Preoperative examination and intraoperative cerebrospinal fluid leakage test for minimally invasive surgery of spinal extradural arachnoid cysts: illustrative case

BACKGROUND

Spinal extradural arachnoid cysts (SEACs) are rare and can cause spinal dysfunction. Total cyst removal and duraplasty via multiple laminectomies are commonly performed. However, to avoid postoperative spinal deformity and axial pain, a minimally invasive surgery via selective laminectomy may be optimal. Therefore, preoperative detection of the dural fistula site is required.

OBSERVATIONS

A 25-year-old male presented with a 2-month history of progressive gait disturbance and back pain. Conventional magnetic resonance imaging (MRI) revealed SEACs at the T9 to L2 level but did not reveal the dural fistula. Further examinations were performed using sagittal time-spatial labeling inversion pulse MRI and cone-beam computed tomography myelography with a spinal intrathecal catheter, which indicated a dural fistula on the left side at the T12 level. On the basis of these results, dural repair was performed via selective laminectomy. Furthermore, an intraoperative cerebrospinal fluid leakage test by intrathecally injecting saline via a spinal catheter confirmed complete closure of the dural fistula, with no other fistulas.

LESSONS

These comprehensive pre and intraoperative examinations may be useful for minimally invasive and selective surgeries in patients with SEACs.

Immunohistological analysis of B7-H4, IDO1, and PD-L1 expression and tumor immune microenvironment based on triple-negative breast cancer subtypes

BACKGROUND

B7 homolog 4 (B7-H4) and indoleamine 2,3-dioxygenase (IDO1) are factors involved in the inhibition of antitumor activity and are new therapeutic targets for immune checkpoint therapy. Our study aimed to simultaneously investigate the interrelationship among B7-H4, IDO1 and programmed cell death ligand 1 (PD-L1) expression in triple-negative breast cancer (TNBC), including tumor immune microenvironment (TIME) and TNBC subtypes.

METHODS

Immunostaining for PD-L1, B7-H4, and IDO1 was performed on whole-slide sections of 119 cases of TNBC. The TIME was evaluated based on stromal tumor infiltrating lymphocytes (sTILs; %), pattern classification of TILs, tumor-stroma ratio (TSR), and tertiary lymphoid structure (TLS). TNBC subtypes were also determined by immunohistochemistry analysis of cytokeratin 5/6 and androgen receptor (AR) expression.

RESULTS

B7-H4 expression was significantly higher in cases with a combined positive score cutoff of 5 for PD-L1 (clone 28-8; p = 0.021), inflamed TIL pattern (p = 0.007), and TLS ≥ 4 (p = 0.006). B7-H4 expression was higher in case of CK5/6 ≥ 10 (p = 0.035). The H-scores of AR and B7-H4 were inversely correlated (ρ = - 0.509, p < 0.001). B7-H4 and IDO1 expression levels were inversely correlated in cases with AR < 10 (ρ = - 0.354, p < 0.001).

CONCLUSIONS

These results suggest that considering the TIL pattern and TLS and identifying the expression of PD-L1 and the basal-like type are useful for estimating B7-H4 expression. In addition, luminal androgen receptor (LAR)-type is frequently deficient in B7-H4 expression. In non-LAR types, B7-H4 and IDO1 expression are exclusive.

Multifocal primary central nervous system angiosarcoma: illustrative case

BACKGROUND

Angiosarcoma is a malignant mesenchymal tumor derived from vascular endothelial cells in which a primary intracranial origin is extremely rare. Most previous reports of primary central nervous system (CNS) angiosarcoma have been solitary cases.

OBSERVATIONS

The authors report a case of primary CNS angiosarcoma that caused the development of multiple disseminated cerebral hemorrhagic lesions within a short period of time. This rapid progression of symptoms resulted in the death of the patient. During surgery, several nodules suggestive of a tumor were removed from just below the surface of the brain, mixed into the hematoma. A pathological examination revealed atypical cells mimicking blood vessels in the subarachnoid space that were positive for specific vascular endothelial markers.

LESSONS

In this case, multifocal angiosarcoma occurred on the brain surface and ventricles, suggesting cerebrospinal fluid dissemination. If multiple cerebral hemorrhages are found on the brain surface, multifocal angiosarcoma should also be considered.

ANCA-associated vasculitis with scleritis, corneal melt, and perforation rescued by rituximab: Case report and literature review

Key Clinical Message

Patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, specifically with myeloperoxidase (MPO)-ANCA, would have a risk for developing corneal melt and perforation abruptly in a short period. It is desirable to have a team of collaboration of rheumatologists and other specialties.

Abstract

An 80-year old man who had been diagnosed 5.5 years previously as ANCA-associated vasculitis by temporal artery biopsy developed corneal melt and perforation with scleritis in both eyes. He underwent successful cataract surgery and retained ambulatory vision with the aid of intravenous rituximab. Two additional patients with similar manifestations were found in the literature.

The effects of losartan or angiotensin II receptor antagonists on cartilage: a systematic review

OBJECTIVE

The aim of this study is to analyze the latest evidence on the effects of losartan or Ang II receptor antagonists on cartilage repair, with a focus on their clinical relevance.

