Assessment of the prognosis, frequency, and isolated bacteria in ventilator-associated pneumonia among patients with severe coronavirus disease 2019 pneumonia: A single-center retrospective observational study

INTRODUCTION

Acute respiratory distress syndrome (ARDS) due to severe coronavirus disease 2019 (COVID-19) pneumonia is associated with a high incidence of ventilator-associated pneumonia (VAP). We aimed to evaluate the epidemiology of VAP associated with severe COVID-19 pneumonia.

METHODS

This retrospective observational study recruited patients with COVID-19-associated ARDS admitted to our center from April 1, 2020, to September 30, 2021. The primary outcome was the survival-to-discharge rate. The secondary outcomes were the VAP rate, time to VAP, length of ICU stay, length of ventilator support, and isolated bacteria.

RESULTS

Sixty-eight patients were included in this study; 23 developed VAP. The survival-to-discharge rate was 60.9 % in the VAP group and 84.4 % in the non-VAP group. The median time to VAP onset was 16 days. The median duration of ventilator support and of ICU stay were higher in the VAP group than in the non-VAP group. The VAP rate was 33.8 %. The most common isolated species was Stenotrophomonas maltophilia. On admission, carbapenems were used in a maximum number of cases (75 %). Furthermore, the median body mass index (BMI) was lower and the median sequential organ failure assessment (SOFA) score on admission was higher in the VAP group than in the non-VAP group.

CONCLUSIONS

The survival-to-discharge rate in VAP patients was low. Moreover, VAP patients tended to have long ICU stays, low BMI, and high SOFA scores on admission. Unusually, S. maltophilia was the most common isolated bacteria, which may be related to the frequent use of carbapenems.

SOD2 orchestrates redox homeostasis in intervertebral discs: A novel insight into oxidative stress-mediated degeneration and therapeutic potential

Low back pain (LBP) is a pervasive global health concern, primarily associated with intervertebral disc (IVD) degeneration. Although oxidative stress has been shown to contribute to IVD degeneration, the underlying mechanisms remain undetermined. This study aimed to unravel the role of superoxide dismutase 2 (SOD2) in IVD pathogenesis and target oxidative stress to limit IVD degeneration. SOD2 demonstrated a dynamic regulation in surgically excised human IVD tissues, with initial upregulation in moderate degeneration and downregulation in severely degenerated IVDs. Through a comprehensive set of in vitro and in vivo experiments, we found a suggestive association between excessive mitochondrial superoxide, cellular senescence, and matrix degradation in human and mouse IVD cells. We confirmed that aging and mechanical stress, established triggers for IVD degeneration, escalated mitochondrial superoxide levels in mouse models. Critically, chondrocyte-specific Sod2 deficiency accelerated age-related and mechanical stress-induced disc degeneration in mice, and could be attenuated by β-nicotinamide mononucleotide treatment. These revelations underscore the central role of SOD2 in IVD redox balance and unveil potential therapeutic avenues, making SOD2 and mitochondrial superoxide promising targets for effective LBP interventions.

A clinical assessment of three-dimensional-printed liver model navigation for thrice or more repeated hepatectomy based on a conversation analysis

PURPOSES

We performed a conversation analysis of the speech conducted among the surgical team during three-dimensional (3D)-printed liver model navigation for thrice or more repeated hepatectomy (TMRH).

METHODS

Seventeen patients underwent 3D-printed liver navigation surgery for TMRH. After transcription of the utterances recorded during surgery, the transcribed utterances were coded by the utterer, utterance object, utterance content, sensor, and surgical process during conversation. We then analyzed the utterances and clarified the association between the surgical process and conversation through the intraoperative reference of the 3D-printed liver.

RESULTS

In total, 130 conversations including 1648 segments were recorded. Utterance coding showed that the operator/assistant, 3D-printed liver/real liver, fact check (F)/plan check (Pc), visual check/tactile check, and confirmation of planned resection or preservation target (T)/confirmation of planned or ongoing resection line (L) accounted for 791/857, 885/763, 1148/500, 1208/440, and 1304/344 segments, respectively. The utterance's proportions of assistants, F, F of T on 3D-printed liver, F of T on real liver, and Pc of L on 3D-printed liver were significantly higher during non-expert surgeries than during expert surgeries. Confirming the surgical process with both 3D-printed liver and real liver and performing planning using a 3D-printed liver facilitates the safe implementation of TMRH, regardless of the surgeon's experience.

CONCLUSIONS

The present study, using a unique conversation analysis, provided the first evidence for the clinical value of 3D-printed liver for TMRH for anatomical guidance of non-expert surgeons.

CG02N Analyzer Accurately Measures Fibrinogen Level in Whole Blood in the Presence of Low- or High-Dose Heparin

Rapid fibrinogen (Fbg) evaluation is important in patients with massive bleeding during severe trauma and those undergoing major surgery. However, there are only a few studies on the point-of-care Fbg analyzer. In this study, we aimed to investigate the accuracy of Fbg level measured using CG02N, with whole blood contained in lithium-heparinized syringes with two different concentrations of heparin. Blood samples were collected in lithium-heparinized tubes, namely PREZA-PAK®II (low-dose heparin group [LG], 7 IU/mL) and Pro-Vent® Plus (high-dose heparin group [HG], 70.5 IU/mL). The Fbg levels in LG and HG were compared with those of citrated plasma Fbg (standard-Fbg). Strong correlations with respect to the Fbg level were observed between standard-Fbg and LG or HG (r = 0.968, p < 0.0001; r = 0.970, p < 0.0001, respectively). We demonstrated that the Fbg level in whole-blood samples was accurately assessed by CG02N and not affected by low- or high-dose heparin.

O-GlcNAcylation is essential for therapeutic mitochondrial transplantation

BACKGROUND

Transplantation of mitochondria is increasingly explored as a novel therapy in central nervous system (CNS) injury and disease. However, there are limitations in safety and efficacy because mitochondria are vulnerable in extracellular environments and damaged mitochondria can induce unfavorable danger signals.

METHODS

Mitochondrial O-GlcNAc-modification was amplified by recombinant O-GlcNAc transferase (OGT) and UDP-GlcNAc. O-GlcNAcylated mitochondrial proteins were identified by mass spectrometry and the antiglycation ability of O-GlcNAcylated DJ1 was determined by loss-of-function via mutagenesis. Therapeutic efficacy of O-GlcNAcylated mitochondria was assessed in a mouse model of transient focal cerebral ischemia-reperfusion. To explore translational potential, we evaluated O-GlcNAcylated DJ1 in CSF collected from patients with subarachnoid hemorrhagic stroke (SAH).

