Treatment Patterns of Biologic Disease-Modifying Antirheumatic Drugs and Janus Kinase Inhibitors in Patients with Rheumatoid Arthritis in Japan: A Claims-Based Cohort Study

BACKGROUND

Reports on treatment patterns of biologic disease-modifying antirheumatic drugs (bDMARDs)/Janus kinase inhibitors (JAKi) for rheumatoid arthritis (RA) in clinical practice are still sparse in Japan, especially in combination with conventional synthetic DMARDs (csDMARDs).

OBJECTIVES

The aim of this study was to investigate treatment patterns of bDMARD/JAKi in the treatment of RA in real-world clinical practice in Japan.

METHOD

A retrospective cohort study was conducted using the Japanese Medical Data Vision health claims database. The inclusion criteria required a recorded diagnosis of RA, defined by ICD-10 codes, in patients aged 18 years and older on the index date. We analyzed 39,903 RA patients treated with DMARDs from 2008 to 2020.

RESULTS

Among analyzed subjects, 10,196 patients (25.6%) were prescribed bDMARDs/JAKi in combination with csDMARDs, and 3067 patients (7.7%) were prescribed these drugs without csDMARDs. Among the bDMARDs/JAKi, tumor necrosis factor inhibitors (TNFi) were the most commonly prescribed DMARD overall, and also the most common first-line therapy, accounting for 60.0% or 45.5% of patients prescribed these drugs in combination with or without csDMARDs, respectively. Switching, temporary discontinuation (restarting with the same agents), and discontinuation of bDMARDs/JAKi were observed in 3150 (30.9%), 1379 (13.5%), and 2025 (19.9%) patients with csDMARDs, and in 849 (27.7%), 513 (16.7%), and 833 (27.2%) patients without csDMARDs, respectively.

CONCLUSIONS

Real-world treatment trajectories of bDMARDs/JAKi with and without csDMARDs was analyzed in RA patients in Japan between 2008 and 2020. TNFi were the predominant first-line therapy, and likely to be switched to different classes. Understanding the current treatment patterns, including discontinuation, is important to find an optimal treatment strategy for RA patients.

Whole-genome sequencing analysis of molecular epidemiology and silent transmissions causing meticillin-resistant Staphylococcus aureus bloodstream infections in a university hospital

BACKGROUND

The emergence of novel genomic-type clones, such as community-associated meticillin-resistant Staphylococcus aureus (MRSA) and livestock-associated MRSA, and their invasion into hospitals have become major concerns worldwide; however, little information is available regarding the prevalence of MRSA in Japan. Whole-genome sequencing (WGS) has been conducted to analyse various pathogens worldwide. Therefore, it is important to establish a genome database of clinical MRSA isolates available in Japan.

AIM

A molecular epidemiological analysis of MRSA strains isolated from bloodstream-infected patients in a Japanese university hospital was conducted using WGS and single-nucleotide polymorphism (SNP) analysis. Additionally, through a review of patients' clinical characteristics, the effectiveness of SNP analysis as a tool for detecting silent nosocomial transmission that may be missed by other methods was evaluated in diverse settings and various time points of detection.

METHODS

Polymerase-chain-reaction-based staphylococcal cassette chromosome mec (SCCmec) typing was performed using 135 isolates obtained between 2014 and 2018, and WGS was performed using 88 isolates obtained between 2015 and 2017.

FINDINGS

SCCmec type II strains, prevalent in 2014, became rare in 2018, whereas the prevalence of SCCmec type IV strains increased from 18.75% to 83.87% of the population, and became the dominant clones. Clonal complex (CC) 5 CC8 and CC1 were detected between 2015 and 2017, with CC1 being dominant. In 88 cases, SNP analyses revealed nosocomial transmissions among 20 patients which involved highly homologous strains.

CONCLUSIONS

Routine monitoring of MRSA by whole-genome analysis is effective not only for gaining knowledge regarding molecular epidemiology, but also for detecting silent nosocomial transmission.

Unveiling new quantum phases in the Shastry-Sutherland compound SrCu2(BO3)2 up to the saturation magnetic field

Under magnetic fields, quantum magnets often undergo exotic phase transitions with various kinds of order. The discovery of a sequence of fractional magnetization plateaus in the Shastry-Sutherland compound SrCu₂(BO₃)₂ has played a central role in the high-field research on quantum materials, but so far this system could only be probed up to half the saturation value of the magnetization. Here, we report the first experimental and theoretical investigation of this compound up to the saturation magnetic field of 140 T and beyond. Using ultrasound and magnetostriction techniques combined with extensive tensor-network calculations (iPEPS), several spin-supersolid phases are revealed between the 1/2 plateau and saturation (1/1 plateau). Quite remarkably, the sound velocity of the 1/2 plateau exhibits a drastic decrease of -50%, related to the tetragonal-to-orthorhombic instability of the checkerboard-type magnon crystal. The unveiled nature of this paradigmatic quantum system is a new milestone for exploring exotic quantum states of matter emerging in extreme conditions.

A Real-World Claims Database Study Assessing Long-Term Persistence with Golimumab Treatment in Patients with Rheumatoid Arthritis in Japan

INTRODUCTION

The persistence of golimumab (GLM) treatment in Japanese patients with rheumatoid arthritis (RA) has been evaluated previously, but evidence of long-term real-world use is lacking. This study assessed the long-term persistence of GLM use, its influencing factors, and impact of prior medications in patients with RA in actual clinical practice in Japan.

METHODS

This is a retrospective cohort study of patients with RA using data from a hospital insurance claims database in Japan. The identified patients were stratified as only GLM treatment (naïve), had one biological disease-modifying anti-rheumatic drug (bDMARD)/Janus kinase (JAK) inhibitor treatment prior to GLM [switch (1)] and had at least two bDMARDs/JAK prior to GLM treatment [switch (≥ 2)]. Patient characteristics were evaluated using descriptive statistics. Kaplan-Meier survival and Cox regression methods were used to analyze GLM persistence at 1, 3, 5, and 7 years and the associated factors. Treatment differences were compared using a log-rank test.

