Is Common Trunk Anomaly Frequent in Hemifacial Spasm? Comparison with Normal Subjects using MRI

PURPOSE

Hemifacial spasm (HFS) results from vascular compression at the root exit of the facial nerve. Although the underlying etiology has yet to be identified, it has been suggested that congenital vascular anomalies are involved. We have hypothesized common trunk anomaly of the anterior inferior cerebellar artery (AICA) and posterior inferior cerebellar artery (PICA), may play a role in HFS. However, no previous studies have directly compared the incidence of this anomaly between HFS patients and normal subjects. The present study was designed to address this gap in the literature.

METHODS

This case-control study compared magnetic resonance angiography data from 65 HFS patients and 65 normal subjects. Dominant AICA/PICA is defined as the absence of PICA/AICA, with the remaining AICA/PICA supplying both vascular territories. The term "common trunk" encompasses both dominant AICA and dominant PICA. The frequency of common trunk and dominant AICA/PICA was compared between the two groups.

RESULTS

There were no significant differences in the incidence of a common trunk (68.5% and 64.6%), dominant AICA (30.8% and 32.3%) and dominant PICA (37.7% and 32.3%) between the two groups. Additionally, no differences were found in the frequency of atherosclerosis risk factors.

CONCLUSIONS

There was no apparent association between common trunk anomaly and HFS. It is suspected that some vascular anomalies other than a common trunk are involved in HFS.

A Case of Unilateral Facial Spasm With Vulnerable Hearing Function Due to a History of Cisplatin Treatment, Resulting in Intraoperative Hearing Loss

A 51-year-old man with a history of cisplatin treatment for a right testicular tumor underwent microvascular decompression for hemifacial spasm. At an early stage in the surgical procedure, the intraoperative auditory brainstem response (ABR) was diminished despite a relatively minimally invasive approach, resulting in irreversible hearing loss. Cisplatin is known to cause dose-dependent hearing impairment primarily affecting the cochlea, but it can also induce neurotoxicity. In the present case, prior cisplatin administration may have caused fragility of the cochlear nerve as well. Patients with a history of ototoxic and neurotoxic drugs such as cisplatin require more careful manipulation and thorough intraoperative auditory monitoring during neurosurgical procedures that may affect hearing, such as those for hemifacial spasms.

[Image Diagnosis for Hemifacial Spasm]

Cisternography using heavy T2-weighted images from 3-Tesla magnetic resonance imaging(MRI)and three-dimensional time-of-flight MR angiography(3D TOF MRA)is useful for identifying conflicting vessels in primary hemifacial spasm(HFS). Cisternography provides high-signal images of the cerebrospinal fluid and low-signal images of the cranial nerves and cerebral blood vessels, whereas 3D TOF MRA provides high-signal images with only vascular information. The combination of these two methods increases the identification rate of conflicting vessels. The neurovascular conflict(NVC)site in HFS is where the facial nerve exits the brainstem. However, on MRI, the true NVC site is often more proximal than the facial nerve attachment to the brainstem. On preoperative MRI, it is important to not miss the blood vessels surrounding the proximal portion of the facial nerve. If multiple compression vessels or deep vessels are located in the supraolivary fossette, they may be missed. Coronal section imaging and multiplanar reconstruction(MPR)minimize the chances of missing a compression vessel. Preoperative MRI and CT can also provide various other information, such as volume of the cerebellum, presence of emissary veins, shape of the petrosal bone, and size of the flocculus.

Neuroprotective Effects of Artificial Cerebrospinal Fluid: Analysis of Brainstem Auditory-Evoked Potential Monitoring During Microvascular Decompression in 117 Consecutive Patients

BACKGROUND AND OBJECTIVES

To study the efficacy of irrigation with artificial cerebrospinal fluid (aCSF) for protection of cranial nerves during surgery; the time required for recovery of brainstem auditory-evoked potentials (BAEPs) that would reflect cochlear function was analyzed in comparison with that for saline irrigation.

METHODS

This retrospective study included 117 consecutive patients (95 women, mean age 51.5 ± 11.4 year) who underwent microvascular decompression for hemifacial spasm. During surgery, BAEPs were monitored to avoid damage to the auditory pathways. When a delayed latency of >1 ms or a decrease in amplitude of >50% was detected in BAEP wave V, surgical maneuvers were halted, and the operative field was irrigated with saline or aCSF. Saline was used for irrigation in 58 patients and aCSF in the other 59. The time required for BAEP recovery at the first halt in each patient was analyzed, and the results were compared between the groups.

RESULTS

Surgical procedures were interrupted because of BAEP latency delays or decreases in amplitude in 51 of the patients in the saline group and 54 in the aCSF group. In both groups, the latencies and amplitudes recovered significantly with time and both recovered earlier after aCSF irrigation than after saline irrigation. Hearing outcome was not significantly different between 2 groups.

CONCLUSION

aCSF is effective for protection of cochlear nerve and promotes recovery from transient dysfunction during surgery. The protective effect may be attributed to multiple factors including conditioned pH, electrolyte composition, glucose, and microelements, such as magnesium and phosphate.

Aggregated chromosomes/chromatin transfer: a novel approach for mitochondrial replacement with minimal mitochondrial carryover: the implications of mouse experiments for human aggregated chromosome transfer

Nuclear transfer techniques, including spindle chromosome complex (SC) transfer and pronuclear transfer, have been employed to mitigate mitochondrial diseases. Nevertheless, the challenge of mitochondrial DNA (mtDNA) carryover remains unresolved. Previously, we introduced a method for aggregated chromosome (AC) transfer in human subjects, offering a potential solution. However, the subsequent rates of embryonic development have remained unexplored owing to legal limitations in Japan, and animal studies have been hindered by a lack of AC formation in other species. Building upon our success in generating ACs within mouse oocytes via utilization of the phosphodiesterase inhibitor 3-isobutyl 1-methylxanthine (IBMX), this study has established a mouse model for AC transfer. Subsequently, a comparative analysis of embryo development rates and mtDNA carryover between AC transfer and SC transfer was conducted. Additionally, the mitochondrial distribution around SC and AC structures was investigated, revealing that in oocytes at the metaphase II stage, the mitochondria exhibited a relatively concentrated arrangement around the spindle apparatus, while the distribution of mitochondria in AC-formed oocytes appeared to be independent of the AC position. The AC transfer approach produced a marked augmentation in rates of fertilization, embryo cleavage, and blastocyst formation, especially as compared to scenarios without AC transfer in IBMX-treated AC-formed oocytes. No significant disparities in fertilization and embryo development rates were observed between AC and SC transfers. However, relative real-time PCR analyses revealed that the mtDNA carryover for AC transfers was one-tenth and therefore significantly lower than that of SC transfers. This study successfully accomplished nuclear transfers with ACs in mouse oocytes, offering an insight into the potential of AC transfers as a solution to heteroplasmy-related challenges. These findings are promising in terms of future investigation with human oocytes, thus advancing AC transfer as an innovative approach in the field of human nuclear transfer methodology.

Preoperative findings in relation to the usefulness of endoscopic assistance for microvascular decompression

PURPOSE

Endoscopy is known to be a useful adjunct for microvascular decompression (MVD) surgery, assisting observation in blind spots such as Meckel's cave in cases of trigeminal neuralgia (TN) and the root exit zone (REZ) in hemifacial spasm (HFS). However, few reports have discussed the usefulness of endoscopy in relation to individual patient characteristics or preoperative magnetic resonance imaging (MRI).

METHODS

We retrospectively reviewed the medical records of 109 patients (98 with HFS and 11 with TN, 85 women, median age 55 years) who had undergone endoscopically assisted MVD at our institution between 2017 and 2021. The usefulness of endoscopy in individual cases was scored by three neurosurgeons using a grading scale: 2, essential and indispensable; 1, useful and helpful; 0, not necessary. The mean value of the assigned scores was taken as an indicator of "usefulness," and endoscopy was considered to have been "useful" in cases with a score of > 1.0.

RESULTS

Endoscopic assistance was judged to have been useful in 69% of the patients. The proportion of patients evaluated as useful was significantly lower for TN (18.2%) than for HFS (74.5%). Patients with superior cerebellar artery compression had significantly lower scores than patients with other vessels. Endoscopy was considered useful in a significantly higher proportion of patients with anatomically complicated offending vessels (bifurcation or strong meandering) in the REZ detected by preoperative MRI (P < 0.005).

CONCLUSION

Endoscopy for MVD is useful for patients with HFS, especially when preoperative MRI shows bifurcation or strongly meandering vessels in the REZ.

