Maternal heart rate variability patterns associated with maternal hypotension and non-reassuring fetal heart rate patterns following initiation of combined spinal-epidural labor analgesia: a prospective observational trial

BACKGROUND

We evaluated whether baseline maternal heart rate variability (HRV), including the Analgesia Nociception Index (ANI), is associated with maternal hypotension and fetal heart rate (FHR) abnormalities following combined spinal-epidural (CSE) labor analgesia.

METHODS

Laboring women were enrolled in this prospective observational study. The primary endpoint was maternal hypotension. The secondary endpoint was FHR abnormalities within 30 min following CSE analgesia initiated with intrathecal plain bupivacaine 1.0 mg and fentanyl 20 µg. The maternal ANI, electrocardiogram, blood pressure, heart rate, oxygen saturation, and FHR tracings were recorded 15 min before and 30 min after CSE. Parturients were grouped based on presence of hypotension and FHR abnormalities. Patient demographics and HRV metrics were compared. Receiver operating characteristics (ROC) curves were constructed for the prediction of hypotension and FHR abnormalities.

RESULTS

No significant intergroup differences were detected in patient characteristics. Several baseline HRV metrics and ANI differed significantly between the normotensive (n = 50) and hypotensive (n = 31) groups and between parturients showing FHR abnormalities (n = 19) and those showing reassuring FHR traces (n = 62). The area under the ROC curve (AUC) for predicting hypotension of the baseline low-frequency (LF)/high-frequency (HF) ratio was 0.677 (95% CI 0.55 to 0.80), and that of the ANI was 0.858 (95% CI 0.78 to 0.94). For predicting non-reassuring FHR patterns, the AUC of the LF/HF ratio was 0.77 (95% CI 0.65 to 0.89), and that of the ANI was 0.833 (95% CI 0.72 to 0.94).

CONCLUSIONS

The ANI can predict the propensity for maternal hypotension and non-reassuring FHR patterns following CSE.

POS0794 PREGNANCY AND CHILDBIRTH IN TAKAYASU ARTERITIS IN JAPAN – A NATIONWIDE RETROSPECTIVE STUDY

Background

Takayasu arteritis (TAK), a granulomatous large vessel vasculitis, mainly involves the aorta and its proximal branches and commonly occurs in young females. However, studies of pregnancy in women with TAK are sparse and limited, probably due to the rarity of the disease.

Objectives

The purpose of this study was to understand the status quo of medical treatments of the primary disease and outcomes of pregnancy in patients with TAK, and birth outcomes of the children in Japan.

Methods

Patients with TAK who conceived after the onset of the disease and were managed at medical facilities participating in the Japan Research Committee of the Ministry of Health, Labour, and Welfare for Intractable Vasculitis (JPVAS) were retrospectively enrolled in this study. The following information was collected from patients who had a live-born baby: age at diagnosis of TAK, disease classification, age at delivery, treatments before and during pregnancy, complications during pregnancy, birth outcomes of the children, and changes in disease activity during pregnancy and after delivery.

Results

Fifty-one cases and 69 pregnancies from 19 ethics committee-approved centers were enrolled during the study period 2019–2021. Of these, 49 cases and 66 pregnancies (95.7%) resulted in delivery and live-born babies. The Numano classification of the 49 cases was as follows: type I, 11; type IIa, 15; type IIb,12; type III, 1; type IV, 1; type V, 9; with type IIa being the most common. The age of diagnosis was 22 years (13–37 years, year of diagnosis 1965–2017), the median age of the delivery of 66 pregnancies was 31 years (year of delivery 1969-2021), and the median duration of illness at delivery was nine years. There were 34 planned pregnancies (51.5%, including four pregnancies by artificial insemination/ovulation induction). Preconception therapy included prednisolone (PSL) in 51 pregnancies (77.3%, median dose 7.5 mg (range 4–30 mg)/day), immunosuppressive drugs in 18 pregnancies (27.3%, azathioprine 8, tacrolimus 7, methotrexate 4, cyclosporin A 1, and colchicine 1), biologics in 12 pregnancies (18.1%, infliximab 6, tocilizumab 5, and adalimumab 1), antihypertensive drugs in 5 pregnancies (7.6%). Surgical treatment had been performed before pregnancy in 6 cases (aortic root replacement 2, subclavian artery dilatation 1, subclavian artery bypass 1, subclavian artery stenting 1, and ascending aorta semicircular artery replacement 1). Medications used during the course of pregnancy included PSL in 48 pregnancies (72.7%, median dose 8 mg (range 4–30 mg)/day, increased in 13 pregnancies, decreased in 1 pregnancy), immunosuppressants in 13 pregnancies (19.7%, azathioprine 6, tacrolimus 6, and cyclosporin A 1), biologics 9 pregnancies (13.6%, infliximab 4, tocilizumab 4, and adalimumab 1). Immunosuppressants and biologics were discontinued in five and four pregnancies after conception. Complications during pregnancy were observed in 20 pregnancies (30.3%), with hypertension being the most common. Complications related to TAK or its treatment were severe infections in two pregnancies and aneurysm enlargement due to increased circulating plasma volume in one pregnancy. Aortic arch replacement was performed after delivery for the latter case. Relapse of TAK was observed in 4 pregnancies (6.1%) during pregnancy and in 8 pregnancies (12.1%) after delivery. One pregnancy resulted in restenosis of subclavian artery for which dilatation procedure was performed prior to the pregnancy. There were 13/66 (19.7%) preterm infants and 17/59 (28.8%) low birth weight infants; all but one had a birth weight of more than 2,000 g and no had serious postnatal abnormalities. Forty-three (82.7%) of the 52 confirmed infants were breastfeed fully or mixed.

Conclusion

Most of the pregnancies in patients with TAK were successfully delivered while they had low disease activity at a dose of less than 10 mg/day of PSL. Relapse occurred during pregnancy and after delivery in some cases. The babies tended to have low birth weight, but 82.7% of them were breastfed without serious complications.

