Impact of control measures including decolonization and hand hygiene for orthopaedic surgical site infection caused by MRSA at a Japanese tertiary-care hospital

BACKGROUND

Meticillin-resistant Staphylococcus aureus (MRSA) is the most common pathogen in orthopaedic surgical site infections (SSIs). However, few studies have investigated the transmission process of orthopaedic MRSA SSI.

AIM

To investigate the transmission process of orthopaedic MRSA SSI using epidemiological and molecular analyses and to determine a method to prevent MRSA SSI in nosocomial orthopaedic surgery.

METHODS

Active MRSA surveillance, preoperative decolonization and contact precautions for MRSA-positive cases was performed at our institution. Changes in epidemic strains were evaluated and the possibility of transmission from patients in an orthopaedic ward of a Japanese tertiary-care hospital was assessed by genotyping stored MRSA strains. In addition, data on the prevalence of MRSA SSI, MRSA colonization, and use of an alcohol antiseptic agent (mL/patient-days) during 2005-2022 were retrospectively assessed.

FINDINGS

SCCmec type II strain in the SSI group decreased over time, associated with fewer outbreaks. Even during a period of high infection rates, no cases of transmission-induced SSI from nasal MRSA carriers were identified. The infection rate correlated negatively with the use of an alcohol antiseptic agent (r = -0.82; P < 0.0001). Two cases among five nasal carriers developed MRSA SSI caused by strains different from those related to nasal colonization.

CONCLUSION

The infection control measures for transmission from the hospital reservoirs including strict adherence to hand hygiene and decolonization of carriers is likely to be important for the prevention of orthopaedic MRSA SSI. However, the need for contact precautions for decolonized nasal carriers might be low.

Ocular candidiasis in a tertiary hospital in Japan: A 10-year single-center retrospective study

Ocular candidiasis is a major complication of candidemia that is sometimes sight-threatening. Although prompt ophthalmologic consultation and antifungal medication have been emphasized, recent changes in the causative species and drug susceptibilities make the picture unclear. This study aimed to determine whether there are trends among patients with ocular candidiasis and included 80 patients with candidemia who underwent ophthalmological screening at our hospital between 2010 and 2020. Data on the clinical characteristics, comorbidities, biochemical test results, causative Candida species, treatment, outcomes, visual acuity, and antifungal susceptibility were collected and analyzed. Statistical analyses were performed by comparing two groups, namely, the ocular candidiasis (n = 29) and non-ocular candidiasis (n = 51) groups. In the ocular candidiasis group, there were significantly more cases of central venous catheter insertion (82.8%, p = 0.026) and Candida albicans candidemia (72.4%, p < 0.001). Regarding ocular involvement, the majority of patients were asymptomatic. Most cases improved with antifungal therapy, but one case underwent vitrectomy. Between 2016 and 2020, there was a diversification of species, with a decrease in Candida parapsilosis and the emergence of Candida glabrata and Candida tropicalis. Regarding drug susceptibility, the minimum inhibitory concentrations of echinocandin and 5-fluorocytosine against Candida albicans, Candida parapsilosis, and Candida glabrata were slightly increased. In conclusion, in addition to appropriately performing ophthalmologic examinations, it is beneficial to select antifungal agents according to the diversity of species and drug susceptibilities.

Dephosphorylation of neural wiring protein shootin1 by PP1 phosphatase regulates netrin-1-induced axon guidance

Axon pathfinding is an essential step in neuronal network formation. Shootin1a is a clutch-linker molecule that is mechanically involved in axon outgrowth and guidance. It was previously shown that concentration gradients of axon guidance molecule netrin-1 in the extracellular environment elicit asymmetrically localized Pak1 kinase-mediated phosphorylation of shootin1a within axonal growth cones, which is higher on the netrin-1 source side. This asymmetric phosphorylation promotes shootin1a-mediated local actin-adhesion coupling within growth cones, thereby generating directional forces for turning the growth cone toward the netrin-1 source. However, how the spatial differences in netrin-1 concentration are transduced into the asymmetrically localized signaling within growth cones remains unclear. Moreover, the protein phosphatases that dephosphorylate shootin1a remain unidentified. Here, we report that protein phosphatase-1 (PP1) dephosphorylates shootin1a in growth cones. We found that PP1 overexpression abolished the netrin-1-induced asymmetric localization of phosphorylated-shootin1a as well as axon turning. In addition, we show PP1 inhibition reversed the asymmetrically localized shootin1a phosphorylation within growth cones under netrin-1 gradient, thereby changing the netrin-1-induced growth cone turning from attraction to repulsion. These data indicate that PP1-mediated shootin1a dephosphorylation plays a key role in organizing asymmetrically-localized phosphorylated shootin1a within growth cones, which regulates netrin-1-induced axon guidance.

P-205 Blastocyst derived from oocytes with smooth endoplasmic reticulum aggregates (SERa) has similar clinical and perinatal outcomes with those of oocytes without SER

Study question

This study was to investigate effect of SERa on the fertilization rate, embryonic development after ICSI, and clinical and perinatal outcomes after single blastocyst transfer.

Summary answer

SERa (+) derived embryo can be selected as embryos for transfer when no available SERa (-) derived embryos.

What is known already

Based on findings that the risk of congenital abnormalities in the newborn is higher in ovum with SERa in the cytoplasm, the Istanbul consensus workshop at the 2011 meeting of the ESHRE recommended against fertilizing ovum with SERa due to these risks. However, there have been several reports of healthy infants born from embryos derived from SERa, suggesting that, while more long-term follow-up is necessary, healthy births are possible from such embryos. In 2017, the 2011 recommendations were reviewed in the Alpha/ESHRE consensus (Vienna), which said the approach should be determined on a case-by-case basis.

Study design, size, duration

We retrospectively investigated 23,007 oocytes which was retrieved between January 2016 and March 2020. Of these, 1,038 oocytes (4.5%) with visible SERa comprised SERa (+), while 21,969 oocytes (95.5%) without SERa comprised SERa (-).

Participants/materials, setting, methods

SERa were observed under the microscopy after denudation. The rate of fertilization, good-quality day-3 embryos, good-quality day-5 blastocysts, and day-5, 6 or 7 blastocysts were evaluated for both groups. We also compared the rate of clinical pregnancy, live birth, miscarriage, and birth defects in single blastocyst transfer between SERa (+) derived 114 blastocysts and SERa (-) derived 6,290 blastocysts from January 2016 and December 2018.

