Fourth national Japanese antimicrobial susceptibility pattern surveillance program: Bacterial isolates from patients with complicated urinary tract infections

INTRODUCTION

Antimicrobial susceptibility patterns of bacterial pathogens isolated from patients with complicated urinary tract infections were analyzed using the national surveillance data, comprising 793 bacterial strains from eight clinically relevant species.

MATERIALS AND METHODS

Data were collected for the fourth national surveillance project from July 2020 to December 2021 by the Japanese Society of Chemotherapy, the Japanese Association for Infectious Disease, and the Japanese Society of Clinical Microbiology. Surveillance was supervised with the cooperation of 43 medical institutions throughout Japan.

RESULTS

Fluoroquinolone required a minimum inhibitory concentration (MIC) of 2-64 mg/L to inhibit the 330 tested Escherichia coli strains. The proportion of levofloxacin-resistant E. coli strains increased from 28.6% in 2008 to 29.6% in 2011, 38.5% in 2015, and 44.5% in 2021. The proportion of levofloxacin-resistant strains of Pseudomonas aeruginosa also increased from previous survey results, showing a continuing downward trend. Conversely, the proportion of levofloxacin-resistant strains of Enterococcus faecalis decreased relative to previous reports. Neither multidrug-resistant P. aeruginosa nor carbapenem-resistant Enterobacteriaceae were detected. For methicillin-resistant Staphylococcus aureus (MRSA), the proportion of vancomycin-susceptible strains (MIC of 2 μg/mL) decreased from 14.7% to 7.7%.

DISCUSSION

Bacterial strains that produced extended-spectrum β-lactamase included E. coli (82/330 strains, 24.8%), Klebsiella pneumoniae (11/68 strains, 16.2%), and Proteus mirabilis (4/26 strains, 15.4%). As compared to previous surveillance reports, these strains showed an increase in proportion over the years.

A case of Legionella pneumonia after robot-assisted radical prostatectomy

Introduction

Postoperative Legionella pneumonia is very rare.

Case presentation

A 71-year-old male patient with prostate cancer (cT2bN0M0) underwent a robotic-assisted radical prostatectomy. On the 5th postoperative day, the patient developed chills and a fever of 39.2°C. Chest radiography revealed decreased permeability in the right middle lung field, leading to the diagnosis of postoperative pneumonia. Antimicrobial therapy was initiated immediately. Blood tests on postoperative day 10 revealed mild liver function abnormalities, electrolyte abnormalities, and a markedly elevated inflammatory response. Legionella pneumonia was suspected based on blood sample results and systemic symptoms, such as diarrhea and nausea. Furthermore, Legionella antigens were detected in the patient's urine, prompting further administration of levofloxacin. The patient's subsequent clinical course was favorable.

Conclusion

When bacterial pneumonia fails to respond to antimicrobial therapy and systemic symptoms develop, atypical pneumonia, caused by pathogens such as Legionella pneumophila, should be considered even in cases of postoperative pneumonia.

Third nationwide surveillance of bacterial pathogens in patients with acute uncomplicated cystitis conducted by the Japanese surveillance committee during 2020 and 2021: Antimicrobial susceptibility of Escherichia coli, Klebsiella pneumoniae, and Staphylococcus saprophyticus

