorticotropic hormone (ACTH) secretory capacity and responded to both positive and negative regulators. When transplanted into hypopituitary mice, the 3D-pituitaries engrafted, improved ACTH levels, and responded to in vivo stimuli. This method of generating purified pituitary tissue opens new avenues of research for pituitary regenerative medicine.

Response to endoplasmic reticulum stress in arginine vasopressin neurons

Arginine vasopressin (AVP) is an antidiuretic hormone synthesized principally in the hypothalamic supraoptic and paraventricular nuclei. The immunoglobulin heavy chain binding protein (BiP), one of the most abundant endoplasmic reticulum (ER) chaperones, is highly expressed in AVP neurons, even under basal conditions. Moreover, its expression is upregulated in proportion to the increase in AVP expression under dehydration. These data suggest that AVP neurons are constantly exposed to ER stress. BiP knockdown in AVP neurons induces ER stress and autophagy, resulting in AVP neuronal loss, indicating that BiP is pivotal in maintaining the AVP neuron system. Furthermore, inhibition of autophagy after BiP knockdown exacerbates AVP neuronal loss, suggesting that autophagy induced under ER stress is a protective cellular mechanism by which AVP neurons cope with ER stress. Familial neurohypophysial diabetes insipidus (FNDI) is an autosomal dominant disorder caused by mutations in the AVP gene. It is characterized by delayed-onset progressive polyuria and eventual AVP neuronal loss. In AVP neurons of FNDI model mice, mutant protein aggregates are confined to a specific compartment of the ER, called the ER-associated compartment (ERAC). The formation of ERACs contributes to maintaining the function of the remaining intact ER, and mutant protein aggregates in ERACs undergo autophagic-lysosomal degradation without isolation or translocation from the ER, representing a novel protein degradation system in the ER.

Outcomes of Window Therapy with Carboplatin and Ifosfamide for Pediatric Osteosarcoma: A Case Series

For the treatment of osteosarcoma, cisplatin (CDDP) can be substituted by carboplatin (CBDCA) to reduce toxicity. We report a single institution experience of CBDCA-based regimen. Two to three cycles of CBDCA + ifosfamide (IFO) therapy (window therapy) were administered as neoadjuvant therapy for osteosarcoma. Depending on the response of window therapy, the subsequent protocols were determined; for good responders, surgery is performed, and postoperative therapies with CBDCA + IFO, adriamycin (ADM) and high-dose methotrexate (MTX) were administered; for stable disease, the postoperative regimens were advanced before surgery, and the remaining amount of postoperative chemotherapy is deduced; for progressive disease, CBDCA-based regimen is changed to CDDP-based regimen. From 2009 to 2019, seven patients were treated with this protocol. During the window therapy, two patients (28.6%) were assessed as good responders and completed the regimen as planned. Four patients (57.1%) had stable disease, and the chemotherapy schedules were modified. One patient (14.2%) with progressive disease was shifted to the CDDP-based regimen. At final follow-up, four patients showed no evidence of disease and three patients died of the disease. Since the efficacy during window therapy was limited, a CBDCA-based regimen in the neoadjuvant setting was considered insufficient for performing adequate surgery.

Median Nerve Recovery and Morphological Change on MRI at 24 Months after Open Carpal Tunnel Release

Background: This study aimed to investigate the relationship between postoperative clinical results and long-term morphological changes in patients with carpal tunnel syndrome (CTS) as observed on magnetic resonance imaging (MRI) before and after open carpal tunnel release (OCTR). Methods: We retrospectively analysed data for 28 hands that had undergone OCTR with at least 24 months of follow-up data. Two-point discrimination (2PD) test results were examined for the first three fingers, as were the distal motor latency (DML) and sensory conduction velocity (SCV) of the median nerve. We also calculated the cross-sectional area (CSA) of the carpal tunnel and the distance from the median nerve to the volar carpal bone at the hamate and the pisiform levels using MRI images. Variables were compared before and 24 months after OCTR. Results: Significant improvements in all variables were observed, including average 2PD scores (Finger I: 13.1 ± 6.2 vs. 7.7 ± 4.3, p < 0.01, Finger II: 11.9 ± 6.6 vs. 7.0 ± 3.5, p < 0.01, Finger III: 13.6 ± 6.1 vs. 7.8 ± 4.5, p < 0.01), average DML (8.3 ± 3.3 vs. 4.3 ± 0.6 m/s, p < 0.01), average SCV (30.8 ± 11.0 vs. 41.3 ± 5.3 m/s, p < 0.01), CSA of the carpal tunnel (hamate level: 194.9 ± 30.6 vs. 254.2 ± 47.6 mm2, p < 0.01, pisiform level: 244.2 ± 46.5 vs. 274.7 ± 75.1 mm2, p = 0.01) and the distance between the median nerve and volar carpal bone (hamate level: 8.7 ± 1.4 vs. 11.2 ± 1.6 mm, p < 0.01, pisiform level: 11.8 ± 1.7 vs. 13.8 ± 2.5 mm, p < 0.01). Conclusions: Our results demonstrate that OCTR is successful in achieving long-term decompression and recovery of the median nerve in patients with CTS. Level of Evidence: Level III (Therapeutic).

Mineralocorticoids induce polyuria by reducing apical aquaporin-2 expression of the kidney in partial vasopressin deficiency

The symptoms of diabetes insipidus may be masked by the concurrence of adrenal insufficiency and emerge after the administration of hydrocortisone, occasionally at high doses. To elucidate the mechanism underlying polyuria induced by the administration of high-dose corticosteroids in the deficiency of arginine vasopressin (AVP), we first examined the secretion of AVP in three patients in whom polyuria was observed only after the administration of high-dose corticosteroids. Next, we examined the effects of dexamethasone or aldosterone on water balance in wild-type and familial neurohypophyseal diabetes insipidus (FNDI) model mice. A hypertonic saline test showed that AVP secretion was partially impaired in all patients. In one patient, there were no apparent changes in AVP secretion before and after the administration of high-dose corticosteroids. In FNDI mice, unlike dexamethasone, the administration of aldosterone increased urine volumes and decreased urine osmolality. Immunohistochemical analyses showed that, after the administration of aldosterone in FNDI mice, aquaporin-2 expression was decreased in the apical membrane and increased in the basolateral membrane in the collecting duct. These changes were not observed in wild-type mice. The present data suggest that treatment with mineralocorticoids induces polyuria by reducing aquaporin-2 expression in the apical membrane of the kidney in partial AVP deficiency.

Resting energy expenditure depends on energy intake during weight loss in people with obesity: a retrospective cohort study

Objective

Resting energy expenditure (REE) decreases if there is reduced energy intake and body weight (BW). The decrease in REE could make it difficult for patients with obesity to maintain decreased BW. This study aimed to investigate the correlation among changes in REE, energy intake, and BW during the weight loss process in patients with obesity.

