Practical use of the central venous access port for contrast-enhanced CT: comparison with peripheral intravenous access regarding enhancement and safety

AIM

To evaluate the efficacy of using the central venous (CV) port compared with peripheral intravenous access for contrast-material injection for contrast enhancement during the portal venous phase.

MATERIALS AND METHODS

Patients were divided into three groups: CV delay, CV routine, and peripheral access (PA) groups. Patients in the CV delay group underwent injection in the arm-down position with an additional delay, while those in the CV routine and PA groups underwent injections with the routine injection protocol for portal venous phase imaging. Contrast enhancement was evaluated by measuring the mean radiodensity (Hounsfield units) values for the aortic arch, abdominal aorta, inferior vena cava, portal vein, and spleen. The peak injection pressure was recorded and compared among the three groups.

RESULTS

No complications related to power injection were observed during 119 contrast-material injections performed using the CV port device. The CV delay group showed significantly lower radiodensity values than the PA group (165.7 ± 20.1 versus 181 ± 19 HU [p<0.01] for the portal vein); however, no significant differences in mean radiodensity values were observed between the CV routine and PA groups (p>0.05). The median peak injection pressure was 73.5, 67, and 47 psi in the CV delay, CV routine, and PA groups, respectively (p<0.01).

CONCLUSION

The CV port can be used for safe contrast-material injection while maintaining contrast enhancement on portal venous phase comparable to that achieved with peripheral intravenous access.

Age-related changes in circulating INSL3 concentrations and their associations with ovarian conditions in Japanese Black beef cattle

Information on circulating levels of insulin-like peptide 3 (INSL3) in female domesticated animals is limited, as their concentrations are significantly lower than in males. The objectives of the present study were to 1) develop a sandwich time-resolved fluorescence immunoassay (TRFIA) with higher detectability to measure blood INSL3 concentrations in female cattle, 2) determine INSL3 concentrations in female cattle among age groups and reproductive conditions, and 3) explore associations between INSL3 levels and ultrasonographic ovarian measurements. Blood was collected repeatedly from Japanese Black beef female calves (n = 12; 0－8 mo), heifers (n = 10; 10－26 mo), and cows (n = 20; 27－200 mo). Blood was taken from the cows (n = 13) at follicular, post-ovulatory, and luteal phases, and from cows with follicular cysts (n = 12). Ultrasonography of ovaries was conducted in the calves (n = 12) and the cows without ovarian diseases (n = 9). The ovarian area, as well as the number and diameters of antral follicles ≥ 2 mm, were determined in each ovary. The proposed method detected a difference in plasma INSL3 between calves (0.01 ng/mL) and heifers (0.18 ng/mL). However, the conventional assay showed similar levels for calves and heifers (1.82 vs 2.07 ng/mL). Plasma INSL3 and testosterone concentrations increased from calves to heifers (P < 0.0001), but only INSL3 rose from heifers to cows (P < 0.0001). INSL3 and testosterone concentrations did not change across the estrus cycle in cows, and the levels of both hormones in follicular cystic cows did not differ from those in the follicular phase. Ovarian area, maximal and average follicular diameters, and total volume of all follicles per animal were higher in cows than calves (P < 0.001). Plasma INSL3 concentrations correlated positively with the total volumes of all follicles in calves (P < 0.05) and cows (P < 0.05), whereas testosterone concentrations did not correlate with ovarian follicular measurements. In conclusion, plasma INSL3 concentrations measured by the proposed sandwich TRFIA showed a clear increase from female calves to cows in beef cattle. These results suggest that circulating levels of INSL3, but not of testosterone, are associated with the total volume of all antral follicles in both ovaries per animal in female cattle.

Evaluation of tuberculosis diagnostic biomarkers in immunocompromised hosts based on cytokine levels in QuantiFERON-TB Gold Plus