Main results and the role of chance

The results are shown. 2PN fertilization rate outcomes after ICSI (SERa(-) eggs vs. SERa(+)eggs),81.4%(17,873/21,969) vs.79.4% (823/1,038),and good-quality day3 rate was 61.1%(10,927/17,873)vs.60.9% (501/823) which was not significantly different. Good-quality day5 blastocyst rate was 46.5% (7,876/16,955) vs. 39.8%(304/763), and day 5 blastocyst success rate was 60.8% (10,317/16,955) vs.54.3% (414/763), which were both significantly lower with SERa(+). (P &lt; 0.001) The day 6 blastocyst success rate was 69.9% (11,849/16,955) vs. 65.5% (500/763) (P = 0.01), and the day 7 blastocyst success rate was 70.9% (12,024/16,955) vs. 67.5% (515/763) (P = 0.04), which were all significantly lower with SERa(+).The clinical pregnancy rate was 39.4% (2,481/6,290) vs. 35.1% (40/114), the live birth rate was 27.7% (1,745/6,290) vs. 26.3% (30/114), and the miscarriage rate was 27.5% (683/2,481) vs. 20.0% (8/40) and the congenital abnormality rate was 1.6% (29/1,757) vs. 0% (0/30) for SERa(-) embryos and SERa(+) embryos, respectively, which were not significantly different. Blastocyst derived from oocytes with SERa has similar clinical and perinatal outcomes with those of oocytes without SERa. Significant differences were examined using the chi-squared test, with p &lt; 0.05, indicating a significant difference.

Limitations, reasons for caution

Embryos derived SERa (+) were transferred when the patient did not want any more oocytes retrievals, no embryos derived SERa (-) were available, and only if the couple desired embryo transfer after the problems associated with SERa (+) embryos were fully explained.

Wider implications of the findings

To the best of our knowledge, this study is the largest number of live births investigating the outcome of SERa (+) derived embryos. SERa (+) derived embryo can be selected as embryos for transfer when no available SERa (-) derived embryos.

Trial registration number

Not Applicable

A case report of coronavirus disease‐2019‐induced acute asthma exacerbation in an obese patient

The coronavirus disease‐2019 (COVID‐19) has spread worldwide. Previous studies indicated a low prevalence of COVID‐19 induced acute exacerbations of asthma. We present a 39‐year‐old‐male obese asthmatic case who experienced acute asthma exacerbation during COVID‐19. On day 8 of infection, his cough and dyspnea worsened with hypoxia and wheezing. Laboratory test results revealed elevated interleukin‐6 (IL‐6) and total immunoglobulin E (IgE) levels without eosinophilia. Two months since the onset, hypoxia disappeared with decreased IL‐6 and IgE levels. Our case suggested that obesity and high serum IL‐6 and IgE levels may have contributed to atypical asthma exacerbation in COVID‐19.

POS0472 AGONISTIC STIMULATION OF GLUCAGON-LIKE PEPTIDE-1 RECEPTOR AMELIORATED INFLAMMATORY MYOPATHIES THROUGH SUPPRESSING MUSCLE FIBER NECROPTOSIS

Background

While glucocorticoids (GC) are the cornerstone of the treatment for polymyositis (PM), GC-induced myopathy is inevitable, which further deteriorates muscle weakness. Therefore, novel therapeutic strategy that not only suppresses muscle inflammation but also improves muscle strength is awaited. We recently found that injured muscle fibers in PM undergo FASLG-mediated necroptosis1, a form of regulated cell death accompanied with release of pro-inflammatory mediators such as HMGB1, which contributes to accelerate muscle inflammation and muscle weakness. We also showed that inhibition of necroptosis or HMGB1 ameliorated the muscle weakness and muscle inflammation1 in C protein-induced myositis (CIM), a murine model of PM. Glucagon-like peptide-1 receptor (GLP-1R) agonists, which have been developed as an anti-diabetic therapy, have pleiotropic actions including anti-inflammatory effects2, suppression of muscle wasting3, and inhibition of cell death4. Accordingly, we hypothesized that GLP-1R agonists have beneficial effects on PM to recover muscle strength and to suppress muscle inflammation.

Objectives

The aims of this study are to examine the role of GLP-1R in PM and the effect of a GLP-1R agonist on in vivo and in vitro models of PM.

Methods

Muscle specimens of PM patients and CIM were examined with immunofluorescence staining for the expression of GLP-1R. The effect of PF1801, a GLP-1R agonist, on CIM was examined in monotherapy or in combination with prednisolone (PSL). As an in vitro model of PM, C2C12-derived myotubes were treated with FAS ligand (FASLG) to induce necroptosis. The levels of HMGB1, TNF-α, and IL-6 in the serum of CIM and in the culture supernatant of the in vitro model were measured by ELISA. The effect of PF1801 on the myotube necroptosis was examined using time lapse imaging 5 and its effect on the activation of AMP-activated protein kinase (AMPK), the expression of PGAM5, and ubiquitination of PGAM5 was assessed with immunoblotting. The levels of reactive oxygen species (ROS) in the myotubes were analyzed with CellROX assay. The effect of PF1801 on the expression of antioxidant molecules in the myotubes was analyzed with quantitative real-time PCR.

Results

GLP-1R was expressed on the inflamed muscle fibers of PM and CIM. The treatment with PF1801 in monotherapy or in combination with PSL suppressed CIM-induced muscle weakness and the muscle weight loss as well as the severity of histological myositis while the monotherapy with PSL did not suppress muscle weakness and muscle weight loss. PF1801 decreased the levels of inflammatory mediators such as HMGB1, TNF-α, and IL-6 in the serum of CIM. In vitro, PF1801 inhibited FASLG-induced myotube necroptosis and decreased the levels of HMGB1, TNF-α, and IL-6 in the supernatant. PF1801 activated AMPK and decreased the levels of PGAM5, which was crucial for FASLG-induced necroptosis of the myotubes. The inhibitory effect of PF1801 on myotube necroptosis was cancelled by compound C, an AMPK-kinase inhibitor, or MG132, a proteasome inhibitor, suggesting that PF1801 promoted ubiquitin-proteasome-mediated PGAM5 degradation through the activation of AMPK. Furthermore, PF1801 suppressed FASLG-induced reactive oxygen species (ROS) accumulation in myotubes, which was also crucial for the execution of necroptosis, thorough up-regulating the antioxidant molecules such as Nfe2l2, Hmox1, Gclm, and Nqo1.

