Assessment of the accuracy of biparametric MRI/TRUS fusion-guided biopsy for index tumor evaluation using postoperative pathology specimens

BACKGROUND

Multiparametric MRI (mpMRI) is widely used for the diagnosis, surveillance, and staging of prostate cancer. However, it has several limitations, including higher costs, longer examination times, and the use of gadolinium-based contrast agents. This study aimed to investigate the accuracy of preoperatively assessed index tumors (ITs) using biparametric MRI (bpMRI)/transrectal ultrasound (TRUS) fusion biopsy compared with radical prostatectomy (RP) specimens.

METHODS

We included 113 patients diagnosed with prostate cancer through bpMRI/TRUS fusion-guided biopsies of lesions with a Prostate Imaging Reporting and Data System (PI-RADS) category ≥ 3. These patients underwent robot-assisted laparoscopic radical prostatectomy (RARP) at our institution between July 2017 and March 2023. We examined the localization of preoperative and postoperative ITs, the highest Gleason score (GS), and tumor diameter in these patients.

RESULTS

The preoperative cT stage matched the postoperative pT stage in 53 cases (47%), while 31 cases (27%) were upstaged, and 29 cases (26%) were downstaged (Weighted Kappa = 0.21). The preoperative and postoperative IT localizations were consistent in 97 cases (86%). The concordance rate between Gleason groups in targeted biopsies and RP specimens was 51%, with an upgrade in 25 cases (23%) and a downgrade in 27 cases (25%) (Weighted Kappa = 0.42). The maximum diameter of the IT and the maximum cancer core length on biopsy were correlated with the RP tumor's maximum diameter (p < 0.001 for both).

CONCLUSION

The diagnostic accuracy of bpMRI/TRUS fusion biopsy is comparable to mpMRI, suggesting that it can be a cost-effective and time-saving alternative.

Modification of ibuprofen to improve the medicinal effect; structural, biological, and toxicological study

Ibuprofen is classified as a non-steroidal anti-inflammatory drug (NSAID) that is employed as an initial treatment option for its non-steroidal anti-inflammatory, pain-relieving, and antipyretic properties. However, Ibuprofen is linked to specific well-known gastrointestinal adverse effects like ulceration and gastrointestinal bleeding. It has been linked to harmful effects on the liver, kidney, and heart. The purpose of the study is to create novel and potential IBU analogue with reduced side effects with the enhancement of their medicinal effects, so as to advance the overall safety profile of the drug. The addition of some novel functional groups including CH3, F, CF3, OCF3, Cl, and OH at various locations in its core structure suggestively boost the chemical as well as biological action. The properties of these newly designed structures were analyzed through chemical, physical, and spectral calculations using Density Functional Theory (DFT) and time-dependent DFT through B3LYP/6-31 g (d,p) basis set for geometry optimization. Molecular docking and non-bonding interaction studies were conducted by means of the human prostaglandin synthase protein (PDB ID: 5F19) to predict binding affinity, interaction patterns, and the stability of the protein-drug complex. Additionally, ADMET (Absorption, Distribution, Metabolism, Excretion, and Toxicity) and PASS (Prediction of Activity Spectra for Substances) predictions were employed to evaluate the pharmacokinetic and toxicological properties of these structures. Importantly, most of the analogues displayed reduced hepatotoxicity, nephrotoxicity, and carcinogenicity in comparison to the original drug. Moreover, molecular docking analyses indicated improved medicinal outcomes, which were further supported by pharmacokinetic calculations. Together, these findings suggest that the modified structures have reduced adverse effects along with improved therapeutic action compared to the parent drug.

High expression of autotaxin is associated with poor recurrence-free survival in cholangiocarcinoma

BACKGROUND AND AIM

Autotaxin (ATX) is an extracellular lysophospholipase D that catalyzes the hydrolysis of lysophosphatidylcholine into lysophosphatidic acid (LPA). Recent accumulating evidence indicates the biological roles of ATX in malignant tumors. However, the expression and clinical implications of ATX in human cholangiocarcinoma (CCA) remain elusive.

METHODS

In this study, the expression of ATX in 97 human CCA tissues was evaluated by immunohistochemistry. Serum ATX levels were determined in CCA patients (n = 26) and healthy subjects (n = 8). Autotaxin expression in cell types within the tumor microenvironment was characterized by immunofluorescence staining.

RESULTS

High ATX expression in CCA tissue was significantly associated with a higher frequency of lymph node metastasis (p = 0.050). High ATX expression was correlated with shorter overall survival (p = 0.032) and recurrence-free survival (RFS) (p = 0.001) than low ATX expression. In multivariate Cox analysis, high ATX expression (p = 0.019) was an independent factor for shorter RFS. Compared with low ATX expression, high ATX expression was significantly associated with higher Ki-67-positive cell counts (p < 0.001). Serum ATX levels were significantly higher in male CCA patients than in healthy male subjects (p = 0.030). In the tumor microenvironment of CCA, ATX protein was predominantly expressed in tumor cells, cancer-associated fibroblasts, plasma cells, and biliary epithelial cells.

CONCLUSIONS

Our study highlights the clinical evidence and independent prognostic value of ATX in human CCA.

Comparison of hemostatic ability between spray coagulation and forced coagulation modes in endoscopic submucosal dissection in patients with early gastric neoplasms: a study protocol for multicenter randomized controlled trial (Spray-G trial)

BACKGROUND

Endoscopic submucosal dissection (ESD) is the standard treatment for early gastric neoplasms (EGN). Controlling intraoperative bleeding is crucial for ensuring safe and reliable procedures. ESD using the spray coagulation mode (SCM-ESD) has been developed to control bleeding more effectively than ESD using the conventional forced coagulation mode (FCM-ESD). This study aims to compare the hemostatic efficacies of SCM-ESD and FCM-ESD.

METHODS

This multicenter, prospective, parallel, randomized, open-label superiority trial will be conducted in five Japanese institutions. Patients with a preoperative diagnosis of intramucosal EGC will be randomized to undergo either SCM-ESD or FCM-ESD. The primary outcome measure is the completion of ESD with an electrosurgical knife alone, without the use of hemostatic forceps. Secondary outcomes include the number and duration of hemostasis using hemostatic forceps, procedure time, curability, and safety. A total of 130 patients will be enrolled in this study.

DISCUSSION

This trial will provide evidence on the hemostatic efficacy of SCM-ESD compared with FCM-ESD in patients with intramucosal EGN, potentially improving the safety and reliability of ESD procedures.

TRIAL REGISTRATION

The trial has been registered at the University Hospital Medical Information Network Clinical Trials Registration (UMIN-CTR) as UMIN000040518. The reception number is R000054009.

Two-devices-in-one-channel method for fractured pancreatic duct stent retrieval in a case of severe chronic pancreatitis

When a pancreatic plastic stent for symptomatic chronic pancreatitis breaks during its removal, severe pancreatic duct stenosis may complicate its retrieval. Takuma and colleagues report on the successful retrieval of a fragmented and displaced pancreatic plastic stent by applying the two-device-in-one-channel method using forceps and a snare.

Olfactory and taste dysfunctions caused by COVID-19: a nationwide study

BACKGROUND

Olfactory dysfunctions (OD) and taste dysfunctions (TD) are widely recognized as characteristic symptoms of COVID-19; however, the frequency and mode of occurrence has varied depending on the viral mutation. The prevalence and characteristics of OD/TD in Japan have not been definitively investigated. The purpose of this study is to assess the prevalence of OD/TD in Japan during the Alpha variant epidemic, and measure symptom prolongation at 6 months and 1 year later following initial infection.

METHODS

Patients treated for COVID-19 between February to May 2021 were evaluated for OD/TD symptoms and provided with a QOL questionnaire. Olfactory tests and taste tests were performed using Open Essence and Taste Strips, respectively.