Tuberculosis (TB) remains a serious health concern globally. QuantiFERON-TB (QFT) is a diagnostic tool for TB detection, and its sensitivity is reduced in immunocompromised hosts with low T lymphocyte counts or abnormal T cell function. This study aimed to evaluate the correlation between T cell and cytokine levels in patients with active TB using QFT-Plus. Forty-five patients with active TB were enrolled, and the cytokines in QFT-Plus tube supernatants were quantified using the MAGPIX System. CD4⁺ T cell count negatively correlated with patient age (p < 0.001, r = -0.51). The levels of TB1-responsive interleukin-1 receptor antagonist (IL-1Ra) and IL-2 correlated with CD4⁺ T cell count, whereas the levels of TB2-responsive IL-1Ra and IFN-γ-induced protein 10 correlated with both CD4⁺ and CD8⁺ T cell counts. Cytokines that correlated with CD4⁺ and CD8⁺ T cell counts might not be suitable TB diagnostic biomarkers in immunocompromised hosts. Notably, cytokines that did not correlate with the T cell counts, such as monocyte chemoattractant protein-1, might be candidate biomarkers for TB in immunocompromised hosts. Our findings might help improve TB diagnosis, which could enable prompt treatment and minimize poor disease outcomes.

Tuberculosis during lung cancer treatment-A case series

This study aimed to clarify the characteristics of patients with lung cancer undergoing treatment until the onset of tuberculosis. Between 2005 and 2019, patients who were admitted to Tokyo National Hospital due to tuberculosis during lung cancer treatment were examined retrospectively. There were 42 patients, and detailed medical information was obtained in 39 patients. The median age of the 39 patients were 75 years (range: 47-92 years), of which 33 were males and 36 were Japanese Baby Boomers or older. Regarding risk factors for developing tuberculosis, smoking was noted in 34 cases, oral corticosteroid use in 13, and previous tuberculosis in six. Thirty-seven patients had one risk factor and 19 had two or more risk factors, but diagnosis of latent tuberculosis infection (LTBI) was obtained in only one patients, and none had received LTBI treatment. The first-line treatment for lung cancer was resection in 13 cases, chemoradiotherapy in 6, chemotherapy in 10, radiation therapy in 3, laser therapy in 1, and best supportive care (BSC) alone in 6. At tuberculosis onset, BSC accounted for 17 cases, but other situations were considerably existed such as anticancer medication (12 cases), and observation after lung cancer treatment (10 cases). Tuberculosis occurred in various situations in elderly patients with lung cancer. It is critical to actively evaluate the risk of tuberculosis and consider LTBI screening and treatment.

Patient Perspectives of Inpatient Telemedicine During COVID-19: A Qualitative Assessment (Preprint)

Background

Telemedicine has been adopted in the inpatient setting to facilitate clinical interactions between on-site clinicians and isolated hospitalized patients. Such remote interactions have the potential to reduce pathogen exposure and use of personal protective equipment but may also pose new safety concerns given prior evidence that isolated patients can receive suboptimal care. Formal evaluations of the use and practical acceptance of inpatient telemedicine among hospitalized patients are lacking.

Objective

We aimed to evaluate the experience of patients hospitalized for COVID-19 with inpatient telemedicine introduced as an infection control measure during the pandemic.

Methods

We conducted a qualitative evaluation in a COVID-19 designated non–intensive care hospital unit at a large academic health center (Stanford Health Care) from October 2020 through January 2021. Semistructured qualitative interviews focused on patient experience, impact on quality of care, communication, and mental health. Purposive sampling was used to recruit participants representing diversity across varying demographics until thematic saturation was reached. Interview transcripts were qualitatively analyzed using an inductive-deductive approach.

Results

Interviews with 20 hospitalized patients suggested that nonemergency clinical care and bridging to in-person care comprised the majority of inpatient telemedicine use. Nurses were reported to enter the room and call on the tablet far more frequently than physicians, who typically entered the room at least daily. Patients reported broad acceptance of the technology, citing improved convenience and reduced anxiety, but preferred in-person care where possible. Quality of care was believed to be similar to in-person care with the exception of a few patients who wanted more frequent in-person examinations. Ongoing challenges included low audio volume, shifting tablet location, and inconsistent verbal introductions from the clinical team.

Conclusions

Patient experiences with inpatient telemedicine were largely favorable. Although most patients expressed a preference for in-person care, telemedicine was acceptable given the circumstances associated with the COVID-19 pandemic. Improvements in technical and care team use may enhance acceptability. Further evaluation is needed to understand the impact of inpatient telemedicine and the optimal balance between in-person and virtual care in the hospital setting.

