Peptidoglycan endopeptidase MepM of uropathogenic Escherichia coli contributes to competitive fitness during urinary tract infections

BACKGROUND

Urinary tract infections (UTIs) are common bacterial infections, primarily caused by uropathogenic Escherichia coli (UPEC), leading to significant health issues and economic burden. Although antibiotics have been effective in treating UPEC infections, the rise of antibiotic-resistant strains hinders their efficacy. Hence, identifying novel bacterial targets for new antimicrobial approaches is crucial. Bacterial factors required for maintaining the full virulence of UPEC are the potential target. MepM, an endopeptidase in E. coli, is involved in the biogenesis of peptidoglycan, a major structure of bacterial envelope. Given that the bacterial envelope confronts the hostile host environment during infections, MepM's function could be crucial for UPEC's virulence. This study aims to explore the role of MepM in UPEC pathogenesis.

RESULTS

MepM deficiency significantly impacted UPEC's survival in urine and within macrophages. Moreover, the deficiency hindered the bacillary-to-filamentous shape switch which is known for aiding UPEC in evading phagocytosis during infections. Additionally, UPEC motility was downregulated due to MepM deficiency. As a result, the mepM mutant displayed notably reduced fitness in causing UTIs in the mouse model compared to wild-type UPEC.

CONCLUSIONS

This study provides the first evidence of the vital role of peptidoglycan endopeptidase MepM in UPEC's full virulence for causing UTIs. MepM's contribution to UPEC pathogenesis may stem from its critical role in maintaining the ability to resist urine- and immune cell-mediated killing, facilitating the morphological switch, and sustaining motility. Thus, MepM is a promising candidate target for novel antimicrobial strategies.

Differences in the expression of myelopathy in a rat model of chronic spinal cord compression

CONTEXT/OBJECTIVE

The degree of spinal cord compression does not always parallel neurological symptoms. We considered that some compensatory neuroprotective mechanism underlies the expression of this neurological phenotype. Oxygen-regulated-protein 150 (ORP150) is neuroprotective and expressed in neurons in response to neuronal ischemia. We sought to elucidate whether ORP150 expression is associated with the severity and variation of neurological recovery in our rat model of chronic spinal cord compression.

METHODS

We made a rat model of chronic spinal cord compression inserting an expandable water-absorbing polyurethane sheet. A neurological behavioral assessment of the severity of paralysis was performed for 10 weeks postoperatively. The rat model was defined as two groups: a myelopathy group with decreased locomotor function and an asymptomatic group. At 10 weeks postoperatively, the spinal cord of the cervical segment was resected for histology and qPCR.

RESULTS

Slowly progressive paralysis appeared at 5-10 weeks postoperatively in 53% of the rats with spinal cord compression. The asymptomatic group had no histological changes indicative of myelopathy. Histology and qPCR showed increased expression of ORP150 in the asymptomatic group, but the ratio of ORP150-positive neuron in the two groups was not significantly different.

CONCLUSION

The expression of ORP150 in neurons associated with spinal cord compression suggested that the spinal cord was under ischemic stress due to compression, but relation to the development of myelopathy was unclear. The results suggested that some other compensatory mechanisms may exist in response to spinal cord compression in asymptomatic rats.

Right main pulmonary artery distensibility on dynamic ventilation CT and its association with respiratory function

BACKGROUND

Heartbeat-based cross-sectional area (CSA) changes in the right main pulmonary artery (MPA), which reflects its distensibility associated with pulmonary hypertension, can be measured using dynamic ventilation computed tomography (DVCT) in patients with and without chronic obstructive pulmonary disease (COPD) during respiratory dynamics. We investigated the relationship between MPA distensibility (MPAD) and respiratory function and how heartbeat-based CSA is related to spirometry, mean lung density (MLD), and patient characteristics.

METHODS

We retrospectively analyzed DVCT performed preoperatively in 37 patients (20 female and 17 males) with lung cancer aged 70.6 ± 7.9 years (mean ± standard deviation), 18 with COPD and 19 without. MPA-CSA was separated into respiratory and heartbeat waves by discrete Fourier transformation. For the cardiac pulse-derived waves, CSA change (CSAC) and CSA change ratio (CSACR) were calculated separately during inhalation and exhalation. Spearman rank correlation was computed.