RESULTS

Among the 251 COVID-19 patients who participated, 119 underwent both olfactory and taste tests. Prevalence of subjective OD and TD at the time of survey was 57.8% and 40.2%, respectively. After 12 months, the prevalence fell to 5.8% for OD and 3.5% for TD. Among the OD/TD patients, 36.6% experienced parosmia, and 55.4% experienced parageusia. Prevalence of parosmia and parageusia was higher at 6 and 12 months than at the time of survey. Patients with long-lasting disease reported qualitative dysfunctions and scored significantly higher in food-related QOL problems. Most patients who were aware of their hyposmia had low scores on the olfactory test (83.1%). In contrast, only 26.7% of patients who were aware of their hypogeusia had low scores on the taste test.

CONCLUSIONS

The prevalence of COVID-19-related OD and TD at the time of survey was 57.8% and 40.2%, respectively. Subjective symptoms of OD and TD persisted for one year in 5.8% and 3.5% of patients, respectively. More than half of the patients with OD or TD complained of qualitative dysfunction and a decrease in their QOL related to eating and drinking. Most patients with TD did not have true TD, but rather developed flavour disorders associated with OD. This conclusion is supported by the finding that patients with subjective OD had low scores on the olfactory test, whereas most patients with subjective TD had normal scores on the taste test.

Pathological features of primary cardiac myxoid tumour in dogs: a review of 11 cases (2002-2022)

This report documents the pathological features of primary cardiac myxoid tumour (MT) in 11 dogs. Macroscopically, all the tumours were located in the tricuspid valve (TV), its septal leaflet being predominantly affected. Therefore, it appears that the TV is the most common site of occurrence for cardiac MT in dogs. Two gross anatomical types of canine valvular MT were evident. Seven of the 11 tumours were round or oval with a smooth or gently lobulated and glistening surface, while the other four were gelatinous, multilobulated and polypoid, with an irregular surface. Microscopically, in nine cases the tumours had an abundant myxoid matrix within which elongated spindle-shaped cells with no remarkable cytological atypia were sparsely embedded, suggesting a benign character (ie, myxoma). In the other two cases the tumours consisted of variably dense, haphazardly arranged, interlacing streams of anaplastic spindle-shaped or polygonal cells containing many mitotic figures, indicative of a malignant form of myxoma (ie, myxosarcoma). Isolated or clustered collections of myxoma cells (eg, cords, rings, syncytia) characteristic of human atrial myxoma were only rarely evident or lacking in all 11 cases, indicating that rarity or absence of such structural features may be specific to valvular MTs. Immunohistochemical findings were indicative of smooth muscle differentiation of the neoplastic cells. Tumour embolization to the intrapulmonary arteries and/or tumour implantation on the endocardium of the right heart chambers was evident only in the four cases of irregular-surfaced MT.

Selective expression of light-harvesting complexes alters phospholipid composition in the intracytoplasmic membrane and core complex of purple phototrophic bacteria

Phospholipid-protein interactions play important roles in regulating the function and morphology of photosynthetic membranes in purple phototrophic bacteria. Here, we characterize the phospholipid composition of intracytoplasmic membrane (ICM) from Rhodobacter (Rba.) sphaeroides that has been genetically altered to selectively express light-harvesting (LH) complexes. In the mutant strain (DP2) that lacks a peripheral light-harvesting (LH2) complex, the phospholipid composition was significantly different from that of the wild-type strain; strain DP2 showed a marked decrease in phosphatidylglycerol (PG) and large increases in cardiolipin (CL) and phosphatidylcholine (PC) indicating preferential interactions between the complexes and specific phospholipids. Substitution of the core light-harvesting (LH1) complex of Rba. sphaeroides strain DP2 with that from the purple sulfur bacterium Thermochromatium tepidum further altered the phospholipid composition, with substantial increases in PG and PE and decreases in CL and PC, indicating that the phospholipids incorporated into the ICM depend on the nature of the LH1 complex expressed. Purified LH1-reaction center core complexes (LH1-RC) from the selectively expressing strains also contained different phospholipid compositions than did core complexes from their corresponding wild-type strains, suggesting different patterns of phospholipid association between the selectively expressed LH1-RC complexes and those purified from native strains. Effects of carotenoids on the phospholipid composition were also investigated using carotenoid-suppressed cells and carotenoid-deficient species. The findings are discussed in relation to ICM morphology and specific LH complex-phospholipid interactions.

Combined endoscopic endonasal and transcranial approach for internal carotid artery aneurysms: usefulness and safety of endonasal proximal control

It is necessary to secure both the proximal and distal sides of the parent artery to prevent premature rupture when clipping cerebral aneurysms. Herein, we describe four cases in which the proximal internal carotid artery (ICA), affected by a paraclinoid aneurysm, was secured using an endoscopic endonasal approach. We used various tools, including a surgical video, cadaver dissection picture, artist's illustration, and intraoperative photographs, to elucidate the process. No patient experienced postoperative complications at our institution. Compared to the cervical or cavernous ICA, the ICA adjacent to the clivus (paraclival ICA) can be anatomically safely and easily exposed using an endoscopic endonasal approach because there is no need to consider cerebrospinal fluid leakage or hemorrhage from the cavernous sinus. Securing the proximal side of the parent artery using an endoscopic endonasal approach may be a viable method for clipping selected ICA aneurysms, such as paraclinoid aneurysms especially for upward or outward aneurysms of the C2 portion.

Deletion of IL-1β exacerbates acrylamide-induced neurotoxicity in mice

Acrylamide is a neurotoxicant in human and experimental animals. Interleukin-1β (IL-1β) is a proinflammatory cytokine known as a critical component of brain reaction to any insult or neurodegenerative pathologies, though its role in electrophile-induced neurotoxicity remains elusive. The aim of this study was to investigate the role of IL-1β in acrylamide-induced neurotoxicity in mice. Ten-week-old male wild-type and IL-1β knock-out mice were allocated into 3 groups each and exposed to acrylamide at 0, 12.5, 25 mg/kg body weight by oral gavage for 28 days. Compared with wild-type mice, the results showed a significant increase in landing foot spread test and a significant decrease in density of cortical noradrenergic axons in IL-1β KO mice exposed to acrylamide at 25 mg/kg body weight. Exposure to acrylamide at 25 mg/kg significantly increased cortical gene expression of Gclc, Gpx1, and Gpx4 in wild-type mice but decreased them in IL-1β KO mice. The same exposure level significantly increased total glutathione and oxidized glutathione (GSSG) in the cerebellum of wild-type mice but neither changed total glutathione nor decreased GSSG in the cerebellum of IL-1β KO mice. The basal level of malondialdehyde in the cerebellum was higher in IL-1β KO mice than in wild-type mice. The results suggest that IL-1β protects the mouse brain against acrylamide-induced neurotoxicity, probably through suppression of oxidative stress by glutathione synthesis and peroxidation. This unexpected result provides new insight on the protective role of IL-1β in acrylamide-induced neurotoxicity.

Role of Nrf2 in 1,2-dichloropropane-induced cell proliferation and DNA damage in the mouse liver

1,2-Dichloropropane (1,2-DCP) is recognized as the causative chemical of occupational cholangiocarcinoma in printing workers in Japan. However, the cellular and molecular mechanisms of 1,2-DCP-induced carcinogenesis remains elusive. The present study investigated cellular proliferation, DNA damage, apoptosis, and expression of antioxidant and proinflammatory genes in the liver of mice exposed daily to 1,2-DCP for 5 weeks, and the role of nuclear factor erythroid 2-related factor 2 (Nrf2) in these responses. Wild-type and Nrf2-knockout (Nrf2-/-) mice were administered 1,2-DCP by gastric gavage, and then the livers were collected for analysis. Immunohistochemistry for BrdU or Ki67 and TUNEL assay revealed that exposure to 1,2-DCP dose-dependently increased proliferative cholangiocytes, whereas decreased apoptotic cholangiocytes in wild-type mice but not in Nrf2-/- mice. Western blot and quantitative real-time PCR showed that exposure to 1,2-DCP increased the levels of DNA double-strand break marker γ-H2AX and mRNA expression levels of NQO1, xCT, GSTM1, and G6PD in the livers of wild-type mice in a dose-dependent manner, but no such changes were noted in Nrf2-/- mice. 1,2-DCP increased glutathione levels in the liver of both the wild-type and Nrf2-/- mice, suggesting that an Nrf2-independent mechanism contributes to 1,2-DCP-induced increase in glutathione level. In conclusion, the study demonstrated that exposure to 1,2-DCP induced proliferation but reduced apoptosis in cholangiocytes, and induced double-strand DNA breaks and upregulation of antioxidant genes in the liver in an Nrf2-dependent manner. The study suggests a role of Nrf2 in 1,2-DCP-induced cell proliferation, antiapoptotic effect, and DNA damage, which are recognized as key characteristics of carcinogens.