Effects of H3 and H4 histones acetylation and bindings of CREB binding protein and p300 at the promoter on hepatic expression of gamma-glutamyltransferase gene in a streptozotocin-induced moderate hypoinsulinemic rat model

Gamma-glutamyltransferase (GGT), a marker of liver disease, has been shown to be associated with increased risk of diabetes and relative insulin secretion deficiency. However, the mechanism of hepatic Ggt regulation has not been explored fully. In this study, we made a concerted effort to understand the mechanism by investigating the effects of acetylation of histones H3 and H4, and bindings of histone acetyltransferases, CREB binding protein (CBP) and p300, at the Ggt promoter on the regulation of the expression of Ggt gene in the livers of streptozotocin (STZ)-induced moderate hypoinsulinemia rat model. The rats treated with STZ showed remarkably higher serum GGT level and hepatic Ggt/GGT expression than the untreated control rats. Furthermore, the acetylation of histones H3 and H4, and the binding of CBP not p300 at the Ggt promoter regions were significantly higher in the livers of STZ rats than those of the control rats. These results suggest that an enhanced hepatic expression of Ggt is associated with increased acetylation of histones H3 and H4 and CBP binding at the Ggt promoter in STZ-induced moderate hypoinsulinemic rats.

IL-1RA in the supernatant of QuantiFERON-TB Gold In-Tube and QuantiFERON-TB Gold Plus is useful for discriminating active tuberculosis from latent infection

INTRODUCTION

The new-generation QuantiFERON (QFT)-TB Gold Plus (QFT-Plus) is expected to be useful because it includes a new peptide that is supposed to induce a CD8⁺ T cell response. There is a need for a new marker with sensitivity higher than that of the conventional IFN-γ release assays owing to false-negative results in the latter. This study aimed to compare cytokines in QFT-plus and QuantiFERON-Gold In-Tube (QFT-GIT) supernatants to discriminate between active tuberculosis and latent tuberculosis infection (LTBI).

METHODS

A cross-sectional study was conducted at Tokyo National Hospital, wherein 21 LTBI patients and age and sex-matched active TB patients were randomly selected. The levels of various cytokines were measured and compared using the MAGPIX System, and receiver operating characteristic (ROC) curves were generated.

RESULTS

IL-1RA, IFN-γ, CXCL10/IP-10, and CCL4/MIP-1β levels were higher in the active TB group than in the LTBI group in QFT-GIT antigen (GIT Ag) tubes. In QFT-plus tubes, IL-1RA was higher in TB1 and TB2 tubes, while CCL2/MCP-1 was higher only in TB2 tubes. In Nil tubes, CCL5/RANTES, TNF-α, PDGF-BB, and IL-2 levels were significantly higher in the active TB group. IL-1RA in GIT Ag tubes showed the highest area under the curve of 0.8367. The sensitivity and specificity of IL-1RA were 66.7% (95% confidence interval [CI]: 43.0-85.4) and 90.5% (95% CI: 69.6-98.8), respectively, which were the highest among the cytokines.

CONCLUSIONS

IL-1RA level in the QFT-GIT supernatant can be a good marker for discriminating active TB from LTBI.

Species identification, antifungal susceptibility, and clinical feature association of Aspergillus section Nigri isolates from the lower respiratory tract

Species of Aspergillus section Nigri are generally identified by molecular genetics approaches, whereas in clinical practice, they are classified as A. niger by their morphological characteristics. This study aimed to investigate whether the species of Aspergillus section Nigri isolated from the respiratory tract vary depending on clinical diagnosis. Forty-four Aspergillus section Nigri isolates isolated from the lower respiratory tracts of 43 patients were collected from February 2012 to January 2017 at the National Hospital Organization (NHO) Tokyo National Hospital. Species identification was carried out based on β-tubulin gene analysis. Drug susceptibility tests were performed according to the Clinical and Laboratory Standards Institute (CLSI) M38 3rd edition, and the clinical characteristics were retrospectively reviewed. A. welwitschiae was isolated most frequently, followed by A. tubingensis. More than half of the A. tubingensis isolates exhibited low susceptibility to azoles in contrast to only one A. welwitschiae isolate. Approximately three quarters of the patients from whom A. welwitschiae was isolated were diagnosed with colonization, whereas more than half the patients from whom A. tubingensis was isolated were diagnosed with chronic pulmonary aspergillosis (CPA). More attention needs to be given to the drug choice for patients with CPA with Aspergillus section Nigri infection because A. tubingensis, which was found to be frequently azole-resistant, was the most prevalent in these patients.