The Japanese surveillance committee conducted a third nationwide surveillance of antimicrobial susceptibility of acute uncomplicated cystitis at 55 facilities throughout Japan between April 2020 and September 2021. In this surveillance, we investigated the susceptibility of Escherichia coli (E. coli), Klebsiella pneumoniae (K. pneumoniae), and Staphylococcus saprophyticus (S. saprophyticus) for various antimicrobial agents by isolating and culturing bacteria from urine samples. In total, 823 strains were isolated from 848 patients and 569 strains of target bacteria, including E. coli (n = 529, 92.9 %), K. pneumoniae (n = 28, 4.9 %), and S. saprophyticus (n = 12, 2.2 %) were isolated. The minimum inhibitory concentrations of 18 antibacterial agents were determined according to the Clinical and Laboratory Standards Institute manual. In premenopausal patients, there were 31 (10.5 %) and 20 (6.8 %) fluoroquinolone (FQ)-resistant E. coli and extended-spectrum β-lactamase (ESBL)-producing E. coli, respectively. On the other hand, in postmenopausal patients, there were 75 (32.1 %) and 36 (15.4 %) FQ-resistant E. coli and ESBL-producing E. coli, respectively. The rate of FQ-resistant E. coli and ESBL-producing E. coli in post-menopausal women was higher than that for our previous nationwide surveillance (20.7 % and 32.1 %: p = 0.0004, 10.0 % and 15.4 %; p = 0.0259). For pre-menopausal women, there was no significant difference in the rate of FQ-resistant E. coli and ESBL-producing E. coli between this and previous reports, but the frequency of FQ-resistant E. coli and ESBL-producing E. coli exhibited a gradual increase. For appropriate antimicrobial agent selection and usage, it is essential for clinicians to be aware of the high rate of these antimicrobial-resistant bacteria in acute uncomplicated cystitis in Japan.

Relationship between blood culture time to positivity, mortality rate, and severity of bacteremia

OBJECTIVES

We investigated the association between patient severity or mortality and time to positivity in bacteremia caused by various pathogens.

PATIENTS AND METHODS

This single-center retrospective study included patients with positive blood culture results.

RESULTS

Longer time to positivity was associated with 30-day mortality for Staphylococcus aureus (221 cases, time to positivity: 17.4 h in the 30-day mortality group vs. 14.1 h in the survival group). Age, chronic kidney disease, cerebrovascular disease, hypertensive drug use, consciousness disorder, and minimal systolic blood pressure were significant predictors of 30-day mortality. For S. aureus, mortality within 30 days was significantly higher when time to positivity was > 24 h (p = 0.04). The time to positivity of Streptococcus pneumoniae, α, β-hemolytic Streptococcus, Enterococcus sp., Enterobacteriaceae, glucose-nonfermenting Gram-negative rods, Candida sp., and anaerobe was not significantly associated with 30-day mortality.

CONCLUSIONS

Among various pathogens, time to positivity > 24 h was associated with 30-day mortality for S. aureus.

Transformation of polar nematic phases in the presence of an electric field

Only a few years have passed since the discovery of polar nematics, and now they are becoming the most actively studied liquid-crystal materials. Despite numerous breakthrough findings made recently, a theoretical systematization is still lacking. In the present paper, we take a step toward systematization. The powerful technique of molecular-statistical physics has been applied to an assembly of polar molecules influenced by electric field. Three polar nematic phases were found to be stable at various conditions: the double-splay ferroelectric nematic N_{F}^{2D} (observed in the lower-temperature range in the absence of or at low electric field), the double-splay antiferroelectric nematic N_{AF} (observed at intermediate temperature in the absence of or at low electric field), and the single-splay ferroelectric nematic N_{F}^{1D} (observed at moderate electric field at any temperature below transition into paraelectric nematic N and in the higher-temperature range (also below N) at low electric field or without it. A paradoxical transition from N_{F}^{1D} to N induced by application of higher electric field has been found and explained. A transformation of the structure of polar nematic phases at the application of electric field has also been investigated by Monte Carlo simulations and experimentally by observation of polarizing optical microscope images. In particular, it has been realized that, at planar anchoring, N_{AF} in the presence of a moderate out-of-plane electric field exhibits twofold splay modulation: antiferroelectric in the plane of the substrate and ferroelectric in the plane normal to the substrate. Several additional subtransitions related to fitting the confined geometry of the cell by the structure of polar phases were detected.

Standardization of preoperative stoma site marking and its utility for preventing stoma leakage: a retrospective study of 519 patients who underwent laparoscopic/robotic rectal cancer surgery

PURPOSE

Stoma site marking is an important preoperative intervention for preventing various stoma-associated complications. In our institution, standardized stoma site marking is routinely performed before rectal cancer surgery with stoma creation, and various stoma-associated factors are recorded in the ostomy-record template. The present study investigated risk factors for stoma leakage.

