AB0095 CHARACTERISTICS OF TUMOR NECROSIS FACTOR-ALPHA AND INTERLEUKIN-6-INDUCED OSTEOCLASTS IN PERIPHERAL BLOOD AND BONE TISSUE FROM PATIENTS WITH RHEUMATOID ARTHRITIS

Background

We have previously reported that stimulation of mouse bone marrow–derived macrophages with tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) induces differentiation of osteoclast-like cells having bone resorption ability1. Recently, we have shown that the combination of TNF-α and IL-6 can induce osteoclasts from human peripheral blood mononuclear cells (PBMCs) via RANKL-independent pathways, and that there are functional differences between TNF-α and IL-6-induced osteoclasts (T6-OCs) and RANKL-induced, conventional osteoclasts (cOCs). In particular, the number of T6-OCs differentiated from PBMCs in patients with rheumatoid arthritis (RA) positively correlated with the modified total Sharp score (mTSS)2. On the other hands, no such correlation was observed between the number of cOCs from RA and mTSS.

Objectives

Objectives of this study were to compare the differentiational potential into T6-OCs of PBMCs from RA patients with those from healthy donors, to clarify mRNA and protein expressions of T6-OCs derived from PBMCs from patients with RA, and to identify tartrate resistant acid phosphatase (TRACP) positive multinuclear cells with the same characters as T6-OCs histologically in the sub-chondral bone tissues from patients with RA and osteoarthritis (OA).

Methods

PBMCs and CD14+ monocytes derived from RA patients and healthy volunteers were stimulated with TNF-α and IL-6 or RANKL. Real-time quantitative PCR and immunofluorescence staining were used to measure expression levels of osteoclast-associated mRNA and protein. Consecutive sections of the proximal tibial bone tissue from patients with RA and OA (n=6 each) were stained by TRACP, and analyzed expression levels of osteoclast-associated molecules by immunohistochemistry.

Results

The number of T6-OCs differentiated from PBMCs in RA patients was significantly increased compared to that in healthy volunteers. Expression levels of RANK mRNA and protein were clearly up-regulated in cOCs differentiated from CD14+ monocytes and were down-regulated in T6-OCs. In contrast, expression levels of MMP-3 mRNA and protein were obviously up-regulated in T6-OCs and down-regulated in cOCs. Therefore, we believe T6-OCs and cOCs were differently identified on bone tissue as TRACP+RANK-/MMP-3+ cells and TRACP+RANK+/MMP-3- cells, respectively. The numbers of TRACP+ osteoclasts in subchondral cancellous bone were significantly increased in RA patients compared to those in OA patients. Interestingly, numerous TRACP+/RANK-/MMP-3+ osteoclasts were present in the subchondral bone from patients with RA, on the other hands, no such cells observed in OA patients.

Conclusion

The PBMCs of RA patients have definitely increased differentiation capacity into T6-OCs, which have potential of degrading chondral tissue. Additionally, cells having same characteristics with T6-OCs are observed in subchondral bone of patients with RA. These results suggest that novel T6-OCs may be involved in the pathogenic mechanisms of inflammatory bone destruction in patients with RA.

References

[1]Yokota K, Sato K, Miyazaki T, Kitaura H, Kayama H, Miyoshi F, Araki Y, Akiyama Y, Takeda K, Mimura T. Combination of Tumor Necrosis Factor α and Interleukin-6 Induces Mouse Osteoclast-like Cells With Bone Resorption Activity Both in Vitro and In Vivo. Arthritis & Rheumatology Jan;66(1):121-9, 2014.

[2]Yokota K, Sato K, Miyazaki T, Aizaki Y, Tanaka S, Sekikawa M, Kozu N, Kadono Y, Oda H, Mimura T. Characterization and Function of Tumor Necrosis Factor alpha and Interleukin-6-Induced Osteoclasts in Rheumatoid Arthritis. Arthritis & Rheumatology Jul;73(7):1145-1154, 2021.

Acknowledgements

We are grateful to H. Kajiyama and Y. Araki (Saitama Medical University) for helpful discussion.

Disclosure of Interests

None declared

Comparison of the effects of two commercially available prescription diet regimens on the fecal microbiomes of client-owned healthy pet dogs

In the present study, we used next-generation sequencing to investigate the impacts of two commercially available prescription diet regimens on the fecal microbiomes of eleven client-owned healthy pet dogs. We tested an anallergenic diet on 6 dogs and a low-fat diet on 5 dogs. Before starting the study, each dog was fed a different commercial diet over 5 weeks. After collecting pre-diet fecal samples, the anallergenic or low-fat diet was administered for 5 weeks. We then collected fecal samples and compared the pre- and post-diet fecal microbiomes. In the dogs on the anallergenic diet, we found significantly decreased proportions of Bacteroides, Ruminococcaceae, and Fusobacteriaceae, belonging to the phyla Bacteroidetes, Firmicutes, and Fusobacteria, respectively. The proportion of the genus Streptococcus belonging to the phylum Firmicutes was significantly increased upon administering the anallergenic diet. In the dogs on the low-fat diet, although the phyla Actinobacteria and Bacteroidetes tended to increase (p=0.116) and decrease (p=0.147) relative to the pre-diet levels, respectively, there were no significant differences in the proportions of any phylum between the pre- and post-diet fecal microbiomes. The anallergenic diet induced a significantly lower diversity index value than that found in the pre-diet period. Principal coordinate analysis based on unweighted UniFrac distance matrices revealed separation between the pre- and post-diet microbiomes in the dogs on the anallergenic diet. These results suggest that, even in pet dogs kept indoors in different living environments, unification of the diet induces apparent changes in the fecal microbiome.

