Detection of dural defect localization using four-dimensional dynamic computed tomography myelography for patients with superficial siderosis

BACKGROUND

There are cases of superficial siderosis (SS) with spinal ventral fluid-filled collection in the spinal canal (VFCC). In our previous study, the balanced steady-state free precession sequence magnetic resonance imaging is useful in identifying the location of dural defects. However, because of its narrow scan area and long scan time, it cannot easily detect the defect location in some patients with small dural defect. In this study, we applied four-dimensional dynamic computed tomography (4DCT) imaging, including time-axis imaging, to myelography using the latest CT imaging equipment, which can perform short-time continuous imaging, to identify the dural defect site.

METHODS

Twenty SS patients with VFCC (9 males, 11 females; mean age 61.6 years) underwent 4DCT myelography (4D-CTM). A 192-row helical CT (SOMATOM Force, SIEMENS) with high-speed scanning capability was used to obtain 9-11 scans per minute at low dose while flowing contrast medium into the subarachnoid space. Then, contrast leakage sites were identified.

RESULTS

The contrast leakage sites could be identified in all 20 cases: C7/Th1, 2 cases; Th1/2, 5 cases; Th2/3, 9 cases; Th3/4, 1 case; Th5/6, 1 case; Th7/8, 1 case; and Th8/9, 1 case. Eighteen cases underwent surgical operation, and actual dural defects were confirmed at the contrast leakage sites. The mean ± standard deviation of leakage time from contrast agent injection was 19.0±9.2 s.

CONCLUSIONS

4D-CTM can be used to reliably identify the location of spinal fluid leakage. In SS cases, dural defects could be visualized in an average of 19 seconds.

Comparison of Postoperative Complications and Outcomes in Anterior Cervical Spine Surgery: Ossification of the Posterior Longitudinal Ligament Versus Cervical Spondylotic Myelopathy

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To compare the frequency of complications and outcomes between patients with ossification of the posterior longitudinal ligament (OPLL) of the cervical spine and those with cervical spondylotic myelopathy (CSM) who underwent anterior surgery.

SUMMARY OF BACKGROUND DATA

Anterior cervical spine surgery for OPLL is an effective surgical procedure; however, it is complex and technically demanding compared with the procedure for CSM. Few reports have compared postoperative complications and clinical outcomes after anterior surgeries between the 2 pathologies.

METHODS

Among 1434 patients who underwent anterior cervical spine surgery at 3 spine centers within the same spine research group from January 2011 to March 2021, 333 patients with OPLL and 488 patients with CSM were retrospectively evaluated. Demographics, postoperative complications, and outcomes were reviewed by analyzing medical records. In-hospital and postdischarge postoperative complications were investigated. Postoperative outcomes were evaluated 1 year after the surgery using the Japanese Orthopaedic Association score.

RESULTS

Patients with OPLL had more comorbid diabetes mellitus preoperatively than patients with CSM ( P <0.001). Anterior cervical corpectomies were more often performed in patients with OPLL than in those with CSM (73.3% and 14.5%). In-hospital complications, such as reoperation, cerebrospinal fluid leak, C5 palsy, graft complications, hoarseness, and upper airway complications, occurred significantly more often in patients with OPLL. Complications after discharge, such as complications of the graft bone/cage and hoarseness, were significantly more common in patients with OPLL. The recovery rate of the Japanese Orthopaedic Association score 1 year postoperatively was similar between patients with OPLL and those with CSM.

CONCLUSION

The present study demonstrated that complications, both in-hospital and after discharge following anterior spine surgery, occurred more frequently in patients with OPLL than in those with CSM.

Action protocol of medical staff for airway obstruction after anterior cervical spine surgery: A systematic review of case reports

BACKGROUND

Postoperative airway obstruction after anterior cervical spine surgery (ACSS) can be a fatal complication. Occasionally, it rapidly progresses to complete obstruction. There are no established standardized protocols on how medical staff should assess for signs and symptoms, seek help, or facilitate airway management after ACSS to prevent unfavorable events. This study aimed to primarily describe a systematic approach by assessing the signs and treatment outcomes of airway compromise in patients who underwent ACSS. Further, it recommended an action protocol after extubation for medical staff according to patients' symptoms to prevent unfavorable outcomes.

METHODS

An extensive literature search was performed on PubMed, Web of Science, and the Cochrane Library to identify case reports, case series, and cohort studies restricted to English and published between January 1990 and March 2023. We included cases that described the signs, symptoms, and treatment of airway obstruction after ACSS. Meanwhile, cases involving complications of other known causes, cases of trauma or occipital-cervical fixation, or those using bone morphogenetic protein were excluded.

RESULTS

Twenty cases from 17 studies were obtained, and their study quality was acceptable. Four patients died, and two presented with hypoxic ischemic encephalopathy. Further, five of six patients had fatal complications that initially developed within 7 h after surgery. Then, 9 (69%) of 13 patients with evidence of hematoma (69%) showed initial symptoms within 12 h after surgery. Finally, 9 of 11 patients with early-stage symptoms had favorable outcomes, and patients who developed late-stage symptoms commonly had unfavorable outcomes.

CONCLUSION

The early identification of signs and symptoms and immediate treatment are important, particularly within 12 h postoperatively. We suggest a novel action protocol for medical staff according to symptom urgency, which includes the measurement of neck circumference using a string for evaluating neck swelling.

Association between skin toxicity and efficacy of necitumumab in squamous non-small-cell lung cancer: a pooled analysis of two randomized clinical trials-SQUIRE and JFCM

BACKGROUND

Efficacy of necitumumab [recombinant human monoclonal antibody that blocks the ligand binding epidermal growth factor receptor (EGFR)] in patients with squamous (SQ) non-small-cell lung cancer (NSCLC) has been confirmed in two randomized clinical trials (SQUIRE and JFCM). This study evaluated the association between efficacy and initial skin toxicity with necitumumab treatment by analyzing pooled data from two clinical trials (SQUIRE and JFCM).

MATERIALS AND METHODS

Data of 635 patients with SQ-NSCLC (intent-to-treat population) treated with necitumumab plus gemcitabine and cisplatin (N + GC) were pooled from two clinical trials (SQUIRE and JFCM). The relationship between skin toxicities developed by the end of the second cycle and efficacy was evaluated. Efficacy endpoints included overall survival (OS), progression-free survival (PFS), and objective response rate (ORR). Univariate and multivariate analyses were carried out for these endpoints.

RESULTS

OS and ORR were associated with skin toxicity, whereas PFS was not. Patients with grade ≥2 or grade 1 skin toxicity had significantly longer OS compared to patients without skin toxicity (grade 0) in the N + GC group [median = 15.0 (grade ≥2); 12.7 (grade 1); 9.4 (grade 0) months; hazard ratio (HR) = 0.51 (grade ≥2 to grade 0); 95% confidence interval (CI) 0.40-0.64, P < 0.001 and HR = 0.64 (grade 1 to grade 0); 95% CI 0.52-0.80, P < 0.001]. In multivariate analysis, OS was significantly associated with skin toxicity.

CONCLUSIONS

A significant association was found between necitumumab-induced skin toxicity and efficacy. These results are consistent with the previously reported association between other EGFR inhibitors-induced skin toxicity and efficacy.

B cell focused transient immune suppression protocol for efficient AAV readministration to the liver

Adeno-associated virus (AAV) vectors are used for correcting multiple genetic disorders. Although the goal is to achieve lifelong correction with a single vector administration, the ability to redose would enable the extension of therapy in cases in which initial gene transfer is insufficient to achieve a lasting cure, episomal vector forms are lost in growing organs of pediatric patients, or transgene expression is diminished over time. However, AAV typically induces potent and long-lasting neutralizing antibodies (NAbs) against capsid that prevents re-administration. To prevent NAb formation in hepatic AAV8 gene transfer, we developed a transient B cell-targeting protocol using a combination of monoclonal Ab therapy against CD20 (for B cell depletion) and BAFF (to slow B cell repopulation). Initiation of immunosuppression before (rather than at the time of) vector administration and prolonged anti-BAFF treatment prevented immune responses against the transgene product and abrogated prolonged IgM formation. As a result, vector re-administration after immune reconstitution was highly effective. Interestingly, re-administration before the immune system had fully recovered achieved further elevated levels of transgene expression. Finally, this immunosuppression protocol reduced Ig-mediated AAV uptake by immune cell types with implications to reduce the risk of immunotoxicities in human gene therapy with AAV.