RESULTS

We show that isolated mitochondria are susceptible to advanced glycation end product (AGE) modification, and these glycated mitochondria induce the receptor for advanced glycation end product (RAGE)-mediated autophagy and oxidative stress when transferred into neurons. However, modifying mitochondria with O-GlcNAcylation counteracts glycation, diminishes RAGE-mediated effects, and improves viability of mitochondria recipient neurons. In a mouse model of stroke, treatment with extracellular mitochondria modified by O-GlcNAcylation reduces neuronal injury and improves neurologic deficits. In cerebrospinal fluid (CSF) samples from SAH patients, levels of O-GlcNAcylation in extracellular mitochondria correlate with better clinical outcomes.

CONCLUSIONS

These findings suggest that AGE-modification in extracellular mitochondria may induce danger signals, but O-GlcNAcylation can prevent glycation and improve the therapeutic efficacy of transplanted mitochondria in the CNS.

Recombinant Laminin-511 Fragment (iMatrix-511) Coating Supports Maintenance of Human Nucleus Pulposus Progenitor Cells In Vitro

The angiopoietin-1 receptor (Tie2) marks specific nucleus pulposus (NP) progenitor cells, shows a rapid decline during aging and intervertebral disc degeneration, and has thus sparked interest in its utilization as a regenerative agent against disc degeneration. However, the challenge of maintaining and expanding these progenitor cells in vitro has been a significant hurdle. In this study, we investigated the potential of laminin-511 to sustain Tie2+ NP progenitor cells in vitro. We isolated cells from human NP tissue (n = 5) and cultured them for 6 days on either standard (Non-coat) or iMatrix-511 (laminin-511 product)-coated (Lami-coat) dishes. We assessed these cells for their proliferative capacity, activation of Erk1/2 and Akt pathways, as well as the expression of cell surface markers such as Tie2, GD2, and CD24. To gauge their regenerative potential, we examined their extracellular matrix (ECM) production capacity (intracellular type II collagen (Col2) and proteoglycans (PG)) and their ability to form spherical colonies within methylcellulose hydrogels. Lami-coat significantly enhanced cell proliferation rates and increased Tie2 expression, resulting in a 7.9-fold increase in Tie2-expressing cell yields. Moreover, the overall proportion of cells positive for Tie2 also increased 2.7-fold. Notably, the Col2 positivity rate was significantly higher on laminin-coated plates (Non-coat: 10.24% (±1.7%) versus Lami-coat: 26.2% (±7.5%), p = 0.010), and the ability to form spherical colonies also showed a significant improvement (Non-coat: 40.7 (±8.8)/1000 cells versus Lami-coat: 70.53 (±18.0)/1000 cells, p = 0.016). These findings demonstrate that Lami-coat enhances the potential of NP cells, as indicated by improved colony formation and proliferative characteristics. This highlights the potential of laminin-coating in maintaining the NP progenitor cell phenotype in culture, thereby supporting their translation into prospective clinical cell-transplantation products.

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

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

Risk Factors for Bleeding in Coronavirus Disease 2019 Patients on Extracorporeal Membrane Oxygenation and Effects of Transcatheter Arterial Embolization for Hemostasis

Purpose

To evaluate risk factors for bleeding events in coronavirus disease 2019 (COVID-19) patients on extracorporeal membrane oxygenation (ECMO) and to share the initial results of transcatheter arterial embolization (TAE) for hemostasis.

Material and Methods

Forty-three COVID-19 patients who received ECMO from May 2020 to September 2021 were enrolled in this study. Patients with sudden onset anemia immediately underwent computed tomography to assess bleeding. We compared laboratory data, duration of ECMO, hospitalization period, and fatality of patients' groups with and without significant hemorrhagic events using the chi-square test and Mann-Whitney U test. We also assessed the results of TAE in patients who received hemostasis.

Results

A total of 25 bleeding events occurred in 24 of the 43 patients. Age was a risk factor for bleeding events and fatality. The average duration of ECMO and hospitalization period were significantly longer in those with bleeding events (42.9 and 54.3 days) than in those without bleeding events (16.2 and 25.0 days) (p < 0.05). In addition, those with bleeding had higher fatality (45.8%) than those without (15.8%) (p < 0.05). Active extravasation was confirmed for 5 events in 4 of 24 patients. TAE was attempted and performed successfully in all but one of these four cases, in whom bleeding ceased spontaneously.

Conclusions

Elderly COVID-19 patients on ECMO had a greater risk of bleeding complications and fatal outcomes. TAE was effective in providing prompt hemostasis for patients who have the treatment indication.

Blood Purification in Patients with Sepsis Associated with Acute Kidney Injury: A Narrative Review

Sepsis leads to organ dysfunction. Acute kidney injury, a common type of organ dysfunction, is associated with a high mortality rate in patients with sepsis. Kidney replacement therapy can correct the metabolic, electrolyte, and fluid imbalances caused by acute kidney injury. While this therapy can improve outcomes, evidence of its beneficial effects is lacking. Herein, we review the indications for blood purification therapy, including kidney replacement therapy, and the current knowledge regarding acute kidney injury in terms of renal and non-renal indications. While renal indications have been well-documented, indications for blood purification therapy in sepsis (non-renal indications) remain controversial. Excessive inflammation is an important factor in the development of sepsis; blood purification therapy has been shown to reduce inflammatory mediators and improve hemodynamic instability. Given the pathophysiology of sepsis, blood purification therapy may decrease mortality rates in these patients. Further trials are needed in order to establish the effectiveness of blood purification therapy for sepsis.

Predicting habitual water intake from lifestyle questions

OBJECTIVE

Previous studies have used selective recall and descriptive dietary record methods, requiring considerable effort for assessing food and water intake. This study created a simplified lifestyle questionnaire to predict habitual water intake (SQW), accurately and quickly assessing the habitual water intake. We also evaluated the validity using descriptive dietary records as a cross-sectional study.

SUBJECTS AND METHODS

First, we used crowdsourcing and machine learning to collect data, predict water intake records, and create questionnaires. We collected 305 lifestyle-related questions as predictor variables and selective recall methods for assessing water intake as an outcome variable. Random forests were used for the machine learning models because of their interpretability and accurate estimation. Random forest and single regression correlation analysis were augmented by the synthetic minority oversampling that trained the model. We separated the data by sex and evaluated our model using unseen hold-out testing data, predicting the individual and overall habitual water intake from various sources, including non-alcoholic beverages, alcohol, and food.