Materials and methods

We conducted a retrospective cohort study of patients hospitalized for the treatment of obesity in Japan. Patients received fully controlled diet during hospitalization and performed exercises if able. REE was measured once a week using a hand-held indirect calorimetry. Energy intake was determined by actual dietary intake.

Results

Of 44 inpatients with obesity, 17 were included in the analysis. Their BW decreased significantly after 1 week (-4.7 ± 2.0 kg, P < 0.001) and 2 weeks (-5.7 ± 2.2 kg, P < 0.001). The change in REE after 1 and 2 weeks was positively correlated with the energy intake/energy expenditure ratio (r = 0.66, P = 0.004 at 1 week, r = 0.71, P = 0.002 at 2 weeks). Using a regression equation (y = 0.5257x - 43.579), if the energy intake/energy expenditure ratio within the second week was 82.9%, the REE after 2 weeks was similar to the baseline level. There was no significant correlation between the change in REE and BW.

Conclusion

Our data suggest that changes in REE depend on energy intake/energy expenditure ratio and that the decrease in REE can be minimized by matching energy intake to energy expenditure, even during the weight loss process.

Generation of hypothalamic neural stem cell-like cells in vitro from human pluripotent stem cells

When damaged, restoring the function of the hypothalamus is currently impossible. It is unclear whether neural stem cells exist in the hypothalamus. Studies have reported that adult rodent tanycytes around the third ventricle function as hypothalamic neural stem cell-like cells. However, it is currently impossible to collect periventricular cells from humans. We attempted to generate hypothalamic neural stem cell-like cells from human embryonic stem cells (ESCs). We focused on retina and anterior neural fold homeobox (RAX) because its expression is gradually restricted to tanycytes during the late embryonic stage. We differentiated RAX::VENUS knockin human ESCs (hESCs) into hypothalamic organoids and sorted RAX⁺ cells from mature organoids. The isolated RAX⁺ cells formed neurospheres and exhibited self-renewal and multipotency. Neurogenesis was observed when neurospheres were transplanted into the mouse hypothalamus. We isolated RAX⁺ hypothalamic neural stem cell-like cells from wild-type human ES organoids. This is the first study to differentiate human hypothalamic neural stem cell-like cells from pluripotent stem cells.

Knockdown of endoplasmic reticulum chaperone BiP leads to the death of parvocellular AVP/CRH neurons in mice

Arginine vasopressin (AVP) is expressed in both magnocellular (magnAVP) and parvocellular AVP (parvAVP) neurons of the paraventricular nucleus, and AVP colocalizes with corticotropin-releasing hormone (CRH) only in the parvocellular neurons. The immunoglobulin heavy chain binding protein (BiP) is a major endoplasmic reticulum (ER) chaperone which regulates the unfolded protein response under ER stress. We previously demonstrated that knockdown of BiP in magnAVP neurons exacerbated ER stress, which resulted in the autophagy-associated cell death of magnAVP neurons. Using the same approach, in the present study we examined the role of BiP in mouse parvAVP/CRH neurons. Our data demonstrate that BiP is expressed in mouse parvAVP/CRH neurons under nonstress conditions and is upregulated in proportion to the increase in CRH expression after adrenalectomy. For BiP knockdown in parvAVP/CRH neurons, we utilized a viral approach in combination with shRNA interference. Knockdown of BiP expression induced ER stress in parvAVP/CRH neurons, as reflected by the expression of C/EBP homologous protein. Furthermore, BiP knockdown led to the loss of parvAVP/CRH neurons after 4 weeks. In summary, our results demonstrate that BiP plays a pivotal role in parvAVP/CRH neurons, which function as neuroendocrine cells producing a large number of secretory proteins.

AB0667 EFFECT OF TEMPERATURE VARIATION ON SERUM KL-6 LEVELS IN PATIENTS WITH SYSTEMIC SCLEROSIS

Background

Serum Krebs von den Lungen-6 (KL-6) levels has much evidence as a biomarker about the progression and prognosis of interstitial lung disease (ILD), including systemic sclerosis (SSc)-associated ILD1-4. However, serum KL-6 levels often fluctuate regardless of the progression of ILD. This sometimes mislead the evaluation of the disease activity, however, the reason for the fluctuation has not been clarified.

Objectives

We tested the hypothesis that serum KL-6 levels are affected by ambient temperature in patients with SSc.

Methods

We defined the warm season（May–October）as the period when the ambient temperature was above the Tokyo metropolitan average ambient temperature announced by the Japan Meteorological Agency, and the cold season (November–April）as the period when the ambient temperature was below the average. ILD was classified based on chest CT findings. Among SSc patients who had visited our department since May 2018, we selected those who had data of serum KL-6 levels at least 3 times in warm and cold seasons from October 2014 to September 2021, respectively. Patients having malignancy were excluded after confirmation of the onset of malignancy using medical record retrospectively. The difference in serum KL-6 levels between warm and cold seasons was evaluated by Wilcoxon’s rank-sum test.

Results

In total, 252 patients with SSc were included. Median age was 66.3 years, with median disease duration of 13.5 (8.9–19.2）years, diffuse cutaneous type of 94 (37.3%）patients, and concomitant ILD of 120（47.6%）patients (Table 1). The median follow-up was 6.4 (4.4–6.8）years, with median KL-6 measurement of 24（14–39）times. Serum KL-6 levels were significantly higher in the cold season than that in the warm season, with a greater difference in the group with ILD（536 IU/L vs. 492 IU/L, p = 0.0012 in the group with ILD, 364 IU/L vs. 345 IU/L in the group without ILD, p = 0.0028）.

Table 1.

Patients characteristics

With ILD (n=120)Without ILD (n=132)P valueFemale, n (%)110 (43.7)128 (52.4)0.1Age, years (IQR)65.8(56.1–73.4)66.4(56.0–72.5)0.77Disease duration, years (IQR)14.0 (9.8-21.0)13.0 (8.7-18.0)0.23Modified Rodnan skin score (IQR)10 (4-15)6 (2-11)0.0017Diffuse SSc, n (%)53 (40.2)27 (20.5)<0.001Pulmonary hypertension, n (%)4 (3.3)3 (2.3)0.71ANA positive, n (%)98 (81.7)112 (84.8)0.50SSc-related autoantibody, n (%)98 (81.7)112 (84.8)0.50Anti-centromere antibody, n (%)17 (14.2)86 (71.7)<0.0001Anti-topoisomeraseⅠ antibody, n (%)63 (52.5)8 (6.1)<0.0001Anti-RNA polymerase Ⅲ antibody, n (%)7 (5.8)11 (8.3)0.62Anti-U1-RNP antibody, n (%)15 (12.5)13 (9.8)0.54KL-6, IU/L (IQR)548 (384–876.8)233 (191.3–302)<0.0001KL-6 measurement, times (IQR)33.5(20-45)18.5(12.3-28)<0.0001Steroid use, n (%)68 (56.7)22 (16.7)<0.0001Cyclophosphamide, n (%)44 (36.7)12 (9.1)<0.0001Other Immunosuppressive agents, n (%)31 (25.8)0.002

Conclusion

Our results suggest that cold ambient temperature may affect serum KL-6 levels in patients with SSc.