Latent ion tracks were finally observed in diamond

Injecting high-energy heavy ions in the electronic stopping regime into solids can create cylindrical damage zones called latent ion tracks. Although these tracks form in many materials, none have ever been observed in diamond, even when irradiated with high-energy GeV uranium ions. Here we report the first observation of ion track formation in diamond irradiated with 2-9 MeV C60 fullerene ions. Depending on the ion energy, the mean track length (diameter) changed from 17 (3.2) nm to 52 (7.1) nm. High resolution scanning transmission electron microscopy (HR-STEM) indicated the amorphization in the tracks, in which π-bonding signal from graphite was detected by the electron energy loss spectroscopy (EELS). Since the melting transition is not induced in diamond at atmospheric pressure, conventional inelastic thermal spike calculations cannot be applied. Two-temperature molecular dynamics simulations succeeded in the reproduction of both the track formation under MeV C60 irradiations and the no-track formation under GeV monoatomic ion irradiations.

The Simons Observatory: Cryogenic half wave plate rotation mechanism for the small aperture telescopes

We present the requirements, design, and evaluation of the cryogenic continuously rotating half-wave plate (CHWP) for the Simons Observatory (SO). SO is a cosmic microwave background polarization experiment at Parque Astronómico de Atacama in northern Chile that covers a wide range of angular scales using both small (⌀0.42 m) and large (⌀6 m) aperture telescopes. In particular, the small aperture telescopes (SATs) focus on large angular scales for primordial B-mode polarization. To this end, the SATs employ a CHWP to modulate the polarization of the incident light at 8 Hz, suppressing atmospheric 1/f noise and mitigating systematic uncertainties that would otherwise arise due to the differential response of detectors sensitive to orthogonal polarizations. The CHWP consists of a 505 mm diameter achromatic sapphire HWP and a cryogenic rotation mechanism, both of which are cooled down to ∼50 K to reduce detector thermal loading. Under normal operation, the HWP is suspended by a superconducting magnetic bearing and rotates with a constant 2 Hz frequency, controlled by an electromagnetic synchronous motor. We find that the number of superconductors and the number of magnets that make up the superconducting magnetic bearing are important design parameters, especially for the rotation mechanism's vibration performance. The rotation angle is detected through an angular encoder with a noise level of 0.07 μrad s. During a cooldown process, the rotor is held in place by a grip-and-release mechanism that serves as both an alignment device and a thermal path. In this paper, we provide an overview of the SO SAT CHWP: its requirements, hardware design, and laboratory performance.

Cytocidal Effect of Irradiation on Gastric Cancer Cells Infected with a Recombinant Mammalian Orthoreovirus Expressing a Membrane-Targeted KillerRed

The outcomes of unresectable gastric cancer (GC) are unfavorable even with chemotherapy; therefore, a new treatment modality is required. The combination of an oncolytic virus and photodynamic therapy can be one of the promising modalities to overcome this. Mammalian orthoreovirus (MRV) is an oncolytic virus that has been used in clinical trials for several cancers. In this study, we developed and evaluated a recombinant MRV strain type 3 Dearing (T3D) that expresses membrane-targeting KillerRed (KRmem), a phototoxic fluorescent protein that produces cytotoxic reactive oxygen species upon light irradiation. KRmem was fused in-frame to the 3' end of the σ2 viral gene in the S2 segment using a 2A peptide linker, enabling the expression of multiple proteins from a single transcript. RNA electrophoresis, Western blotting, and immunofluorescence analyses confirmed functional insertion of KRmem into the recombinant virus. The growth activity of the recombinant virus was comparable to that of the wild-type MRV in a cultured cell line. The recombinant virus infected two GC cell lines (MKN45P and MKN7), and a significant cytocidal effect was observed in MKN45P cells infected with the recombinant virus after light irradiation. Thus, recombinant MRV-expressing KRmem has the potential to serve as a novel treatment tool for GC.

Factors Associated With Nonunion After Cervical Fusion Surgery

Background Bony fusion is a critical factor in the outcome of cervical spinal fusion surgery. While several factors have been proposed to affect bony fusion, their relative importance remains unclear. This study aimed to investigate the factors associated with bony fusion after cervical spinal fusion surgery. Methods We retrospectively evaluated the significance of the various factors on bone fusion after cervical fusion surgery. Then, multivariate logistic regression analyses were performed to determine the independent factors associated with bony fusion. A receiver operating characteristic (ROC) analysis was performed to evaluate the cutoff threshold. Results This study included a total of 52 patients with a mean age of 64 years. Among them, 28 (54%) were male, and 39 (75.0%) achieved bony fusion. The multivariate logistic regression analysis showed that preoperative intact parathyroid hormone (PTH) levels (odds ratio, 1.04; 95% confidence interval, 1.01-1.08; p-value = 0.02) and hemoglobin A1c (HbA1c) levels (odds ratio, 2.87; 95% confidence interval, 1.07-8.74; p-value = 0.04) were significant factors associated with bony fusion after cervical fusion surgery. The optimum cutoff values of intact PTH and HbA1c were 63.5 pg/mL and 6.2%, respectively. Conclusions This study identified preoperative intact PTH and HbA1c as significant factors associated with bony fusion after cervical fusion surgery. These biomarkers can be used to identify patients at higher risk of nonunion to optimize patient conditions and guide preoperative and postoperative management strategies.

Predictors for onset of extended-spectrum beta-lactamase-producing Escherichia coli-induced bacteraemia: a systematic review and meta-analysis

Extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli bacteraemia can induce unfavourable clinical outcomes due to delay in appropriate antimicrobial treatment and limited therapeutic options. Therefore, elucidating the predictors of ESBL-producing E. coli-induced bacteraemia is crucial to improve clinical outcomes. However, a literature search did not reveal any studies that incorporate a meta-analysis of the predictors of ESBL-producing E. coli-induced bacteraemia. As such, this review was undertaken to assess current evidence on the predictors of ESBL-producing E. coli-induced bacteraemia. PubMed, Web of Science and Cochrane Library databases were searched for all relevant publications from January 2000 to September 2021. This systematic review evaluated 10 observational studies, comprising a total of 2325 patients with E. coli-induced bacteraemia and 850 (36.6%) ESBL-producing strains. In the meta-analysis, previous antibiotic therapy [pooled risk ratio (RR) 2.72; P<0.001], especially with cephalosporins (pooled RR 4.66; P<0.001) and quinolones (pooled RR 5.47; P<0.001), and urinary catheter use (pooled RR 3.79; P<0.001) were predictive of ESBL-producing E. coli-induced bacteraemia. Antibiotic therapy for patients with the above-mentioned risk factors should be selected considering the possibility of ESBL-producing E. coli-induced bacteraemia compared with non-ESBL-producing E. coli-induced bacteraemia. It is important to elucidate whether appropriate modulation of the identified risk factors can potentially mitigate the risk of ESBL-producing E. coli-induced bacteraemia compared with non-ESBL-producing E. coli-induced bacteraemia.

5-Aminolevulinic acid/sodium ferrous citrate improves the quality of heat-stressed bovine oocytes by reducing oxidative stress

A high temperature-humidity index during summer has deleterious effects on mitochondrial function, reducing oocyte developmental competence. 5-Aminolevulinic acid (5-ALA) and sodium ferrous citrate (SFC) are both known to support mitochondrial function and have strong anti-oxidant and anti-apoptotic activities. This study aimed to determine the mechanism of action of 5-ALA/SFC on oocyte quality. Bovine oocytes were collected from medium-sized follicles during summer (July-September, temperature-humidity index:76.6), cultured with 0, 1, 2, 4, and 8 µM 5-ALA with SFC at a molar ratio of 1:0.125, fertilized, and cultured for 10 days. The addition of 8/1 µM 5-ALA/SFC had a deleterious effect on oocyte cleavage rate in comparison with control oocytes, but did not affect the blastocyst rate, while 1/0.125 µM 5-ALA/SFC had a significantly higher increase in blastocyst rate than 8/1 µM 5-ALA/SFC. The addition of 1/0.125 and 2/0.25 µM 5-ALA/SFC improved oocyte quality by increasing the mitochondrial distribution pattern and metaphase-II oocytes, reducing reactive oxygen species and upregulating nuclear factor erythroid-2-related factor 2, heme oxygenase-1, and superoxide dismutase-1 in oocytes, and nuclear factor erythroid-2-related factor 2 and mitochondrial transcription factor A in cumulus cells. These results indicate that 1/0.125 and 2/0.25 µM 5-ALA/SFC may support oocyte quality and developmental competence and provide anti-oxidant actions in cumulus-oocyte complexes.