RESULT

In the group without COPD as well as all cases, CSACR exhalation was inversely correlated with percent residual lung volume (%RV) and RV/total lung capacity (r = -0.68, p = 0.003 and r = -0.58, p = 0.014). In contrast, in the group with COPD, CSAC inhalation was correlated with MLDmax and MLD change rate (MLDmax/MLDmin) (r = 0.54, p = 0.020 and r = 0.64, p = 0.004) as well as CSAC exhalation and CSACR exhalation.

CONCLUSION

In patients with insufficient exhalation, right MPAD during exhalation was decreased. Also, in COPD patients with insufficient exhalation, right MPAD was reduced during inhalation as well as exhalation, which implied that exhalation impairment is a contributing factor to pulmonary hypertension complicated with COPD.

RELEVANCE STATEMENT

Assessment of MPAD in different respiratory phases on DVCT has the potential to be utilized as a non-invasive assessment for pulmonary hypertension due to lung disease and/or hypoxia and elucidation of its pathogenesis.

KEY POINTS

• There are no previous studies analyzing all respiratory phases of right main pulmonary artery distensibility (MPAD). • Patients with exhalation impairment decreased their right MPAD. • Analysis of MPAD on dynamic ventilation computed tomography contributes to understanding the pathogenesis of pulmonary hypertension due to lung disease and/or hypoxia in patients with expiratory impairment.

Molecular characterization of a carbon dioxide-dependent Proteus mirabilis small-colony variant isolated from a clinical specimen

INTRODUCTION

Carbon dioxide-dependent Proteus mirabilis has been isolated from clinical specimens. It is not clear whether mutations in carbonic anhydrase are responsible for the carbon dioxide dependence of P. mirabilis. The pathogenicity of carbon dioxide-dependent P. mirabilis also remains unclear. The purpose of this study was to determine the cause carbon dioxide dependence of P. mirabilis and its pathogenicity.

METHODS

The DNA sequence of can encoding carbonic anhydrase of a carbon dioxide-dependent P. mirabilis small colony variant (SCV) isolate was analyzed. To confirm that impaired carbonic anhydrase activity is responsible for the formation of the carbon dioxide-dependent SCV phenotype of P. mirabilis, we performed complementation experiments using plasmids with intact can. Additionally, mouse infection experiments were performed to confirm the change in virulence due to the mutation of carbonic anhydrase.

RESULTS

We found that the can gene of the carbon dioxide-dependent P. mirabilis SCV isolate showed had a frameshift mutation with a deletion of 1 bp (c. 173delC). The can of P. mirabilis encodes carbonic anhydrase was also found to function in Escherichia coli. The cause of the carbon dioxide-dependent SCV phenotype of P. mirabilis was an abnormality in carbonic anhydrase. Nevertheless, no changes were observed in virulence due to the mutation of carbonic anhydrase in mouse infection experiments.

CONCLUSIONS

The can gene is essential for the growth of P. mirabilis in ambient air. The mechanisms underlying this fitness advantage in terms of infection warrant further investigation.

The Guidelines for Percutaneous Transhepatic Portal Vein Embolization: English Version

Preoperative portal vein embolization is a beneficial option to reduce the risk of postoperative liver failure by promoting the growth of the future liver remnant. In particular, a percutaneous transhepatic procedure (percutaneous transhepatic portal vein embolization) has been developed as a less-invasive approach. Although percutaneous transhepatic portal vein embolization is widely recognized as a safe procedure, various complications, including rare but fatal adverse events, have been reported. Currently, there are no prospective clinical trials regarding percutaneous transhepatic portal vein embolization procedures and no standard guidelines for the PTPE procedure in Japan. As a result, various methods and various embolic materials are used in each hospital according to each physician's policy. The purpose of these guidelines is to propose appropriate techniques at present and to identify issues that should be addressed in the future for safer and more reliable percutaneous transhepatic portal vein embolization techniques.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

Boehringer Ingelheim and Eli Lilly.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

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

[Sleeve Resection for Right Upper Lobe Non-small Cell Lung Cancer After Systemic Chemotherapy and Immune Checkpoint Inhibitor Administration]

A man in his 50s was diagnosed with right upper lobe non-small-cell lung cancer (cT3N1M0, stage ⅢA) on bronchoscopy. The tumor was located at the right hilum and was bordered extensively on the pulmonary artery. We observed significant tumor shrinkage (ycT1bN1M0, stage ⅡB), following three cycles of systemic chemotherapy combined with an immune checkpoint inhibitor and performed right upper sleeve lobectomy + ND2a-2 via thoracotomy for radical resection. Postoperative histopathological examination showed no residual tumor cells, and the patient was deemed to have a histopathologic complete response. Currently, the patient is being followed up without adjuvant chemotherapy. Several recent studies have reported the usefulness of systemic chemotherapy combined with immune checkpoint inhibitor administration as preoperative induction chemotherapy. However, the role of adjuvant immunotherapy in patients with a histopathologic complete response remains unclear, and careful treatment decision-making is important.