References

[1]Distler O, et al. Eur Respir J.2020;55:1902026.

[2]Kuwana M et al. J Rheumatol 2016;43:1825-31

[3]Volkmann et al. Arthritis Rheumatol.2019;71:2059-2067

[4]Elhai M et al. Arthritis Rheumatol. 2019;71:972-982.

Figure 1.

Disclosure of Interests

Hikaru Hirose Grant/research support from: Bayer Yakuhin, Ltd, Tomoaki Higuchi: None declared, Kae Takagi: None declared, Akiko Tochimoto: None declared, Yasushi Kawaguchi: None declared, Masayoshi Harigai Speakers bureau: AbbVie Japan, Ayumi, Boehringer Ingelheim Japan, Bristol-Myers Squibb, Chugai, Eisai, Eli Lilly Japan, GlaxoSmithKline, Kissei, Pfizer Japan Inc, Takeda, Teijin, Consultant of: AbbVie Japan, Boehringer Ingelheim Japan, Bristol-Myers Squibb, Kissei, Teijin, Grant/research support from: AbbVie Japan, Asahi Kasei, Astellas, Ayumi, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Kissei, Mitsubishi Tanabe, Nippon Kayaku, Sekisui Medical, Shionogi, Taisho, Takeda, Teijin

OP0112 THE EVER-LARGEST ASIAN GWAS FOR SYSTEMIC SCLEROSIS AND TRANS-POPULATION META-ANALYSIS IDENTIFIED SEVEN NOVEL LOCI AND A CANDIDATE CAUSAL SNP IN A CIS-REGULATORY ELEMENT OF THE FCGR REGION

Background

Genome-wide association studies (GWASs) have identified 29 disease-associated single nucleotide polymorphisms (SNPs) for systemic sclerosis (SSc) in non-human leukocyte antigen (HLA) regions (1-7). While these GWASs have clarified genetic architectures of SSc, study subjects were mainly Caucasians limiting application of the findings to Asians.

Objectives

The study was conducted to identify novel causal variants for SSc specific to Japanese subjects as well as those shared with European population. We also aimed to clarify mechanistic effects of the variants on pathogenesis of SSc.

Methods

A total of 114,108 subjects comprising 1,499 cases and 112,609 controls were enrolled in the two-staged study leading to the ever-largest Asian GWAS for SSc. After applying a strict quality control both for genotype and samples, imputation was conducted using the reference panel of the phase 3v5 1,000 genome project data combined with a high-depth whole-genome sequence data of 3,256 Japanese subjects. We conducted logistic regression analyses and also combined the Japanese GWAS results with those of Europeans (6) by an inverse-variance fixed-effect model. Polygenicity and enrichment of functional annotations were evaluated by linkage disequilibrium score regression (LDSC), Haploreg and IMPACT programs. We also constructed polygenic risk score (PRS) to predict SSc development.

Results

We identified three (FCRLA-FCGR, TNFAIP3, PLD4) and four (EOMES, ESR1, SLC12A5, TPI1P2) novel loci in Japanese GWAS and a trans-population meta-analysis, respectively. One of Japanese novel risk SNPs, rs6697139, located within FCGR gene clusters had a strong effect size (OR 2.05, P=4.9×10-11). We also found the complete LD variant, rs10917688, was positioned in cis-regulatory element and binding motif for an immunomodulatory transcription factor IRF8 in B cells, another genome-wide significant locus in our trans-ethnic meta-analysis and the previous European GWAS. Notably, the association of risk allele of rs10917688 was significant only in the presence of the risk allele of the IRF8. Intriguingly, rs10917688 was annotated as one enhancer-related histone marks, H3K4me1, in B cells, implying that FCGR gene(s) in B cells may play an important role in the pathogenesis of SSc. Furhtermore, significant heritability enrichment of active histone marks and a transcription factor C-Myc were found in B cells both in European and Japanese populations by LDSC and IMPACT, highlighting a possibility of a shared disease mechanism where abnormal B-cell activation may be one of the key drivers for the disease development. Finally, PRS using effects sizes of European GWAS moderately fit in the development of Japanese SSc (AUC 0.593), paving a path to personalized medicine for SSc.

Conclusion

Our study identified seven novel susceptibility loci in SSc. Downstream analyses highlighted a novel disease mechanism of SSc where an interactive role of FCGR gene(s) and IRF8 may accelerate the disease development and B cells may play a key role on the pathogenesis of SSc.

References

[1]F. C. Arnett et al. Ann Rheum Dis, 2010.

[2]T. R. Radstake et al. Nat Genet, 2010.

[3]Y. Allanore et al. PLoS Genet, 2011.

[4]O. Gorlova et al. PLoS Genet, 2011.

[5]C. Terao et al. Ann Rheum Dis, 2017.

[6]E. López-Isac et al. Nat Commun, 2019.

[7]W. Pu et al. J Invest Dermatol, 2021.

Disclosure of Interests

None declared

Reverse lateral upper arm flaps for treating large soft tissue defects extending from the elbow to the forearm

In this study, we report three cases wherein reverse lateral upper arm flaps were used to treat very large tissue defects extending from the elbow to the forearm. The flap sizes were 19 × 6.5 cm, 20 × 7 cm, and 17 × 7 cm. All flaps survived and elbow motion recovered sufficiently.

Increased Risk of Thyroid Dysfunction by PD-1 and CTLA-4 Blockade in Patients Without Thyroid Autoantibodies at Baseline

BACKGROUND

Previous studies showed that although the risk of thyroid dysfunction [thyroid immune-related adverse events (irAEs)] induced by anti-programmed cell death-1 antibodies (PD-1-Ab) was as low as 2% to 7% in patients negative for anti-thyroid antibodies (ATAs) at baseline, it was much higher (30%-50%) in patients positive for ATAs. However, whether a similar increase occurs with combination therapy using PD-1-Ab plus anti-cytotoxic T-lymphocyte antigen-4 antibody (CTLA-4-Ab) is unknown.

METHODS

A total of 451 patients with malignancies treated with PD-1-Ab, CTLA-4-Ab, or a combination of PD-1-Ab and CTLA-4-Ab (PD-1/CTLA-4-Abs) were evaluated for ATAs at baseline and for thyroid function every 6 weeks for 24 weeks after treatment initiation and then observed until the last clinical visit.