Relationship between anti-insulin antibody production and severe insulin resistance in a diabetic cat

A 5-year-old castrated male domestic shorthair cat was diagnosed with diabetic ketoacidosis and severe insulin resistance. Although the conventional treatment for diabetic ketoacidosis was provided, the cat required frequent hospitalization because of severe dehydration and repeated diabetic ketoacidosis. We detected anti-insulin antibodies for human in this cat. Serum insulin-binding IgG levels were markedly elevated compared with those in healthy cats and other diabetic cats. We initiated prednisolone to suppress the effects of anti-insulin antibodies. After initiation of prednisolone, the cat was gradually recovered with increasing activity and appetite. Furthermore, satisfactory glycemic control was achieved with combined subcutaneous injection of insulin detemir and insulin degludec.

Relationship between anti-insulin antibody production and severe insulin resistance in a diabetic cat

A 5-year-old castrated male domestic shorthair cat was diagnosed with diabetic ketoacidosis and severe insulin resistance. Although the conventional treatment for diabetic ketoacidosis was provided, the cat required frequent hospitalization because of severe dehydration and repeated diabetic ketoacidosis. We detected anti-insulin antibodies for human in this cat. Serum insulin-binding IgG levels were markedly elevated compared with those in healthy cats and other diabetic cats. We initiated prednisolone to suppress the effects of anti-insulin antibodies. After initiation of prednisolone, the cat was gradually recovered with increasing activity and appetite. Furthermore, satisfactory glycemic control was achieved with combined subcutaneous injection of insulin detemir and insulin degludec.

Cell-Based Biohybrid Sensor Device for Chemical Source Direction Estimation

This paper describes a method to estimate the direction from which the signal molecule reaches the sensor by using living cells. In this context, biohybrid sensors that utilize a sophisticated sensing system of cells can potentially offer high levels of chemical-detection sensitivity and selectivity. However, biohybrid-sensor-based chemical-source-direction estimation has not received research attention because the cellular response to chemicals has not been examined in the context of directional information. In our approach, we fabricated a device that can limit the interface between the cell-laden hydrogel and the chemical solution of interest to enhance the time difference over which the chemical solution reaches the cells. Chemical detection by cells that express specific receptors is reflected as the fluorescence of the calcium indicator within the cells. Our device has eight chambers that each house 3D cell-laden collagen hydrogels facing circularly outward. The device also works as a cover to prevent chemicals from permeating the hydrogel from above. In our study, by observing the time course of the fluorescence emission of each chamber, we were able to successfully estimate the chemical-source direction within an error range of 7–13°. Our results suggest that a combination of microstructure devices embedded with living cells can be used to exploit cell functionalities to yield chemical-source directional information.

Comparison of cholesterol levels among lipoprotein fractions separated by anion-exchange high-performance liquid chromatography in periparturient Holstein-Friesian dairy cows

Changes in lipoprotein profiles occur in dairy cows during the periparturient period and in cows with transition cow disease. Here, the lipoprotein profiles of Holstein–Friesian dairy cows during the periparturient period were obtained by anion-exchange, high-performance liquid chromatography to evaluate the usefulness of lipoprotein profile evaluation during the periparturient period and in cows with fatty liver and milk fever. Lipoprotein levels (including total and high- (HDL-C) and low-density lipoprotein (LDL-C) cholesterol) in 10 healthy cows were low 4 weeks prepartum, with the lowest values at calving or within 1 week of calving; the values increased at 8 weeks postpartum. The lipoprotein levels were measured in 16 cows diagnosed with fatty liver (n=10) or milk fever (n=6) and compared to 10 healthy dairy cows. A significant difference was observed in HDL-C between healthy cows (at calving and 1 week postpartum), and the fatty liver and milk fever cows. Cows with fatty liver and milk fever had a lower mean HDL-C than the 10 healthy dairy cows at calving and 1 week postpartum. HDL-C might be a good indicator of energy balance for differentiating healthy cows from those with transition cow disease.

The effect of Insulin Degludec on glycemic control in diabetic cats over a 12-month period

Insulin degludec (IDeg) is a long-acting basal insulin recently developed for use in humans. This study aimed to investigate the effects of IDeg on glycemic control in diabetic cats. Changes in body weight, IDeg dosage, and glycated albumin (GA) were evaluated at 0, 1, 3, 6, 9, and 12 months following initiation of IDeg. A significant decrease in GA was observed and a mean GA level below 25% was achieved between 3 and 12 months. Furthermore, a significant increase in body weight was observed between 3 and 12 months. The mean IDeg dose was 0.75 ± 0.68 IU/kg/day at 12 months. Taken together, long-term glycemic control was successfully achieved in diabetic cats using IDeg.

P10 A possible link between sarcopenia and major bleeding risk among patients with atrial fibrillation treated with oral anticoagulation undergoing coronary stenting

Background/Introduction

In patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) with stent implantation, oral anticoagulation (OAC) plus dual antiplatelet therapy (DAPT) increases the risk of bleeding. The PRECISE-DAPT (P-DAPT) and DAPT scores were created to predict increased bleeding versus ischemic risk in patients undergoing DAPT. However, not much information is available on predicting bleeding risk associated with OAC concomitant with DAPT in patients with AF treated with coronary stents. Physical frailty or sarcopenia is considered an emerging predictor for bleeding in AF patients.

