Risk factors for adverse events associated with endoscopic submucosal dissection for superficial pharyngeal cancer

BACKGROUND

Superficial pharyngeal cancer can be treated with curative intent while preserving function using minimally invasive peroral endoscopic resection techniques such as endoscopic submucosal dissection (ESD). However, severe adverse events occasionally occur, such as laryngeal edema requiring temporary tracheotomy and fistula formation. Therefore, we investigated the risk factors for adverse events associated with ESD for superficial pharyngeal cancer.

METHODS

This retrospective observational study was conducted at a single institution, and 63 patients who underwent ESD were enrolled. The primary outcome was the risk factors for adverse events associated with ESD. The secondary outcomes were adverse events associated with ESD and their frequency.

RESULTS

The overall adverse event rate was 15.9% (10/63). The incidence of laryngeal edema requiring prophylactic temporary tracheotomy was 11.1%, while laryngeal edema requiring emergency temporary tracheotomy, postoperative bleeding, aspiration pneumonia, fistula, abscess, and stricture formation occurred in 1.6% of patients, respectively. Logistic regression analyses showed that a history of radiotherapy for head and neck cancer was a risk factor for adverse events (odds ratio [OR], 16.67; 95% confidence interval [CI], 3.04-91.34; p = 0.001). After adjusting the model for differences in the baseline risk factors using the inverse probability of treatment weighting method, the adverse events were found to increase in association with a history of radiotherapy for head and neck cancer (OR, 39.66; 95% CI,5.85-268.72; p < 0.001).

CONCLUSION

History of radiotherapy for head and neck cancer is an independent risk factor for adverse events associated with ESD for superficial pharyngeal cancer. Among adverse events, laryngeal edema requiring prophylactic temporary tracheotomy was particularly high.

Influence of a biliary stent in patients with advanced pancreatic cancer treated with modified FOLFIRINOX

Endoscopic biliary drainage is the recommended 1st-line treatment for malignant biliary obstruction. Although a high incidence of febrile neutropenia has been reported in patients treated with FOLFIRINOX and a biliary stent, it remains unknown whether the biliary stent contributes to patient survival. Thus, we aimed to elucidate the effects of biliary stents on the survival of patients with advanced pancreatic cancer treated with modified FOLFIRINOX (mFFX). We retrospectively reviewed medical charts of patients with advanced pancreatic cancer treated with mFFX between January 2014 and April 2020. We compared the overall survival (OS) of patients with and without biliary stent during mFFX treatment and examined the independent effect on mortality using propensity score matching. Overall, we included 89 patients (stent group, n = 24; non-stent group, n = 65). The proportion of patients with pancreatic head cancer was significantly higher in the stent group than in the non-stent group (P < .01). Stratification analysis in patients with pancreatic head cancer revealed that OS was significantly shorter in the stent group than in the non-stent group (P = .03). After propensity score matching, 19 pairs of patients in each group were analyzed. The stent group revealed a significantly shorter survival than the non-stent group (median OS, 10.3 vs 24.9 months; P < .01). The incidences of febrile neutropenia (P = .01) and biliary tract-related events that required biliary stenting or stent replacement (P < .01) were significantly higher in the stent group than in the non-stent group. Stent insertion was an independent risk factor for overall mortality. Biliary stents may reduce survival in patients with advanced pancreatic cancer. The rate of febrile neutropenia was higher in the stent group than in the non-stent group. There is a need to assess the patient's condition with discretion and develop a treatment strategy with short prognosis in mind after stent insertion.

Angle of covered self-expandable metallic stents after placement is a risk factor for recurrent biliary obstruction

BACKGROUND

Studies have shown that covered self-expandable metallic stents (CSEMS) with a low axial forces after placement can cause early recurrent biliary obstruction (RBO) due to precipitating sludge formation.

AIM

To ascertain whether the angle of CSEMS after placement is a risk factor for RBO in unresectable distal malignant biliary obstruction (MBO).