RESULTS

We found a 0.60 Spearman's correlation coefficient for total water intake between the predicted and the selective recall method values, reflecting the target value to be achieved. This question set was then used for feasibility tests. The descriptive dietary record method helped to obtain a ground-truth value. We categorized the data by gender, season, and source: non-alcoholic beverages, alcohol, food, and total water intake, and the correlation was confirmed. Consequently, our results showed a Pearson's correlation coefficient of 0.50 for total water intake between the predicted and the selective recall method values.

CONCLUSIONS

We hypothesize that dissemination of SQW can lead to better health management by easily determining the habitual water intake.

Association of the quantitative oral health status of patients with COVID-19 with their organ status and immunity: A single-centre observational study

Objectives

To evaluate the prevalence of oral complications in patients with severe COVID-19; investigate the association between their oral health, organ status, and immunity; and determine whether the resazurin disc test is an effective substitute for the Oral Assessment Guide.

Research methodology/design

A single-centre observational study.

Setting

Intensive care unit with restricted access specialising in extracorporeal membrane oxygenation for COVID-19 treatment.

Main outcome measures

We investigated the oral health of 13 patients with COVID-19 receiving extracorporeal membrane oxygenation therapy between April and December 2021 using the Oral Assessment Guide and colour reactive resazurin disc test. The Sequential Organ Failure Assessment and Prognostic Nutritional Index were used to assess organ status and immunity, respectively. The correlation of oral health status with organ status and immunity was investigated.

Results

High bacterial levels, revealed by the resazurin disc test, were associated with elevated Oral Assessment Guide scores, indicating oral health deterioration, particularly in terms of teeth and dentures. Increased Sequential Organ Failure Assessment scores and decreased Prognostic Nutritional Index were correlated with poor oral health, revealed by the Oral Assessment Guide and resazurin disc test.

Conclusion

Poor oral health is an important risk factor for severe COVID-19 complications in patients admitted to an intensive care unit. The Oral Assessment Guide and resazurin disc test can evaluate oral conditions; however, the resazurin disc test is quantitative and does not require salivary specimens to be transferred outside the patient ward for evaluation. The resazurin disc test can be a useful substitute for the Oral Assessment Guide in intensive care units with restricted access.

Implications for clinical practice

The resazurin disc test can be used for quantitative assessment of patients’ oral condition in isolation wards. Multidisciplinary management of patients with COVID-19 should be promoted and involve oral healthcare providers such as dentists and dental hygienists.

Investigation of the Mitigation of DMSO-Induced Cytotoxicity by Hyaluronic Acid following Cryopreservation of Human Nucleus Pulposus Cells

To develop an off-the-shelf therapeutic product for intervertebral disc (IVD) repair using nucleus pulposus cells (NPCs), it is beneficial to mitigate dimethyl sulfoxide (DMSO)-induced cytotoxicity caused by intracellular reactive oxygen species (ROS). Hyaluronic acid (HA) has been shown to protect chondrocytes against ROS. Therefore, we examined the potential of HA on mitigating DMSO-induced cytotoxicity for the enhancement of NPC therapy. Human NPC cryopreserved in DMSO solutions were thawed, mixed with equal amounts of EDTA-PBS (Group E) or HA (Group H), and incubated for 3-5 h. After incubation, DMSO was removed, and the cells were cultured for 5 days. Thereafter, we examined cell viability, cell proliferation rates, Tie2 positivity (a marker of NP progenitor cells), and the estimated numbers of Tie2 positive cells. Fluorescence intensity of DHE and MitoSOX staining, as indicators for oxidative stress, were evaluated by flow cytometry. Group H showed higher rates of cell proliferation and Tie2 expressing cells with a trend toward suppression of oxidative stress compared to Group E. Thus, HA treatment appears to suppress ROS induced by DMSO. These results highlight the ability of HA to maintain NPC functionalities, suggesting that mixing HA at the time of transplantation may be useful in the development of off-the-shelf NPC products.

Probing the symmetry breaking of a light-matter system by an ancillary qubit

Hybrid quantum systems in the ultrastrong, and even more in the deep-strong, coupling regimes can exhibit exotic physical phenomena and promise new applications in quantum technologies. In these nonperturbative regimes, a qubit-resonator system has an entangled quantum vacuum with a nonzero average photon number in the resonator, where the photons are virtual and cannot be directly detected. The vacuum field, however, is able to induce the symmetry breaking of a dispersively coupled probe qubit. We experimentally observe the parity symmetry breaking of an ancillary Xmon artificial atom induced by the field of a lumped-element superconducting resonator deep-strongly coupled with a flux qubit. This result opens a way to experimentally explore the novel quantum-vacuum effects emerging in the deep-strong coupling regime.

Adrenaline-resistant anaphylactic shock caused by contrast medium in a patient after risperidone overdose: a case report

BACKGROUND

In Japan, the use of risperidone in combination with adrenaline is contraindicated, except in cases of anaphylaxis. Therefore, there is limited clinical evidence regarding the interaction of these two drugs. Here, we report the clinical course of a case of adrenaline-resistant anaphylactic shock induced by a contrast medium injection after a risperidone overdose.

CASE PRESENTATION

A man in his 30s was transported to our hospital after attempting suicide by taking 10 mg of risperidone and jumping from a height of 10 m. To determine the location and severity of his injuries, he was injected with an iodinated contrast medium, after which he developed generalized erythema and hypotension and was diagnosed with anaphylactic shock. A 0.5 mg dose of adrenaline was administered with no improvement, followed by another 0.5 mg dose that did not change his blood pressure. After infusion of a sodium bicarbonate solution (8.4%), administration of fresh frozen plasma, and additional administration of adrenaline (0.6-1.2 µg/min), his blood pressure improved, and he recovered from the anaphylactic shock.

CONCLUSIONS

This was a rare case of a risperidone overdose followed by adrenaline-resistant anaphylactic shock. The resistance is likely associated with the high blood concentration of risperidone. Our findings indicate that the potential for decreased adrenergic responsiveness should be considered in patients undergoing risperidone treatment in the event of anaphylactic shock.