Bilateral Low-Frequency Hearing Impairment After Microvascular Decompression Surgery

BACKGROUND

Hearing impairment is an important complication of microvascular decompression (MVD). In patients after MVD, we have occasionally noted slight to moderate hearing deterioration at low frequencies that is difficult to detect using pure tone average.

OBJECTIVE

To assess the incidence and features of low-frequency hearing impairment (LF-HI) after MVD and evaluate its associated factors.

METHODS

This single-center, retrospective observational study assessed the audiometric outcome of 270 patients who underwent MVD between January 2015 and December 2020. Preoperative and postoperative hearing levels were compared for each frequency. LF-HI was defined as a hearing deterioration of ≥15 dB at 125, 250, or 500 Hz. The incidence, symptoms, and associated factors of LF-HI were analyzed.

RESULTS

Statistical analysis of the patients overall demonstrated slight but significant decreases in the hearing level after MVD at lower frequencies on both the operative and contralateral sides. Eighty-one patients (30.0%) had LF-HI: 49 on the operative side, 24 on the contralateral side, and 8 on both sides, while pure tone average was worsened in 5 patients (1.8%). Subjective symptoms, including hearing deterioration, ear fullness, tinnitus, and dizziness, developed in 10.4% of the patients with LF-HI but improved subsequently within several weeks. "Older age" and "operative side" were associated with LF-HI.

CONCLUSION

Decreases in lower-frequency hearing levels in both the ipsilateral and contralateral (nonoperative) ears were observed after trigeminal neuralgia and hemifacial spasm surgery. LF-HI does not cause permanent symptoms but may be a noteworthy phenomenon, possibly involved in the contralateral hearing loss encountered occasionally after other types of posterior cranial fossa surgery.

Surgical repair of an unroofed coronary sinus in a dog

A 5-year-old, 7.9 kg castrated male Miniature Dachsund presented with heart enlargement on radiography. The dog was asymptomatic. Echocardiography revealed a tubular structure running along the posterior wall of the left atrium and connecting to the right atrium on the caudal side of the left atrium and annulus, which was presumed to be a dilated coronary sinus. After confirming a shunt between the left atrium and coronary sinus by cardiovascular catheterization, an unroofed coronary sinus was diagnosed. Open-heart surgery using cardiopulmonary bypass was performed through left atriotomy. The defect between the left atrium and the coronary sinus was closed by suturing. The cardiac enlargement improved after surgery. The dog was still alive 1227 days after surgery without clinical signs.

Aspiration Surgery with Appropriate Antibiotic Treatment Yields Favorable Outcomes for Bacterial Brain Abscess

BACKGROUND

Even in the era of advanced medical treatment, brain abscess still has a high mortality rate. At our institution, brain abscess has been treated mainly using stereotactic or echo-guided aspiration followed by relatively long-term antibiotic treatment, achieving favorable outcomes. To evaluate the efficacy of our strategy involving less-invasive aspiration surgery and long-term selective antibiotic administration for brain abscess, a single-institution series of cases was investigated.

METHODS

We retrospectively reviewed and analyzed the medical records of 25 cases of brain abscess treated at Saitama Medical University Hospital between 2008 and 2021. The patients comprised 16 men and 9 women aged between 39 and 85 years (median 62 years). Neurosurgical intervention was performed for 23 (92.0%) of the patients and the remaining 2 received antibiotics alone.

RESULTS

Among the neurosurgery patients, 22 (95.7%) underwent echo-guided or stereotactic aspiration, and only 1 underwent craniotomy. Anaerobic bacteria were detected in 11 patients. In the surgical and conservative groups, the median duration of antibiotic treatment was 16 weeks and 23 weeks, respectively. Since 2014 when metronidazole first became available, it has replaced meropenem to cover anaerobic bacteria. The overall mortality rate was 4.0% and a favorable outcome (Glasgow Outcome Scale 4 or 5) was achieved in 76% of the patients. There was no surgical mortality or morbidity.

CONCLUSIONS

Most patients underwent aspiration surgery and achieved favorable outcomes. Along with antibiotic treatment for a sufficiently long period to cover anaerobes, this approach can be expected to yield good results.

OP0062 EFFICACY AND SAFETY OF ADALIMUMAB WITH LOW AND HIGH DOSE-METHOTREXATE IN PATIENTS WITH RHEUMATOID ARTHRITIS WITH INADEQUATE RESPONSE TO METHOTREXATE: THE RANDOMISED CONTROLLED MIRACLE STUDY

Background

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that causes not only joint pain but also bone destruction resulting in impairment of quality of life. Tumor necrosis factor inhibitors have improved prognosis of patients with rheumatoid arthritis dramatically, especially in combination with methotrexate, however, the optimal dose of the concomitant methotrexate is unclear.

Objectives

To evaluate the efficacy and safety of adalimumab in combination with reduced dose of methotrexate in patients with early RA with inadequate response to methotrexate.

Methods

The MIRACLE study was a multinational, randomized, open-label study in patients with RA with inadequate response to methotrexate conducted in Asia. It compared low dose and high dose methotrexate upon starting adalimumab. Methotrexate-naive patients with RA with a disease duration of less than two years started methotrexate at 6 to 8 mg/week and increased it to the maximum tolerable dose by week 12. Patients who have not achieved remission according to simplified disease activity index (SDAI) despite methotrexate ≥ 10 mg/week at week 24 were randomised to the maximum tolerable dose of methotrexate group (10 to 25 mg/week) or the reduced dose group (6 to 8 mg/week) and started to receive subcutaneous adalimumab 40 mg every other week. The primary endpoint was non-inferiority in the achievement of SDAI remission at week 48 in the reduced dose group compared with the maximum tolerable dose group with a non-inferiority margin of -15% based on two-sided 90% confidence interval. (NCT03505008)

Results

A total of 300 patients were enrolled in the study. Among them, 291 started methotrexate and were included in the analysis. The mean age was 57.7±15.2 years, female was 74.6%, and the mean disease duration from the diagnosis of RA was 21.1±56.2 days. Anti-CCP antibody was positive in 211 (73.0%) and the mean SDAI at study enrollment was 26.5±12.4. At week 24, with the mean dose of methotrexate of 12.6±2.9 mg/week, 108 patients (37.1%) achieved remission according to SDAI and continued MTX monotherapy. 134 patients (46.0%) were randomised and started adalimumab with 68 patients in the maximum tolerable dose group and 66 patients in the reduced dose group. At week 48, the remission achievement rates were 38.4 % and 44.8 %, respectively, with the adjusted risk difference of the reduced dose group to the maximum tolerable dose group of 6.4% (-7.0% to 19.8%, 90% CI), which met the criterion for noninferiority. No significant difference was found in health assessment questionnaire disability index ≤0.5 (59.1% vs 62.0%, respectively, p=0.72) and in radiological remission rates (Δmodified total Sharp score ≤0.5, 66.3% vs 62.0 %, respectively, p=0.59). Adverse drug reactions tended to be more frequent in the maximum tolerable dose group than in the reduced dose group (22.1% vs 9.1%, respectively, p=0.06).

Conclusion

The MIRACLE randomised study demonstrated that, in patients with inadequate response to methotrexate, the efficacy of adalimumab with reduced dose of concomitant methotrexate was not inferior to that with maximum tolerable dose of methotrexate with better safety profile.