METHODS

Between January 2010 and March 2019, 261 consecutive patients underwent self-expandable metallic stent insertion by endoscopic retrograde cholangiopancreatography at our facility, and 87 patients were included in this study. We evaluated the risk factors for RBO, including the angle of CSEMS after placement as the primary outcome. We measured the obtuse angle of CSEMS after placement on an abdominal radiograph using the SYNAPSE PACS system. We also evaluated technical and functional success, adverse events, time to RBO (TRBO), non-RBO rate, survival time, cause of RBO, and reintervention procedure as secondary outcomes.

RESULTS

We divided the patients into two cohorts based on the presence or absence of RBO. The angle of CSEMS after placement (per 1° and per 10°) was evaluated using the multivariate Cox proportional hazard analysis, which was an independent risk factor for RBO in unresectable distal MBO [hazard ratio, 0.97 and 0.71; 95% confidence interval (CI): 0.94-0.99 and 0.54-0.92; P = 0.01 and 0.01, respectively]. For early diagnosis of RBO, the cut-off value of the angle of CSEMS after placement using the receiver operating characteristic curve was 130° [sensitivity, 50.0%; specificity 85.5%; area under the curve 0.70 (95%CI: 0.57-0.84)]. TRBO in the < 130° angle group was significantly shorter than that in the ≥ 130° angle group (P < 0.01).

CONCLUSION

This study suggests that the angle of the CSEMS after placement for unresectable distal MBO is a risk factor for RBO. These novel results provide pertinent information for future stent management.

[Current real-world treatments for Japanese patients with eosinophilic esophagitis]

A total of 306 patients with eosinophilic esophagitis (EoE) were analyzed at our department. Proton pump inhibitors or potassium-competitive acid blockers were used as the first-line treatment in 286 (93.5%) patients. Fifty-five (18.0%) patients received topical steroid swallowing therapy. During 17.7-month mean follow-up, 46.4% of the patients were followed-up with no medications, 37.3% of the patients received maintenance or on-demand therapy using acid-suppressive drugs, and 9.8% of the patients received maintenance therapy with steroid swallowing. The majority of patients with EoE were treated using a therapeutic strategy similar to that used for gastroesophageal reflux disease. However, some patients were refractory to the treatment. Current real-world treatment strategies for Japanese patients with EoE are clarified.

Evaluation of long-term survival in patients with severe comorbidities after endoscopic submucosal dissection for esophageal squamous cell carcinoma

BACKGROUND

Endoscopic submucosal dissection (ESD) is becoming widely popular as a less invasive treatment option for superficial esophageal squamous cell carcinoma. However, data on long-term survival after esophageal ESD in patients with severe comorbidities are limited. This study aimed to evaluate long-term survival after ESD in such patients.

METHODS

Altogether, 584 consecutive patients underwent esophageal ESD at our institution from May 2004 to September 2016. Based on the American Society of Anesthesiologists Physical Status (ASA-PS) classification system, patients were grouped according to severe (ASA-PS ≥ 3) or non-severe comorbidities (ASA-PS 1/2). The overall survival (OS), disease-specific survival (DSS), and risk factors for mortality were compared between the groups using a propensity score matching analysis.

RESULTS

In a matched cohort of 69 pairs, the 5-year OS rate was poorer in ASA-PS 3 patients than in ASA-PS 1/2 patients (63.9% vs. 92.5%, P < 0.01), while the 5-year DSS rate was similar between the groups (100% vs. 100%). The mortality rate was significantly higher in ASA-PS 3 patients than in ASA-PS 1/2 patients (hazard ratio 3.47; 95% confidence interval 1.79-6.74; P < 0.01). Death due to exacerbation of comorbidities was significantly more frequent in ASA-PS 3 patients than in ASA-PS 1/2 patients (42.4% vs. 8.3%, P < 0.04).

CONCLUSION

Because of the exacerbation of comorbidities, patients with severe comorbidities had poorer long-term outcomes after esophageal ESD than those with non-severe comorbidities. Further studies will be necessary to evaluate esophageal ESD in patients with severe comorbidities.