Disclosure of Interests

Takako Miyamae: None declared, Yusuke Manabe: None declared, takahiko sugihara Speakers bureau: TS has received honoraria from Abbvie Japan Co., Ltd., AsahiKASEI Co., Ltd., Astellas Pharma Inc., Ayumi Pharmaceutical, Bristol Myers Squibb K.K., Chugai Pharmaceutical Co., Ltd., Eli Lilly Japan K.K., Mitsubishi-Tanabe Pharma Co., Ono Pharmaceutical, Pfizer Japan Inc., Takeda Pharmaceutical Co. Ltd., and UCB Japan Co., Grant/research support from: TS has received research grants from AsahiKASEI Co., Ltd., Daiichi Sankyo., Chugai Pharmaceutical Co., Ltd., and Ono Pharmaceutical., Natsuka Umezawa: None declared, Hajime Yoshifuji Speakers bureau: HY has received lecture fees from Janssen and Chugai., Naoto Tamura: None declared, Yoshiyuki Abe: None declared, Shunsuke Furuta Speakers bureau: Chugai Pharmaceutical Co.,Ltd.

DaiichiSankyo Co.,Ltd.

Asahi-Kasei Pharma Corporation, Manami Kato: None declared, Takashi Kumagai: None declared, Kaito Nakamura: None declared, Hiroko Nagafuchi: None declared, Jun Ishizaki: None declared, Naoko Nakano: None declared, Tatsuya Atsumi Speakers bureau: Mitsubishi Tanabe Pharma Co., Chugai Pharmaceutical Co., Ltd., Astellas Pharma Inc., Takeda Pharmaceutical Co., Ltd., Pfizer Inc., AbbVie Inc., Eisai Co. Ltd., Daiichi Sankyo Co., Ltd., Bristol-Myers Squibb Co., UCB Japan Co. Ltd., Eli Lilly Japan K.K., Novartis Pharma K.K., Eli Lilly Japan K.K., Kyowa Kirin Co., Ltd.,TAIHO PHARMACEUTICAL CO., LTD., Consultant of: AstraZeneca plc., MEDICAL & BIOLOGICAL LABORATORIES CO., LTD., Pfizer Inc., AbbVie Inc., ONO PHARMACEUTICAL CO. LTD.,

Novartis Pharma K.K., Nippon Boehringer Ingelheim Co., Ltd., Grant/research support from: Astellas Pharma Inc., TAIHO PHARMACEUTICAL CO., LTD.AbbVie Inc., Nippon Boehringer Ingelheim Co., Ltd.,Takeda Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Chugai Pharmaceutical Co., Ltd., Daiichi Sankyo Co. Ltd., Otsuka Pharmaceutical Co., Ltd. and Pfizer Inc. Alexion Inc., TEIJIN PHARMA LIMITED., Kohei Karino: None declared, Koichi Amano Speakers bureau: AbbVie GK, Asahi-Kasei Pharma, Astellas, Chugai Pharmaceutical Co.Ltd., Eisai, Eli Lilly, GlaxoSmithKlein, Janssen Pharma, Pfizer Japan, Grant/research support from: Asahi-Kasei Pharma,Chugai Pharmaceutical Co.Ltd., Takahiko Kurasawa: None declared, Shuichi Ito: None declared, Ryusuke Yoshimi: None declared, Noriyoshi Ogawa: None declared, Shogo Banno: None declared, Taio Naniwa Speakers bureau: Chugai, Tanabe, Abbbvie, Eisai, Grant/research support from: Chugai, Tanabe, Abbbvie, Eisai, Satoshi Ito Speakers bureau: SI has received speaker’s fees from pharmaceutical companies., Akinori Hara: None declared, Shinya Hirahara: None declared, Haruhito A. Uchida: None declared, Yasuhiro Onishi: None declared, Yohko Murakawa Speakers bureau: Astellas, UCB, Chugai, AbbVie, Grant/research support from: Chugai, AbbVie, Yoshinori Komagata: None declared, Yoshikazu Nakaoka: None declared, Masayoshi Harigai Speakers bureau: MH has received speaker’s fee from AbbVie Japan GK, Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Janssen Pharmaceutical K.K., Kissei Pharmaceutical Co., Ltd., Novartis Japan, Pfizer Japan Inc., Mitsubishi Tanabe Pharma Co., Teijin Pharma Ltd and UCB Japan., Consultant of: MH is a consultant for AbbVie, Boehringer-Ingelheim, Kissei Pharmaceutical Co., Ltd., and Teijin Pharma.

Serum level of soluble urokinase plasminogen activator receptor (suPAR) as a disease severity marker of myasthenia gravis: a pilot study

Myasthenia gravis (MG) is an autoantibody-mediated inflammatory disease of the neuromuscular junction. Biomarkers indicating disease activity in MG are warranted. Recently, the soluble urokinase plasminogen activator receptor (suPAR) has been reported to be associated with inflammation, tissue damage, disease activity and prognosis in various diseases, including autoimmune diseases. In this study, serum suPAR levels were measured in 40 patients with anti-acetylcholine receptor antibody-positive MG and 30 controls, and their correlations with clinical variables and severity scale scores were investigated. We identified that serum suPAR levels significantly correlated with MG activities of daily living scale (Spearman's ρ = 0·45; P = 0·004) and MG Foundation of America classification (Spearman's ρ = 0·37; P = 0·02) at serum sampling, but not with anti-acetylcholine receptor antibody titers. In conclusion, serum suPAR levels can be a candidate for a novel biomarker of disease activity in anti-acetylcholine receptor antibody-positive MG.

Diagnostic Value of Model-Based Iterative Reconstruction Combined with a Metal Artifact Reduction Algorithm during CT of the Oral Cavity

BACKGROUND AND PURPOSE

Metal artifacts reduce the quality of CT images and increase the difficulty of interpretation. This study compared the ability of model-based iterative reconstruction and hybrid iterative reconstruction to improve CT image quality in patients with metallic dental artifacts when both techniques were combined with a metal artifact reduction algorithm.

MATERIALS AND METHODS

This retrospective clinical study included 40 patients (men, 31; women, 9; mean age, 62.9 ± 12.3 years) with oral and oropharyngeal cancer who had metallic dental fillings or implants and underwent contrast-enhanced ultra-high-resolution CT of the neck. Axial CT images were reconstructed using hybrid iterative reconstruction and model-based iterative reconstruction, and the metal artifact reduction algorithm was applied to all images. Finally, hybrid iterative reconstruction + metal artifact reduction algorithms and model-based iterative reconstruction + metal artifact reduction algorithm data were obtained. In the quantitative analysis, SDs were measured in ROIs over the apex of the tongue (metal artifacts) and nuchal muscle (no metal artifacts) and were used to calculate the metal artifact indexes. In a qualitative analysis, 3 radiologists blinded to the patients' conditions assessed the image-quality scores of metal artifact reduction and structural depictions.