Protein-Ligand Interaction Analyses with Nuclear Magnetic Resonance Spectroscopy Enhanced by Dissolution Triplet Dynamic Nuclear Polarization

Solution-state nuclear magnetic resonance spectroscopy (NMR) is a powerful method for the analysis of intermolecular interactions within a biomolecular system. However, low sensitivity is one of the major obstacles of NMR. We improved the sensitivity of solution-state ¹³C NMR for the observation of intermolecular interactions between protein and ligand using hyperpolarized solution samples at room temperature. Eutectic crystals composed of ¹³C-salicylic acid and benzoic acid doped with pentacene were hyperpolarized by dynamic nuclear polarization using photoexcited triplet electrons, and a ¹³C nuclear polarization of 0.72 ± 0.07% was achieved after dissolution. The binding of human serum albumin and ¹³C-salicylate was observed with several hundred times sensitivity enhancement under mild conditions. The established ¹³C NMR was applied for pharmaceutical NMR experiments by observation of the partial return of the ¹³C chemical shift of salicylate by competitive binding with other non-isotope-labeled drugs.

Comparison of the cytokine adsorption ability in continuous renal replacement therapy using polyethyleneimine-coated polyacrylonitrile (AN69ST) or polymethylmethacrylate (PMMA) hemofilters: a pilot single-center open-label randomized control trial

BACKGROUND

Sepsis occurs as a result of dysregulated host response to infection. However, cytokine adsorption therapy may restore the balance of proinflammatory and anti-inflammatory mediator responses in patients with sepsis. This study aimed to determine the cytokine adsorption ability of two different types of continuous renal replacement therapy (CRRT) hemofilters for polyethyleneimine-coated polyacrylonitrile (AN69ST) (surface-treated) and polymethylmethacrylate (PMMA) CRRT.

METHODS

We performed a randomized controlled trial among sepsis patients undergoing CRRT, who were randomly assigned (1:1) to receive either AN69ST or PMMA-CRRT. The primary outcome was cytokine clearance of hemofilter adsorption (CHA). The secondary endpoints were the intensive care unit (ICU) and 28-day mortalities.

RESULTS

We randomly selected 52 patients. Primary outcome data were available for 26 patients each in the AN69ST-CRRT and PMMA-CRRT arms. The CHA of high-mobility group box 1, tumor necrosis factor, interleukin (IL)-8, monokine induced by interferon-γ, and macrophage inflammatory protein were significantly higher in the AN69ST-CRRT group than in the PMMA-CRRT group (P < 0.001, P < 0.01, P < 0.001, P < 0.001 and P < 0.001, respectively). In contrast, the CHA of IL-6 was significantly higher in the PMMA-CRRT group than in the AN69ST-CRRT group (P < 0.001). In addition, the 28-day mortality was not significantly different between the two groups (50% in AN69ST-CRRT vs. 30.8% in PMMA-CRRT, P = 0.26).

CONCLUSION

AN69ST and PMMA membranes have different cytokine CHA in patients with sepsis. Therefore, these two hemofilters may have to be used depending on the target cytokine.

TRIAL REGISTRATION NUMBER

This study was registered in the University Hospital Medical Information Network on November 1, 2017 (Trial No: UMIN000029450, https://center6.umin.ac.jp ).

Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with metastatic colorectal cancer

The European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with metastatic colorectal cancer (mCRC), published in late 2022, were adapted in December 2022, according to previously established standard methodology, to produce the Pan-Asian adapted (PAGA) ESMO consensus guidelines for the management of Asian patients with mCRC. The adapted guidelines presented in this manuscript represent the consensus opinions reached by a panel of Asian experts in the treatment of patients with mCRC representing the oncological societies of China (CSCO), Indonesia (ISHMO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), the Philippines (PSMO), Singapore (SSO), Taiwan (TOS) and Thailand (TSCO), co-ordinated by ESMO and the Japanese Society of Medical Oncology (JSMO). The voting was based on scientific evidence and was independent of the current treatment practices, drug access restrictions and reimbursement decisions in the different Asian countries. The latter are discussed separately in the manuscript. The aim is to provide guidance for the optimisation and harmonisation of the management of patients with mCRC across the different countries of Asia, drawing on the evidence provided by both Western and Asian trials, whilst respecting the differences in screening practices, molecular profiling and age and stage at presentation, coupled with a disparity in the drug approvals and reimbursement strategies, between the different countries.

Safety Profile of the Concomitant Use of Atorvastatin and Cyclosporine in Renal Transplant Recipients

Cyclosporine (CyA) and atorvastatin (AT) are often administered concomitantly to treat dyslipidemia in renal transplant recipients. However, CyA greatly increases the plasma concentration of AT; therefore, concomitant use might increase the frequency of statin-induced adverse effects. The aim of this study was to investigate whether concomitant use of CyA and AT increases intolerance of the latter agent in Japanese renal transplantation recipients. We performed a retrospective cohort analysis of renal transplant recipients aged 18 years and older who had concomitantly received AT and CyA, or tacrolimus (Tac) therapy. We defined statin intolerance as a decrease in dose or discontinuation of AT due to adverse effects. We evaluated the incidence of statin intolerance in concomitant therapy with CyA for 100 days after the initial administration of AT in comparison with Tac. A total of 144 renal transplant recipients who received AT and CyA, or Tac between January 2013 and December 2019 were included. There was no statistical difference in the incidence of statin intolerance in both the CyA (1.8%; 1/57 patients) and Tac (3.4%; 3/87 patients) groups. Concomitant use of CyA and AT might not increase the incidence of statin intolerance in Japanese renal transplant recipients.

Daily combined measurement of platelet count and presepsin concentration can predict in-hospital death of patients with severe coronavirus disease 2019 (COVID-19)

The purpose of this study was to classify patients with severe COVID-19 into more detailed risk groups using coagulation/fibrinolysis, inflammation/immune response, and alveolar/myocardial damage biomarkers, as well as to identify prognostic markers for these patients. These biomarkers were measured every day for eight intensive care unit days in 54 adult patients with severe COVID-19. The patients were classified into survivor (n = 40) and non-survivor (n = 14) groups. Univariate and multivariate analyses showed that the combined measurement of platelet count and presepsin concentrations may be the most valuable for predicting in-hospital death, and receiver operating characteristic curve analysis further confirmed this result (area under the curve = 0.832). Patients were consequently classified into three groups (high-, medium-, and low-risk) on the basis of their cutoff values (platelet count 53 × 10³/µL, presepsin 714 pg/mL). The Kaplan-Meier curve for 90-day survival by each group showed that the 90-day mortality rate significantly increased as risk level increased (P < 0.01 by the log-rank test). Daily combined measurement of platelet count and presepsin concentration may be useful for predicting in-hospital death and classifying patients with severe COVID-19 into more detailed risk groups.

Comprehensive clinical and molecular characterization of claudin 18.2 expression in advanced gastric or gastroesophageal junction cancer

BACKGROUND

We conducted comprehensive clinical and molecular characterization of claudin 18.2 expression (CLDN18.2) in advanced gastric or gastroesophageal junction cancer (GC/GEJC).