Disclosure of Interests

Hiroya Tamai Speakers bureau: Eisai, Grant/research support from: Eisai, Kei Ikeda Speakers bureau: AbbVie, Eisai, Eli Lilly, Novartis, Gilead, Asahi-Kasei, Grant/research support from: Mitsubishi-Tanabe, Toshiaki Miyamoto: None declared, Hiroaki Taguchi: None declared, Chang-Fu Kuo: None declared, Kichul Shin: None declared, Shintaro Hirata Speakers bureau: AbbVie, Asahi-Kasei, Astellas, Ayumi, Bristol Myers Squibb, Celgene, Chugai, Eisai, Eli Lilly, Gilead, Glaxo SmithKline, Janssen, Kyorin, Novartis, Pfizer, Sanofi, Tanabe-Mitsubishi, UCB, Paid instructor for: AbbVie, Mitsubishi-Tanabe, Consultant of: AbbVie, Astellas, Bristol Myers Squibb, Eisai, Gilead, Ily Lilly, Grant/research support from: AbbVie, Asahi-Kasei, Eisai, Otsuka, Sanofi, Shionogi, Chugai, Pfizer, Tanabe-Mitsubishi, Eli Lilly, UCB, yutaka okano: None declared, Shinji Sato Speakers bureau: AbbVie, Eisai, Grant/research support from: AbbVie, Eisai, Hidekata Yasuoka Speakers bureau: AbbVie, Asahi Kasei Pharma, Astellas, Daiichi-Sankyo, Eisai, Kissei, Takeda, Mitsubishi-Tanabe, Chugai, Novartis, Eli Lilly, Pfizer, Janssen, Sanofi, Teijin, Boehringer-Ingelheim, Bayer, Glaxo Smith Kline, Paid instructor for: AbbVie, Consultant of: AbbVie, Asahi Kasei, Grant/research support from: Mitsubishi-Tanabe, Takeda, Daiichi-Sankyo, Chugai, Bristol-Myers, MSD, Astellas, In Ah Choi Speakers bureau: Abbvie, Eisai, Sung-Hwan Park: None declared, Meng-Yu Weng Paid instructor for: Novartis, Eli Lilly, ChuGai, Abbvie, Consultant of: Abbvie, Masataka Kuwana Speakers bureau: Astellas, Asahi Kasei Pharma, Boehringer-Ingelheim, Chugai, Eisai, Janssen, Mochida, Nippon Shinyaku, Ono Pharmaceuticals, Pfizer, Mitsubishi-Tanabe, Consultant of: Boehringer-Ingelheim, Kissei, Mochida, Grant/research support from: AbbVie, Asahi Kasei Pharma, Boehringer-Ingelheim, Chugai, Eisai, MBL, Nippon Shinyaku, Ono Pharmaceuticals, Mitsubishi-Tanabe, Yun Jong Lee Grant/research support from: Yuhan, Tomonori Ishii Speakers bureau: Chugai, Mitsubishi-Tanabe, Glaxo Smith Kline, Pfizer, Eli Lilly, Janssen, AbbVie, Eisai, Astellas, Jinhyun Kim: None declared, Hideto Kameda Speakers bureau: AbbVie, Pfizer, Consultant of: AbbVie, Grant/research support from: AbbVie, Eisai, Toshihisa Kojima Speakers bureau: AbbVie, Pfizer, Eisai, Grant/research support from: AbbVie, Han Joo Baek: None declared, Ping-Ning Hsu: None declared, Chun-Ming Huang Paid instructor for: Abbvie, Pfizer, Tien-Tsai Cheng Paid instructor for: Abbvie, Grant/research support from: Abbvie, Wan-Yu Sung: None declared, Takehiro Taninaga Shareholder of: Eisai.co.,Ltd., Employee of: Eisai.co.,Ltd., Masahiko Mori Shareholder of: Eisai.co.,Ltd., Employee of: Eisai.co.,Ltd., Hideaki Miyagishi Shareholder of: Eisai.co.,Ltd., Employee of: Eisai.co.,Ltd., Yasunori Sato Speakers bureau: Eisai Co., Ltd. Kowa Company, Ltd., Consultant of: MOCHIDA PHARMACEUTICAL CO., LTD, Tsutomu Takeuchi Speakers bureau: Astellas, AbbVie, Ayumi, Bristol Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Glaxo Smith Kline, Janssen, Mitsubishi-Tanabe, Nippon-kayaku, Novartis, Pfizer, Sanofi, UCB, Grant/research support from: Asahi Kasei, AbbVie, Ayumi, Boehringer-Ingelheim, Chugai, Eisai, Eli Lilly, Mitsubishi-Tanabe, Sanofi, UCB, Yuko Kaneko Speakers bureau: Asahi Kasei, Astellas, Ayumi, Bristol Myers Squibb, Chugai, Eisai, Elli Lilly, Mitsubishi-Tanabe, Novartis, UCB, Grant/research support from: AbbVie, Chugai, Eisai, Mitsubishi-Tanabe, UCB.

POS0822 HYPERTROPHIC PACHYMENINGITIS IN ANTINEUTROPHIL CYTOPLASMIC ANTIBODY-ASSOCIATED VASCULITIS: A MULTICENTER SURVEY IN JAPAN

Background

Hypertrophic pachymeningitis (HP), characterized by an inflammatory disorder indicating intracranial or spinal thickening of dura mater, is found to develop as a neurological involvement in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). Meanwhile, the previous studies focusing on HP in AAV have been reported as a single-institution study, and the analyses were performed in a small number of patients because HP is a rare neurological disorder. Therefore, neither etiological nor clinical characteristics of HP in AAV have been adequately elucidated.

Objectives

This study clarified the characteristics of HP in AAV by analyzing the information of multicenter study in Japan (Japan collaborative registry of ANCA-associated vasculitis: J-CANVAS).

Methods

We analyzed the clinical information from 541 Asian patients with AAV enrolled in J-CANVAS. Of them, newly diagnosed and relapsed AAV were included in 448 and 93, respectively. The epidemiological and clinical findings were compared between patients with and without HP. Clinical manifestations related to AAV were evaluated based on the Birmingham Vasculitis Activity Score version 3. To elucidate independent factors in HP development, logistic regression analyses were additionally performed.

Results

Of the total 541 patients (mean age: 71±14 years, M:F = 1:1.2), HP was demonstrated in 28 (5.17%), including 17 (3.79%) in newly diagnosed AAV and 11 (11.8%) in relapsed AAV. The classification of granulomatosis with polyangiitis (GPA) was significantly higher in patients with HP than those without HP (50% vs. 21%, p = 0.0007). In newly diagnosed AAV, patients with HP significantly had higher GPA classification and higher positivity for PR3-ANCA than those without HP (53% vs. 17%, p = 0.001; 29% vs. 9%, p = 0.015, respectively). Conversely, positivity for MPO-ANCA was significantly higher in patients with HP than those without HP in relapsed AAV (91% vs. 55%, p = 0.025), despite not significantly different in the classification of AAV. Headache and cranial neuropathies were significant neurological symptoms in patients with HP compared to those without HP (82% vs. 6.6%, p < 0.0001; 32% vs. 2.9%, p < 0.0001, respectively). Besides, ear, nose and throat (ENT) and mucous membranes/eyes were significantly higher involvements in patients with HP than in those without HP (54% vs. 26%, p = 0.003; 29% vs. 9%, p = 0.003, respectively). Moreover, higher complications of “conjunctive hearing loss” and “sudden visual loss”, which are included in the categories of ENT and mucous membranes/eyes involvement, respectively, were significantly indicated in patients with HP than those without HP (39% vs. 7.2%, p < 0.0001; 21% vs. 1.2%, p < 0.0001, respectively). Multivariable logistic regression analysis identified that ENT (odds ratio [OR] 1.28, 95% confident interval [CI] 1.09 to 1.49, p = 0.002) and mucous membranes/eyes involvement (OR 1.37, CI 1.14 to 1.65, p = 0.0006), as well as conjunctive hearing loss (OR 4.52, CI 1.56 to 13.05, p = 0.005) and sudden visual loss (OR 1.84, CI 1.12 to 3.00, p = 0.015), were independent related factors in patients with HP.

Conclusion

GPA could be significantly classified in patients with HP. Notably, patients with HP significantly showed higher positivity for PR3-ANCA than those without HP in newly diagnosed AAV. Furthermore, sudden visual loss and conjunctive hearing loss might be implicated in HP development.

Disclosure of Interests

None declared

AB0625 Association between Cytomegalovirus Reactivation and Renal Prognosis during Remission Induction Therapy for ANCA-Associated Vasculitis

Background

Cytomegalovirus (CMV) has been associated with atherosclerosis in patients with chronic renal failure, and may cause secondary nephrotic syndrome. Therefore, we hypothesized that the reactivation of CMV by immunosuppressive therapy in patients with vasculitis may affect renal function.

Objectives

The purpose of this study was to investigate relationships between CMV infection and renal function during ANCA-associated vasculitis remission induction therapy.

Methods

This retrospective cohort study enrolled microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA), and eosinophilic granulomatosis with polyangiitis patients at 25 sites in Japan who had a first or severe relapse between January 2017 and June 2020. Of these, patients with MPA or GPA who had a positive renal lesion score on BVAS (version 3) at baseline, or vasculitis findings on renal biopsy, CMV assayed by 48 weeks of treatment, were included. Patients were divided into two groups based on the presence or absence of a positive CMV antigen test during the remission induction phase (0–48 weeks of treatment). Outcomes were the rate of change in estimated glomerular filtration rate (eGFR) at 48 weeks after initiation of treatment in both groups, as determined by (eGFR at 48 weeks - eGFR at the initiation of treatment)/eGFR at the initiation of treatment; where lower values were associated with worse renal function. General linear models adjusted for age, gender, presence of diabetes or chronic kidney disease, and the use of rituximab or cyclophosphamide were generated.

