More than 10 years' follow-up of the Swanson metacarpophalangeal joint arthroplasty for the rheumatoid hand

BACKGROUND

In recent years, advances in pharmacotherapy for rheumatoid arthritis have dramatically improved the control of disease activity. However, a significant number of patients still develop hand deformity and require surgical reconstruction. The objective of this study was to evaluate the long-term efficacy and drawbacks of the Swanson metacarpophalangeal joint arthroplasty for patients with rheumatoid arthritis over 10 years.

METHODS

Clinical and radiological evaluations were performed for 87 joints of 29 hands in 27 patients who underwent metacarpophalangeal joint arthroplasty using the Swanson implant, and who were followed up for an average of 11.4 (10-14) years.

RESULTS

The number of operated tender and swollen metacarpophalangeal joints decreased from 24 (27.6%) and 28 (32.2%) to 1 (1.1%) and 2 (2.3%), respectively. The patients' general health and disease activity score 28-erythrocyte sedimentation rate improved at the last survey. Mild recurrence of ulnar drift was observed, but the deformity was generally well-corrected. Implant fracture was noted in eight joints (9.2%), and revision surgery was performed in two joints (2.3%). The average active range of extension/flexion changed from -46.3°/65.9° to -32.3°/56.6°. While a significant change was not noted in grip or pinch strength, patients were satisfied with the operation especially in terms of pain relief and improved hand appearance.

CONCLUSIONS

The long-term results of Swanson metacarpophalangeal joint arthroplasty were good in pain relief and correction of deformity, but some problems remain with regard to implant durability and mobility.

Cytochromes P450 involved in Bacterial RiPP Biosyntheses

Ribosomally synthesized and post-translationally modified peptides (RiPPs) are a large class of secondary metabolites that have garnered scientific attention due to their complex scaffolds with potential roles in medicine, agriculture, and chemical ecology. RiPPs derive from the cleavage of ribosomally-synthesized proteins and the additional modifications, catalyzed by various enzymes to alter the peptide backbone or side chains. Of these enzymes, cytochromes P450 are a superfamily of heme-thiolate proteins involved in many metabolic pathways, including RiPP biosyntheses. In this review, we focus our discussion on cytochromes P450 involved in RiPP pathways and the unique chemical transformations they mediate. Previous studies have revealed a wealth of cytochromes P450 distributed across all domains of life. While the number of characterized cytochromes P450 involved in RiPP biosyntheses is relatively small, they catalyze various enzymatic reactions such as C-C or C-N bond formation. Formation of some RiPPs is catalyzed by more than one cytochrome P450, enabling structural diversity. With the continuous improvement of the bioinformatic tools for RiPP prediction and advancement in synthetic biology techniques, it is expected that further cytochrome P450-mediated RiPP biosynthetic pathways will be discovered.

The Efficacy of Biological Disease-modifying Antirheumatic Drugs on Sarcopenia in Patients with Rheumatoid Arthritis

Objective Sarcopenia is characterized by a loss of muscle mass and strength, which leads to frailty and mortality. Rheumatoid arthritis (RA) is considered to be a cause of sarcopenia. The present study assessed the effectiveness of biological disease-modifying antirheumatic drugs (bDMARDs) on sarcopenia. Methods This was a prospective cohort study including 48 patients [11 men, 37 women; 67.5 (57.0-74.8) years old] with RA who started bDMARDs in Niigata Rheumatic Center. We monitored the physical ability, nutritional status and body composition at the baseline, 6 months and 12 months. The physical activity was measured by the Health Assessment Questionnaire (HAQ) and 10-m walking test (10MWT). The nutritional status was assessed by the controlling nutrition status (CONUT) score. Results Among the 48 patients who started bDMARDs, 21 were classified as having sarcopenia. The physical activity and nutritional status were significantly ameliorated after 12 months of bDMARDs. The body composition analysis showed a significant increase in the body weight but no significant increase in the skeletal muscle mass index. The proportion of patients diagnosed with sarcopenia decreased significantly after 12 months of bDMARDs (43.8% vs. 27.1%, p=0.039). Among the 21 patients who were diagnosed with sarcopenia when starting bDMARDs, the skeletal muscle index was significantly increased after 12 months of bDMARDs. [5.22 (4.76-5.43) kg/m² vs. 5.44 (4.84-5.77), p=0.039]. Conclusion Biologics may be useful in the treatment of sarcopenia through mechanisms such as improving the disease activity, physical activity and nutritional status.

Time-lapse imaging of primary cilium behavior with physiological expression of fluorescent ciliary proteins

Almost all cell types of mammals have a small protrusion named a primary cilium on their surface. Primary cilia are enriched by cilia-specific ion channels and G-protein-coupled receptors. They are known to regulate various cellular functions that contribute to the development and homeostasis of living organisms by receiving extracellular signals and transfusing them to the cell body. All functions are performed when the structure of the primary cilia is maintained properly. Abnormalities in primary cilia or their signaling can lead to a collection of diseases in various organs called ciliopathies. The primary cilium is dynamic, static, or fixed. The length of primary cilia varies as the cell cycle progresses and is also altered by extracellular stimuli. Ligand binding to cilia-specific receptors is also known to alter the length. Thus, there is a need for a method to study the morphological changes of the primary cilium in a time-dependent manner, especially under stimuli or mechanical shocks. Time-lapse imaging of primary cilia is one of the most powerful methods to capture the time-dependent behavior of primary cilia. Overexpression of ciliary proteins fused to fluorescent proteins is commonly used for the time-lapse imaging of primary cilia. However, overexpression has drawbacks in terms of artifacts. In addition, the time-lapse imaging of the tiny primary cilia requires some technical tricks. Here, we present a detailed description of the methods for time-lapse imaging of primary cilium, from the generation of cell lines that stably express fluorescent protein-labeled cilia-localized proteins at the physiological level to image analysis, including quantification through image acquisition.

ActinoBase: tools and protocols for researchers working on Streptomyces and other filamentous actinobacteria

Actinobacteria is an ancient phylum of Gram-positive bacteria with a characteristic high GC content to their DNA. The ActinoBase Wiki is focused on the filamentous actinobacteria, such as Streptomyces species, and the techniques and growth conditions used to study them. These organisms are studied because of their complex developmental life cycles and diverse specialised metabolism which produces many of the antibiotics currently used in the clinic. ActinoBase is a community effort that provides valuable and freely accessible resources, including protocols and practical information about filamentous actinobacteria. It is aimed at enabling knowledge exchange between members of the international research community working with these fascinating bacteria. ActinoBase is an anchor platform that underpins worldwide efforts to understand the ecology, biology and metabolic potential of these organisms. There are two key differences that set ActinoBase apart from other Wiki-based platforms: [1] ActinoBase is specifically aimed at researchers working on filamentous actinobacteria and is tailored to help users overcome challenges working with these bacteria and [2] it provides a freely accessible resource with global networking opportunities for researchers with a broad range of experience in this field.

More than 20 years' follow-up of metatarsal neck shortening oblique osteotomy for rheumatoid forefoot deformity

BACKGROUND

In recent years, advances in pharmacotherapy for rheumatoid arthritis (RA) have dramatically improved the control of disease activity. However, a significant number of patients still develop forefoot deformity. The purpose of this study was to investigate the results of more than 20 years' follow-up of metatarsal neck shortening oblique osteotomy (SOO) for forefoot deformity in patients with RA.