Impact of the COVID-19 pandemic on the trajectory of the number of bronchoscopies performed in a tertiary hospital in Kyoto city

The coronavirus disease 2019 (COVID-19) pandemic has restricted many medical practices. We aimed to investigate the impact of the COVID-19 pandemic on the number of bronchoscopies, outpatients, and hospital admissions. We retrospectively analyzed the number of outpatients, admissions, and bronchoscopies performed between March 2020 and May 2022. We defined "Peak month of the pandemic," "Wave of the pandemic," "Month in the wave," and "Period of a state of emergency" for each analysis. In the first year of the COVID-19 pandemic, analysis of variance (ANOVA) in linear mixed models indicated significant effects of "month in each wave" on the number of bronchoscopies (P = .003), outpatients (P = .041), and admissions (P = .017). The number of outpatients, admissions, and bronchoscopies was significantly influenced by the first wave of the COVID-19 pandemic. In contrast, in the second year of the COVID-19 pandemic, a mixed-ANOVA indicated significant effects of "month in each wave" only on the number of outpatients (P = .020) but no significant effects on the number of bronchoscopies (P = .407) and admissions (P = .219). During the second year of the pandemic, the number of bronchoscopies and admissions was not significantly affected by the waves of the pandemic. There were no significant differences in the number of admissions and bronchoscopies between the fourth and sixth waves. Although the number of bronchoscopies was found to be significantly affected in the early stages of the COVID-19 pandemic, the impact of the pandemic was much more limited thereafter.

Mutations identified in engineered Escherichia coli with a reduced genome

Characterizing genes that regulate cell growth and survival in model organisms is important for understanding higher organisms. Construction of strains harboring large deletions in the genome can provide insights into the genetic basis of cell growth compared with only studying wild-type strains. We have constructed a series of genome-reduced strains with deletions spanning approximately 38.9% of the E. coli chromosome. Strains were constructed by combining large deletions in chromosomal regions encoding nonessential gene groups. We also isolated strains Δ33b and Δ37c, whose growth was partially restored by adaptive laboratory evolution (ALE). Genome sequencing of nine strains, including those selected following ALE, identified the presence of several Single Nucleotide Variants (SNVs), insertions, deletions, and inversions. In addition to multiple SNVs, two insertions were identified in ALE strain Δ33b. The first was an insertion at the promoter region of pntA, which increased cognate gene expression. The second was an insertion sequence (IS) present in sibE, encoding the antitoxin in a toxin-antitoxin system, which decreased expression of sibE. 5 strains of Δ37c independently isolated following ALE harboring multiple SNVs and genetic rearrangements. Interestingly, a SNV was identified in the promoter region of hcaT in all five strains, which increased hcaT expression and, we predict, rescued the attenuated Δ37b growth. Experiments using defined deletion mutants suggested that hcaT encodes a 3-phenylpropionate transporter protein and is involved in survival during stationary phase under oxidative stress. This study is the first to document accumulation of mutations during construction of genome-reduced strains. Furthermore, isolation and analysis of strains derived from ALE in which the growth defect mediated by large chromosomal deletions was rescued identified novel genes involved in cell survival.

Association of Respiratory Functional Indices and Smoking with Pleural Movement and Mean Lung Density Assessed Using Four-Dimensional Dynamic-Ventilation Computed Tomography in Smokers and Patients with COPD

Purpose

To correlate the ratio of the non-dependent to dependent aspects of the maximal pleural movement vector (MPMV_ND/D) and gravity-oriented collapse ratio (GCR_ND/D), and the mean lung field density (MLD) obtained using four-dimensional (4D) dynamic-ventilation computed tomography (DVCT) with airflow limitation parameters and the Brinkman index.