Risk Factors for Postoperative Unfavorable Ambulatory Status After Spinal Surgery for Metastatic Spinal Tumor

STUDY DESIGN

A retrospective comparative study.

OBJECTIVE

This study aimed to investigate factors associated with postoperative unfavorable ambulatory status following surgery for metastatic spinal tumors using a nationwide in-hospital database.

SUMMARY OF BACKGROUND DATA

Surgical treatment for metastatic spinal tumors can improve the ambulatory status and quality of life. However, some patients fail to regain the ability to walk, thereby resulting in poor quality of life. No large-scale study has previously evaluated factors associated with postoperative poor ambulatory status in this clinical context.

MATERIALS AND METHODS

The Diagnosis Procedure Combination database from 2018 to 2019 was used to extract data from patients who underwent surgical procedures for spinal metastasis. Postoperative unfavorable ambulatory status was defined as (1) nonambulatory at discharge or (2) a decreased mobility score of the Barthel Index between admission and discharge. Multivariable logistic regression was used to evaluate factors associated with postoperative unfavorable ambulatory status while adjusting for confounders.

RESULTS

This study analyzed 1786 eligible patients. Of whom, 1061 (59%) patients were ambulatory on admission and 1249 (70%) on discharge. Postoperative unfavorable ambulatory status was observed in 597 (33%) patients, with a significantly lower rate of discharge to home (41%/81%, P <0.001) and a longer postoperative hospital stay (46.2 days/31.4 days, P <0.001). Multivariable regression analysis revealed male sex [odds ratio (OR): 1.43, P =0.002], laminectomy without fusion (OR: 1.55, P =0.034), Charlson Comorbidity Index of ≥7 (OR: 1.37, P =0.014), and preoperative nonambulatory status (OR: 6.61, P <0.001) as factors associated with postoperative unfavorable ambulatory status.

CONCLUSIONS

Our large-scale database analysis revealed that 33% of patients experienced unfavorable ambulatory status following spinal metastasis surgery. Laminectomy without fusion and preoperative nonambulatory status were among several factors influencing the prospect of unfavorable ambulatory status following surgery.

Quality of Palliative Radiation Therapy Assessed Using Quality Indicators: A Multicenter Survey

PURPOSE/OBJECTIVE(S)

Clinical practice is not always performed in accordance with guideline recommendations. Quality indicators (QIs) are valuable tools for evaluating the quality of healthcare systems. We sought to identify potential gaps between clinical practice and evidence using QIs previously developed using a modified Delphi method.

MATERIALS/METHODS

We used seven QIs (Table 1) to assess the quality of radiation therapy for bone (BoM) and brain metastases (BrM) at 29 centers; 13 (45%) were academic (12 university hospitals and 1 cancer center) and 16 (55%) were nonacademic hospitals. Compliance rate was calculated as the percentage of patients for whom recommended medical care was conducted. Random effects models were used to estimate pooled compliance rates. Mixed effects models with a Q test were used to compare compliance rates between academic and nonacademic centers.

RESULTS

The estimates of the compliance rates with 95% confidence intervals are presented in Table 1. For BoM-1, the compliance rate was higher in academic hospitals (100% [100-100%]) than in non-academic hospitals (96% [89-100%]) (P = 0.021). For BrM-3, the compliance rate was lower in academic hospitals (92% [81-99%]) than in nonacademic hospitals (100% [98-100%]) (P = 0.016).

CONCLUSION

A quality assessment based on these seven QIs is feasible. Overall, compliance rates were high; however, for BoM-3, the practice remains to be improved in some centers. Based on BoM-4 compliance rates, steroids are infrequently used concurrently with radiation therapy for malignant spinal cord compression. Extended fractionation for BoM was less frequently performed in academic than in nonacademic centers. The initiation of radiation therapy for brain metastases was more frequently delayed in academic than in nonacademic centers.

Effect of vitamin D deficiency on surgical outcomes of degenerative cervical myelopathy

Background

Due to its association with bone metabolic status and muscle strength/mass, vitamin D deficiency has the potential to affect neurological symptom recovery after surgery for degenerative cervical myelopathy (DCM). However, few studies have investigated the effects of vitamin D deficiency (serum 25(OH)D <20 ng/mL) on surgical outcomes in DCM patients. Herein, we investigated the prevalence of vitamin D deficiency in patients with DCM, and determined whether vitamin D deficiency affects surgical outcomes for DCM.

Methods

In this retrospective observational study we assessed the recovery rate 1 year after surgery in 91 patients diagnosed with DCM who underwent surgery. First, we analyzed the correlation between vitamin D levels and various background factors. Then, patients were divided into 2 groups according to vitamin D sufficiency, and univariate analysis was performed on vitamin D and surgical outcomes. Finally, Spearman correlation analyses were performed to identify factors correlated with recovery rate after surgery for DCM.

Results

The average Japanese Orthopedic Association score for the assessment of cervical myelopathy (C-JOA score) improved postoperatively. Age was positively correlated with vitamin D levels, and parathyroid hormone levels were negatively correlated with vitamin D levels. Among the 91 patients, 79.1% of patients were diagnosed with vitamin D deficiency. No significant differences in recovery rate were found between the vitamin D-deficient and vitamin D-sufficient groups. Finally, the Spearman correlation analysis showed a positive correlation between the preoperative C-JOA motor dysfunction score in the lower extremities and the recovery rate, while age demonstrated a negative correlation with recovery rate.

Conclusions

No association was found between vitamin D deficiency and clinical outcomes after surgery for DCM. The results of this study do not support the need to normalize vitamin D levels for achieving neurological improvements in patients with DCM.

Double-Barrel Nitinol Stent Placement for Iliocaval Reconstruction: The Effect of Deployment Sequence and Direction on Final Configuration

Double-barrel stent placement across the iliocaval confluence is commonly used for the treatment of chronic bilateral iliocaval occlusion. The difference in the deployment outcomes of synchronous parallel stent deployment versus asynchronous or antiparallel deployment and the underlying stent interactions are poorly understood. In this study, 3 strategies of double-barrel nitinol self-expanding stent deployment across the iliocaval confluence (synchronous parallel, asynchronous parallel, and synchronous antiparallel) were contrasted in vivo in 3 swine followed by assessment of the explanted stent construct. Synchronous parallel stent deployment achieved a desired double-barrel configuration. The asynchronous parallel and antiparallel deployment strategies both resulted in a crushed stent despite subsequent simultaneous balloon angioplasty. These animal model results suggested that in patients who undergo double-barrel iliocaval reconstruction, synchronous parallel stent deployment may provide the desired stent conformation and increase the chance for clinical success.

The lower Osteotomy Level is Associated With Decreased Revision Surgery Due to Mechanical Complications After Three-Column Osteotomy in Patients With Adult Spinal Deformity: A Multi-Institutional Retrospective Study

STUDY DESIGN

A multi-institutional retrospective study.

OBJECTIVES

To investigate risk factors of mechanical failure in three-column osteotomy (3COs) in patients with adult spinal deformity (ASD), focusing on the osteotomy level.

METHODS

We retrospectively reviewed 111 patients with ASD who underwent 3COs with at least 2 years of follow-up. Radiographic parameters, clinical data on early and late postoperative complications were collected. Surgical outcomes were compared between the low-level osteotomy group and the high-level osteotomy group: osteotomy level of L3 or lower group (LO group, n = 60) and osteotomy of L2 or higher group (HO group, n = 51).

RESULTS

Of the 111 patients, 25 needed revision surgery for mechanical complication (mechanical failure). A lower t-score (odds ratio [OR] .39 P = .002) and being in the HO group (OR 4.54, P = .03) were independently associated with mechanical failure. In the analysis divided by the osteotomy level (LO and HO), no difference in early complications or neurological complications was found between the two groups. The rates of overall mechanical complications, rod failure, and mechanical failure were significantly higher in the HO group than in the LO group. After propensity score matching, mechanical complications and failures were still significantly more observed in the HO group than in the LO group (P = .01 and .029, respectively).

CONCLUSIONS

A lower t-score and osteotomy of L2 or higher were associated with increased risks of mechanical failure. Lower osteotomy was associated with better correction of sagittal balance and a lower rate of mechanical complications.