METHODS

The metatarsal neck SOO was performed on 163 feet in 108 patients between January 1985 and December 1996 in the authors' hospital. For the patients, who met the survey criteria, an observational study was performed clinically and radiologically at the baseline and at more than 20 years after surgery.

RESULTS

A retrospective cohort study was conducted on 36 feet in 22 patients, all of whom were female, and the mean age at surgery was 45.6 (35.0-63.0) years old. The follow-up period was 25.1 (21.0-31.0) years. The presence of painful callosities in the surgically treated feet without revised surgeries decreased from 32 feet (100%) to 4 feet (12.5%) at the last follow-up with mild pain that did not cause any footwear problems. Re-osteotomy at the metatarsal of the lessor toe was performed on four feet in two patients. Radiologically, among 128 toes without revised surgeries, 85% were able to have the joint space preserved, and 89% maintained a pain-free condition without any recurrence of deformity. The mean total Japanese Society for Surgery for the Foot (JSSF) RA foot and ankle score was 64.0/100, and the visual analogue scale (VAS) of overall satisfaction was 62 (0: dissatisfied, 100: highly satisfied). The overall satisfaction had a positive correlation with calcaneal pitch and negative correlation with joint space narrowing at the talocrural joint.

CONCLUSIONS

Metatarsal neck SOO appeared to be effective for patients with RA. The deformity was corrected and retained for a long time.

Effectiveness and Safety of Golimumab for Patients ≥75 Years Old with Rheumatoid Arthritis

Objective Treatment of elderly patients with rheumatoid arthritis (RA) has been controversial because they often have serious comorbidities and cannot use methotrexate (MTX). In Japan, golimumab (GLM) 100 mg without MTX is approved. We investigated the effectiveness and safety of GLM in elderly patients with RA. Methods The GLM survival rate was evaluated using the Kaplan-Meier method. Disease activities, laboratory findings, and treatments were evaluated. Patients We enrolled 168 patients with RA in our hospital. Using age ≥75 years old to identify elderly patients, younger (n=111) and elderly (n=57) groups were established. Elderly patients were divided into 2 groups according to the MTX treatment status (with, n=27; without, n=25). Results The GLM survival rates were 80.8% and 82.3% in elderly and younger patients, respectively (p=0.762). At 52 weeks, the Disease Activity Score 28-erythrocyte sedimentation rate (DAS28-ESR) was improved in elderly patients (4.26 vs. 3.31, p<0.001); the Health Assessment Questionnaire Disability Index (HAQ-DI) was unchanged (1.12 vs. 0.88, p=0.694). When elderly patients were compared according to the MTX treatment status, the DAS28-ESR had improved in both groups (with MTX: 3.82 vs. 2.68, p<0.001; without MTX: 4.76 vs. 4.25, p=0.026); however, the HAQ-DI had not. The GLM survival rates at 52 weeks were 85% and 76% in patients with and without MTX, respectively. Conclusion In elderly patients with RA, GLM was effective, regardless of MTX treatment status, but it did not affect the HAQ-DI. GLM survival rates were comparable between elderly and younger patients. GLM may be a suitable option for elderly patients with RA who cannot use MTX.

[A Case of Adenoid Cystic Carcinoma of the Breast]

Primary adenoid cystic carcinoma(ACC)of the breast is a rare type of breast cancer. A 53-year-old woman with a right breast mass was examined at our institute. Ultrasonography showed 12.5×10.3×8.4 mm sized an ill-defined hypoechoic mass at zone C of the right breast. Pathological examination of core needle biopsy revealed atypical cells with solid and cribriform growth pattern. Computed tomography did not reveal lymph node metastases or distant metastases. The preoperative diagnosis was Stage ⅠA(cT1cN0M0, ER/PgR/HER2=-/-/1+)invasive ductal carcinoma or ACC. Surgery consisted of breast-conserving surgery and sentinel node biopsy. Pathological examination of the excised specimen revealed a so- called adenoid cystic pattern, so the final diagnosis was Stage ⅠA(pT1cN0M0, ER/PgR/HER2=-/-/1+)ACC. After 1 year of observation without adjuvant treatment, there has been no recurrence.

The Combination of Modified Mitchell's Osteotomy and Shortening Oblique Osteotomy for Patients with Rheumatoid Arthritis: An Analysis of Changes in Plantar Pressure Distribution

The present study aims to evaluate changes in plantar pressure distribution after joint-preserving surgery for rheumatoid forefoot deformity. A retrospective study was performed on 26 feet of 23 patients with rheumatoid arthritis (RA) who underwent the following surgical combination: modified Mitchell's osteotomy (mMO) of the first metatarsal and shortening oblique osteotomy of the lateral four metatarsals. Plantar pressure distribution and clinical background parameters were evaluated preoperatively and one year postoperatively. A comparison of preoperative and postoperative values indicated a significant improvement in the visual analog scale, Japanese Society for Surgery of the Foot scale, and radiographic parameters, such as the hallux valgus angle. A significant increase in peak pressure was observed at the first metatarsophalangeal joint (MTPJ) (0.045 vs. 0.082 kg/cm²; p < 0.05) and a significant decrease at the second and third MTPJs (0.081 vs. 0.048 kg/cm²; p < 0.05, 0.097 vs. 0.054 kg/cm²; p < 0.05). While overloading at the lateral metatarsal heads following mMO has been reported in previous studies, no increase in peak pressure at the lateral MTPJs was observed in our study. The results of our study show that this surgical combination can be an effective and beneficial surgical combination for RA patients with mild to moderate joint deformity.

Correction of rheumatoid swan-neck deformity of the finger using the modified Thompson-Littler method

OBJECTIVES

To investigate the outcomes of the modified Thompson-Littler (m-TL) method, a corrective surgical method utilising a dynamic tenodesis, in patients with rheumatoid swan-neck deformity.

METHODS

Twenty-seven fingers in 10 patients with rheumatoid arthritis (RA) underwent surgical correction. The mean age at the time of surgery was 60.3 (45-77) years, the mean duration of RA was 19.3 (4-34) years, and the mean postoperative follow-up period was 2.4 (0.5-6) years.

RESULTS

The deformity was corrected and the proximal interphalangeal (PIP) joint pain disappeared in all operated fingers. The mean pinch power between the thumb and the operated finger increased. The active extension decreased, the active flexion increased, and the total arc of motion decreased. Comparing the range of motion by Nalebuff's type classification, the postoperative arc of motion decreased as the type advanced.

CONCLUSIONS

The m-TL method provided a favourable outcome in cases of Type ≤III rheumatoid swan-neck deformity without severe joint deterioration at the PIP joint. Aesthetic and functional improvements were observed and the patients were satisfied with the operation.

Functional reconstruction of a hand that was severely deformed due to Jaccoud's arthropathy

A 54-year-old woman suspected of having localised systemic sclerosis (SSc) started steroid treatment around 40 years old. She had Jaccoud's arthropathy in her right hand with severe deformities but no bone erosion. The metacarpophalangeal (MP) joint of the index through the little fingers was dislocated palmo-ulnarly with flexion contracture of about 120° and a swan-neck deformity. The palmar skin crease was digging deeply into the skin and was soggy. Severe boutonnière deformity of the thumb was also noted. Due to her severely deformed hand, she could not grasp large objects or show her hand in public. Reconstructive surgery was performed in two stages using finger joint arthroplasty or fusion at the digital joints. After surgery, the appearance as well as the function of the hand was successfully restored. She was able to grasp the steering wheel of her car and was extremely satisfied with the results of the surgery.