RESULTS

Hybrid iterative reconstruction + metal artifact reduction algorithms and model-based iterative reconstruction + metal artifact reduction algorithms yielded significantly different metal artifact indexes of 82.2 and 73.6, respectively (95% CI, 2.6-14.7; P < .01). The latter algorithms resulted in significant reduction in metal artifacts and significantly improved structural depictions(P < .01).

CONCLUSIONS

Model-based iterative reconstruction + metal artifact reduction algorithms significantly reduced the artifacts and improved the image quality of structural depictions on neck CT images.

P1531 Changes in mitral annular dynamics with three different types of annuloplasty devices: measurement using three-dimensional transoesophageal echocardiography

OnBehalf

National Cerebral and Cardiovascular Center, Japan

Background/Purpose

Mitral annuloplasty plays a crucial role during mitral valve (MV) repair. The dynamics of the mitral annulus (MA) may be variously affected by the annuloplasty device. Therefore, we investigated the differences in MA dynamics when using a semi-rigid ring, semi-rigid band, and flexible ring.

Methods

We retrospectively reviewed 61 patients with mitral regurgitation who underwent MV repair, which included annuloplasty. Semi-rigid rings were used in 33 patients, flexible bands in 21, and semi-rigid bands in seven. Three-dimensional transoesophageal echocardiography (3D-TEE) images of the MV were recorded before and after annuloplasty. The 3D-TEE image datasets were analysed using semi-automated analysis software. We measured anterolateral–posteromedial (AL–PM) and anteroposterior (AP) diameter and height of the MV. The sphericity index (AP diameter divided by AL-PM diameter) and annular height to commissural width ratio (AHCWR) were calculated as the circular and saddle-shaped geometries, respectively. The differences in these values between end diastole (ED) and end systole (ES) were compared by t-test before and after mitral annuloplasty to analyse the MA among the semi-rigid ring, semi-rigid band, and flexible ring.

Results

Before annuloplasty (n = 61), the AL–PM diameter was significantly larger (ED: 4.26 ± 0.08 vs. ES: 4.24 ± 0.07, p = 0.016) and the sphericity index was significantly smaller (ED: 0.93 ± 0.01 vs. ES: 0.94 ± 0.01, p = 0.017) at ED than at ES. Table 1 shows the analysis after annuloplasty for each device. After annuloplasty, not every group demonstrated significant differences in AL–PM diameter or sphericity index. MA dynamics were reduced equally with the three devices.

Conclusion

Mitral annuloplasty reduced MA dynamics equally when using a semi-rigid ring, semi-rigid band, and flexible ring. There were no distinctive differences among the three devices in terms of maintaining flexibility and a saddle-shaped geometry.

MV dynamics after mitral annuloplasty Semi-rigid ring (n = 33) Flexible band (n = 21) Semi-rigid band (n = 7) ES ED P value ES ED P value ES ED P value AP (cm) 2.61 ± 0.38 2.67 ± 0.44 0.15 2.61 ± 0.38 2.67 ± 0.44 0.15 2.79 ± 0.44 2.80 ± 0.43 0.75 AL-PM (cm) 2.85 ± 0.31 2.91 ± 0.39 0.20 2.85 ± 0.31 2.91 ± 0.39 0.20 2.70 ± 0.39 2.73 ± 0.42 0.15 Height (cm) 0.49 ± 0.20 0.51 ± 0.21 0.35 0.63 ± 0.17 0.62 ± 0.17 0.48 0.63 ± 0.13 0.63 ± 0.13 1.00 SI 0.92 ± 0.09 0.92 ± 0.09 0.45 0.91 ± 0.09 0.91 ± 0.08 0.85 0.95 ± 0.12 0.95 ± 0.11 0.34 AHCWR(%) 17.1 ± 6.65 17.4 ± 6.67 0.56 20.4 ± 5.00 20.2 ± 5.10 0.52 21.3 ± 4.49 21.3 ± 4.80 0.95 Data are expressed mean ± standard deviation. AP: anterior posterior; AL-PM: anterolateral-posteromedial; SI: Sphericity index; AHCWR: annular height to commissure width ratio; ES: endsystole; ED: enddiastole.

Abstract P1531 Figure

P977Selective liner ablation according to the type of tachycardia induced after pulmonary vein isolation in single-procedure for long-standing persistent atrial fibrillation

Background

The most effective approach for long-standing persistent atrial fibrillation (LSPAF) ablation remained undetermined. Here, we hypothesized that selective linear ablation (SLA) according to the type of tachycardia induced by burst atrial pacing (BAP) after pulmonary venous isolation (PVI) in single-procedure reduces the recurrence.

Methods

A cohort of 66 LSPAF patients (Mean age 71.0±8.2 years, AF duration 40.5±58.8 months) who underwent PVI in single-procedure between April 2016 and November 2018 was evaluated.

Results

Any sustained atrial tachycardia (AT) or AF were not inducible by BAP after PVI in 21 patients (Non-inducible group, 31.8%, 71.3±7.9 years, 34.4±54.2 months). These patients underwent cavo-tricuspid isthmus (CTI) ablation after PVI. Forty-one patients underwent selective liner ablation according to the type of tachycardia induced by BAP after PVI (SLA group, 62.1%, 71.2±8.3 years, 39.3±55.6 months). Maccroreentry ATs (6 common atrial flutter, 5 AT originating from left atrial anterior wall, 2 peri-mitral atrial flutter, 1 roof-dependent atrial flutter) were induced by BAP in 14 patients of SLA group (73.2±19.7 years, 51.7±83.5 months). RF applications created the complete linear lesions to terminate maccroreentry ATs. Sustained AF was induced by BAP after PVI in 27 patients of SLA group (70.2±9.2 years, 32.9±31.2 months). These patients underwent posterior wall isolation (PWI) and CTI ablation. Unmappable AT was induced by BAP after PVI in 4 patients (Non-SLA group, 6.1%, 67.0±9.7 years, 84.5±105.6 months). These patients underwent PWI, CTI and mitral isthmus ablation on an empirical basis instead of SLA. Using a 90-day blanking period, the single-procedure Kaplan-Meier estimates of AT or AF event-free survival were 79% at 12 months. During follow-up (14.5±8.0 months), although 19 /21 (90.5%) of Non-inducible group patients and 33/41 (80.5%) of SLA group patients did not experience AT or AF recurrence, all of Non-SLA group patients experienced AF recurrence. There was no difference between Non-inducible group and SLA group in predicting recurrence of AT or AF (p=0.3). However, there was a difference when compared with Non-SLA group (each p<0.001). Non-SLA group was an independent powerful predictor resulting in recurrence of AF after adjusting for potential confounding factors (adjusted hazard ratio = 7.17; 95% confidence interval; 2.2–23.1, p=0.001, Wald χ2=10.9). Furthermore, in Kaplan-Meier survival curves for predicting AT or AF recurrence, Non-SLA group was the significant predictive marker of AT or AF recurrence (Log-Lank χ2=18.0, p<0.001).