Conclusion

GLP-1R agonist could be a novel therapy for PM that restores muscle strength as well as suppresses muscle inflammation through inhibiting muscle fiber necroptosis.

References

[1]Kamiya M, et al. Nat Commun. 2022;13:166

[2]Du X, et al. Int Immunopharmacol. 2019;75:105732.

[3]Hong Y, et al. J Cachexia Sarcopenia Muscle. 2019;10:903–918.

[4]Younce CW, et al. Am J Physiol - Cell Physiol. 2013;304:508–518.

[5]Kamiya M, et al. Rheumatology (Oxford). 2020; 59:224-232

Acknowledgements

We thank Katsuko Yamasaki for the histological analysis.

Disclosure of Interests

Mari Kamiya Speakers bureau: Pfizer and Ono Pharmaceutical, Grant/research support from: GlaxoSmithKline, Fumitaka Mizoguchi Speakers bureau: AbbVie, Asahi Kasei Pharma, Bristol-Myers Squibb, Chugai Pharmaceutical, Eizai, Eli Lilly and Company, Glaxo Smith Kline, Ono Pharmaceutical, and Pfizer., Consultant of: Asahi Kasei Pharma and ImmunoForge., Grant/research support from: AbbVie, Astellas Pharma, Bristol-Myers Squibb, Chugai Pharmaceutical, Daiichi Sankyo Company, Eisai, Eli Lilly and Company, ImmunoForge, Japan Blood Products Organization, Mitsubishi Tanabe Pharma, Novartis Pharma Japan, Ono Pharmaceutical, Otsuka Pharmaceutical Factory, Pfizer, Sanofi, Takeda Pharmaceutical Company and Teijin, Hirokazu Sasaki: None declared, Natsuka Umezawa: None declared, Shinsuke Yasuda Speakers bureau: Abbvie, Asahi Kasei Pharma, Chugai Pharmaceutical, Eisai, Eli Lilly, GlaxoSmithKline, Mitsubishi Tanabe Pharma, Ono pharmaceutical, and Pfizer., Consultant of: ImmunoForge, Grant/research support from: Abbvie, Asahi Kasei Pharma, Chugai Pharmaceutical, CSL Behring, Eisai, ImmunoForge, Mitsubishi Tanabe Pharma, and Ono pharmaceutical.

Case Report: Eosinophilic Bronchiolitis With Eosinophil ETosis in Mucus Plugs Successfully Treated With Benralizumab

Eosinophilic bronchiolitis is a rare allergic disorder caused by eosinophilic inflammation in the bronchioles of the lungs. An effective treatment strategy is needed in cases resistant to steroids. However, its pathophysiology remains unclear owing to the limited number of cases. We herein present the case of a 31-year-old man who experienced eosinophilic bronchiolitis with eosinophil ETosis (EETosis) in the mucus plugs. The patient was diagnosed with asthma. His respiratory symptoms worsened with eosinophilia when treated with the standard asthma regimen, including inhaled corticosteroids, long-acting β2-agonist, long-acting muscarinic antagonist, and leukotriene receptor antagonist. Chest computed tomography revealed bronchial wall thickening and centrilobular nodules in the lower lobes of both lungs. Bronchoscopy showed obstruction of the subsegmental bronchus with mucus plugs. Histological analysis demonstrated abundant eosinophils in the mucus plugs. Cytolytic eosinophils together with Charcot–Leyden crystal formations and deposition of major basic proteins were also observed, indicating the occurrence of EETosis. Introduction of benralizumab, an anti-interleukin-5 receptor α antibody, successfully controlled the patient’s condition and reduced the amount of systemic corticosteroids administered. Our findings confirm that this antibody strongly decreases airway eosinophils in patients with severe asthma. Thus, benralizumab might be an optimal therapeutic agent for the treatment of mucus plug-forming and/or EETosis-occurring eosinophilic lung diseases, including eosinophilic bronchiolitis.

Federated learning for predicting clinical outcomes in patients with COVID-19

Federated learning (FL) is a method used for training artificial intelligence models with data from multiple sources while maintaining data anonymity, thus removing many barriers to data sharing. Here we used data from 20 institutes across the globe to train a FL model, called EXAM (electronic medical record (EMR) chest X-ray AI model), that predicts the future oxygen requirements of symptomatic patients with COVID-19 using inputs of vital signs, laboratory data and chest X-rays. EXAM achieved an average area under the curve (AUC) >0.92 for predicting outcomes at 24 and 72 h from the time of initial presentation to the emergency room, and it provided 16% improvement in average AUC measured across all participating sites and an average increase in generalizability of 38% when compared with models trained at a single site using that site's data. For prediction of mechanical ventilation treatment or death at 24 h at the largest independent test site, EXAM achieved a sensitivity of 0.950 and specificity of 0.882. In this study, FL facilitated rapid data science collaboration without data exchange and generated a model that generalized across heterogeneous, unharmonized datasets for prediction of clinical outcomes in patients with COVID-19, setting the stage for the broader use of FL in healthcare.

Efficacy of Chest Radiography as a Primary Care Triage Tool in Severe Coronavirus Disease

Objective Severe acute respiratory syndrome coronavirus 2 has spread globally, and it is important to utilize medical resources properly, especially in critically ill patients. We investigated the validity of chest radiography as a tool for predicting aggravation in coronavirus disease (COVID-19) cases. Methods A total of 104 laboratory-confirmed COVID-19 cases were referred from the cruise ship "Diamond Princess" to the Self-Defense Forces Central Hospital in Japan from February 11 to 25, 2020. Fifty-nine symptomatic patients were selected. Chest radiography was performed upon hospitalization; subsequently, patients were categorized into the positive radiograph (Group A) and negative radiograph (Group B) groups. Radiographic findings were analyzed with a six-point semiquantitative score. Group A was further classified into two additional subgroups: patients who required oxygen therapy during their clinical courses (Group C) and patients who did not (Group D). Clinical records, laboratory data, and radiological findings were collected for an analysis. Results Among 59 patients, 34 were men with a median age of 60 years old. Groups A, B, C, and D consisted of 33, 26, 12, and 21 patients, respectively. The number of patients requiring oxygen administration was significantly larger in Group A than in Group B. The consolidation score on chest radiographs was significantly higher in Group C than in Group D. When chest radiographs showed consolidation in more than two lung fields, the positive likelihood ratio of deterioration was 10.6. Conclusions Chest radiography is a simple and easy-to-use clinic-level triage tool for predicting the severity of COVID-19 and may contribute to the allocation of medical resources.