Long-term Use of Golimumab in Daily Practice for Patients with Rheumatoid Arthritis

Objective To evaluate the effectiveness and drug retention rate of golimumab (GLM) for long-term use in daily practice for patients with rheumatoid arthritis (RA). Methods Patients with RA who started GLM therapy with a minimum follow-up period of 52 weeks were included. The patients were divided into a biologic-naïve group and switch group. The disease activity score (DAS) 28-erythrocyte sedimentation rate (ESR) (DAS28-ESR), grip power, and Japanese version of the health assessment questionnaire (J-HAQ) score were assessed. In addition, the treatment continuation rate was evaluated at the final follow-up. Patients Sixty-five patients [58 women and 7 men; median (range) age, 69 (61-74) years; median (range) disease duration, 9 (5-16) years] were included. Twenty-eight patients were biologic-naïve (naïve group), and 37 were switched to biologics (switch group). Results The median (range) follow-up period was 134 (58-162) weeks. The DAS28-ESR improved from a median (range) of 4.31 (3.52-5.25) to 2.65 (2.28-3.77) in the naïve group and from 4.27 (3.19-4.89) to 2.89 (2.49-3.88) in the switch group. The grip power improved in both groups (p<0.01); however, the J-HAQ score showed no marked improvement in either group. The continuation rates were 22/28 (78.6%) in the naïve group, and 26/37 (70.3%) in the switch group at the final follow-up. Conclusion We herein report for the first time that the long-term use of GLM improves the grip power. Improving the grip power may help prevent sarcopenia and frailty in the future. Given the efficacy and high continuation rate, we suggest that GLM would be a well-tolerated treatment option for RA.

Antimicrobial activity of the volatile compound 3,5-dichloro-4-methoxybenzaldehyde, produced by the mushroom Porostereum spadiceum, against plant-pathogenic bacteria and fungi

AIMS

In this study, volatile compounds released from mycelia of some aromatic mushrooms were investigated for their inhibitory activity against plant-pathogenic bacteria and fungi.

METHODS AND RESULTS

A screening revealed that volatile compounds from mycelia of Porostereum spadiceum remarkably inhibited the colony formation of plant-pathogenic bacteria, including Clavibacter michiganensis subsp. michiganensis and Ralstonia solanacearum while also inhibiting the conidial germination of plant-pathogenic fungi including Alternaria brassicicola and Colletotrichum orbiculare. The volatile compounds were isolated from the culture filtrate of P. spadiceum, and 3,4-dichloro-4-methoxybenzaldehyde (DCMB) was identified as a major compound. DCMB significantly inhibited bacterial colonization at 10 μg ml^-1 and fungal conidial germination at 0·1-1 μg ml^-1 as a vapour.

CONCLUSIONS

This is the first report on the production of the volatile compound DCMB by P. spadiceum and on the antimicrobial activity of DCMB against plant-pathogenic bacteria and fungi at low concentrations. It may be possible to use the compound as an agent for protecting crops from bacterial and fungal diseases during cultivation and storage.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study provides an understanding of antimicrobial activity of the mushroom volatile compound that may be useful as a novel biological control agent for protecting various plant diseases.

Twenty years' follow-up of radiocarpal arthrodesis for rheumatoid wrists

OBJECTIVES

A pain-free stable wrist is a prerequisite for patients with rheumatoid arthritis to improve their activity of daily life. The present study investigated whether or not radiocarpal arthrodesis yielded good results for more than 20 years.

METHODS

A retrospective study was performed on 20 unstable wrists in 17 patients with rheumatoid arthritis. Radiocarpal arthrodesis combined with synovectomy and the Darrach procedure was performed. Wrist pain, grip power, the range of motion, pharmacotherapy, ESR, CRP, and serial radiographs were investigated at the baseline and 20 years after the operation. Patient-reported outcomes using the mHAQ, DASH and patient's satisfaction level were investigated at the final follow-up.

RESULTS

Pain had disappeared completely in all patients at 20 years after the operation. The average grip power increased in 16 wrists (80%) and decreased in 4 wrists (20%). Wrist extension and flexion significantly decreased, and supination and pronation remained within the functional range. Radiographically, ulnar shift and palmar subluxation initially improved and remained unchanged for a long time. Fourteen patients (82.4%) with 17 wrists were satisfied with this operation.

CONCLUSION

Radiocarpal arthrodesis for rheumatoid wrists provided painless stability for a long period for 20 years or more.

Prognostic Significance of Neoadjuvant Rectal Score and Indication for Postoperative Adjuvant Therapy in Rectal Cancer Patients After Neoadjuvant Chemoradiotherapy

BACKGROUND/AIM

Neoadjuvant chemoradiotherapy (CRT) is a standard treatment for patients with clinical Stage II/III rectal cancer. However, the benefit of postoperative adjuvant chemotherapy for patients after neoadjuvant CRT is uncertain. Recently, neoadjuvant rectal (NAR) score was suggested as an independent prognostic factor for patients with rectal cancer after neoadjuvant CRT. The aim of this study was to examine the prognostic significance of NAR score in rectal cancer patients who underwent neoadjuvant CRT followed by surgery, and to investigate which patients may benefit from postoperative adjuvant therapy.

PATIENTS AND METHODS

A total of 72 patients who underwent neoadjuvant CRT followed by R0 resection for clinical stage II /III rectal cancer were evaluated. The correlation between NAR score, various clinicopathological factors and disease recurrence were evaluated.

RESULTS

Disease recurrence was significantly more often observed in patients with incomplete neoadjuvant CRT, tumor regression grade (TRG) 3-4, and high NAR score. Multivariate analysis revealed that NAR score was an independent predictor of disease recurrence.

CONCLUSION

NAR score may be one of the predictive markers for disease recurrence in patients who underwent neoadjuvant CRT followed by surgery for rectal cancer. Patients with a low NAR score may benefit form postoperative adjuvant chemotherapy.

AB0297 THE LONG-TERM OBSERVATION OF PATIENTS WITH RHEUMATOID ARTHRITIS WHO ACHIEVED A BIO-FREE CONDITION WITH ADALIMUMAB

Background:

Biological disease-modifying antirheumatic drugs (bDMARDs) caused a paradigm shift in the treatment of rheumatoid arthritis (RA). However, their high cost is a burden for patients and the national medical economy.

Objectives:

To analyze the long-term outcomes of patients with RA who achieved a bio-free condition (BF) with adalimumab (ADA).

Methods:

We followed 25 patients (male 6, female 19) who discontinued ADA with clinical remission (CR), and one female with a low disease activity (LDA), over 19.4 ±7.8 months of ADA treatment1). At the introduction of ADA, the average age was 51.2 ± 11.9 years old, and the average disease duration was 45.1 ± 48.4 months. The disease activity measured by disease activity score based on C-reactive protein (DAS28-CRP) was defined as follows: CR, <2.3; LDA, 2.3 - 2.7; moderate DA, 2.7 -4.1; and high DA, > 4.1, since the DAS28-CRP tends to be lower than the DAS28-based on the erythrocyte sedimentation rate in Japanese patients2).