Renal tubular acidosis without interstitial nephritis in Sjögren's syndrome: a case report and review of the literature

BACKGROUND

Renal tubular acidosis is the principal clinical feature associated with tubulointerstitial nephritis in patients with primary Sjögren's syndrome. Renal tubular dysfunction due to interstitial nephritis has been considered the underlying pathophysiology connecting renal tubular acidosis and primary Sjögren's syndrome. However, the detailed mechanisms underlying the pathophysiology of renal tubular acidosis in primary Sjögren's syndrome is not fully understood.

CASE PRESENTATION

A 30-year-old woman was admitted with complaints of weakness in the extremities. The patient was hospitalized thirteen years earlier for similar issues and was diagnosed with hypokalemic paralysis due to distal renal tubular acidosis with primary Sjögren's syndrome. This diagnosis was based on a positive Schirmer's test. Besides, anti-Sjögren's syndrome-related antigen A was also detected. Laboratory tests indicated distal RTA; however, a renal biopsy showed no obvious interstitial nephritis. Laboratory tests conducted during the second admission indicated distal renal tubular acidosis. Therefore, a renal biopsy was performed again, which revealed interstitial nephritis. Histological analysis of acid-base transporters revealed the absence of vacuolar type H+-ATPases in the collecting duct. The vacuolar type H+-ATPase was also absent in the past renal biopsy, suggesting that the alteration in acid-base transporters is independent of interstitial nephritis.

CONCLUSIONS

This case study demonstrates that vacuolar-type H+-ATPases are associated with distal renal tubular acidosis, and distal renal tubular acidosis precedes interstitial nephritis in patients with primary Sjögren's syndrome.

A decision tree analysis to predict clinical outcome of minimally invasive lumbar decompression surgery for lumbar spinal stenosis with and without coexisting spondylolisthesis and scoliosis

BACKGROUND CONTEXT

Implementing machine learning techniques, such as decision trees, known as prediction models that use logical construction diagrams, are rarely used to predict clinical outcomes.

PURPOSE

To develop a clinical prediction rule to predict clinical outcomes in patients who undergo minimally invasive lumbar decompression surgery for lumbar spinal stenosis with and without coexisting spondylolisthesis and scoliosis using a decision tree model.

STUDY DESIGN/SETTING

A retrospective analysis of prospectively collected data.

PATIENT SAMPLE

This study included 331 patients who underwent minimally invasive surgery for lumbar spinal stenosis and were followed up for ≥2 years at 1 institution.

OUTCOME MEASURES

Self-report measures: The Japanese Orthopedic Association (JOA) scores and low back pain (LBP)/leg pain/leg numbness visual analog scale (VAS) scores. Physiologic measures: Standing sagittal spinopelvic alignment, computed tomography, and magnetic resonance imaging results.

METHODS

Low achievement in clinical outcomes were defined as the postoperative JOA score at the 2-year follow-up <25 points. Univariate and multiple logistic regression analysis and chi-square automatic interaction detection (CHAID) were used for analysis.

RESULTS

The CHAID model for JOA score <25 points showed spontaneous numbness/pain as the first decision node. For the presence of spontaneous numbness/pain, sagittal vertical axis ≥70 mm was selected as the second decision node. Then lateral wedging, ≥6° and pelvic incidence minus lumbar lordosis (PI-LL) ≥30° followed as the third decision node. For the absence of spontaneous numbness/pain, sex and lateral olisthesis, ≥3mm and American Society of Anesthesiologists physical status classification system score were selected as the second and third decision nodes. The sensitivity, specificity, and the positive predictive value of this CHAID model was 65.1, 69.8, and 64.7% respectively.

CONCLUSIONS

The CHAID model incorporating basic information and functional and radiologic factors is useful for predicting surgical outcomes.

β Cell microRNAs Function as Molecular Hubs of Type 1 Diabetes Pathogenesis and as Biomarkers of Diabetes Risk

MicroRNAs (miRNAs) are small non-coding RNAs that play a crucial role in modulating gene expression and are enriched in cell-derived extracellular vesicles (EVs). We investigated whether miRNAs from human islets and islet-derived EVs could provide insight into β cell stress pathways activated during type 1 diabetes (T1D) evolution, therefore serving as potential disease biomarkers. We treated human islets from 10 cadaveric donors with IL-1β and IFN-γ to model T1D ex vivo. MicroRNAs were isolated from islets and islet-derived EVs, and small RNA sequencing was performed. We found 20 and 14 differentially expressed (DE) miRNAs in cytokine- versus control-treated islets and EVs, respectively. Interestingly, the miRNAs found in EVs were mostly different from those found in islets. Only two miRNAs, miR-155-5p and miR-146a-5p, were upregulated in both islets and EVs, suggesting selective sorting of miRNAs into EVs. We used machine learning algorithms to rank DE EV-associated miRNAs, and developed custom label-free Localized Surface Plasmon Resonance-based biosensors to measure top ranked EVs in human plasma. Results from this analysis revealed that miR-155, miR-146, miR-30c, and miR-802 were upregulated and miR-124-3p was downregulated in plasma-derived EVs from children with recent-onset T1D. In addition, miR-146 and miR-30c were upregulated in plasma-derived EVs of autoantibody positive (AAb+) children compared to matched non-diabetic controls, while miR-124 was downregulated in both T1D and AAb+ groups. Furthermore, single-molecule fluorescence in situ hybridization confirmed increased expression of the most highly upregulated islet miRNA, miR-155, in pancreatic sections from organ donors with AAb+ and T1D.

Development of a Real-Time RT-PCR System Applicable for Rapid and Pen-Side Diagnosis of Foot-and-Mouth Disease Using a Portable Device, PicoGene® PCR1100

Foot-and-mouth disease (FMD) is a highly contagious viral vesicular disease, causing devastating losses to the livestock industry. A diagnostic method that enables quick decisions is required to control the disease, especially in FMD-free countries. Although conventional real-time reverse transcription polymerase chain reaction (RT-PCR) is a highly sensitive method widely used for the diagnosis of FMD, a time lag caused by the transport of samples to a laboratory may allow the spread of FMD. Here, we evaluated a real-time RT-PCR system using a portable PicoGene PCR1100 device for FMD diagnosis. This system could detect the synthetic FMD viral RNA within 20min with high sensitivity compared with a conventional real-time RT-PCR. Furthermore, the Lysis Buffer S for crude nucleic extraction improved the viral RNA detection of this system in a homogenate of vesicular epithelium samples collected from FMD virus-infected animals. Furthermore, this system could detect the viral RNA in crude extracts prepared using the Lysis Buffer S from the vesicular epithelium samples homogenized using a Finger Masher tube, which allows easy homogenization without any equipment, with a high correlation compared to the standard method. Thus, the PicoGene device system can be utilized for the rapid and pen-side diagnosis of FMD. (199 words).

A Novel Non-invasive Qualitative Assay Using Urinary Fluorescence Imaging to Assess Kidney Disease

In patients with chronic kidney disease, it is necessary to identify the etiology of glomerular disease. Renal biopsy is the gold standard for assessing the underlying pathology; however, it has the risk of potential complications. We have established a urinary fluorescence imaging technique to assess enzymatic activity using an activatable fluorescent probe targeting two enzymes: gamma-glutamyl transpeptidase and dipeptidyl-peptidase. The urinary fluorescence images can be easily obtained by adding an optical filter to the microscope with short incubation of the fluorescent probes. Urinary fluorescence imaging could help to assess underlying etiologies of kidney diseases and is a potential non-invasive qualitative assessment technique for kidney diseases in patients with diabetes. Key features Non-invasive assessment of kidney disease. Urinary fluorescent imaging with enzyme-activatable fluorescent probes. Enables differentiation of diabetic kidney disease and glomerulonephritis.

Transarterial ethiodised oil marking before CT-guided renal cryoablation: evaluation of tumour visibility in various renal cell carcinoma subtypes

AIM

To evaluate ethiodised oil retention of transarterial embolisation using ethiodised oil (ethiodised oil marking) before computed tomography (CT)-guided percutaneous cryoablation (PCA) according to renal cell carcinoma (RCC) subtype.