RESULTS

GLM persistence rate in the naïve group was 58.8%, 32.1%, 21.4%, and 11.4% at 1, 3, 5, and 7 years, respectively. Overall persistence rates in the naïve group were higher than in switch groups. Higher GLM persistence was observed among patients aged 61-75 years and those concomitantly using methotrexate (MTX). Also, women were less likely to discontinue treatment compared to men. Higher Charlson Comorbidity Index score, initial GLM dose of 100 mg, and switch from bDMARDs/JAK inhibitor were related to a lower persistence rate. As a prior medication, infliximab showed the longest persistence for subsequent GLM, and using this as a reference, tocilizumab, sarilumab, and tofacitinib subgroups had significantly shorter persistence, respectively (p = 0.001, 0.025, 0.041).

CONCLUSION

This study presents the long-term real-world results for persistence of GLM and its potential determinants. These most recent and long-term observations demonstrated that GLM and other bDMARDs continue to benefit patients with RA in Japan.

Persistence and Safety of Golimumab in Elderly Patients with Rheumatoid Arthritis and Renal Dysfunction in a Real-World Setting

BACKGROUND

The efficacy and safety of golimumab in elderly patients with renal dysfunction are not well evaluated due to the exclusion criteria of clinical trials.

OBJECTIVE

To assess the persistence and safety of golimumab in elderly rheumatoid arthritis patients with renal dysfunction.

PATIENTS AND METHODS

In this retrospective observational study, we used Japan's nationwide electronic medical records and claims database to identify patients aged 65 years and older who were newly prescribed golimumab for rheumatoid arthritis between July 2011 and June 2018. Patients were divided into three groups according to estimated glomerular filtration rate (eGFR; high, ≥ 90; moderate, ≥ 60, < 90; low, ≥ 30, < 60), and the persistence of golimumab and adverse events were compared between the groups.

RESULTS

A total of 423 patients met the eligibility criteria. At 6 months, the persistence rates of golimumab were 62.4%, 63.7% and 67.0% in the high, moderate and low eGFR groups, respectively. In Cox proportional hazards regression analysis, baseline eGFR was not associated with golimumab persistence or adverse events, but concomitant methotrexate and low baseline C-reactive protein (CRP) were associated with longer golimumab persistence.

CONCLUSION

Reduced renal function was not associated with continuation of golimumab or incidence of adverse events, suggesting that the persistence of golimumab therapy in patients with rheumatoid arthritis is independent of the baseline level of renal function. On the other hand, concomitant use of methotrexate and low baseline CRP levels were suggested as factors that may affect the persistence of golimumab treatment.

14 EXAMINING THE IMPACT OF SAFETY MONITORING DEVICES ON CARE WORK AND PROCESSES IN JAPANESE NURSING HOMES

Background

Although the impact of new technology on the workplace has been discussed for many years, little has been reported regarding the effect of new technology in nursing homes. The aim of the research was to test the effect of a safety monitoring device on night-time work patterns.

Methods

A monitoring sensor with an infrared camera was installed in Tokyo-based residential nursing homes in April 2020. A pre/post intervention and observation study was conducted before and after the introduction of the device. Four care professionals worked each night in pairs (one person providing care, and the other observing and keeping minute-by-minute records of task and time allocated to each task. The tasks were divided into 33 items). The data were collected by two pairs at three different nights for pre-intervention and from two pairs at two nights for post-intervention. Ten care professionals participated in the study, and they were looking after 30 older adults (86.8 +/- 6.8 years old).

Results

The total time for executing various tasks marginally increased from 978 mins to 1033 mins. However, statistically significant changes were found mainly among items related to medical care and safety. While nurse call response time decreased significantly, the proportion of time allocated to personal care such as vital checks (from 1 to 2 percent) and mobility (from 4 to 9 percent) assistance doubled. Break time also increased significantly.

Conclusion

While the introduction of a safety monitoring system did not radically reduce the workload, it changed the patterns of caregiving during the night shift. Some behavioural changes were directly caused by functions of the system, while others were by-products. Staff’s break length also increased. The findings suggest that the introduction of Information and Communication Technology (ICT) in nursing homes has the potential to release time to care.

Endoscopic modified transseptal bi-nostril approach for pituitary tumors. Efficacy of complex preservation of every turbinate and olfaction: A STROBE analysis

AIMS

Endoscopic modified transseptal bi-nostril approach minimizes turbinate and olfactory mucosal invasion and ensures preservation of the turbinates and bilateral olfaction. The main objective of this study was to investigate the pre- and postoperative variations in olfactory function in patients using this approach, and the secondary objective was to investigate the complications associated with the surgical procedure.

MATERIAL AND METHODS

This study is a single-center prospective cohort study using STROBE analysis. To completely protect the bilateral turbinates and olfactory epithelium, this procedure provided access to the sphenoid sinus by a transseptal approach via the left nasal cavity and by the olfactory cleft approach via the right nasal cavity without any turbinate resection. A T&T olfactometer was used to assess the mean recognition threshold of the left, right, and bilateral nasal passages before and after surgery, and complications associated with the surgical approach were investigated.

OBJECTIVES

We included 27 patients who underwent endoscopic modified transseptal pituitary surgery with an olfactory and turbinate preservation approach at our hospital between April 2018 and December 2019.

RESULTS

The mean postoperative recognition threshold of the right, left, and bilateral nasal cavities did not worsen (P<0.001 for all) relative to the preoperative values, and there was no difference in values between the right and left nasal cavities (P=0.85). The nasal turbinates were preserved in all patients during the study period, and no recurrence was observed.

CONCLUSION

Our modified EETSA could be implemented as an approach for turbinate and olfaction preservation.

Glomerular hyperfiltration with hyperglycemia in the spontaneously diabetic Torii (SDT) fatty rat, an obese type 2 diabetic model

Glomerular hyperfiltration is observed in an early stage of kidney diseases including diabetic nephropathy. A better understanding of pathophysiological changes in glomerular hyperfiltration is essential for development of new therapies to prevent kidney disease progression. In this study, we investigated glomerular changes including glomerular filtration rate (GFR) and glomerular size in the Spontaneously Diabetic Torii (SDT) fatty rat, an obese type 2 diabetic model, and we also evaluated pharmacological effects of the sodium glucose cotransporter 2 inhibitor dapagliflozin on the renal lesions. Dapagliflozin was administered to SDT fatty rats from 5 to 17 weeks of age. Blood and urinary biochemical parameters were periodically measured. GFR was determined by transdermal GFR monitor at 16 weeks of age and histopathological analysis was performed at 17 weeks of age. SDT fatty rat developed severe hyperglycemia and exhibited pathophysiological abnormalities in the kidney, such as an increased GFR, glomerular hypertrophy and tissue lesions. Dapagliflozin achieved good glycemic control during the experimental period, inhibited the increase in GFR, and improved histopathological abnormalities in tubules. These results suggest that the SDT fatty rat is a useful model for analyzing the pathogenesis of diabetic nephropathy during its early stage and dapagliflozin improves not only hyperglycemia but also glomerular hyperfiltration and tubule lesions in SDT fatty rat.