Results:

We lost one patient with a transfer to another hospital. Four patients re-started ADA due to flare (DAS28-CRP>2.7) but achieved CR (in BF) again with the intensification of the treatment (dose increase or initiation of prednisolone [PSL] and/or conventional synthetic [cs] DMARDs such as tacrolimus or iguratimode). The DAS28-CRP significantly decreased from 3.45 ± 1.32 at base line (BL) to 1.55 ± 0.41 (p<0.0001) at BF. It remained 1.59 ± 0.59 (n=25) at 24 months after BF, 1.56 ± 0.39 (n= 20) at 48 months, 1.8 ± 0.7 (n=11) at 60 months. At the last observation, every patient remained in CR up to 84 months (n=2, Figure 1). The modified health assessment questionnaire score significantly decreased from 0.42 ± 0.46 (BL, n=19) to 0.02 ± 0.05 (p<0.002) at BF. It remained 0.03 ± 0.07 (n=19) at 24 months and 0.06 ± 0.14 (n=14) at 48 months, 0.04 ± 0.08 at 60 months (n=9). The PSL dose (mg/day) decreased from 3.2 ± 3.3 (BL) to 2.2 ± 2.8 at BF and 2.04 ± 2.13 (n=25) at 24 months, 1.73 ± 1.9 (n=20) at 48 months, and 1.6 ± 2.3 (n=11) at 60 months, but there were no significant changes. The methotrexate (MTX) dose (mg/week) increased from 10.1 ± 2.9 (BL) to 10.6 ± 2.6 (p< 0.78) at BF, 10.4 ± 3.3 (n=25) at 24 months, 10.7 ± 3.4 (n=20) at 48 months, 10.4 ± 3.1 at 60 months (not significant). The number of csDMARDs significantly increased from 0.8 ± 0.6 (BL) to 1.3 ± 0.9 (p<0.001, at BF), 2.56 ± 0.94 (n=25) at 24 months, 1.6 ± 1.01 (n=20) at 48 mnths, and 1.6 ± 2.3 at 60 months (n=11, Figure 2).

Conclusion:

BF can be sustained with an adequate dose of MTX and combination of csDMARDs.

References:

[1]Ito S, et al. An analysis of the biological disease-modifying antirheumatic drug-free condition of adalimumab-treated rheumatoid arthritis patients. Intern Med 58: 511-519, 2019

[2]Inoue E, et al. Comparison of Disease Activity Score (DAS)28-erythrocyte sedimentation rate and DAS28- C-reactive protein threshold values. Ann Rheum Dis. 66:407-409, 2007.

Disclosure of Interests:

Satoshi Ito Speakers bureau: Abbvie,Eisai, Shunsuke sakai: None declared, Yoichi Kurosawa: None declared, Daisuke Kobayashi: None declared, Ryo Okabayashi: None declared, Asami Abe: None declared, Hiroshi Otani: None declared, Kiyoshi Nakazono: None declared, Akira Murasawa: None declared, Ichiei Narita: None declared, Hajime Ishikawa: None declared

Arthrodesis of the digital joint using intraosseous wiring in patients with rheumatoid arthritis

OBJECTIVE

Digital joints affected by rheumatoid arthritis often have severe deformity and/or dislocation, and arthrodesis in a functional position is required.

METHODS

Arthrodesis was performed using intraosseous wiring (modified Lister's method) from January 2011 to December 2015, and we investigated the union rate, postoperative complications, and patient satisfaction with the operation at the final follow-up. The DASH score, grip power, and pinch power were also investigated before the operation and at the final follow-up.

RESULTS

Arthrodesis was performed for 90 digital joints in 56 patients. Bone union was obtained in 85 of 89 joints (96%). Wire removal was needed due to subcutaneous protrusion in 20 joints and superficial infection in five joints. The mean preoperative DASH score of 50.5 improved to 45.2 at the final follow-up. The pulp pinch power of the index fingers through the little fingers changed significantly. In the questionnaire regarding the operated digit using a visual analogue scale (VAS, 0 [worst] to 100 [best]), the overall satisfaction was 70.

CONCLUSION

With this approach, we achieved painless stability as well as deformity correction. A restored prehensile pattern and improvement in the activities of daily life can thus be expected after surgery.

Two-year Outcomes of Infliximab Discontinuation in Patients with Rheumatoid Arthritis: A Retrospective Analysis from a Single Center

Objective To investigate the clinical outcomes of rheumatoid arthritis (RA) patients who discontinued infliximab (IFX) treatment at our hospital. Methods Among 249 patients receiving IFX from 2007 to 2015, we retrospectively investigated the clinical courses of 18 who discontinued IFX after achieving the 28-joint disease activity score based on the erythrocyte sedimentation (DAS28-ESR) clinical remission (CR) and whose clinical courses were available continuously for 96 weeks after discontinuation. Results At IFX introduction, the median age was 56.9 (range 36.1-72.4) years, and the disease duration was 5.2 (0.4-25.6) years. The median duration of maintaining either CR or a low disease activity (LDA) with IFX was 37.2 (4.0-91.4) months, and the total duration of IFX therapy was 45.8 (17.1-96.9) months. After discontinuation, 8 patients (44.4%) maintained CR/LDA for 96 weeks (no-flare group), and 10 (55.6%) experienced flares (DAS28-ESR≥3.2) within 96 weeks (flare group). In the no-flare group, six patients receiving intensified conventional synthetic disease-modifying antirheumatic drug (csDMARD) therapy to prevent flare ups simultaneously either with or immediately after discontinuing IFX. In the flare group, four patients received intensified csDMARD therapy. Six patients restarted biological DMARDs (bDMARDs), and all achieved CR again. Ultimately, 12 patients (66.7%) maintained a Bio-free disease control for 96 weeks. A comparison of the clinical backgrounds between the flare and no-flare groups showed no marked difference in their disease duration, IFX dosage, duration of maintaining CR with IFX, or concomitant csDMARDs use. Conclusion Irrespective of the RA disease duration, more than half of all patients maintained a Bio-free condition for 96 weeks. Continuing LDA with IFX for a sufficiently long period of time before discontinuation and preventive intensification of csDMARD therapy may help maintain a Bio-free condition.

Key diagnostic characteristics of fever of unknown origin in Japanese patients: a prospective multicentre study

OBJECTIVE

To identify the key diagnostic features and causes of fever of unknown origin (FUO) in Japanese patients.

DESIGN

Multicentre prospective study.

SETTING

Sixteen hospitals affiliated with the Japanese Society of Hospital General Medicine, covering the East and West regions of Japan.

PARTICIPANTS

Patient aged ≥20 years diagnosed with classic FUO (axillary temperature≥38.0°C at least twice within a 3-week period, cause unknown after three outpatient visits or 3 days of hospitalisation). A total of 141 cases met the criteria and were recruited from January 2016 to December 2017.

INTERVENTION

Japanese standard diagnostic examinations.

OUTCOME MEASURES

Data collected include usual biochemical blood tests, inflammatory markers (erythrocyte sedimentation rate (ESR), C reactive (CRP) protein level, procalcitonin level), imaging results, autopsy findings (if performed) and final diagnosis.