Kaplan-Meier survival curves

Conclusions

In LSPAF patients without inducibility of any tachycardia after PVI, sinus rhythm was highly maintained without stepwise ablation other than CTI ablation. SLA reduced recurrence of AF in LSPAF patients with AT and AF induced after PVI. In addition, nonselective liner ablations for unmappable AT after PVI were less effective in LSPAF patients.

P5697J-wave elevation in the inferior leads is a predictor of lethal ventricular arrhythmia initiated by premature ventricular contractions with right bundle branch block and superior axis

Background

Lethal-ventricular-arrhythmia (VA) could be sometimes initiated by idiopathic Premature Ventricular Contractions (PVCs) originated form inferior wall. Furthermore, J-wave elevation in inferior leads was sometimes associated with lethal-VA. However, it was unclear the relationship between these PVCs and J-wave elevation in patients with lethal-VA.

Purpose

The aim of this study was to investigate the relationship between PVCs and J-wave elevation.

Methods and results

We studied 32 patients who underwent radiofrequency (RF) ablation of idiopathic PVCs with RBBB and superior axis. These PVCs were originating from inferior wall of left ventricular. Lethal-VA was defined as ventricular fibrillation (VF) or ventricular tachycardia (VT) with loss of consciousness (LOC). Among 32 patients, 3 had VF and 2 had VT with LOC. Other 27 had non-lethal-VA. Baseline clinical characteristics were not significantly difference between lethal and non-lethal-VA. The ratio of J-wave elevation in lethal-VA was significant higher as compared to those with non-lethal-VA (5/5 (100%) vs. 3/27 (11.1%), p<0.0001). Furthermore, no patients had recurrence of lethal-VA with J wave elevation in inferior leads after RF ablation of these PVCs with RBBB and superior axis,

Conclusions

We speculated that J-wave elevation in inferior leads might be a predictor of lethal-VA initiated by PVCs with RBBB and superior axis. RF ablation of these PVCs were useful method of treating lethal-VA.

Acknowledgement/Funding

None

A robust control system for targeting melanoma by a supermolecular DDMC/paclitaxel complex

A DEAE-dextran-MMA copolymer (DDMC)-paclitaxel (PTX) conjugate was prepared using PTX as the guest and DDMC as the host. The resistance of B16F10 melanoma cells to PTX was confirmed, while the DDMC-PTX conjugate showed excellent anticancer activity that followed the Hill equation. The robustness in the tumor microenvironment of the allosteric system was confirmed via BIBO stability. This feedback control system, explained via a transfer function, was very stable and showed the sustainability of the system via a loop, and it showed superior anti-cancer activity without drug resistance from cancer cells. The block diagram of this signal system in the tumor microenvironment used its loop transfer function G(s) and the dN(s) of the external force. This indicial response is an ideal one without a time lag for the outlet response. The cell death rate of DDMC-PTX is more dependent on the Hill coefficient n than on the Michaelis constant Km. This means that this supermolecular reaction with tubulin follows an "induced fit model".

Diagnostic Usefulness of APRI and FIB-4 for the Prediction of Liver Fibrosis After Liver Transplantation in Patients Infected with Hepatitis C Virus

BACKGROUND

Aspartate transaminase-to-platelet ratio index (APRI) and fibrosis-4 (FIB-4) are well known as representative indirect serum biomarkers related to liver fibrosis. The usefulness of these markers for the diagnosis of liver fibrosis after liver transplantation (LT) in hepatitis C virus (HCV)-infected patients and the influence of splenectomy were investigated.

METHODS

From June 2003 to May 2014, 31 HCV-infected patients who underwent LT and postoperative follow-up liver biopsies were included in this study. The association between liver fibrosis and serum biomarkers and the influence of splenectomy on APRI and FIB-4 were also investigated.

RESULTS

A total of 195 biopsy specimens were collected, and liver fibrosis was identified as: F0, 59.7%; F1, 34.1%; and F2, 6.3%. Both APRI and FIB-4 were significantly higher in patients who showed F1 and F2 in liver biopsy specimen than F0 (P values, .009 and .022, respectively); sensitivity and specificity of APRI were, respectively, 63.4% and 66.7%, and those of FIB-4 were 57.7% and 69.6%. In 11 patients (35.5%) who underwent splenectomy at the time of LT, the cutoff values for APRI and FIB-4 were 0.61 and 1.41, which were significantly lower than the corresponding values (1.00 and 3.64) of patients without splenectomy.

CONCLUSIONS

APRI and FIB-4 could effectively estimate liver fibrosis after LT for HCV-related liver disease. For LT patients with splenectomy, APRI and FIB-4 were also useful to estimate liver fibrosis, but the standard values should be adjusted lower than those for patients without splenectomy.

Preventive radioecological assessment of territory for optimization of monitoring and countermeasures after radiation accidents

A methodology of a preventive radioecological assessment of the territory has been developed for optimizing post-emergency monitoring and countermeasure implementation in an event of a severe radiation accident. Approaches and main stages of integrated radioecological zoning of the territory are described. An algorithm for the assessment of the potential radioecological criticality (sensitivity) of the area is presented. The proposed approach is validated using data of the dosimetric passportization in Ukraine after the Chernobyl accident for the test site settlements.