DESIGN

The PubMed, Embase, and Cochrane Library databases were searched up to November 12th 2021 to evaluate the effects of losartan or Ang II receptor antagonists on cartilage repair in in vitro studies and in vivo animal studies. Study design, sample characteristics, treatment type, duration, and outcomes were analyzed. The risk of bias and the quality of the eligible studies were assessed using the Systematic Review Centre for Laboratory Animal Experimentation (SYRCLE) risk of bias assessment tool and Collaborative Approach to Meta-Analysis and Review of Animal Data from Experimental Studies (CAMARADES).

RESULTS

A total of 12 studies were included in this systematic review. Of the 12 eligible studies, two studies were in vitro human studies, three studies were in vitro animal studies, one study was an in vitro human and animal study, and six studies were in vivo animal studies. The risk bias and quality assessments were predominantly classified as moderate. Since meta-analysis was difficult due to differences in treatment type, dosage, route of administration, and method of outcome assessment among the eligible studies, qualitative evaluation was conducted for each study.

CONCLUSIONS

Both in vitro and in vivo studies provide evidence to demonstrate beneficial effects of Ang II receptor antagonists on osteoarthritis and cartilage defect models across animal species.

Circulating α-Klotho Counteracts Transforming Growth Factor-β-Induced Sarcopenia

α-Klotho is a longevity-related protein. Its deficiency shortens lifespan with prominent senescent phenotypes, including muscle atrophy and weakness in mice. α-Klotho has two forms: membrane α-Klotho and circulating α-Klotho (c-α-Klotho). Loss of membrane α-Klotho impairs a phosphaturic effect, thereby accelerating phosphate-induced aging. However, the mechanisms of senescence on c-α-Klotho loss remain largely unknown. Here, we show that, with the aging of wild-type mice, c-α-Klotho declined, whereas Smad2, an intracellular transforming growth factor (TGF)-β effector, became activated in skeletal muscle. Moreover, c-α-Klotho suppressed muscle-wasting TGF-β molecules, including myostatin, growth and differentiation factor 11, activin, and TGF-β1, through binding to ligands as well as type I and type II serine/threonine kinase receptors. Indeed, c-α-Klotho reversed impaired in vitro myogenesis caused by these TGF-βs. Oral administration of Ki26894, a small-molecule inhibitor of type I receptors for these TGF-βs, restored muscle atrophy and weakness in α-Klotho (-/-) mice and in elderly wild-type mice by suppression of activated Smad2 and up-regulated Cdkn1a (p21) transcript, a target of phosphorylated Smad2. Ki26894 also induced the slow to fast myofiber switch. These findings show c-α-Klotho's potential as a circulating inhibitor counteracting TGF-β-induced sarcopenia. A novel therapy involving TGF-β blockade could thus be developed to prevent sarcopenia.

[Granulocyte-colony stimulating factor-producing multiple myeloma presenting with neutrophilia]

A 71-year-old woman complained of nausea and anorexia. Laboratory tests revealed significant neutrophilia and immunoglobulin A-kappa type M proteinemia, as well as increased plasma cells on bone marrow examination. Furthermore, the serum granulocyte-colony stimulating factor (G-CSF) concentration was high at 160 pg/ml, and the colony stimulating factor 3 receptor (CSF3R)-T618I mutation was negative. Immunohistochemical (IHC) analysis of bone marrow specimens using the anti-G-CSF antibody revealed immunopositivity of some myeloma cells. The patient was diagnosed using G-CSF-producing myeloma and was treated with daratumumab, lenalidomide, and dexamethasone. Her treatment resulted in a very good partial response, with normalization of both serum G-CSF levels and neutrophil count. There have been a few cases of G-CSF -producing myeloma reported, and it has previously been reported as chronic neutrophilic leukemia with M proteinemia. According to previous reports, techniques such as serum G-CSF measurements, IHC with an anti-G-CSF antibody, and CSF3R gene mutation analysis are useful for differentiating G-CSF-producing myeloma. However, the clinical characteristics and long-term prognosis of G-CSF-producing myeloma remain unknown. Additional case gathering and investigations are required.

Becker Muscular Dystrophy Accompanied by Anti-HMGCR Antibody-positive Immune-mediated Necrotizing Myopathy

Becker muscular dystrophy (BMD) is an X-linked neuromuscular disease characterized by progressive muscle weakness that currently has no cure. Immune-mediated necrotizing myopathy (IMNM) is a type of autoimmune inflammatory myopathy characterized by proximal muscle weakness that is treated with immunosuppressive therapy. We herein report a patient diagnosed with BMD complicated with IMNM by a pathological analysis. Notably, the patient had an elevated serum anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase antibody level. Oral glucocorticoid and methotrexate treatment partially improved the muscle weakness with decreased levels of serum creatine kinase. An accurate diagnosis is important for therapeutic decisions in these complicated cases.