Development of non-electrically controlled SalivaDirect LAMP (NEC-SD-LAMP), a new nonelectrical infectious disease testing method

In this study, non-electrically controlled SalivaDirect loop-mediated isothermal amplification (NEC-SD-LAMP), which can detect infections by amplifying viral DNA expression in saliva without using electrical control systems, was developed. By this method, only by adding water to the device, viral DNA was extracted from saliva using SalivaDirect, the extracted DNA was amplified via loop-mediated isothermal amplification (LAMP), and the results were visually confirmed. Melting palmitic acid maintained the optimal temperature for the LAMP reaction, as the temperature of palmitic acid is maintained at 62.9 °C, its melting point. By exploiting the proximity of the melting point to the optimal temperature for LAMP, LAMP can be performed without electricity. We detected several viruses in the saliva using this method. NEC-SD-LAMP could clearly distinguish 3 types of viral DNA, indicating the high specificity of this reaction. Furthermore, the viral concentration detection limit of the device was 2 copies per µL, indicating that it is possible to detect DNA viral infections in saliva even before the onset of viral infection.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Effect of a Low Concentration of Sevoflurane Combined With Propofol on Transcranial Electrical Stimulation Motor Evoked Potential: A Case Series

Transcranial electrical motor evoked potential (TCeMEP) is used to monitor the integrity of intraoperative motor function. Total intravenous anesthesia (TIVA) is the preferred method because its effect on MEP is relatively smaller than volatile anesthetics. However, maintaining the balanced anesthesia in long-time surgery using TIVA is challenging and may sometime cause problems including body movement during microsurgery. Such problems can be avoided by intraoperative anesthesia management using a mixture of propofol and a low concentration of sevoflurane. We recorded TCeMEP under a mixture of propofol and low concentration of sevoflurane anesthesia in three cases of neurosurgery. Anesthesia was induced with a 5.0 µg/mL target-controlled infusion of propofol and 0.6 mg/kg rocuronium. General anesthesia was maintained by propofol and 0.1-0.25 µg/kg/min remifentanil infusion. After the recording of control TCeMEP, sequential inhalation of 0.2 minimum alveolar concentration (MAC) and 0.5 MAC of sevoflurane was performed. The duration of each sevoflurane inhalation was 10 minutes, and the MACs were adjusted by the patient's age. In our cases, the combination of propofol and 0.2 MAC sevoflurane suppressed the amplitude of TCeMEP to 38.0±21.7% (379.8±212.0 µV), but the amplitude was high enough for evaluation of motor function monitoring. On the other hand, the combination of 0.5 MAC sevoflurane greatly decreased the amplitude of TCeMEP to 6.3±6.0% (71.9±66.9 µV) resulting in less than 150 µV, and it was difficult to record the change in TCeMEP amplitude over time. The combination of 0.2 MAC sevoflurane with TIVA might enable TCeMEP monitoring with TIVA.

[Assessment of Motor and Language Function during Awake Surgery]

Awake surgery enables the evaluation of neurological functions that are difficult to assess with a conventional electrophysiological examination and is useful in the evaluation of language function. Awake surgery is a team effort involving anesthesiologists and rehabilitation physicians who evaluate motor and language functions, and information sharing during the perioperative period is important. Some points regarding surgical preparation and anesthesia methods are unique and must be well understood. For example, supraglottic airway devices must be used to secure the airway, and ventilation must be checked for availability when positioning the patient. Preoperative neurological evaluation is important in determining the method of intraoperative neurological evaluation, including choosing the simplest possible method of evaluation and sharing the information with the patient prior to surgery. Motor function assessment evaluates small movements that do not affect the surgery. Visual naming and auditory comprehension are useful in the evaluation of language function.

Steady-State Cortico-Cortical Evoked Potential

PURPOSE

The present study evaluated the utility of the steady-state responses of cortico-cortical evoked potentials (SSCCEPs) and compared them with the responses of conventional CCEPs.

METHODS

Eleven patients with medically intractable focal epilepsy who underwent the implantation of subdural electrodes or stereoelectroencephalography were enrolled. Conventional CCEPs were obtained by averaging responses to alternating 1-Hz electrical stimuli, and 5-Hz stimuli were delivered for recording SSCCEPs. The distribution of SSCCEPs was assessed by a frequency analysis of fast Fourier transform and compared with conventional CCEPs.

RESULTS

Steady-state responses of cortico-cortical evoked potentials were successfully recorded in areas consistent with conventional CCEPs in all patients. However, SSCCEPs were more easily disturbed by the 5-Hz stimulation, and small responses had difficulty generating SSCCEPs.

CONCLUSIONS

Steady-state responses of cortico-cortical evoked potentials may be a useful alternative to conventional CCEPs.

Rapid acquisition of absorption spectra to monitor proton migration in nanoliter space using the RGB-spectrum-conversion method with a 10 ms interval

Acquisition protocol of absorption spectra at nanoliter spaces from the RGB values preserved in video data at 10 ms intervals was established using the principal-component-analysis-based RGB-conversion method. Proton behavior was monitored using a camera to acquire the video footage to monitor colorimetric change in the nanoliter space. The RGB values observed in the video were converted into a score vector using a conversion matrix. A linear combination of the predetermined loading vectors with the score values was calculated to reproduce the absorption spectra. The reproduced absorption spectra correlated well with those acquired using a conventional spectrophotometer during a short period. This method was applied to monitor the proton diffusion from a single cationic ion-exchange resin into hydrogels at low concentrations. The rapid acquisition and quick response of this method may enable the monitoring of the initial diffusion of protons, which is challenging with conventional spectrophotometry and electrochemical approaches.

Transcranial electrical stimulation technique for induction of unilateral motor evoked potentials

OBJECTIVE

Transcranial electrical stimulation motor evoked potentials (TES-MEP) are widely used to monitor motor function; however, broad current spread and induced body movement are limitations of this technique. We herein report a localized stimulation technique for TES-MEP that induces unilateral MEP responses.

METHODS

The stimulation of C1(+)-C4(-) or C2(+)-C3(-) was performed to induce right- or left-sided muscle contraction, respectively, in 70 patients. Electromyography was recorded by placing electrodes on the bilateral abductor pollicis brevis (APB) and abductor hallucis (AH) muscles. Stimulation conditions were regulated in the range to induce unilateral muscle contractions contralateral to the anodal stimulation. The thresholds and amplitudes of TES-MEP were retrospectively analyzed.

RESULTS

The thresholds of APB were lower than those of AH in 47 patients, AH thresholds were lower than those of APB in 6 patients, and both APB and AH started to respond at the same intensity in 15 patients. This technical stimulation induced contralateral limb contractions with a suprathreshold stimulation of 129.4 ± 35.6 mA (mean ± standard deviation) in 68 patients (97%). Amplitudes in the suprathreshold stimulation of APB and AH responses were 727.5 ± 695.7 and 403.3 ± 325.7 μV, respectively.

CONCLUSIONS

The C1(+)-C4/C2(+)-C3(-) stimulation in TES-MEP enables a localized stimulation to induce unilateral MEP responses.

SIGNIFICANCE

Our stimulation technique enables the stable and safe monitoring of unilateral limbs, and contributes to the reliable monitoring of motor function in neurosurgery.