Successful Blood Transfusion Management of a Living Donor Liver Transplant Recipient in the Presence of Anti-Jra: A Case Report

A 48-year-old Japanese woman was diagnosed with Budd-Chiari syndrome and transferred for possible living donor liver transplantation (LDLT). Examinations before LDLT revealed that the recipient had anti-Jr^a and preformed donor-specific anti-human leukocyte antigen (HLA) antibodies (DSA). Rituximab was administrated at 16 days prior to the patient's scheduled LDLT for the prophylaxis of antibody-mediated rejection by DSA. The clinical significance of anti-Jr^a has not been clearly established because of the rarity of this antibody, so we discussed blood transfusion strategy with the Department of Blood Transfusion Service and prepared for Jr^a-negative packed red blood cells (RBCs). Intraoperative blood salvage was used during LDLT procedures to reduce the use of packed RBCs. Although post-transplantation graft function was excellent, a total of 44 U of Jr^a-negative RBCs were transfused during the entire perioperative period. Because sufficient amounts of Jr^a-negative packed RBCs were supplied, Jr^a mismatched blood transfusion was avoided. The patient was discharged from our hospital on postoperative day 102 without clinical evidence of any blood transfusion-related adverse events. Although there are some controversies of blood transfusion related to anti-Jr^a antibodies, the current strategies of blood transfusion for liver transplantation with anti-Jr^a are as follows: (1) sufficient supply and transfusion of Jr^a-negative matched packed RBCs and (2) application of intraoperative blood salvage to reduce the total amount of rare blood type RBCs. These strategies may be changed when the mechanism of anti-Jr^a alloimmunization is fully understood in the future.

Optimization of antitumor treatment conditions for transcutaneous CO2 application: An in vivo study

Carbon dioxide (CO2) therapy can be applied to treat a variety of disorders. We previously found that transcutaneous application of CO2 with a hydrogel decreased the tumor volume of several types of tumors and induced apoptosis via the mitochondrial pathway. However, only one condition of treatment intensity has been tested. For widespread application in clinical antitumor therapy, the conditions must be optimized. In the present study, we investigated the relationship between the duration, frequency, and treatment interval of transcutaneous CO2 application and antitumor effects in murine xenograft models. Murine xenograft models of three types of human tumors (breast cancer, osteosarcoma, and malignant fibrous histiocytoma/undifferentiated pleomorphic sarcoma) were used to assess the antitumor effects of transcutaneous CO2 application of varying durations, frequencies, and treatment intervals. In all human tumor xenografts, apoptosis was significantly induced by CO2 treatment for ≥10 min, and a significant decrease in tumor volume was observed with CO2 treatments of >5 min. The effect on tumor volume was not dependent on the frequency of CO2 application, i.e., twice or five times per week. However, treatment using 3- and 4-day intervals was more effective at decreasing tumor volume than treatment using 2- and 5-day intervals. The optimal conditions of transcutaneous CO2 application to obtain the best antitumor effect in various tumors were as follows: greater than 10 min per application, twice per week, with 3- and 4-day intervals, and application to the site of the tumor. The results suggest that this novel transcutaneous CO2 application might be useful to treat primary tumors, while mitigating some side effects, and therefore could be safe for clinical trials.

Changes in Muscle Strength and Six-Minute Walk Distance Before and After Living Donor Liver Transplantation

BACKGROUND

Impaired exercise capacity and muscle weakness are important characteristics of liver transplantation recipients. Perioperative rehabilitation has been introduced to promote early mobilization of patients and to prevent postoperative pulmonary complications. However, it is unknown how physical status recovers during the hospital stay after a liver transplant. The purpose of this study was to evaluate the changes in clinical indicators that represent the functional exercise capacity and muscle strength before and after living donor liver transplantation (LDLT).

METHODS

We retrospectively reviewed 21 consecutive patients who underwent LDLT with perioperative rehabilitation from April 2014 to December 2015. Twelve patients who were tested for 6-minute walk distance, hand-grip strength, and isometric knee extensor muscle strength before and 4 weeks after LDLT were enrolled.

RESULTS

At the preoperative baseline, the 6-minute walk distance significantly correlated with the Model for End-stage Liver Disease score and pulmonary functions (vital capacity, forced vital capacity, and forced expiratory volume in 1 second of predictive values). Comparisons between the preoperative and postoperative values revealed significant decreases in weight, Barthel Index, hand-grip strength, and isometric knee extensor muscle strength. Changes in hand-grip strength and isometric knee extensor muscle strength after LDLT correlated with the preoperative Model for End-stage Liver Disease score.

CONCLUSIONS

Physical functional status had not been fully recovered 4 weeks after LDLT. Further investigation regarding developing a strategy for prevention of muscle atrophy before LDLT and recovery of physical fitness after LDLT would be helpful.

Psychological and endocrine factors and pain after mastectomy

BACKGROUND

This prospective study was designed to examine the associations of demographic, clinical, psychological and neuroendocrine factors with acute and chronic post-operative pain following partial mastectomy.

METHODS

Sixty-four female patients scheduled for partial mastectomy were enrolled. Pre-operative anxiety/depression was assessed, using the Hospital Anxiety and Depression Scale (HADS). Pre-operative 24-h urinary cortisol levels were measured 2 days before surgery. Post-operative pain was examined using a visual analog scale (VAS) for acute pain on 0-2 post-operative day (POD), and a short-form McGill Pain Questionnaire for chronic pain at 6 months after surgery. In the last 29 subjects, post-operative 24-h urinary cortisol levels were also measured on 0 POD and were subjected to correlation analysis.

RESULTS

Multivariate logistic regression analysis revealed that lower pre-operative cortisol secretion and greater pre-operative anxiety were significantly associated with an increased risk of moderate to severe acute post-operative pain [Odds Ratio (95% Confidence Interval); 0.96 (0.92-0.98), and 1.24 (1.04-1.54)], and that patients with greater pre-operative anxiety and moderate to severe acute pain were more likely to develop chronic post-operative pain [OR (95% CI); 1.63 (1.23-2.40), and 5.07 (1.30-24.6)]. Correlational analysis demonstrated that the post-operative cortisol level was inversely correlated with pre-operative anxiety and the intensity of acute post-operative pain (r = -0.40, p < 0.05, and r = -0.50, p < 0.01), but not with the intensity of chronic pain.

CONCLUSIONS

This study confirms that pre-operative anxiety is associated with both acute and chronic post-operative pain after partial mastectomy. It also suggests that lower perioperative cortisol secretion might be associated with greater acute post-operative pain.

SIGNIFICANCE

Although the associations between psychological stress/stress hormone levels and chronic post-operative pain remain to be determined, pre-operative psychological stress and perioperative cortisol levels are correlated with acute post-operative pain.

