The Incidence of Severe Radiation-Induced Lymphopenia during Chemoradiotherapy for Stage Ⅲ Non-Small Cell Lung Cancer: A Comparative Study of Proton Versus Photon-Based Radiotherapy

PURPOSE/OBJECTIVE(S)

To investigate the incidence of severe radiation-induced lymphopenia (SRL) and the survival in patients with stage Ⅲ non-small cell lung cancer treated with concurrent chemoradiotherapy with passive scattering proton beam (PSPT) or photon-based radiotherapy (XRT) including 3D-CRT and IMRT.

MATERIALS/METHODS

We conducted a retrospective cohort study including 355 patients who received definitive concurrent chemoradiotherapy with PSPT (n = 38) or XRT (n = 317) at our institution between January 2010 and December 2020. SRL during concurrent chemoradiotherapy was defined as absolute lymphocyte counts (ALCs) of <500 cells/mm3. Propensity score matching (PSM) analysis was performed to adjust for the patient characteristics between the PSPT and XRT groups. Propensity scores were calculated using age, sex, PS (0-1 vs. 2), primary tumor location (upper/middle vs. lower lobe), pathology (Adeno vs. Others), PTV volume, ALCs at pretreatment, year of treatment (before vs. after July 2018, when durvalumab approved in Japan), and platinum-based chemotherapy regimen (CDDP based vs. CBDCA based). After PSM, the incidence of SRL and the overall survival (OS) were analyzed.

RESULTS

The GTV and PTV volumes were significantly lower in the PSPT group than in the XRT group (median, 57 vs. 103 mm3; p < 0.05, 322 vs. 399 mm3; p < 0.05, respectively). ALCs at pretreatment were significantly lower in the PSPT group than in the XRT group (median, 1531 vs. 1718 cells/mm3; p < 0.05). SRL was observed in 275 patients (87%) in the XRT group and 27 patients (71%) in the PSPT group (p < 0.05). After PSM, PSPT significantly reduced the incidence of SRL compared to XRT (68.6 % vs. 88.6 %, p < 0.05), and the patients without SRL may have better 3-year OS than those with SRL (71.1 % vs. 55.3 %; p = 0.062).

CONCLUSION

Compared with XRT, PSPT significantly reduced the incidence of SRL, and the patients without SRL had a good prognosis.

O-130 The influence of vaginal microbiota on frozen blastocyst implantation after transfer: a prospective study through next-generation 16S rRNA sequencing

Study question

A prospective study to investigate the relationship between the composition of vaginal microbiota through next-generation sequencing and the efficacy of single frozen blastocyst transfer in the same cycle.

Summary answer

Dominant presence of lactobacillus and other lactate producing microbes in the upper vagina was highly correlated with implantation of transferred blastocyst in this pilot study.

What is known already

Next-generation sequencing of 16S rRNA detected microbes in the uterine cavity and recent studies indicated that dominant presence of Lactobacillus correlated highly with successful implantation of the transferred embryos. Aberrant vaginal microbiota has been known to cause poor obstetrical outcomes, however little is known for its effect on embryo implantation in assisted reproduction.

Study design, size, duration

A prospective study with 25 female subjects transferring a frozen blastocyst using autologous oocyte, over 14 months period in 2019-2020.

Participants/materials, setting, methods

25 female patients without tubal and uterine pathology and no history of multiple miscarriages and implantation failures were recruited with consent at a private ART clinic. Transdermal estrogen was used to prepare endometrium. Upper vaginal fluid was obtained in follicular phase of the the same cycle and analyzed through next-generation sequencing, but the result was reported after pregnancy confirmation. Single frozen blastocyst transfer and standard luteal phase support were performed. Institutional IRB approved the protocol.