Safety of Endoscopic Mucosal Resection Using a Bipolar Snare for Superficial Nonampullary Duodenal Epithelial Tumors and the Predictive Factors of Piecemeal Resection

INTRODUCTION

Endoscopic mucosal resection for small superficial nonampullary duodenal epithelial tumors is a noninvasive treatment; however, perforations can occur. Bipolar snares can reduce the risk of perforation due to small tissue damage. Currently, only few studies have reported endoscopic mucosal resection for small superficial nonampullary duodenal epithelial tumors using a bipolar snare and the effect of preoperative findings.

OBJECTIVE

To investigate (1) resectability and adverse events of endoscopic mucosal resection using a bipolar snare for small superficial nonampullary duodenal epithelial tumors and (2) the predictions of piecemeal resection.

METHODS

Between 2007 and 2017, 89 patients with 107 lesions underwent endoscopic mucosal resection using a bipolar snare. Among them, 88 lesions of 77 patients were evaluated. The primary outcome was the incidence of en bloc resection and R0 resection and adverse events. Risk factors associated with piecemeal resection, including preoperative lesion findings, were also examined.

RESULTS

The incidence rates of en bloc and R0 resections were 85.2 and 48.9%, respectively. Neither intraoperative or delayed perforations nor procedure-related mortality was noted. The nonlifting sign after submucosal injection was associated with an increase in piecemeal resection (odds ratio: 20.3, 95% confidence interval: 2.53-162; p = 0.005).

CONCLUSION

Endoscopic resection for small superficial nonampullary duodenal epithelial tumors can cause perforation; however, endoscopic mucosal resection using a bipolar snare can be a safe treatment option as it does not cause perforations. The nonlifting sign after submucosal injection is a predictive factor for piecemeal resection.

Comparison of the Diagnostic Efficiency of Radial- and Convex-Arrayed Echoendoscopes for Indirect Findings of Pancreatic Cancer: A Retrospective Comparative Study Using Propensity Score Method

Simple Summary

Pancreatic cancer (PC) has a poor prognosis; however, diagnosing PC at an earlier stage could improve long-term patient outcomes. Endoscopic ultrasonography (EUS) plays an important role in PC detection, and the indirect findings (caliber change, retention cysts, and dilatation of the branch duct) that are detected by EUS are especially important for the early detection of PC. The aim of this retrospective study was to compare the diagnostic efficacy of radial- and convex-arrayed echoendoscope for the detection rate of indirect findings. As a result, the radial-arrayed echoendoscope was found to be an independent detection factor of indirect findings by multivariate analysis. The radial-arrayed echoendoscope is useful for the detection of indirect findings.

Abstract

Endoscopic ultrasonography (EUS) is useful for detecting early-stage pancreatic cancer. Because the detection of small lesions is difficult, it is important to detect indirect findings, namely caliber change, retention cysts, and dilatation of the branch duct, during the procedure. Although two types of EUS endoscopes are frequently used, there is no comparative study on their efficacy for detecting indirect findings. Therefore, we aimed to compare the diagnostic efficacy of these two types for indirect findings. We retrospectively analyzed 316 consecutive patients who had undergone EUS for pancreaticobiliary disease at a single center between January 2017 and December 2018. The main outcome was the detection rate of indirect findings and its comparison between the two echoendoscope types. This outcome was achieved using the inverse probability of treatment weighting (IPTW) analysis. The detection rate of indirect findings was higher for the radial-arrayed endoscope than for the convex-arrayed echoendoscope (9.2% vs. 2.3% (p = 0.02)). The univariate analysis also revealed that the radial-arrayed echoendoscope was significantly superior to the convex-arrayed echoendoscope in terms of the detection of indirect findings (odds ratio, 5.94; 95% confidence interval, 1.68–21.10; p = 0.01) after IPTW. After adjustment for magnetic resonance imaging (MRI) and computed tomography (CT), radial-arrayed echoendoscope remained an independent factor for indirect finding detection (odds ratio, 6.04; 95% confidence interval, 1.74–21.00; p = 0.01). Finally, five patients who had indirect EUS findings were diagnosed with pancreatic cancer. Our results indicate that the radial-arrayed echoendoscope is useful for the detection of indirect findings.