RESULTS

The most frequent age group was 65-79 years old (mean: 58.6±9.1 years). The most frequent cause of FUO was non-infectious inflammatory disease. After a 6-month follow-up period, 21.3% of cases remained undiagnosed. The types of diseases causing FUO were significantly correlated with age and prognosis. Between patients with and without a final diagnosis, there was no difference in CRP level between patients with and without a final diagnosis (p=0.121). A significant difference in diagnosis of a causative disease was found between patients who did or did not receive an ESR test (p=0.041). Of the 35 patients with an abnormal ESR value, 28 (80%) had causative disease identified.

CONCLUSIONS

Age may be a key factor in the differential diagnosis of FUO; the ESR test may be of value in the FUO evaluation process. These results may provide clinicians with insight into the management of FUO to allow adequate treatment according to the cause of the disease.

Nutritional status as the risk factor of serious infection in patients with rheumatoid arthritis

Objectives: The aim of this study was to identify the risk factors associated with severe infection in RA patients, with a particular focus on the association of the nutritional status.Methods: We retrospectively analyzed data from 74 patients with RA (male, n = 21; female, n = 53; age 74.2 ± 12.4) admitted to our hospital between 2016 and 2017 for infection (infection group). We also recruited control RA patients (n = 222) who were matched for age, gender and disease duration, with a match ratio of 1:3 (non-infection group). The nutritional condition was assessed based on controlling nutrition status (CONUT) score, and prognostic nutritional index (PNI). The data of the infection group were obtained from the most recent visit prior to the present admission, and non-infection group from the last regular visit in 2017.Results: The respiratory tract was the most frequent site of infection. The BMI and PNI were significantly lower and the CONUT score significantly higher in the infection group than in the non-infection group. A logistic regression analysis revealed that the CONUT score, underlying lung disease and use of prednisolone and biological disease-modifying anti-rheumatic drugs were independent and significant risk factors for serious infection.Conclusion: Poor nutritional status increases the risk of serious infection.

Changes in radiographic findings and plantar pressure distribution following forefoot reconstructive surgery for patients with rheumatoid arthritis

Objectives: To evaluate changes in radiographic findings and plantar pressure distribution after rheumatoid forefoot surgery.Methods: This study was performed on patients with rheumatoid arthritis (RA) who underwent Swanson implant arthroplasty for the 1st metatarsophalangeal (MTP) joint combined with shortening oblique osteotomy at the 2nd through 5th metatarsal necks (group Sw, 55 feet). The following two groups were used as controls: group NS, consisting of 75 feet in RA patients without scheduled forefoot surgery, and group HC, consisting of 24 feet in healthy female subjects. Plantar pressure distribution, and radiographic findings of hallux valgus angle, the angle between the metatarsal bones, talocalcaneal angle, calcaneal pitch angle and calcaneo-first metatarsal angle (CFMA) were measured pre- and one year postoperatively. Peak pressure was measured in nine sections.Results: Calcaneal pitch angle decreased and CFMA increased in group Sw. Peak pressure at the 1st interphalangeal joint (IP) and the 2nd and 3rd MTPs in group Sw decreased, while that at midfoot increased.Conclusion: While the clinical outcome in group Sw was favorable, postoperative longitudinal arch decreased. Postoperative peak pressure at the 2nd through 5th MTPs was comparable with that in group NS; however, it was significantly lower than that in group HC.

CRAGE enables rapid activation of biosynthetic gene clusters in undomesticated bacteria

It is generally believed that exchange of secondary metabolite biosynthetic gene clusters (BGCs) among closely related bacteria is an important driver of BGC evolution and diversification. Applying this idea may help researchers efficiently connect many BGCs to their products and characterize the products' roles in various environments. However, existing genetic tools support only a small fraction of these efforts. Here, we present the development of chassis-independent recombinase-assisted genome engineering (CRAGE), which enables single-step integration of large, complex BGC constructs directly into the chromosomes of diverse bacteria with high accuracy and efficiency. To demonstrate the efficacy of CRAGE, we expressed three known and six previously identified but experimentally elusive non-ribosomal peptide synthetase (NRPS) and NRPS-polyketide synthase (PKS) hybrid BGCs from Photorhabdus luminescens in 25 diverse γ-Proteobacteria species. Successful activation of six BGCs identified 22 products for which diversity and yield were greater when the BGCs were expressed in strains closely related to the native strain than when they were expressed in either native or more distantly related strains. Activation of these BGCs demonstrates the feasibility of exploiting their underlying catalytic activity and plasticity, and provides evidence that systematic approaches based on CRAGE will be useful for discovering and identifying previously uncharacterized metabolites.

An Analysis of the Biological Disease-modifying Antirheumatic Drug-free Condition of Adalimumab-treated Rheumatoid Arthritis Patients

Objectives The present study was performed with the aim of analyzing the biological disease-modifying antirheumatic drug (bDMARD)-free (Bio-free) condition of adalimumab (ADA)-treated rheumatoid arthritis (RA) patients in a real-world setting. Methods ADA was used in the treatment of 130 (male, n=21; female, n=109 females) RA patients. Among them, 26 patients (20.0%) discontinued ADA due to a good response. We analyzed 20 patients who were followed up for more than 6 months after the discontinuation of ADA. The Disease Activity Score 28 based on C-reactive protein (DAS28-CRP) and modified health assessment questionnaires (mHAQs) were evaluated. Results The mean age of the patients was 53.4±11.1 years. The mean disease duration was 4.5±4.3 years. Sixteen patients were bDMARD-naïve, while 4 switched from bDMARDs to ADA. At 6 months after the discontinuation ADA, 19 patients had achieved a clinical remission, and 1 had achieved a low disease activity. The Bio-free period was 26.4±15.5 months. The dose of prednisolone was significantly reduced from baseline (3.45±3.17 mg/day) at 6 months after the discontinuation of ADA (2.63±2.78 mg/day). The dose of methotrexate was unchanged. The number of conventional synthetic DMARDs (csDMARDs) was significantly increased (0.8±0.6 to 1.4±1.06). The mHAQ values were significantly ameliorated by ADA and remained good in patients with a Bio-free condition. A multivariate analysis showed that the dose of methotrexate (MTX) was an important factor for achieving a Bio-free condition. Conclusion A sustainable Bio-free condition in a real clinical setting can be achieved and may be a suitable way of reducing medical costs. The dose of MTX and the additional administration of csDMARDs is therefore thought to be important for ensuring a good outcome in these patients.

New voyages to explore the natural product galaxy

Natural products are a large family of diverse and complex chemical molecules that have roles in both primary and secondary metabolism, and over 210,000 natural products have been described. Secondary metabolite natural products are of high commercial and societal value with therapeutic uses as antibiotics, antifungals, antitumor and antiparasitic products and in agriculture as products for crop protection and animal health. There is a resurgence of activity in exploring natural products for a wide range of applications, due to not only increasing antibiotic resistance, but the advent of next-generation genome sequencing and new technologies to interrogate and investigate natural product biosynthesis. Genome mining has revealed a previously undiscovered richness of biosynthetic potential in novel biosynthetic gene clusters for natural products. Complementing these computational processes are new experimental platforms that are being developed and deployed to access new natural products.