Maximal Multistage Shuttle Run Test-induced Myalgia in a Patient with Muscle Phosphorylase B Kinase Deficiency

Muscle phosphorylase b kinase (PHK) deficiency is a rare mild metabolic disorder caused by mutations of the PHKA1 gene encoding the αM subunit of PHK. A 16-year-old boy experienced myalgia during the maximal multistage 20-m shuttle run test targeting the maximal oxygen consumption. Although an ischemic forearm exercise test was normal, a muscle biopsy revealed subsarcolemmal glycogen accumulation. He harbored a novel insertion mutation in the PHKA1 gene that resulted in premature termination of the αM subunit close to the C-terminus. Compared with previously reported cases, his reduction in PHK activity was relatively mild.

The "Ant-farm"-like Appearance of Restricted Lower Limb Vasculitis on Fluorodeoxyglucose-positron Emission Tomography

Restricted lower limb vasculitis is a type of localized muscle vasculitis limited to the lower limbs. The usefulness of fluorodeoxyglucose-positron emission tomography (FDG-PET) for the diagnosis of this entity has not yet been reported. We herein report three patients with a fever and persistent lower limb pain. FDG-PET revealed linear and patchy FDG uptakes in their lower limbs. Combined with magnetic resonance imaging and histological findings, they were diagnosed with lower limb vasculitis. Linear and patchy FDG uptakes are considered to reflect the presence of muscle vasculitis. The characteristic "ant-farm"-like FDG-PET images can be a diagnostic clue for the currently overlooked vasculitis.

Myxoid type and non-myxoid type of intimal sarcoma in large vessels and heart: review of histological and genetic profiles of 20 cases

Intimal sarcoma is one of the most common and well-known primary malignant neoplasms of the aorta and heart. The authors reviewed cases of intimal sarcoma from histological, immunohistochemical and genetic perspectives. Twenty cases of intimal sarcoma were retrieved. Immunohistochemistry and FISH of MDM2 and PDGFRA genes were performed. All 20 tumours were composed of spindle-shaped, stellate, oval or polygonal tumour cells with irregular hyperchromatic nuclei arranged in a haphazard pattern, accompanied by nuclear pleomorphism and frequent mitotic figures. Other histological findings were as follows: abnormal mitosis in 10 cases (50%), necrosis in 15 cases (75%), myxoid stroma in 12 cases (60%), cartilaginous formation in 1 case (5%), haemorrhage in 12 cases (60%) and fibrinous deposition in 14 cases (70%). The tumours were positive for MDM2 in 16 cases (80%), ERG in 4 cases (20%), alpha-smooth muscle actin in 6 cases (30%), desmin in 5 cases (25%) and AE1/AE3 in 4 cases (20%). Immunohistochemical positivity was focal in each case. Loss of H3K27me3 expression was noted in 2 cases (10%). MDM2 and PDGFRA gene amplifications were detected in 11 cases (55%) and 1 case (5%), respectively. Fisher's exact test revealed a significant correlation between MDM2 gene amplification and myxoid stroma (p = 0.0194). No parameters showed any association with the anatomical location of the tumours. It was suggested that myxoid histology of intimal sarcoma may be associated with MDM2 gene amplification and that intimal sarcoma may be divided into myxoid and non-myxoid types.

A case of primary aortic sarcoma with tumor infarction after stent graft placement

Primary aortic sarcoma is a very rare disease, and most primary aortic tumors are malignant mesenchymal tumors. We present the case of a 62-year-old man with sudden epigastric and back pain. Contrast-enhanced computed tomography (CT) revealed a mass lesion about 33.8 mm in diameter, in contact with the left side of the abdominal aorta. Impending rupture of an abdominal aortic aneurysm was suspected, so cardiovascular surgery for stent graft placement was performed the same day. Symptoms immediately improved and CT at 3 months postoperatively showed a marked decrease in lesion size, but the lesion subsequently grew again. Fluorodeoxyglucose (FDG)-positron emission tomography/CT was performed due to the possibility of malignant solid tumor, revealing markedly increased FDG accumulation (maximum standardized uptake value, 36.95) in the mass lesion. Primary aortic sarcoma was diagnosed from thoracoscopic biopsy. Here, we report a primary aortic sarcoma that shrank due to tumor infarction after stent graft placement, followed by tumor regrowth.

Cutaneous adenomyoepithelioma with histopathological heterogeneity: A case report

Some skin adnexal tumors display both epithelial and myoepithelial cell populations and can be broadly categorized as biphasic tumors. These include apocrine hidrocystoma, mixed tumor, adenomyoepithelioma (AME), and adenoid cystic carcinoma (ACC). Myoepithelioma is the myoepithelial cell-predominant type in this category. Cutaneous AME is exceedingly rare and usually has a benign prognosis, but it is considered to have the potential for local recurrence and metastasis. We report the case of a 57-year-old man with a 1-year history of an ulcerated nodule on his scalp. Microscopically, it was a defined cutaneous nodule with a focal lobulated architecture, composed of epithelial cells forming ducts and myoepithelial cells distributed around the ducts. In addition to these findings of typical AME, the present case focally revealed atypical features, such as increased mitotic activity (7/10 high power fields), invasive growth, and necrosis. However, cytological atypia was not significant. We conclusively diagnosed cutaneous AME with atypical features, suggesting malignant potential. Moreover, areas showing appearances similar to apocrine hidrocystoma, mixed tumor, myoepithelioma, and ACC were focally observed. We present a unique case of cutaneous AME exhibiting histopathological heterogeneity. The recognition of morphological variation could be helpful in appropriately diagnosing and treating AME of the skin.