Main results and the role of chance

The mean age was 36.2 y.o.(range 29-41 y.o.), and 14 gestational sacs (implantation rate 56%), and 3 miscarriage (21.4%) were observed. Next-generation sequencing for 16S rRNA revealed average 69.2% presence of Lactobacillus (0-100%) and average 78.0% (0.2-100%) lactate producing microbes (LPM: Lactobacillus, Bifidobacterium, Streptococcus, and Enterococcus) in the vaginal fluid. Using 90% as cut-off, implantation rates were 11/15 (73.3%) and 3/10 (30%) with Lactobacillus dominant and non-dominant, 12/16 (75%) and 2/9 (22.2%) with LPM dominant and non-dominant microbiota, respectively. The difference in each group were not statistically significant. The relative risks for pregnancy were 2.63 (95%CI 1.03-6.67, P=0.04) for Lactobacillus and 3.11 (95%CI 1.24-7.79, P=0.02) for LPM. As for ROC analysis for embryo implantation and dominant microbes, AUC and associated criterion were 0.62 and 90.7% (sensitivity 78.6%, specificity 72.7%) for Lactobacillus, 0.69 and 96.6% (sensitivity 85.7%, specificity 72.7%) for LPM, respectively. The difference of AUC was not significant (P=0.24).

Limitations, reasons for caution

Despite prospective nature of the study, small sample size limited the analytical power of the study. Aneuploidy screening was not performed to remove confounding factor.

Wider implications of the findings

Our pilot study revealed possible relationship between vaginal microbiota and embryo implantation. Dominance of Lactobacillus or other lactate producing microbes may be advantageous for successful ART. Sampling vaginal fluid for microbe analysis is less invasive than endometrial sampling and can obtain more abundant RNA with possible higher accuracy of analysis.

Trial registration number

not applicable

Effect of climatic elements on Campylobacter colonization in broiler flocks reared in southern Japan from 2008 to 2012

To demonstrate the effect of climatic elements on Campylobacter colonization in broiler chickens reared in Japan, the correlation between Campylobacter isolated from chickens (191 of 236 flocks, 80.9%) between 2008 and 2012 and climatic elements was analyzed by logistic regression. We divided the rearing process into 13 terms of 5 d each (total: 65 d). Terms were numbered backwards, wherein a 0-term lag was considered as the sampling day plus 4 d before sampling; 1-term lag was the 5-d term before the 0-term lag, and so on, until the 12-term lag. We obtained climatic data tracing back from the 0-term to the 12-term lags. For evaluation in each season, we divided chickens reared during periods of rising temperature (spring, summer) and decreasing temperature (autumn, winter). Air temperature showed a positive correlation with Campylobacter colonization from the 0- to 12-term lags in chickens reared during the period of rising temperature (odds ratio [OR], 1.069 to 1.104), and from the 0- to 4- and 6-term lags (OR, 1.079 to 1.105) in chickens reared during the period of decreasing temperature. The strong positive effect of air temperature on Campylobacter colonization, particularly during the period of rising temperature, may be associated with the effect on the Campylobacter environmental sources and/or vectors. A positive correlation was observed between Campylobacter colonization and humidity when chicken houses were empty and new chicks were introduced (from the 9- to 12-term lags) during the period of decreasing temperature (OR, 1.076 to 1.141). Thus, high humidity would be an important factor causing carry-over of Campylobacter infection during the period of decreasing temperature. We also found that solar radiation increased Campylobacter colonization during the period of decreasing temperature, from the 2- to 8-term lags, except for the 4- and 5-term lags, in Japan. The results of this study demonstrate the effects of air temperature, humidity, and solar radiation on Campylobacter colonization in broiler chickens, and are potentially important for developing strategies to reduce the risk of Campylobacter contamination in broiler chickens.

Low-dose gonadotropin-releasing hormone agonist therapy (draw-back therapy) for successful long-term management of adenomyosis associated with cerebral venous and sinus thrombosis from low-dose oral contraceptive use

The authors report a case of cerebral venous and sinus thrombosis (CVST) in a patient receiving a low-dose estrogen-progestin combination (oral contraceptives, OCs) for uterine adenomyosis. She was switched to gonadotropin-releasing hormone agonist (GnRHa) draw-back therapy, which was successfully administered long-term.