Metallic ground states of undoped Ti2O3 films induced by elongated c-axis lattice constant

Ti₂O₃ exhibits unique metal–insulator transition (MIT) at ~ 450 K over a wide temperature range of ~ 150 K. The close relationship between MIT and crystal deformation has been proposed. However, as physical properties are governed by the thermodynamic equilibrium in bulk systems, conducting experimental studies under different lattice deformations remains challenging. Epitaxial thin films can offer high flexibility to accommodate adaptive crystal lattices and provide efficient platforms for investigating the MIT. In this study, we report the synthesis of corundum-type Ti₂O₃ films on various growth temperatures. We found that the metallic ground states appeared in the films grown at low temperatures. The electronic ground states were further investigated by the electronic-structure calculations. Results suggest that the electrical properties of Ti₂O₃ films were governed by the c/a ratio of the crystal structure, and the absence of the MIT was attributed to the lattice deformation characterized by an elongated c lattice constant.

Competition for growth substrates in river water between Escherichia coli and indigenous bacteria illustrated by high-resolution mass spectrometry

Escherichia coli normally cannot grow in the environment. One environmental stress that prevents E. coli growth may be the competition for growth substrates with co-existing micro-organisms. In this study, the growth substrates of E. coli were screened by high-resolution mass spectrometry and compared with those of indigenous bacteria in river water. In an incubation experiment, E. coli multiplied in sterilized river water, but did not multiply when indigenous micro-organisms were present in the water. By analysing dissolved organic matter in the river water before and after E. coli growth, 35 compounds were identified as putative growth substrates of E. coli. Among them, 33 compounds were also identified as putative growth substrates of indigenous bacteria. These results indicate that E. coli and indigenous bacteria compete for organic substrates in river water, which could suppress the growth of E. coli.

Diagnostic reliability of quantitative flow ratio for detection of myocardial ischemia compared with other angiographic and experience-dependent visual predicted indices

Background

Quantitative flow ratio (QFR) is an image-based virtual fractional flow reserve (FFR) computed by three dimensional quantitative coronary angiography (3D-QCA) and estimated flow velocity. Several studies have reported that QFR had a good diagnostic performance as compared with wire-based FFR or instantaneous wave-free ratio (iFR).

Purpose

We compared the diagnostic reliability of QFR for detection of myocardial ischemia with other angiographic and visual predicted indices.

Methods

In 301 coronary lesions (263 patients) from our QFR database for previously-reported two studies, the diagnostic reliability of QFR, several angiographic and visual predicted indices were investigated using ROC analysis as reference of FFR≤0.8 or iFR≤0.89. Visual predicted FFR were estimated by 3 physicians (25-year experienced expert, 10-year experienced senior physician and 3-year experienced trainee) blinded to other indices.

Results

Area under the curve (AUC) of each index in ROC analysis is shown in Table.

Conclusion

QFR was reliable index detecting myocardial ischemia compared with other angiographic and experience-dependent visual predicted indices.

Funding Acknowledgement

Type of funding source: None

Prognostic value of hybrid cardiac perfusion SPECT/CT for patients with coronary artery disease after coronary artery bypass grafting

Introduction

Patients with coronary artery disease (CAD) undergoing coronary artery bypass grafting (CABG) occasionally experience recurrent myocardial ischemia. Because of their severe CAD and its complicated hemodynamics, conventional cardiac perfusion SPECT often cannot reveal the severity and prognosis solely. Hybrid cardiac SPECT/CT imaging simultaneously shows myocardial ischemia distribution, coronary artery lesion distribution, and their relationship, and this modality may enable detailed interpretation and risk stratification for such patients.

Aim

This study aimed to assess the prognostic value of hybrid cardiac SPECT/CT for patients with CAD and suspected myocardial ischemia after CABG.

Methods

A total of 201 consecutive patients, registered between April 2016 and September 2018, with suspected recurrent angina pectoris after CABG requiring examinations for myocardial ischemia were included in this study. Among these, 135 patients who underwent cardiac perfusion SPECT, cardiac CT, and hybrid cardiac SPECT/CT imaging were analyzed. In the SPECT-only analysis, SDS was calculated, and the patients were divided into none-to-mild (SDS &lt;4) and moderate-to-severe ischemia (SDS ≥4) groups. In the SPECT/CT analysis, the patients were divided into a matched group (SPECT reversible accumulation defects [SDS ≥2] along coronary arteries with significant lesions) and an unmatched group (accumulation defects not coincided with coronary artery territories or no significant stenoses in the corresponding coronary arteries). All patients were observed from the time of these tests for the occurrence of major adverse cardiac events (MACE), and the prognostic performances of these analyses were compared.

Results

In the SPECT-only analysis, 62 were in the none-to-mild group and 73 were in the moderate-to-severe group. In the SPECT/CT analysis, 61 were in the matched group and 74 were in the unmatched group. Within the follow-up period of 29±8 months, 15 patients experienced MACE. The patients' prognoses were clearly stratified by hybrid SPECT/CT analysis (matched: 13/61, 21.3% vs. unmatched: 2/74, 2.7%) compared with SPECT-only analysis (moderate-to-severe: 11/73, 15.0% vs. none-to-mild: 4/62, 6.5%). The hybrid cardiac SPECT/CT analysis was more strongly associated with the occurrence of MACE compared with SPECT-only analysis (p=0.008 vs. p=0.04, respectively).

Conclusions

Hybrid cardiac SPECT/CT imaging can have higher prognostic value compared with stand-alone cardiac perfusion SPECT for patients with CAD after CABG.

Funding Acknowledgement

Type of funding source: None

Changes in the ear canal microbiota of dogs with otitis externa

AIMS

Otitis externa (OE), one of the most common ear diseases in dogs, is caused by bacterial pathogens such as Staphylococcus sp. To understand the network of microbial communities in the canine ear canal affected with OE, we performed a cross-sectional study using next-generation sequencing.