Obstructive Jaundice Due to Duodenal Ulcer Induced by Lenvatinib Therapy for Hepatocellular Carcinoma

An 82-year-old man with hepatocellular carcinoma presented with upper abdominal pain, vomiting, and jaundice. He had been taking a standard lenvatinib dose for three months. Although acute cholangitis was suggested, imaging studies failed to detect the biliary obstruction site. An endoscopic examination following discontinuation of lenvatinib and aspirin revealed multiple duodenal ulcers, one of which was formed on the ampulla of Vater and causing cholestasis. Endoscopic biliary drainage and antibiotics improved concomitant Enterobacter cloacae bacteremia. Ulcer healing was confirmed after rabeprazole was replaced with vonoprazan and misoprostol. Our case shows that lenvatinib can induce duodenal ulcers resulting in obstructive jaundice.

Continuous warfarin administration versus heparin bridging therapy in post colorectal polypectomy haemorrhage: a study protocol for a multicentre randomised controlled trial (WHICH study)

Background

Endoscopic removal of colorectal adenoma is considered an effective treatment for reducing the mortality rates associated with colorectal cancer. Warfarin, a type of anticoagulant, is widely used for the treatment and prevention of thromboembolism; however, bleeding may increase with its administration after polypectomy. In recent times, a high incidence of bleeding after endoscopic polypectomy has been reported in patients receiving heparin bridge therapy. However, previous studies have not compared the bleeding rate after endoscopic colorectal polypectomy between patients who continued with anticoagulant therapy and those who received heparin bridge therapy. We hypothesised that endoscopic colorectal polypectomy under the novel treatment with continuous warfarin is not inferior to endoscopic colorectal polypectomy under standard treatment with heparin bridge therapy with respect to the rate of postoperative bleeding. This study aims to compare the efficacy of endoscopic colorectal polypectomy with continuous warfarin administration and endoscopic colorectal polypectomy with heparin bridge therapy with respect to the rate of postoperative bleeding.

Methods

We will conduct a prospective multicentre randomised controlled non-inferiority trial of two parallel groups. We will compare patients scheduled to undergo colorectal polypectomy under anticoagulant therapy with warfarin. There will be 2 groups, namely, a standard treatment group (heparin bridge therapy) and the experimental treatment group (continued anticoagulant therapy). The primary outcome measure is the rate of postoperative bleeding. On the contrary, the secondary outcomes include the rate of cumulative bleeding, rate of overt haemorrhage (that does not qualify for the definition of haemorrhage after endoscopic polypectomy), incidence of haemorrhage requiring haemostasis during endoscopic polypectomy, intraoperative bleeding during endoscopic colorectal polypectomy requiring angiography, abdominal surgery and/or blood transfusion, total rate of bleeding, risk factors for postoperative bleeding, length of hospital stay, incidence of thromboembolism, prothrombin time-international ratio (PT-INR) 28 days after the surgery, and incidence of serious adverse events.

Discussion

The results of this randomised controlled trial will provide valuable information for the standardisation of management of anticoagulants in patients scheduled to undergo colorectal polypectomy.

Trial registration

UMIN-CTR UMIN000023720. Registered on 22 August 2016

The usefulness of serial pancreatic juice aspiration cytological examination for pancreatic cancer not diagnosed by EUS-FNAB

Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) is safe and useful for the diagnosis of pancreatic cancer. However, sometimes a diagnosis cannot be established by EUS-FNAB. The efficacy of serial pancreatic juice aspiration cytological examination (SPACE) for pancreatic cancer was reported. SPACE may be useful in cases in which diagnosis by EUS-FNAB is difficult; however, this has not been reported previously. We herein report two cases of pancreatic cancer diagnosed by SPACE when diagnosis by EUS-FNAB was difficult. Case 1 was a 77-year-old female. She was suspected of pancreatic cancer because of new-onset diabetes. We performed EUS-FNAB to the lesion in the pancreatic body; however, diagnosis failed. We performed SPACE and diagnosed pancreatic cancer finally. Case 2 was 72 years old female. She was suspected of having pancreatic cancer because of the dilatation of the pancreatic duct. We performed EUS-FNAB twice to the lesion in the pancreatic head, however, diagnosis failed. Therefore, we performed SPACE and got final diagnosis as pancreatic cancer. From our experience, we suggest that SPACE is a useful diagnostic method for patients with pancreatic cancer that are difficult to diagnose.