Prediction of Early Postoperative Language Function by Quantitative Evaluation with Visual and Auditory Naming Tasks during Awake Craniotomy for Brain Tumor Resection: Significance of Auditory Naming Task

Language tasks for monitoring intraoperative language symptoms have not yet been established. This study aimed to examine whether the quantitative evaluation of language function with visual and auditory naming during awake craniotomy predicts early postoperative language function in patients. Thirty-seven patients with brain tumors in the language-dominant hemisphere were included. They underwent visual and auditory naming preoperatively and at the end of tumor resection for intraoperative evaluation. Using the Western Aphasia Battery, their overall language functions were evaluated preoperatively, early postoperatively (within 1 week), and late postoperatively (after 1 month). The preoperative and intraoperative changes in the visual and auditory naming scores were significantly correlated with most of the Western Aphasia Battery score changes between the preoperative and early postoperative evaluations, which was more remarkable for auditory naming. Multiple linear regression analysis showed that changes in the auditory naming score predicted the preoperative to early postoperative changes in the aphasia quotient of the Western Aphasia Battery. Receiver operating characteristics analysis showed a higher area under the curve or discriminative power for auditory than visual naming in predicting the development or exacerbation of aphasia in the early postoperative period. Considering the analyses applied separately for low- and high-grade glioma, auditory naming, which taps into a wider range of linguistic functions, may be more informative than visual naming as language evaluation in awake craniotomy for the early postoperative development of aphasia, especially for patients with high-grade glioma.

Formation and evolution of carbonaceous asteroid Ryugu: Direct evidence from returned samples

Samples of the carbonaceous asteroid Ryugu were brought to Earth by the Hayabusa2 spacecraft. We analyzed 17 Ryugu samples measuring 1 to 8 millimeters. Carbon dioxide-bearing water inclusions are present within a pyrrhotite crystal, indicating that Ryugu's parent asteroid formed in the outer Solar System. The samples contain low abundances of materials that formed at high temperatures, such as chondrules and calcium- and aluminum-rich inclusions. The samples are rich in phyllosilicates and carbonates, which formed through aqueous alteration reactions at low temperature, high pH, and water/rock ratios of <1 (by mass). Less altered fragments contain olivine, pyroxene, amorphous silicates, calcite, and phosphide. Numerical simulations, based on the mineralogical and physical properties of the samples, indicate that Ryugu's parent body formed ~2 million years after the beginning of Solar System formation.

Identification of bleeding points after bile duct biopsy using red dichromatic imaging during peroral cholangioscopy: A case report

Red dichromatic imaging is a new image-enhancement technology that clarifies the differences in blood concentrations and improves the visibility of the bleeding point. A 71-year-old man was presented with a common bile duct stone, which was completely removed using electrohydraulic shock wave lithotripsy with peroral cholangioscopy. During peroral cholangioscopy, a nodular lesion was found at the confluence of the cystic duct, and a forceps biopsy was performed. It was difficult to confirm the bleeding point using white-light imaging because of the pooling of blood. After switching to red dichromatic imaging mode 2 and washing the bile duct with saline solution, the bleeding point was observed in darker yellow than the surrounding blood, allowing the identification of the bleeding point. Red dichromatic imaging can be used in the future to maintain hemostasis during peroral cholangioscopy.

Characterization and role of collagen gene expressing hepatic cells following partial hepatectomy in mice

BACKGROUND AND AIMS

The mechanism underlying liver regeneration following partial hepatectomy (PH) is not fully elucidated. We aimed to characterize collagen gene expressing hepatic cells following PH and examine their contribution to liver regeneration.

APPROACH AND RESULTS

Col-GFP mice, which express GFP under the control of the collagen gene promoter, were used to detect collagen gene expressing cells following PH. The GFP-expressing cells were analyzed via single-cell RNA sequencing (scRNA-seq). Additionally, Col-ER Cre/RFP and Col-ER Cre/DTA mice were utilized to examine the cell fates and functional roles of collagen gene expressing cells in liver regeneration, respectively. The number of collagen gene expressing cells was found to be increased on day 3 and subsequently decreased on day 7 following PH. ScRNA-seq analysis of sorted collagen gene expressing cells showed that the regenerating liver was characterized by three distinct hepatic stellate cell (HSC) clusters, including one representing classic myofibroblasts. The other HSC clusters included an intermediately activated HSC cluster and a proliferating HSC cluster. Of these, the latter cluster was absent in the CCl 4 -induced liver fibrosis model. Cell fate tracing analysis using Col-ER Cre/RFP mice demonstrated that the collagen gene expressing cells escaped death during regeneration and remained in an inactivated state in the liver. Further, depletion of these cells using Col-ER Cre/DTA mice resulted in impaired liver regeneration.

CONCLUSIONS

Heterogeneous HSC clusters, one of which was a unique proliferating cluster, were found to appear in the liver following PH. Collagen gene expressing cells, including HSCs, were found to promote liver regeneration.

The anatomical basis of third-degree atrioventricular block in dogs with atrioventricular valve endocardiosis

The cardiac conduction system was examined histologically in 13 canine cases of atrioventricular (AV) valve endocardiosis with third-degree AV block. In all cases, gross examination revealed marked thickening and distortion of the base of the central fibrous body (CFB) and varying degrees of endocardial thickening of the upper portion of the ventricular septum (VS) as well as marked thickening of the mitral and tricuspid valve leaflets due to myxomatous degeneration. Microscopically, the thickened and distorted CFB had encased or trapped, either partly or totally, the underlying penetrating and branching portions of the AV bundle. The myxomatous and/or fibrofatty tissue, which had proliferated at the base of the extensive CFB, protruded into or encroached on the AV bundle, causing severe (51-75%) to very severe (76% or more) reduction of the conduction fibres. The upper portions of the left and right bundle branches were involved in the endocardial thickening due to degenerative and fibrotic changes at the uppermost VS; however, both bundle branches were much less severely affected than the AV bundle, the degree of reduction of the conduction fibres ranging from mild (25% or less) to moderate (26-50%). These observations suggest that the sites most vulnerable to lesions in the AV conduction system are the penetrating and branching portions of the AV bundle, which would represent the anatomical basis for third-degree AV block in canine cases of AV valve endocardiosis.

The intraoperative motor-evoked potential when propofol was changed to remimazolam during general anesthesia: a case series

Remimazolam is a short-acting benzodiazepine that was approved for clinical use in 2020. We report three patients who underwent surgery for cerebral and spinal cord tumors, in whom transcranial electrical stimulation-motor-evoked potential (TES-MEP) was successfully monitored under general anesthesia with remimazolam. During total intravenous anesthesia with propofol at a target concentration of 2.7 - 3.5 µg/mL and 0.1 - 0.35 µg/kg/min of remifentanil, delayed awakening, bradycardia, and hypotension during propofol anesthesia were expected in all three cases. With patient safety as the top priority, we considered changing the anesthetic agent. Propofol was replaced with remimazolam at a loading dose of 12 mg/kg/h for a few seconds (case 3), followed by 1 mg/kg/h for maintenance (cases 1-3). TES-MEP was recorded during propofol and remimazolam administration in all three patients. Amplitudes of TES-MEP during anesthesia with propofol and remimazolam were 461.5 ± 150 µV and 590.5 ± 100.9 µV, 1542 ± 127 µV and 1698 ± 211 µV, and 581.5 ± 91.3 µV and 634 ± 82.7 µV sequentially from Case 1. Our findings suggest that intraoperative TES-MEP could be measured when anesthesia was managed with remimazolam at 1 mg/kg/h.

Effect of remimazolam on intraoperative neurophysiology monitoring of visual-evoked potential: a case series

There are very few reports on the effects of benzodiazepines such as midazolam and diazepam on intraoperative visual-evoked potential (VEP), and there is no report on the effect of remimazolam at all. Five patients underwent neurosurgery using VEP monitoring for avoiding surgical injury to the optic nerve. In all cases, drug administration was based on actual body weight. General anesthesia was induced with propofol and remifentanil, and then maintained with propofol at target concentrations of 2.7-3.5 µg/ml for maintaining bispectral index (BIS) between 40 and 60. After resection of the tumor under stable VEP, we discontinued propofol immediately followed by infusion of remimazolam at 12 mg/kg/h for a few seconds, then reduced to 1 mg/kg/h. After a time, when blood levels of remimazolam appeared to be stable, VEP was monitored again and compared to controls. In all cases, we were able to confirm that there was reproducibility. Remimazolam may provide a comparable quality of anesthesia to that of existing drugs for VEP in neurosurgery.