METHODS AND RESULTS

Ear swab samples were collected from 23 OE-affected and 10 healthy control dogs, and the 16S rRNA gene sequenced using Illumina MiSeq. The otic microbiota in the OE-affected dogs showed significantly decreased alpha diversity compared to controls. The community composition also differed in the affected group, with significantly higher relative abundance of the phylum Firmicutes and the genus Staphylococcus (P = 0·01 and 0·04 respectively). Contrary to our expectations, the severity of the disease did not impact the otic microbiota in OE-affected dogs.

CONCLUSIONS

The ear canal microbiota of OE-affected dogs is distinct from that of healthy dogs, irrespective of disease status.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study, one of the few detailed analyses of the otic microbiota, can provide practical information for the appropriate treatment of canine OE.

Correction to: Effect of Golimumab Dose Escalation in Japanese Patients With Rheumatoid Arthritis: Post-Hoc Analysis of Post-Marketing Surveillance Data

Under Results section, heading: Effectiveness of GLM Stratified by the Time to Dose Escalation, the remission based on values of DAS28, SDAI, and CDAI was published incorrectly. The correct values are: 16.1%, 5.0% and 4.3.

Clinical response among golimumab-treated Japanese patients with rheumatoid arthritis by number of previous biologic therapies: Real-world evidence from post-hoc analysis of post-marketing surveillance data

OBJECTIVES

To assess the real-world effectiveness of golimumab in Japanese patients with rheumatoid arthritis who had previously received one or more biologic therapies.

METHODS

A post-hoc analysis of post-marketing surveillance was performed. The clinical response to golimumab was analyzed in 1216 patients who had previously received one or more biologic agents including non-TNF inhibitors with stratification by the number of previous biologic agents. Logistic regression analyses were conducted to identify factors associated with DAS28-CRP response to golimumab.

RESULTS

While treatment persistence is comparable, the response to golimumab declined with an increasing number of previous biologic therapies. When stratified by golimumab dose, patients receiving golimumab at 100 mg had higher disease activity at baseline with an increasing number of previous bDMARDs, but they still achieved comparable disease activity at 24 weeks regardless of how many bDMARDs had been previously used. Univariate and multivariate analyses both identified concomitant oral corticosteroid therapy as a factor negatively associated with the likelihood of achieving a DAS28-CRP response.

CONCLUSION

Switching to golimumab was effective regardless of how many biologic agents had been previously used, but the response declined with an increasing number of prior biologic agents. A golimumab dose of 100 mg was also effective for those who previously received three or more bDMARDs.

Effectiveness of golimumab in rheumatoid arthritis patients with inadequate response to first-line biologic therapy: Results from a Japanese post-marketing surveillance study

OBJECTIVES

To assess the real-world effectiveness of golimumab in Japanese patients with rheumatoid arthritis who had previously received first-line biologic therapy.

METHODS

A post-hoc analysis of post-marketing surveillance was performed. The effectiveness of golimumab was assessed in 731 patients with an inadequate response to first-line biologic therapy stratified by their prior biologic agents. Outcome variables included DAS28-CRP, DAS28-ESR, SDAI and CDAI, and medication persistence. Logistic regression analyses were conducted to identify factors associated with the likelihood of achieving a DAS28-CRP response (good/moderate) after 24 weeks of golimumab treatment.

RESULTS

Patients demonstrated significant improvement in the clinical signs and symptoms of rheumatoid arthritis at 24 weeks, as indicated by the reduction of DAS28-CRP (Δ0.87), DAS28-ESR (Δ0.85), SDAI (Δ7.32), and CDAI (Δ6.98) scores. This result was consistent across the subgroups stratified by previous biologic therapy. Multivariate analysis failed to identify any factors associated with response to golimumab.

CONCLUSION

In the real-world clinical setting, switching to golimumab was effective for Japanese patients with an inadequate response to first-line biologic therapy regardless of the biologic agent, including both TNF and non-TNF inhibitors.

Preliminary study: Measurement of ion beam energy spreads produced by a Penning ionization gauge-type ion source using electromagnets for a mega-electron volt compact ion microbeam system

The energy spreads of ion beams generated from a penning ionization gauge-type ion source with electromagnets were measured using a parallel electrostatic analyzer. The ion source was developed to be installed in a mega-electron volt (MeV) compact ion microbeam system. A gaseous ion beam of expectedly high brightness and narrow energy spread was generated from the ion source to form a microbeam. To produce such an ion beam, a high-density plasma with a small volume was generated using a strong magnetic field in the ion source. The beam energy spread width was of particular importance because it forms an ion microbeam by reducing the chromatic aberration at a focusing lens. In this report, the energy spread was investigated by changing the parameters of the ion source, e.g., extraction voltage, excitation current of electromagnets, vacuum, and anode voltage. The investigation showed that spread widths are influenced by the extraction voltage, vacuum, and anode voltage. The minimum width of ∼5.0 ± 0.1 eV was obtained at a beam energy of 200 eV. This value is acceptable for the MeV compact ion microbeam system.

Fetal echocardiographic prediction score for perinatal mortality in tricuspid valve dysplasia and Ebstein's anomaly

OBJECTIVES

Tricuspid valve dysplasia (TVD) and Ebstein's anomaly (EA) diagnosed by fetal echocardiography vary greatly in terms of clinical severity and prognosis. The Celermajer index and Simpson-Andrews-Sharland (SAS) score have been reported previously for the prediction of prognosis in cases of TVD/EA; however, they do not take into account the hemodynamic impact of left ventricular (LV) function, which has recently been implicated as being important in the pathophysiology of TVD/EA. The aim of this study was to develop a novel scoring system that includes LV function for the prediction of perinatal death in fetuses diagnosed with TVD/EA.

METHODS

The clinical records of 36 fetuses diagnosed prenatally with TVD/EA between 2000 and 2015 in our hospital were reviewed. Univariate analysis was used to assess the association between perinatal death (defined as death between 22 weeks' gestation and 4 weeks after delivery) and gestational age at diagnosis, cardiothoracic area ratio (CTAR), degree of pulmonary artery flow, direction of ductal flow, right-to-left ventricular diameter ratio, tricuspid regurgitation (TR) maximum velocity, Celermajer index, SAS score and LV-Tei index. A new prognostic score, the TRIPP score (TRIcuspid malformation Prognosis Prediction score), was developed using the parameters found to be associated significantly with perinatal death. The predictive value of this score was assessed in an additional nine fetuses diagnosed with TVD/EA.