FRI0266 THE REAL-WORLD EFFICACY OF THE 2015 EULAR/ACR RECOMMENDATIONS FOR THE MANAGEMENT OF POLYMYALGIA RHEUMATICA WITH ADDITIONAL TOCILIZUMAB THERAPY

Background:

A Part of patients with polymyalgia rheumatica (PMR) are refractory to the 2015 EULAR/ACR algorism for the management of PMR. Recent reports have demonstrated that tocilizumab (TCZ) may be efficacious for refractory and relapsing PMR.

Objectives:

To determine the real-world efficacy of the 2015 EULAR/ACR algorism for the management of PMR plus introduction of TCZ for refractory and relapsing PMR.

Methods:

Patients who had been diagnosed with PMR according to the 2012 EULAR/ACR provisional classification criteria for PMR were recruited in the study. Registered variables included demographic data, disease characteristics, prednisolone (PSL) dosage and duration, addition of methotrexate (MTX) and TCZ, adverse effects, and clinical outcomes.

Results:

There were 101 patients who had originally diagnosed as PMR (50 males and 65 females) and followed up for at least one year; the mean ± SD age at onset was 73 ±11 years at onset, with the mean observational period being 44 ± 26 months. Their treatments were initiated with PSL of 15.5 ± 4.3 mg/day. 41 patients experienced disease recurrence after 9.6 ± 6.7 months (median 9 month) of GC therapy, while receiving PSL at 5 ± 4.5 mg/day (3.7 mg/day). Baseline factors that were associated with relapse in our cohort were higher-grade thrombocytosis and higher-dose of initial GC by multivariate analysis. In 30 of the 41 patients who failed GC monotherapy, MTX was added. Five patients reached GC-free remission, but 25 patients failed GC tapering. In such refractory patients to a combination of GC plus MTX, 8 patients agreed to add TCZ therapy, and 5 of them reached drug-free remission. At present, 67 of the total 101 patients maintained drug-free remission, but most others were still receiving low-dose GC and/or MTX (n=17). No significant adverse effects did not occur during therapy, except for GC-related adverse effects such as diabetes, dyslipidemia and osteoprotic fractures.

Conclusion:

Our experience indicated that there is notable heterogeneity across PMR patients in terms of drug response, and the patients with severe inflammation, e.g. thrombocytosis, may need higher-dose of initial GC and addition of biologics such as TCZ on the 2015 EULAR/ACR algorism.

Acknowledgments:

None

Disclosure of Interests:

None declared

Leak-free million-fold DNA amplification with locked nucleic acid and targeted hybridization in one pot

An isothermal cascade reaction that exponentially amplifies pre-designed, single-stranded DNA as a sensor and signal amplifier module for DNA-based computing and molecular robotics was developed. Taking advantage of the finding that locked nucleic acid can suppress problematic ab initio DNA synthesis, up to million-fold amplification rates and concurrent hybridization were achieved at a physiological temperature in a single reactor. Although the effect of locked nucleic acid introduction to the templates was complicated, undesired leak DNA amplification was generally suppressed in the amplification reaction for distinct DNA sequences. The present reaction that senses one DNA as an input and generates a large amount of another DNA as an output, exhibiting a high correlation between the molecular concentration and the amplification time, is applicable for nucleic acid quantification.

[A case of pancreatic neuroendocrine tumor with ring-like enhancement]

An 82-year-old female underwent contrast computed tomography (CT) that revealed multiple ring-like enhanced masses in the pancreatic tail. Additionally, the inside of the masses showed enhancement on contrast endoscopic ultrasound (EUS). She was diagnosed with a pancreatic neuroendocrine tumor on histopathological examination after EUS-guided fine-needle aspiration, and distal pancreatectomy and splenectomy were performed. In the resected specimen, toward the tumor center, tumor cells with lipid droplets and fibrosis were remarkably observed. These rare histopathological features well reflected the image findings of contrast CT and contrast EUS.