Zosteriform skin metastasis caused by retrograde lymphatic migration of metastatic squamous cell lung carcinoma

BACKGROUND

Zosteriform skin metastasis (ZSM) is rare, and its etiology is not well understood. ZSM is possibly derived from the retrograde movement of cancer cells through the lymphatic vessels during disease development. However, it has been difficult to demonstrate it, as no specific findings have been observed.

CASE PRESENTATION

A 68-year-old man presented to our department with neck lymphadenopathy. After detailed examinations, squamous cell lung carcinoma (cT2aN3M1c) was diagnosed. Although cisplatin combined with gemcitabine was administered, his cancerous lymphangiopathy was exacerbated, and ZSM was observed on his right chest. Pembrolizumab was initiated as a second-line chemotherapy; however, the patient died 7 months after the initial presentation. In this case, fluorodeoxyglucose-positron emission tomography indicated the presence of skin metastasis and cancerous lymphangiopathy. Similarly, after performing an autopsy, tumor-cell filled lymph ducts were observed in the right subclavian and the cutaneous lymphatic vessel from the right hilar lymph nodes.

CONCLUSIONS

To the best of our knowledge, this is the first study to demonstrate that the localization of ZSM in the cutaneous lymphatics was caused by the retrograde movement of cancer cells through the lymphatic vessels, using radiographical and pathological analysis. In addition, fluorodeoxyglucose-positron emission tomography may help predict skin metastasis induced by cancerous lymphangiopathy.

Federated Learning used for predicting outcomes in SARS-COV-2 patients

'Federated Learning' (FL) is a method to train Artificial Intelligence (AI) models with data from multiple sources while maintaining anonymity of the data thus removing many barriers to data sharing. During the SARS-COV-2 pandemic, 20 institutes collaborated on a healthcare FL study to predict future oxygen requirements of infected patients using inputs of vital signs, laboratory data, and chest x-rays, constituting the "EXAM" (EMR CXR AI Model) model. EXAM achieved an average Area Under the Curve (AUC) of over 0.92, an average improvement of 16%, and a 38% increase in generalisability over local models. The FL paradigm was successfully applied to facilitate a rapid data science collaboration without data exchange, resulting in a model that generalised across heterogeneous, unharmonized datasets. This provided the broader healthcare community with a validated model to respond to COVID-19 challenges, as well as set the stage for broader use of FL in healthcare.

The advanced lung cancer inflammation index predicts outcomes in patients with Crohn's disease after surgical resection

AIM

Precise biomarkers for predicting prognosis could help to identify high-risk Crohn's disease (CD) patients to facilitate better follow-up during the postoperative course. In this study, the primary aim is the identification of the most reliable nutrition marker that predicts surgical relapse in CD patients.

METHOD

We first evaluated the predictive value of various nutrition markers for postoperative surgical relapse in CD patients and identified the advanced lung cancer inflammation index (ALI) as a promising biomarker. Then, we assessed the clinical significance of preoperative ALI in CD patients using two cohorts.

RESULTS

Preoperative ALI showed the highest correlation with reoperation rate compared with other nutritional parameters in CD patients receiving surgical resection (sensitivity 53%, specificity 86%, area under the curve 0.71). Lower levels of preoperative ALI were significantly correlated with the presence of perianal disease. A lower level of preoperative ALI was an independent prognostic factor for reoperation rate after an intestinal resection (hazard ratio 3.37, 95% CI 1.38-10.12, P = 0.006), and the prognostic impact of preoperative ALI was successfully validated in an independent cohort using the same cut-off value.

CONCLUSION

Preoperative ALI might be useful for postoperative management of CD patients.

Prediction of an increase in oxygen requirement of SARS-CoV-2 pneumonia using three different scoring systems

Introduction

In patients with severe coronavirus disease 2019 (COVID-19), respiratory failure is a major complication and its symptoms occur around one week after onset. The CURB-65, A-DROP and expanded CURB-65 tools are known to predict the risk of mortality in patients with community-acquired pneumonia. In this retrospective single-center retrospective study, we aimed to assess the correlations of the A-DROP, CURB-65, and expanded CURB-65 scores on admission with an increase in oxygen requirement in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia.

Methods

We retrospectively analyzed 207 patients who were hospitalized with SARS-CoV-2 pneumonia at the Self-Defense Forces Central Hospital in Tokyo, Japan. Performance of A-DROP, CURB-65, and the expanded CURB-65 scores were validated. In addition, we assessed whether there were any associations between an increase in oxygen requirement and known risk factors for critical illness in COVID-19, including elevation of liver enzymes and C-reactive protein (CRP), lymphocytopenia, high D-dimer levels and the chest computed tomography (CT) score.

Results

The areas under the curve for the ability of CURB-65, A-DROP, and the expanded CURB-65 scores to predict an increase in oxygen requirement were 0.6961, 0.6980 and 0.8327, respectively, and the differences between the three groups were statistically significant (p < 0.001). Comorbid cardiovascular disease, lymphocytopenia, elevated CRP, liver enzyme and D-dimer levels, and higher chest CT score were significantly associated with an increase in oxygen requirement

Conclusions

The expanded CURB-65 score can be a better predictor of an increase in oxygen requirement in patients with SARS-CoV-2 pneumonia.