RESULTS

Thirty-six fetuses were diagnosed prenatally with TVD/EA, two of which were terminated, one was lost to follow-up and two died before 22 weeks' gestation. Of the 31 included fetuses, 10 (32%) died in the perinatal period. Univariate analysis demonstrated that TR maximum velocity was significantly lower (2.22 ± 0.17 m/s vs 3.26 ± 0.12 m/s; P < 0.001) and SAS score was significantly higher (5.7 ± 0.6 points vs 2.8 ± 0.4 points; P = 0.0014) in cases of perinatal death than in surviving fetuses. The degree of pulmonary artery flow and the direction of ductal flow were also associated significantly with perinatal death (P < 0.01 for both). Notably, LV-Tei index was significantly higher in cases of perinatal death than in surviving fetuses (0.81 ± 0.08 vs 0.50 ± 0.05; P < 0.001). In contrast, there was no significant difference in Celermajer index, CTAR or right-to-left ventricular diameter ratio. Finally, we established a novel combinatorial scoring system, the TRIPP score, including the four significant factors: TR maximum velocity, pulmonary artery flow, direction of ductal flow and LV-Tei index. The TRIPP score was found to predict efficiently perinatal mortality in fetuses with TVD/EA.

CONCLUSIONS

Our novel combinatorial score of echocardiographic parameters, the TRIPP score, including LV-Tei index, is easy to measure and provides a good tool for the prediction of perinatal mortality in fetuses diagnosed prenatally with TVD/EA. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

1181Role of rho-mdia1 signaling to maintain cardiac function in response to pressure overload in mice

Background

Cardiac hypertrophy is a compensatory response to pressure overload that leads to heart failure. Recent studies have shown that Rho signaling has crucial regulatory roles in actin cytoskeleton rearrangement during cardiac hypertrophic responses. Rho is rapidly activated in response to pressure overload, but the mechanisms by which Rho and its downstream proteins control actin dynamics during hypertrophic responses remain unclear.

Objective

To identify the essential roles of mDia1 (Rho-effector molecule) in pressure overload-induced ventricular hypertrophy.

Methods and results

Male wild-type (WT) and mDia1-knockout (mDia1KO) mice (10–12 weeks old) were subjected to transverse aortic constriction (TAC) or a sham operation. The heart weight/tibia length ratio, cardiomyocyte cross-sectional area, left ventricular wall thickness, and expression of hypertrophy-specific genes were significantly decreased in mDia1KO mice 3 weeks after TAC, and the mortality rate was higher at 12 weeks. Echocardiography and the pressure-volume loop indicated that mDia1 deletion increased the severity of heart failure 8 weeks after TAC. Microarray gene expression profiling showed that the induction of immediate early genes due to the TAC operation was significantly lower in mDia1KO mice than WT mice, as was the activation of extracellular signal-regulated kinase (ERK) and focal adhesion kinase (FAK). We examined the role of mDia1 in neonatal rat ventricular cardiomyocytes (NRVMs) exposed to mechanical stress. The siRNA-mediated silencing of mDia1 attenuated stretch-induced ERK and FAK phosphorylation, and gene expression of c-fos. Importantly, loss of mDia1 suppressed an increase in the F/G-actin ratio in response to pressure overload in the mice. In addition, increases in nuclear myocardin-related transcription factors (MRTFs) and serum response factor (SRF) were perturbed in response to pressure overload in mDia1KO mice and to mechanical stretch in mDia1 depleted NRVMs.

Conclusions

Rho-mDia1, through actin dynamics, plays critical roles in pressure overload-induced hypertrophy by regulating ERK and FAK phosphorylation and the transcriptional activity of MRTF-SRF.

4090Maximum standardized uptake value of pericardial fat for prediction of ventricular arrhythmias in patients with cardiac sarcoidosis

Background

Cardiac sarcoidosis is a cause of epicarditis and sustained life-threatening ventricular arrhythmias. These arrhythmias occasionally arise from epicardial. Positron emission tomogramphy-comututed tomography (PET-CT) is useful for diagnosis with sarcoidosis. However, the usefulness for prediction of ventricular arrhythmias in patients with cardiac sarcoidosis is unknown.

Objective

We hypothesized that the evaluation of pericardial fat inflammation could identify high-risk sarcoidosis patients for ventricular arrhythmias.

Methods

We enrolled 20 consecutive patients with cardiac sarcoidosis performed PET-CT between August 2016 and December 2018. In each case, we measured the maximum standardized uptake value (SUVmax) of pericardial fat around the left atrium, both ventricules, atrioventricular groove, and left main coronary.

Results

Seven patients experienced ventricular tachycardia (VT) or ventricular fibrillation (VF). VT/VF patients had significantly more complete right bundle branch block (P=0.035), larger left atrial dimension (P=0.021), larger left ventricular end-diastolic dimension (P=0.005), lower ejection fraction (P=0.007), and higher E/e' (P=0.004). SUVmax of pericardial fat in the roof of left atrium (LA) and left ventricular (LV) with VT/VF patients were significantly higher than non-VT/VF patients (LA: 1.63 vs 1.32, P=0.0311; LV: 1.84 vs 1.26, P=0.045). The cut-off values of SUVmax derived from the ROC curve in the roof of LA and LV are 1.47 and 1.59 respectively. The Kaplan Meire estimator showed that high SUVmax patients in the roof of LA had significantly more detection of NSVT.

Conclusions

Our results suggest the relationship between SUVmax and VT/VF occurrence in patients with cardiac sarcoidosis. The evaluateon of SUVmax may be useful for VT/VF risk stratification.

P1628Angiopoietin-like protein (Angptl) 2 secreted from epicardial adipose tissue induces atrial myocardial fibrosis

Background

Using excised human left atrial appendage samples, we previously demonstrated that epicardial adipose tissue (EAT) are highly associated with atrial myocardial fibrosis as a substrate of atrial fibrillation (AF). We also reported the relationship between Angptl2 in EAT and atrial fibrosis. However, the mechanism is not clear. The purpose is to clarify the mechanisms underlying the effect of EAT on the atrial myocardium.

Methods

Human peri-left atrial EAT and abdominal subcutaneous adipose tissue (SAT) samples were obtained from 6 cases (2 females, 70.2±13.2 years). 50 mg of EAT and SAT were quickly washed with PBS and centrifuged 1min at 1200rpm. After 3 times this procedures, adipose tissues were cultured in DMEM F12 medium with Fetal bovine Serum (FBS) overnight.