Relationship Between Initial Renal Function and the Inhibitory Effect of Dipeptidyl Peptidase-4 Inhibitor Treatment on Renal Function Decline

We retrospectively investigated the renal function index of patients with type 2 diabetes mellitus (T2DM) to examine the influence of dipeptidyl peptidase-4 (DPP-4) inhibitors on renal function between patients up to early nephropathy and after overt nephropathy. Patients with T2DM (>18 years old) who had been prescribed hypoglycemic agents for ≥3 months at Gifu Municipal Hospital between March 2010 and April 2014 were included in the study. Renal function was evaluated as the estimated glomerular filtration rate (eGFR) decline from baseline at 12 months. Patients in the DPP-4 inhibitor-treated and untreated groups with an eGFR ≥60 (358 [58.2 %] and 257 [41.8 %], respectively) and eGFR <60 (115 [60.2 %] and 76 [39.8 %], respectively) were subjected to multiple logistic regression analysis. Among patients with an eGFR ≥60, no significant differences were observed in eGFR decline rates over time. However, among patients with an eGFR <60, significant decreases were observed in eGFR decline rates >10 % (6 months; odds ratio, 0.476; P = 0.043, 12 months; odds ratio, 0.413; P = 0.010). Similar results were obtained for an eGFR decline rate >20 % (12 months; odds ratio, 0.369; P = 0.049). DPP-4 inhibitors are renoprotective in patients with T2DM and an eGFR <60.

An investigation of visual hallucinations associated with voriconazole administration to patients with hematological malignancies

Voriconazole (VRCZ) is commonly administered to treat fungal infections in patients with hematological malignancies. Some of these patients experience VRCZ-associated visual hallucinations. We conducted a retrospective survey to investigate the characteristic features of this side effect. Patients with hematological malignancies who were treated with VRCZ for a fungal infection after hospitalization at Ichinomiya municipal hospital between 1 October 2005 and 31 December 2015 were included in this study (n = 103). Fifteen of these (14.6%) reported visual hallucinations that started on day 1-7. Seven of these 15 patients developed this symptom rapidly (day 1 or 2). Three patients had transient symptoms (lasting 2-12 days), 6 patients experienced hallucinations throughout the treatment, and the duration was unknown in 6 patients. Eleven patients experienced visual hallucinations when their eyes were closed (73 %) and these disappeared when they opened their eyes. One patient had visual hallucinations with open eyes, while the state of the eyes was unknown in 3 patients. The patients saw a range of images including people, animals, landscapes, and foods; several reported seeing images like those found in movies. In addition, 9 of 15 patients (60%) with visual hallucinations had visual disturbances. This was a higher proportion than that observed in patients who did not develop hallucinations (17 of 88; 19.3 %; P < 0.05). However, we found no significant difference between the blood VCRZ concentrations of patients who developed or did not develop visual hallucinations. This study indicated that most of these patients had visual hallucinations that manifested on eye closure, and they did not progress to serious mental illness. Our findings emphasized the importance of fully explaining the features of this symptom to each patient prior to starting VRCZ administration in order to reduce anxiety. In addition, since VRCZ discontinuation will compromise patient management, therapeutic drug monitoring should be used to increase the likelihood of successful therapy.

Development of Collaterals to the Spinal Cord after Endovascular Stent Graft Repair of Thoracic Aneurysms

OBJECTIVES

In thoracic and thoraco-abdominal aortic aneurysm repair, spinal cord injury (SCI) is devastating. Detection of the Adamkiewicz artery might be important for preventing SCI. Although thoracic endovascular stent grafts often occlude the segmental artery, the incidence of SCI in thoracic endovascular aortic repair is thought to be low compared with open repair. This study aimed to evaluate how the Adamkiewicz artery is supplied after segmental arteries are occluded by stent grafts.

METHODS

From March 2007 to August 2015, 32 patients were enrolled whose segmental arteries that were connected to the Adamkiewicz arteries were occluded by stent grafts. Segmental arteries, Adamkiewicz arteries, collateral circulation into the Adamkiewicz arteries, and anterior spinal arteries were pre- and post-operatively evaluated by computed tomography angiography.