CASE

The patient was a 38-year-old nulligravida with a history of smoking. She presented to this hospital with dysmenorrhea and postmenstrual lower abdominal pain. Adenomyosis was diagnosed using ultrasound and magnetic resonance imaging. She was instructed to stop smoking and was administered low-dose OCs. CVST occurred 18 months later. OC therapy was halted, and only antiplatelet therapy was administered. After six months, her chief complaint symptoms intensified, therefore GnRHa draw-back therapy was administered after obtaining informed consent. No uterine enlargement was observed, and the abdominal pain resolved. During 2.5 years of therapy, her bone density levels remained within normal limits. CVST did not recur and no other thromboses were observed.

Use of cytokeratin 18 and EAU score to predict tumor recurrence in patients with non-muscle-invasive bladder cancer following single postoperative immediate intravesical chemotherapy instillation

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Background: We examined the prognostic factors for recurrence after TURBT using molecular markers as well as the scoring system of the EAU.

Methods: Eighty-eight patients with primary or recurrent bladder tumors who underwent TURBT followed by the single postoperative immediate instillation of pirarubicin and no further instillations were enrolled between 2003 and 2006; the median follow-up period was 46 months. The time to first recurrence was the primary end point of this study. Patients were divided into EAU recurrence risk groups as follows: low-risk group (total score, 0), intermediate-risk group (total score, 1-9) and high-risk group (total score, 9-17). The intermediate-risk group patients were subdivided into a total score of 1-4 and a total score of 5-9. Immunostaining using Ki-67, pHH3, CK18 and Survivin were performed on the TURBT specimens.

Results: According to the risk stratification, 5, 82, and 1 were assigned to the low-, intermediate-, and high-risk recurrence groups, respectively. During the follow-up, recurrences were observed in 0% of the low-risk group, 45% (37 out of 82) in the intermediate-risk group and 100% in the high-risk group. We evaluated various predictors of a recurrence-free outcome among the 82 intermediate-risk patients. In univariate analyses, EAU score (1-4, 32.1% vs 5-9, 62.1%; p = 0.0011), high CK18 expression (negative, 31.4% vs positive 88.8%; p < 0.0001), high Ki-67 index (< 5%, 35.4% vs > 5%, 52.5%; p = 0.017) and high Survivin nuclear staining (< 5%, 35.9% vs > 5%, 62.5%; p = 0.004) were associated with recurrence. In a multivariate analysis, EAU score (HR 2.95, p = 0.003) and a high CK18 immunostaining (HR 6.70, p < 0.0001) were independent predictors of disease recurrence.

Conclusions: A single immediate chemotherapy instillation is, by itself, insufficient for the treatment of patients in the intermediate- or high-risk recurrence groups defined by the EAU guidelines. Strong immunohistochemical expression of CK18 and the EAU scoring system appeared to be independent predictors of clinical outcome among patients with urothelial carcinoma of the bladder.

No significant financial relationships to disclose.

Gypsum and organic matter distribution in a mixed construction and demolition waste sorting process and their possible removal from outputs

With insufficient source separation, construction and demolition (C&D) waste becomes a mixed material that is difficult to recycle. Treatment of mixed C&D waste generates residue that contains gypsum and organic matter and poses a risk of H(2)S formation in landfills. Therefore, removing gypsum and organic matter from the residue is vital. This study investigated the distribution of gypsum and organic matter in a sorting process. Heavy liquid separation was used to determine the density ranges in which gypsum and organic matter were most concentrated. The fine residue that was separated before shredding accounted for 27.9% of the waste mass and contained the greatest quantity of gypsum; therefore, most of the gypsum (52.4%) was distributed in this fraction. When this fine fraction was subjected to heavy liquid separation, 93% of the gypsum was concentrated in the density range of 1.59-2.28, which contained 24% of the total waste mass. Therefore, removing this density range after segregating fine particles should reduce the amount of gypsum sent to landfills. Organic matter tends to float as density increases; nevertheless, separation at 1.0 density could be more efficient.