Relapse of cervical tuberculous lymphadenitis immediately after completion of effective anti-tuberculosis treatments

Most cases of lymph node enlargement after completing tuberculosis (TB) treatment are due to paradoxical reaction (PR), not relapse, and therefore, do not require re-treatment. We herein report a case of a 28-year-old man who had developed cervical TB lymphadenitis and exhibited re-enlargement of the same lymph nodes one month after completing effective TB chemotherapy, which was microbiologically proven as relapse. The patient noticed painful cervical lymphadenopathy one month after completion of chemotherapy for TB lymphadenitis. Combination chemotherapy with multiple anti-TB drugs was resumed with suspicion of relapse. But, with his symptoms having worsened, surgical excision was performed. Mycobacterium tuberculosis was cultured from the dissected lymph nodes. Early regrowth of the lymph nodes after completing treatment can derive from microbiological relapse, in addition to PR. Surgical excision was useful for the microbiological diagnosis of the relapse. We must take care of lymph node re-enlargement in consideration of TB relapse.

Patency Capsule Aspiration

A 77-year-old man with anemia who had undergone 2 abdominal surgeries for colon and gastric cancer experienced dyspnea after swallowing a patency capsule before endoscopy for investigating the cause of anemia. Chest radiography and computed tomography revealed that the patency capsule was located within the bronchus intermedius. It was successfully removed by flexible bronchoscopy. The balloon was placed over the capsule and inflated. Subsequently, the catheter was pulled, while thus dragging the capsule with it and preventing its destruction. In cases of patency capsule aspiration, the capsule must be removed without deformity, before it causes inflammation by releasing barium into the airway.

Evaluation of cytokine levels using QuantiFERON-TB Gold Plus in patients with active tuberculosis

OBJECTIVES

A recently released new QuantiFERON (QFT) product, QFT TB Gold plus (QFT-plus), is optimized for both CD4 and CD8 responses and reported to have higher sensitivity compared to the former QFT-3 G. Previously, using supernatants of QFT-3 G, we and others have demonstrated that cytokines other than IFN-γ may be useful in diagnosing tuberculosis. The present study aimed to identify cytokines that are useful for accurately diagnosing active tuberculosis by using QFT-plus and compared the data to those with QFT-3 G.

METHODS

Eighty-three active tuberculosis patients and 70 healthy control subjects who were examined by QFT at Tokyo National Hospital from June 2017 to July 2018 were enrolled. QFT-3 G and QFT-plus were performed according to the manufacturer's instructions. At the same time, blood cell culture supernatants were collected and assayed for their cytokine levels using R&D Systems Luminex Assay and MAGPIX System. The levels of cytokines were compared between different antigen-containing tubes (3 G Ag, TB1 and TB2 tubes), as well as between the patients and the control subjects. ROC curves were drawn, and the AUCs were calculated.

RESULTS

Five cytokines, i.e., IL-2, IL-6, IL-8, IP-10 and MIP-1β, produced by human blood cells in three independent tubes containing different tuberculosis antigens were higher in the 3 G Ag tube compared to both the TB1 and TB2 tubes. Further, when the TB1 and TB2 tubes were compared, TB2 showed greater production of only PDGF-BB, and less production of IL-6 and TNF-α. For diagnosing active tuberculosis, the levels of IP-10 were superior to the level of IFN-γ based on showing a larger AUC for ROC curves in our present study setting. Finally, the levels of IFN-γ, IL-1RA, IL-2, IP-10, MCP-1 and MIP-1β were distinctly different between the active tuberculosis patients and healthy controls.

CONCLUSIONS

In summary, there was no cytokine that was higher in the tubes of QFT-plus compared to the tube of QFT-3 G, suggesting inferiority of QFT-plus antigens to 3 G Ag in terms of elicitation of cytokine production. Our results also suggest the usefulness of cytokines that showed a significant difference between the active tuberculosis patients and the healthy controls-namely, IFN-γ, IL-1RA, IL-2, IP-10, MCP-1 and MIP-1β-for diagnosing tuberculosis, but the roles of these cytokines in the pathogenesis of tuberculosis need to be elucidated (UMIN000035253).

P1444 Occurrence and predictors of right ventricular dysfunction after pericardiocentesis

Background—The changes in cardiac function that occur after pericardiocentesis are unclear.Purpose—This study was performed to assess right ventricular (RV) and left ventricular (LV) function with echocardiography before and after pericardiocentesis.