Materials and Methods

Forty-seven patients, including 22 patients with COPD, 13 non-COPD smokers, and 12 non-smokers, with no/slight pleural adhesion confirmed using a thoracoscope, underwent 4D-DVCT with 16 cm coverage. Coordinates for the lung field center, as well as ventral and dorsal pleural points, set on the central trans-axial levels in the median and para-median sagittal planes at end-inspiration, were automatically measured (13-17 frame images, 0.35 seconds/frame). MPMV_ND/D and GCR_ND/D were calculated based on MPMV and GCR values for all the included points and the lung field center. MLD was automatically measured in each of the time frames, and the maximal change ratio of MLD (MLD_CR) was calculated. These measured values were compared among COPD patients, non-COPD smokers, and non-smokers, and were correlated with the Brinkman index, FEV₁/FVC, FEV₁ predicted, RV/TLC, and FEF_25-75% using Spearman's rank coefficients.

Results

MPMV_ND/D was highest in non-smokers (0.819±0.464), followed by non-COPD smokers (0.405±0.131) and patients with COPD (-0.219±0.900). GCR_ND/D in non-smokers (1.003±1.384) was higher than that in patients with COPD (-0.164±1.199). MLD_CR in non-COPD smokers (0.105±0.028) was higher than that in patients with COPD (0.078±0.027). MPMV_ND/D showed positive correlations with FEV₁ predicted (r=0.397, p=0.006), FEV₁/FVC (r=0.501, p<0.001), and FEF_25-75% (r=0.368, p=0.012). GCR_ND/D also demonstrated positive correlations with FEV₁ (r=0.397, p=0.006), FEV₁/FVC (r=0.445, p=0.002), and FEF_25-75% (r=0.371, p=0.011). MPMV_ND/D showed a negative correlation with the Brinkman index (r=-0.398, p=0.006).

Conclusion

We demonstrated that reduced MPMV_ND/D and GCR_ND/D were associated with respiratory functional indices, in addition to a negative association of MPMV_ND/D with the Brinkman index, which should be recognized when assessing local pleural adhesion on DVCT, especially for ventral pleural aspects.

A-910823, a squalene-based emulsion adjuvant, induces T follicular helper cells and humoral immune responses via α-tocopherol component

Background

Adjuvants are chemical or biological materials that enhance the efficacy of vaccines. A-910823 is a squalene-based emulsion adjuvant used for S-268019-b, a novel vaccine against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that is currently in clinical development. Published evidence has demonstrated that A-910823 can enhance the induction of neutralizing antibodies against SARS-CoV-2 in humans and animal models. However, the characteristics and mechanisms of the immune responses induced by A-910823 are not yet known.

Methods and Results

To characterize A-910823, we compared the adaptive immune response profile enhanced by A-910823 with that of other adjuvants (AddaVax, QS21, aluminum salt-based adjuvants, and empty lipid nanoparticle [eLNP]) in a murine model. Compared with other adjuvants, A-910823 enhanced humoral immune responses to an equal or greater extent following potent T follicular helper (Tfh) and germinal center B (GCB) cell induction, without inducing a strong systemic inflammatory cytokine response. Furthermore, S-268019-b containing A-910823 adjuvant produced similar results even when given as a booster dose following primary administration of a lipid nanoparticle-encapsulated messenger RNA (mRNA-LNP) vaccine. Preparation of modified A-910823 adjuvants to identify which components of A-910823 play a role in driving the adjuvant effect and detailed evaluation of the immunological characteristics induced by each adjuvant showed that the induction of humoral immunity and Tfh and GCB cell induction in A-910823 were dependent on α-tocopherol. Finally, we revealed that the recruitment of inflammatory cells to the draining lymph nodes and induction of serum cytokines and chemokines by A-910823 were also dependent on the α-tocopherol component.

Conclusions

This study demonstrates that the novel adjuvant A-910823 is capable of robust Tfh cell induction and humoral immune responses, even when given as a booster dose. The findings also emphasize that α-tocopherol drives the potent Tfh-inducing adjuvant function of A-910823. Overall, our data provide key information that may inform the future production of improved adjuvants.