MATERIALS AND METHODS

Ethiodised oil marking was performed 1-3 days before PCA in 99 patients with 99 RCCs from 2016 to 2020. Ethiodised oil retention on CT images was evaluated retrospectively and CT attenuation values in the tumour were measured. Regions of interest (ROI) were placed on the tumours to calculate: average (ROI-average), maximal (ROI-max), minimum (ROI-min), and standard deviation (ROI-SD). Qualitative scores comprising a five-point scale (5, excellent; 1, poor) were evaluated for the retention scores (RS) of ethiodised oil in the tumour (ethiodised oil-RS) and the visualisation scores (VS) of the boundary between the tumour and renal parenchyma (boundary-VS).

RESULTS

The histological subtypes comprised clear cell (ccRCC; n=85), papillary (pRCC; n=6), and chromophobe/oncocytoma renal cell carcinoma (chrRCC; n=8). The mean ROI-average, ROI-max, and ROI-SD were significantly higher in ccRCCs than in chrRCCs and pRCCs (p<0.05). The mean ethiodised oil-RS was significantly lower in pRCCs than in ccRCCs (p=0.039), and the mean boundary-VS was >4 in all subtypes. Even with poor intratumour ethiodised oil retention (n=6), sufficient boundary-VS was obtained due to "inverted marking." All PCA procedures were completed without additional intravenous contrast material injection at the time of PCA.

CONCLUSION

Regardless of the tumour subtypes, ethiodised oil marking aids in visualising the boundary between the tumour and parenchyma on non-contrast CT in PCA.

REBOA Zone Estimation from the Body Surface Using Semantic Segmentation

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular procedure for hemorrhage control. In REBOA, the balloon must be placed in the precise place, but it may be performed without X-ray fluoroscopy. This study aimed to estimate the REBOA zones from the body surface using deep learning for safe balloon placement. A total of 198 abdominal computed tomography (CT) datasets containing the regions of the REBOA zones were collected from open data libraries. Then, depth images of the body surface generated from the CT datasets and the images corresponding to the zones were labeled for deep learning training and validation. DeepLabV3+, a deep learning semantic segmentation model, was employed to estimate the zones. We used 176 depth images as training data and 22 images as validation data. A nine-fold cross-validation was performed to generalize the performance of the network. The median Dice coefficients for Zones 1-3 were 0.94 (inter-quarter range: 0.90-0.96), 0.77 (0.60-0.86), and 0.83 (0.74-0.89), respectively. The median displacements of the zone boundaries were 11.34 mm (5.90-19.45), 11.40 mm (4.88-20.23), and 14.17 mm (6.89-23.70) for the boundary between Zones 1 and 2, between Zones 2 and 3, and between Zone 3 and out of zone, respectively. This study examined the feasibility of REBOA zone estimation from the body surface only using deep learning-based segmentation without aortography.

Molecular Analysis of Rabies Virus Using RNA Extracted from Used Lateral Flow Devices

Molecular analysis of rabies virus can provide accurate diagnosis and information on its genetic diversity. The transportation of rabies brain samples from remote areas to a central laboratory is challenging owing to biohazard risks and decomposability. We investigated the utility of used lateral flow devices (LFDs) for subsequent molecular analysis and assessed the necessary storage temperatures. Using RNA extracted from used LFD strips, we performed conventional reverse transcription-PCR (RT-PCR) using an LN34 primer set to amplify short fragments (165 bp) for rabies virus detection and the P1-304 primer set to amplify long fragments of the entire N gene amplicon (1,506 bp) for phylogenetic analysis. Among 71 used LFDs stored in a refrigerator and 64 used LFDs stored at room temperature, the LN34 assay showed high sensitivities (96.2% and 100%, respectively) for the diagnosis of rabies, regardless of the storage temperature. A significant reduction in the sensitivity of rabies diagnosis was observed when using the P1-304 primer set for used LFDs stored at room temperature compared to those stored at refrigeration temperature (20.9% versus 100%; P < 0.05). Subsequent sequencing and phylogenetic analysis were successfully performed using the amplicons generated by the P1-304 RT-PCR assays. Used LFDs are thus promising resources for rabies virus RNA detection and sequence analysis. Virus detection via RT-PCR, amplifying a short fragment, was possible regardless of the storage temperature of the used LFDs. However, refrigerated storage is recommended for RT-PCR amplification of long fragments for phylogenetic analysis.

Nosocomial Severe Fever with Thrombocytopenia Syndrome in Companion Animals, Japan, 2022

In Japan, 2 cats that underwent surgery in a room where a sick dog had been euthanized became ill within 9 days of surgery. Severe fever with thrombocytopenia syndrome virus was detected in all 3 animals; nucleotide sequence identity was 100%. Suspected cause was an uncleaned pulse oximeter probe used for all patients.

Suppression of anti-drug antibody formation against coagulation factor VIII by oral delivery of anti-CD3 monoclonal antibody in hemophilia A mice

Active tolerance to ingested dietary antigens forms the basis for oral immunotherapy to food allergens or autoimmune self-antigens. Alternatively, oral administration of anti-CD3 monoclonal antibody can be effective in modulating systemic immune responses without T cell depletion. Here we assessed the efficacy of full length and the F(ab')2 fragment of oral anti-CD3 to prevent anti-drug antibody (ADA) formation to clotting factor VIII (FVIII) protein replacement therapy in hemophilia A mice. A short course of low dose oral anti-CD3 F(ab')2 reduced the production of neutralizing ADAs, and suppression was significantly enhanced when oral anti-CD3 was timed concurrently with FVIII administration. Tolerance was accompanied by the early induction of FoxP3+LAP-, FoxP3+LAP+, and FoxP3-LAP+ populations of CD4+ T cells in the spleen and mesenteric lymph nodes. FoxP3+LAP+ Tregs expressing CD69, CTLA-4, and PD1 persisted in spleens of treated mice, but did not produce IL-10. Finally, we attempted to combine the anti-CD3 approach with oral intake of FVIII antigen (using our previously established method of using lettuce plant cells transgenic for FVIII antigen fused to cholera toxin B (CTB) subunit, which suppresses ADAs in part through induction of IL-10 producing FoxP3-LAP+ Treg). However, combining these two approaches failed to improve suppression of ADAs. We conclude that oral anti-CD3 treatment is a promising approach to prevention of ADA formation in systemic protein replacement therapy, albeit via mechanisms distinct from and not synergistic with oral intake of bioencapsulated antigen.

Seroprevalence of severe fever with thrombocytopenia syndrome virus in medium-sized wild mammals in Miyazaki, Japan

Severe fever with thrombocytopenia syndrome (SFTS) is a fatal emerging tick-borne zoonotic disease caused by the SFTS virus (SFTSV). SFTSV infection in humans and companion animals is a matter of concern in endemic areas. Various wild animals are involved in the transmission cycle of SFTSV with vector ticks. Because the home range of medium-sized wild mammals commonly overlaps with humans' living spheres, this study aimed to reveal the endemicity of SFTSV in such mammals. This study investigated the prevalence of antibodies against SFTSV and viral RNA in medium-sized wild mammals in Miyazaki Prefecture, Japan where human cases have been most frequently reported in Japan and performed a phylogenetic analysis to compare the detected SFTSV with those previously reported. Forty-three of 63 (68%) Japanese badgers (Meles anakuma) and 12 of 53 (23%) Japanese raccoon dogs (Nyctereutes procyonoides viverrinus) had antibodies against SFTSV. Japanese marten (n = 1), weasels (n = 4), and Japanese red fox (n = 1) were negative. Two of 63 (3%) badgers tested positive for SFTSV RNA, whereas the other species were negative. Phylogenetic analysis of the partial nucleotide sequence of SFTSV revealed that viral RNA detected from badgers exhibited 99.8% to 100% similarity to SFTSV, as previously reported in humans, cat, and ticks in the study area. This study demonstrated high seropositivity of antibodies in medium-sized wild mammals and suggested that SFTSV could be shared among these mammals, humans, and companion animals in endemic areas.

Predictors of hypervirulent Klebsiella pneumoniae infections: a systematic review and meta-analysis

BACKGROUND

Hypervirulent Klebsiella pneumoniae (hvKp) infections confer notable morbidity and mortality. Differential diagnosis to determine whether the infections are caused by either the hvKp or classical K. pneumoniae (cKp) strain is particularly important for undertaking optimal clinical care and infection control efforts.

AIM

To identify and assess the potential predictors of hvKp infections.