Method and Results—In total, 19 consecutive patients who underwent pericardiocentesis for more than moderate pericardial effusion were prospectively enrolled from August 2015 to October 2017. Comprehensive transthoracic echocardiography was performed before, immediately after (within 3 hours), and 1 day after pericardiocentesis to investigate the changes in RV and LV function. RV dysfunction is defined as meeting three of the four criteria: a TAPSE of &lt;17 mm, an S’ of &lt;9.5 cm, an FAC of &lt;35%, and an RV free wall longitudinal strain &gt;−20%. The mean age of all patients was 72.6 ± 12.2 years. The changes of echocardiographic parameters related to RV function are shown in Table. After pericardiocentesis, RV inflow and outflow diameters increased and the parameters of RV function significantly decreased. These abnormal values or RV dysfunction remained at 1 day after pericardiocentesis. Conversely, no parameters of LV function parameters changed after pericardiocentesis. Of 19 patients, 13 patients showed RV dysfunction immediately after pericardiocentesis and 6 patients did not. RV free wall longitudinal strain before pericardiocentesis was higher in patients with post-procedural RV dysfunction (−18.9 ± 3.6%) than in those without (−28.4 ± 6.3%). ROC analysis revealed that a RV free wall longitudinal strain cut-off value of −23.0% had a sensitivity of 100% and a specificity of 83.3% for predicting the occurrence of RV dysfunction after pericardiocentesis (AUC = 0.910).

Conclusions—The occurrence of RV dysfunction after pericardiocentesis should be given more attention. Pre-existing RV dysfunction maybe related to the occurrence of RV dysfunction after pericardiocentesis.

Changes in RV function before and after Before Immediately after One day after P−value Basal right ventricular linear dimension (mm) 32.8 ± 5.0 37.1 ± 4.4† 33.6 ± 5.4 0.028 Mid-cavity right ventricular linear dimension (mm) 34.5 ± 4.6 38.8 ± 5.3† 37.0 ± 5.6 0.0504 Proximal right ventricular outflow diameter (mm) 30.2 ± 4.0 33.9 ± 3.5† 31.4 ± 3.9 0.014 TAPSE (mm) 20.0 ± 4.2 13.6 ± 4.3* 14.7 ± 3.9 &lt;0.001 S" (cm/s) 12.6 ± 3.3 8.7 ± 2.4* 9.1 ± 2.4 &lt;0.001 Fractional area change (%) 48.3 ± 5.9 37.8 ± 8.0* 40.0 ± 9.0 &lt;0.001 Right ventricular free wall strain (%) −21.3 ± 6.3 −15.8 ± 6.7* −16.9 ± 5.2 0.036 Tricuspid regurgitation velocity peak (m/s) 2.41 ± 0.29 2.43 ± 0.25 2.34 ± 0.32 0.37

P37 Long-term outcomes of patients at risks for Fontan operation: role of temporary fenestration

Purpose

Whereas fenestration at Fontan operation was reported to be effective for smooth initiation to Fontan circulation, subsequently developed aortopulmonary collateral arteries under the presence of remaining hypoxia were a matter of concern.So as our institutional policy, it is closed as much and early as possible (temporary fenestration). This study aimed to reveal long-term outcomes for patients at riskswho underwent Fontan operation with temporary fenestration.

Methods

Of 107 patients undergoing Fontan operation from 1995 to 2004, 79 patients (73.8%) were free from any risks (NR group) and 28 patients (26.2%) had risks for Fontan operation (R group). Hypoplastic left heart syndrome, heterotaxy syndrome with obstructive total anomalous of pulmonary venous connection, and individual cases with high preoperative pulmonary artery pressure (PAP), systemic ventricular end diastolic pressure (SVEDP) or low ejection fraction (SVEF) were defined as a risk for Fontan completion.Age at Fontan operation was older in R group (6.6 vs 2.3years-old, p = 0.0004). Preoperative PAP (12.8 vs 11.3mmHg, p = 0.03) and SVEDP (8.8 vs 7.1mmHg, p = 0.02) were higher and SVEF (53.7 vs 60.0%, p = 0.002) was lower in R group. Pulmonary vascular resistance (PVR) was not different. Fenestration was created in all patients in R group, then it was closed at the mean duration of 2.9 years after Fontan operation.