Results

A total of 387 patients had CMV antigen measured during ANCA-associated vasculitis treatment, of which 164 had renal involvement and eGFR measured at 48 weeks. Seventy-seven (47.0%) were male and the median age was 75 years (range 69–80 years). CMV reactivation was observed in 44 patients (26.8%). The beta coefficient of multiple regression analysis with CMV positive as 1 and negative as 0 was 0.08 (95% confidence interval -0.13 to 0.29) (p = 0.47). The rate of change in eGFR was higher in the CMV positive group, but not statistically significantly.

Conclusion

Contrary to our hypothesis, renal prognoses tended to be better when CMV reactivation was observed. The patients in the CMV reactivation group may have been treated more aggressively, and some patients with a poor prognosis who were not followed up for 48 weeks dropped out. Further research investigating the adjustment of treatment methods is required.

Disclosure of Interests

None declared

POS0247 GLUCOCORTICOID TAPERING STRATEGY FOR ANCA-ASSOCIATED VASCULITIS: ADDRESSING THE GAP BETWEEN RECOMMENDATIONS AND REAL-WORLD PRACTICE

Background

Antineutrophil cytoplasmic antibody -associated vasculitis (AAV) is usually treated with combination of high-dose glucocorticoid (GC) and immunosuppressive agents, followed by tapering GC dose. Although the European League Against Rheumatism (EULAR) has specific recommendations for tapering the GC dose, clinicians often taper it slower than recommended due to concerns of potential disease relapse. However, such slower taper may prolong GC exposure for the patients, increasing the risk of adverse events, particularly infection.

Objectives

The aims of our study were (1) to clarify GC dose tapering in the treatment of AAV in a real-world setting, in contrast to the EULAR recommendation of 2015 and (2) to compare the incidence of AAV relapse and severe infection between patients underdoing EULAR-recommended tapering and those undergoing slower tapering than the recommendation.

Methods

In this multicenter (25 sites in Japan), observational, retrospective study of AAV, 541 patients who had initial or severe relapse were enrolled between January 2017 and June 2020. Of these, 349 patients with microscopic polyangiitis (MPA) or granulomatosis with polyangiitis (GPA) who entered in GC tapering phase after successful induction treatment were included. These patients were then grouped on the pace of GC tapering, defined as the GC dose at 12 weeks after treatment initiation: (1) EULAR group: 7.5-10 mg/day of GC, according to the EULAR recommendation of 2015, and (2) SLOWER group: >10 mg/day of GC. Their baseline characteristics and clinical outcomes were compared. Primary outcome was defined as relapse-free days from treatment initiation, whereas secondary outcome included the incidence of infectious events requiring hospitalization within 48 weeks from treatment initiation. Multivariable analysis was performed to assess the relationship between tapering pace and clinical outcomes.

Results

There were 44 patients (12.6%) in the EULAR group and 290 (83.2%) in the SLOWER group. Regarding baseline characteristics, compared with the EULAR group, the SLOWER group had significantly higher serum C-reactive protein level (EULAR, 5.89 ± 6.89 mg/dL vs SLOWER, 7.56 ± 6.01 mg/dL; p = 0.03), as well as a trend toward higher Birmingham Vasculitis Activity Score (version 3) (EULAR, 11.80 ± 7.01 SLOWER, 13.93 ± 7.06; p = 0.08) We did not observe any significant differences in the frequency of relapses between the two groups (EULAR, 8/44, 18.2% vs SLOWER, 55/290, 19.0%; p = 0.63). Multivariable Cox proportional hazard analysis revealed no relationship GC dose at 12 weeks from treatment initiation and incidence of relapse. However, upon logistic regression analysis, the SLOWER group was found to have significant higher risk of a severe infectious event within 48 weeks from treatment initiation (p = 0.046; hazard ratio, 1.27; 95% confidence interval, 1.004 – 1.601).

Conclusion

Our finding indicates that clinicians tended to taper GC slower for patients with higher disease activity. However, slower GC taper was not found to reduce the frequency of relapse. In addition, slower GC taper was found to increase the risk of a severe infection. Hence, clinicians should pay attention not only relapsing but also late GC taper resulting in the risk of serious infection, especially in patients with higher disease activity of AAV.

References

[1]Eur J Clin Invest 2015;45 (3): 346–368.

[2]Rheumatology (Oxford). 2021 Dec 24;61(1):205-212.

[3]Arthritis Res Ther. 2021 Mar 20;23(1):90.

[4]Scand J Rheumatol. 2022 Jan 20;1-13.

[5]J Rheumatol. 2018 Apr;45(4):521-528.

[6]Rheumatol Adv Pract. 2021 Mar 9;5(3):rkab018.

[7]Ann Rheum Dis. 2016 Sep;75(9):1583-94.

Figure 1.

Acknowledgements

We would like to thank Editage (www.editage.com) for English language editing.

Disclosure of Interests

None declared

[Technique of Microvascular Decompression for Hemifacial Spasm Based on Surgical Anatomy]

This article describes the anatomical approach and operative points of microvascular decompression for hemifacial spasm based on the author's personal experience with 1,000 cases. As vascular compression of the facial nerve is often quite caudal, it is necessary to ensure that the compressing arteries in this area are moved. Neither the vessels nor the prosthesis used to move them should not touch the root exit zone of the nerve(vascular transposition nerve isolation technique). It should also be emphasized that every effort should be made to avoid complications such as hearing impairment and postoperative subcutaneous spinal fluid accumulation.

Professional dental care provision systems for persons with disabilities by prefecture in Japan

OBJECTIVE

The number of persons with disabilities has increased and aged. Although it is important to maintain good oral health to extend healthy life expectancy, it is difficult for such people. This study aimed to analyze regional disparities in dental care provision systems for disabled people and to propose measures for the establishment of an appropriate system.

BASIC RESEARCH DESIGN

To examine regional disparities in dental care provision systems for persons with disabilities, the number of practicing dentists and dental clinics per 100,000 population, dentists certified by the Japanese Society for Disability and Oral Health, and institutions with certified dentists per 100,000 disabled persons for each prefecture were calculated. The Gini coefficient of each was also calculated to visualize and analyze regional disparities.

RESULT

The Gini coefficients were 0.09 and 0.07 for practicing dentists and dental clinics and 0.32 and 0.28 for the certified dentists and institutions with the certified dentists, respectively. Dental institutions for the disabled abounded in the three metropolitan areas: Tokyo, Aichi, and Osaka, and their density tended to be lower in northern and southern Japan. In prefectures with few such institutions, there was no correlation between the number of institutions and prefectural residents' income, and some prefectures had similar incomes but had many institutions.

CONCLUSION

The distribution of dental care to the disabled is highly uneven in Japan, therefore, a system needs to be established to address this issue.

AB0253 COMPARISON OF PHARMACODYNAMICS OF METHOTREXATE AS METHOTREXATE-POLYGLUTAMATES CONCENTRATIONS IN RHEUMATOID ARTHRITIS; INTERIM DATA EVALUATION OF MIRACLE STUDY CONDUCTED IN JAPAN, KOREA AND TAIWAN

Background:

Methotrexate (MTX) is the first-line therapy for rheumatoid arthritis (RA). The concentrations of MTX-polyglutamates (PG) in erythrocytes, an active form of MTX, are useful markers for the optimal usage of MTX in patients with RA. The concentrations of MTX-PG have been reported to be different between Japanese and Caucasians. However, the difference among Asian ethnicity remains unclear.

Objectives:

To examine MTX-PG concentrations in association with MTX dose during the first 24 weeks after the initiation of MTX for newly diagnosed RA patients in Japan, Korea and Taiwan.

Methods:

MIRACLE study is a multicenter, open-label, randomized, 48 weeks interventional study conducted in Japan, Korea and Taiwan to evaluate non-inferiority of low dose to high dose of MTX as an add-on therapy to adalimumab in 300 patients with RA who do not achieve remission after 24 weeks MTX monotherapy in stipulated dosage. In the first 24 weeks, MTX was started at 6 to 8 mg/week for newly diagnosed RA patients, and promptly escalated to the maximum tolerable dose in 12 weeks in principle. This interim data evaluation was intended to investigate the differences among countries in the relationship between MTX dose, safety and MTX-PG concentrations in erythrocytes during the first 24 weeks. The efficacy of the treatment is not included at this point.