Focal pancreatic ductal change induced by 10-Fr S-type plastic stent in chronic pancreatitis

BACKGROUND AND AIM

Stent-induced ductal change (SIDC) is a complication of endoscopic pancreatic stenting (EPS) in patients with chronic pancreatitis (CP). However, the evaluation of SIDC associated with S-type pancreatic plastic stent (PS) and large-caliber PS, such as 10 Fr, is limited. This study aimed to analyze the SIDC of the main pancreatic duct (MPD) associated with 10-Fr S-type PS in patients with CP.

METHODS

Between January 2008 and December 2021, 132 patients with CP in whom a 10-Fr S-type PS had been installed by EPS were retrospectively reviewed. The SIDC incidence rate was examined, and the clinical features of patients with and without SIDC were investigated, including the outcomes for detected SIDC.

RESULTS

Stent-induced ductal change during EPS was confirmed in 41 patients (31.1%) of 132 patients at a site coincident with the PS tip or distal flap in the MPD. All patients were asymptomatic during the development of SIDC. Morphological changes in the MPD were detected as elevated (75.6%) or bearing stricture changes (24.4%). A total of 90.2% of SIDC developed after the first 10-Fr PS installation. No significant differences were noted between the patients with and without SIDC. The outcomes of continued PS installment for SIDC showed persistence and secondary change.

CONCLUSIONS

Stent-induced ductal change-associated 10-Fr PS installation was performed in just under one-third of the patients, indicating a substantial incidence rate and a possible development of SIDC from early stages onwards. More emphasis should be placed on SIDC as the complication.

Are Newer Extracorporeal Shock Wave Lithotripsy Models Truly Improving Pancreatolithiasis Lithotripsy Performance? A Japanese Single-Center Study Using Endoscopic Adjunctive Treatment

Background/Aims

Many Japanese institutions use electromagnetic extracorporeal shock wave lithotripsy (ESWL) systems for treating pancreatic duct stones. However, there are no reports on direct comparisons between recent electromagnetic lithotripters. This study aimed to verify whether the new electromagnetic lithotripter can improve the efficiency of pancreatic stone fragmentation, and to clarify the role of combined endoscopic treatment on the clearance of pancreatic duct stones.

Methods

We retrospectively identified 208 patients with pancreatolithiasis who underwent endoscopic adjunctive treatment after pancreatic ESWL at a single Japanese center over a 17-year period. We evaluated the outcome data of this procedure performed with SLX-F2 (last 2 years; group A) and Lithostar/Lithoskop (first 15 years; group B), as well as additional endoscopic treatments for pancreatolithiasis. We also performed logistic regression analysis to detect various factors associated with the procedure.

Results

For pancreatic head stones, ESWL disintegration was achieved in 93.7% of group A patients and 69.0% of group B patients (p=0.004), and adjunctive endoscopic treatment removed stones in 96.8% of group A patients and 73.0% of group B patients (p=0.003). Multivariate analysis revealed that lithotripter type (odds ratio, 6.99; 95% confidence interval, 1.56 to 31.33; p<0.01) and main pancreatic duct stricture (odds ratio, 2.87; 95% confidence interval, 1.27 to 6.45; p<0.01) were significant factors for ESWL fragmentation.

Conclusions

The SLX F2 showed high performance in fragmenting the pancreatic duct stones. In addition, endoscopic adjunctive treatment improved the overall success rate of the procedure. The improved ESWL lithotripter has many advantages for patients undergoing pancreatic lithotripsy treatment.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Comparison of vestibular ocular reflex and gross motor development in children with semicircular canal aplasia and hypoplasia

OBJECTIVE

To examine the effect of vestibular ocular reflex on gross motor development in children with semicircular canal aplasia and hypoplasia.

STUDY DESIGN

Case series.

MATERIALS AND METHODS

Children with congenital hearing loss underwent temporal bone computed tomography to assess their inner ear morphology. In this study, we examined eight children with bilateral complete aplasia of semicircular canals and seven children with bilateral hypoplasia of semicircular canals. Their vestibular ocular reflex was assessed using a damped rotational chair test. Their gross motor development was assessed by examining their ages of acquisition of head control and independent walking.

RESULTS

All eight children with semicircular canal aplasia were diagnosed as having CHARGE syndrome and five children were found to have CHD7 mutations. Cochlear morphological examination showed that cochlear hypoplasia type III was the most common in eight of 16 ears in children with semicircular canal aplasia. In semicircular canal hypoplasia, incomplete partition type II was found in seven of 14 ears. All eight children with semicircular canal aplasia showed no response in the damped rotational chair test. Even the three children followed up were unresponsive in all tests. In the group with semicircular canal hypoplasia, three children showed normal responses, one child showed no response, and three children showed poor responses. The mean age of acquisition of head control was 9.1 ± 6.3 months and that of independent walking was 31 ± 8.1 months in children with semicircular canal aplasia. The mean age of acquisition of head control was 6.0 ± 2.8 months and that of independent walking was 19.9 ± 4.9 months in children with semicircular canal hypoplasia.

CONCLUSIONS

We found that children with semicircular canal aplasia have severe dysfunction of the vestibular ocular reflex, and vestibular sensory cells derived from the semicircular canal may not be present. Semicircular canal hypoplasia is associated with dysfunction of the vestibular ocular reflex, but vestibular sensory cells may be present, and rotary nystagmus develops with growth similar to that observed in normal children previously reported. Semicircular canal aplasia is associated with CHARGE syndrome, and affected children tended to have a slower gross motor development. It was suggested that the combination of visual impairment and mental retardation may delay the development of central-level integrated functions and may further delay motor development.

Post-infarct VT substrate ablation based on evoked delayed potential elimination as well-defined target: results from a prospective multicenter study

Background

In patients with VT after myocardial infarction (MI), substrate-based ablation is superior to approaches that target clinical and tolerated VTs only. Different substrate modification strategies have been reported. However, proposed ablation targets are prone to operator interpretation (e.g. abnormal electrograms). Accordingly, ablation results can also be operator dependent. Evoked delayed potentials (EDP) are a well-defined target. Elimination of EDP has been effective to prevent VT recurrence in a retrospective, single center cohort.

Aim

(1)To evaluate the outcome of EDP ablation in a prospective cohort of patients included on an intention-to-treat principle and (2)to assess the outcome of EDP ablation following one uniform protocol when performed in centers without prior experience with this strategy.

Methods

Consecutive patients referred for post-MI VT ablation were prospectively enrolled in one center with extensive experience in EDP ablation and 5 centers with no prior experience. Substrate mapping focused on EDP identification followed a uniform protocol across all centers. In brief, all electrograms located within the infarct area were analyzed during sinus rhythm, RV pacing at a fixed rate and during the application of one short-coupled RV extra-stimulus (S2). Sites showing low-voltage, nearfield electrograms with &gt;10ms delay or block in response to S2 were categorized as EDP and targeted for ablation. After ablation, re-mapping to confirm EDP elimination and a complete stimulation protocol (up to 4 extra's from RV and LV) were performed. Patients were followed for VT recurrence and mortality.

Results

130 patients (69±10 years, 87% men, 42% anterior MI, LVEF 34% (IQR 24–43), 71% NYHA II–III, 42% on amiodarone, 52% ≥1 ICD shock, 22% with electrical storm or incessant VT) were included. The extra-stimulation protocol was systematically conducted in 127 (98%) patients and in 121 (93%), EDPs were identified. EDPs were successfully eliminated in 117/121 (97%) patients. After 23 (IQR 14–35) min of RF, 102 (78%) patients were rendered non-inducible. Median procedural duration was 212 (IQR 179–262) min. During follow-up of 14 (IQR 8–18) months, 36 (28%) patients had VT recurrence and 13 (10%) died or received a LVAD. VT-free survival was 79% (95% CI: 72–86) and 72% (95% CI: 63–80) at 6 and 12 months follow-up. Of note, VT-free survival at 12 month was not significantly different between patients undergoing the procedure in centers with and without prior experience in EDP ablation (76% (95% CI: 61–90) vs. 70% (95% CI: 59–81); P=0.269).