Results

Freedom from death or protein-losing enteropathy rate at 5, 10, and 15 years after Fontan operation were 97, 96, and 93% in NR group and 96, 93, and 86% in R group (log-rank: p = 0.20). Fifty-one patients (64.6%) in NR group and 17 patients (60.7%) in R group underwent serial catheter examinations at 5, 10, and 15 years after Fontan operation and exercise capacity testing at 15 years after Fontan operation (Figure). In R group, arterial oxygen saturation was lower and PVR was higher even after close of fenestration (Figure). In addition, 12 patients (71%) in R group developed significant veno-venous collaterals, which were defined by more than 3mm in diameter of collateral veins or a condition where pulmonary veins were contrasted in venography. On the contrary, cardiac index (CI), SVEDP, and PAP were not different and no significant difference on peak oxygen uptake and anaerobic threshold were observed between in 2 groups. 

Conclusions

Although the mild cyanosis remained due to the development of veno-venous collaterals after the closure of temporary fenestration, CI, SVEDP and PAP well maintained in patients at risk for Fontan operation. These results might to lead acceptable life prognosis and freedom fromprotein-losing enteropathy rate for patients at risk for Fontan operation.

Abstract P37 Figure

High-Fructose Diet-Induced Hypertriglyceridemia Is Associated With Enhanced Hepatic Expression of ACAT2 in Rats

High levels of fructose induce hypertriglyceridemia, characterized by excessive levels of triglyceride-rich lipoproteins such as very low-density lipoprotein (VLDL); however, the underlying mechanisms are poorly understood. The aim of this short communication was to examine hepatic changes in the expression of genes related to cholesterol metabolism in rats with hypertriglyceridemia induced by high-fructose or high-glucose diets. Rats were fed a 65 % (w/w) glucose diet or a 65 % (w/w) fructose diet for 12 days. Serum levels of triglycerides, total cholesterol, and VLDL+LDL-cholesterol, hepatic levels of triglycerides and cholesterol, and ACAT2 expression at the gene and protein levels were significantly higher in the fructose diet group compared to the glucose diet group. The hepatic levels of Abcg5/8 were lower in the fructose group than in the glucose group. Serum high-density lipoprotein (HDL)-cholesterol and hepatic expression levels of Hmgcr, Ldlr, Acat1, Mttp, Apob, and Cyp7a1 did not differ significantly between groups. These findings suggest that high-fructose diet-induced hypertriglyceridemia is associated with increased hepatic ACAT2 expression.

P1624Blockade of protease activated receptor-1 signaling attenuates cardiac hypertrophy and fibrosis in renin-overexpressing hypertensive mice

Introduction

Recent evidences have demonstrated that coagulation pathway is involved in cardiovascular remodeling induced by renin-angiotensin system (RAS), which finally leads to heart failure. Protease activated receptor-1 (PAR-1) is widely expressed in the vasculature and the heart, and plays important roles in pro-inflammatory process in the cardiovascular system. Recently, we demonstrated that the activity of factor Xa (FXa), which functions not only as a coagulation factor but as an agonist for PAR-1, was enhanced in renin-overexpressing hypertensive mice (Ren-Tg).

Purpose

The purpose of this study was to investigate whether inhibition of PAR-1 signaling has protective effects on the progression of heart failure induced by chronic RAS activation in Ren-Tg.

Methods and results

We treated 12–16 weeks-old male wild type mice (WT) and Ren-Tg with continuous subcutaneous infusion of PAR-1 antagonist SCH79797 (25mg/kg/day) or vehicle for 4 weeks. After treatment period, left ventricular (LV) wall thickness calculated as interventricular septum plus posterior wall thickness measured by echocardiography was greater in Ren-Tg than in WT (0.25±0.003 versus 0.18±0.002 mm), and SCH79797 attenuated the increase to 0.22±0.01 mm in Ren-Tg (both p<0.05, respectively). The ratio of heart weight to body weight was greater in Ren-Tg than in WT (6.1±0.4 versus 4.6±0.7 mg/g), and SCH79797 attenuated the increase to 5.2±0.1 mg/g (both p<0.05). The area of cardiac fibrosis evaluated by Masson-trichrome staining was greater in Ren-Tg than in WT (2.6±0.2 versus 1.4±0.3%), and SCH79797 attenuated it to 1.6±0.3% in Ren-Tg (both p<0.05). Cardiac mRNA expressions of tumor necrosis factor-α, transforming growth factor-β1, and β-myosin heavy chain were all greater in Ren-Tg than in WT, and SCH79797 attenuated the increases in Ren-Tg (all p<0.05).