Results:

A total of 166 patients (106 in Japan, 35 in Korea, 25 in Taiwan) were included in this interim data. The age at treatment initiation was 57.2 years old on average and female was 79.5%. The time course changes in total and individual MTX-PG levels differed in the three countries. At 24 weeks, whereas the mean total MTX-PG concentrations were comparable (112.9 nmol/L in Japan, 104.4 nmol/L in Korea, and 115.7 nmol/L in Taiwan) with a dose of MTX of 12.3 mg/week, 14.1 mg/week, and 12.2 mg/week, respectively, the individual MTX-PG concentrations were different. The MTX-PG1 and MTX-PG2 concentrations were lower in Korea than Japan and Taiwan whereas MTX-PG3, MTX-PG4 and MTX-PG5 concentrations were the highest in Korea.

Conclusion:

The distribution of short-chain and long-chain MTX-PG concentrations were various among Asian countries despite similar dose of MTX administration: NCT03505008.

Disclosure of Interests:

Hiroya Tamai: None declared, Yuko Kaneko Speakers bureau: AbbVie, Astellas, Ayumi, Bristol–Myers Squibb, Chugai, Eisai, Eli Lilly, Hisamitsu, Jansen, Kissei, Kirin, Pfizer, Sanofi, Takeda, Tanabe-Mitsubishi, and UCB., Grant/research support from: Sanofi, Hideto Kameda Speakers bureau: AbbVie, Pfizer, Consultant of: AbbVie, Grant/research support from: AbbVie, Eisai, Masataka Kuwana Speakers bureau: Astellas, Asahi Kasei Pharma, Boehringer- Ingelheim, Chugai, Eisai, Janssen, Mochida, Nippon Shinyaku, Ono Pharmaceuticals, Pfizer, Mitsubishi-Tanabe, Consultant of: Corbus, Grant/research support from: AbbVie, Asahi Kasei Pharma, Boehringer- Ingelheim, Chugai, Eisai, MBL, Nippon Shinyaku, Ono Pharmaceuticals, Mitsubishi-Tanabe, Yutaka Okano: None declared, Tomonori Ishii Speakers bureau: Chugai, Mitsubishi- Tanabe, Glaxo Smith Kline, Pfizer, Eli Lilly, Janssen, AbbVie, Eisai, Astellas, Kei Ikeda Speakers bureau: AbbVie, Eli Lilly, Novartis, Mitsubishi-Tanabe, Eisai, BMS, Grant/research support from: Mitsubishi-Tanabe, Hiroaki Taguchi: None declared, Shinji Sato: None declared, Toshiaki Miyamoto: None declared, Shintaro Hirata Speakers bureau: AbbVie, Asahi Kasei Pharma, Astellas, Ayumi, Bristol Myers Squibb, Chugai, Eisai, Eli Lilly, Janssen, Glaxo Smith Kline, Kissei, Pfizer, Sanofi, Mitsubishi- Tanabe, UCB, Paid instructor for: AbbVie, Mitsubishi- Tanabe, Consultant of: AbbVie, Eisai, Gilead, Grant/research support from: AbbVie, Chugai, Mitsubishi-Tanabe, UCB, Hidekata Yasuoka Speakers bureau: AbbVie, Asahi Kasei Pharma, Astellas, Daiichi- Sankyo, Eisai, Kissei, Takeda, Mitsubishi- Tanabe, Chugai, Novartis, Eli Lilly, Pfizer, Janssen, Sanofi, Teijin, Boehringer- Ingelheim, Bayer, Glaxo Smith Kline, Paid instructor for: AbbVie, Consultant of: AbbVie, Asahi Kasei, Grant/research support from: Mitsubishi-Tanabe, Takeda, Daiichi-Sankyo, Chugai, Bristol-Myers, MSD, Astellas, Toshihisa Kojima Speakers bureau: AbbVie, Pfizer, Eisai, Grant/research support from: AbbVie, Sung-Hwan Park: None declared, Kichul Shin: None declared, Han Joo Baek: None declared, Yun Jong Lee Grant/research support from: research fund, In Ah Choi Speakers bureau: Abbvie, Eizai, Grant/research support from: Abbvie, Eizai, Jinhyun Kim: None declared, Ping-Ning Hsu: None declared, Chang-Fu Kuo: None declared, Chun-Ming Huang Paid instructor for: AbbVie, Pfizer, Meng-Yu Weng Consultant of: AbbVie, Wan-Yu Sung: None declared, Wen-Chan Tsai: None declared, Tien-Tsai Cheng Paid instructor for: AbbVie, Grant/research support from: AbbVie, Takehiro Taninaga Shareholder of: Eisai Co., Ltd., Employee of: Eisai Co., Ltd., Masahiko Mori Shareholder of: Eisai Co., Ltd., Employee of: Eisai Co., Ltd., Hideaki Miyagishi Employee of: Eisai Co., Ltd., Yasunori Sato: None declared, Tsutomu Takeuchi Speakers bureau: Astellas, Abbvie, Daiichi Sankyo, Ayumi, Eisai, GlaxoSmithKline, Mitsubishi Tanabe, Chugai, Novartis, Eli Lilly, Pfizer, Bristol Myers Squibb, Janssen, UCB, TaishoToyama, Sanofi–Aventis, Nipponkayaku, Taiho, Gilead, Boehringer Ingelheim, Grant/research support from: Asahikasei, Astellas, Abbvie, Daiichi Sankyo, Ayumi, Eisai, Takeda, Mitsubishi Tanabe, Chugai, Eli Lilly, UCB, Sanofi–Aventis, Nipponkayaku, Boehringer Ingelheim

Loss of Ftsj1 perturbs codon-specific translation efficiency in the brain and is associated with X-linked intellectual disability

FtsJ RNA 2'-O-methyltransferase 1 (FTSJ1) gene has been implicated in X-linked intellectual disability (XLID), but the molecular pathogenesis is unknown. We show that Ftsj1 is responsible for 2'-O-methylation of 11 species of cytosolic transfer RNAs (tRNAs) at the anticodon region, and these modifications are abolished in Ftsj1 knockout (KO) mice and XLID patient-derived cells. Loss of 2'-O-methylation in Ftsj1 KO mouse selectively reduced the steady-state level of tRNA^Phe in the brain, resulting in a slow decoding at Phe codons. Ribosome profiling showed that translation efficiency is significantly reduced in a subset of genes that need to be efficiently translated to support synaptic organization and functions. Ftsj1 KO mice display immature synaptic morphology and aberrant synaptic plasticity, which are associated with anxiety-like and memory deficits. The data illuminate a fundamental role of tRNA modification in the brain through regulation of translation efficiency and provide mechanistic insights into FTSJ1-related XLID.

Natural Dural Defect of the Posterior Fossa Dura as a Risk Factor for Postoperative Cerebrospinal Fluid Leakage

BACKGROUND

During microvascular decompression surgery (MVD), small (2-3 mm diameter) natural dural defects have been noticed occasionally but never reported. These tiny dural defects cannot be detected by preoperative imaging studies or even in anatomical cadaver dissection, but may lead to complications including cerebrospinal fluid (CSF) leakage. Our objective was to analyze the features of these natural defects in the posterior fossa dura.

METHODS

Surgical reports and videos of 593 consecutive patients who underwent MVD surgery for trigeminal neuralgia (TN) or hemifacial spasm (HFS) were analyzed retrospectively. Video recording confirmed that these small holes were not related to the craniotomy procedure itself and were natural defects.

RESULTS

Such natural defects of the posterior fossa dura were found in 6 of the 593 patients. All of the defects were about 2 mm in diameter and occurred on the left side in female patients with HFS. All were managed by patching with a fascial or muscle graft. Multivariate analysis showed that the defect was significantly associated with the left side and had a female predilection. Neither disease (HFS or TN) nor age was correlated with the presence of dural defects.

CONCLUSIONS

After posterior fossa craniotomies, CSF leakage or pseudomeningocele may occur at the dural suture site because of the hydrostatic pressure. Because such natural dural defects may be a cause of CSF complications after posterior fossa surgery, their possible occurrence should be considered. This is the first report to document the occurrence of such natural defects of the posterior fossa dura.

AB0612 SHORT-TERM REVERSIBLE IMPROVEMENT IN EARLY-PHASE ELEMENTS OF NAILFOLD CAPILLARY ABNORMALITIES IN PATIENTS WITH SYSTEMIC SCLEROSIS BY INTRAVENOUS CYCLOPHOSPHAMIDE (IVCY)

Background:

Nailfold capillary abnormalities are one of representative signs in systemic sclerosis (SSc). However, previous reports about changes in nailfold capillary by immunosuppressive therapy have been limited. Especially, there have been no reports about short-term changes in nailfold capillary abnormalities.

Objectives:

To clarify whether intravenous cyclophosphamide (IVCY) treatment for SSc patients can improve nailfold capillary abnormalities in half a year.