RESULTS

Of the 451 patients, 51 developed thyroid irAEs after immunotherapy [41 of 416 (9.9%) treated with PD-1-Ab, 0 of 8 (0%) treated with CTLA-4-Ab, and 10 of 27 (37.0%) treated with PD-1/CTLA-4-Abs]. The cumulative incidence of thyroid irAEs was significantly higher in patients who were positive vs negative for ATAs at baseline after both PD-1-Ab [28/87 (32.2%) vs 13/329 (4.0%), P < 0.001] and PD-1/CTLA-4-Abs [6/10 (60.0%) vs 4/17 (23.5%), P < 0.05] treatments. The risk of thyroid irAEs induced by PD-1/CTLA-4Abs, which was significantly higher than that induced by PD-1-Ab, in patients negative for ATAs at baseline was not statistically different from that induced by PD-1-Ab in patients positive for ATAs at baseline.

CONCLUSIONS

This study showed that the incidence of thyroid irAEs was high and not negligible after PD-1/CTLA-4-Abs treatment even in patients negative for ATAs at baseline.

Functional Lactotrophs in Induced Adenohypophysis Differentiated From Human iPS Cells

Prolactin (PRL), a hormone involved in lactation, is mainly produced and secreted by the lactotrophs of the anterior pituitary (AP) gland. We previously reported a method to generate functional adrenocorticotropic hormone-producing cells by differentiating the AP and hypothalamus simultaneously from human induced pluripotent stem cells (iPSCs). However, PRL-producing cells in the induced AP have not been investigated. Here, we confirmed the presence of PRL-producing cells and evaluated their endocrine functions. We differentiated pituitary cells from human iPSCs using serum-free floating culture of embryoid-like aggregates with quick reaggregation (SFEB-q) method and evaluated the appearance and function of PRL-producing cells. Secretion of PRL from the differentiated aggregates was confirmed, which increased with further culture. Fluorescence immunostaining and immunoelectron microscopy revealed PRL-producing cells and PRL-positive secretory granules, respectively. PRL secretion was promoted by various prolactin secretagogues such as thyrotropin-releasing hormone, vasoactive intestinal peptide, and prolactin-releasing peptide, and inhibited by bromocriptine. Moreover, the presence of tyrosine hydroxylase-positive dopaminergic nerves in the hypothalamic tissue area around the center of the aggregates connecting to PRL-producing cells indicated the possibility of recapitulating PRL regulatory mechanisms through the hypothalamus. In conclusion, we generated pituitary lactotrophs from human iPSCs; these displayed similar secretory responsiveness as human pituitary cells in vivo. In the future, this is expected to be used as a model of human PRL-producing cells for various studies, such as drug discovery, prediction of side effects, and elucidation of tumorigenic mechanisms using disease-specific iPSCs. Furthermore, it may help to develop regenerative medicine for the pituitary gland.

Prognostic role of preoperative carcinoembryonic antigen level in part-solid lung adenocarcinoma

BACKGROUND

Part-solid lung adenocarcinoma appears as a heterogeneous subgroup, and its surgical management is controversial. This study aimed to elucidate whether preoperative carcinoembryonic antigen, a time-honored tumor marker, can be used as a prognostic factor that contributes to its management.

METHODS

We retrospectively reviewed consecutive patients with clinical-T1a-cN0M0 part-solid adenocarcinoma who underwent surgical resection between January 2011 and December 2015 at two institutions.

RESULTS

Overall, 288 patients were identified. The median age was 69 years with 176 patients (61%) being female. The median follow-up time was 5.6 years. Lymph node metastases were found in 6 (15%) of 41 patients with elevated carcinoembryonic antigen levels, while 10 (4.0%) of 247 patients had normal carcinoembryonic antigen levels (P = 0.016). The 5-year overall survival rates in patients with normal and elevated carcinoembryonic antigen levels were 96.9% and 87.2%, respectively (P = 0.006), and the 5-year relapse-free survival rates were 91.8% and 62.8%, respectively (P < 0.001). The multivariable analysis revealed that preoperative carcinoembryonic antigen level was a significant prognostic factor for relapse-free survival (hazard ratio [HR] = 2.92, 95% confidence interval [CI] = 1.63-5.25, P < 0.001). Among the patients with elevated carcinoembryonic antigen levels, the 5-year overall survival rates in those undergoing lobar resection and segmentectomy were 87.0% and 88.9%, respectively (P = 0.59), and the 5-year relapse-free survival rates were 61.7% and 66.7%, respectively (P = 0.84).

CONCLUSIONS

Our data suggest that preoperative carcinoembryonic antigen level appears to be an important predictor of postoperative survival outcomes in early-stage part-solid adenocarcinoma. Further studies are required to optimize management of patients with elevated preoperative carcinoembryonic antigen levels, although segmentectomy appeared acceptable in those patients.

The Janus kinase inhibitor (baricitinib) suppresses the rheumatoid arthritis active marker gliostatin/thymidine phosphorylase in human fibroblast-like synoviocytes

Gliostatin/thymidine phosphorylase (GLS/TP) is known to have angiogenic and arthritogenic activities in the pathogenesis of rheumatoid arthritis (RA). The novel oral Janus kinase (JAK) inhibitor baricitinib has demonstrated high efficacy in RA. However, the effect of baricitinib on fibroblast-like synoviocytes (FLSs), a key component of invasive synovitis, has not been still elucidated. This study investigated whether GLS/TP production could be regulated by JAK/signal transducers and activators of transcription (STAT) signaling in FLSs derived from patients with RA. FLSs were cultured and stimulated by interferon (IFN)γ in the presence of baricitinib. Expression levels of GLS/TP were determined using reverse transcription-polymerase chain reaction (RT-PCR), enzyme-linked immunosorbent assay (ELISA), and immunocytochemistry. Phosphorylation of STAT proteins was investigated by Western blot. In cultured FLSs, GLS/TP mRNA and protein levels were significantly induced by treatment with IFNγ and these inductions were suppressed by baricitinib treatment. Baricitinib inhibited IFNγ-induced STAT1 phosphorylation, while JAK/STAT activation played a pivotal role in IFNγ-mediated GLS/TP upregulation in RA. These results suggested that baricitinib suppressed IFNγ-induced GLS/TP expression by inhibiting JAK/STAT signaling, resulting in the attenuation of neovascularization, synovial inflammation, and cartilage destruction.

Subcutaneous abscess due to empyema necessitans caused by Porphyromonas gingivalis in a patient with periodontitis

Empyema necessitans is a rare empyema complication characterized by an extension of empyema out of the pleural space into the subcutaneous tissues of the chest wall. We herein report a case of empyema necessitans that presented as a subcutaneous chest wall abscess caused by Porphyromonas gingivalis (P. gingivalis), an important anaerobic periodontal pathogen, in a 74-year-old woman with periodontitis. The patient was admitted to our hospital with a painful soft tissue mass in the chest wall extending from a subpleural lung abscess associated with empyema. Exploratory percutaneous puncture and aspiration of the chest wall mass yielded foul-smelling chocolate-colored pus, which was found to be caused due to infection with P. gingivalis. Treatment with antibacterials resulted in a relapse of empyema necessitans requiring a second admission 1 month later. An additive treatment with surgical open drainage and decortication of the subcutaneous abscess successfully cured the abscess. Physicians must be aware of emphysema necessitans as an etiology of a chest wall mass and should consider periodontitis as a source of infection.