Homologous and heterologous booster vaccinations of S-268019-b, a recombinant S protein-based vaccine with a squalene-based adjuvant, enhance neutralization breadth against SARS-CoV-2 Omicron subvariants in cynomolgus macaques

SARS-CoV-2 Omicron subvariants such as BA.2.12.1, BA.4 and BA.5 have been spreading rapidly and become dominant worldwide. Here we report the homologous or heterologous booster effects of S-268019-b, a recombinant spike protein vaccine with the squalene-based adjuvant A-910823 in cynomolgus macaques. In macaques which had been primed with S-268019-b or mRNA vaccines, boosting with S-268019-b enhanced neutralizing antibodies (NAb) against ancestral SARS-CoV-2. Since boosting with the antigen without adjuvant did not efficiently restore NAb titers, adjuvant A-910823 was essential for the booster effect. Importantly, boosting with S-268019-b enhanced NAb against all of the Omicron subvariants we tested, including BA.2.12.1, BA.4 and BA.5, in comparison to two vaccine doses. Additionally, expansion of Omicron-specific B cells was confirmed after boosting with S-268019-b. These results indicate that a booster dose of S-268019-b with the adjuvant enhances the neutralization breadth.

Immune response and protective efficacy of the SARS-CoV-2 recombinant spike protein vaccine S-268019-b in mice

Vaccines that efficiently target severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the etiological agent for coronavirus disease (COVID-19), are the best means for controlling viral spread. This study evaluated the efficacy of the COVID-19 vaccine S-268019-b, which comprises the recombinant full-length SARS-CoV-2 spike protein S-910823 (antigen) and A-910823 (adjuvant). In addition to eliciting both Th1-type and Th2-type cellular immune responses, two doses of S-910823 plus A-910823 induced anti-spike protein IgG antibodies and neutralizing antibodies against SARS-CoV-2. In a SARS-CoV-2 challenge test, S-910823 plus A-910823 mitigated SARS-CoV-2 infection-induced weight loss and death and inhibited viral replication in mouse lungs. S-910823 plus A-910823 promoted cytokine and chemokine at the injection site and immune cell accumulation in the draining lymph nodes. This led to the formation of germinal centers and the induction of memory B cells, antibody-secreting cells, and memory T cells. These findings provide fundamental property of S-268019-b, especially importance of A-910823 to elicit humoral and cellular immune responses.

Association between Escherichia coli with NotI-restriction resistance and urinary tract infections

BACKGROUND

Escherichia coli is the most common cause of urinary tract infections (UTIs). It is widely accepted that uropathogenic E. coli (UPEC) mainly emerge from the distal gut microbiota. Identification of bacterial characteristics that are able to differentiate UPEC from fecal commensal strains will facilitate the development of novel strategies to detect and monitor the spread of UPEC.

METHODS

Fifty fecal commensal, 83 UTI-associated and 40 biliary tract infection (BTI)-associated E. coli isolates were analyzed. The NotI restriction patterns of chromosomal DNA in the isolates were determined by pulse-field gel electrophoresis. The phylogenetic types and the presence of 9 known virulence genes of each isolate were determined by PCR analyses. Additionally, the susceptibilities of the isolates to antibiotics were revealed. Then the associations of NotI resistance with UTI-associated isolates, phylotypes, and antibiotic resistance were assessed.

RESULTS

NotI resistance was correlated with UTI-associated isolates, compared to the fecal isolates. Consistently, NotI-resistant isolates harbored a greater number of virulence factors and mainly belonged to phylotype B2. Additionally NotI resistance was correlated with chloramphenicol resistance among the bacteria. Among the fecal, UTI-associated and BTI-associated groups, the distribution of NotI-resistant group B2 isolates was correlated with UTI-associated bacteria.

CONCLUSION

NotI resistance alone is a potential marker for distinguishing fecal strains and UPEC, while the combination of NotI resistance and B2 phylogeny is a candidate marker to differentiate UPEC from fecal and other extraintestinal pathogenic E. coli. Additionally, NotI resistance may be valuable for assessing the potential of chloramphenicol resistance of E. coli.