Methods:

Among patients diagnosed as having SSc according to the 2013 ACR/EULAR classification criteria at our hospital from May 2018 to December 2019, those who treated with IVCY for interstitial lung disease (ILD) were consecutively registered. All patients received IVCY six times. Nailfold capillary abnormalities on eight fingers including both second to the fifth fingers were observed with a nailfold videocapillaroscopy (NVC). Each finger was evaluated for enlarged capillary, giant capillaries, hemorrhage, loss of capillary, disorganization of the vascular array, and capillary ramification. Quantitative scoring was performed on a scale of 0 to 3 in accordance with the ratio of each of them. NVC tests were evaluated before IVCY treatment intervention and after IVCY. In all cases, the evaluation of NVC after IVCY treatment was performed 6 months after the administration day. Skin changes were evaluated by modified Rodnan’s total skin thickness score (mRSS) at performing NVC. Anti-centromere antibodies, anti-Scl-70 antibodies, anti-RNA polymerase III, and anti-RNP antibodies were measured. Pulmonary function tests (PFTs) including forced vital capacity (FVC) and diffusing capacity of the lung carbon monoxide (DLCO) were performed before and after IVCY. The statistical significance of the differences between means of two groups was evaluated by paired t-test. A p level of 0.05 or less was considered statistically significant.

Results:

Five patients were included. The mean age was 59 years and 4 patients were female (80%). High dose corticosteroids were used in 2 patients (40%). Anti-RNA polymerase III was positive in 2 patients (40%), anti-Scl-70 antibody was positive in 1 (20%), and negative test for any specific antibodies was in 2 (40%). Changes in NVC scores, which were total scores of 8 fingers, were as follows: Enlarged; 13.2±4.8 to 6.4±5.9 (p=0.018), Giant; 7.0±5.7 to 1.6±1.1 (p=0.0314), Hemorrhage; 8.4±6.2 to 3.2±2.3 (p=0.0274), Loss; 4.0±2.5 to 0.6±1.3 (p=0.0288), Disorganization; 0.6±0.9 to 1.0±1.0 (p=0.7065), Ramification; 0.6±0.9 to 0.8±1.8 (p=0.5730). (Table) After IVCY treatment, mRSS reduced in 4 cases (80%). Changes in mRSS scores were as follows: 18.8±8.3 to 12.4±13.3 (p=0.0677). The cases with improved mRSS and those with improved NVC findings were consistent. The mean FVC before and after IVCY was 2077 ml and 2062 ml, respectively. The mean DLCObefore and after IVCY was 9.88 mL/min/mmHg and 9.58 mL/min/mmHg, respectively.

Conclusion:

Nailfold capillary abnormalities in patients with SSc could be improved in half a year with IVCY. Especially, early phase elements including enlargement, giant, and hemorrhage were specifically reversible.

Table.No.(E)(G)(H)(L)(D)(R)mRSS121→1416→319→70→00→20→014→9212→34→26→14→02→11→015→1314→118→26→27→00→00→410→5410→46→18→34→30→22→025→1259→01→03→35→01→00→030→35mean ± SD13.2±4.87.0±5.78.4±6.24.0±2.50.6±0.90.6±0.918.8±8.36.4±5.91.6±1.13.2±2.30.6±1.31.0±1.00.8±1.812.4±13.3p-value0.0180.03140.02740.02880.70650.57300.0677

E: enlarged, G: giant, H: hemorrhage, L: loss, D: disorganization, R: ramification.

The table shows the total of eight points for each finding in the NVC test. The previously described values are before treatment and the later values are after treatment.

Disclosure of Interests:

Tomohiro Sugimoto: None declared, Shintaro Hirata Grant/research support from: Eli Lilly, Consultant of: Bristol-Myers Squibb, UCB, Paid instructor for: AbbVie, Eisai, Tanabe-Mitsubishi, Speakers bureau: AbbVie, Eisai, Tanabe-Mitsubishi, Astellas, Ayumi, Bristol-Myers Squibb, UCB, Chugai, Eli Lilly, Janssen, Kissei, Sanofi, Takeda, Hiroki Kohno: None declared, Hirofumi Watanabe: None declared, Yusuke Yoshida Grant/research support from: Astellas, Paid instructor for: Astellas, Tanabe Mitsubishi, Sanofi, Novartis, GlaxoSmithKline, Eli Lilly, Bristol-Myers Squibb, Chugai, Asahikasei, Eisai, Janssen, Speakers bureau: Astellas, Tanabe Mitsubishi, Sanofi, Novartis, GlaxoSmithKline, Eli Lilly, Bristol-Myers Squibb, Chugai, Asahikasei, Sho Mokuda: None declared, Eiji Sugiyama Grant/research support from: AbbVie, Astellas, Ayumi, Kissei, Pfizer, Sanofi, Takeda, Tanabe-Mitsubishi, Bristol-Myers Squibb, Chugai, Eisai, Eli Lilly, Speakers bureau: AbbVie, Astellas, Ayumi, Kissei, Pfizer, Sanofi, Takeda, Tanabe-Mitsubishi, Bristol-Myers Squibb, Chugai, Eisai, Eli Lilly, Actelion

AB0452 PREDICTIVE FACTORS FOR INSUFFICIENT RESPONSE TO INITIAL TREATMENT OR RECURRENCE IN PATIENTS WITH LUPUS ENTERITIS

Background:

Lupus enteritis (LE) is a rare but well-known complication of systemic lupus erythematosus (SLE). However, little knowledge about risk factors for insufficient response to initial treatment or recurrence have been reported.

Objectives:

To identify prognostic factors associated with poor response in patients with LE.

Methods:

Patients diagnosed as having LE at our hospital were consecutively registered from January 2009 to October 2019. The diagnosis of LE was made according to the criteria of BILAG 2004 which is defined as either vasculitis or inflammation of small or large bowel with supportive imaging and/or biopsy findings. Poor response was defined as insufficient response to initial therapy or relapse. We retrospectively compared clinical characteristics collected from medical records of the patients with good vs. poor response, using a non-parametric Wilcoxon signed-rank test for numerical variables and Fisher’s exact test for categorical variables.

Results:

A total of 12 patients (16 episodes) diagnosed with LE were reviewed. The median age was 44.5 years and 11 were females. Six patients had a history of SLE (median disease duration; 3.0 years), of which 4 had a history of LE prior to the study period. And in the remaining 6 patients, LE was the primary symptom (Table 1). The comorbidities were 4 lupus cystitis, 1 biopsy-proven lupus nephritis, 1 pseudo-obstruction and 1 protein-losing enteropathy. Computed Tomography (CT) imaging of all 16 episodes showed small bowel wall thickening. Dilatation of intestine was observed in 81.3%, ascites in 81.3%, comb sign in 80.0% and target sign in 62.5%. When comparing clinical characteristics between the groups revealed that CT findings were similar in both groups, however serum CH50 levels (median (interquartile ranges (IQR)) 37.2 (25.3-46.9) U/mL vs 17.6 (7.1-21.4) U/mL, p=0.0095) were significantly lower in poor response group. Furthermore, patients who initiated glucocorticoids (GCs) at a lower dose (less than or equal to 0.6mg/kg prednisolone equivalent dose (PEQ)) was significantly more frequent in poor response group (Table 2).

Table 1.

Baseline demographics and outcomes of LE patients

VariablesN=12DemographicsFemale (%)91.7Age (yrs), median (IQR)44.5 (34.0-47.5)SLE duration (yrs), median (IQR)3.0 (0-9.0)Baseline therapyPrednisolone (mg), median (IQR)7.0 (0-10.5)Cyclosporine (%)16.7Azathioprine (%)8.3Mycophenolate mofetil (%)8.3Tacrolimus (%)8.3OutcomesFollow-up period (yrs), median (IQR)4.0 (1.9-5.0)Poor response to initial therapy (%)33.3Recurrence (%)33.3Need for surgical intervention (%)8.3Death (%)0Table 2.