PATIENTS AND METHODS

Patients with advanced GC/GEJC who received systemic chemotherapy from October 2015 to December 2019 with available tumor specimens were analyzed. We evaluated clinicopathological features of CLDN18.2 expression with four molecular subtypes: mismatch repair deficient, Epstein-Barr virus-positive, human epidermal growth factor receptor 2-positive, and others. In addition, programmed death-ligand 1 (PD-L1) combined positive score (CPS), genomic alterations, and the expression of immune cell markers were assessed. Clinical outcomes of standard first- or second-line chemotherapy and subsequent anti-programmed cell death protein 1 (anti-PD-1) therapy were also investigated according to CLDN18.2 expression.

RESULTS

Among 408 patients, CLDN18.2-positive (moderate-to-strong expression in ≥75%) was identified in 98 patients (24.0%) with almost equal distribution in the four molecular subtypes or CPS subgroups. CLDN18.2-positive was associated with Borrmann type 4, KRAS amplification, low CD16, and high CD68 expression. Overall survival with first-line chemotherapy was not significantly different between CLDN18.2-positive and -negative groups [median 18.4 versus 20.1 months; hazard ratio 1.26 (95% confidence interval 0.89-1.78); P = 0.191] regardless of stratification by PD-L1 CPS ≥5. Progression-free survival and objective response rates of first- and second-line chemotherapy, and anti-PD-1 therapy also showed no significant differences according to CLDN18.2 status.

CONCLUSIONS

CLDN18.2 expression in advanced GC/GEJC was associated with some clinical and molecular features but had no impact on treatment outcomes with chemotherapy or checkpoint inhibition. CLDN18.2-positive also had no impact on overall survival. This information could be useful to interpret the results from currently ongoing clinical trials of CLDN18.2-targeted therapies for advanced GC/GEJC and to consider a treatment strategy for CLDN18.2-positive GC/GEJC.

Effect of quercetin glycosides on cognitive functions and cerebral blood flow: a randomized, double-blind, and placebo-controlled study

OBJECTIVE

This study aimed to examine the effects of quercetin glycoside-containing beverages on cognitive function and cerebral blood flow (CBF) in adult men and women aged between 60 and 75 years.

PATIENTS AND METHODS

Eighty healthy men and women with no cognitive impairment and aware of ageing-related forgetfulness underwent a placebo-controlled, randomized, double-blind, and parallel-group trial. They regularly consumed 500 mL of beverage containing 110 mg of quercetin glycoside as isoquercitrin for 40 weeks. Cognitive function assessment by Cognitrax was the endpoint of the study. The participants were assessed for CBF, health-related quality of life, as well as physical, biological, and hematological parameters, and lateral index.

RESULTS

Cognitrax demonstrated that the reaction time significantly improved in the quercetin glycoside intake group. The CBF measurement suggested that quercetin glycoside intake could likely suppress the decrease in cerebral blood volume, CBF, and cerebral activity owing to stress alleviation and inhibition of the accumulation of amyloid β (Aβ), a waste product in the brain, although there were no significant differences between the groups.

CONCLUSIONS

Quercetin glycoside intake as a beverage could improve reaction time and may potentially inhibit the decrease in CBF and suppress Aβ accumulation.

Measurement of Paα line from pellet ablation cloud in Heliotron J

The Pa_α line (1875.13 nm) in the near-infrared (NIR) region was evaluated to apply Stark broadening of the line spectrum to the electron density measurement of the small-pellet ablation cloud in Heliotron J, a medium-sized helical-axis heliotron device. Pa_α is three-to-four times broader than the visible H_β line (486.13 nm) for the same electron density. Using a portable NIR spectrometer, preliminary proof-of-concept experiments determined the marginal density, below which the broadening was undetectable. The lower detection density limit can be decreased using a narrower entrance slit or a denser grating.

Prognostic value of estimating appendicular muscle mass in heart failure using creatinine/cystatin C

Objectives

As heart failure with concomitant sarcopenia has a poor prognosis, simple methods for evaluating the appendicular skeletal muscle mass index (ASMI) are required. Recently, a model incorporating anthropometric data and the sarcopenia index, that is, the ratio of serum creatinine to cystatin C (Cre/CysC), was developed to estimate the appendicular skeletal muscle mass. We hypothesized that this model would be superior to the previous model, which uses only anthropometric data to predict the prognosis. This study aimed to compare the prognostic value of low ASMI as defined by the biomarker and anthropometric models in patients with heart failure.

Methods

Among 847 patients, we estimated ASMI using an anthropometric model consisting of age, body weight, and height in 791 patients and a biomarker model that incorporates age, body weight, hemoglobin, and Cre/CysC in 562 patients. Patients were divided into low and non-low ASMI groups according to the ASMI estimated by each model, using the cut-off proposed by the Asian Working Group for Sarcopenia. The primary outcome was all-cause mortality.

Results

Overall, 53.4% and 39.1% of patients were diagnosed with low ASMI by anthropometric and biomarker models, respectively. The agreement of the diagnosis of low ASMI between the two models was poor, with a kappa coefficient of 0.56 (95% confidence interval: 0.49–0.63). Kaplan-Meier curves showed that a low ASMI was significantly associated with all-cause death in both models. However, this association was retained after adjustment for other covariates in the biomarker model (hazard ratio: 2.60, p=0.003), but not in the anthropometric model (hazard ratio: 0.70, p=0.257).

Conclusions and implications

Among patients hospitalized with heart failure, a low ASMI estimated using the biomarker model, but not the anthropometric model, was significantly associated with all-cause mortality.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Japan Agency for Medical Research and Development

N-acetylcysteine attenuates oxidative stress-mediated cell viability loss induced by dimethyl sulfoxide in cryopreservation of human nucleus pulposus cells: A potential solution for mass production

Background

Cell therapy is considered a promising strategy for intervertebral disc (IVD) regeneration. However, cell products often require long-term cryopreservation, which compromises cell viability and potency, thus potentially hindering commercialization and off-the-shelf availability. Dimethyl sulfoxide (DMSO) is a commonly used cryoprotectant, however, DMSO is associated with cytotoxicity and cell viability loss. This study aimed to investigate the effects of DMSO on human nucleus pulposus cells (NPC) and the role of oxidative stress in DMSO-induced cytotoxicity. Furthermore, we examined the potential of antioxidant N-acetylcysteine (NAC) supplementation to mitigate the negative effects of DMSO.