An Older Thrombus Delays Reperfusion after Mechanical Thrombectomy for Ischemic Stroke

Background  Thrombosis is a dynamic process, and a thrombus undergoes physical and biochemical changes that may alter its response to reperfusion therapy. This study assessed whether thrombus age influenced reperfusion quality and outcomes after mechanical thrombectomy for cerebral embolism.

Methods  We retrospectively evaluated 185 stroke patients and thrombi that were collected during mechanical thrombectomy at three stroke centers. Thrombi were pathologically classified as fresh or older based on their granulocytes' nuclear morphology and organization. Thrombus components were quantified, and the extent of NETosis (the process of neutrophil extracellular trap formation) was assessed using the density of citrullinated histone H3-positive cells. Baseline patient characteristics, thrombus features, endovascular procedures, and functional outcomes were compared according to thrombus age.

Results  Fresh thrombi were acquired from 43 patients, and older thrombi were acquired from 142 patients. Older thrombi had a lower erythrocyte content ( p  < 0.001) and higher extent of NETosis ( p  = 0.006). Restricted mean survival time analysis revealed that older thrombi were associated with longer puncture-to-reperfusion times (difference: 15.6 minutes longer for older thrombi, p  = 0.002). This association remained significant even after adjustment for erythrocyte content and the extent of NETosis (adjusted difference: 10.8 minutes, 95% confidence interval [CI]: 0.6–21.1 minutes, p  = 0.039). Compared with fresh thrombi, older thrombi required more device passes before reperfusion ( p  < 0.001) and were associated with poorer functional outcomes (adjusted common odds ratio: 0.49; 95% CI: 0.24–0.99).

Conclusion  An older thrombus delays reperfusion after mechanical thrombectomy for ischemic stroke. Adding therapies targeting thrombus maturation may improve the efficacy of mechanical thrombectomy.

A case of total hysterectomy due to massive maternal bleeding immediately after fetoscopic laser surgery for twin-twin transfusion syndrome

Twin-twin transfusion syndrome (TTTS) complicates approximately 10% of monochorionic twin pregnancies and is associated with almost 90% mortality if left untreated. Fetoscopic laser photocoagulation (FLP) is the first-line therapy for TTTS, and an overall twin survival rate of 75% and at least one survival rate of 90% have been established. We report a case of TTTS complicated with bleeding from the uterine wall by inserting the procedure after FLP. The patient consequently underwent emergency caesarean section. The bleeding was uncontrollable due to atonic bleeding and emergency hysterectomy was performed. To detect the possibility of amniotic fluid embolism (AFE), biochemical blood samples demonstrated that there was no inflow of fetal ingredients in blood vessels of uterine tissue. There was no evidence of damage to any specific vessels by histopathological staining. These findings indicated that the cause of massive bleeding was unlikely to have been AFE. It was concluded that atonic bleeding was likely caused by uncontrollable hemorrhage from an injury lesion where an endoscope had been inserted.

Coexistence of three nevus lipomatosus cutaneus superficialis with typical, cutaneous adenolipoma-like, and dermal spindle cell lipoma-like histopathological features in a patient

We report an unique case of a patient who showed coexistence of three nevus lipomatosus cutaneus superficialis (NLCS) with typical, cutaneous adenolipoma (AL)-like, and dermal spindle cell lipoma (SCL)-like histopathological features. A 53-year-old woman presented with a 20-year history of skin-colored and slightly elevated nodules. These lesions were separately located on the lateral side (lesion 1) and medial side (lesion 2) of her left buttock and on her right thigh (lesion 3). Microscopically, all were ill-defined dermal lesions with some subcutaneous involvement and were mostly composed of mature adipocytes. The adipocytes formed small aggregates around blood vessels in the upper dermis. Lesions 1, 2, and 3 were diagnosed as NLCS, and additional features were recognized in lesions 2 and 3. Lesion 2 revealed eccrine glands and ducts amongst the lipomatous component, as seen in cutaneous AL. Lesion 3 had scattered CD34-positive spindle cells, which is representative of dermal SCL. These appearances were considered to be on the morphological spectrum of NLCS. In all three lesions, CD34-positive cells proliferated between the upper dermal blood vessels and their peripheral mature adipocytes. This pathological finding could be principal in NLCS and might be associated with its pathogenesis.

Prospective validation of 0-hour/1-hour algorithm using high-sensitivity cardiac troponin I in Japanese patients presenting to emergency department

Background

The diagnostic performance of 0-hour/1-hour algorithm using high-sensitivity cardiac troponin I (hsTnI) for non-ST-segment elevation myocardial infarction (NSTEMI) has not been evaluated in an Asian population.

Purpose

We aimed to prospectively validate the 0-hour/1-hour algorithm using hsTnI in a Japanese population.