AICAR induces mitochondrial apoptosis in human osteosarcoma cells through an AMPK-dependent pathway

The AMP-activated protein kinase (AMPK) activator 5-aminoimidazole-4-carboxamide ribonucleotide (AICAR) modulates cellular energy metabolism, and promotes mitochondrial proliferation and apoptosis. Previous studies have shown that AICAR has anticancer effects in various cancers, however the roles of AMPK and/or the effects of AICAR on osteosarcoma have not been reported. In the present study, we evaluated the effects of AICAR on tumor growth and mitochondrial apoptosis in human osteosarcoma both in vitro and in vivo. For in vitro experiments, two human osteosarcoma cell lines, MG63 and KHOS, were treated with AICAR, and the effects of AICAR on cell growth and mitochondrial apoptosis were assessed by WST assays, TUNEL staining, and immunoblot analyses. In vivo, human osteosarcoma-bearing mice were treated with AICAR, and the mitochondrial proliferation and apoptotic activity in treated tumors were assessed. In vitro experiments revealed that AICAR activated AMPK, inhibited cell growth, and induced mitochondrial apoptosis in both osteosarcoma cell lines. In vivo, AICAR significantly reduced osteosarcoma growth without apparent body weight loss and AICAR increased both mitochondrial proliferation and apoptotic activity in treated tumor tissues. AICAR showed anticancer effects in osteosarcoma cells through an AMPK-dependent peroxisome proliferator-activated receptor-γ coactivator-1α (PGC-1α)/mitochondrial transcription factor A (TFAM)/mitochondrial pathway. The findings in this study strongly suggest that AICAR could be considered as a potent therapeutic agent for the treatment of human osteosarcoma.

Numerical study of sediment and 137Cs discharge out of reservoirs during various scale rainfall events

Contamination of reservoirs with radiocesium is one of the main concerns in Fukushima Prefecture, Japan. We performed simulations using the three-dimensional finite volume code FLESCOT to understand sediment and radiocesium transport in generic models of reservoirs with parameters similar to those in Fukushima Prefecture. The simulations model turbulent water flows, transport of sediments with different grain sizes, and radiocesium migration both in dissolved and particulate forms. To demonstrate the validity of the modeling approach for the Fukushima environment, we performed a test simulation of the Ogaki Dam reservoir over Typhoon Man-yi in September 2013 and compared the results with field measurements. We simulated a set of generic model reservoirs systematically varying features such as flood intensity, reservoir volume and the radiocesium distribution coefficient. The results ascertain how these features affect the amount of sediment or ¹³⁷Cs discharge downstream from the reservoirs, and the forms in which ¹³⁷Cs is discharged. Silt carries the majority of the radiocesium in the larger flood events, while the clay-sorbed followed by dissolved forms are dominant in smaller events. The results can be used to derive indicative values of discharges from Fukushima reservoirs under arbitrary flood events. For example the generic model simulations indicate that about 30% of radiocesium that entered the Ogaki Dam reservoir over the flood in September 2015 caused by Typhoon Etau discharged downstream. Continued monitoring and numerical predictions are necessary to quantify future radiocesium migration in Fukushima Prefecture and evaluate possible countermeasures since reservoirs can be a sink of radiocesium.

Postoperative Psychiatric Complications in Living Liver Donors

BACKGROUND

To understand the impact of psychologic variables on donor quality of life, we studied long-term data on postoperative psychiatric complications in living liver donors. This study is a focused psychological investigation of diagnoses, treatments, and long-term clinical courses of living liver donors with psychiatric complications.

METHODS

Of the 142 donors who underwent live-donor liver transplantation at Nagoya University Hospital between April 2004 and July 2014, we investigated those without a history of mental illness who had developed such illness after transplantation and required psychiatric treatment.

RESULTS

A total of 6 (4.2%) donors developed the following psychiatric complications after transplantation: major depressive disorder (n = 2), panic disorder (n = 2), conversion disorder (n = 1), and substance use disorder (n = 1). Concerning psychiatric treatment, all donors received antianxiety drugs, 3 took antidepressants, and supportive psychiatric therapy was concomitantly provided to all subjects. The average treatment period was 53.3 months. Regarding subject outcomes, 3 donors achieved remission, and the other 3 continued treatment. All subjects showed improvement in Global Assessment of Functioning Scale.

CONCLUSION

It is important to accurately diagnose postoperative psychiatric complications and provide long-term treatment in close coordination with transplant surgeons.

Reconstruction of the Midfoot Using a Free Vascularized Fibular Graft After En Bloc Excision for Giant Cell Tumor of the Tarsal Bones: A Case Report

We report the case of a 32-year-old Japanese female with a giant cell tumor of bone involving multiple midfoot bones. Giant cell tumors of bone account for approximately 5% of all primary bone tumors and most often arise at the ends of long bones. The small bones, such as those of the hands and feet, are rare sites for giant cell tumors. Giant cell tumors of the small bones tend to exhibit more aggressive clinical behavior than those of the long bones. The present patient underwent en bloc tumor excision involving multiple tarsals and metatarsals. We reconstructed the longitudinal arch of the foot with a free vascularized fibular graft. At the 2-year follow-up visit, bony union had been achieved, with no tumor recurrence.

Insulin degludec versus insulin glargine, both once daily as add-on to existing orally administered antidiabetic drugs in insulin-naive Japanese patients with uncontrolled type 2 diabetes: subgroup analysis of a pan-Asian, treat-to-target phase 3 trial

Insulin degludec (IDeg) is a novel basal insulin analogue with an ultralong duration of action that provides flat and stable reductions in blood glucose. The BEGIN ONCE ASIA trial was a phase 3 pan-Asian study examining the efficacy and safety of IDeg once daily (OD) versus insulin glargine (IGlar) OD in insulin-naive patients with type 2 diabetes (T2D). In this multinational, 26-week, open-label, treat-to-target trial, participants were randomised (2:1) to IDeg OD or IGlar OD, administered with one or more antidiabetic drugs (OAD) per os. Here we report the results from a post hoc analysis of Japanese patients enrolled in the trial [n = 133; 63.2 % male; mean age 61.0 years; mean body mass index 24.1 kg/m²; mean glycosylated haemoglobin (HbA_1c) 8.5 %]. After 26 weeks, mean HbA_1c levels were similar between the two groups [estimated mean treatment difference 0.11 %; 95 % confidence interval (CI) -0.09, 0.31]. Confirmed hypoglycaemia was reported in 53.4 and 61.4 % of patients in the IDeg OD and IGlar OD groups [rate ratio (IDeg/IGlar) 0.87; 95 % CI 0.51, 1.48]. Confirmed nocturnal hypoglycaemia was reported in 17.0 and 22.7 % of patients in the IDeg OD and IGlar OD groups, respectively [rate ratio (IDeg/IGlar) 0.50; 95 % CI 0.19, 1.32]. Adverse event rates were similar between treatment groups. Initiating insulin treatment with IDeg OD in Japanese patients with T2D, inadequately maintained on OADs and requiring treatment intensification, provided effective glycaemic control with low rates of confirmed and nocturnal confirmed hypoglycaemia.