After pre-incubation, EAT and SAT tissues were washed and centrifuge d three times and cultured in medium without FBS for 24hours. Finally, we collected oozed medium (conditioned medium) and used for experiments.

Concentrations of Angptl2 in conditioned medium were measured by ELISA.

To study the effects of conditioned medium, we used “organo-culture” system. Isolated atrium from 8week old male Sprague-Dawley rats were placed on the porous membrane with the endothelial face toward the membrane. After that, loading medium (conditioned medium:culture medium = 1:4), culture medium (control), or recombinant Angptl2 were dropped onto the epicardial face of the atrium once a day and incubated for 7 days (37°C, 5% CO2).

Then, histological and immunohistochemical analysis were performed. We also performed quantitative reverse transcription–polymerase chain reaction (RT–PCR) analysis.

Next, we isolated and cultured neonatal rat fibroblast and loaded Angptl2 for 24 hours.After collected these cells, we performed western blotting analysis.

Results

Atria organo-culture incubated for 7 days with conditioned medium showed global fibrosis. At epicardial side, fibrotic area of EAT group was significantly greater compared to that of SAT and control group (P<0.05).

mRNA of Col1a1, col3a1 and TGFβ1 were significantly increased in EAT group compared with the SAT and control group.

And, the concentration of conditioned medium created from EAT was significant higher than that from SAT (P<0.05).

Then, we dropped 500 ng/ml of recombinant Angptl2 onto the rat atria. Fibrotic area of Angptl22 group significantly greater than that of control with increasing number of α-SMA positive cells, and mRNA of col3a1 and TGFβ1 were significantly increased in Angptl2 group compared with control group.

In cultured fibroblasts, α-SMA and p-ERK expression were increased in Angptl2 group measured by western blotting analysis.

Conclusions

Our results demonstrated that EAT rather than SAT induces atrial myocardial fibrosis. There is a possibility that Angptl2 effused from EAT plays a part in atrial fibrosis thought EAT paracrine effect.

Acknowledgement/Funding

ONO PHARMACEUTICAL CO

Histopathological Features of Mycobacterium chelonae Infection in Two Farmed Japanese Pufferfish (Takifugu rubripes)

Granulomatous lesions were observed in the swim bladder, kidney, spleen and gills of two farmed Japanese pufferfish (Takifugu rubripes) infected with Mycobacterium chelonae. Three types of lesions were noted: unencapsulated clusters of epithelioid cells without central necrosis (type 1), encapsulated granulomas without central necrosis (type 2) and encapsulated granulomas with central necrosis (type 3). Type 3 lesions occurred most frequently in the swim bladder, while type 1 and type 2 lesions occurred frequently in the kidney and spleen, and the gills exhibited mostly type 1 lesions. This suggests that the lesions in the swim bladder were more fully developed than those occurring elsewhere and that the swim bladder may be more susceptible to infection with M. chelonae. This is the first report describing the histopathological features of M. chelonae infection in Tetraodontidae.

Equol inhibits growth and spore formation of Clostridioides difficile

AIMS

Equol is a nonsteroidal oestrogen of the isoflavone class. We investigated the antibacterial ability of equol with respect to the growth rate, toxin production and spore-forming abilities of Clostridioides difficile BI/027/NAP1.

METHODS AND RESULTS

Isoflavones, or female hormones, were added to bacterial culture, which was grown at 35°C. The absorbance of the culture was measured at various time points for evaluating the growth inhibition. The toxin levels in the media and morphological changes were also assessed. To evaluate the influence of equol on the sporulation of C. difficile, cells were collected at various time points from the equol-supplemented culture and the number of spores was counted. Our results show that equol inhibits bacterial growth in a concentration-dependent manner. However, it does not inhibit the production of toxin by C. difficile. Other isoflavones and female hormones did not inhibit the C. difficile growth. At the 14th day, approximately 600 spores were present in the control medium and only six were seen in the equol-containing medium.

CONCLUSION

Our results suggest that equol may directly inhibit the C. difficile growth in a concentration-dependent manner and spore formation.

SIGNIFICANCE AND IMPACT OF THE STUDY

This is the first report on the antimicrobial ability of equol.

Release of Plasminogen Activator from Isolated Perfused Dog Heart

The release and the local activity of plasminogen activator (PA) were studied in isolated perfused dog hearts, without or with intimal injury induced by means of a balloon catheter inserted into the left anterior descending coronary artery (LAD). Thrombin but not DFP-thrombin induced a dose-dependent PA release in doses of 8 to 32 units. ADP 20 or 200 μmol but not ergonovine 20 or 200 μg induced a weak PA release. The local PA activity was much lower in the LAD at 1 or 4 weeks after this injury than in the intact LAD. However, the release of PA from the hearts after intimal injury was similar to findings in the intact hearts.

We conclude from this study that thrombin plays an important role in regulating the coagulation-fibrinolysis system in endothelial cells and that changes in the properties of the endothelial cells may lead to initiation and enhancement of atherosclerosis.

Immunohistochemical and Histochemical Investigations on In Vivo Thrombolysis with Urokinase in Rabbits

Using human urokinase in vivo thrombolysis was studied in autologous artificial thrombi in the pulmonary circulation of rabbits by immunofluorescence and Todd’s fibrinolysis autography techniques.

As compared to the control thrombi of the untreated rabbits, a small increase of thrombolysis was found in the rabbits treated with urokinase.

Urokinase fluorescence was observed in the leukocytes, but not along the fibrin fibrils in the thrombi of the rabbits treated with urokinase. By Todd’s fibrinolysis autography, lytic areas were observed around aggregated leukocytes in the thrombi of the rabbits treated with urokinase.

The small lysis of autologous artificial thrombi of rabbits by human urokinase may be caused by (1) low affinity of human urokinase for rabbit plasminogen, (2) weak adsorption of human urokinase to rabbit fibrin, (3) phagocytosis of human urokinase by leukocytes and (4) high level of antifibrinolytic activity of rabbit plasma.