An Analysis of the Femoral Drilling Angle to Avoid Tunnel Collision during Double-Bundle Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction on the Knee

Concomitant anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction has been reported as an effective technique for providing rotational control of the knee. However, the intraoperative risk of collision with an ACL tunnel during the drilling for the femoral ALL tunnel has been described. The purpose of this study was to investigate the various femoral drilling procedures to avoid tunnel collisions during combined double-bundle ACL and ALL reconstruction. Nine cadaveric knees were used in this study. ACL drilling was performed through the anteromedial portal to footprints of the posterolateral bundle at 120° (PL120) and 135° (PL135) knee flexion and the anteromedial bundle at 120° (AM120) and 135° (AM135) knee flexion. ALL drilling was performed at 0° (Cor0-ALL) and 30° (Cor30-ALL) coronal angles using a Kirschner wire (K-wire). The distance between the ALL footprint and ACL K-wire outlets, axial angles of ALL K-wires colliding with ACL K-wires, and distances from the ALL footprint to the collision point were measured. From these values, the safe zone, defined as the range of axial angles in which no collisions or penetrations occurred, was identified by simulation of tunnels utilized for reconstruction grafts in each drilling procedure. The point-to-point distance from the ALL footprint to the K-wire outlet was significantly greater in the AM120 than the AM135 (13.5 ± 3.1, 10.8 ± 3.2 mm; p = 0.048) and in the PL135 than the PL120 (18.3 ± 5.5, 16.1 ± 6.5 mm; p = 0.005) conditions, respectively. During an ACL drilling combination of PL135/AM120, a safe zone of > 45° in Cor30-ALL was identified. With a narrow safe zone during the PL135/AM120 combination only, the risk of femoral tunnel collisions in combined double-bundle ACL and ALL reconstruction is high. AM drilling at 120° and PL drilling at > 135° knee flexion, combined with ALL drilling at 30° coronal angle and > 45° axial angle, may reduce this risk.

The Inducible Nitric Oxide Synthase Pathway Promotes Osteoclastogenesis under Hypoxic Culture Conditions

Bone homeostasis depends on the balance between bone resorption by osteoclasts (OCs) and bone formation by osteoblasts. Bone resorption can become excessive under various pathologic conditions, including rheumatoid arthritis. Previous studies have shown that OC formation is promoted under hypoxia. However, the precise mechanisms behind OC formation under hypoxia have not been elucidated. The present study investigated the role of inducible nitric oxide synthase (iNOS) in OC differentiation under hypoxia. Primary bone marrow cells obtained from mice were stimulated with receptor activator of NF-κB ligand and macrophage colony-stimulating factor to induce OC differentiation. The number of OCs increased in culture under hypoxia (oxygen concentration, 5%) compared with that under normoxia (oxygen concentration, 20%). iNOS gene and protein expression increased in culture under hypoxia. Addition of an iNOS inhibitor under hypoxic conditions suppressed osteoclastogenesis. Addition of a nitric oxide donor to the normoxic culture promoted osteoclastogenesis. Furthermore, insulin-like growth factor 2 expression was significantly altered in both iNOS inhibition experiments and nitric oxide donor experiments. These data might provide clues to therapies for excessive osteoclastogenesis under several hypoxic pathologic conditions, including rheumatoid arthritis.

Impact of social support on severity of depressive symptoms by remission status in patients with rheumatoid arthritis

OBJECTIVES

We aimed to examine the psychosocial characteristics of patients with rheumatoid arthritis (RA) by remission status and determine the impacts of social support on severity of depressive symptoms.

METHODS

We enrolled RA patients aged 40-79 years who visited university hospitals' outpatient clinics. Severity of depressive symptoms (Beck Depression Inventory-II), physical disability (Health Assessment Questionnaire), and support were evaluated. Furthermore, RA disease activity was evaluated by 28-point Disease Activity Score (DAS28) calculation. The independent impacts of instrumental and emotional social support on depressive symptoms by remission status defined as DAS28 score < 2.6 were estimated by multivariable regression analysis.

RESULTS

This study included 360 RA patients. In the remission group, emotional support showed a statistically significant negative impact on depressive symptoms, whereas instrumental support had an extremely limited contribution to severity of depressive symptoms. In the non-remission group, instrumental support showed a negative tendency of impact on severity of depressive symptoms, whereas emotional support had a wide range of influence.

CONCLUSIONS

Favourable association between emotional support and depressive symptoms is confirmed only among RA patients in remission status. The influence of emotional support in non-remission patients and that of instrumental support regardless of remission status are inconclusive.

Insidious Onset Compartment Syndrome of the Forearm in a Teenager: A Case Report and Review of the Literature

Compartment syndrome affecting the upper extremities is a relatively underreported event compared with compartment syndrome affecting the lower extremities. Moreover, insidious onset forearm compartment syndrome has been rarely reported and is usually limited to single case reports. We report a compartment syndrome of the forearm in a teenager. She hit her right proximal forearm lightly on the cash register, but there was no pain. However, the next day, she had difficulty in moving her right hand. Although she underwent electrotherapy, her right forearm gradually became swollen, and she felt numbness in the ring and little fingers of her right hand. Six day after the onset, she came to our hospital and underwent fasciotomy. There was no aftereffect, and very good functional recovery was obtained. All clinicians need to keep the case of forearm compartment syndrome in a young individual with a diffuse course, such as in this case in mind.

Deficiency of WFS1 leads to the impairment of AVP secretion under dehydration in male mice

Wolfram syndrome (WS) is mainly caused by mutations in the WFS1 gene and characterized by diabetes mellitus, optic atrophy, hearing loss, and central diabetes insipidus (CDI). WFS1 is an endoplasmic reticulum (ER)-resident transmembrane protein, and Wfs1 knockout (Wfs1-/-) mice, which have been used as a mouse model for WS, reportedly manifested impairment of glucose tolerance due to pancreatic β-cell loss. In the present study, we examined water balance, arginine vasopressin (AVP) secretion, and ER stress in AVP neurons of the hypothalamus in Wfs1-/- mice. There were no differences in urine volumes between Wfs1-/- and wild-type mice with free access to water. Conversely, when mice were subjected to intermittent water deprivation (WD) for 20 weeks, during which water was unavailable for 2 days a week, urine volumes were larger in Wfs1-/- mice, accompanied by lower urine AVP concentrations and urine osmolality, compared to wild-type mice. The mRNA expression of immunoglobulin heavy chain binding protein, a marker of ER stress, was significantly increased in the supraoptic nucleus and paraventricular nuclei in Wfs1-/- mice compared to wild-type mice after WD. Our results thus showed that Wfs1 knockout leads to a decrease in AVP secretion during dehydration, which could explain in part the mechanisms by which Wfs1 mutations cause CDI in humans.