Comparison of baseline characteristics and initial treatment between LE patients with good vs. poor response

VariablesGood response(N=10)Poor response(N=6)p valueComorbiditiesLupus cystitis (%)30.033.31.0Lupus nephritis (%)016.70.38CT findingsMaximum external diameterof small intestine (mm), median (IQR)30.8 (22.2-37.9)25.3 (19.4-29.0)0.083Colon involvement (%)30.066.70.30Dilatation of intestine (%)90.066.70.52Ascites (%)90.066.70.52Comb sign (%)90.066.70.52Target sign (%)70.050.00.61Laboratoryfindingsanti-dsDNA Ab (IU/mL), median (IQR)5.4 (1.6-12.6)10.1 (3.8-111.5)0.17CH50 (U/mL), median (IQR)37.2 (25.3-46.9)17.6 (7.1-21.4)0.0095C4 (mg/dL), median (IQR)16.0 (10.5-27.3)10.0 (10.0-13.8)0.11C3 (mg/dL), median (IQR)66.0 (56.8-79.8)46.5 (33.0-58.3)0.10Initial treatmentLess than or equal to 0.6mg/kg PEQ (%)10.066.70.036Intravenous cyclophosphamide10.016.71.0

Conclusion:

Lower level of CH50 and initial treatment with GCs at a lower dose were identified as prognostic factors associated with poor response to initial therapy or recurrence in LE.

Disclosure of Interests: :

Yusuke Yoshida Grant/research support from: Astellas, Paid instructor for: Astellas, Tanabe Mitsubishi, Sanofi, Novartis, GlaxoSmithKline, Eli Lilly, Bristol-Myers Squibb, Chugai, Asahikasei, Eisai, Janssen, Speakers bureau: Astellas, Tanabe Mitsubishi, Sanofi, Novartis, GlaxoSmithKline, Eli Lilly, Bristol-Myers Squibb, Chugai, Asahikasei, Tomohiro Sugimoto: None declared, Hiroki Kohno: None declared, Hirofumi Watanabe: None declared, Sho Mokuda: None declared, Shintaro Hirata Grant/research support from: Eli Lilly, Consultant of: Bristol-Myers Squibb, UCB, Paid instructor for: AbbVie, Eisai, Tanabe-Mitsubishi, Speakers bureau: AbbVie, Eisai, Tanabe-Mitsubishi, Astellas, Ayumi, Bristol-Myers Squibb, UCB, Chugai, Eli Lilly, Janssen, Kissei, Sanofi, Takeda, Eiji Sugiyama Grant/research support from: AbbVie, Astellas, Ayumi, Kissei, Pfizer, Sanofi, Takeda, Tanabe-Mitsubishi, Bristol-Myers Squibb, Chugai, Eisai, Eli Lilly, Speakers bureau: AbbVie, Astellas, Ayumi, Kissei, Pfizer, Sanofi, Takeda, Tanabe-Mitsubishi, Bristol-Myers Squibb, Chugai, Eisai, Eli Lilly, Actelion

NWChem: Past, present, and future

Specialized computational chemistry packages have permanently reshaped the landscape of chemical and materials science by providing tools to support and guide experimental efforts and for the prediction of atomistic and electronic properties. In this regard, electronic structure packages have played a special role by using first-principle-driven methodologies to model complex chemical and materials processes. Over the past few decades, the rapid development of computing technologies and the tremendous increase in computational power have offered a unique chance to study complex transformations using sophisticated and predictive many-body techniques that describe correlated behavior of electrons in molecular and condensed phase systems at different levels of theory. In enabling these simulations, novel parallel algorithms have been able to take advantage of computational resources to address the polynomial scaling of electronic structure methods. In this paper, we briefly review the NWChem computational chemistry suite, including its history, design principles, parallel tools, current capabilities, outreach, and outlook.

Surgical Technique and Outcome of Extensive Frontal Lobectomy for Treatment of Intracable Non-lesional Frontal Lobe Epilepsy

Although extensive frontal lobectomy (eFL) is a common surgical procedure for intractable frontal lobe epilepsy (FLE), there have been very few reports regarding surgical techniques for eFL. This article provides step-by-step descriptions of our surgical technique for non-lesional FLE. Sixteen patients undergoing eFL were included in this study. The goals were to maximize gray matter removal, including the orbital gyrus and subcallosal area, and to spare the primary motor and premotor cortexes and anterior perforated substance. The eFL consists of three steps: (1) positioning, craniotomy, and exposure; (2) lateral frontal lobe resection; and (3), resection of the rectus gyrus and orbital gyrus. Resection ahead of bregma allows preservation of motor and premotor area function. To remove the orbital gyrus preserving anterior perforated substance, it is essential to visualize the olfactory trigone beneath the pia. It is important to observe the surface of the contralateral medial frontal lobe for complete removal of the subcallosal area of the frontal lobe. Thirteen patients (81.25%) became seizure-free and three patients (18.75%) continued to have seizures. None of the patients showed any complications. The eFL is a good surgical technique for the treatment of intractable non-lesional FLE. For treatment of epilepsy by eFL, it is important to resect the non-eloquent area of the frontal lobe as much as possible with preservation of the eloquent cortex.

Geographic distribution of dental specialists permitted to advertise dental practices in Japan

OBJECTIVE

The purpose of this study was to determine the geographic distribution of dental specialists permitted to advertise dental practices in Japan.

METHOD

We identified the populations of 349 secondary medical zones nationwide from the 2015 population census, as well as the number of dentists in five specialties, namely oral surgeons, pedodontists, periodontists, dental anesthesiologists, and dental radiologists, who had been permitted to advertise dental practices, from a 2016 survey of physicians, dentists, and pharmacists. We determined the placement rate, Lorenz curve, and Gini coefficient for dentists in each specialty in order to describe their geographic distributions.

RESULTS

The placement rates of at least one of these types of dentist in each secondary medical zone were 73.9% for oral surgeons, 66.2% for pedodontists, 60.5% for periodontists, 31.8% for dental anesthesiologists, and 18.3% for dental radiologists. The Gini coefficients were 0.397, 0.400, 0.491, 0.650, and 0.761, respectively.

CONCLUSION

The dentists in each specialty were few in number and were unequally distributed among the zones, but less so for oral surgeons and pedodontists. Dental anesthesiologists and radiologists were located primarily at university hospitals in urban areas and, therefore, were more unequally distributed.

SURG-21. STEREOTACTIC BIOPSY FOR DEEP SEATED BRAIN LESIONS USING THE LEKSELL STEREOTACTIC FRAME SYSTEM

PURPOSE

To evaluate the results of stereotactic biopsies.

PATIENTS AND METHODS

Fifty-two patients with intraaxial lesions suspected of brain tumor. The locations of lesions includes, 19 deep cerebral white matter, 9 basal ganglia, 10 thalamus, 4 midbrain and 6 pons. Patients age ranged from 9 to 86 years (median 65 years), 33 were men and 19 were women. Under local anesthesia the Leksell stereotactic frame was fixed and the MRI were taken. Neuroimages such as enhanced CT scan or PET study were also used as references. After MRI patients were transferred to OR and under general anesthesia, several samples were taken with 2.1mm diameter needle by aspiration. Most of the cases the biopsy was done through frontal lobe, but in some cases through temporal lobe or through cerebellum. The samples were taken deeper and nearer regions of the designed targets with same trajectory, also. If there were cysts, aspiration of the cyst was performed as much as possible. The trajectory should avoid sulci, cortical veins or ventricular system. After biopsy inside the needle were irrigated repeatedly with 0.1 - 0.2 ml saline using thin plastic tube until the fluid does not contain bloody fluids to ensure hemostasis.

RESULTS

In all patients appropriate samples for pathological diagnosis were obtained. The diagnoses were 28 gliomas (pilocytic 1, grade II 8, grade III 11, grade VI (GBM) 6, high grade 1, glial tumor 1), 17 lymphomas, 3 germinoma and 2 were non-tumorous pathology. There were no symptomatic bleeding nor neurological complications.

CONCLUSION

With detailed planning, stereotactic biopsy was safely performed even from basal ganglia or brainstem. Trajectories other than from frontal can be also considered for some lesions. Repeated irrigation with saline might effective to prevent symptomatic bleeding and this case series shows lower complication rates compared to the published literatures.

A Large Mass Mimicking Calcified Hematoma of the Skull Showing Involvement of Myeloma Cells and a Good Response to Irradiation

Patients with multiple myeloma often show skull bone involvement, although in most cases this is manifested as skull erosion and large masses develop only rarely. Here we report a patient who presented with a large cranial mass mimicking a subdural hematoma with calcification. The tumor shrunk with 37.5 Gy of focal irradiation in 15 fractions after biopsy. After irradiation the patient was treated with Bortezomib but died because of adverse events. The differential diagnosis of lenticular lesion of the skull and treatment strategy for large skull mass with myeloma cells are discussed.

Large-vessel vasculitis associated with PEGylated granulocyte-colony stimulating factor

A 71-year-old female with advanced endometrial cancer was treated with pegfilgrastim. She developed a fever within seven days, and contrast-enhanced computed tomography scans repeated within three days revealed rapidly progressive thickening of the aortic wall. When clinicians administer PEGylated granulocyte-colony stimulating factor (G-CSF) to cancer patients, drug-associated vasculitis should be suspected. This report discusses the manifestation of G-CSF-associated large-vessel vasculitis (LVV).