METHODS

PubMed, Web of Science, and Cochrane Library databases were searched for all relevant publications from January 2000 to March 2022. The search terms included a combination of the following terms: (i) Klebsiella pneumoniae or K. pneumoniae and (ii) hypervirulent or hypervirulence. A meta-analysis of factors for which risk ratio was reported in three or more studies was conducted, and at least one statistically significant association was identified.

FINDINGS

In this systematic review of 11 observational studies, a total of 1392 patients with K. pneumoniae infection and 596 (42.8%) with hvKp strains were evaluated. In the meta-analysis, diabetes mellitus and liver abscess (pooled risk ratio: 2.61 (95% confidence interval: 1.79-3.80) and 9.04 (2.58-31.72), respectively; all P < 0.001) were predictors of hvKp infections.

CONCLUSION

For patients with a history of the abovementioned predictors, prudent management, including the search for multiple sites of infection and/or metastatic spread and the enforcement of an early and appropriate source control procedure, should be initiated in consideration of the potential presence of hvKp. We believe that this research highlights the urgent need for increasing clinical awareness of the management of hvKp infections.

Possible transmission of severe fever with thrombocytopenia syndrome virus (SFTSV) to a person who buried the corpus of a dead cat, which died of SFTSV infection

Severe fever with thrombocytopenia syndrome virus (SFTSV) is a causative agent of SFTS. Although SFTS is a fatal tick-borne zoonosis, the virus can infect humans without tick bite exposure. Recently, direct SFTSV transmission from companion pets to humans has become a significant problem. Herein, we reported a case of SFTSV transmission from a dead community cat to a woman who buried the cat in Miyazaki prefecture, Japan. The community cat died without a diagnosis of SFTS, and the woman buried it without precaution. Nine days later, the woman developed symptoms of SFTS. SFTS viral RNA and anti-SFTSV antibodies were detected in the woman. The animal carcass was exhumed, and tissue samples were collected to confirm viral infection in the cat. High copy numbers of viral RNA were detected. Sequences of the SFTSV M segment in samples from the cat and the woman showed 100% homology. The woman stated that she had touched blood that had leaked from the body when she buried it. On the other hand, the woman could have been infected when she took the cat to the animal hospital. This study highlights the risk of SFTSV infection via contact with sick or dead community cats.

Fine Particle Adsorption Capacity of Volcanic Soil from Southern Kyushu, Japan

"Akahoya" is a volcanic soil classified as a special soil deposited in Kyushu, Japan. Many of its properties are not yet clearly understood. We found that Akahoya had the potential to adsorb bacteria in cattle feces, which prompted us to investigate its material properties and perform experiments to comprehensively evaluate its adsorption performance for various fine particles such as acidic and basic dyes, NO_x/SO_x gas, and phosphoric acid ions, in addition to bacteria. Akahoya had a very high specific surface area owing to the large number of nanometer-sized pores in its structure; it exhibited a high adsorption capacity for both NO₂ and SO₂. Regarding the zeta potential of Akahoya, the point of zero charge was approximately pH 7.0. The surface potential had a significant effect on the adsorption of acidic and basic dyes. Akahoya had a very high cation exchange capacity when the sample surface was negatively charged and a high anion exchange capacity when the sample surface was positively charged. Akahoya also exhibited a relatively high adsorption capacity for phosphoric acid because of its high level of Al₂O₃, and the immersion liquid had a very high Al ion concentration. Finally, filtration tests were performed on Escherichia coli suspension using a column filled with Akahoya or another volcanic soil sample. The results confirmed that the Escherichia coli adhered on the Akahoya sample. The results of the Escherichia coli release test, after the filtration test, suggested that this adhesion to Akahoya could be phosphorus-mediated.

Implications of the antiviral drug favipiravir on rabies immunoglobulin for post-exposure prophylaxis of rabies in mice model with category III-like exposures

Rabies is a fatal zoonotic disease caused by the rabies virus (RABV), with almost 100% mortality if proper post-exposure prophylaxis (PEP), consisting of rabies immunoglobulin (RIG) and rabies vaccine, is not applied in a timely manner. However, this is challenged by the limited availability of RIG, especially in resource-constrained countries. In this study, we assessed the scope of the antiviral drug favipiravir to treat rabies-infected mice as an alternative to RIG. Category III-like wounds were induced in RABV-challenged mice treated with favipiravir instead of RIG in the PEP regimen. The use of favipiravir followed by rabies vaccine provided complete protection against rabies-related death in 100% of mice, even after RABV propagated to the central nervous system during infection. Additionally, the virus-neutralizing antibody titer in the favipiravir and vaccine group was significantly higher than that of the RIG and vaccine recipients. The use of favipiravir with rabies vaccine seemingly prevents fatal outcomes and even rescues the cases that already express clinical symptoms. A clinical trial of this approach is warranted, especially in countries with low RIG availability.

Predicting the Readmission and Mortality in Older Patients Hospitalized with Pneumonia with Preadmission Frailty

BACKGROUND

In older people, frailty has been recognized as an important prognostic factor. However, only a few studies have focused on multidimensional frailty as a predictor of mortality and readmission among inpatients with pneumonia.

OBJECTIVE

The present study aimed to assess the association between preadmission frailty and clinical outcomes after the hospitalization of older patients with pneumonia.

DESIGN

Single-center, retrospective case-control study.

SETTING

Acute phase hospital at Kobe, Japan.

PARTICIPANTS

The present study included 654 consecutive older inpatients with pneumonia.

MEASUREMENTS

Frailty status before admission was assessed using total Kihon Checklist (KCL) score, which has been used as a self-administered questionnaire to assess comprehensive frailty, including physical, social, and cognitive status. The primary outcome was a composited 6-month mortality and readmission after discharge.

RESULTS

In total, 330 patients were analyzed (median age: 79 years, male: 70.4%, median total KCL score: 10 points), of which 68 were readmitted and 10 died within 6 months. After multivariate analysis, total KCL score was associated with a composited 6-month mortality and readmission (adjusted hazard ratio, 1.07; 95% confidence interval, 1.02-1.12; p = 0.006). The cutoff value for total KCL score determined by receiver operating characteristic curve analysis was 15 points (area under the curve = 0.610). The group with a total KCL score ≥ 15 points had significantly higher readmission or mortality rates than the groups with a total KCL score < 15 points (p < 0.001).

CONCLUSIONS

Preadmission frailty status in older patients with pneumonia was an independent risk factor for readmission and survival after hospitalization.

IL-15 blockade and rapamycin rescue multifactorial loss of factor VIII from AAV-transduced hepatocytes in hemophilia A mice

Hepatic adeno-associated viral (AAV) gene transfer has the potential to cure the X-linked bleeding disorder hemophilia A. However, declining therapeutic coagulation factor VIII (FVIII) expression has plagued clinical trials. To assess the mechanistic underpinnings of this loss of FVIII expression, we developed a hemophilia A mouse model that shares key features observed in clinical trials. Following liver-directed AAV8 gene transfer in the presence of rapamycin, initial FVIII protein expression declines over time in the absence of antibody formation. Surprisingly, loss of FVIII protein production occurs despite persistence of transgene and mRNA, suggesting a translational shutdown rather than a loss of transduced hepatocytes. Some of the animals develop ER stress, which may be linked to hepatic inflammatory cytokine expression. FVIII protein expression is preserved by interleukin-15/interleukin-15 receptor blockade, which suppresses CD8+ T and natural killer cell responses. Interestingly, mice with initial FVIII levels >100% of normal had diminishing expression while still under immune suppression. Taken together, our findings of interanimal variability of the response, and the ability of the immune system to shut down transgene expression without utilizing cytolytic or antibody-mediated mechanisms, illustrate the challenges associated with FVIII gene transfer. Our protocols based upon cytokine blockade should help to maintain efficient FVIII expression.

Temporal Profiles of Symptom Scores After Palliative Radiotherapy for Bleeding Gastric Cancer With Adjustment for the Palliative Prognostic Index: An Exploratory Analysis of a Multicentre Prospective Observational Study (JROSG 17-3)

AIMS

Although palliative radiotherapy for gastric cancer may improve some symptoms, it may also have a negative impact due to its toxicity. We investigated whether symptoms improved after radiotherapy with adjustment for the Palliative Prognostic Index (PPI) considering that patients with limited survival tend to experience deterioration of symptoms.

MATERIALS AND METHODS

This study was an exploratory analysis of the Japanese Radiation Oncology Study Group study (JROSG 17-3). We assessed six symptom scores (nausea, anorexia, fatigue, shortness of breath, pain at the irradiated area and distress) at registration and 2, 4 and 8 weeks thereafter. We tested whether symptoms linearly improved after adjusting for the baseline PPI. Shared parameter models were used to adjust for potential bias in missing data.