Conclusion

In a large prospective cohort of patients with post-MI VT, substrate ablation based on EDP elimination resulted in excellent long-term outcome. Of importance, procedural outcomes were similar in centers with or without experience in EDP ablation, indicating that this approach can be easily reproduced by operators previously not familiar with the technique.

Funding Acknowledgement

Type of funding sources: None.

MR Imaging Detection of CNS Lesions in Tuberous Sclerosis Complex: The Usefulness of T1WI with Chemical Shift Selective Images

BACKGROUND AND PURPOSE

CNS lesions of tuberous sclerosis complex are diagnosed mainly by T2WI, FLAIR, and sometimes T1WI with magnetization transfer contrast. The usefulness of T1WI with chemical shift selective images was recently reported in focal cortical dysplasia type IIb, which has histopathologic and imaging features similar to those of tuberous sclerosis complex. We investigated the usefulness of the T1WI with chemical shift selective images in detecting CNS lesions of tuberous sclerosis complex.

MATERIALS AND METHODS

We retrospectively reviewed 25 consecutive patients with tuberous sclerosis complex (mean age, 11.9 [SD, 8.9] years; 14 males) who underwent MR imaging including T1WI, T1WI with magnetization transfer contrast, T1WI with chemical shift selective, T2WI, and FLAIR images. Two neuroradiologists assessed the number of CNS lesions in each sequence and compared them in 2 steps: among T1WI, T1WI with magnetization transfer contrast and T1WI with chemical shift selective images, and among T2WI, FLAIR, and T1WI with chemical shift selective images. We calculated the contrast ratio of the cortical tubers and of adjacent normal-appearing gray matter and the contrast ratio of radial migration lines and adjacent normal-appearing white matter in each sequence and compared them.

RESULTS

T1WI with chemical shift selective images was significantly superior to T1WI with magnetization transfer contrast for the detection of radial migration lines and contrast ratio of radial migration lines. There was no significant difference between T1WI with chemical shift selective images and T1WI with magnetization transfer contrast for the detection of cortical tubers and the contrast ratio of the cortical tubers. Both T2WI and FLAIR were statistically superior to T1WI with chemical shift selective images for the detection of cortical tubers. T1WI with chemical shift selective images was significantly superior to T2WI and FLAIR for the detection of radial migration lines.

CONCLUSIONS

The usefulness of T1WI with chemical shift selective images in detecting radial migration lines was demonstrated. Our findings suggest that the combination of T1WI with chemical shift selective images, T2WI, and FLAIR would be useful to evaluate the CNS lesions of patients with tuberous sclerosis complex in daily clinical practice.

Mito-FUNCAT-FACS reveals cellular heterogeneity in mitochondrial translation

Mitochondria possess their own genome that encodes components of oxidative phosphorylation (OXPHOS) complexes, and mitochondrial ribosomes within the organelle translate the mRNAs expressed from the mitochondrial genome. Given the differential OXPHOS activity observed in diverse cell types, cell growth conditions, and other circumstances, cellular heterogeneity in mitochondrial translation can be expected. Although individual protein products translated in mitochondria have been monitored, the lack of techniques that address the variation in overall mitochondrial protein synthesis in cell populations poses analytic challenges. Here, we adapted mitochondrial-specific fluorescent noncanonical amino acid tagging (FUNCAT) for use with fluorescence-activated cell sorting (FACS) and developed mito-FUNCAT-FACS. The click chemistry-compatible methionine analog L-homopropargylglycine (HPG) enabled the metabolic labeling of newly synthesized proteins. In the presence of cytosolic translation inhibitors, HPG was selectively incorporated into mitochondrial nascent proteins and conjugated to fluorophores via the click reaction (mito-FUNCAT). The application of in situ mito-FUNCAT to flow cytometry allowed us to separate changes in net mitochondrial translation activity from those of the organelle mass and detect variations in mitochondrial translation in cancer cells. Our approach provides a useful methodology for examining mitochondrial protein synthesis in individual cells.

Validity of preoperative screening before open-heart surgery in reduction of perioperative ischemic stroke

OBJECTIVES

Cerebrovascular event after open-heart surgery is a critical complication and contributes to poor prognosis, including increased mortality. The purpose of this study is to investigate the appropriate preoperative risk assessment and monitoring for reducing the risk of ischemic stroke after open-heart surgery.

MATERIALS AND METHODS

184 patients who underwent surgery for valvular heart disease were included in this study. Near-infrared oxygen saturation monitoring (INVOS system) was performed during open-heart surgery. For the purpose of perioperative stroke risk assessment, we evaluated the clinical and radiological factors of the group that underwent preoperative consultation and the group that did not, and of the patients with and without postoperative ischemic stroke.

RESULTS

Preoperative consultation was performed in 60 cases. Large vessel steno-occlusive disease was found in nine cases, of which three had undergone revascularization surgery. Cerebral infarction developed in four cases, all of which had no large vessel steno-occlusive disease. There was no significant association between the development of postoperative ischemic stroke and presence of large vessel steno-occlusive disease. Preoperative baseline INVOS value was significantly low in the ischemic stroke group (49.5 ± 12.5) compared to the non-ischemic stroke group (66.8 ± 10.0), (P = 0.012).

CONCLUSIONS

In open-heart surgery for valvular heart disease, low preoperative baseline INVOS values were associated with cerebral ischemic stroke after surgery. The combination of appropriate preoperative screening for large vessel steno-occlusive disease and measurement of INVOS could be used as a simple and useful method in screening for the risk of ischemic stroke after open-heart surgery.

Post-infarct VT substrate ablation based on evoked delayed potential elimination as well-defined target : results from a prospective multicenter study

Funding Acknowledgements

Type of funding sources: None.

Background

Substrate ablation is superior to approaches that target clinical and tolerated VTs in patients with post-myocardial infarction (MI) VT. Different substrate modification strategies have been reported. However, proposed ablation targets are prone to operator interpretation (e.g. abnormal electrograms). Accordingly, ablation results can also be operator dependent. Evoked delayed potentials (EDP) are a well-defined target. Elimination of EDP has been effective to prevent VT recurrence in a retrospective, single center cohort.

Aim

(1)To evaluate the outcome of EDP ablation in a prospective cohort of patients included on an intention-to-treat principle and (2)to assess the outcome of EDP ablation following one uniform protocol when performed in centers without prior experience with this strategy.

Methods

Consecutive patients referred for post-MI VT ablation were prospectively enrolled in one center with extensive experience in EDP ablation and 5 centers with no prior experience. Substrate mapping focused on EDP identification followed a uniform protocol across all centers. In brief, all electrograms located within the infarct area were analyzed during sinus rhythm, RV pacing at a fixed rate and during the application of one short-coupled RV extra (S2). Sites showing low-voltage, nearfield electrograms with &gt;10ms delay or block in response to S2 were categorized as EDP and targeted for ablation. After ablation, re-mapping to confirm EDP elimination and a complete stimulation protocol (up to 4 extra’s from RV and LV) were performed.

Results

131 patients (69±10 years, 87% men, 42% anterior MI, LVEF 33±11%, 70% NYHA II-III, 43% on amiodarone, 52% ≥1 ICD shock, 34% with electrical storm or incessant VT) were included. Multipolar catheters or catheters with micro-electrodes in the tip were used in 53%. The extra-stimulation protocol was systematically conducted in 127 (97% ) patients and in 121 (92%), EDPs were identified. EDPs were successfully eliminated in 117/121 (97%) patients. After 23 (IQR 14-35) min of RF, 101 (77%) patients were rendered non-inducible. Median procedural duration was 213 (IQR 180-267) min. During follow-up of 14 (IQR 8-19) months, 36 (27%) patients had VT recurrence and 14 (11%) died or received a LVAD. VT-free survival was 78% (CI95% 71-85) and 71% (CI95% 63-80) at 6 and 12 months follow-up. Of note, VT-free survival at 12 month was not significantly different between patients undergoing the procedure in centers with and without prior experience in EDP ablation (76% (CI95% 62-90) vs. 69% (CI95% 59-80); P=0.269).