Precision Analysis of the ^{136}Xe Two-Neutrino ββ Spectrum in KamLAND-Zen and Its Impact on the Quenching of Nuclear Matrix Elements

We present a precision analysis of the ^{136}Xe two-neutrino ββ electron spectrum above 0.8 MeV, based on high-statistics data obtained with the KamLAND-Zen experiment. An improved formalism for the two-neutrino ββ rate allows us to measure the ratio of the leading and subleading 2νββ nuclear matrix elements (NMEs), ξ_{31}^{2ν}=-0.26_{-0.25}^{+0.31}. Theoretical predictions from the nuclear shell model and the majority of the quasiparticle random-phase approximation (QRPA) calculations are consistent with the experimental limit. However, part of the ξ_{31}^{2ν} range allowed by the QRPA is excluded by the present measurement at the 90% confidence level. Our analysis reveals that predicted ξ_{31}^{2ν} values are sensitive to the quenching of NMEs and the competing contributions from low- and high-energy states in the intermediate nucleus. Because these aspects are also at play in neutrinoless ββ decay, ξ_{31}^{2ν} provides new insights toward reliable neutrinoless ββ NMEs.

Tumour necrosis factor α augments the inhibitory effects of CTLA-4-Ig on osteoclast generation from human monocytes via induction of CD80 expression

Cytotoxic T lymphocyte antigen-4-immunoglobulin (CTLA-4-Ig) exerts anti-rheumatic action via negative regulation of the co-stimulation process between antigen-presenting cells and T cells. CTLA-4-Ig also binds to CD80/CD86 on monocytes of osteoclast precursors. However, little is known about the effect of CTLA-4-Ig on osteoclastogenesis in rheumatoid arthritis (RA). In this study we evaluated the effects of CTLA-4-Ig on osteoclast generation from human blood monocytes (PBM) and rheumatoid synovial fluid monocytes (RSFM). Highly purified monocytes were cultured with receptor activator of nuclear factor kappa-B ligand (RANKL) and macrophage colony-stimulating factor (M-CSF) in the presence of CTLA-4-Ig. CTLA-4-Ig inhibited RANKL-induced osteoclast generation in PBM and RSFM, as determined by tartrate-resistant acid phosphatase (TRAP) staining and bone resorption assay using osteo assay surface plates. In addition, CTLA-4-Ig reduced the gene and protein expressions of nuclear factor of activated T cells, cytoplasmic 1 (NFATc1) and cathepsin K during osteoclastogenesis. Furthermore, CTLA-4-Ig significantly inhibited cell proliferation during osteoclastogenesis. Interestingly, the gene expression of indoleamine 2,3-dioxygenase-1, an inducer of apoptosis, was enhanced by CTLA-4-Ig. We next examined the effect of tumour necrosis factor (TNF)-α, a major inflammatory cytokine in rheumatoid synovium, on the expression of CD80 and CD86 by flow cytometric analysis. TNF-α potently induced the surface expression of CD80, which is known to have much higher affinity to CTLA-4-Ig than CD86, and this induction was observed at mRNA levels. Interestingly, freshly prepared rheumatoid synovial monocytes also expressed CD80 as much as TNF-α-treated PBM. Furthermore, TNF-α enhanced CTLA-4-Ig-induced inhibition of osteoclastogenesis and cell proliferation. Taken together, the TNF-α-induced CD80 may augment CTLA-4-Ig-induced inhibition of osteoclastogenesis, suggesting that CTLA-4-Ig potently inhibits osteoclast differentiation and protects bone destruction in rheumatoid inflamed joints.

Efficacy and safety of anti-CD20 antibody rituximab for patients with refractory systemic lupus erythematosus

Objective

We examined the efficacy and safety of rituximab in patients with refractory systemic lupus erythematosus (SLE).

Methods

The study enrolled 63 SLE patients who were treated with rituximab between 2002 and 2015. The participants underwent a battery of tests before treatment and at one year. Treatment ranged from two to four times at 500 or 1000 mg.

Results

Baseline characteristics were males:females = 6:57, age 33.9 years, and disease duration 87.2 months. The primary endpoint: The rate of major clinical response (MCR) was 60% while the partial clinical response (PCR) was 25%. Thirty of 36 (83%) patients with lupus nephritis (WHO II: 2, III: 5, IV: 22, V: 4, IV+V: 2, not assessed: 1) and 22 of 24 patients (92%) with neuropsychiatric SLE, who could be followed at one year, showed changes from BILAG A or B score to C or D score at one year. Multivariate analysis identified high anti-dsDNA antibody and shorter disease duration as significant determinants of MCR at one year. Repeat examination was conducted at five years. Primary failure was recorded in 8.8% and secondary failure in 32.4% (time to relapse: 24.4 months). Rituximab was well tolerated although 65 adverse events, mostly infections, were recorded within one year.

Conclusion

Rituximab is potentially efficacious for the treatment of patients with refractory SLE.

PU.1 acts as tumor suppressor for myeloma cells through direct transcriptional repression of IRF4

We previously reported that PU.1 is downregulated in the majority of myeloma cell lines and primary myeloma cells of certain myeloma patients, and conditional expression of PU.1 in such myeloma cell lines induced cell cycle arrest and apoptosis. We found downregulation of IRF4 protein in the U266 myeloma cell line following induction of PU.1. Previous studies reported that knockdown of IRF4 in myeloma cell lines induces apoptosis, prompting us to further investigate the role of IRF4 downregulation in PU.1-induced cell cycle arrest and apoptosis in myeloma cells. PU.1 induced downregulation of IRF4 at the protein level, cell cycle arrest and apoptosis in six myeloma cell lines. Chromatin immunoprecipitation (ChIP) revealed that PU.1 directly binds to the IRF4 promoter, whereas a reporter assay showed that PU.1 may suppress IRF4 promoter activity. Stable expression of IRF4 in myeloma cells expressing PU.1 partially rescued the cells from apoptosis induced by PU.1. As it was reported that IRF4 directly binds to the IRF7 promoter and downregulates its expression in activated B cell-like subtype of diffuse large B cell lymphoma cells, we performed ChIP assays and found that IRF4 directly binds the IRF7 promoter in myeloma cells. It is known that IRF7 positively upregulates interferon-β (IFNβ) and induces apoptosis in many cell types. Binding of IRF4 to the IRF7 promoter decreased following PU.1 induction, accompanied by downregulation of IRF4 protein expression. Knockdown of IRF7 protected PU.1-expressing myeloma cells from apoptosis. Furthermore, IFNβ, which is a downstream target of IRF7, was upregulated in myeloma cells along with IRF7 after PU.1 induction. Finally, we evaluated the mRNA expression levels of PU.1, IRF4 and IRF7 in primary myeloma cells from patients and found that PU.1 and IRF7 were strongly downregulated in contrast to the high expression levels of IRF4. These data strongly suggest that PU.1-induced apoptosis in myeloma cells is associated with IRF4 downregulation and subsequent IRF7 upregulation.

Chimpanzee Personality and the Arginine Vasopressin Receptor 1A Genotype

Polymorphisms of the arginine vasopressin receptor 1a (AVPR1a) gene have been linked to various measures related to human social behavior, including sibling conflict and agreeableness. In chimpanzees, AVPR1a polymorphisms have been associated with traits important for social interactions, including sociability, joint attention, dominance, conscientiousness, and hierarchical personality dimensions named low alpha/stability, disinhibition, and negative emotionality/low dominance. We examined associations between AVPR1a and six personality domains and hierarchical personality dimensions in 129 chimpanzees (Pan troglodytes) living in Japan or in a sanctuary in Guinea. We fit three linear and three animal models. The first model included genotype, the second included sex and genotype, and the third included genotype, sex, and sex × genotype. All personality phenotypes were heritable. Chimpanzees possessing the long form of the allele were higher in conscientiousness, but only in models that did not include the other predictors; however, additional analyses suggested that this may have been a consequence of study design. In animal models that included sex and sex × genotype, chimpanzees homozygous for the short form of the allele were higher in extraversion. Taken with the findings of previous studies of chimpanzees and humans, the findings related to conscientiousness suggest that AVPR1a may be related to lower levels of impulsive aggression. The direction of the association between AVPR1a genotype and extraversion ran counter to what one would expect if AVPR1a was related to social behaviors. These results help us further understand the genetic basis of personality in chimpanzees.