Purpose

To investigate the relationship between skeletal muscle mass and major bleeding risk in AF patients undergoing PCI and subsequent OAC and DAPT.

Methods

A total of 1,234 consecutive patients after PCI using newer-generation drug eluting stents were evaluated. An anti-thrombotic regimen without OAC was given to 1,077 patients, whereas OAC was required in 157 patients (12.7%) including AF (n = 96). The P-DAPT, DAPT, and HAS-BLED scores were calculated for each of the patients. Any out-of-hospital major bleeding events were identified based on BARC criteria during a median follow-up of 2.9 years. The fat-free mass index (FFMI; kg/m2) was calculated to evaluate skeletal muscle mass as follows: (7.38 + 0.02908 × urinary creatinine (mg/day)) / (height squared (m2)). A Cox proportional hazards model was used to test the significance of the FFMI and these risk scores as predictors of major bleeding, defined as BARC 3 or 5 events in AF patients. The receiver operating characteristic curve (ROC) analyses were used to examine the predictive ability of the FFMI and these scores to identify patients with major bleeding events.

Results

Major bleeding events were observed in 9 (9.3%) patients. Major bleeding was associated with a lower FFMI (hazard ratio [HR] 0.53; 95% confidence interval [CI] 0.36-0.79; p = 0.002), and higher P-DAPT score (HR, 1.07; 95% CI, 1.02-1.11; p = 0.003), but not with the DAPT (HR, 0.71; 95% CI, 0.45-1.12; p = 0.147) and the HAS-BLED score (HR, 1.00; 95% CI, 0.48-2.09; p = 0.990). In the non-OAC cohort, major bleeding was related to a higher P-DAPT score (HR, 1.05; 95% CI, 1.02-1.07; p < 0.0001), but the FFMI (HR, 0.89; 95% CI, 0.73-1.09; p = 0.265) and the DAPT score were not correlated. C-statistics for major bleeding events were 0.82 (95% CI, 0.71-0.93, p = 0.001) for the FFMI and 0.79 (95% CI, 0.68-0.90, p = 0.004) for the P-DAPT score.

Conclusions

Assessment of the FFMI for screening sarcopenia is useful to predict major bleedings specifically in patients with AF undergoing coronary stenting. Both the FFMI and P-DAPT could successfully predict major bleedings in AF patients after PCI. Whether novel bleeding risk scores combined with measuring body composition adequately identify high risk patients needs to be validated.

Comparison of the effects of four commercially available prescription diet regimens on the fecal microbiome in healthy dogs

The effects of prescription diets on canine intestinal microbiota are unknown. In this study, we used next generation sequencing to investigate the impact of four commercially available prescription diet regimens on the fecal microbiome in six healthy dogs. The diet regimens used were as follows: weight-loss diet, low-fat diet, renal diet, and anallergenic diet. We found a significantly decreased proportion of phylum Actinobacteria with the weight-loss diet compared to the anallergenic diet. There were no significant differences in the proportion of phylum Bacteroidetes between the four diets. The proportion of phylum Firmicutes was significantly decreased with the weight-loss diet compared to the anallergenic diet. The proportion of phylum Fusobacteria was significantly increased with the weight-loss diet compared to the anallergenic diet. There were no significant differences in the proportion of phylum Proteobacteria after consumption of the four diets. We therefore demonstrated that commercial prescription diet influences the fecal microbiome in healthy dogs. These results might be useful when choosing a prescription diet for targeting a disease.

Evaluation of changes in periodontal bacteria in healthy dogs over 6 months using quantitative real-time PCR

Porphyromonas gulae, Tannerella forsythia and Campylobacter rectus are considered dominant periodontal pathogens in dogs. Recently, quantitative real-time PCR (qRT-PCR) methods have been used for absolute quantitative determination of oral bacterial counts. The purpose of the present study was to establish a standardized qRT-PCR procedure to quantify bacterial counts of the three target periodontal bacteria (P. gulae, T. forsythia and C. rectus). Copy numbers of the three target periodontal bacteria were evaluated in 26 healthy dogs. Then, changes in bacterial counts of the three target periodontal bacteria were evaluated for 24 weeks in 7 healthy dogs after periodontal scaling. Analytical evaluation of each self-designed primer indicated acceptable analytical imprecision. All 26 healthy dogs were found to be positive for P. gulae, T. forsythia and C. rectus. Median total bacterial counts (copies/ng) of each target genes were 385.612 for P. gulae, 25.109 for T. forsythia and 5.771 for C. rectus. Significant differences were observed between the copy numbers of the three target periodontal bacteria. Periodontal scaling reduced median copy numbers of the three target periodontal bacteria in 7 healthy dogs. However, after periodontal scaling, copy numbers of all three periodontal bacteria significantly increased over time (p<0.05, Kruskal-Wallis test) (24 weeks). In conclusion, our results demonstrated that qRT-PCR can accurately measure periodontal bacteria in dogs. Furthermore, the present study has revealed that qRT-PCR method can be considered as a new objective evaluation system for canine periodontal disease.