Pressure-induced stacking disorder in boehmite

The structure of an aluminum layered hydroxide, boehmite (γ-AlOOH), as a function of pressure was studied by using in situ synchrotron X-ray and neutron diffraction. Peak broadening, which is only found for hkl (h ≠ 0) peaks in the X-ray diffraction patterns, is explained by stacking disorder accompanying a continuously increasing displacement of the AlO6 octahedral layer along the a-axis. This finding could be the first experimental result for pressure-induced stacking disorder driven by continuous layer displacement. The magnitude of the layer displacement was estimated from the X-ray scattering profile calculation based on the stacking disordered structure model. Hydrogen bond geometries of boehmite, obtained by structure refinements of the observed neutron diffraction patterns for the deuterated sample up to 10 GPa, show linearly approaching O-D covalent and DO hydrogen bond distances and they merge below 26 GPa. Pressure-induced stacking disorder makes the electrostatic potential of hydrogen bonds asymmetric, yielding less chance for proton-tunnelling.

Pathophysiological characteristics of non-alcoholic steatohepatitis-like changes in cholesterol-loaded type 2 diabetic rats

Spontaneously Diabetic Torii (SDT) fatty rats, a new obese diabetic model, reportedly presented with features of non-alcoholic steatohepatitis (NASH) after 32 weeks of age. We tried to accelerate the onset of NASH in SDT fatty rats using dietary cholesterol loading and noticed changes in the blood choline level which is expected to be a NASH biomarker. Body weight and biochemical parameters were measured from 8 to 24 weeks of age. At 16, 20, 24 weeks, pathophysiological analysis of the livers were performed. Hepatic lipids, lipid peroxides, and the expression of mRNA related to triglyceride (TG) synthesis, inflammation, and fibrosis were evaluated at 24 weeks. Hepatic fibrosis was observed in SDT fatty rats fed cholesterol-enriched diets (SDT fatty-Cho) from 16 weeks. Furthermore, hepatic lipids and lipid peroxide were significantly higher in SDT fatty-Cho than SDT fatty rats fed normal diets at 24 weeks. Hepatic mRNA expression related to TG secretion decreased in SDT fatty-Cho, and the mRNA expression related to inflammation and fibrosis increased in SDT fatty-Cho at 24 weeks. Furthermore, SDT fatty-Cho presented with increased plasma choline, similar to human NASH. There were no significant changes in the effects of feeding a cholesterol-enriched diet in Sprague-Dawley rats. SDT fatty-Cho has the potential to become a valuable animal model for NASH associated with type 2 diabetes and obesity.

Medial and lateral laxity in knees with advanced medial osteoarthritis

OBJECTIVE

An increase in coronal laxity is recognized as a risk factor for progression of knee osteoarthritis (OA). The purpose of this study was to evaluate coronal laxity, which was defined as the angular motion from the neutral, unloaded (baseline) position to the loaded position, in patients with advanced medial knee OA.

METHOD

Preoperative coronal laxity was assessed using radiographs in patients with medial knee OA undergoing total knee arthroplasty by applying a force of 150 N with an arthrometer. A consecutive series of 211 knees with OA and 40 normal control knees were examined. A knee with OA was defined as clinically "balanced" when the difference between medial and lateral laxity was 3° or less. Values are expressed as median [25^th, 75^th percentile].

RESULTS

The laxity was 4° [3, 5] from the baseline on the medial side and 3° [2, 4] on the lateral side. The distribution of medial and lateral laxity indicated that 90% (189/211) of patients fell within 3°. The equivalence test showed that the medial and lateral laxity was similar, with an equivalence margin of 3° (P < 0.001). In the control knees, the laxity was 3° [2, 4] from the baseline on the medial side and 2° [2, 4] on the lateral side. The differences between the knees with advanced OA and the controls were significant (P = 0.005, medial; P = 0.006, lateral).

CONCLUSION

This study showed that a clinically balanced knee was maintained even in patients with advanced medial knee OA.

Safety, Effectiveness, and Treatment Persistence of Golimumab in Elderly Patients with Rheumatoid Arthritis in Real-World Clinical Practice in Japan

INTRODUCTION

Golimumab has been proven as an effective treatment for rheumatoid arthritis in clinical trials. However, there is a scarcity of data regarding its use in elderly patients in a real-world setting. This study aims to evaluate the safety, effectiveness, and treatment persistence of golimumab in elderly Japanese patients (≥ 75 years) with rheumatoid arthritis.

METHODS

This study was a post hoc analysis of post-marketing surveillance data on 5137 Japanese patients with active rheumatoid arthritis who received golimumab for 24 weeks. The study population was divided into two age groups (younger: < 75 years and elderly: ≥ 75 years), and the safety, effectiveness, and treatment persistence of golimumab were assessed. Also, the reasons for discontinuing golimumab treatment were analyzed by multi-logistic regression.

RESULTS

During golimumab treatment over 24 weeks, younger and elderly groups exhibited comparable improvement of disease activity as measured by EULAR response criteria with similar overall rates of adverse events. However, the survival curve of golimumab for elderly patients was significantly different from that for younger patients due largely to the discontinuation at 4 weeks. The most common reason for discontinuation in elderly patients was patient choice, while it was disease progression in younger patients. Analysis of elderly patients who discontinued treatment by their own decision identified EULAR good response as a factor associated with continuation of golimumab treatment whereas no predictive factor associated with discontinuation was identified.

CONCLUSIONS

The safety and effectiveness of golimumab treatment in elderly Japanese patients aged 75 years or older were comparable to those in younger patients in real-world clinical practice. Analysis of the survival curves suggested that continuous use of golimumab might further improve clinical benefit of golimumab in elderly patients, underpinning the importance of effective communication between physicians and elderly patients based on the treat-to-target strategy.

FUNDING

Janssen Pharmaceutical K.K. and Mitsubishi Tanabe Pharma Corporation.

Real-World Treatment Patterns for Golimumab and Concomitant Medications in Japanese Rheumatoid Arthritis Patients

INTRODUCTION

The aim of this study was to investigate real-world treatment patterns for use of golimumab and concomitant medications in Japanese patients with rheumatoid arthritis.

METHODS

This study was a post hoc retrospective analysis from post-marketing surveillance data on 2350 Japanese patients with moderate/severe rheumatoid arthritis who received golimumab for 24 weeks. The study population was divided based on initiation treatment or dose adjustment patterns with golimumab, methotrexate, or oral glucocorticoids.