Anterolateral ligament reconstruction in addition to primary double-bundle anterior cruciate ligament reconstruction for grade 3 pivot shift improves residual knee instability during surgery

Purpose

High-grade pivot shift in the anterior cruciate ligament (ACL) injured knee is a risk factor for postoperative residual pivot shift. Procedures in addition to ACL reconstruction such as anterolateral ligament (ALL) reconstruction have been performed for patients with a high-risk of residual pivot shift. The aim of this study was to investigate the effect of the addition of ALL reconstruction to primary double-bundle ACL reconstruction in patients with preoperative high-grade pivot shift to improve stability as evaluated by quantitative measurement.

Methods

Patients with ACL injuries who showed preoperative grade 3 subjective pivot shift and who underwent primary double-bundle ACL reconstruction combined with ALL reconstructions were retrospectively enrolled. Anterior tibial translation (ATT) in the Lachman test, and acceleration and external rotational angular velocity (ERAV) in the pivot shift were measured as quantitative values. Quantitative values before surgical intervention for ACL-injured knees (ACLD) and uninjured contralateral knees (intact), after temporary fixation of the isolated ACL grafts (ACLR), and subsequently after temporary fixation of both ACL and ALL grafts (ACLR + ALLR) were measured with the patient under general anaesthesia.

Results

In total, 18 patients were included. The ATT was lower in ACLR and ACLR + ALLR than in intact (P = .008 and .005), while there was no significant difference between ACLR and ACLR + ALLR (P > .05). The acceleration of ACLR + ALLR was lower than that for ACLR (P = .008), while there was no significant difference between intact and ACLR or ACLR + ALLR (P > .05). The ERAV of ACLR was higher than that of intact (P < .001), while that of ACLR + ALLR was lower than that of ACLR (P < 0.001), and there was no significant difference in ERAV between intact and ACLR + ALLR (P > 0.05).

Conclusion

According to quantitative assessment of the pivot shift, the addition of ALL reconstruction to primary double-bundle ACL reconstruction improved residual knee instability and restored knee stability during surgery. Combination of ALL reconstruction with primary double-bundle ACL reconstruction was effective for patients with ACL injuries exhibiting a preoperative grade 3 subjective pivot shift.

Level of evidence

IV

Different patterns of pneumothorax in patients with soft tissue tumors treated with pazopanib: A case series analysis

To investigate pneumothorax patterns in pazopanib treatment by focusing on the positional relationship between the visceral pleura and metastatic lung tumor, we examined 20 patients with advanced soft tissue tumors who developed lung metastases and underwent pazopanib treatment between 2012 and 2019. Pneumothorax was classified into two types based on the location of the metastatic lesion around the visceral pleural area before pazopanib treatment: subpleural type, within 5 mm from the pleura; and central type, >5 mm from the pleura. We investigated the rates of pneumothorax and the associated risk factors. Five patients experienced pneumothorax (three subpleural and two central types). Cavitation preceded pneumothorax in 83% of patients and led to connection of the cavitated cyst of the metastatic lesion to the chest cavity in the shorter term in patients with the subpleural type. Conversely, a more gradual increase in the cavity size and sudden cyst rupture were observed in the central type. The risk factors for pneumothorax were cavitation after initiating pazopanib and intervention before pazopanib, either ablation or surgery. The location of the metastatic lesions was not a risk factor for the occurrence of pneumothorax. In conclusion, pneumothorax is an adverse event associated with pazopanib treatment. Therefore, attention must be paid to predisposing factors such as the formation of cavitation after pazopanib initiation and previous interventions to the lungs. Moreover, because subpleural pneumothorax tends to occur earlier than the central type, a different time course can be anticipated based on the positional relationships of the metastatic lesions to the visceral pleura.

The predictive power of artificial intelligence on mediastinal lymphnode metastasis

OBJECTIVE

The aim of this study was to create the preoperative predictive model on mediastinal lymph-node metastasis based on artificial intelligence in surgically resected lung adenocarcinoma.

METHODS

We enrolled 301 surgical resections of patients with clinical stage N0-1 lung adenocarcinoma, who received positron emission tomography preoperatively between 2015 and 2019. We randomly assigned the patients into two groups: the training (n = 201) and validation groups (n = 100). The training group was used to obtain basic data for learning by artificial intelligence, whereas the validation group was used to verify the constructed algorithm. We used an automatic machine learning platform, to create artificial intelligence model. For comparison, multivariate analysis was performed in the training group, whereas for calculating and verifying the prediction accuracy rate, significant predicting factors were applied to the validation group.

RESULTS

Of the 301 patients, 41 patients were diagnosed as mediastinal lymph node metastasis. In multivariate analysis, the maximum standardized uptake value was an individual predictive factor. The accuracy rate of artificial intelligence model was 84%, and the specificity was 98% which were higher than those of the maximum standardized uptake value (61% and 57%). However, in terms of sensitivity, artificial intelligence model remarked low at 12%.

CONCLUSIONS

An artificial intelligence-based diagnostic algorithm showed remarkable specificity compared with the maximum standardized uptake value. Although this model is not ready to practical use and the result was preliminary because of poor sensitivity, artificial intelligence could be able to complement the shortcomings of existing diagnostic modalities.

Three-dimensional spheroid culture induces apical-basal polarity and the original characteristics of immortalized human renal proximal tubule epithelial cells

The proximal tubules, which are part of the kidney, maintain blood homeostasis by absorbing amino acids, glucose, water, and ions such as sodium (Na), potassium, and bicarbonate. Proximal tubule dysfunction is associated with the pathogenesis of many kidney diseases. Renal proximal tubular epithelial cells (RPTECs) are responsible for the main functions of the proximal tubules. Therefore, in vitro experiments using RPTECs would greatly enhance our understanding of nephron physiology and pathobiology. It is preferable to use immortalized cell lines, such as human kidney-2 (HK-2) cells, because they are derived from humans and maintain growth indefinitely. However, tissue-specific RPTEC phenotypes, including apical-basal polarization, are frequently lost in conventional two-dimensional culture methods in part due to microenvironmental deficiencies. To overcome this limitation, we developed a three-dimensional (3D) spheroid culture method for HK-2 cells using an extracellular matrix. HK-2 spheroids in 3D culture formed a tubule-like architecture with cellular polarity and showed markedly restored Na transport function. 3D culture of HK-2 cells also increased expression of kidney development-related genes, including WNT9B. Models of human renal tubules using HK-2 spheroids will greatly improve our understanding of the physiology and pathobiology of the kidney.