Method

We enrolled 754 Japanese patients (mean age of 70 years, 395 men) presenting to our emergency department with symptoms suggestive of NSTEMI. The hsTnI concentration was measured using the Siemens ADVIA Centaur hsTnI assay at presentation and after 1 hour. Patients were divided into three groups according to the algorithm: hsTnI below 3 ng/L (only applicable if chest pain onset &gt;3 hours) or below 6 ng/L and delta 1 hour below 3 ng/L were the “rule-out” group; hsTnI at least 120 ng/L or delta 1 hour at least 12 ng/L were in the “rule-in” group; the remaining patients were classified as the “observe” group. Based on the Fourth Universal Definition of Myocardial Infarction, the final diagnosis was adjudicated by 2 independent cardiologists using all available information, including coronary angiography, coronary computed tomography, and follow-up data. Safety of rule-out was quantified by the negative predictive value (NPV) for NSTEMI, accuracy of rule-in by the positive predictive value (PPV), and overall efficacy by the proportion of patients triaged towards rule-out or rule-in within 1 hour.

Results

Prevalence of NSTEMI was 6.5%. The safety of rule-out (NPV 100%), accuracy of rule-in (PPV 26%), and overall efficacy (54%) were shown in Figure.

Conclusion

The 0-hour/1-hour algorithm using hsTnI is very safe and effective in triaging Japanese patients with suspected NSTEMI.

Funding Acknowledgement

Type of funding source: None

Gender differences in patterns of relationship between body mass index and AF incidence

Background

Obesity is reportedly associated with the new incidence of atrial fibrillation (AF). However, gender differences in patterns of relationship between body mass index (BMI) and the risk of AF are unknown.

Methods

We analyzed 21,382 middle-aged Japanese subjects (10923 men, 10459 women) without AF from a cohort of employees undergoing annual health examinations, with a follow-up period of 4.8±3.7 years. We examined the relationship between BMI at baseline to AF incidence in unadjusted and adjusted analyses. This relationship was also studied using linear and quadratic models.

Results

AF had developed in 137 subjects (119 men; mean age, 54.4±8.2 years; incidence, 2.19 and 0.38 per 1000 person-years in men and women, respectively). In multivariable Cox proportional-hazard models, increasing age (hazard ratio [HR], 2.72 per year; 95% CI, 2.22 to 3.33; P&lt;0.001), male gender (HR, 3.28; 95% CI, 1.86 to 5.76; P&lt;0.001) and BMI (HR, 1.08; 95% CI, 1.02 to 1.15; P=0.007) were associated with the new incidence of AF in all cohorts. The shape of the BMI-incident AF relationship showed a linear association in women and a J-shaped association in men. (Figure) In particular, a U-shaped relationship was observed in young men aged 40–49, with increased risk among those with higher BMI and with very low BMI. In analyses adjusted for comorbidities and risk factors for CV disease, the U-shaped AF incidence versus BMI curves were not attenuated, suggesting that other genetic or congenital factors may mediate this relationship.

Conclusion

Our results indicate that the shape of the BMI-incident AF relation differs by sex and in particular a U-shaped relationship was observed in young men.

Patterns of relation among BMI and AF

Funding Acknowledgement

Type of funding source: None

Circulating presepsin (soluble CD14 subtype) as a novel marker of mortality in patients treated at medical cardiac intensive care units

Background

Presepsin, a subtype of soluble CD14, is an inflammatory marker, which largely reflects monocyte activation. The association between presepsin levels and mortality in patients treated at medical cardiac intensive care units (CICUs) remains poorly known.

Objective

We aimed to understand the prognostic value of presepsin levels on admission to medical CICUs for mortality.

Methods

We prospectively studied 1636 heterogeneous patients (median age; 71 years) treated at medical (non-surgical) CICUs. Patients with stage 5 chronic kidney disease (estimated glomerular filtration rate [eGFR] &lt;15 mL/min/1.73 m2) were excluded. Acute coronary syndrome was present in 46% of the patients, and acute decompensated heart failure in 36%. Upon admission, baseline plasma presepsin levels were measured. The primary endpoint was all-cause death.

Results

During a mean follow-up period of 44.6 months after admission, there were 323 (19.7%) deaths. Patients who died were older (median: 75 vs. 71 years, P&lt;0.0001); had higher levels of presepsin (194 vs. 110 pg/mL, P&lt;0.0001), B-type natriuretic peptide (BNP: 520 vs. 144 pg/mL, P&lt;0.0001), high-sensitivity C-reactive protein (hsCRP: 4.7 vs. 2.0 mg/L, P&lt;0.0001), and sequential organ failure assessment (SOFA) score (3 vs. 2, P&lt;0.0001); and had lower levels of eGFR (55 vs. 69 mL/min/1.73m2, P&lt;0.0001) and left ventricular ejection fraction (46% vs. 52%, P&lt;0.0001) than those of the survivors. Multivariate Cox regression analyses revealed presepsin levels as independent predictors of all-cause deaths when assessed as either continuous variables (relative risk [RR] 3.33 per 10-fold increment; P&lt;0.0001) or variables categorized according to quartiles (RR quartile 4 vs. 1, 3.60; P&lt;0.0001). Quartiles of presepsin levels were significantly (P&lt;0.0001) associated with increased risk of mortality (Figure). Adding presepsin levels to a baseline model that included established risk factors, BNP, and hsCRP further enhanced reclassification (P=0.009) and discrimination (P=0.0008) beyond that of the baseline model alone.