The influence of excluding patients with bystander return of spontaneous circulation in the current OHCA database

BACKGROUND

The effect of bystander interventions has been extensively evaluated by cerebral function after 1 month post-resuscitation. However, patients who received bystander cardiopulmonary resuscitation (BCPR) and achieved the return of spontaneous circulation (ROSC) before the arrival of the emergency medical system (EMS) are routinely defined with an unknown electrocardiogram (ECG) and are usually excluded before analysis. The aim is to determine the influence of excluding patients with unknown first monitored rhythm, which includes cases of bystander ROSC, from the out-of-hospital cardiac arrest (OHCA) database.

METHODS

This nationwide population-based observational study was conducted in Japan using Utstein data from 2011 to 2014. In total, 91,995 patients with bystander-witnessed cardiogenic OHCA received resuscitation attempts in the pre-hospital setting. These patients were divided into three groups by the first monitored rhythm upon EMS arrival. We analysed the differences of datasets that included and excluded the unknown group and determined the effect on outcomes by multivariate logistic regression and odds ratios (ORs) with 95% confidence intervals (95% CIs).

RESULTS

When the unknown group was excluded from the data, the adjusted odds ratio (AOR) of cardiopulmonary resuscitation (CPR) to favourable cerebral performance category (CPC) 1 or 2 was decreased (conventional CPR: AOR, 1.90 to 1.58; chest-compression-only CPR: AOR, 2.08 to 1.69) compared to the unknown group's inclusion. Conversely, the AOR of public-access defibrillation (PAD) was increased (AOR, 4.51 to 6.13).

CONCLUSIONS

The exclusion of unknown ECGs from a dataset may lose ROSC patients by bystander CPR, causing selection bias to affect outcomes.

Long-term patient reported outcomes of elbow, wrist and hand surgery for rheumatoid arthritis

AIM

A retrospective questionnaire survey was conducted to investigate the long-term outcomes of elbow, wrist and hand surgery for rheumatoid arthritis (RA).

METHODS

One hundred and thirteen RA patients underwent primary elective elbow, wrist or hand surgery at our hospital between January 2002 and December 2003. To evaluate the outcomes at 10 years after surgery, the patient-reported outcomes were assessed using an original questionnaire that inquired about the site of treatment; the modified Stanford Health Assessment Questionnaire (mHAQ) was also used.

RESULTS

Responses were obtained from 67 patients (98 sites). In the 10 years after surgery, the Disease Activity Score of 28 joint - erythrocyte sedimentation rate (4) and the modified Health Assessment Questionnaire scores of the patients showed significant improvement. Nearly 85% of patients were satisfied with the outcome at the surgical site. The most frequent reason for perceived improvement was 'pain relief' (all surgical sites). An 'improved appearance' was frequently reported after finger surgery and 'increased power' was frequently reported after wrist and thumb surgeries. With regard to elbow surgery, 30% of the patients were satisfied with the increase in motion and power. In contrast, approximately 20% of patients complained of decreased power around the surgical site after elbow and thumb surgeries.

CONCLUSIONS

Our original patient-reported outcome assessment tool revealed that elbow, wrist and hand surgery provided long-lasting benefits in RA patients. While the efficacy differed in some of the surgical sites, pain relief was the most favorable effect. Altered medical therapy may also have impacted the patient-perceived outcomes of surgery at 10 years.

The Efficacy of Minodronate in the Treatment of Glucocorticoid-induced Osteoporosis

Objective To investigate the efficacy of minodronate in the treatment of glucocorticoid-induced osteoporosis (GIO). Methods The study population included patients in whom the administration of minodronate (50 mg, once every 4 weeks) had been newly started for the treatment of GIO in Niigata Rheumatic Center from 2012 to 2015. Patients who were bisphosphonate-naïve and those who switched from other bisphosphonates were classified into the naïve and switch groups, respectively. The changes in the bone mineral density (BMD) and bone metabolic markers after one year of minodronate treatment were retrospectively evaluated. We also compared the BMD and bone turnover marker changes of minodronate-naïve patients with those in whom alendronate or risedronate had been prescribed as a first bisphosphonate (control group). Results Minodronate was prescribed to 142 patients, and data were successfully obtained from 120 patients. New vertebral fractures were observed in 5 of the 142 patients; 1 fracture occurred during the cessation of minodronate for dental treatment, and 3 patients already had multiple vertebral fractures before the initiation of minodronate. The patients' tartrate-resistant acid phosphatase 5b (TRACP-5b) (-27.0%, p<0.001) and bone alkaline phosphatase (BAP) (-15.7%, p<0.01) levels were decreased, but no patients showed a decrease to below the normal range. One year of treatment with minodronate significantly increased the lumbar BMD in the naïve (+3.9%, p<0.001) and switch (+2.3%, p<0.001) groups. Although the femoral BMD did not change to a significant extent overall, the patients with a low young adult mean (YAM) (<80%) at baseline showed a significant increase in their femoral BMD (+2.1%, p=0.034) values. Compared with the control group, the minodronate-naïve group showed a significant decrease in the TRACP-5b levels and a significant increase in the lumbar BMD. Conclusion The administration of minodronate appears to be an effective treatment for GIO.

Neoadjuvant Radiotherapy with Capecitabine Plus Bevacizumab for Locally Advanced Lower Rectal Cancer: Results of a Single-institute Phase II Study

BACKGROUND/AIM

A single-arm phase II clinical trial was conducted to evaluate the safety and efficacy of adding bevacizumab to standard capecitabine-based neoadjuvant chemoradiotherapy (CRT) for the treatment of locally advanced rectal cancer (LARC).

PATIENTS AND METHODS

Twenty-five patients were enrolled. Patients received capecitabine-based CRT for 5 weeks and 3 days. Bevacizumab was administered every 2 weeks during CRT. Within 6-10 weeks after completion of CRT, surgery was performed.

RESULTS

With regard to CRT-related acute toxicities, most of the adverse events were limited to grade 1. A pathological complete response was obtained in four (16%) patients. In total, six patients (24%) developed postoperative complications. Six out of five (83%) patients healed without the need for surgical intervention.

CONCLUSION

Although acute toxicity during CRT with bevacizumab was minimal and postoperative complications do not seem to increase, the addition of bevacizumab apparently offers no clinically-significant benefit for patients with LARC.

Metacarpophalangeal Joint Arthroplasty Using Flexible Hinge Toe Implant with Grommets for Boutonnière Deformity of Rheumatoid Thumb

BACKGROUND

MP joint arthroplasty is one of the treatment options for the rheumatoid thumb with boutonniere deformity. The use of flexible hinge toe implant for MP joint reconstruction was introduced; however, the outcome of flexible toe implantation for the reconstruction of the MP joint has not as yet been reported in detail. Therefore, in this study, we retrospectively investigated the clinical outcome and radiological findings.

METHODS

We assessed 56 Swanson implant arthroplasties that used flexible hinge toe implants with grommets to address boutonnière deformity of the thumb MP joint. The minimum follow-up period was 6 months. Pain, the range of motion, grip strength, pinch strength, General health Visual analogue scale and DASH (Disabilities of Hand, Shoulder and Hand) were assessed.