Lung adenocarcinoma with repetitive endotracheal/endobronchial metastasis 20 years after surgery: A case report

The occurrence of endotracheal/endobronchial metastasis (EEM) after complete resection of a primary lung cancer is rare. Here, we report the case of an 86‐year‐old woman in whom EEM occurred twice over a 20‐year period following complete resection of a primary adenocarcinoma localized to the left main bronchus and trachea. The presence of EEM was confirmed by establishing immunohistochemical homology of the metastases with the primary tumor. To the best of our knowledge, this is the first reported case of repetitive EEM of primary lung adenocarcinoma. Lymphatic invasion in the primary lesion suggested that a possible route for EEM was the peripheral lymphatic tract, explaining the slow recurrence rate. We conclude that observation of the trachea/bronchus over a long period post operation could be important in monitoring for EEM, particularly if lymphatic invasion is confirmed in the primary tumor.

Beneficial effects of balloon pulmonary angioplasty on clinical outcomes in patients with residual pulmonary hypertension after pulmonary endarterectomy

Background

Although pulmonary endarterectomy (PEA) is an established surgical treatment for chronic thromboembolic pulmonary hypertension (CTEPH), a part of patients after PEA show residual pulmonary hypertension, leading to limited exercise capacity. Recently, several studies have indicated that balloon pulmonary angioplasty (BPA) improves hemodynamics, exercise capacity and prognosis in inoperable CTEPH patients. However, the effects of BPA in patients with residual pulmonary hypertension after PEA remain to be elucidated.

Aim

In the present study, we investigated comprehensive efficacy of BPA on hemodynamics, exercise capacity and right ventricular function in those with residual pulmonary hypertension after PEA.

Methods

From October 2010 to February 2019, 227 patients with CTEPH underwent PEA in our institution. Right heart catheterization after PEA (median follow up period from PEA to right heart catheterization 39 [10.5, 90] months) showed that 55 patients showed residual PH (mean pulmonary artery pressure (mPAP)≥25mmHg), and 38 of them referred to BPA (mean age 57 years old, male 8 (21%)) due to residual symptoms. In 29 out of 38 patients (76%) who completed BPA and underwent follow-up right heart catheterization, we examined hemodynamics, exercise capacity and right ventricular function before and after BPA. Follow-up examination was performed 3 months after last BPA session.

Results

In this study population (N=29), PEA significantly improved mPAP (47±7 to 38±10 mmHg), pulmonary vascular resistance (PVR, 14.6±4.6 to 9.2±4.6 WU) and right ventricular ejection fraction measured by magnetic resonance imaging (26.6±11.3 to 38.4±6.8%) (Figure). Median period from PEA to first BPA procedure was 42 [13.5, 94] months. Total session number during study period was 160 sessions, and mean session number of BPA was 5.5±1.5 per patient. Follow-up study revealed that BPA additionally improved mPAP (38±10 to 27±8 mmHg) and PVR (9.2±4.6 to 5.1±2.2 WU) (Figure). Similarly, 6-minute walk distance (393±125 to 452±125 m) and peak VO2 (16.4±3.8 to 18.1±4.6 ml/min/kg, p&lt;0.05) were increased, and WHO functional class also significantly improved by BPA (I/II/III/IV, 0/21/8/ 0 to 1/27/1/0, p&lt;0.01). In addition, right ventricular ejection fraction (38.4±6.8 to 44.2±7.1%) was increased after BPA (Figure). There were no procedure-related deaths and major lung injuries requiring oral intubation during study period. 3-year survival in patients after BPA was 100% (median follow-up period after last BPA session, 32 [18, 46] months).

Conclusion

In CTEPH patients with residual pulmonary hypertension after PEA, additional BPA significantly improved hemodynamics, right ventricular function, exercise capacity and residual symptoms without severe complications, leading to good prognosis. These results suggest that combination therapy of PEA and BPA could be an effective therapeutic option for post PEA patients with residual symptoms and exercise limitation.

Figure 1

Funding Acknowledgement

Type of funding source: None

Suppressing dynamical diffraction artefacts in differential phase contrast scanning transmission electron microscopy of long-range electromagnetic fields via precession

It is well known that dynamical diffraction varies with changes in sample thickness and local crystal orientation (due to sample bending). In differential phase contrast scanning transmission electron microscopy (DPC-STEM), this can produce contrast comparable to that arising from the long-range electromagnetic fields probed by this technique. Through simulation we explore the scale of these dynamical diffraction artefacts and introduce a metric for the magnitude of their contribution to the contrast. We show that precession over an angular range of a few milliradian can suppress this contribution to the contrast by one-to-two orders of magnitude. Our exploration centres around a case study of GaAs near the [011] zone-axis orientation using a probe-forming aperture semiangle on the order of 0.1 mrad at 300 keV, but the trends found and methodology used are expected to apply more generally.

Comparison of COVID-19 disease between young and elderly patients: Hidden viral shedding of COVID-19

Objectives

The symptoms of Coronavirus disease 2019 (COVID-19) vary among patients. The aim of this study was to investigate the clinical manifestation and disease duration in young versus elderly patients.

Methods

We retrospectively analyzed 187 patients (87 elderly and 100 young patients) with confirmed COVID-19. The clinical characteristics and chest computed tomography (CT) extent as defined by a score were compared between the two groups.

Results

The numbers of asymptomatic cases and severe cases were significantly higher in the elderly group (elderly group vs. young group; asymptomatic cases, 31 [35.6%] vs. 10 [10%], p < 0.0001; severe cases, 25 [28.7%] vs. 8 [8.0%], p = 0.0002). The proportion of asymptomatic patients and severe patients increased across the 10-year age groups. There was no significant difference in the total CT score and number of abnormal cases. A significant positive correlation between the disease duration and patient age was observed in asymptomatic patients (ρ = 0.4570, 95% CI 0.1198–0.6491, p = 0.0034).

Conclusions

Although the extent of lung involvement did not have a significant difference between the young and elderly patients, elderly patients were more likely to have severe clinical manifestations. Elderly patients were also more likely to be asymptomatic and a source of COVID-19 viral shedding.

Serial serum SARS-CoV-2 RNA results in two COVID-19 cases with severe respiratory failure

Coronavirus disease 2019 (COVID-19) is spreading worldwide and poses an imminent threat to public health. We encountered 2 cases of COVID-19 with progression resulting in severe respiratory failure and improvement without any specific treatment.

To examine the course of infection, we performed reverse-transcription (RT) polymerase chain reaction assay with serum specimens, and serum SARS-CoV-2 RNA was detected in both cases when body temperature increased and respiratory status deteriorated. We, then examined, retrospectively and prospectively, the clinical course during hospitalization by performing serial examinations of serum SARS-CoV-2 RNA status. The findings from our cases suggest that not only is detection of viremia useful as a predictive marker of severity, but also serial serum SARS-CoV-2 RNA results can be helpful for predicting the clinical course.