Spontaneous Deceleration and Acceleration of Growth Rate in Medullary Thyroid Carcinomas Suggested by Changes in Calcitonin Doubling Times Over Long-Term Surveillance

BACKGROUND

Based on our long-term observation of medullary thyroid carcinoma (MTC) patients, we hypothesized that some MTCs have spontaneous deceleration or regression of tumor growth over a long term and that a minority may acquire growth acceleration. We thus compared the calcitonin doubling time (Ct-DT) in the earlier and later half-periods of MTC patients' postoperative course.

METHODS

We followed 26 MTC patients (14 hereditary and 12 sporadic MTCs) with postoperative hypercalcitoninemia with periodic measurements of serum calcitonin (Ct) for >10 years without major interventions. The median period of Ct measurements was 18.3 years (range 10.6-30.2 years). We divided the individual patients' study periods into the earlier and later halves and calculated the Ct-DTs for both periods.

RESULTS

In the hereditary group, the Ct-DT in the later half-period (Later-Ct-DT) was significantly longer than that in the earlier half-period (Earlier-Ct-DT) (median 20.0 years vs. 7.1 years, p = 0.013). These values in the sporadic group were 20.0 years versus 11.1 years, respectively (p =0.774). Twelve patients (seven hereditary and five sporadic) had Later-Ct-DTs significantly longer than their Earlier-Ct-DTs (median 27.4 years vs. 4.9 years) and good prognoses. Two patients (one hereditary, one sporadic) had Later-Ct-DTs significantly shorter than their Earlier-Ct-DTs, and both developed structural recurrence and died of the disease.

CONCLUSION

Many of the hereditary and some of the sporadic MTC patients had elongated Ct-DTs over a long period, suggesting spontaneous deceleration and regression of tumor growth. A minority of the MTC patients showed Ct-DT shortening, suggesting tumor growth acceleration.

Appropriateness of the revised Japanese guidelines' risk classification for the prognosis of papillary thyroid carcinoma: a retrospective analysis of 5,845 papillary thyroid carcinoma patients

The revised Japan Association of Endocrine Surgeons (JAES)/Japanese Society of Thyroid Surgery (JSTS) guidelines for patients with papillary thyroid carcinoma (PTC) describe four risk classes: very-low-risk, low-risk, intermediate-risk, and high-risk. Here we conducted a retrospective analysis to evaluate the appropriateness of these guidelines' risk classification of PTCs. Lymph node recurrence-free, distant recurrence-free and cause-specific survivals at 15-year of high-risk group were significantly poorer than those at 15-year of intermediate-group and these survivals of intermediate-group were poorer than of low- or very-low-risk patients. In the subset analyses based on patient age (≥55 years and <55 years), we obtained the same results in both subsets. Age significantly worsen the whole prognosis of high-risk patients and cause-specific survival of intermediate-risk patients, but not the prognosis of low- or very-low-risk patients. Therefore, the risk classification of the revised JAES/JSTS guidelines is appropriate, and therapeutic strategies should be decided based on the risk class together with the patients' age.

Long-term management and postmortem examination in a diabetic cat with acromegaly treated with two courses of radiation therapy

A 12-year-old, castrated male cat with diabetes mellitus was diagnosed with acromegaly and examined with magnetic resonance imaging (enlarged pituitary gland, 8 mm); serum hormone concentrations were measured. After the first course of radiation therapy (4 Gy, 12 fractions), insulin administration was not required from day 420 after diagnosis. Enlarged pituitary tumor (8 mm) recurred, and insulin dosage amount of the cat was increased on day 1,065. The second course of radiation therapy (6 Gy, 4 fractions) was performed on day 1,201 and insulin administration was again discontinued. However, the cat died from lymphoma on day 1,397. Postmortem examination revealed pituitary adenoma. Most tumor cells were positive for chromogranin A, synaptophysin, and growth hormone immunohistochemistry. The pancreatic islet cells revealed diffuse hyperplasia. We achieved long-term successful management of an acromegalic cat with two courses of RT. However, a protocol for a second course of RT for feline recurrent pituitary tumor should be further discussed.

Natural history of papillary thyroid microcarcinoma: Kinetic analyses on tumor volume during active surveillance and before presentation

BACKGROUND

We report on the growth of papillary microcarcinoma during active surveillance and before clinical presentation.

METHODS

We conducted a retrospective study of 169 patients with papillary microcarcinoma who were enrolled in active surveillance at our hospital between 2000 and 2004. Patients were followed for a median of 10.1 years using serial ultrasonography (median, 12 examinations), used to calculate the tumor doubling time. To contextualize tumor growth rates during active surveillance, we calculated the hypothetical tumor doubling time before clinical presentation. To resolve the limitations in tumor doubling time, tumor doubling rates were inversely transformed into doubling rates.

RESULTS

The doubling rates (per year) during active surveillance (median: 0.0) were >0.5, 0.1 to 0.5, -0.1 to 0.1, and <-0.1 in 5, 38, 97, and 29 cases, respectively. The proportions of tumors with rather rapid growth, slow growth, stable, and a decrease in size were 3%, 22%, 57%, and 17%, respectively.

CONCLUSION

Tumor growth of papillary microcarcinomas varies from rather rapid growth to a decrease in size during active surveillance.