RESULTS

For most of the patients, the procedure provided painless motion and stability to the thumb. In the radiological assessments, the preoperative flexion angles at the MP joint were 45° improved to 17°. The origin of arc was shifted toward the extended position and the average arc of motion was 21°, with a flexion arc from 23° to 44°. The severity of boutonniere deformity was improved in most cases. The average grip strength changed from 110 to 121 mmHg and the average side pinch power changed from 1.5 to 2.2 kgf. General health VAS improved from 40 to 29 (p = 0.019), and the DAS28-CRP decreased from 3.3 to 2.4 (p < 0.001). Infection occurred in one case, and there were no implant fractures.

CONCLUSIONS

Swanson flexible hinge toe implant arthroplasty with grommets applied to the MP joint of the thumb was one of the recommended procedures for the reconstruction of boutonnière deformity of the thumb.

Efficacy and safety of infliximab: A comparison with other biological disease-modifying anti-rheumatic drugs

OBJECTIVES

The intensification of infliximab (IFX) treatment, involving escalation of the dose and shortening of interval, was approved in Japan in July 2009. We consider IFX intensification therapy to be preferable for patients with treatment-resistant active rheumatoid arthritis (RA). We retrospectively compared the efficacy of IFX with that of other bDMARDs in methotrexate (MTX)-resistant patients.

METHODS

Patients who satisfied the following criteria were enrolled: (i) those who started bDMARDs between February 2011 and December 2016, and (ii) those who required bDMARDs after 180 d of MTX treatment. We compared 33 patients who had been treated with IFX (IFX group) and 146 who had received other bDMARDs treatment (non-IFX group).

RESULTS

IFX was administered at a dose of 6.98 mg/kg/8-week equivalent at 52 weeks. Clinical disease activity index clinical remission (CDAI-CR) was achieved in 49 of the 179 patients at 52 weeks and 13 of these 49 patients received IFX. Logistic regression analysis showed that treatment with IFX was an important variable for the achievement of CDAI-CR at 52 weeks (odds ratio 2.69, 95% confidence interval 1.13-6.42). The severity and frequency of adverse events did not differ.

CONCLUSION

Intensification of IFX was effective and well tolerated for MTX resistant patients.

Characterization of key triacylglycerol biosynthesis processes in rhodococci

Oleaginous microorganisms have considerable potential for biofuel and commodity chemical production. Under nitrogen-limitation, Rhodococcus jostii RHA1 grown on benzoate, an analog of lignin depolymerization products, accumulated triacylglycerols (TAGs) to 55% of its dry weight during transition to stationary phase, with the predominant fatty acids being C16:0 and C17:0. Transcriptomic analyses of RHA1 grown under conditions of N-limitation and N-excess revealed 1,826 dysregulated genes. Genes whose transcripts were more abundant under N-limitation included those involved in ammonium assimilation, benzoate catabolism, fatty acid biosynthesis and the methylmalonyl-CoA pathway. Of the 16 atf genes potentially encoding diacylglycerol O-acyltransferases, atf8 transcripts were the most abundant during N-limitation (~50-fold more abundant than during N-excess). Consistent with Atf8 being a physiological determinant of TAG accumulation, a Δatf8 mutant accumulated 70% less TAG than wild-type RHA1 while atf8 overexpression increased TAG accumulation 20%. Genes encoding type-2 phosphatidic acid phosphatases were not significantly expressed. By contrast, three genes potentially encoding phosphatases of the haloacid dehalogenase superfamily and that cluster with, or are fused with other Kennedy pathway genes were dysregulated. Overall, these findings advance our understanding of TAG metabolism in mycolic acid-containing bacteria and provide a framework to engineer strains for increased TAG production.

Serum Fibroblast Growth Factor 23 (FGF23) in Patients with Rheumatoid Arthritis

Objective Rheumatoid arthritis (RA) is a chronic inflammatory disease accompanied by periarticular and systemic osteoporosis. Fibroblast growth factor 23 (FGF23), which is mainly produced by osteocytes, circulates to the kidneys and regulates bone metabolism. We herein assessed serum FGF23 and its relationship to inflammation and osteoporosis in patients with RA. Methods Sixty-one patients with RA were included. Serum concentrations of FGF23 were determined using a sandwich enzyme-linked immunosorbent assay. Results The mean (± standard deviation) serum FGF23 concentration was 34.9±9.2 (range, 21.0-61.0) pg/mL. The serum FGF23 level was significantly and positively correlated with the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) levels, disease activity score-28 based on the ESR (DAS-28 ESR) and DAS-28 CRP (r=0.261, p=0.044, r=0.280, p=0.029, r=0.409, p=0.001 and r=0.421, p=0.001, respectively). The serum matrix metalloproteinase-3 level was also significantly and positively correlated with the serum FGF23 level (r=0.331, p=0.015). Concentrations of type I collagen cross-linked N-telopeptide in the serum was significantly correlated with the serum FGF23 level (r=0.272, p=0.034). Neither the bone mineral density in the femoral neck nor lumbar was significantly correlated with the serum FGF23 level. Serum phosphate, calcium, 25-hydroxy vitamin D, and intact parathyroid hormone were not related to the serum FGF23 level. Conclusion In patients with RA, serum FGF23 is correlated with inflammation, the disease activity of RA, and bone absorption markers. Serum FGF23 may be associated with abnormal bone absorption related to RA inflammation. Further studies are necessary to clarify the mechanism underlying this association.

The activity of CouR, a MarR family transcriptional regulator, is modulated through a novel molecular mechanism

CouR, a MarR-type transcriptional repressor, regulates the cou genes, encoding p-hydroxycinnamate catabolism in the soil bacterium Rhodococcus jostii RHA1. The CouR dimer bound two molecules of the catabolite p-coumaroyl-CoA (Kd = 11 ± 1 μM). The presence of p-coumaroyl-CoA, but neither p-coumarate nor CoASH, abrogated CouR's binding to its operator DNA in vitro. The crystal structures of ligand-free CouR and its p-coumaroyl-CoA-bound form showed no significant conformational differences, in contrast to other MarR regulators. The CouR-p-coumaroyl-CoA structure revealed two ligand molecules bound to the CouR dimer with their phenolic moieties occupying equivalent hydrophobic pockets in each protomer and their CoA moieties adopting non-equivalent positions to mask the regulator's predicted DNA-binding surface. More specifically, the CoA phosphates formed salt bridges with predicted DNA-binding residues Arg36 and Arg38, changing the overall charge of the DNA-binding surface. The substitution of either arginine with alanine completely abrogated the ability of CouR to bind DNA. By contrast, the R36A/R38A double variant retained a relatively high affinity for p-coumaroyl-CoA (Kd = 89 ± 6 μM). Together, our data point to a novel mechanism of action in which the ligand abrogates the repressor's ability to bind DNA by steric occlusion of key DNA-binding residues and charge repulsion of the DNA backbone.

Inflammation-based factors and prognosis in patients with colorectal cancer

Several parameters for predicting survival in patients with colorectal cancer have been identified, including the performance status, age, gender and tumor-node-metastasis (TNM) stage. Although the TNM stage is important and useful for predicting the prognosis and determining the appropriate treatment, it is well known that the survival time varies widely, even in patients with the same stage of disease. Therefore, the identification of new parameters capable of more precisely predicting patient survival is needed to help select the optimal treatment, especially in patients in the advanced stage of disease. Although the TNM stage reflects the tumor characteristics, cancer progression and survival are not determined solely based on the local characteristics of the tumor, but also the host systemic immune/inflammatory response. Therefore, using a combination of parameters that reflect both tumor characteristics and the host systemic inflammatory status is thought to be important for accurately predicting patient survival.