Immunogenicity and protective efficacy of SARS-CoV-2 recombinant S-protein vaccine S-268019-b in cynomolgus monkeys

The vaccine S-268019-b is a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike (S)-protein vaccine consisting of full-length recombinant SARS-CoV-2 S-protein (S-910823) as antigen, mixed with the squalene-based adjuvant A-910823. The current study evaluated the immunogenicity of S-268019-b using various doses of S-910823 and its vaccine efficacy against SARS-CoV-2 challenge in cynomolgus monkeys. The different doses of S-910823 combined with A-910823 were intramuscularly administered twice at a 3-week interval. Two weeks after the second dosing, dose-dependent humoral immune responses were observed with neutralizing antibody titers being comparable to that of human convalescent plasma. Pseudoviruses harboring S proteins from Beta and Gamma SARS-CoV-2 variants displayed approximately 3- to 4-fold reduced sensitivity to neutralizing antibodies induced after two vaccine doses compared with that against ancestral viruses, whereas neutralizing antibody titers were reduced >14-fold against the Omicron variant. Cellular immunity was also induced with a relative Th1 polarized response. No adverse clinical signs or weight loss associated with the vaccine were observed, suggesting safety of the vaccine in cynomolgus monkeys. Immunization with 10 µg of S-910823 with A-910823 demonstrated protective efficacy against SARS-CoV-2 challenge according to genomic and subgenomic viral RNA transcript levels in nasopharyngeal, throat, and rectal swab specimens. Pathological analysis revealed no detectable vaccine-dependent enhancement of disease in the lungs of challenged vaccinated monkeys. The current findings provide fundamental information regarding vaccine doses for human trials and support the development of S-268019-b as a safe and effective vaccine for controlling the current pandemic, as well as general protection against SARS-CoV-2 moving forward.

AB0653 The association of autoantibodies with morbidity and mortality of scleroderma renal crisis in Japan

Background

The morbidity of scleroderma renal crisis (SRC) and autoantibodies in systemic sclerosis (SSc) vary by races and regions. Anti-RNA polymerase III is associated with SRC in America and European countries. However, the association of autoantibodies with SRC had not been elucidated in Japan.

Objectives

We aimed to investigate the association of autoantibodies with morbidity and mortality of SRC in Japan.

Methods

The clinical characteristics and mortality of 330 patients with systemic sclerosis (SSc) at Kyoto University Hospital were retrospectively analyzed, focusing on anti-centromere, anti-RNA polymerase III, anti-topoisomerase I, and anti-U1-RNP. Logistic regression analyses were performed to examine the association of autoantibodies with the development and mortality of SRC. Kaplan-Meier survival analysis was performed comparing the groups classified by autoantibodies.

Results

Anti-centromere (n = 177/318, 56%), anti-topoisomerase I (n = 80/311, 26%), anti-RNA polymerase III (n = 27/204, 13%), and anti-U1-RNP (n = 24/305, 8%) were found in SSc patients (n = 330). SRC was observed in 24 out of 330 SSc patients, including anti-topoisomerase I (n = 12/24, 50%), anti-RNA polymerase III (n = 7/24, 29%), anti-U1-RNP (n = 5/24, 21%), and anti-centromere (n = 3/24, 13%). Anti-U1-RNP (odds ratio [95% confidence interval], 3.63 [1.11–10.2]), anti-RNA polymerase III (3.29 [1.16–8.70]), and anti-topoisomerase I (3.22 [1.37–7.57]) were associated with the development of SRC. All patients with SRC were treated with ACE inhibitors and the 1-year survival rate was 54%. Anti-topoisomerase I was associated with the 1-year mortality of SRC (6.00 [1.11–41.1]). When the survival rate was compared between the patients positive for anti-topoisomerase I (n=12) and negative for anti-topoisomerase I (n=12), the 1-year survival rate was 33% vs 75% (p=0.041), respectively (Figure 1A). Furthermore, the 1-year survival of anti-centromere (100%), anti-RNA polymerase III (83%), and others/not detected (50%) were shown in patients negative for anti-topoisomerase I (Figure 1B).

Figure 1.

Overall survival of patients with SRC according to the type of autoantibodies.

(A) The survival rates in SRC patients who were positive for anti-topoisomerase I (solid line, n = 12) and those who were negative for anti-topoisomerase I (dotted line, n = 12).

(B) SRC patients negative for anti-topoisomerase I were classified as patients with anti-RNA polymerase III (dotted line, n = 6), anti-centromere (broken line, n = 2), and others/not detected (chain line, n = 4).

Conclusion

Specific SSc-related autoantibodies were associated with the morbidity and mortality in SRC.

References

[1]Nihtyanova SI, et al. Arthritis Rheumatol 2020;72(3):465-76.

[2]Hamaguchi Y, et al. Arthritis Rheumatol 2015;67(4):1045-52.