Time-action profiles of insulin degludec in healthy dogs and its effects on glycemic control in diabetic dogs

Insulin degludec (IDeg) is a new insulin formulation that facilitates long-term control of glucose level in humans. In this study, we investigated the effects of IDeg on glycemic control in dogs. Its time-action profiles were monitored in healthy dogs using an artificial pancreas apparatus under euglycemic conditions. At 9.0-13.5 hr post-IDeg injection, an indistinct peak of glucose level was detected. Moreover, the action of IDeg was persistent for >20 hr. Both IDeg and neutral protamine Hagedorn insulin (NPH) lowered blood glucose concentrations in diabetic dogs, but IDeg caused postprandial hyperglycemia and a somewhat lower preprandial glucose level than that caused by NPH. IDeg might be ineffective in concurrently preventing postprandial hyperglycemia and preprandial hypoglycemia in a single-agent administration.

Prognostic value of the 8th edition of the tumor-node-metastasis classification for patients with papillary thyroid carcinoma: a single-institution study at a high-volume center in Japan

The tumor-node-metastasis (TNM) staging system is most commonly adopted to evaluate the prognosis of patients with thyroid carcinoma. The 8^th edition of the TNM staging system, an extensively revised version of the 7^th edition, was recently released. We aimed to investigate whether and how well the 8^th edition reflects the cause-specific survival (CSS) of patients with papillary thyroid carcinoma by analyzing the cases in 5,892 patients who underwent initial surgery at Kuma Hospital between 1987 and 2005. The median postoperative follow-up duration was 178 months (range: 6-357 months). One patient with T4b disease was excluded from the analysis. Overall, 116 (2.0%) patients died of thyroid carcinoma. The proportion of variance explained (PVE) for CSS in the 7^th and 8^th editions was 10.69 and 10.97, respectively. Using the 7^th edition, CSS of patients with stage IVA and stage III disease was similar (p = 0.32). In contrast, using the 8^th edition, CSS was poorer in stage II than in stage I (p < 0.001), in stage III than in stage II (p < 0.001), and in stage IVB than in stage III (p < 0.001). Similar results were observed for disease-free survival. Although we could not establish any objective evidence that the 8^th edition is superior to the 7^th edition, the 8^th edition is simpler and more convenient, as it includes fewer stages and addresses the issue of the 7^th edition where stage IVA and III patients had similar prognoses.

Prognostic value of the 8th tumor-node-metastasis classification for follicular carcinoma and poorly differentiated carcinoma of the thyroid in Japan

Follicular thyroid carcinoma (FTC), a form of differentiated thyroid carcinoma, is the second most common malignancy arising from thyroid follicular cells. Recently, the tumor-node-metastasis (TNM) classification for differentiated thyroid carcinoma was revised from the 7^th to the 8^th edition. The diagnostic criteria for poorly differentiated carcinoma (PDC) were also updated in the latest World Health Organization (WHO) classification. In this study, we investigated whether these changes are appropriate for accurately predicting prognosis. Three hundred and twenty-nine patients diagnosed with postoperative pathologically confirmed FTC, who underwent initial surgery at our hospital between 1984 and 2004, were enrolled. For this study, patients were re-evaluated and diagnosed with FTC (N = 285) or PDC (N = 44) without typical nuclear findings of papillary thyroid carcinoma. For FTC, the 8^th TNM classification was a more accurate predictor of prognosis than the 7^th TNM classification. In the 8^th TNM classification, cause-specific survival became significantly poorer from Stage I to IVB. The cause-specific survival of PDC based on the latest WHO classification was worse than, but did not significantly differ from, that of PDC based only on the former WHO classification. For PDC, neither of the TNM classifications could accurately predict prognosis. Taken together, we conclude that (1) the 8^th TNM classification more accurately reflects the prognosis of FTC than the 7^th TNM classification; (2) PDC based on the former WHO classification should be retained, at least in Japan; and (3) the TNM classification may not be suitable for predicting the prognosis of PDC.

Trends in the Implementation of Active Surveillance for Low-Risk Papillary Thyroid Microcarcinomas at Kuma Hospital: Gradual Increase and Heterogeneity in the Acceptance of This New Management Option

BACKGROUND

Active surveillance (AS) of low-risk papillary thyroid microcarcinoma (PMC) was adopted as a management modality in both the Japanese guidelines in 2011 and the American Thyroid Association guidelines in 2015. AS was initiated at Kuma Hospital in 1993 but was not immediately accepted by all physicians. This study investigated the history of acceptance of AS at Kuma Hospital over time. The results should assist in the implementation of AS at other hospitals in Japan and other countries.

METHODS

This study included 4023 patients who were cytologically diagnosed with low-risk PMC at Kuma Hospital during the 24-year period between October 1993 and June 2016. The trend in the frequency of AS use over time was analyzed, dividing the 24-year study period into five parts based on the change in frequency of AS use: 1993-1997, 1998-2002, 2003-2006, 2007-2013, and 2014-2016.

RESULTS

The frequency of AS use in the present cohort was 65%. The frequency gradually increased from 30% in 1993-1997 to 88% in 2014-2016, with a slight decrease from 51% in 1998-2002 to 42% in 2003-2006. Until 2007, patients were mostly seen by surgeons, and the frequency of AS use varied remarkably among individual surgeons. Since 2007, the number of patients whose therapeutic strategies are determined by endocrinologists has increased, and the frequency of AS use for low-risk PMC by endocrinologists has been higher than that by surgeons.

CONCLUSIONS

At Kuma Hospital, acceptance of AS for low-risk PMC gradually increased over the 24-year study period, but AS was not equally accepted by all physicians. Such variations in the acceptance of AS among individual physicians are also expected to exist in other hospitals. However, due to increasing evidence of the safety and superiority of AS over immediate surgery for this indolent disease, it is expected that AS will gain faster acceptance in other hospitals in Japan and around the world.