RESULTS

Logistic regression analysis revealed that the baseline factors associated with administration of golimumab (100 mg) were higher body weight, failure of prior biological therapy (bio-failure), no previous methotrexate use, and respiratory disease, while previous methotrexate use and absence of renal impairment or respiratory disease were associated with concomitant methotrexate therapy, and previous glucocorticoid use was associated with concomitant glucocorticoid therapy. The following associations were identified with regard to dose adjustment during treatment: bio-failure, no previous methotrexate use, previous csDMARDs use, presence of respiratory disease, allergy history, and higher CRP for golimumab dose escalation; shorter disease duration, previous GC, and no previous methotrexate use for methotrexate dose escalation; no prior biological therapy and renal impairment for methotrexate dose reduction; no previous GC use for glucocorticoid dose escalation; and absence of Steinbrocker's stage II/III/IV, absence of Steinbrocker's class II, no bio-failure, and no previous csDMARDs use for glucocorticoid dose reduction.

CONCLUSIONS

This study revealed that various baseline factors were associated with initiation of treatment and dose adjustment of golimumab, methotrexate, or oral glucocorticoids, reflecting both the treatment strategies of physicians for improving RA symptoms and/or reducing adverse events.

FUNDING

Janssen Pharmaceutical K.K. and Mitsubishi Tanabe Pharma Corporation.

Intermetallic: A Pseudoelement for Catalysis

A clear correlation between electronic structure and CO₂ selectivity for steam reforming of methanol (SRM) was obtained with PdZn, PtZn, NiZn, and PdCd intermetallics on the basis of experiments and calculations. In order to rule out the effects of oxide supports, the intermetallic powders were simply prepared by alloying in an arc furnace followed by crushing in a mortar. PdZn and PdCd exhibit valence electronic densities of states similar to that of Cu and significant chemical shifts (larger than 1 eV) of Pd 3d states with respect to pure Pd, as verified by high-resolution hard X-ray photoelectron spectroscopy (HXPS) measurements and density functional theory (DFT) calculations. Consequently, they show the similar high selectivity of CO₂ for the SRM reaction. However, this is not the case for PtZn and NiZn because of the slight differences in their valence electronic structures from that of PdZn. The interval between the Fermi level and the top of the d band is closely related to the selectivity of CO₂ for the SRM: the larger the interval is, the higher is the selectivity of CO₂. According to DFT calculations for bulk PdZn performed by Chen et al. ( Phys. Rev. B 2003 , 68 , 075417 ), the (111) and (100) surfaces exposing Zn and Pd in an equimolar ratio are more stable than the (001) or (110) surfaces terminated by alternative Zn or Pd layers. First-principles slab calculations for PdZn, PtZn, and NiZn show that bond breaking on the surface leads to a reduction in the d bandwidth but that the d band for stable (111) or (100) surfaces remains essentially unchanged from that of the bulk. It is intriguing that PdZn and PdCd do not contain Cu but show similar valence electronic structure and catalytic selectivity, and hence, a concept is proposed where PdZn and PdCd are regarded as pseudoelements of Cu. The basis of this concept is like electronic structure, like catalysis, which has been demonstrated by experiments and calculations. This is a logical way to enable us to look for new catalysts in which precious metals are partially or completely replaced by base metals. We do not expect that this concept can be applied to all catalytic reactions, but this approach is one of most promising ways to derive a better understanding of the origin of catalytic mechanisms and eventually allow us to design useful catalysts intentionally in the future. This Account reviews the authors' published works on this topic.

Clinical efficacy, radiographic, and safety results of golimumab monotherapy in Japanese patients with active rheumatoid arthritis despite prior therapy with disease-modifying antirheumatic drugs: Final results of the GO-MONO trial through week 120

OBJECTIVE

Evaluate the safety and efficacy of golimumab through week 120 in Japanese patients with active rheumatoid arthritis (RA) previously treated with DMARDs.

METHODS

Japanese patients with active RA despite prior DMARDs were randomized to placebo (Group 1, n = 105), golimumab 50 mg (Group 2, n = 101), or golimumab 100 mg (Group 3, n = 102). At week 16, Group 1 patients crossed over to golimumab 50mg; after week 52, a one-time golimumab dose reduction from 100 to 50 mg was permitted. Assessments included ACR20/50/70 responses and good/moderate DAS28-ESR responses. Radiographic progression was assessed with the van der Heijde-modified Sharp (vdH-S) score. Safety and efficacy were assessed through week 120.

RESULTS

ACR20 response rates at week 52 in Group 1, Group 2, and Group 3 were 70.6%, 71.4%, and 81.9%, respectively, and maintained through week 104 (87.2%, 85.1%, 88.9%, respectively) and week 120 (86.1%, 87.0%, 89.5%, respectively). Similar trends were observed for ACR50, ACR 70, and DAS28-ESR. Median change in total vdH-S at weeks 52, 104, and 120 ranged from 0.0 to 1.5 across treatment groups. Through week 120, 93.8%/97.1% had an AE with golimumab 50 mg/100 mg, respectively, and 19.7%/11.8% had an SAE. Infections were the most common AE.

CONCLUSION

Clinical response to golimumab 50 mg and 100 mg was maintained over 2 years in Japanese patients with active RA despite prior DMARDs.

Pathophysiological analysis of the progression of hepatic lesions in STAM mice

Nonalcoholic steatohepatitis (NASH) is a current health issue since the disease often leads to hepatocellular carcinoma; however, the pathogenesis of the disease has still not been fully elucidated. In this study, we investigated the pathophysiological changes observed in hepatic lesions in STAM mice, a novel NASH model. STAM mice, high fat-diet (HFD) fed mice, and streptozotocin (STZ) treated mice were prepared, and changes over time, such as biological parameters, mRNA expression, and histopathological findings, were evaluated once animal reached 5, 7, and 10 weeks of age. STZ mice presented with hyperglycemia and an increase in oxidative stress in immunohistochemical analyses of Hexanoyl-lysine: HEL from 5 weeks, with fibrosis in the liver also being observed from 5 weeks. HFD mice presented with hyperinsulinemia from 7 weeks and the slight hepatosteatosis was observed at 5 weeks, with changes significantly increasing until 10 weeks. STAM mice at 10 weeks showed significant hepatic changes, including hepatosteatosis, hypertrophic hepatocytes, and fibrosis, indicating pathological changes associated with NASH. These results suggested that the increase in oxidative stress with hyperglycemia triggered hepatic lesions in STAM mice, and insulin resistance promoted lesion formation with hepatic lipid accumulation. STAM mice may be a useful model for elucidating the pathogenesis of NASH with diabetes.