RESULTS

The present study analysed all 55 patients enrolled in JROSG 17-3. With time from registration as the only explanatory variable in the model, a significant linear decrease was observed in shortness of breath, pain and distress (slopes, -0.26, -0.22 and -0.19, respectively). Given that the interaction terms (i.e. PPI × time) were not significantly associated with symptom scores in any of the six symptoms, only PPI was included as the main effect in the final multivariable models. After adjusting for the PPI, shortness of breath, pain and distress significantly improved (slope, -0.25, -0.19 and -0.17; P < 0.001, 0.002 and 0.047, respectively). An improvement in fatigue and distress was observed only in patients treated with a biologically effective dose ≤14.4 Gy.

CONCLUSION

Shortness of breath, pain and distress improved after radiotherapy. Moreover, a higher PPI was significantly associated with higher symptom scores at all time points, including baseline. In contrast, PPI did not seem to influence the improvement of these symptoms. Regardless of the expected survival, patients receiving radiotherapy for gastric cancer can expect an improvement in shortness of breath, pain and distress over 8 weeks. Multiple-fraction radiotherapy might hamper the improvement in fatigue and distress by its toxicity or treatment burden.

A Novel Imaging Technique for The On-site Assessment of Renal Biopsy Specimens

When performing renal biopsy, it is necessary to identify the cortex, where glomeruli are exclusively distributed, to ensure the quality of the specimen for histological diagnosis. However, conventional methods using a stereomicroscope or magnifying lens often fail to clarify the quality of the specimen. We have established a fluorescent-based imaging technique for the on-site assessment of renal biopsy specimens. The fluorescent images can be easily obtained by adding an optical filter to the microscope and with a short incubation of an activatable fluorescent probe. This novel imaging technique can be applied to renal biopsy specimens for distinguishing the renal cortex.

POS1339 FACTORS RELATED TO SERUM IgG4 ELEVATION AND DEVELOPMENT OF IgG4-RELATED DISEASE: DATA FROM RESIDENT EXAMINATION

Background

Elevated serum IgG4 levels are one of the characteristic findings in immunoglobulin G4 (IgG4)-related disease (IgG4-RD). Serum IgG4 levels have an impact to a certain extent on the diagnosis of IgG4-RD although there are some issues in their sensitivity and specificity. In the reports from Japan, China, USA, and Europe, elevated serum IgG4 levels were reported to be observed in 83-97% of patients with IgG4-RD [1-5]. In the past investigations of hospital patients, some studies reported that 10-15% of hospital patients with elevated serum IgG4 levels had IgG4-RD [6,7]. However, in general adults with no symptom, investigations of prevalence of elevated serum IgG4 levels and/or IgG4-RD have rarely been conducted.

Objectives

This study aimed to investigate the frequency of serum IgG4 elevation in the general Japanese population and its associated factors using data from resident examinations.

Methods

We measured the serum IgG4 levels in 1,204 residents who underwent a general medical examination in Ishikawa prefecture, Japan. Logistic regression analysis was used to search for factors related to elevated serum IgG4 levels. Secondary examinations were conducted for participants in whom elevation was identified.

Results

The mean serum IgG4 level was 44 mg/dL, and elevated serum IgG4 levels were observed in 42 patients (3.5%). Univariate logistic regression analyses showed that male sex, older age, lower estimated glomerular filtration rates based on cystatin C (eGFR-CysC), serum high-density lipoprotein cholesterol levels, and higher hemoglobin A1c (HbA1c) levels were associated with elevated serum IgG4 levels. Subgroup analyses in men showed that older age, lower eGFR-CysC levels, and higher serum HbA1c levels were associated with elevated serum IgG4 levels. In contrast, the analyses in women found no significant factors. One of the 10 residents who underwent secondary examinations was diagnosed with possible IgG4-related retroperitoneal fibrosis.

Conclusion

In the general population, elevated serum IgG4 levels are more common in elderly men, which is similar to the epidemiological features of IgG4-RD.

References

[1]Inoue D, et al. IgG4-related disease: dataset of 235 consecutive patients. Medicine (Baltimore). 2015;94(15):e680.

[2]Yamada K, et al. New clues to the nature of immunoglobulin G4-related disease: a retrospective Japanese multicenter study of baseline clinical features of 334 cases. Arthritis Res Ther. 2017;19(1):262

[3]Culver EL, et al. Elevated serum IgG4 levels in diagnosis, treatment response, organ involvement, and relapse in a prospective IgG4-related disease UK cohort. Am J Gastroenterol 2016;111:733–43.

[4]Lin W, et al. Clinical characteristics of immunoglobulin G4-related disease: a prospective study of 118 Chinese patients. Rheumatology (Oxford). 2015;54(11):1982–90.

[5]Carruthers MN, et al. The diagnostic utility of serum IgG4 concentrations in IgG4-related disease. Ann Rheum Dis 2015;74:14-18.

[6]James Yun, et al. Poor positive predictive value of serum immunoglobulin G4 concentrations in the diagnosis of immunoglobulin G4-related sclerosing disease. Asia Pac Allergy. 2014 Jul;4(3):172-176.

[7]Taiwo N Ngwa, et al. Sreum immunoglobulin G4 ｌevel is a poor predictor of immunoglobulin G4–related disease. Pancreas. 2014 Jul;43(5):704-7.

Disclosure of Interests

None declared

POS0615 CLINICAL DEMOGRAPHICS AND FACTORS AFFECTING DRYNESS IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Sjogren’s syndrome (SS) is known to coexist with rheumatoid arthritis (RA). However, the prevalence of RA with SS varies widely, from 2.4% to 30%, and some patients with RA without SS also show dryness. The prevalence and clinical demographics of dryness in patients with RA are not well recognized.

Objectives

The aim of this study was to clarify the prevalence, clinical demographics, and related factors of dryness in patients with RA who have not been diagnosed with (SS).

Methods

We enrolled 166 patients with RA (129 females, 37 males; mean age 65.8±14.3 years; disease duration 14.1±10.9 years; DAS28-CRP 2.30±0.92) who were not diagnosed with SS. We analyzed CRP, the estimated glomerular filtration rate (eGFR), RF, anti-CCP antibody, antinuclear antibody, anti-SS-A antibody (SSA), and disease activity score (DAS) 28-CRP, and identified treatments for RA. We used each question item of the EULAR SS Patient Reported Index (ESSPRI) to clarify dryness, somatic and mental fatigue, and pain. History of smoking, comorbidities, such as interstitial pneumonia, fibromyalgia, and psychiatric disorders, and narcotic and/or psychotropic medication use were determined from the medical records. We defined patients with dryness as greater than or equal to one point, and those with severe dryness as greater than or equal to five points, of the visual analog scale (VAS).

Results

Dryness was observed in 93/166 (56.0%) patients and severe dryness was identified in 57/166 (34.4%) patients, and SSA was positive in 23/139 patients(13.9%). We divided our patients into dryness and non-dryness groups and compared their clinical demographics. The dryness group was relatively younger (64.0±14.5 vs. 68.1±13.8 years, p=0.052), had a female predominance (89.2% vs. 63.0%, p<0.001), had severe fatigue (4.06±2.59 vs 2.60±2.78, p<0.001), and had severe pain (3.52±2.41 vs. 2.73±2.32, p=0.020). However, the prevalence of SSA did not significantly differ in this cohort, compared with the non-dryness group (19.3% vs. 11.8%, p=0.248). Next, we analyzed the clinical characteristics of the patients with severe dryness. The severe dryness group was younger (61.9±15.5 vs. 67.9±13.2 years, p=0.022), had higher eGFR (76.1±15.5 vs. 68.9±22.7, p=0.020), had more severe fatigue (4.89±2.42 vs. 2.85±2.63), p<0.001), and had more severe pain (4.16±2.51 vs. 2.65±2.18, p<0.001), compared with non-severe dryness group. The prevalence of SSA was also significantly higher in the severe dryness group (91.2% vs. 70.6%, p=0.002). We then performed a multifactorial analysis using logistic regression analysis with a stepwise method. Female sex (OR 3.739, 1.247-11.207) and VAS of fatigue (OR 1.269, 1.054-1.526) were found to independently relate to dryness.