Effects of Dialysis Membranes on the Kinetics of Tumor Necrosis Factor-α Production by Peripheral Mononuclear Cells in Chronic Hemodialysis Patients

To evaluate the biocompatibility of dialysis membranes, blood samples were collected from 10 hemodialysis patients immediately before dialysis and peripheral blood mononuclear cells were isolated. The 3.0 x 105 cells/ml were then passed 30 times through modules made of a polyethylene glycolgrafted cellulose membrane, a polyacrylonitrile membrane, and a polysulfone membrane. Expression of messenger RNA for tumor necrosi factor-α (TNF-α) was determined. Cells were also cultured for 2 h with and without lipopolysaccharide and TNF-α levels in the supernatant were measured.

TNF-α messenger RNA expression was significantly higher immediately after passage through the polyacrylonitrile membrane compared with the other membranes. Cells cultured without lipopolysaccharide, produced significantly less TNF-α after passage through the polysulfone membrane, while lipopolysaccharide significantly increased TNF-α production by cells passed through the polyacrylonitrile membrane. These results suggest that biocompatibility differs even among dialysis membranes believed to cause no complement activation.

Successful treatment of refractory demodicosis and transient papules with a single dose of fluralaner in a dog with uncontrolled severe endocrine disease

A 12-year-old female Shih-Tzu with hyperadrenocorticism and hypothyroidism developed concurrent refractory generalized demodicosis that did not respond to doramectin treatment. Although amitraz treatment was effective, the dog developed severe diabetes, which resulted in the cessation of amitraz and trilostane. Attempts to control the diabetes were unsuccessful, and its hyperadrenocorticism was left untreated, leading to the recurrence of demodicosis. However, demodicosis went into complete remission with a single dose of fluralaner. Transient erythematous papules appeared on the trunk three days after the administration of fluralaner, but no other adverse reactions were noted. We demonstrated that fluralaner is a potent treatment for demodicosis, and skin eruptions are possible after the first dose of the drug.

Usefulness of Immunoadsorption Therapy for Systemic Lupus Erythematosus Associated with Transverse Myelitis. A Case Report

Transverse myelitis (TM) is a very rare complication of systemic lupus erythematosus (SLE) and its prognosis is poor. It therefore needs to be treated aggressively. We describe a patient suffering from SLE associated with TM, who responded well to a combination of immunoadsorption therapy and steroid mini-pulse therapy. His serum interleukin 6 levels as well as clinical indicators fell to normal after this treatment.

Insights into the Management of Papillary Microcarcinoma of the Thyroid

BACKGROUND

Rapid increases in the incidence of thyroid carcinoma with stable mortality rates from thyroid carcinoma have been reported from many countries, and these increases are thought to be due mostly to the increased detection of small papillary thyroid carcinomas (PTCs), including papillary microcarcinomas (PMCs; i.e., PTCs ≤10 mm). Some researchers have suggested that small PTCs have been overdiagnosed and overtreated. In Japan, the active surveillance of patients with low-risk PMCs was initiated by Kuma Hospital (1993) and Tokyo's Cancer Institute Hospital (1995) based on the extremely higher incidences of both latent thyroid carcinomas in autopsy studies and small PTCs detected in mass screening studies using ultrasound examinations compared to the prevalence of clinical thyroid carcinomas.

METHODS

The above two institutions' data are summarized regarding the active surveillance of low-risk PMCs, and future prospects for their management are discussed.

RESULTS

At 10-year observations in the Kuma Hospital series of 1235 patients, only 8% and 3.8% of the PMC patients showed size enlargement by ≥3 mm and the novel appearance of node metastasis, respectively. In contrast to clinical PTC, PMCs are most unlikely to grow in older patients (≥60 years). In the Kuma Hospital series, the 974 patients who underwent immediate surgery had significantly higher incidences of unfavorable events than the 1179 patients who chose active surveillance. The total cost of immediate surgery, including the costs for salvage surgery and postoperative care for 10 years, was 4.1 times the total cost of 10-year management by active surveillance. Only 8% of the 51 PMC patients showed tumor enlargement during pregnancy, and the rescue surgeries after delivery were successful. In the Cancer Institute Hospital series of 230 patients with 300 lesions, only 7% and 1% of the patients showed size enlargement and novel node metastasis, respectively, and that institution's analysis also revealed that macroscopic or rim calcification and poor vascularity were correlated with non-progressing disease. In both series, none of the patients who underwent rescue surgery after progression signs were detected showed significant recurrence or died of PTC.

CONCLUSION

Active surveillance of low-risk PMC can be the first-line management. Interestingly, older patients with low-risk PMCs are the best candidates for active surveillance.

Estimation of the lifetime probability of disease progression of papillary microcarcinoma of the thyroid during active surveillance

BACKGROUND

We reported that a minority of patients with low-risk papillary microcarcinoma of the thyroid showed disease progression during active surveillance and that older patients had significantly lower disease progression rates than younger patients. Here, we estimated lifetime (≤85 years old) probabilities of disease progression during active surveillance according to the age at presentation based on age decade-specific disease progression rates.