Antitumor effect of YM155, a novel small-molecule survivin suppressant, via mitochondrial apoptosis in human MFH/UPS

Survivin is a member of the inhibitor of apoptosis family, which is known to inhibit mitochondrial apoptosis. Survivin is highly expressed in cancers and plays an important role in cancer cell survival, and increased survivin expression is an unfavorable prognostic marker in cancer patients. YM155, a novel small-molecule survivin suppressant, selectively suppresses survivin expression, resulting in the induction of apoptosis in various malignancies. However, the roles of survivin in human malignant fibrous histiocytoma/undifferentiated pleomorphic sarcoma (MFH/UPS) have not been studied. In the present study, we examined survivin expression in human musculoskeletal tumor tissues, and the effect of survivin inhibition by siRNA or YM155 on apoptotic activity in human MFH/UPS cell lines. In tumor tissues, mRNA expression of survivin was significantly higher in MFH/UPS samples than in benign schwannomas. Moreover, in vitro studies revealed that both survivin siRNA and YM155 suppressed survivin expression and inhibited MFH/UPS cell proliferation in a dose- and a time-dependent manner. Further, the numbers of apoptotic cells significantly increased with YM155 treatment. In vivo, tumor volume in YM155-treated groups was significantly reduced without significant bodyweight loss. Increased apoptotic activity along with decreased survivin expression was also observed in YM155-treated tumors. The findings in this study strongly suggest that survivin suppressants, including YM155, contribute to the suppression of human MFH/UPS cell growth via promoting mitochondrial apoptosis, and that survivin may be a potent therapeutic target for the novel treatment of human MFH/UPS.

Sediment and (137)Cs behaviors in the Ogaki Dam Reservoir during a heavy rainfall event

We performed a simulation of sediment and (137)Cs behaviors in the Ogaki Dam Reservoir, one of the main irrigation reservoirs in the Fukushima prefecture, Japan, during a heavy rainfall event occurred in 2013. The one-dimensional river and reservoir simulation scheme TODAM, Time-dependent One-dimensional Degradation and Migration, was applied for calculating the time dependent migration of sediment and (137)Cs in dissolved and sediment-sorbed forms in the reservoir. Continuous observational data achieved in the upper rivers were used as the input boundary conditions for the simulation. The simulation results were compared with the continuous data achieved in the lower river and we confirmed the predicted values of sediment and (137)Cs in sediment-sorbed form at the exit of reservoir satisfactorily reproduced the observational data. We also performed sediment and (137)Cs behavioral simulation by changing the water level of the reservoir, because such a dam operation could control the quantities of sediment and (137)Cs discharge from and/or deposition in the reservoir. The simulation clarified that the reservoir played an important role to delay and buffer the movement of radioactive cesium in heavy rainfall events and the buffer effect of the reservoir depended on particle sizes of suspended sediment and the water level. It was also understood that silt deposition was the main source of the bed contamination (except for the initial fallout impact), while clay was the main carrier of (137)Cs to the lower river at a later stage of rainfall events.

Search for bosonic superweakly interacting massive dark matter particles with the XMASS-I detector

Bosonic superweakly interacting massive particles (super-WIMPs) are a candidate for warm dark matter. With the absorption of such a boson by a xenon atom, these dark matter candidates would deposit an energy equivalent to their rest mass in the detector. This is the first direct detection experiment exploring the vector super-WIMPs in the mass range between 40 and 120 keV. With the use of 165.9 day of data, no significant excess above background was observed in the fiducial mass of 41 kg. The present limit for the vector super-WIMPs excludes the possibility that such particles constitute all of dark matter. The absence of a signal also provides the most stringent direct constraint on the coupling constant of pseudoscalar super-WIMPs to electrons. The unprecedented sensitivity was achieved exploiting the low background at a level 10(-4)  kg-1 keVee-1 day-1 in the detector.

Predicting the long-term (137)Cs distribution in Fukushima after the Fukushima Dai-ichi nuclear power plant accident: a parameter sensitivity analysis

Radioactive materials deposited on the land surface of Fukushima Prefecture from the Fukushima Dai-ichi Nuclear Power Plant explosion is a crucial issue for a number of reasons, including external and internal radiation exposure and impacts on agricultural environments and aquatic biota. Predicting the future distribution of radioactive materials and their fates is therefore indispensable for evaluation and comparison of the effectiveness of remediation options regarding human health and the environment. Cesium-137, the main radionuclide to be focused on, is well known to adsorb to clay-rich soils; therefore its primary transportation mechanism is in the form of soil erosion on the land surface and transport of sediment-sorbed contaminants in the water system. In this study, we applied the Soil and Cesium Transport model, which we have developed, to predict a long-term cesium distribution in the Fukushima area, based on the Universal Soil Loss Equation and simple sediment discharge formulas. The model consists of calculation schemes of soil erosion, transportation and deposition, as well as cesium transport and its future distribution. Since not all the actual data on parameters is available, a number of sensitivity analyses were conducted here to find the range of the output results due to the uncertainties of parameters. The preliminary calculation indicated that a large amount of total soil loss remained in slope, and the residual sediment was transported to rivers, deposited in rivers and lakes, or transported farther downstream to the river mouths. Most of the sediment deposited in rivers and lakes consists of sand. On the other hand, most of the silt and clay portions transported to river were transported downstream to the river mouths. The rate of sediment deposition in the Abukuma River basin was three times as high as those of the other 13 river basins. This may be due to the larger catchment area and more moderate channel slope of the Abukuma River basin than those of the other rivers. Annual sediment outflows from the Abukuma River and the total from the other 13 river basins were calculated as 3.2 × 10(4)-3.1 × 10(5) and 3.4 × 10(4)-2.1 × 10(5)ty(-1), respectively. The values vary between calculation cases because of the critical shear stress, the rainfall factor, and other differences. On the other hand, contributions of those parameters were relatively small for (137)Cs concentration within transported soil. This indicates that the total amount of (137)Cs outflow into the ocean would mainly be controlled by the amount of soil erosion and transport and the total amount of (137)Cs concentration remaining within the basin. Outflows of (137)Cs from the Abukuma River and the total from the other 13 river basins during the first year after the accident were calculated to be 2.3 × 10(11)-3.7 × 10(12) and 4.6 × 10(11)-6.5 × 10(12)Bqy(-1), respectively. The former results were compared with the field investigation results, and the order of magnitude was matched between the two, but the value of the investigation result was beyond the upper limit of model prediction.