Antimicrobial resistance of Campylobacter: prevalence and trends in Japan

Campylobacter is one of the most frequently diagnosed bacterial causes of human gastroenteritis in Japan and throughout the world. Resistance to quinolones in Campylobacter jejuni and C. coli isolated from humans has emerged in many countries during the past 15 years because fluoroquinolones are the drug of choice for the treatment of suspected bacterial gastroenteritis. Food contaminated with Campylobacter is the usual source of human infection; therefore, the presence of antimicrobial resistance strains in the food chain has raised concerns that the treatment of human infections will be compromised. The use of antimicrobial agents for food animals and in veterinary medicine is suspected to be correlated with an increase in quinolone-resistant strains of Campylobacter in food animals, especially in poultry products. In contrast to macrolide resistance in C. jejuni and C. coli isolated from humans showing a stable low rate, resistant Campylobacter spp. to quinolones have emerged in Japan. The paper summarizes food-borne Campylobacter infection in Japan, and the prevalence and trends of antimicrobial resistance of Campylobacter from the authors' data and other Japanese papers which reported the antimicrobial resistance of Campylobacter.

Immature platelet fraction for prediction of platelet engraftment after allogeneic stem cell transplantation

Platelet regeneration represents an important and separate element in the engraftment process for allogeneic stem cell transplantation. Fully automated flow cytometry using blood cell counters now allows reliable quantification of reticulated platelets, expressed as the immature platelet fraction (IPF). We studied the kinetics of IPF in six patients grafted with allogeneic peripheral blood stem cell transplantation (PBSCT), 12 patients with bone marrow transplantation (BMT) and seven patients with cord blood transplantation (CBT). Preconditioning therapy caused an immediate and rapid fall in tri-lineage hematopoiesis. IPF rose transiently above 3% after a mean duration of 11 days post-PBSCT, 18 days post-BMT and 19 days post-CBT. This was 1, 4 and 13 days earlier than platelet engraftment, respectively. A linear correlation model showed a close association between the rise of IPF and tri-lineage engraftment after transplantation. IPF counting may thus provide an accessible measure of thrombopoietic activity, leading to early evaluation of marrow function and allowing monitoring of platelet regeneration.

Efficacy and safety of recombinant human soluble thrombomodulin (ART-123) in disseminated intravascular coagulation: results of a phase III, randomized, double-blind clinical trial

BACKGROUND

Soluble thrombomodulin is a promising therapeutic natural anticoagulant that is comparable to antithrombin, tissue factor pathway inhibitor and activated protein C.

OBJECTIVES

We conducted a multicenter, double-blind, randomized, parallel-group trial to compare the efficacy and safety of recombinant human soluble thrombomodulin (ART-123) to those of low-dose heparin for the treatment of disseminated intravascular coagulation (DIC) associated with hematologic malignancy or infection.

METHODS

DIC patients (n = 234) were assigned to receive ART-123 (0.06 mg kg(-1) for 30 min, once daily) or heparin sodium (8 U kg(-1) h(-1) for 24 h) for 6 days, using a double-dummy method. The primary efficacy endpoint was DIC resolution rate. The secondary endpoints included clinical course of bleeding symptoms and mortality rate at 28 days.

RESULTS

DIC was resolved in 66.1% of the ART-123 group, as compared with 49.9% of the heparin group [difference 16.2%; 95% confidence interval (CI) 3.3-29.1]. Patients in the ART-123 group also showed more marked improvement in clinical course of bleeding symptoms (P = 0.0271). The incidence of bleeding-related adverse events up to 7 days after the start of infusion was lower in the ART-123 group than in the heparin group (43.1% vs. 56.5%, P = 0.0487).

CONCLUSIONS

When compared with heparin therapy, ART-123 therapy more significantly improves DIC and alleviates bleeding symptoms in DIC patients.

Safety and Efficacy of Foscarnet for Preemptive Therapy Against Cytomegalovirus Reactivation After Unrelated Cord Blood Transplantation

In association with the increased use of unrelated cord blood transplantation (UCBT) in adults, numerous patients have developed cytomegalovirus (CMV) reactivation concomitant with cytopenia. Although foscarnet appears to offer similar efficacy and higher safety as a preemptive therapy against CMV infection than ganciclovir, little is known about the usefulness of foscarnet in such patients. Foscarnet was administered as preemptive therapy against CMV antigenemia in 10 UCBT recipients who were unable to receive ganciclovir due to cytopenia or poor response to ganciclovir. Fatal CMV disease developed in one patient, whereas CMV antigenemia resolved without progression to CMV disease in the remaining nine patients. Foscarnet was well tolerated without serious hematotoxicity and was not discontinued due to adverse events in any patient. Foscarnet represents a safe and effective agent for preemptive therapy against CMV infection and may offer a feasible alternative to ganciclovir in UCBT recipients.