Conclusion

In a large prospective cohort of patients with post-MI VT, substrate ablation based on EDP elimination resulted in excellent long-term outcome. Of importance, procedural outcomes were similar in centers with or without experience in EDP ablation, indicating that this approach can be easily reproduced by operators previously not familiar with the technique.

Area weighted unipolar voltage to predict heart failure death in patients with ischemic cardiomyopathy and ventricular tachycardia

Funding Acknowledgements

Type of funding sources: None.

Background

Patients with ischemic cardiomyopathy (ICM) referred for catheter ablation (CA) of ventricular tachycardia (VT) are at risk for end-stage heart failure (HF) due to adverse remodeling of the left ventricle (LV). Local unipolar voltages (UV) decrease with loss of viable myocardium. A UV mapping derived parameter that corrects for oversampling of the infarct area may reflect the total amount of remaining LV viable myocardium.

Objective

To evaluate if the newly proposed parameter, `area weighted unipolar voltage’ (awUV), can predict HF related death/LVAD/Heart transplant (HFD) in ICM.

Methods

Voltage maps from consecutive patients with ICM referred for CA of VT, were transferred to Paraview after valve area removal. AwUV was calculated by mathematically interpolating all mapping points weighted for relative distances divided by the LV endocardial surface. Unipolar low voltage areas (ULVA, UV&lt;8.27mV) were measured as percentage of the total LV surface. Associations between clinical and mapping derived parameters and HFD (HF-related death/LVAD/heart transplant) were evaluated and validated in a second cohort of consecutive patients.

Results

Eighty-nine patients in the study group (age 68±8; LVEF 33% [IQR 24-40%]; ULVA 64% [IQR 46-86%]; awUV 7.01 [IQR 5.01-8.52]) and 69 patients in the validation group (age 68±9; LVEF 39% [IQR 29-44%]; ULVA 59% [IQR 43-77%]; awUV 7.60 [IQR 6.16-8.69]) were included. Follow-up was 32±17 months in the study group, 28±17 months in the validation group. HFD was 20% in the study group, 10% in the validation cohort. Patients with HFD had lower LVEF and awUV, and larger ULVA than patients without HFD (LVEF 23±10% vs. 35±11%; awUV: 5.12±1.92 vs. 7.75±2.64; LVA 86±21% vs. 60±23%, all P&lt;0.001). Univariable analysis showed that LVEF, ULVA and awUV were associated with HFD (HR and 95% CI: LVEF 1.10 [1.05 – 1.16]; LVA 1.05 [1.02 – 1.08]; awUV 2.18 [1.58 – 3.40], all P&lt;0.01). AwUV was superior to ULVA to predict HFD in likelihood ratio calculations (awUV: LR 5.66, P=0.02; LVA: 1.76 P=0.18) and ROC analysis (AUC awUV: 0.86; LVA 0.78). The optimal cut-off for awUV of&lt;5.27 was highly accurate to predict HFD in the validation cohort (log-rank P&lt;0.001).

Conclusion

The newly proposed parameter awUV, easily available from routine voltage mapping, may be useful at identifying ICM patients at risk for HFD.

Non-invasive identification of slow conducting anatomical isthmuses in patients with tetralogy of Fallot by 3D late gadolinium enhancement cardiovascular magnetic resonance

Funding Acknowledgements

Type of funding sources: None.

Background

Patients with repaired tetralogy of Fallot (rTOF) remain at risk of sudden cardiac death due to reentrant sustained monomorphic ventricular tachycardia (SMVT). Slow conducting anatomical isthmuses (SCAI), in particular SCAI3 at the outlet septum, bordered by the pulmonary annulus and the ventricular septal defect patch, are the dominant substrate for SMVT. Electroanatomical mapping (EAM) is the invasive gold standard to identify SCAIs, and transection of SCAI by catheter ablation has been correlated with favorable long-term outcome. Non-invasive identification of SCAI for risk stratification and treatment planning is needed but has not been established yet. Three-dimensional (3D) late gadolinium-enhanced (LGE) cardiovascular magnetic resonance (CMR) facilitates accurate visualization of morphologically complex hearts with high-spatial resolution.

Objective

The study thought to determine whether 3D LGE-CMR can identify SCAIs.

Methods

Consecutive patients with rTOF who underwent right ventricular (RV) EAM and 3D LGE-CMR were included. LGE-CMR-derived 3D RV reconstructions were created (ADAS-3D) and merged with 3D RV EAM data. Mapping points were superimposed on the CMR-derived 3D reconstruction allowing for direct comparison of EAM data and local signal intensity (SI). The optimal SI cut-off to identify low bipolar voltage (LBV, BV&lt;1.76mV) was determined by receiver operating characteristic carve. An abnormal AI on LGE-CMR was defined as AI with continuous SI above the obtained cut-off connecting AI borders.

Results

Forty-eight rTOF patients (34±16 years, 58% male) were included. At EAM, 21 patients had normal AI, and 20 and 7 had a SCAI (&lt;0.5m/s) or blocked AI, which was AI3 in all. Patients with SCAI showed low BV of AI3 (median 0.7 [range 0.25-2.59] mV). In 11 patients, 14 SMVTs could be induced, all related to SCAI3.

A total of 9240 points were analyzed, showing a significant correlation between BV and SI (R=0.4, P&lt;0.001). The optimal SI cut-off to identify LBV was 42% of the maximal SI (MSI) (AUC 0.80; sensitivity, 74%; specificity, 78%). Using this cut-off of MSI, a SCAI or blocked AI3 could be correctly identified by LGE-CMR in all 27 patients, and a normal AI3 could be correctly confirmed by LGE-CMR in 14/21 patients with normal EAM findings (Figure). The sensitivity and specificity of 3D LGE-CMR for identifying SCAI or blocked AI3 were 100% and 67%, respectively. Of note, among patients with normal EAM findings, those with abnormal AI3 on LGE-CMR had significantly lower BV of AI3 than those with normal AI3 on LGE-CMR (2.06 [Range, 1.62-2.60] vs. 3.53 [2.22-5.67] mV, P&lt;0.01).

Conclusion

3D LGE-CMR can identify SCAI with 100% sensitivity and may identify diseased AI3 even before critical conduction delay occurs. This technique may allow for non-invasive risk stratification of VT and can refine patient selection for invasive EAM.

The relation between Phase Angle as muscle function by BIA and physical function and nutrition states in cardiac patients

Funding Acknowledgements

Type of funding sources: None.

[Purpose] Phase angle (PhA) by BIA was studied as muscle function in various diseases. However the effects of nutrition states to phase angle is unclear especially in cardiac patients. This study examined the relationship between PhA, physical function and nutritional index in patients with heart disease.

Methods

PhA was measured using InBody770 for 33 heart disease patients (age: 71.6 ± 13.4 years, EF: 58.6 + 11.0%) who underwent cardiac rehabilitation during hospitalization. Short Physical Performance Battery (SPPB) was performed for physical function evaluation, and ALB, eGFR, and NT-ProBNP were evaluated for blood tests. calorie intake and GNRI were calculated as nutritional assessments.

Results

PhA was 4.1 ± 0.9 °. PhA has a positive correlation with SMI (r = 0.62), chair rise time (r = 0.62), dietary calorie intake (r = 0.49), GNRI (r = 0.50), NT-ProBNP (r = -0.631), ECW A negative correlation was found with / TBW (r = -0.91). As a result of multiple regression analysis with PhA as the dependent variable, ECW / TBW (β = -0.73), SMI (β = 0.33), and chair rise time (β = 0.10) were extracted as significant independent factors (β = -0.13). r² = 0.96).

[Conclusion] PhA in patients with heart disease was correlated with physical function and nutritional index, and a significant independent factor was physical function. In particular, lower limb muscle strength was extracted independently of extracellular water ratio and muscle mass. These results suggest that PhA may be a comprehensive index of physical function in cardiac patients.