METHODS

From 1993-2013, 1,211 low-risk papillary microcarcinoma patients aged 20-79 years underwent active surveillance at Kuma Hospital. We calculated the disease progression rate at the 10-year point of active surveillance for each age-decade group (20s to 70s) with the Kaplan-Meier method. The lifetime disease progression probability for each age group was calculated as (1 - cumulative probability of progression-free survival calculated with age decade-specific disease progression rates) until the patients reached their 80s (i.e., 85 years on average).

RESULTS

The age decade-specific disease progression rates at 10 years of active surveillance were 36.9% (20s), 13.5% (30s), 14.5% (40s), 5.6% (50s), 6.6% (60s), and 3.5% (70s); the respective lifetime disease progression probabilities were 60.3%, 37.1%, 27.3%, 14.9%, 9.9% and 3.5% according to the age at presentation.

CONCLUSION

The estimated lifetime disease progression probabilities of papillary microcarcinoma during active surveillance vary greatly according to the age at presentation.

Evaluation of newly developed veterinary portable blood glucose meter with hematocrit correction in dogs and cats

This study evaluated the accuracy of a newly developed veterinary portable blood glucose meter (PBGM) with hematocrit correction in dogs and cats. Sixty-one dogs and 31 cats were used for the current study. Blood samples were obtained from each dog and cat one to six times. Acceptable results were obtained in error grid analysis between PBGM and reference method values (glucose oxidation methods) in both dogs and cats. Bland–Altman plot analysis revealed a mean difference between the PBGM value and reference method value of −1.975 mg/dl (bias) in dogs and 1.339 mg/dl (bias) in cats. Hematocrit values did not affect the results of the veterinary PBGM. Therefore, this veterinary PBGM is clinically useful in dogs and cats.

Low-risk papillary microcarcinoma of the thyroid: A review of active surveillance trials

Papillary microcarcinoma (PMC) of the thyroid is defined as papillary thyroid carcinoma (PTC) measuring ≤1 cm. Many autopsy studies on subjects who died of non-thyroidal diseases reported latent small thyroid carcinoma in up to 5.2% of the subjects. A mass screening study for thyroid cancer in Japanese adult women detected small thyroid cancer in 3.5% of the examinees. This incidence was close to the incidence of latent thyroid cancer and more than 1000 times the prevalence of clinical thyroid cancer in Japanese women reported at that time. The question of whether it was correct to treat such PMCs surgically then arose. In 1993, according to Dr. Miyauchi's proposal, Kuma Hospital initiated an active surveillance trial for low-risk PMC as defined in the text. In 1995, Cancer Institute Hospital in Tokyo, Japan, started a similar observation trial. The accumulated data from the trials at these two institutions strongly suggest that active surveillance (i.e., observation without immediate surgery) can be the first-line management for low-risk PMC. Although our data showed that young age and pregnancy might be risk factors of disease progression, we think that these patients can also be candidates for active surveillance, because all of the patients who showed progression signs were treated successfully with a rescue surgery, and none of them died of PTC. In this review, we summarize the data regarding the active surveillance of low-risk PMC as support for physicians and institutions that are considering adopting this strategy.

Comparison of the costs of active surveillance and immediate surgery in the management of low-risk papillary microcarcinoma of the thyroid

The incidence of thyroid cancer is increasing rapidly in many countries, resulting in rising societal costs of the care of thyroid cancer. We reported that the active surveillance of low-risk papillary microcarcinoma had less unfavorable events than immediate surgery, while the oncological outcomes of these managements were similarly excellent. Here we calculated the medical costs of these two managements. We created a model of the flow of these managements, based on our previous study. The flow and costs include the step of diagnosis, surgery, prescription of medicine, recurrence, salvage surgery for recurrence, and care for 10 years after the diagnosis. The costs were calculated according to the typical clinical practices at Kuma Hospital performed under the Japanese Health Care Insurance System. If conversion surgeries were not considered, the 'simple cost' of active surveillance for 10 years was 167,780 yen/patient. If there were no recurrences, the 'simple cost' of immediate surgery was calculated as 794,770 yen/patient to 1,086,070 yen/patient, depending on the type of surgery and postoperative medication. The 'simple cost' of surgery was 4.7 to 6.5 times the 'simple cost' of surveillance. When conversion surgeries and recurrence were considered, the 'total cost' of active surveillance for 10 years became 225,695 yen/patient. When recurrence were considered, the 'total cost' of immediate surgery was 928,094 yen/patient, which was 4.1 times the 'total cost' of the active surveillance. At Kuma Hospital in Japan, the 10-year total cost of immediate surgery was 4.1 times expensive than active surveillance.

Influence of various carbohydrate sources on postprandial glucose, insulin and NEFA concentrations in obese cats

Carbohydrate is an important source of energy, which can significantly affect postprandial blood glucose and insulin levels in cats. In healthy animals, this is not a big concern; however, in obese and diabetic animals, this is an important detail. In the present study, the impact of four different carbohydrate sources (glucose, maltose, corn starch, and trehalose) on short-term post-prandial serum glucose, insulin, and non-esterified fatty acid (NEFA) concentrations was investigated with four obese cats. Each of the carbohydrate sources was added to a commercial wet food diet for feeding the animals. A significant difference was observed in postprandial glucose, insulin, and NEFA area under the curve (AUC) values between each carbohydrate source in obese cats. Furthermore, glucose and maltose induced the highest postprandial glucose and insulin AUC values, whereas trehalose induced the lowest postprandial glucose and insulin AUC value amongst all carbohydrate sources, respectively, in obese cats. However, trehalose has a higher risk of inducing side effects, such as diarrhea, as compared to other carbohydrate sources. As such, different carbohydrate sources appear to have a very significant impact on post-prandial glycemia and subsequent insulin requirement levels in obese cats. These results might be useful when selecting a prescription diet for obese or diabetic cats. In addition, maltose appears to be capable of inducing experimentally evoked postprandial hyperglycemia in obese cats, which may serve as a good tool for use to check the impact and effectiveness of newly developed oral hypoglycemic drugs or supplements for cats in future experiments.