Methods

NPC were exposed to various concentrations of DMSO with or without a freezing cycle. Cell viability, cell apoptosis and necrosis rates, intracellular reactive oxygen species (ROS) levels, and gene expression of major antioxidant enzymes were evaluated. In addition, NAC was added to cryopreservation medium containing 10% DMSO and its effects on ROS levels and cell viability were assessed.

Results

DMSO concentrations ≤1% for 24 h did not significantly affect the NPC viability, whereas exposure to 5 and 10% DMSO (most commonly used concentration) caused cell viability loss (loss of 57% and 68% respectively after 24 h) and cell death in a dose- and time-dependent manner. DMSO increased intracellular and mitochondrial ROS (1.9-fold and 3.6-fold respectively after 12 h exposure to 10% DMSO) and downregulated gene expression levels of antioxidant enzymes in a dose-dependent manner. Tempering ROS through NAC treatment significantly attenuated DMSO-induced oxidative stress and supported maintenance of cell viability.

Conclusions

This study demonstrated dose- and time-dependent cytotoxic effects of DMSO on human NPC. The addition of NAC to the cryopreservation medium ameliorated cell viability loss by reducing DMSO-induced oxidative stress in the freeze-thawing cycle. These findings may be useful for future clinical applications of whole cells and cellular products.

The whole blood transcriptional regulation landscape in 465 COVID-19 infected samples from Japan COVID-19 Task Force

Coronavirus disease 2019 (COVID-19) is a recently-emerged infectious disease that has caused millions of deaths, where comprehensive understanding of disease mechanisms is still unestablished. In particular, studies of gene expression dynamics and regulation landscape in COVID-19 infected individuals are limited. Here, we report on a thorough analysis of whole blood RNA-seq data from 465 genotyped samples from the Japan COVID-19 Task Force, including 359 severe and 106 non-severe COVID-19 cases. We discover 1169 putative causal expression quantitative trait loci (eQTLs) including 34 possible colocalizations with biobank fine-mapping results of hematopoietic traits in a Japanese population, 1549 putative causal splice QTLs (sQTLs; e.g. two independent sQTLs at TOR1AIP1), as well as biologically interpretable trans-eQTL examples (e.g., REST and STING1), all fine-mapped at single variant resolution. We perform differential gene expression analysis to elucidate 198 genes with increased expression in severe COVID-19 cases and enriched for innate immune-related functions. Finally, we evaluate the limited but non-zero effect of COVID-19 phenotype on eQTL discovery, and highlight the presence of COVID-19 severity-interaction eQTLs (ieQTLs; e.g., CLEC4C and MYBL2). Our study provides a comprehensive catalog of whole blood regulatory variants in Japanese, as well as a reference for transcriptional landscapes in response to COVID-19 infection.

Genetic mechanisms influencing COVID-19 susceptibility are not well understood. Here, the authors analyzed whole blood RNA-seq data of 465 Japanese individuals with COVID-19, highlighting thousands of fine-mapped variants affecting expression and splicing of genes, as well as the presence of COVID-19 severity-interaction eQTLs.

Kinematic Differences Between the Dominant and Nondominant Legs During a Single-Leg Drop Vertical Jump in Female Soccer Players

BACKGROUND

In soccer, the roles of the dominant (kicking) and nondominant (supporting) legs are different. The kinematic differences between the actions of the dominant and nondominant legs in female soccer players are not clear.

PURPOSE

To clarify the kinematic differences between dominant and nondominant legs during a single-leg drop vertical jump (DVJ) in female soccer players.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 64 female high school and college soccer players were included in this study. Participants performed a single-leg DVJ test utilizing video motion capture with artificial intelligence during the preseason period. This study assessed the knee flexion angles, knee valgus angles, hip flexion angles, and lower leg anterior inclination angle at 3 time points (initial contact, maximum flexion of the knee, and toe-off) and compared them between the dominant and nondominant legs. These angles were calculated from motion capture data and analyzed in 3 dimensions. A paired t test was used to analyze the differences between legs, and the significance level was set at P < .05.

RESULTS

The knee valgus angle at initial contact was greater in the nondominant leg (mean ± SD, 0.8°± 5.2°) than the dominant leg (-0.9°± 4.9°) (P < .01). There were no differences between legs for any other angles at any of the time points.

CONCLUSION

The kinematics of the dominant and nondominant legs of female soccer players in a single-leg DVJ differ in knee valgus angle.

CLINICAL RELEVANCE

Leg dominance is associated with the risk of sports injuries. Kinematic differences between the dominant and nondominant legs may be a noteworthy factor in elucidating the mechanisms and risk of sports injury associated with leg dominance.

Mitochondrial surface coating with artificial lipid membrane improves the transfer efficacy

Extracellular mitochondria are present and act as non-cell-autonomous signals to support energetic homeostasis. While mitochondria allograft is a promising approach in rescuing neurons, glia, and vascular cells in CNS injury and disease, there are profound limitations in cellular uptake of mitochondria together with the efficacy. Here, we modified mitochondria by coating them with cationic DOTAP mixed with DOPE via a modified inverted emulsion method to improve mitochondrial transfer and efficacy. We initially optimized the method using control microbeads and liposomes followed by using mitochondria isolated from intact cerebral cortex of male adult C57BL/6J mice. After the coating process, FACS analysis indicated that approximately 86% of mitochondria were covered by DOTAP/DOPE membrane. Moreover, the artificial membrane-coated mitochondria (AM-mito) shifted the zeta-potential toward positive surface charge, confirming successful coating of isolated mitochondria. Mitochondrial proteins (TOM40, ATP5a, ACADM, HSP60, COX IV) and membrane potentials were well maintained in AM-mito. Importantly, the coating improved mitochondrial internalization and neuroprotection in cultured neurons. Furthermore, intravenous infusion of AM-mito immediately after focal cerebral ischemia-reperfusion amplified cerebroprotection in vivo. Collectively, these findings indicate that mitochondrial surface coating with artificial lipid membrane is feasible and may improve the therapeutic efficacy of mitochondria allograft.

Development of a radiopaque tiltmeter to improve reproducibility for Fowler's position on chest radiography

INTRODUCTION

We have developed a novel radiopaque tiltmeter (ROT) that can indicate patient tilt during a radiography examination and display it on X-ray images. This study evaluated the effect of variation of patient tilt on the reproducibility of Fowler's position for chest radiography and the accuracy of the ROT.