Arginine vasopressin-Venus reporter mice as a tool for studying magnocellular arginine vasopressin neurons

Arginine vasopressin (AVP) synthesized in the magnocellular neurons of the hypothalamus is transported through their axons and released from the posterior pituitary into the systemic circulation to act as an antidiuretic hormone. AVP synthesis and release are precisely regulated by changes in plasma osmolality. Magnocellular AVP neurons receive innervation from osmosensory and sodium-sensing neurons, but previous studies showed that AVP neurons per se are osmosensitive as well. In the current study, we made AVP-Venus reporter mice and showed that Venus was expressed exclusively in AVP neurons and was upregulated under water deprivation. In hypothalamic organotypic cultures from the AVP-Venus mice, Venus-labeled AVP neurons in the supraoptic and paraventricular nuclei survived for 1 month, and Venus expression was upregulated by forskolin. Furthermore, in dissociated Venus-labeled magnocellular neurons, treatment with NaCl, but not with mannitol, decreased Venus fluorescence in the soma of the AVP neurons. Thus, Venus expression in AVP-Venus transgenic mice, as well as in primary cultures, faithfully showed the properties of intrinsic AVP expression. These findings indicate that AVP-Venus mice as well as the primary hypothalamic cultures could be useful for studying magnocellular AVP neurons.

Contour prognostic model for predicting survival after resection of colorectal liver metastases: development and multicentre validation study using largest diameter and number of metastases with RAS mutation status

BACKGROUND

Most current models for predicting survival after resection of colorectal liver metastasis include largest diameter and number of colorectal liver metastases as dichotomous variables, resulting in underestimation of the extent of risk variation and substantial loss of statistical power. The aim of this study was to develop and validate a new prognostic model for patients undergoing liver resection including largest diameter and number of colorectal liver metastases as continuous variables.

METHODS

A prognostic model was developed using data from patients who underwent liver resection for colorectal liver metastases at MD Anderson Cancer Center and had RAS mutational data. A Cox proportional hazards model analysis was used to develop a model based on largest colorectal liver metastasis diameter and number of metastases as continuous variables. The model results were shown using contour plots, and validated externally in an international multi-institutional cohort.

RESULTS

A total of 810 patients met the inclusion criteria. Largest colorectal liver metastasis diameter (hazard ratio (HR) 1.11, 95 per cent confidence interval 1.06 to 1.16; P < 0.001), number of colorectal liver metastases (HR 1.06, 1.03 to 1.09; P < 0.001), and RAS mutation status (HR 1.76, 1.42 to 2.18; P < 0.001) were significantly associated with overall survival, together with age, primary lymph node metastasis, and prehepatectomy chemotherapy. The model performed well in the external validation cohort, with predicted overall survival values almost lying within 10 per cent of observed values. Wild-type RAS was associated with better overall survival than RAS mutation even when liver resection was performed for larger and/or multiple colorectal liver metastases.

CONCLUSION

The contour prognostic model, based on diameter and number of lesions considered as continuous variables along with RAS mutation, predicts overall survival after resection of colorectal liver metastasis.

The utility of three-dimensional computed tomography for prediction of tumor invasiveness in clinical stage IA lung adenocarcinoma

Background

It is critical to have an accurate measurement of solid tumor size in order to predict the invasiveness of small lung adenocarcinomas. Some lesions cannot be measured accurately via High-resolution computed tomography (HRCT) due to their irregular shape and unclear borders. For this reason, we evaluated the relative efficacy of three-dimensional (3D) CT for predicting invasive adenocarcinoma.

Methods

We evaluated 195 patients with clinical stage IA adenocarcinomas, including 109 with lesions documented as invasive that were surgically resected at our institute during 2017. All lesions were categorized as either (I) lesions that were difficult to evaluate (i.e., hazy lesions; HL) or (II) more typical lesions (TL). The relationships between solid tumor size as determined by HRCT, solid tumor volume as determined by 3D CT and pathologic diagnosis were evaluated.

Results

Fifty-seven patients (29%) were diagnosed with HL. We set the cut-off value for the solid volume at 225 mm³ as predictive for invasive adenocarcinoma. When evaluating all 195 patients as a group, the accuracy, sensitivity, and specificity based on the solid tumor volume were similar to those based on the solid tumor size. When we limit our analysis to the HL group, the specificity based on solid tumor volume (65.5%) was higher than that based on solid tumor size (44.8%) with a difference that approached statistical significance (P=0.070).

Conclusions

3D CT was equivalent to HRCT for predicting invasive adenocarcinoma and may be particularly useful for diagnosing lesions that are difficult to evaluate on HRCT.

p38 Mitogen-Activated Protein Kinase Is Involved in Interleukin-6 Secretion from Human Ligamentum Flavum-Derived Cells Stimulated by Tumor Necrosis Factor-α

Study Design

Human ligamentum flavum–derived cells (HFCs) were obtained from surgical samples for a basic experimental study.

Purpose

We sought to evaluate the inflammatory response of human ligamentum flavum cells to investigate hypertrophic changes occurring in the ligamentum flavum.

Overview of Literature

Lumbar spinal stenosis (LSS) is a disease commonly observed in the elderly. The number of patients with LSS has increased over time, yet the pathomechanisms of LSS still have not been fully elucidated. One of the clinical features of LSS is hypertrophy of the ligamentum flavum, which results in narrowing of the lumbar spinal canal. Some reports have suggested that ligamentum flavum hypertrophy is associated with inflammation and fibrosis; meanwhile, the p38 mitogen-activated protein (MAP) kinase is involved in the hypertrophy of human ligamentum flavum cells.

Methods

HFCs were obtained from patients with LSS who underwent surgery. HFCs were stimulated by tumor necrosis factor-α (TNF-α) and a p38 MAP kinase inhibitor, SB203580. Phosphorylation of the p38 MAP kinase was analyzed by western blotting. The concentration of interleukin-6 (IL-6) in the conditioned medium was measured by enzyme-linked immunoassay and IL-6 messenger RNA expression levels were determined by real-time polymerase chain reaction.

Results

TNF-α induced the phosphorylation of p38 MAP kinase in a time-dependent manner, which was suppressed by the p38 MAP kinase inhibitor, SB203580. TNF-α also stimulated IL-6 release in both a time- and dose-dependent manner. On its own, SB203580 did not stimulate IL-6 secretion from HFCs; however, it dramatically suppressed the degree of IL-6 release stimulated by TNF-α from HFCs.

Conclusions

This is the first report suggesting that TNF-α stimulates the gene expression and protein secretion of IL-6 via p38 MAP kinase in HFCs. A noted association between tissue hypertrophy and inflammation suggests that the p38 MAP kinase inflammatory pathway may be a therapeutic molecular target for LSS.