Evaluation of portable blood glucose meters using canine and feline pooled blood samples

This study evaluated the accuracy and reproducibility of a human portable blood glucose meter (PBGM) for canine and feline whole blood. Reference plasma glucose values (RPGV) were concurrently measured using glucose oxidation methods. Fifteen healthy dogs and 6 healthy cats were used for blood sampling. Blood glucose concentrations and hematocrits were adjusted using pooled blood samples for our targeted values. A positive correlation between the PBGM and RPGV was found for both dogs (y = 0.877, x = -24.38, r = 0.9982, n = 73) and cats (y = 1.048, x = -27.06, r = 0.9984, n = 69). Acceptable results were obtained in error grid analysis between PBGM and RPGV in both dogs and cats; 100% of these results were within zones A and B. Following ISO recommendations, a PBGM is considered accurate if 95% of the measurements are within ± 15 mg/dl of the RPGV when the glucose concentration is <100 mg/dl and within ±15% when it is ≥100 mg/dl; however, small numbers of samples were observed inside the acceptable limits for both dogs (11%, 8 of 73 dogs) and cats (39%, 27 of 69 cats). Blood samples with high hematocrits induced lower whole blood glucose values measured by the PBGM than RPGV under hypoglycemic, normoglycemic, and hyperglycemic conditions in both dogs and cats. Therefore, this device is not clinically useful in dogs and cats. New PBGMs which automatically compensate for the hematocrit should be developed in veterinary practice.

Molecular Characterization of the Cytidine Monophosphate-N-Acetylneuraminic Acid Hydroxylase (CMAH) Gene Associated with the Feline AB Blood Group System

Cat’s AB blood group system (blood types A, B, and AB) is of major importance in feline transfusion medicine. Type A and type B antigens are Neu5Gc and Neu5Ac, respectively, and the enzyme CMAH participating in the synthesis of Neu5Gc from Neu5Ac is associated with this cat blood group system. Rare type AB erythrocytes express both Neu5Gc and Neu5Ac. Cat serum contains naturally occurring antibodies against antigens occurring in the other blood types. To understand the molecular genetic basis of this blood group system, we investigated the distribution of AB blood group antigens, CMAH gene structure, mutation, diplotypes, and haplotypes of the cat CMAH genes. Blood-typing revealed that 734 of the cats analyzed type A (95.1%), 38 cats were type B (4.9%), and none were type AB. A family of three Ragdoll cats including two type AB cats and one type A was also used in this study. CMAH sequence analyses showed that the CMAH protein was generated from two mRNA isoforms differing in exon 1. Analyses of the nucleotide sequences of the 16 exons including the coding region of CMAH examined in the 34 type B cats and in the family of type AB cats carried the CMAH variants, and revealed multiple novel diplotypes comprising several polymorphisms. Haplotype inference, which was focused on non-synonymous SNPs revealed that eight haplotypes carried one to four mutations in CMAH, and all cats with type B (n = 34) and AB (n = 2) blood carried two alleles derived from the mutated CMAH gene. These results suggested that double haploids selected from multiple recessive alleles in the cat CMAH loci were highly associated with the expression of the Neu5Ac on erythrocyte membrane in types B and AB of the feline AB blood group system.

Revisiting Low-Risk Thyroid Papillary Microcarcinomas Resected Without Observation: Was Immediate Surgery Necessary?

INTRODUCTION

Low-risk thyroid papillary microcarcinomas (PMCs) without evidence of metastasis grow slowly if at all. However, we recommended surgery for tumors touching the trachea (TR) or located in the course of the recurrent laryngeal nerve (RN). Here we compared the cases of low-risk PMC patients who underwent immediate surgery to cases of TR- and RN-involved PMCs.

MATERIALS AND METHODS

We enrolled 1143 low-risk PMC patients who underwent immediate surgery in the years 2006-2014. The PMCs of 437 patients touched the TR on imaging studies: 270, 104, and 63 were graded as low, intermediate, and high risk, respectively, for TR invasion based on the angles between the tumor and the TR surface. The tumor was in the course of the RN in 144 patients, with 35 graded low risk and 109 high risk for RN invasion based on the normal rim of the thyroid in the direction of the RN.

RESULTS

Invasion of the TR cartilage was observed only in high-risk patients. Peritracheal connective tissue was resected in 21, 15, and 6 of the high-, intermediate- and low-risk patients, respectively. Significant invasion of the RN requiring complete resection was observed in only nine patients at high risk for RN invasion. The incidence of TR invasion in high- and intermediate patients and the incidence of RN invasion in the high-risk patients were significantly higher than those of the low-risk patients. Tumors <7 mm did not show TR or RN invasion.

CONCLUSION

Among PMCs that touched the TR or were located in the course of the RN, observation could be the first choice for tumors < 7 mm and those ≥ 7 mm judged as low risk for TR or RN invasion. However, for PMCs with high-risk features, immediate surgery after cytological diagnosis by a needle aspiration biopsy is recommended.