Conclusions

Circulating concentration of presepsin on admission may be a potent and independent predictor of mortality, and it may improve the risk stratification of patients admitted at medical CICUs.

Presepsin quartiles and mortality

Funding Acknowledgement

Type of funding source: None

A low amyloidogenic E61K transthyretin mutation may cause familial amyloid polyneuropathy

Patients with transthyretin (TTR)-type familial amyloid polyneuropathy (FAP) typically exhibit sensory dominant polyneuropathy and autonomic neuropathy. However, the molecular pathogenesis of the neuropathy remains unclear. In this study, we characterize the features of FAP TTR the substitution of lysine for glutamic acid at position 61 (E61K). This FAP was late-onset, with sensory dominant polyneuropathy, autonomic neuropathy, and cardiac amyloidosis. Interestingly, no amyloid deposits were found in the endoneurium of the four nerve specimens examined. Therefore, we examined the amyloidogenic properties of E61K TTR in vitro. Recombinant wild-type TTR, the substitution of methionine for valine at position 30 (V30M) TTR, and E61K TTR proteins were incubated at 37°C for 72 hr, and amyloid fibril formation was assessed using the thioflavin-T binding assay. Amyloid fibril formation by E61K TTR was less than that by V30M TTR, and similar to that by wild-type TTR. E61K TTR did not have an inhibitory effect on neurite outgrowth from adult rat dorsal root ganglion (DRG) neurons, but V30M TTR did. Furthermore, we studied the sural nerve of our patient by terminal deoxynucleotidyl transferase dUTP nick end labeling and electron microscopy. A number of apoptotic cells were observed in the endoneurium of the nerve by transferase dUTP nick end labeling. Chromatin condensation was confirmed in the nucleus of non-myelinating Schwann cells by electron microscopy. These findings suggest that E61K TTR is low amyloidogenic, in vitro and in vivo. However, TTR aggregates and amyloid fibrils in the DRG may cause sensory impairments in FAP because the DRG has no blood-nerve barrier. Moreover, Schwann cell apoptosis may contribute to the neurodegeneration.

Boron neutron capture therapy for head and neck cancer: Relevance of nuclear-cytoplasmic volume ratio and anti-tumor effect. -A preliminary report

BNCT is a type of particle beam radiation therapy that utilizes an α particle and 7Li nucleus generated when a thermal neutron is captured by a 10B nucleus involved in the boron compound that has been taken up into tumor tissue selectively. In this report, the relevance of N/C ratio of tumor cell and anti-tumor effect for BNCT clinical cases of head and neck cancer were verified. Examination of pre-irradiated tumor histopathological specimens of 9 BNCT treated head and neck cancer patients (4 CR patients, 5 non-CR patients) was performed. The statistically significant difference between the CR group and the non-CR group was examined for the physical dose was multiplied by the absolute biological effectiveness (ABE) value determined from the patient's tumor specific N/C ratio. Analysis showed the mean tumor dose could not distinguish between CR and non-CR groups. However, the ABE dose could clearly distinguish between the CR group and the non-CR group (p = 0.0250). The N/C ratio of tumor cell can influence the anti-tumor effect of BNCT for HNC.

Demonstration of Machine Learning-Based Model-Independent Stabilization of Source Properties in Synchrotron Light Sources

Synchrotron light sources, arguably among the most powerful tools of modern scientific discovery, are presently undergoing a major transformation to provide orders of magnitude higher brightness and transverse coherence enabling the most demanding experiments. In these experiments, overall source stability will soon be limited by achievable levels of electron beam size stability, presently on the order of several microns, which is still 1-2 orders of magnitude larger than already demonstrated stability of source position and current. Until now source size stabilization has been achieved through corrections based on a combination of static predetermined physics models and lengthy calibration measurements, periodically repeated to counteract drift in the accelerator and instrumentation. We now demonstrate for the first time how the application of machine learning allows for a physics- and model-independent stabilization of source size relying only on previously existing instrumentation. Such feed-forward correction based on a neural network that can be continuously online retrained achieves source size stability as low as 0.2  μm (0.4%) rms, which results in overall source stability approaching the subpercent noise floor of the most sensitive experiments.

Orbitotemporal Bone Cyst of Metastatic Breast Cancer: Case Report and Literature Review

BACKGROUND

Metastatic breast cancer in the bone rarely has a cystic appearance, and while it is common in the orbit, its metastasis to the orbitotemporal skull is rare. Consequently, it is difficult to diagnose it. We report and discuss a rare case of metastatic breast cancer with simple cyst appearance in the orbitotemporal region of the skull.

CASE DESCRIPTION

A 63-year-old woman presented with mild double vision only on left gaze that lasted for 2 months. Ten and a half years ago, the patient underwent surgery for tumor resection of a stage 3 breast adenocarcinoma, followed by radiotherapy and administration of anticancer therapy. Thereafter, she continued hormonal therapy with antiestrogen drugs, which was discontinued a half year ago because there was no recurrence during treatment. On admission, magnetic resonance imaging (MRI) showed a single and simple cystic lesion in the orbitotemporal region of the skull. The cyst was filled with fluid of different intensity, indicative of a hemorrhagic component. Additional gadolinium-contrasted MRI showed no enhancing effects in the lesion. The cyst was totally removed by surgery, and the histologic examination confirmed the diagnosis of breast adenocarcinoma. Intensity-modulated radiotherapy was then administered, and the patient started follow-up hormonal therapy with antiestrogen agents. No recurrence in the orbitotemporal region of the skull occurred during 6 months after the surgery.