Transcutaneous application of CO2 enhances the antitumor effect of radiation therapy in human malignant fibrous histiocytoma

Sarcomas are relatively resistant because of hypoxia. We previously demonstrated that the transcutaneous CO(2) therapy reduced hypoxic conditions in human malignant fibrous histiocytoma (MFH). Therefore, we hypothesized that transcutaneous CO(2) therapy could enhance the antitumor effect of radiation therapy in human MFH. Our purpose was to evaluate the effects of transcutaneous CO(2) therapy on the antitumor efficacy of X-ray irradiation using MFH. First, in an in vitro study, we assessed apoptotic activity and reactive oxygen species (ROS) production using flow cytometric and immunoblot analysis at 24 h after X-ray irradiation under three different oxygen conditions (normoxic, reoxygenated and hypoxic). In addition, in the in vivo study, 24 male athymic BALB/c nude mice with MFH tumors that were inoculated in the dorsal subcutaneous area were randomized into four groups: control, CO(2), X-ray irradiation and combination (CO(2) and X-ray irradiation). Treatments were performed twice weekly for 2 weeks, four times in total. Tumor volume was calculated. All tumors were excised and apoptotic activity, ROS production, related proteins and HIF-1α expression were assessed using flow cytometric and immunoblot analysis. The in vitro study revealed that X-ray irradiation induced increased apoptosis and ROS production in MFH cells under normoxic and reoxygenated conditions relative to hypoxic conditions (P<0.01). In the in vivo study, tumor volume in the combination group was reduced to 28, 42 and 47% of that in the control, CO(2), and X-ray groups, respectively (P<0.05). Apoptotic activity and ROS production in the combination group were strongly increased with decreasing HIF-1α expression relative to the control, CO(2) and X-ray groups. The transcutaneous CO(2) system enhanced the antitumor action of X-ray irradiation and could be a novel therapeutic tool for overcoming radio-resistance in human malignancies.

Living donor liver transplantation using a right liver graft with additional vein reconstructions for patient with situs inversus

Living donor liver transplantation (LDLT) using a right liver graft with additional vein reconstructions has not been previously reported in a situs inversus (SI) patient. A 60-year-old man with SI was referred for LDLT for end-stage cirrhosis secondary to hepatitis B. The calculated regional volumes of the individual hepatic vein territories in the right liver graft suggested that the middle hepatic vein (MHV) tributaries and the inferior right hepatic veins (IRHVs) should be reconstructed in addition to the right hepatic vein (RHV). On the back-table, the recipient's recanalized umbilical vein graft was anastomosed to the V5 opening, and the other side of vein graft was anastomosed to the RHV and V8 opening to create a large single orifice. After total hepatectomy, the right liver graft was placed in the left subphrenic space at the reversed position. The common orifice of hepatic venous drainage from RHV, V8 and V5 was anastomosed to the anatomical RHV conduit of the recipient, followed by IRHV anastomosis to the inferior vena cava. Postoperative course was almost uneventful, and no vascular complications were experienced. Even for SI patients, LDLT using a right liver graft with reconstructions of the MHV tributaries and the IRHVs is feasible.

Regulation of mitochondrial proliferation by PGC-1α induces cellular apoptosis in musculoskeletal malignancies

A number of studies have reported that decreased mitochondrial numbers are linked with neoplastic transformation and/or tumor progression, including resistance to apoptosis. Peroxisome proliferator-activated receptor gamma coactivator-1 alpha (PGC-1α) is a multi-functional transcriptional coactivator that regulates the activities of multiple nuclear receptors and transcriptional factors involved in mitochondrial biogenesis. In this study, we observed that the number of mitochondria in sarcoma tissues, such as osteosarcoma and malignant fibrous histiocytoma, is significantly lower than that in normal muscle tissue or benign tumors and that increasing the number of mitochondria by PGC-1α overexpression induces mitochondrial apoptosis in human sarcoma cell lines. The findings suggest that decreased mitochondrial numbers may contribute to musculoskeletal tumor progression and that regulation of mitochondrial numbers by PGC-1α could be a potent therapeutic tool for human malignancies.

Effects of KIR ligand incompatibility on clinical outcomes of umbilical cord blood transplantation without ATG for acute leukemia in complete remission

To clarify the effect of killer cell immunoglobulin-like receptor (KIR) ligand incompatibility on outcomes of acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) patients in complete remission after single cord blood transplantation (CBT), we assessed the outcomes of CBT registered in the Japan Society for Hematopoietic Cell Transplantation (JSHCT) database. A total of 643 acute leukemia (357 AML and 286 ALL) patient and donor pairs were categorized according to their KIR ligand incompatibility by determining whether or not they expressed HLA-C, Bw4 or A3/A11 by DNA typing. A total of 128 patient–donor pairs were KIR ligand-incompatible in the graft-versus-host (GVH) direction and 139 patient–donor pairs were incompatible in the host-versus-graft (HVG) direction. Univariate and multivariate analyses showed no significant differences between the KIR ligand-incompatible and compatible groups in the GVH direction for both AML and ALL patients of overall survival, disease-free survival, relapse incidence, non-relapse mortality and acute GVH disease. However, KIR incompatibility in the HVG direction ameliorated engraftment in ALL patients (hazard ratio 0.66, 95% confidence interval 0.47–0.91, P=0.013). Therefore, there were no effects of KIR ligand incompatibility in the GVH direction on single CBT outcomes for acute leukemia patients without anti-thymocyte globulin use. However, it is necessary to pay attention to KIR incompatibility in the HVG direction for engraftment.