Conclusion

More than half of the patients with RA had dryness, although only 13.9% of patients were SSA positive. Dryness was related to female predominance and fatigue. Simon et al. reported that SS was found in 2.42% of patients with RA (1). On the other hand, Harrold et al. reported that SS was found in 30% of patients with RA, and the prevalence of SS increased with duration of RA (2). Our data indicate that patients with fatigue, regardless of pain, tend to have dryness, which may be a key factor in diagnosing SS in patients with RA.

References

[1]Simon TA, Kawabata H, Ray N, et.al. Prevalence of Co-existing Autoimmune Disease in Rheumatoid Arthritis: A Cross-Sectional Study. Adv Ther. 2017 Nov;34(11):2481-2490.

[2]Harrold LR, Shan Y, Rebello S, et al. Prevalence of Sjögren’s syndrome associated with rheumatoid arthritis in the USA: an observational study from the Corrona registry. Clin Rheumatol. 2020 Jun;39(6):1899-1905.

Disclosure of Interests

None declared

Usefulness of Preoperative Planning by Three-Dimensional Planning Software for Pedicle Screw Placement in Thoracolumbar Surgeries: <i>Misplacement Rate and Associated Risk Factors</i>

Introduction

A number of imaging technologies have been developed to reduce the risk of pedicle screw (PS) misplacement. For example, preoperative three-dimensional (3D) planning can reportedly enhance implant placement accuracy in some orthopedic surgeries. However, no study has investigated the effect of preoperative 3D planning on PS placement without intraoperative 3D navigation. Thus, in this study, we aim to examine the accuracy of PS placement and identify the risk factors for PS misplacement in thoracolumbar surgeries performed using preoperative 3D planning software with intraoperative fluoroscopic guidance in a retrospective study.

Methods

In total, 25 consecutive patients (197 PSs) underwent thoracic or lumbar spinal fusion surgeries using preoperative 3D planning with intraoperative fluoroscopic guidance. PS misplacement was graded based on the degree of perforation (Grade 0, no perforation; Grade 1, <2 mm; Grade 2, 2-4 mm; Grade 3, >4 mm) observed in postoperative computed tomography (CT). Deviations between planned and actual PSs were evaluated by matching preoperative and postoperative CT volume images for each vertebra.

Results

The overall PS misplacement rate was 6.6% (Grade 1: 4.0%, Grade 2: 1.5%, Grade 3: 1.0%). The median linear deviations of PS entry points between planned and actual locations were determined to be 3.3 mm and 3.3 mm for the horizontal and vertical axes, respectively. The median angular deviations of the PS axis were 6.2° and 4.5° for the transverse and sagittal planes, respectively. Multivariate analysis revealed that horizontal deviation of the PS entry point was the sole factor associated with Grade ≥1 PS misplacement (odds ratio=2.47, p<0.001).

Conclusions

Preoperative 3D planning software without intraoperative 3D navigation was able to achieve a relatively low PS misplacement ratio among the reported ratio of conventional techniques without navigation. Surgeons should carefully ensure that the entry point is consistent with preoperative planning, especially in the mediolateral direction to avoid misplacement in this method.

Neck Pain and Related Factors in Patients with Rheumatoid Arthritis

OBJECTIVES

In rheumatoid arthritis, neck pain can be caused by inflammatory reactions or cervical lesions, but the prevalence and associated factors have not been well studied. This study aimed to investigate the prevalence of neck pain in patients with rheumatoid arthritis and elucidate the related factors.

METHODS

This study included 146 patients with rheumatoid arthritis. Neck pain, quality of life, and levels of anxiety and depression were evaluated using a questionnaire. Cervical lesions and spinal alignment were evaluated using plain radiograph and magnetic resonance imaging. Factors associated with neck pain were analysed using a logistic regression model.

RESULTS

Fifty-six percent of the patients had neck pain, and the quality of life scores were significantly worse in these patients. Multivariate analysis revealed age, C7 sagittal vertical axis (SVA), upper cervical lesion, and endplate erosion as factors associated with neck pain in patients with rheumatoid arthritis.

CONCLUSIONS

More than half the patients with rheumatoid arthritis suffer from neck pain, and neck pain affects the quality of life and activities of daily living. Neck pain was associated with upper cervical lesion and endplate erosion suggesting the importance of radiological examination in patients with rheumatoid arthritis and neck pain.

Budd-Chiari Syndrome during Long-term Follow-up after Allogeneic Umbilical Cord Blood Transplantation

A series of abdominal computed tomography scans of an asymptomatic 40-year-old woman with a history of umbilical cord blood transplantation (CBT) for leukemia at 19 years old revealed the long-term gradual development of a right hepatic vein thrombus and stenosis of the inferior vena cava, leading to a diagnosis of Budd-Chiari syndrome. The Budd-Chiari syndrome in this case might have been influenced by the patient's history of multiple liver abscesses after CBT and associated thrombus formation, in addition to the hormone replacement therapy with estradiol and dydrogesterone she was taking. This case provides insight into the development of Budd-Chiari syndrome.

Steatosis is involved in the progression of kidney disease in a high-fat-diet-induced non-alcoholic steatohepatitis mouse model

Chronic kidney disease (CKD) and non-alcoholic steatohepatitis (NASH) are major health issues associated with the metabolic syndrome. Although NASH is a known risk factor of CKD, the mechanisms linking these two diseases remain poorly understood. We aimed to investigate alterations in the kidney complicated with dyslipidemia in an established NASH mouse model. Male C57BL6/J mice were fed with control diet or high-fat diet (HFD), containing 40% fat, 22% fructose, and 2% cholesterol for 16 weeks. Metabolic characteristics, histological changes in the kidney, endoplasmic reticulum (ER) stress, apoptosis, and fibrosis were evaluated by histological analysis, immunoblotting, and quantitative reverse transcription-polymerase chain reaction. Levels of serum aspartate aminotransferase, alanine aminotransferase, alkali-phosphatase, total cholesterol, and urinary albumin were significantly higher in mice fed with HFD. Remarkable steatosis, glomerular hypertrophy, and interstitial fibrosis were also shown in in the kidney by leveraging HFD. Furthermore, HFD increased the mRNA expression levels of Casp3, Tgfb1, and Nfe2l2 and the protein level of BiP. We observed the early changes of CKD and speculate that the underlying mechanisms that link CKD and NASH are the induction of ER stress and apoptosis. Further, we observed the activation of Nfe2l2 in the steatosis-induced CKD mouse model. This NASH model holds implications in investigating the mechanisms linking dyslipidemia and CKD.

Life Expectancy Is Poor in Patients with Diffuse Idiopathic Skeletal Hyperostosis-Related Pyogenic Vertebral Osteomyelitis

Introduction

Pyogenic vertebral osteomyelitis (PVO) is an uncommon but life-threatening infectious disease. Diffuse idiopathic skeletal hyperostosis (DISH) is an age-related disorder and sometimes problematic in terms of spinal instability or high mortality, especially in cases of DISH-related fracture. Meanwhile, no reports have focused on the impact of DISH on the clinical outcomes after treatment for PVO. We hypothesized that PVO occurring at DISH-related segments might contribute to poor clinical results or high mortality rates. The purpose of this study was to investigate the impact of DISH on mortality after treatment for PVO in a retrospective cohort study.

Methods

This study involved patients who were hospitalized and treated for PVO at a single institution. DISH-related PVO was defined as PVO within a segment ossified by DISH or PVO at the neighboring intervertebral level of the segment ossified by DISH. Differences in mortality between patients with DISH-related and non-DISH-related PVO were investigated.

Results

This study included 55 patients. DISH-related PVO was observed in 13 patients. The mortality rate was significantly higher in patients with DISH-related PVO than in those with non-DISH-related PVO (62% and 23%, respectively; p=0.016). Propensity score-adjusted analysis showed that DISH-related PVO was an independent risk factor for mortality (adjusted hazard ratio, 2.79; p=0.034). The survival probability was significantly shorter in patients with DISH-related PVO than in those with non-DISH-related PVO (p=0.006). PVO in which the intravertebral body was the center of involvement was significantly more common in DISH-related PVO than in non-DISH-related PVO (38% and 5%, respectively; p=0.006).

Conclusions

DISH-related PVO was associated with a higher mortality rate and shorter life expectancy than non-DISH-related PVO. Similar to advanced age, PVO at the segment ossified by DISH should be recognized as a risk factor for mortality when choosing the optimal treatment strategy.