P377Zero-fluoroscopy ablation with ultrasound-guided sheath insertion

Background

Radiation exposure during catheter ablation procedures is a risk for both the patient and electrophysiology staff. Recently, the feasibility and effectiveness of zero-fluoroscopy ablation have been shown. However, ensuring a safe sheath insertion through the venous system toward the heart is a concern in catheter ablation using the zero-fluoroscopy technique. 

Purpose

The objective of this study was to confirm feasibility and safety for zero-fluoroscopy ablation using ultrasound-guided sheath insertion.

Methods

Zero-fluoroscopy catheter ablation was performed in 220 patients (185 patients with atrial fibrillation (AF), 26 patients with supraventricular tachycardia (SVT), and nine patients with ventricular arrhythmias (VA)) using a 3-dimensional electro-anatomical mapping system, contact force monitoring, and intracardiac echocardiography (ICE) imaging. In all cases, ultrasound-guided sheath insertion was performed through the femoral vein. In 6 cases of VA, the retrograde approach through the femoral artery was performed with ICE imaging and contact-force monitoring. The endpoint of ablation for AF was pulmonary vein ablation in all cases and addition of left atrial posterior wall isolation in persistent AF cases. The endpoint of ablation for SVT and VA was noninducibility after ablation.

Results

The endpoints of ablation were achieved in all cases. The fluoroscopic time during ablation procedures was 0 seconds. There were two complications (one cardiac tamponade and one acute heart failure). There were no complications related to sheath insertion. 

Conclusions

Zero-fluoroscopy catheter ablation with ultrasound-guided sheath insertion may be feasible and can be performed safely. This method eliminates exposure radiation safely, which is a concern of zero-fluoroscopy endocardial catheter ablation.

Excellent performance of aromatic polyguanamines induced by multiple hydrogen bondable tetraazacalix[2]arene[2]-triazine ring in their main chain

A series of poly(guanamine) (c-PG)s containing tetraazacalix[2]arene[2]-triazine (mPDA₂CyC₂) were successfully prepared by solution polycondensation of mPDA₂CyC₂ with various aromatic diamines in an aprotic organic solvent with a lithium chloride additive (5 wt%) at 150 °C for 6 hours. The number-average molecular weights (M_n)s of these c-PG polymers reached up to 31 500, with a relatively broad molecular weight distribution (M_w/M_n) of 5.3. They showed good solubility in aprotic organic solvents, such as N-methylpyrrolidone and N,N-dimethylacetamide at a concentration of 2 mg mL⁻¹. The glass transition temperatures (T_g) of the c-PG polymers were in the range 359 °C–392 °C, approximately 160 °C higher than those of counterpart polymers (i.e., with no aza-calixarene-based PG (l-PG)). The coefficients of thermal expansion (CTEs) of the c-PG polymers were 29.7–48.1 ppm K⁻¹ (at 100 °C–150 °C), much lower than those of l-PG samples, i.e., 59.1–85.1 ppm K⁻¹. Transparent and almost colorless c-PG films were successfully prepared by a solution casting method, showing maximum tensile strength (σ_S), modulus (E_γ), and elongation at break (E_b) values of 151 MPa, 6.3 GPa, and 4.4%, respectively, for the c-PG polymer from mPDA₂CyC₂ and 4,4′-oxydianiline monomers. The corresponding l-PG film exhibited σ_S, E_γ, and E_b values of just 76 MPa, 5.4 GPa, and 1.6%, respectively. These outstanding thermal and mechanical properties of the c-PG polymers can be attributed to their multiple hydrogen bonding interaction between mPDA₂CyC₂ residues in the polymer backbone. This interaction was identified by infrared spectroscopy measurements at the broad absorption band around 3000–3400 cm⁻¹.

Poly(guanamine)s containing tetraazacalix[2]arene[2]triazine ring within the polymer main-chain show outstanding thermal and mechanical properties arisen from the multiple-hydrogen bond.

Pazopanib-induced organizing pneumonia in a patient with leiomyosarcoma: A case report

Pazopanib, a multityrosine kinase inhibitor used for treating malignant soft tissue tumors, rarely causes adverse events associated with the respiratory system. We report a case of a 73-year-old male with leiomyosarcoma treated with pazopanib. Four months after treatment initiation, chest computed tomography showed bilateral patchy consolidation and ground-glass opacities. Bronchoscopy revealed increased lymphocytes in the bronchoalveolar lavage fluid. Histological analysis of lung tissue demonstrated intraluminal fibrotic changes in alveolar spaces. According to these findings, we diagnosed the patient with pazopanib-induced organizing pneumonia. To best of our knowledge, this is the first report of such a case.

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Pazopanib is a multityrosine kinase inhibitor used for treating soft tissue tumors.

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Pazopanib rarely causes adverse events associated with the respiratory system.

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This is the first report of a patient with pazopanib-induced organizing pneumonia.

Successful Control of Dasatinib-related Chylothorax by the Japanese Herbal Medicine "Goreisan"

Dasatinib-related chylothorax is a rare adverse event, and the mechanism underlying its occurrence is still not fully understood. We herein report the case of a 73-year-old woman with chronic myeloid leukemia (CML) who developed dasatinib-related chylothorax refractory to conventional treatments, except for steroids. To the best of our knowledge, this is the first case of dasatinib-related chylothorax which was successfully controlled by combining diuretics with the Japanese herbal medicine "Goreisan." "Goreisan" is known to inhibit aquaporin channels and regulate the water flow. Our findings showed that "Goreisan" is an effective treatment option for uncontrollable dasatinib-related chylothorax.

Development of Allergic Bronchopulmonary Aspergillosis in a Patient with Crohn's Disease

Allergic bronchopulmonary aspergillosis (ABPA) is an eosinophilic inflammatory condition characterized by exaggerated immune responses to the fungal genus Aspergillus. Pulmonary manifestations in patients with Crohn's disease (CD) are frequent comorbidities. A 66-year-old man with CD treated with an anti-tumor necrosis factor-α antibody presented with dyspnea. Laboratory findings of elevated blood eosinophils and total serum IgE and positive aspergillus-specific antibodies as well as imaging findings of central bronchiectasis and mucoid impaction indicated a diagnosis of ABPA. To our knowledge, this is the first report of ABPA arising in a patient with CD. We discuss the pathophysiological mechanism of this rare complication.