Abstract 5276: Epithelial mesenchymal transition may contribute to anaplastic change of pancreatic ductal adenocarcinoma

Introduction: Anaplastic pancreatic cancer (APC) is a rare subtype of pancreatic ductal adenocarcinoma (PDA). The prognosis of APC is poorer than that of ordinary PDA. There is no established therapeutic strategy as well as PDA. In this study, we compared the expression of molecular markers in intratumoral different lesions which are undifferentiated lesion (UL) and ductal lesion (DL) to reveal progression pattern of APC and hold important clue for the therapy of APC.

Materials & Methods: Formalin fixed paraffin embedded blocks were made from the primary APC tissues obtained from 6 patients. Each block was manipulated for staining with Hematoxylin and Eosin (H&E) and immunohistochemistry (IHC) for SOX9, E-cadherin, vimentin, ZEB-1, Snail, N-cadherin, CD24 and CD44. Using H&E slice, each sample was divided from cancerous lesion and non-cancerous lesion. Furthermore, cancerous lesion were divided from DL and UL. And then, for each marker, the intensity of staining of UL was compared with that of DL. The intensity was scored from 0 to 3. The relation between DL and UL was estimated based on the intensity score of each sample.

Results: The proportion of DL to all cancerous lesion was 0.5% to 32%. The score of SOX9 was all 3 except one case in both lesions. Although the expression of E-cadherin was almost negative in UL, DL showed various scores. About vimentin, the intensity in UL was largely 2 and 3. In contrast, that of DL was very weak or none. The score of ZEB1 was 0 or 1 in DL and 1 or 3 in UL. Although Snail showed various scores in both regions, the score was mostly higher in UL than in DL. The score of N-cadherin expression was comparatively high in UL. CD24 and CD44 were not almost expressed in DL. In UL, the expression of these markers were various intensity.

Disscusion: In the current study, it was suggested that APC might be derived from PDA by showing the expression of SOX9. Previous studies were reported from the view of KRAS mutation and cytokeratin expression about the origin of APC. However, recent studies were reported that these markers were often expressed even in other pancreatic neoplasm. Furthermore the expression of SOX9 is only identified in PDA among pancreatic neoplasms.

Also, it was suggested that UL might change from DL through EMT by confirming the difference of the expression pattern of markers relating EMT in DL and UL.

Because the expression of CD24 and CD44 varied in each case, it is unclear whether the stemness concerned with the progression to APC in our study. We also need to estimate the other stem cell markers including CD133, Oct3/4 or Nanog.

Conclusion: It was suggested that EMT might induce the progression from PDA to APC.

Citation Format: Kotaro Miura, Kenjiro Kimura, Ryosuke Amano, Sadaaki Yamazoe, Go Ohira, Kohei Nishio, Masatsune Shibutani, Katsunobu Sakurai, Hisashi Nagahara, Takahiro Toyokawa, Naoshi Kubo, Hiroaki Tanaka, Kazuya Muguruma, Hiroshi Otani, Masakazu Yashiro, Kiyoshi Maeda, Masaichi Ohira, Kosei Hirakawa. Epithelial mesenchymal transition may contribute to anaplastic change of pancreatic ductal adenocarcinoma. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 5276. doi:10.1158/1538-7445.AM2015-5276

MRI study of atherosclerotic plaque progression using ultrasmall superparamagnetic iron oxide in Watanabe heritable hyperlipidemic rabbits

OBJECTIVE

The purpose of this study was to evaluate plaque progression by using MRI with ultrasmall superparamagnetic iron oxide (USPIO) and by histopathological studies.

METHODS

We divided 12 Watanabe heritable hyperlipidemic (WHHL) rabbits into 4 groups based on their age (3, 9, 14 and 26 months) and injected them intravenously with 0.8 mmol (Fe) kg(-1) of USPIO (size, 32 nm; concentration, 15 mg dl(-1)). On the fifth post-injection day, they were again given an intravenous injection with 40 μmol kg(-1) of the same USPIO, and MR angiography (MRA) was performed. The signal-to-noise ratio (SNR) in regions of interest in the wall of the upper abdominal aorta was calculated on coronal images. Specimens from the same level of the aorta were subjected to iron staining and RAM-11 immunostaining and used for histopathological study. For statistical analysis of the MRA and histopathological findings, we used analysis of variance [Tukey's honest significant difference (HSD) test].

RESULTS

In 9-month-old rabbits, the SNR was significantly lower than in rabbits of the other ages (p < 0.01), and the area of RAM-11 (DAKO Corporation, Glostrup, Denmark) and iron uptake in the aortic wall was significantly larger (RAM-11, p < 0.01; iron, p < 0.05). These areas were the smallest in 3-month-old rabbits.

CONCLUSION

Histopathologically, the number of macrophages was the greatest in 9-month-old rabbits. Our findings indicate that the SNR on MRI scans reflects the number of macrophages in the aortic wall of WHHL rabbits.

ADVANCES IN KNOWLEDGE

USPIO-enhanced MRI visualized the accumulation of macrophages in early atherosclerotic plaques of WHHL rabbits in the course of natural progression.

The rate of decrease in the disease activity of rheumatoid arthritis during treatment with adalimumab depends on the dose of methotrexate

OBJECTIVE

The aim of this study was to analyze the efficacy of adalimumab (ADA) in patients with rheumatoid arthritis treated with or without methotrexate (MTX) and determine impact of the MTX dose.

METHODS

Pearson's product-moment correlation coefficient was used to assess the correlations between the improvement in the Disease Activity Score (DAS) 28- erythrocyte sedimentation rate (ESR) score and the MTX dose in patients receiving treatment with MTX at a dose of <8 mg/week, 8 mg/week and >8 mg/week.

PATIENTS

ADA therapy was initiated in 68 rheumatoid arthritis patients between July 2008 and June 2013. The mean MTX dose was 9.6 ± 2.6 mg/week, and the patients were followed for 24 weeks.

RESULTS

The mean DAS28-ESR scores at baseline and week 24 were 4.6 ± 1.3 and 2.7 ± 1.2 in the 60 patients treated with MTX and 4.5 ± 1.0 and 4.2 ± 1.5 in the eight patients treated without MTX, respectively. Clinical remission was achieved in 48% and 25% of the patients, respectively, by week 24. Moreover, 90.0% of the patients taking MTX continued to receive ADA until week 24, while 50.0% of the patients not taking MTX continued to receive ADA until week 24. Among the 35 patients receiving MTX at a dose of >8 mg/week, the DAS28-ESR scores decreased rapidly from 4.4 ± 1.2 at baseline to 3.2 ± 1.1 at week 4 and further decreased to 2.4 ± 1.0 at week 24. Meanwhile, clinical remission was achieved in 57% of the patients receiving MTX at a dose of >8 mg/week and 36% of those receiving MTX at a dose of ≤8 mg/week. A significant correlation was noted between the improvement in the DAS-ESR score and the MTX dose.

CONCLUSION

In this study population, enhanced clinical efficacy of ADA was achieved in combination with the administration of a sufficient dose of MTX, determined to be >8 mg/week.