Reduced-intensity unrelated cord blood transplantation for treatment of metastatic renal cell carcinoma: first evidence of cord-blood-versus-solid-tumor effect

We report a 69-year-old man with cytokine-resistant metastatic renal cell carcinoma treated with reduced-intensity unrelated cord blood transplantation. The patient achieved durable donor engraftment with minimal graft-versus-host disease. The patient showed regression of metastatic disease, providing the first evidence of a graft-versus-tumor effect on a solid tumor resulting from cord blood graft.

Resuscitation of the viable but non-culturable state of Salmonella enterica serovar Oranienburg by recombinant resuscitation-promoting factor derived from Salmonella Typhimurium strain LT2

A gene encoding the resuscitation-promoting factor (Rpf) from Salmonella Typhimurium LT2 was cloned and characterized. The amino acid sequence encoded by S. Typhimurium LT2 rpf gene shares 24.2% homology with Micrococcus luteus Rpf, which is secreted by growing cells, and required to resuscitate from viable but non-culturable (VNC) state. The S. Typhimurium LT2 rpf gene is 696 bp long, and shared a conserved segment with Salmonella enterica serovar Oranienburg (99.4%). Recombinant Rpf (rRpf) proteins of S. Typhimurium LT2 after expression in E. coli BL21 harboring the pET15-b plasmid was approximately 25 kDa. Since S. Oranienburg cells are relatively quick to enter the VNC state just after incubating in the presence of 7% NaCl at 37 degrees C for 3 days, we evaluated the biological effect of rRpf by using S. Oranienburg VNC cells. The rRpf not only promoted proliferation but also induced resuscitation of VNC cells to the culturable state in a dose-dependent manner. Therefore, rRpf may be useful for detection of bacterial contaminants present in the VNC form in food samples and the environment.

Selective inducible nitric oxide synthase inhibition attenuates organ dysfunction and elevated endothelin levels in LPS-induced DIC model rats

We examined the role of nitric oxide (NO) produced by an inducible isoform of NO synthase (iNOS) using N[6]-(iminoethyl)-lysine (L-NIL), a selective iNOS inhibitor, in the rat model of lipopolysaccharide (LPS)-induced disseminated intravascular coagulation (DIC) and investigated changes in organ function, plasma levels of NOX (metabolites of NO) and endothelin. We induced experimental DIC by the sustained infusion of 30 mg kg(-1) LPS for 4 h via the tail vein. We then investigated the effect of L-NIL (6 mg kg(-1), from - 0.5 to 4 h) on LPS-induced DIC. Blood was withdrawn at 4 and 8 h, and all four groups (LPS with or without L-NIL at 4 and 8 h) consisted of eight rats. Three of the animals in the 8-h LPS group died, and we examined blood samples from five rats in this group. None of the other rats died. The LPS-induced elevation of creatinine, alanine aminotransferase, glomerular fibrin deposition and plasminogen activator inhibitor was significantly suppressed by L-NIL coadministration, although L-NIL did not affect the platelet count, fibrinogen concentration or the level of thrombin-antithrombin complex. Moreover, plasma levels of the D-dimer that reflect the lysis of cross-linked fibrin were significantly increased by L-NIL coadministration in the LPS-induced DIC model. Plasma levels of NOX and endothelin were obviously increased by LPS infusion. However, both levels were significantly suppressed in the LPS + L-NIL group, when compared with the LPS group. Although mean arterial pressure (MAP) was significantly decreased between 2 and 8 h compared with the control in the LPS group, this depression was significantly attenuated in the LPS + L-NIL group. Our results suggest that NO induced by iNOS contributes to hypotension (depressed MAP), the progression of hepatic and renal dysfunction, microthrombus deposition and elevated endothelin levels in the rat model of LPS-induced DIC.