COMPARATIVE STUDY ON PERFORMANCE OF VARIOUS ENVIRONMENTAL RADIATION MONITORS

After the Fukushima Daiichi Nuclear Power Plant accident, the radiation dose for first responders was not evaluated accurately due to lack of the monitoring data. It has been important to evaluate a radiation dose for workers in emergency response at a nuclear accident. In this study, a new device which can evaluate both of external and internal exposure doses was developed and the performance of various environmental radiation monitors including commercially available monitors were tested and compared from the viewpoint of an environmental monitoring at emergency situation. Background counts of the monitors and the ambient dose equivalent rate were measured in Fukushima Prefecture. The detection limit for beta particles was evaluated by the method of ISO11929. The sensitivity for gamma-rays of the dust monitor using a ZnS(Ag) and a plastic scintillator was high, but that of the external exposure monitor using a silicon photodiode with CsI(Tl) crystal was relatively low. The detection limit ranged 190-280 Bq m-3 at 100 μSv h-1, exceeding the detection limit of 100 Bq m-3 in the minimum requirement by the National Regulation Authority in Japan. Use of the shielding with lead is necessary to achieve the minimum requirement. These results indicate that the dust monitor using a ZnS(Ag) scintillator and a plastic scintillator is suitable for the external exposure monitor and the developed internal exposure monitor is for the internal exposure monitor at emergency situation among the evaluated monitors. In the future study, the counting efficiency, the relative uncertainty and the performance of the detection for alpha particles will be evaluated, and it will be considered which type of a monitor is suitable after taking the portability into account.

Hepatitis A virus-associated fulminant hepatitis with human immunodeficiency virus coinfection

Hepatitis A virus (HAV) commonly causes acute hepatitis in humans and is transmitted through the fecal-oral route or by ingestion of contaminated food or water. HAV infection generally follows a self-limiting course; it can seldom cause fulminant hepatitis that increases the risk of mortality. To the best of our knowledge, this is the first reported fatal case of fulminant hepatitis caused by HAV in a 40-year-old male with human immunodeficiency virus (HIV) infection. The HAV genotype in this case was IA, which has recently become common globally among people living with HIV (PLWHIV), intravenous drug users, and homeless people especially in developed countries. His HIV infection was stabilized by antiretroviral drugs and his CD4 values were stable. He developed acute hepatic encephalopathy, did not respond to repeated plasma exchange therapy, and died rapidly. It is known that HIV co-infection sometimes leads to fulminant non-HAV hepatitis, although evidence supporting a correlation between fulminant hepatitis A risk and HIV infection is still lacking. This case demonstrated the fatal risk of HAV infection in PLWHIV; it was suggested that education about appropriate preventive measures and vaccination are important for preventing HAV infections among PLWHIV.

Empyema with Multiple Bronchopleural Fistulae Improved by Bronchial Occlusion Using an Endobronchial Watanabe Spigot with the Push and Slide Method

The push and slide method is a method of endoscopic bronchial occlusion using an endobronchial Watanabe spigot that facilitates occlusion of the target bronchus rapidly and accurately using a guidewire. We herein report the case of a man who was diagnosed with empyema forming bronchopulmonary fistulae that was successfully treated by endoscopic bronchial occlusion. Because of the multiple fistulae, balloon occlusion was not a favorable therapeutic approach. Instead, the push and slide method was used in order to detect the fistulae. Endoscopic occlusion, particularly that using the push and slide method, may be a valid treatment option for empyema with multiple bronchopulmonary fistulae.

Percentage of CD19+ Cells in Peripheral Blood Lymphocytes After Rituximab-Based Desensitization as a Predictor of Acute Antibody-Mediated Rejection in ABO-Incompatible Kidney Transplantation

BACKGROUND

Rituximab (RIT) is effective as a part of the desensitization therapy before ABO-incompatible kidney transplantation (ABOi-KTx), and a single dose of RIT at 375 mg/m² or less is recommended. However, adequate RIT dose recommendations have not yet been established for individual recipients. Therefore, we evaluated the relationship between the proportion of B cells in peripheral blood and acute antibody-mediated rejection (AAMR).

METHODS

Forty-four consecutive ABOi-KTx recipients were enrolled in this retrospective study. Before transplantation, subjects were treated with RIT at various doses, ranging from 65 to 400 mg/body (46-263 mg/m²), followed by plasmapheresis and intravenous immunoglobulin as a desensitization therapy. The percentage of CD19⁺ cells in the total peripheral blood lymphocytes population (%CD19) was determined the day before transplantation. Transplant recipients were divided into 2 groups according to pretransplant %CD19, as follows: low %CD19 group, ≤ 1.2% (n = 35) and high %CD19 group, > 1.2% (n = 9). The relationship between %CD19 and incidence of AAMR was evaluated, and the predicting factors for AAMR incidence were determined by univariate and multivariate analyses.

RESULTS

The incidence of AAMR was significantly higher in the high %CD19 group than in the low %CD19 group (44.4% vs 5.7%, P = .006). Furthermore, multivariate analysis showed that %CD19 > 1.2% was the only independent factor to predict AAMR, with an odds ratio of 14.31 (P = .038).

CONCLUSION

High %CD19 values after rituximab administration in ABOi-KTx recipients implies insufficient depletion of B cells, which can lead to AAMR.

A Case of Feline T-cell Lymphoma with Tropism for Striated Muscle and Peripheral Nerve

An 11-year-old female American shorthair cat was presented with a 3-month history of hindlimb ataxia and knuckling of the left forelimb. Clinical abnormalities included weight loss, hyperaesthesia of the neck and back, cardiac murmur and systemic muscle atrophy. The cat died 10 days after the initial presentation and a necropsy examination was performed. Grossly, extensive pale lesions were seen in the wall of the left ventricle and the septum of the heart. There were no detectable masses in the heart, skeletal muscles or peripheral nerves. Histopathological examination revealed diffuse, extensive infiltration of atypical lymphoid cells in the heart; the cardiac muscles were markedly degenerate and atrophic and were replaced by the neoplastic cells. Neoplastic cells with similar morphology were seen in all specimens of the skeletal muscles and peripheral nerves. Clonality analysis of the paraffin wax-embedded heart tissue revealed a monoclonal rearrangement of the gene encoding the T-cell receptor γ chain. Based on these findings, the case was diagnosed as T-cell lymphoma with tropism for striated muscle and peripheral nerve.