Conclusions

Inhibition of PAR-1 signaling attenuates cardiac hypertrophy and fibrosis in Ren-Tg via inhibition of inflammatory cytokines production. These results support the involvement of PAR signaling in the development of heart failure induced by RAS, and may provide novel therapeutic insights for the treatment of hypertensive heart failure.

A 56-Year-Old Woman With Multiple Pulmonary Cysts and Severe Chest Pain

A 56-year-old woman presented to our hospital with a 4-month history of worsening chest pain. She denied having any respiratory symptoms, such as dyspnea, sputum, cough, or hemoptysis, or any history of smoking or exposure to dusts. One year previously she had a vertebral fracture. There was no specific family history, including pulmonary or autoimmune diseases. Chest CT performed 3 years earlier showed multiple thin-walled pulmonary cysts, although no further investigations were performed.

Pulmonary Adenocarcinoma, Harboring Both an EGFR Mutation and ALK Rearrangement, Presenting a Stable Disease to Erlotinib and a Partial Response to Alectinib

A 63-year-old woman with pulmonary adenocarcinoma (stage IIIB) that was positive for an epidermal growth factor receptor (EGFR) mutation and an anaplastic lymphoma kinase (ALK) rearrangement was treated with erlotinib as the first-line treatment, resulting in a stable disease. Due to skin rashes, fatigue and anorexia, erlotinib was suspended on erlotinib day 44. Alectinib was administered as the second-line treatment, exhibiting a partial response. On alectinib day 56, drug-induced lung injury forced suspension of alectinib, which was cured with corticosteroid therapy. ALK-tyrosine kinase inhibitors may be more effective for patients positive for both EGFR mutation and ALK rearrangement than other agents.

A successful pembrolizumab treatment case of lung adenocarcinoma after becoming resistant to ALK-TKI treatment due to G1202R mutation

BACKGROUND

In current guidelines, the role of immune checkpoint inhibitors is not yet determined in the treatment strategy for NSCLC harboring ALK translocations.

CASE

A 51-year-old woman with lung adenocarcinoma harboring ALK translocation was treated with alectinib until PD. After the second (CDDP/PEM) and third (crizotinib) line treatment, a second biopsy was performed, revealing PD-L1 tumor proportion score of 70-80% and G1202R mutation of ALK. Pembrolizumab was selected for the fourth line, leading to PR for more than 6 months.

CONCLUSIONS

While alectinib might induce resistance to ALK-TKI, it could increase PD-L1 positive cells to become sensitive to PD-1/PD-L1 inhibitors.

Condyloma Acuminata of the Urethra in a Male Renal Transplant Recipient: A Case Report

BACKGROUND

Condyloma acuminatum (CA) is a common sexually transmitted disease associated with human papilloma virus (HPV). CA occurring in the urethra is rare and has not been reported in male renal transplant recipients. In addition, despite immunosuppressive conditions and increased risk of HPV-related malignant neoplasms in transplant recipients, HPV testing in male transplant recipients has been uncommon. Here we report a case of urethral CA in a male deceased donor renal transplantation recipient and discuss the importance of HPV testing in male transplant recipients.

CASE PRESENTATION

A 33-year-old male deceased donor renal transplant recipient presented with miction pain 5 years after the transplantation. He reported repeated urinary tract infections with no sexual contact since the renal transplantation. Multiple papillary tumors in his penile urethra were detected by cystoscopy, and a biopsy sample was pathologically diagnosed with CA. Transurethral tumor resection was performed, and the tumors were completely resected. Additional HPV risk type screening with a urethral smear sample showed the prevalence of low-risk HPV. Although tacrolimus was switched to everolimus and imiquimod cream was administered, the tumors recurred 6 months after the resection, and a second resection was performed. No further recurrence has been observed for 1 year to date.

CONCLUSION

As the urethral CA was possibly related to immunosuppressive conditions and a risk for HPV-related malignant neoplasm, the case required careful diagnosis, including HPV risk type. The methodology of sampling for HPV testing in men has not been established. This case suggests the necessity for further discussion about HPV testing in male transplant recipients.