Related factors and changes of angiopoietin-like protein 2 with chronic heart failure patients participating in phase III cardiac rehabilitation

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): the research grant D2 from Kansai Medical University

Objectives

Angiopoietin-like protein 2 (ANGPTL2) is a protein, whose structure is similar to that of angiopoietin, but binds to a different receptor. Overexpression of ANGPTL2 promotes chronic inflammation and relates to the development of aging-related diseases. ANGPTL2 has been reported to be mainly secreted by adipose tissue. Although ANGPTL2 has been implicated in the pathogenesis of heart failure, there are no studies about serum ANGPTL2 levels in patients with heart failure participating in cardiac rehabilitation program. The aim of this study was to investigate the characteristics, related factors and changes of ANGPTL2 in patients with chronic heart failure during phase III of cardiac rehabilitation program.

Methods

The subjects included 57 patients (70.1 ± 10.2 years old; 46 men) with chronic heart failure whose serum ANGPTL2 levels were measured during the maintenance phase of cardiac rehabilitation program. Furthermore, we classified 25 patients (70.6 ± 7.5 years old; 23 men) from the 6-month course into a reduced group and an unchanged group to characterize change in ANGPTL2. We excluded patients who were admitted or discharged within 3 months of the evaluation of serum ANGPTL2. We evaluated exercise tolerance using the cardiopulmonary exercise test, grip strength, body composition using a body composition analyzer, blood examinations, and echocardiography. Serum ANGPTL2 was measured by solid-phase sandwich enzyme-linked immunosorbent assay (ELISA).

Results

The median value of ANGPTL2 was 4.05 ng/ml. ANGPTL2 was positively correlated with body weight, body mass index, body fat mass, body fat percentage, C-reactive protein (CRP) and total protein (TP) levels, and negatively correlated with skeletal muscle mass percentage and anaerobic threshold (AT). From the result of the logistic regression analysis, AT (OR=0.68, 95% CI:0.47-0.97and TP (OR=20.1, 95% CI:2.52-160.63) were extracted as independent factors related to the level of ANGPTL2. In addition, overall serum ANGPTL2 levels decreased significantly after 6 months. Changes in ANGPTL2 in the reduced group showed a positive correlation between baseline peak VO2, left ventricular ejection fraction and skeletal muscle rate, and a negative correlation with baseline ANGPTL2, CRP, body fat mass. In an unchanged group, HbA1c increased, but no significant change was observed in other factors.

Conclusions

Exercise tolerance in patients with chronic heart failure during maintenance phase might be related to the inflammation marker ANGPTL2. Serum ANGPTL2 levels with stable chronic heart failure patients decreased significantly 6 months after continued cardiac rehabilitation.

Endoscopic Ablation of Upper Tract Urothelial Carcinoma: A Report of Two Cases with Long Disease Recurrence-Free Periods

Upper tract urothelial carcinoma (UTUC) is a relatively rare disease that accounts for 5% to 10% of all urothelial carcinomas (UCs). Radical nephroureterectomy (RNU) with a bladder cuff is the current gold standard for the management of UTUC; however, endoscopic ablation is also an option for low-risk UTUC to preserve kidney function. Herein, we present two cases of solitary kidney with a right lower ureteral tumor. Both patients underwent left RNU in the past. An 82-year-old man with a right ureteral tumor whose histopathological examination revealed low-grade UC. Laser ablation was performed with ureteroscopy, and there was no recurrence for 7 years after treatment. A 67-year-old woman with a right lower ureteral tumor whose histopathological examination also revealed low-grade UC. Laser ablation was performed, and there was no recurrence for 5 years after the treatment. We closely followed-up our two patients after RNU. This allowed for early detection of tumor recurrence, after which we could perform laser ablation therapy.

Bile duct regeneration with an artificial bile duct made of gelatin hydrogel non-woven fabrics

Although choledochojejunostomy is the standard technique for biliary reconstruction, there are various associated problems that need to be solved such as reflux cholangitis. Interposition with an artificial bile duct (ABD) to replace the resected bile duct maintains a physiological conduit for bile and may solve this problem. This study investigated the usefulness of an ABD made of gelatin hydrogel non-woven fabric (GHNF). GHNF was prepared by the solution blow spinning method. The migration and activity of murine fibroblast L929 cells were examined in GHNF sheets. L929 cells migrated into GHNF sheets, where they proliferated and synthesized collagen, suggesting GHNF is a promising scaffold for bile duct regeneration. ABDs made of GHNF were implanted in place of resected bile duct segments in rats. The rats were sacrificed at 2, 6, and 12 weeks post-implantation. The implantation site was histologically evaluated for bile duct regeneration. At postoperative 2 weeks, migrating cells were observed in the ABD pores. The implanted ABD was mostly degraded and replaced by collagen fibers at 6 weeks. Ki67-positive bile duct epithelial cells appeared within the implanted ABD. These were most abundant within the central part of the ABD after 6 weeks. The percentages of Ki67-positive cells were 31.7%±9.1% in the experimental group and 0.8%±0.6% in the sham operation group at 6 weeks (p<0.05), indicating that mature biliary epithelial cells at the stump proliferated to regenerate the biliary epithelium. Biliary epithelial cells had almost completely covered the bile duct lumen at 12 weeks (epithelialization ratios: 10.4%±6.9% at 2 weeks, 93.1%±5.1% at 6 weeks, 99.2%±1.6% at 12 weeks). The regenerated epithelium was positive for the bile duct epithelium marker cytokeratin 19. Bile duct regeneration was accompanied by angiogenesis, as evidenced by the appearance of CD31-positive vascular structures. Capillaries were induced 2 weeks after implantation. The number of capillaries reached a maximum at 6 weeks and decreased to the same level as that of normal bile ducts at 12 weeks. These results showed that an ABD of GHNF contributed to successful bile duct regeneration in rats by facilitating the cell migration required for extracellular matrix synthesis, angiogenesis, and epithelialization.

Endoscopic therapy for recurrent pancreatitis complicated with pancreatolithiasis in a case of annular pancreas

Annular pancreas is a congenital abnormality in which part of the pancreatic head completely or partially surrounds the duodenum in a ring-like manner. The condition is thought to be an abnormality of the ventral pancreatic bud. While pancreatitis is a common complication of the annular pancreas, its recurrence may be prevented by improving the outflow of pancreatic juice. The present case report describes a 23-year-old woman who had been referred to our hospital for recurrent pancreatitis since childhood. An endoscopic incision was made on the orifice of the annular pancreas, after which pancreatitis of the annular pancreas did not recur for 6 years. The patient subsequently exhibited pancreatolithiasis in the dorsal pancreatic duct, which was successfully treated with endoscopic treatment. Endoscopic pancreatic sphincterotomy may prevent the recurrence of pancreatitis and avoid further surgical interventions by improving the flow of pancreatic juice.

Increased Expressions of Programmed Death Ligand 1 and Galectin 9 in Transplant Recipients Who Achieved Tolerance After Immunosuppression Withdrawal

Programmed death 1 (PD1)/its ligand PD-L1 concomitant with T cell immunoglobulin and mucin domain-containing protein 3 (TIM-3)/its ligand galectin 9 (Gal-9) and the forkhead box P3 (FOXP3) might be involved in tolerance after liver transplantation (LT). Liver biopsies from 38 tolerant, 19 nontolerant (including 16 samples that triggered reintroduction of immunosuppression [IS] and 19 samples after IS reintroduction), and 38 control LT patients were studied. The expressions of PD1, PD-L1, Gal-9, and FOXP3 were determined by immunohistochemical and immunofluorescence (IF) staining. The success period of IS withdrawal was calculated using Kaplan-Meier curve analysis. Tolerant and control patients exhibited higher PD-L1, Gal-9, and FOXP3 levels than nontolerant patients at the moment of triggering IS reintroduction. High expressions of PD-L1 and Gal-9 were associated with prolonged success of tolerance (83.3% versus 36.7% [P < 0.01] and 73.1% versus 42.9% [P = 0.03]). A strong correlation between PD-L1 and Gal-9 expression levels was detected (Spearman r = 0.73; P ≤ 0.001), and IF demonstrated colocalization of PD-L1 and Gal-9 in the cytoplasm of hepatocytes. In conclusion, the present study demonstrated that increased expressions of PD-L1 and Gal-9 were associated with sustained tolerance after IS withdrawal in pediatric liver transplantation.