CONCLUSIONS

Metastatic breast cancer should be considered in the differential diagnosis even if it appears as a simple cyst in the orbitotemporal bone after long-term remission.

Enhancing laser beam performance by interfering intense laser beamlets

Increasing the laser energy absorption into energetic particle beams represents a longstanding quest in intense laser-plasma physics. During the interaction with matter, part of the laser energy is converted into relativistic electron beams, which are the origin of secondary sources of energetic ions, γ-rays and neutrons. Here we experimentally demonstrate that using multiple coherent laser beamlets spatially and temporally overlapped, thus producing an interference pattern in the laser focus, significantly improves the laser energy conversion efficiency into hot electrons, compared to one beam with the same energy and nominal intensity as the four beamlets combined. Two-dimensional particle-in-cell simulations support the experimental results, suggesting that beamlet interference pattern induces a periodical shaping of the critical density, ultimately playing a key-role in enhancing the laser-to-electron energy conversion efficiency. This method is rather insensitive to laser pulse contrast and duration, making this approach robust and suitable to many existing facilities.

Enhanced coupling of laser energy to the target particles is a fundamental issue in laser-plasma interactions. Here the authors demonstrate increased photon absorption leading into higher laser to electron and proton energy transfer through the interference of multiple coherent beamlets.

Living Kidney Donor With Small Lymphocytic Lymphoma at the Time of Donation: A Case Report

Living kidney donor guidelines recommend that donors in whom a malignancy is diagnosed should be excluded. Although preoperative screening for malignancies was performed, we experienced a case of living donor with small lymphocytic lymphoma (SLL) at the time of donation. A 53-year-old woman was referred to our hospital for a kidney donation to her son. She had no past medical history of malignancy. We screened the patient using medical examinations, but there was no obvious presence of malignancy. Although preoperative computed tomography showed a small lymph node swelling at the left renal hilum, we diagnosed it as an insignificant lymph node. When a laparoscopic donor nephrectomy was performed, however, we recognized the small lymph node during the surgery and performed a lymphadenectomy. Postoperatively, pathologic examination showed that the small node was lymphocytic lymphoma, known as a low malignant potential disease. Currently, there is no presence of malignancy transmission with the recipient. To the best of our knowledge, this is the first case report of living kidney donor with SLL. Although SLL is considered a low-grade malignancy, it is crucial to follow it carefully in both the donor and the recipient.

A multichannel gated neutron detector with reduced afterpulse for low-yield neutron measurements in intense hard X-ray backgrounds

A design of multichannel gated photomultiplier tube (PMT) is presented for the 960-channel neutron time-of-flight detector at the Institute of Laser Engineering of Osaka University. This is important for the fusion science and the nuclear photonics where intense hard X-rays are generated from the interaction of ultra-short laser pulse of petawatt power density with matter. The hard X-rays often overload PMTs and cause signal-induced background noises called afterpulses, making the detection of subsequent neutrons impossible. For this reason, the PMTs are coupled with an electrical time-gating (ETG) system to avoid overloading. The ETG system disables the PMT by modulating the dynode potential during the primary X-ray flash. An after-pulsing suppression technique is demonstrated by applying a reverse bias voltage between the photocathode and the first dynode. The presented multichannel scheme provides a gate response time of 80 ns, a signal cutoff ratio of 2.5 × 10², and requires reasonably low power consumption.

A large-aperture high-sensitivity avalanche image intensifier panel

A large-aperture high-sensitivity image intensifier panel that consists of an avalanche photodiode array and a light-emitting diode array is presented. The device has 40% quantum efficiency, over 10⁴ optical gain, and 80-ns time resolution. The aperture size of the device is 20 cm, and with the current manufacturing process, it can be scaled to arbitrarily larger sizes. The device can intensify the light from a single particle scintillation emission to an eye-visible bright flash. The image resolution of the device is currently limited by the size of the avalanche photodiode that is 2 mm, although it can be scaled to smaller sizes in the near future. The image intensifier is operated at a small voltage, typically +57 V. The device can be applied to various applications, such as scintillation imaging, night vision cameras, and an image converter from non-visible light (such as infrared or ultraviolet) to visible light.

Plaque Characteristics of Patients with Symptomatic Mild Carotid Artery Stenosis

BACKGROUND

Carotid revascularization may be considered for severe stenosis, but its use for symptomatic mild stenosis (<50%) with vulnerable plaque or ulcer remains uncertain. The characteristics of patients with symptomatic mild stenosis who underwent revascularization are reviewed.