Table 1.

Univariate logistic regression analysis for mortality in SRC (n = 24).

VariablesOdds ratio (95% CI)P valueAge1.07 (0.99, 1.16)0.08Female sex3.00 (0.32, 66.6)0.38Diffuse/limited (diffuse %)0.25 (0.04, 1.36)0.12BMI0.67 (0.41, 0.93)0.049Modified Rodnan skin score0.95 (0.88, 1.02)0.15Digital ulcer0.52 (0.10, 2.63)0.43Reflux esophagitis0.60 (0.02, 17.1)0.73Pulmonary hypertension7.50 (1.17, 69.2)0.046Pleural effusion7.20 (1.23, 62.0)0.04Glucocorticoid use3.86 (0.65, 32.4)0.16Hemoglobin0.55 (0.25, 1.01)0.09Platelet1.00 (0.98, 1.01)0.44Total protein0.17 (0.02, 0.69)0.04Creatinine0.95 (0.67, 1.24)0.69CRP0.90 (0.67, 1.17)0.46Anti-topoisomerase I6.00 (1.11, 41.1)0.048Anti-centromere7.4x10-9 (--, 0.93)1.00Anti-RNA polymerase III0.36 (0.04, 2.18)0.29Anti-U1-RNP0.74 (0.08, 5.49)0.77

Disclosure of Interests

None declared

POS0532 DRUG RETENTION OF BIOLOGICS OR JAK INHIBITORS IN PATIENTS WITH DIFFICULT-TO-TREAT RHEUMATOID ARTHRITIS: RESULTS FROM THE ANSWER COHORT

Background

Difficult-to-treat rheumatoid arthritis (D2T RA) is defined as RA in which disease activity is uncontrolled despite the use of two or more biologics or Janus kinase inhibitors (JAKi) with different mechanisms of action (MOA).

Objectives

To explore the optimal treatment strategy for D2T RA, we evaluated the drug retention, efficacy, and reasons for discontinuation of biologics or JAKi used for patients with D2T RA in a longitudinal multicenter cohort.

Methods

RA patients with clinical disease activity index (CDAI) >10 despite the use of at least two biologics or JAKi with different MOA and further treated with biologics or JAKi were included. The drug retention rates of biologics (TNFi, IL-6Ri, and CTLA4-Ig) or JAKi were estimated at 12 months using the Kaplan-Meier method and adjusted for potential confounders (age, sex, disease duration, concomitant MTX and PSL use, and the number of switched biologics or JAKi) using Cox proportional hazards models.

Results

A total of 251 treatment courses (TCs) from 167 patients were included (TNFi: 97 TCs, IL-6Ri: 67 TCs, CTLA4-Ig: 27 TCs, JAKi: 60 TCs). Baseline characteristics showed no difference in age, sex, disease duration, ACPA positivity, CDAI, and concomitant MTX and PSL use between the four groups. Drug retention excluding non-toxic reasons and remission was significantly higher in patients treated with JAKi or IL-6Ri than in patients treated with TNFi or CTLA4-Ig (P=0.00172). Multivariate analysis using Cox proportional hazards models demonstrated that discontinuation of the drug was associated with the use of TNFi or CTLA4-Ig (HR: 3.29, 95%CI: 1.15-9.42, P=0.027) and concomitant PSL use (HR: 1.14, 95%CI: 1.04-1.26, P=0.0084). In terms of disease activity evaluated with CDAI, no difference was observed between the four groups at 3 months (P=0.90), at 6 months (P=0.77), and at 12 months (P=0.75).

Conclusion

In patients with D2T RA, JAKi or IL-6Ri may have treatment advantages compared with TNFi or CTLA4-Ig.

References

[1] EULAR definition of difficult-to-treat rheumatoid arthritis.

Nagy G, Roodenrijs NMT, Welsing PM, Kedves M, Hamar A, van der Goes MC, Kent A, Bakkers M, Blaas E, Senolt L, Szekanecz Z, Choy E, Dougados M, Jacobs JW, Geenen R, Bijlsma HW, Zink A, Aletaha D, Schoneveld L, van Riel P, Gutermann L, Prior Y, Nikiphorou E, Ferraccioli G, Schett G, Hyrich KL, Mueller-Ladner U, Buch MH, McInnes IB, van der Heijde D, van Laar JM.