METHODS

We evaluated the reproducibility of Fowler's position based on changes from the first day in the central venous catheter (CVC) tip position and the cardiothoracic ratio (CTR) with and without a digital tiltmeter to verify its efficacy in patients who underwent mobile chest radiography. The ROT contains radiopaque liquid consisting of white barium sulfate solution and oil and has a scale bar of 15°-75° with increments of 15° to indicate ROT tilt. The ROT tilt was increased from 10° to 80° in increments of 10°. We then evaluated (1) the difference between the ROT tilt and the tilt measured with a digital tiltmeter, and (2) the ROT tilt displayed on the X-ray image.

RESULTS

With regard to reproducibility in Fowler's position, changes in the CVC tip position were 2.8 ± 3.9 mm and 10.7 ± 10.6 mm with and without the tiltmeter, respectively (p < 0.05) and the respective rates of change in the CTR were 0.7% ± 0.6% and 4.0% ± 2.1% (p < 0.05). Differences between the ROT tilt and the tilt measured by the digital tiltmeter were within ±2.5°. All ROT tilts displayed on the X-ray images were recognized exactly as each tilt.

CONCLUSION

Our novel ROT had the potential to accurately indicate patient tilt during chest radiography, which could be helpful in terms of reproducibility and precise follow-up.

IMPLICATIONS FOR PRACTICE

Use of the ROT for determination of patient tilt can improve reproducibility in Fowler's position, allowing more accurate serial X-ray imaging.

P-027 which is the best method of testicular sperm retrieval for NOA? an answer from 1071 TESE cases in my clinics over 25 years

Study question

Which improves sperm recovery rate (SRR) for men with non-obstructive azoospermia (NOA), microdissection TESE (m-TESE) or conventional TESE (c-TESE)?

Summary answer

SRR of c-TESE vs. m-TESE for NOA was not significant. We need to develop a safer, less-invasive technique with fewer complications and higher SRR.

What is known already

m-TESE has been performed for men with NOA since Schlegel P’s report (Hum Reprod, 1999). Seminiferous tubules containing many developing germ cells were likely to be larger and more opaque and the ability to find spermatozoa increased from 45% (10/22) to 63% (17/27) after introduction of the microdissection technique. However, Jarvis S et al. (Turek PG group, 2019) reported that at least one site revealed mature sperm in 24 (29.3%) of 82 men with prior failed micro TESE procedures, and sperm were more likely to be found in the testis periphery rather than centrally with FNA mapping.

Study design, size, duration

TESE was performed in 1071 azoospermic patients in my clinics; c-TESE was performed for all azoospermic patients between 1996 and 2005 in Sendai; c-TESE for OA and m-TESE for NOA was performed from 2006 in Sendai, and from 2012 in Takanawa. The patients were divided into four groups; 1) FSH≦9.2mIU/ml, Testicular volume(TV)≧15/ml (OA), 2) FSH≦9.2mIU/ml, TV &lt; 15ml, 3) FSH&gt;9.2mIU/ml, TV≧15ml, 4) FSH&gt;9.2mIU/ml, TV &lt; 15ml (NOA).

Participants/materials, setting, methods

c-TESE was performed in 178 azoospermic men (50, 12, 7, 109, respectively) in 1996-2005. c-TESE was performed in 181 patients (131, 26, 15, 9, respectively) and m-TESE was performed in 541 patients (56, 33, 35, 416, respectively) in 2006 -2020. SRR, pregnancy rate (PR), and birth rate (BR) in 1996-2005 were compared with those in 2006-2020.

Main results and the role of chance

Statistical analysis was performed by chi-square analysis. SRR in c-TESE was 96.0% (48/50) in group 1 (OA) vs. 36.7% (40/109) in group 4 (NOA) in Sendai between 1996 and 2005 (P &lt; 0.001).

SRR of c-TESE was 36.7% (40/109) in group 4 (NOA, in Sendai, 1996-2006), whereas SRR of m-TESE was 31.3% (130/416) in group 4 (NOA, in Sendai and Takanawa, 2006-2020). There was no significant difference (np).

Total SRR of conventional TESE for all azoospermic patients between 1996 and 2005 was 54.9% (96/175), whereas total SRR of c-TESE for OA and m-TESE for NOA between 2006 and 2020 was 51.7% (373/721). NOA rate 4) of azoospermic patients of 1996-2005 and that of 2006-2020 was 61.2% (109/178) and 58.9% (425/721), respectively. There was no significant difference (np).

PR was 37.4% (61/163) and BR was 31.9% (52/263) in c-TESE (1996-2005), PR was 39.6% (388/980), and BR was 27.6% (270//980) in both c-TESE and m-TESE (2006–2020). There was a significant difference in birth rate (P &lt; 0.05).

In conclusion, SRR, PR, and BR were not improved even after m-TESE was performed. Considering the fact that m-TESE cannot find sperm thoroughly, adopting other techniques such as sperm fine-needle aspiration may be required.

Limitations, reasons for caution

Not applicable.

Wider implications of the findings

We could not show the effectiveness of m-TESE compared with c-TESE. However, the total volume of seminiferous tubules collected by c-TESE was the higher. The new one-step fine-needle aspiration has the potential to achieve higher sperm yield with fewer complications. Further advanced technology will hopefully improve the SRR in NOA.

Trial registration number

none

P-763 effect of duration of cryo-storage of vitrified embryos on obstetric and perinatal outcomes

Study question

Does the duration of cryo-storage of vitrified embryos affect obstetric and perinatal outcomes?

Summary answer

Duration of cryo-storage with an open vitrification system did not affect obstetric and perinatal outcomes.

What is known already

Frozen-thawed blastocyst transfer has been performed widely with improvement of embryo culture conditions and cryopreservation techniques. Although blastocyst vitrification has become an essential method to improve clinical outcomes of IVF, there has been little study into the relationship between a long duration of cryo-storage in liquid nitrogen and obstetric and perinatal outcomes.

Study design, size, duration

This retrospective study was conducted at Kyono ART Clinic from January 2007 to December 2020. This study includes a total of 1053 singletons derived from 2461 frozen-thawed blastocyst transfers in 2461 patients. Steel’s multiple comparison test was performed for clinical and perinatal outcomes with cases of cryo-storage of less than 3 months as a control group. P &lt; 0.05 was considered statistically significant.

Participants/materials, setting, methods

The subjects are patients who underwent their first single frozen-thawed blastocyst transfer (FBT) with an open vitrification system. Females &gt;40 years old at cryopreservation and those who underwent preimplantation genetic testing were excluded. According to cryo-storage duration, patients were grouped as follows: group A, 0-3 months (1255 cycles); group B, 3-6 months (1008 cycles); group C, 6-12 months (162 cycles), group D, 12-24 months (36 cycles).