RESULTS

Post-operatively, Adamkiewicz arteries were detected in 24 (75%) patients, except for two patients with paraplegia and six without paraplegia. Post-operative Adamkiewicz arteries were the same as pre-operative Adamkiewicz arteries, except for one Adamkiewicz artery that was located at two vertebral levels below the pre-operative level. SCI occurred in two (6.3%) patients. The distribution of feeding arteries into the Adamkiewicz artery post-operatively was divided into three patterns as follows: a segmental artery below the distal landing zone of the stent graft (53%), branches of the left subclavian artery (33%), and a branch of the left external iliac artery (13%).

CONCLUSIONS

The length of the stent graft should be as short as possible. Blood supply to the left subclavian artery should be maintained because segmental arteries below the segmental artery occluded by the stent graft and branches of the left subclavian artery can become collaterals post-operatively.

Stable neutral radicals of planar N2O2-type dipyrrin platinum complexes: hybrid radicals of the delocalized organic π-orbital and platinum d-orbital

Neutral radicals of N2O2-dipyrrin platinum complexes were synthesized by the reaction of dipyrrin ligands with PtCl2(cod) and successive one-electron oxidation. The radicals are very stable even under aerobic and ambient conditions. X-ray crystallographic analysis revealed the stacking array of the planar dipyrrin complex moieties. The ESR signals were broadened and significantly downfield shifted. The absorption spectra exhibited NIR bands. These results indicated a delocalized radical character with a contribution by the platinum d-orbital.

Changes in axial alignment of the ipsilateral hip and knee after total hip arthroplasty

AIMS

We investigated changes in the axial alignment of the ipsilateral hip and knee after total hip arthroplasty (THA).

PATIENTS AND METHODS

We reviewed 152 patients undergoing primary THA (163 hips; 22 hips in men, 141 hips in women) without a pre-operative flexion contracture. The mean age was 64 years (30 to 88). The diagnosis was osteoarthritis (OA) in 151 hips (primary in 18 hips, and secondary to dysplasia in 133) and non-OA in 12 hips. A posterolateral approach with repair of the external rotators was used in 134 hips and an anterior approach in 29 hips. We measured changes in leg length and offset on radiographs, and femoral anteversion, internal rotation of the hip and lateral patellar tilt on CT scans, pre- and post-operatively.

RESULTS

The mean internal rotation increased by 11° (-15° to 46°) and was associated with underlying disease (OA), pre-operative range of internal rotation, gender, surgical approach, leg lengthening, and change of femoral anteversion (adjusted R(2) : 0.253, p < 0.001). The mean lateral patellar tilt increased by 4° (-5° to 14°) and was associated with age, leg lengthening, and increment of hip internal rotation (adjusted R(2): 0.193, p < 0.001).

CONCLUSION

Both internal rotation of the hip at rest and lateral patellar tilt are increased after THA. Changes in rotation after THA may affect gait, daily activities, the rate of dislocation of the hip, and ipsilateral knee pain.

TAKE HOME MESSAGE

Internal rotation of the hip at rest and lateral patellar tilt increase after THA.

Preliminary validation of an instrument to assess social support and tuberculosis stigma in patients' families

SETTING

Ribeirão Preto, São Paulo, Brazil.

OBJECTIVE

To develop and validate a preliminary instrument for assessing social support and tuberculosis (TB) stigma in families of TB patients.

DESIGN

A literature review on social support and TB stigma was used to generate the theoretical domains for the instrument. A focus group was then conducted with TB patients and their families to revise the domains. Reviewers were invited to judge the appropriateness of the items in the instrument. A cross-sectional survey was carried out among 110 family members to assess the factorial structure using principal component analysis and confirmatory factor analysis to assess construct validity. Reliability was assessed in terms of internal consistency using Cronbach's alpha.

RESULTS

After semantic validation and a pilot study, 23 items were selected for the scale. Examination of the factorial structure of the 16 items that were factorable using principal component analysis led to the extraction of two factors. The 16-item instrument was assessed for construct validity with confirmatory factor analysis, which confirmed a model with four items for each dimension.

CONCLUSION

The study analysed the psychometric properties of an instrument that is still in its preliminary stages. Other studies on a similar scale in the Brazilian setting are required.