Depression, physical function, and disease activity associated with frailty in patients with rheumatoid arthritis

OBJECTIVES

To investigate the clinical and psychosocial backgrounds of frailty in rheumatoid arthritis (RA) patients.

METHODS

Patients with RA between 40 and 79 years of age who visited university hospitals in an urban area were recruited. Well-validated self-reported questionnaires were used to evaluate patient physical function (Health Assessment Questionnaire, HAQ), depressive symptoms (Beck Depression Inventory-II, BDI-II), and frailty (Kihon Checklist). A 28-point Disease Activity Score (DAS-28) was calculated to evaluate RA disease activity.

RESULTS

A total of 375 RA patients, 323 of whom were women, were enrolled (average age: 65.2 ± 9.7 years; average disease duration: 16.6 ± 11.9 years). The prevalence rates of frailty, working-age (40-64 years), young-old (65-74 years), and old-old (≥75 years) patients were 18.5, 28.8, and 36.6%, respectively. Higher age and longer disease duration were associated with frailty. Multivariable logistic regression analysis revealed that HAQ, DAS-28, and BDI-II scores were independently associated with frailty in RA patients.

CONCLUSION

Frailty is common, even among working-age RA patients. Physical function, disease activity, and depressive symptoms were independently associated with frailty. A multidisciplinary intervention approach, along with adequate pharmacological therapy, may promote successful aging in patients with RA.

Usefulness of lead delivery catheter system for true right ventricular septal pacing

Background

Right ventricular (RV) septal pacing is often selected to preserve a more physiologic ventricular activation. But the pacing leads are not always located in true septal wall, rather in hinge or free wall in some cases with the conventional stylet-guided lead implantation. In recent years, new guiding catheter systems has attracted attention as a solution to that problem.

Objective

The aim of this study is to investigate that true ventricular sepal pacing can be achieved by use of the new guiding catheter system for pacing lead.

Methods

We enrolled 198 patients who underwent RV septal lead implantation and computed tomography (CT) after pacemaker implantation. 16 cases were used delivery catheter (Delivery), and 182 cases were used stylet for targeting ventricular septum (Conventional). We analyzed the lead locations with CT, and evaluated capture thresholds, R-wave amplitudes, lead impedances and 12-lead electrocardiogram findings one month after implantation.

Results

All cases of delivery catheter group had true septal lead positions (Delivery; 100% vs Conventional; 44%, p&lt;0.01). Capture thresholds and lead impedances had not significant differences between between two groups (0.65±0.15V vs 0.60±0.15V, p=0.21, 570±95Ω vs 595±107Ω, p=0.39, respectively). R-wave amplitudes were significantly higher in delivery catheter group (13.0±4.8mV vs 10±4.6mV, p&lt;0.01). Paced QRS durations were shorter in delivery catheter group (128±16ms vs 150±21ms, p&lt;0.01).

Conclusions

The delivery catheter system designated for pacing lead can contribute to select the true ventricular septal sites and to attain the more physiologic ventricular activation.

Funding Acknowledgement

Type of funding source: None

Degradation of Mutant Protein Aggregates within the Endoplasmic Reticulum of Vasopressin Neurons

Misfolded or unfolded proteins in the ER are said to be degraded only after translocation or isolation from the ER. Here, we describe a mechanism by which mutant proteins are degraded within the ER. Aggregates of mutant arginine vasopressin (AVP) precursor were confined to ER-associated compartments (ERACs) connected to the ER in AVP neurons of a mouse model of familial neurohypophysial diabetes insipidus. The ERACs were enclosed by membranes, an ER chaperone and marker protein of phagophores and autophagosomes were expressed around the aggregates, and lysosomes fused with the ERACs. Moreover, lysosome-related molecules were present within the ERACs, and aggregate degradation within the ERACs was dependent on autophagic-lysosomal activity. Thus, we demonstrate that protein aggregates can be degraded by autophagic-lysosomal machinery within specialized compartments of the ER.

•

Mutant AVP precursors are confined to ERACs connected to the ER of FNDI AVP neurons

•

Lysosomes fuse with ERACs surrounded by phagophore-like membranes

•

Lysosome-related molecules are localized within ERACs

•

Rapamycin reduces and chloroquine increases protein aggregate accumulation in ERACs

Preoperative Knee Instability Affects Residual Instability as Evaluated by Quantitative Pivot-Shift Measurements During Double-Bundle ACL Reconstruction

Background:

The pivot-shift test is an important indicator of functional outcomes after anterior cruciate ligament (ACL) reconstruction (ACLR). Preoperative instability as indicated by the pivot-shift test is associated with residual instability after ACLR. Few studies have used quantitative means to evaluate the pivot shift after ACLR.

Purpose:

To investigate the relationship between preoperative and residual instability and to identify the risk factors for residual instability by using quantitative measurements of the pivot shift.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

A total of 91 patients undergoing primary double-bundle ACLR were retrospectively enrolled. Quantitative measurements of instability for ACL-deficient knees (ACLD) and uninjured contralateral knees (intact) preoperatively, as well as ACLR knees intraoperatively, were performed under general anesthesia using the pivot-shift test, with inertial sensors to measure acceleration and external rotational (ER) angular velocity. The ratios of intact to ACLD (ACLD/I) and intact to ACLR (ACLR/I) were measured. Patients who showed an ACLR/I of >1 were classified into the residual instability group, and those with an ACLR/I of ≤1 were classified into the noninstability group. Regarding demographic, surgical, and quantitative measurement factors, between-group comparisons and multivariate logistic regression were conducted for predictors of residual instability. Receiver operating characteristic curves were used to evaluate the correlations between ACLD/I and ACLR/I and the cutoff value of ACLD/I in predicting residual instability.

Results:

The predictive factors for intraoperative residual instability included female sex (odds ratio [OR], 0.3 [95% CI, 0.1-0.9]; P = .034) and ACLD/I for acceleration (OR, 1.6 [95% CI, 1.2-2.1]; P < .001), and ACLD/I for ER angular velocity (OR, 1.9 [95% CI, 1.2-3.1]; P = .013). Correlations between ACLD/I and ACLR/I were moderate with respect to both acceleration (r = 0.435; P < .001) and ER angular velocity (r = 0.533; P < .001). The cutoff points for ACLD/I were 4.9 for acceleration (sensitivity, 65.1%; specificity, 85.7%; area under the curve [AUC], 0.76) and 2.4 for ER angular velocity (sensitivity, 80.0%; specificity, 50.0%; AUC, 0.74).

Conclusion:

Greater preoperative instability was a risk factor for residual instability as measured intraoperatively by a quantitatively evaluation in the pivot shift during ACL reconstruction. Quantitative measurements of instability during the pivot shift mechanism under general anesthesia may enable surgeons to predict postoperative residual instability.