Main results and the role of chance

Both the mean maternal age at blastocyst cryopreservation (A: 33.7±3.6, B: 34.1±3.5, C: 34.8±3.2, D: 35.1±3.3) and the mean maternal age at FBT (A: 33.8±3.6, B: 34.4±3.5, C: 35.5±3.1, D: 36.4±3.3) in groups B, C, and D were significantly higher compared to those in group A.. There was no significant difference in the survival rate after blastocyst thawing [A: 97.4% (1256/1290), B: 98.3% (1010/1027), C: 99.4% (163/164), D: 97.2% (35/36)]. The pregnancy rate in group C was significantly lower compared to group A [A: 60.0% (752/1254), B: 61.4% (619/1008), C: 48.1% (78/162), D: 63.9% (23/36)] The gestational age of group C was significantly lower compared to group A (A: 39.5±1.8, B: 39.4±1.8, C: 38.4±3.1, D: 39.8±1.6), but there were no significant differences in live birth weight or height. There were no significant differences in congenital abnormality rate [A: 1.3% (7/541), B: 2.5% (11/440), C: 1.8% (1/56), D: 0.0% (0/16)], placental abnormalities such as placenta previa [A: 1.3% (7/541), B: 1.6% (7/440), C: 1.8% (1/56), D: 0.0% (0/16)], perinatal abnormalities such as hypertensive disorders of pregnancy or gestational diabetes [A: 6.1% (33/541), B: 8.6% (38/440), C: 1.8% (1/56), D: 6.3% (1/16)] among the four groups.

Limitations, reasons for caution

We could not provide sufficient information on confounding factors such as smoking habits, and the sample size was too small for multivariate analysis. The safety of longer storage will need to be verified as this has not been clarified in this study.

Wider implications of the findings

The pregnancy rate in group C was significantly lower than that in group A, but the effect was small: 0.065, power of 0.78. Our data suggested that the duration of cryopreservation with an open vitrification system in liquid nitrogen did not affect obstetric or perinatal outcomes.

Trial registration number

not applicable

Single-agent anti-PD-1 or combined with ipilimumab in patients with mucosal melanoma: an international, retrospective, cohort study

BACKGROUND

Mucosal melanoma (MM) is a rare melanoma subtype with distinct biology and poor prognosis. Data on the efficacy of immune checkpoint inhibitors (ICIs) is limited. We determined the efficacy of ICIs in MM, analysed by primary site and ethnicity/race.

PATIENTS AND METHODS

Retrospective cohort study from 25 cancer centres in Australia, Europe, USA and Asia. Patients with histologically confirmed MM were treated with anti-PD1+/-ipilimumab. Primary endpoints were response rate (RR), progression-free survival (PFS), overall survival (OS) by primary site (naso-oral, urogenital, anorectal, other), ethnicity/race (Caucasian, Asian, Other) and treatment. Univariate and multivariate Cox proportional hazard model analyses were conducted.

RESULTS

In total, 545 patients were included: 331 (63%) Caucasian, 176 (33%) Asian and 20 (4%) Other. Primary sites included 113 (21%) anorectal, 178 (32%) urogenital, 206 (38%) naso-oral and 45 (8%) other. 348 (64%) received anti-PD1 and 197 (36%) anti-PD1/ipilimumab. RR, PFS and OS did not differ by primary site, ethnicity/race or treatment. RR for naso-oral was numerically higher for anti-PD1/ipilimumab (40%, 95% CI 29-54%) compared with anti-PD1 (29%, 95% CI 21-37%). 35% of patients that initially responded progressed. Median duration of response (mDOR) was 26 months (95% CI 18-NR [Not Reached]). Factors associated with short PFS were ECOG PS ≥3 (p<0.01), LDH >ULN (p=0.01), lung metastases (p<0.01) and ≥1 previous treatments (p<0.01). Factors associated with short OS were ECOG PS ≥1 (p<0.01), LDH >ULN (p=0.03), lung metastases (p<0.01) and ≥1 previous treatments (p<0.01).

CONCLUSIONS

MM has poor prognosis. Treatment efficacy of anti-PD1+/-ipilimumab was similar and did not differ by ethnicity/race. Naso-oral primaries had numerically higher response to anti-PD1/ipilimumab, without difference in survival. The addition of ipilimumab did not show greater benefit over anti-PD1 for other primary sites. In responders, mDOR was short and acquired resistance was common. Other factors, including site and number of metastases were associated with survival.

Association with sagittal alignment and osteoporosis-related fractures in outpatient women with osteoporosis

The baseline sagittal vertical axis (SVA) and pelvic tilt (PT) are independent risk factors of osteoporosis-related fractures in women with osteoporosis. We clarified the SVA and PT to predict the incidence of osteoporosis-related fractures.

PURPOSE

Sagittal alignment with osteoporosis women deteriorates with advancing age and sagittal alignment may indicate osteoporosis-related fractures in the future. However, whether the sagittal alignment predicts future osteoporosis-related fracture in patients with osteoporosis has not been clarified. We aimed to investigate the association between sagittal alignment and future osteoporosis-related fractures.

METHODS

This was a retrospective cohort study. Of the 313 participants (mean follow-up period, 2.9 years), 236 were included in the analysis. At baseline, we measured bone mineral density (BMD) of the lumbar spine and the femoral neck, sagittal vertical axis (SVA), thoracic kyphosis, pelvic incidence minus lumbar lordosis, sacral slope, pelvic tilt (PT), geriatric locomotive function scale (GLFS), two-step value, and stand-up test. The information on medications and the duration of treatment were reviewed from the medical records. Additionally, participants reported their history of falls at baseline. Multiple logistic regression analysis was used to determine the association of future osteoporosis-related fracture, and adjusted Odds ratios (OR) and 95% confidence interval (CI) were calculated with all predictors as covariates. All continuous variables were calculated using standardized OR (sOR).

RESULTS

Osteoporosis-related fractures occurred in 33 of 313 participants (10.5%). Multiple logistic regression analysis showed that a history of falls (OR =4.092, 95% CI: 1.029-16.265, p =0.045), SVA (sOR =4.228, 95% CI: 2.118-8.439, p <0.001), and PT (sOR =2.497, 95% CI: 1.087-5.733, p =0.031) were independent risk factors for future osteoporosis-related fractures.

CONCLUSIONS

This study revealed the SVA and PT to predict osteoporosis-related fractures.

TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION

UMIN000036516 (April 1, 2019).