METHODS

The subjects of this study were 18 patients with symptomatic mild stenosis (<50%) on angiography from among 175 patients who underwent revascularization in our department. The plaques were evaluated by black-blood magnetic resonance imaging (BB-MRI) and ultrasonography (US) and classified into 2 types: type 1 (n = 15), a lesion with an ulcer or mobile plaque or thrombosis on angiography or US; and type 2 (n = 3), a lesion without any of the above. Fourteen patients underwent carotid endarterectomy (CEA), and 4 patients underwent carotid artery stenting.

RESULTS

The stenosis on angiography was 27.2% ± 10.7 (5%-41%), and the area carotid artery stenosis rate on US was 69.8 ± 14.5% (44.5%-97%). The stenosis rate of these 2 methods was not at all correlated. In type 1 plaque that underwent CEA, 10 of 11 patients had vulnerable plaque by histopathology, and 1 patient had thrombus on the plaque by operative findings. In type 2 plaque that underwent CEA, all patients had vulnerable plaque by histopathology. During the follow-up period, none of the patients had restenosis or stroke.

CONCLUSIONS

The findings of US and BB-MRI in patients with symptomatic mild stenosis (<50%) on angiography are important for determining treatment. If BB-MRI or US shows the findings of vulnerable plaque in mild stenosis, surgical treatment may be considered for these patients.

Massage therapy for home care patients using the health insurance system in Japan

OBJECTIVES

To clarify the status of home care massage services provided to patients. This will help in understanding how many patients utilize this service and the circumstances under which treatment is provided.

DESIGN

A retrospective study.

SETTING

Fifty-four acupuncture, moxibustion, and massage clinics. Participants were patients who had received home care massage for six months or more. We collected a total of 1587 responses from these 54 massage clinics; of these, 1415 responses (mean age = 79.1 ± 11.5 years) were valid (valid response rate 89.2%).

MAIN OUTCOME MEASURES

Actual patients and actual care services.

RESULTS

The most common disorder observed among patients who utilized home care massage services was cerebrovascular disease (at approximately 36%), while the second most common were arthropathy-related disorders (16.3%). Although most patients received massage, approximately 30% received manual therapy (e.g. manual correction) and hot fomentation as part of thermotherapy. Notably, only around 10% of patients received massage alone; the majority received treatment in combination with range of motion and muscle-strengthening exercises.

CONCLUSIONS

This study helped to clarify the actual state of patients receiving home care massage and the details of the massage services provided. This study clearly showed the treatment effectiveness of massage, which can be used by home medical care stakeholders to develop more effective interventions.

Enhancement of Osteogenesis by Concanavalin a in Human Bone Marrow Mesenchymal Stem Cell Cultures

This study investigates concanavalin A (ConA) as a novel factor that may enhance osteogenesis of mesenchymal stem cells (MSCs) in vitro. Various factors, such as cytokine bone morphogenetic protein-2 (BMP-2), have been studied for their possible promotion of MSC osteogenesis in vivo and in vitro. However, the factor that might be safer, more effective, and less expensive than these has not been determined. We therefore cultured human MSCs in osteogenic medium in the presence or absence of ConA, and used calcium assays to compare the effects of ConA and BMP-2 on MSC calcification. We also used enzyme-linked immunosorbent assay (ELISA) and quantitative polymerase chain reaction (PCR) to evaluate the expression levels of bone-specific markers. ConA and BMP-2 enhanced calcification with comparable effectiveness. The combination of ConA and BMP-2 further enhanced calcification slightly but significantly. ConA also increased osteocalcin and BMP-2 protein levels in MSC culture medium. Furthermore, ConA increased osteocalcin, RUNX2, BMP-2, BMP-4, and BMP-6 mRNA expression levels. However, the gene expression pattern of ConA-stimulated MSCs was different from that of MSCs stimulated by BMP-2. Together, these results suggest that ConA and BMP-2 enhance MSC osteogenesis via different pathways. ConA-induced bone formation in MSC cultures may be useful in regenerative medicine or tissue engineering in clinical studies, as well as in basic research on bone formation.

Boosting laser-ion acceleration with multi-picosecond pulses

Using one of the world most powerful laser facility, we demonstrate for the first time that high-contrast multi-picosecond pulses are advantageous for proton acceleration. By extending the pulse duration from 1.5 to 6 ps with fixed laser intensity of 1018 W cm-2, the maximum proton energy is improved more than twice (from 13 to 33 MeV). At the same time, laser-energy conversion efficiency into the MeV protons is enhanced with an order of magnitude, achieving 5% for protons above 6 MeV with the 6 ps pulse duration. The proton energies observed are discussed using a plasma expansion model newly developed that takes the electron temperature evolution beyond the ponderomotive energy in the over picoseconds interaction into account. The present results are quite encouraging for realizing ion-driven fast ignition and novel ion beamlines.

Ultrasonography of Thymoma with Pathologic Correlation

Preoperative ultrasonograms of 11 surgically proved thymomas and ex vivo ultrasonograms of 3 resected specimens were compared with pathologic findings of resected specimens. Among 11 thymomas 7 appeared solid, 3 were solid with several cystic regions, and the remaining one was unilocular cystic in appearance. Cystic regions on ultrasonograms corresponded to cystic changes on pathologic specimens. Six malignant thymomas showed a typical lacy appearance on ultrasonograms, which corresponded to the lobulated configuration separated by fibrous septa shown on the pathologic specimens.