Mass Preparation of Primary Porcine Hepatocytes and the Design of a Hybrid Artificial Liver Module using Spheroid Culture for a Clinical Trial

To isolate a large number of porcine hepatocytes, we originally developed a mass preparation method that combined the usual collagenase perfusion method of a whole liver with a collagenase redigestion method of tissue fragments after liver perfusion. Using a pig of 10kg, collagenase perfusion only resulted in a yield of 63 ± 78 x 108 total cells with a viability of 69.2 ± 25.3 %, but our combined method had a yield of 167 ± 31 x 108 total cells with a viability of 87.9 ± 4.4 % (mean ± SD). Also, the combined method was applied to two pigs of 10kg body weight at the same time, and isolated 387 ± 89 x 108 hepatocytes with a viability of 87.1 ± 6.9 % and a purity of 93.6 ± 2.8 % in 11 experiments.

We designed a large multi-capillary polyurethane foam (MC-PUF) packed-bed module containing 1 x 1010 porcine hepatocytes on a clinical trial scale. The porcine hepatocytes in the module formed spherical multicellular aggregates (spheroids) of 200 – 500 μm diameter. Most hepatocytes forming spheroids were viable judged by fluorescein diacetate and ethidium bromide staining. The activities of ammonia removal, albumin secretion and oxygen consumption of the large MC-PUF module were the same as for a small MC-PUF module containing 2 x 108 porcine hepatocytes, and were maintained for at least 9 days of culture. These results show that a large MC-PUF module is successfully scaled up 50 times.

In conclusion, we succeeded in developing a mass preparation method of porcine hepatocytes and a large hybrid artificial liver module on a clinical trial scale.

Development of a Hybrid Artificial Liver using a Polyurethane Foam/Hepatocyte-Spheroid Packed-Bed Module

Primary dog hepatocytes spontaneously formed spheroids in the pores of polyurethane foam (PUF) within 1–2 days of stationary culture. The spheroids, about 100–150 μm in diameter, partly attached to the surface and immobilized inside these pores.

The lidocaine disappearance rate decreased to about 4 μg/105 viable cells/day for 10 days, while in the PUF/spheroid culture the rate was maintained at almost the initial level of 8 μg/105 viable cells/day for 10 days. Then, two scales of PUF packed-bed modules were designed. A small module (PUF volume; 14.5 cm3) was used for in vitro culture to investigate optimum culture conditions, and a large module (PUF volume; 300 cm3) was designed for dog experiments. Hepatocytes inoculated in these modules also formed spheroids and maintained almost the same activity of albumin secretion rate (111 μg/cm3 PUF/day in the small module and 87.7 μg/cm3 PUF/day in the large module). These results indicate that the PUF packed-bed module containing hepatocyte-spheroids is promising as a hybrid artificial liver

The Efficacy of Nafamostat Mesilate on the Performance of a Hybrid-artificial Liver using a Polyurethane foam/porcine Hepatocyte Spheroid Culture System in Human Plasma

Nafamostat mesilate (FUT) is a protease inhibitor of complement activation. The present study investigates whether FUT protects porcine hepatocytes from being injured by human plasma in a multi-capillary polyurethane foam packed-bed culture system (MC-PUF) such as the hybrid-artificial liver (PUF-HAL). Human plasmas with 1 mM of added ammonia were perfused using a small-scale PUF-HAL with porcine hepatocytes. FUT was continuously infused (10 μ g/ml, 50 μ g/ml,). The ammonia detoxification was maintained in human plasma for 24 hours and for 48 hours with FUT which suppressed the rapid increase of asparaginic acid aminotransferase (AST) and alanine aminotransferase (ALT). After 60 hours of perfusion, hepatocyte spheroids completely collapsed in the human plasma, but a small amount of hepatocyte spheroid was maintained by FUT. The effect of FUT was slightly greater at 50 μ g/ml than at 10 μ g/ml. Our results suggest that FUT has protective effects against porcine hepatocytes in human plasma, and our PUF-HAL using porcine hepatocytes can function in human plasma for about 48 hours with FUT.

Conditions Required for a Hybrid Artificial Liver Support System using a PUF/Hepatocyte-Spheroid Packed-Bed Module and it's use in Dogs with Liver Failure

We studied the effects of a hybrid artificial liver support system we developed on dogs with hepatic failure. The system consisted of a multi-channel polyurethane foam packed-bed culture module, including primary dog hepatocyte spheroids.

Blood ammonia was well metabolized by 20 g hepatocytes, but the other functions such as glucose concentration, total bile acid concentration, and survival time required 30 g hepatocytes to improve conditions. We found that we should use a culture substratum that easily forms spheroids, and that an artificial liver module should be used as soon as possible after spheroid formation by hepatocytes in the module.