Ann Rheum Dis. 2021 Jan;80(1):31-35.

[2] Prevalence and predictive factors of difficult-to-treat rheumatoid arthritis: the KURAMA cohort.

Watanabe R, Hashimoto M, Murata K, Murakami K, Tanaka M, Ohmura K, Ito H, Matsuda S.

Immunol Med. 2021 May 25:1-10.

Disclosure of Interests

Ryu Watanabe Speakers bureau: Eli Lilly, Mitsubishi Tanabe, Pfizer, Sanofi, AbbVie, Asahi Kasei, Eisai, Bristol-Myers Squibb, UCB Japan, Chugai, Janssen, Astellas, Nippon Shinyaku, Daiichi Sankyo, Gilead Sciences Japan, and Boehringer ingelheim., 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, Shinsuke Yamada: None declared, Wataru Yamamoto: None declared, Koichi Murata Speakers bureau: Eisai Co., Ltd., Chugai Pharmaceutical Co., Ltd.; Asahi Kasei Pharma Corp.; and Mitsubishi Tanabe Pharma Co., and Daiichi Sankyo Co. Ltd., Kosaku Murakami: None declared, Kosuke Ebina Speakers bureau: AbbVie, Amgen, Asahi-Kasei, Astellas, Ayumi, Bristol-Myers Squibb, Chugai, Eisai, Eli Lilly, Janssen, Mitsubishi-Tanabe, Ono Pharmaceutical, Pfizer, Sanofi, and UCB Japan., Grant/research support from: AbbVie, Amgen, Asahi-Kasei, Astellas, Chugai, Eisai, Mitsubishi-Tanabe, Ono Pharmaceutical, Teijin Pharma, and UCB Japan, Yuichi Maeda Speakers bureau: Eli Lilly Japan K.K., Chugai Pharmaceutical Co. Ltd., Pfizer Inc., Bristol Myers Squibb, and Mitsubishi Tanabe Pharma Corporation., Sadao Jinno Speakers bureau: AbbVie G.K., Asahi Kasei Pharma., Bristol-Myers Squibb., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., Janssen Pharmaceutical K.K., and Mitsubishi Tanabe Pharma, and Ono Pharmaceutical Co, Iku Shirasugi: None declared, Yonsu Son: None declared, Hideki Amuro Speakers bureau: Chugai Pharmaceutical Co.,Ltd, Masaki Katayama: None declared, Ryota Hara: None declared, Kenichiro Hata Speakers bureau: AbbVie, Asahi-Kasei, Chugai, Janssen, Mitsubishi-Tanabe, Eisai, Ayaka Yoshikawa: None declared, Motomu Hashimoto Grant/research support from: Abbvie, Asahi-Kasei, Brystol-Meyers, Eisai, Eli Lilly, Novartis Pharma.

The risk of footswitch misstep during robot-assisted thoracoscopic surgery: a case report

The Da Vinci Surgical System is an ergonomically devised and excellent surgical support device. However, surgeon skill is of paramount importance since human error cannot be completely eliminated. We report a case of bleeding from the pulmonary artery due to a footswitch misstep. A 72-year-old male with suspected right upper lobe lung cancer underwent robot-assisted thoracoscopic surgery (RATS). While avoiding the pulmonary artery with the right arm spatula and trying to cauterize V2t with the left arm bipolar-forceps, the footswitch was accidently activated and the spatula was energized, resulting in pulmonary artery trauma and blood loss. After this case, we changed the surgical procedure from a monopolar-bipolar combination use to a bipolar-only use and noted no significant difference in the console duration, and less intraoperative blood loss. Human errors can occur anytime. Especially for surgeons new to RATS, simplified foot management should be considered until RATS mastery is achieved.

[Experience of Treatment for Pneumothorax with Coronavirus Disease 2019( COVID-19) Pneumonia]

A 73 years old male patient with the past history of kidney transplantation was admitted to our hospital for treatment of coronavirus disease 2019 (COVID-19) pneumonia. On the 25th day after the onset of symptoms when his condition was improving, he suddenly developed pneumothorax. Chest tube drainage was performed and connected the tube to the drainage device using a high efficiency particulate air (HEPA) filter. Because of the improvement of infection, the HEPA filter was removed from the drainage device on day 28. Chest tube drainage was continued by day 35, and he was discharged and introduced home oxygen therapy on day 51.