Serum Amyloid A Contributes to Chronic Apical Periodontitis via TLR2 and TLR4

In the current concept of bacterial infections, pathogen-associated molecular patterns (PAMPs) derived from pathogens and damage-associated molecular patterns (DAMPs) released from damaged/necrotic host cells are crucial factors in induction of innate immune responses. However, the implication of DAMPs in apical and marginal periodontitis is unknown. Serum amyloid A (SAA) is a DAMP that is involved in the development of various chronic inflammatory diseases, such as rheumatoid arthritis. In the present study, we tested whether SAA is involved in the pathogenesis of periapical lesions, using human periapical surgical specimens and mice deficient in SAA and Toll-like receptors (TLR). SAA1/2 was locally expressed in human periapical lesions at the mRNA and protein levels. The level of SAA protein appeared to be positively associated with the inflammatory status of the lesions. In the development of mouse periapical inflammation, SAA1.1/2.1 was elevated locally and systemically in wild-type (WT) mice. Although SAA1.1/2.1 double-knockout and SAA3 knockout mice had redundant attenuation of the extent of periapical lesions, these animals showed strikingly improved inflammatory cell infiltration versus WT. Recombinant human SAA1 (rhSAA1) directly induced chemotaxis of WT neutrophils in a dose-dependent manner in vitro. In addition, rhSAA1 stimulation significantly prolonged the survival of WT neutrophils as compared with nonstimulated neutrophils. Furthermore, rhSAA1 activated the NF-κB pathway and subsequent IL-1α production in macrophages in a dose-dependent manner. However, TLR2/TLR4 double deficiency substantially diminished these SAA-mediated proinflammatory responses. Taken together, the SAA-TLR axis plays an important role in the chronicity of periapical inflammation via induction of inflammatory cell infiltration and prolonged cell survival. The interactions of PAMPs and DAMPs require further investigation in dental/oral inflammation.

Routine Referral by Urologists Increase Opportunities for Corneal Donation

BACKGROUND

The levels of corneal donation are insufficient to meet the demand for corneal transplantation in Japan. To overcome this problem, we started to routinely mention the possibility of corneal donation to the families of patients who died in our hospital's Urology Department in February 2008. In this study, we evaluated the effectiveness of this approach.

METHODS

We retrospectively reviewed the medical records of the patients who died in the Department of Urology, St. Marianna University School of Medicine Hospital, and analyzed the patients' characteristics and information about corneal donation.

RESULTS

In total, 211 patients died in our department between February 2008 and March 2017, and 155 patients were medically suitable corneal donors. We mentioned the possibility of corneal donation to 129 (83.2%) families, and 29 (18.7%) families agreed. Three families subsequently withdrew their consent. Finally, 26 (16.8%) of the families that were approached about corneal donation by urologists agreed to donate their relatives' corneas. Another 2 families voluntarily offered to donate their relatives' corneas. Thus, 28 (18.1%) of 155 medically suitable donors donated their corneas for transplantation. Twenty-six (92.8%) donors were 60 years or older and all donors were affected with malignant genitourinary tumors. Fifty-four (96.4%) corneas were successfully transplanted into recipients.

CONCLUSIONS

Even elderly patients who die of solid carcinoma can be an important source of corneal donors. In this study, we showed that routine referral by urologists increased corneal donation. If this approach were adopted by other departments, it might further increase the number of corneal donations.

The relationship of waist circumference and body mass index to grey matter volume in community dwelling adults with mild obesity

Objective

Previous work has shown that high body mass index (BMI) is associated with low grey matter volume. However, evidence on the relationship between waist circumference (WC) and brain volume is relatively scarce. Moreover, the influence of mild obesity (as indexed by WC and BMI) on brain volume remains unclear. This study explored the relationships between WC and BMI and grey matter volume in a large sample of Japanese adults.

Methods

The participants were 792 community-dwelling adults (523 men and 269 women). Brain magnetic resonance images were collected, and the correlation between WC or BMI and global grey matter volume were analysed. The relationships between WC or BMI and regional grey matter volume were also investigated using voxel-based morphometry.

Results

Global grey matter volume was not correlated with WC or BMI. Voxel-based morphometry analysis revealed significant negative correlations between both WC and BMI and regional grey matter volume. The areas correlated with each index were more widespread in men than in women. In women, the total area of the regions significantly correlated with WC was slightly greater than that of the regions significantly correlated with BMI.

Conclusions

Results show that both WC and BMI were inversely related to regional grey matter volume, even in Japanese adults with somewhat mild obesity. Especially in populations with less obesity, such as the female participants in current study, WC may be more sensitive than BMI as a marker of grey matter volume differences associated with obesity.

Ostomy creation with fewer sutures using tissue adhesives (cyanoacrylates) in inflammatory bowel disease: a pilot study

Introduction Fistula formation around the ostomy site is a stoma-related complication often requiring surgical intervention. This complication may be caused by sutures or may develop as a complication of inflammatory bowel disease. Before conducting a clinical trial, we set out to investigate the safety of ostomy creation with fewer sutures using tissue adhesives in this pilot study. Methods Patients with inflammatory bowel disease who required surgery with ostomy creation at the Hyogo College of Medicine between January 2014 and December 2015 were enrolled. Safety was assessed by evaluating the incidence of stoma-related complications. Ostomy was restricted to loop ileostomy and was created with two sutures and tissue adhesives. Results A total of 14 patients were enrolled. Mean body mass index was 18.9 ± 2.0 kg/m². There were no cases of ostomy retraction and no severe adverse events were observed. Conclusions This pilot study demonstrates that ostomy creation using tissue adhesives is safe. Although retraction and adverse events were not observed, even in patients with inflammatory bowel disease who generally exhibit delayed wound healing, the body mass index was extremely low in this series. This study does not strongly recommend ostomy creation with tissue adhesives; further studies are needed to clarify the efficacy and safety of the procedure.