Renal involvement in rheumatoid arthritis: analysis of renal biopsy specimens from 100 patients

Abstract  We analyzed renal biopsy specimens from 100 patients to evaluate the characteristics of renal involvement in patients with rheumatoid arthritis (RA). Membranous nephropathy (MN) was the most common renal histological pattern (31%). Mesangial proliferative glomerulonephritis (GN) was found in 21% of cases (IgA nephropathy 12%, non-IgA GN 9%), minor changes in 17%, renal amyloidosis in 11%, interstitial nephritis in 9%, sclerotic GN in 4%, and crescentic GN in 2%. MN was relatively more frequent in men than in women, and most developed nephrotic syndrome, while a few developed renal failure. Disease-modifying antirheumatic drugs (DMARDs) correlated with MN in 26 of 31 cases. Mesangial proliferative GN showed high-grade hematuria. Amyloidosis correlated with long duration of RA; approximately half of the cases with amyloidosis also had nephrotic syndrome, and 82% developed renal failure. Of the 100 patients, 82% showed some tubulo-interstitial changes, which might be related to non-steroidal anti-inflammatory drugs. Because renal lesions in RA are very diverse, and early stage cases of MN and amyloidosis can be detected only by histological examinations, renal biopsy should be performed in cases with continuous urinary abnormalities or progressive renal failure.

Stereospecific oxidation of the (S)-enantiomer of RS-8359, a selective and reversible monoamine oxidase A (MAO-A) inhibitor, by aldehyde oxidase

In a previous paper by the authors on RS-8359, a new selective and reversible monoamine oxidase A (MAO-A) inhibitor, it was reported that the (S)-enantiomer of RS-8359 is rapidly eliminated from rats, monkeys and humans as a result of the formation of a 2-oxidative metabolite. The present study investigates the properties of the enzyme responsible for the 2-oxidation of RS-8359. Subcellular localization, cofactor requirement and the inhibitory effects of typical compounds were studied using rat liver preparations. In addition, the enzyme was purified from rat liver cytosol for further characterization. The enzyme activity was localized in the cytosolic fraction without the need for any cofactor and was extensively inhibited by menadione, chlorpromazine and quinacrine. The purified enzyme was also a homodimer with a monomeric molecular weight of 140 kDa and it had an A280/A450 ratio of 5.1 in the absorption spectrum. The results suggest that the enzyme responsible for the biotransformation of RS-8359 to give the 2-keto derivative is aldehyde oxidase (EC 1.2.3.1). The reaction of aldehyde oxidase is highly stereoselective for the (S)-configuration of RS-8359 and the (9R)-configuration of cinchona alkaloids.

Asymmetric Surface Roughness Formationon Moving Non-isothermal Liquid Coatings

We present a lubrication model of thermo-capillary flows in moving volatile liquid film coatings. The forced air impingement from a slit nozzle onto the moving coating imposes an axi-symmetric surface temperature distribution, and thus the local surface-tension gradients on the liquid surface. Despite the symmetric temperature profile, local thickness variations became asymmetric and exhibited a particular ridge in downstream and a depression in upstream. The competing feature between the surface-tension-driven and the pressure-driven flows gives a characteristic growth and decay in the surface roughness as the temperature profile travels in the opposite direction to the moving coating. The model prediction showed that the surface roughness was first enhanced and then suppressed with increasing the impinging air velocity, suggesting some directions for achieving more uniform coatings at higher speeds.

[Aortic valve replacement presence of anti-Jr(a) antibody]

A 65-year-old female with a heart murmur developed progressive symptom of chest oppression. She was diagnosed severe aortic valve stenosis with echocardiogram. Antibody screening revealed anti-Jr(a) antibody. Preoperatively, erythropoietin was administered. Over 14 days, a total 1,000 ml of her blood was drawn and stored for autologous transfusion. The aortic valve was replaced with ATS mechanical valve [18 mm advanced performance (AP)]. Following surgery, her stored blood was administered to him. But her HCT was 17% on the 1st postoperative day. Frozen thawed red cells were transferred 7th postoperative day.