METHODS

Our stoma site marking is standardized so that it can be performed by non-stoma specialists. To identify risk factors of stoma leakage at 3 months after surgery, various preoperative factors associated with stoma site marking in our ostomy-record template were retrospectively analyzed in 519 patients who underwent rectal cancer surgery with stoma creation from 2015 to 2020.

RESULTS

Stoma leakage was seen in 35 of the 519 patients (6.7%). The distance between the stoma site marking and the umbilicus was less than 60 mm in 27 of the 35 patients (77%) who experienced stoma leakage, so a distance of less than 60 mm was identified as an independent risk factor for stoma leakage. Aside from preoperative factors, stoma leakage was also caused by postoperative skin wrinkles or surgical scars near the stoma site in 8 of 35 patients (23%).

CONCLUSION

Preoperative standardized stoma site marking is necessary to achieve reliable marking that is easy to perform. To reduce the risk of stoma leakage, a distance of 60 mm or more between the stoma site marking and the umbilicus is ideal, and surgeons need to contrive ways to keep surgical scars away from the stoma site.

The third nationwide surveillance of antimicrobial susceptibility against Neisseria gonorrhoeae from male urethritis in Japan, 2016-2017

Neisseria gonorrhoeae is one of the important pathogens of sexually transmitted infections. N. gonorrhoeae is rapidly becoming antimicrobial resistant, and there are few drugs that are effective in the initial treatment of gonorrhea. To understand the trends of antimicrobial susceptibility of N. gonorrhoeae, the Surveillance Committee of the Japanese Society of Infectious Diseases, the Japanese Society for Chemotherapy, and the Japanese Society of Clinical Microbiology conducted the third nationwide antimicrobial susceptibility surveillance of N. gonorrhoeae isolated from male urethritis. The specimens were collected from male patients with urethritis at 30 facilities from May 2016 to July 2017. From the 159 specimens collected, 87 N. gonorrhoeae strains were isolated, and 85 were tested for susceptibility to 21 antimicrobial agents. All strains were non-susceptible to penicillin G. Seven strains (8.2%) were β-lactamase-producing strains. The rates of susceptibility to cefixime and cefpodoxime were 96.5% and 52.9%, respectively. Three strains were non-susceptible with a minimum inhibitory concentration (MIC) of 0.5 mg/L for cefixime. None of the strains were resistant to ceftriaxone or spectinomycin. The susceptibility rate for ciprofloxacin was 23.5% (20 strains), and no strains showed intermediate susceptibility. The susceptibility rate against azithromycin was 81.2%, with one strain isolated with a MIC of 8 mg/L against azithromycin. The results of this surveillance indicate that ceftriaxone and spectinomycin, which are currently recommended for gonococcal infections in Japan, appear to be effective. It will be necessary to further expand the scale of the next surveillance to understand the current status of drug-resistant N. gonorrhoeae in Japan.

Online Adaptive Radiotherapy for Pharyngeal Cancer: Dose-Volume Histogram Analysis between Adapted and Scheduled Plan

PURPOSE/OBJECTIVE(S)

The present study aimed to evaluate whether online adapted plan with artificial intelligence (AI) driven work flow could be used in clinical settings with variable changes of the targets and organs at risk (OARs) for pharyngeal cancer.

MATERIALS/METHODS

Ten patients with pharyngeal cancer who underwent chemoradiotherapy at our institution between January and July 2020 were included for the analysis. All patients had been previously aligned daily with cone-beam computed tomography (CBCT) and treated by O-ring Linac. A simulated treatment was performed on the treatment emulator. Weekly fractions, once in every 4-5 fractions, were simulated in the treatment emulator for each patient using their previous on-treatment CBCTs. The dataset was divided into three groups according to the treatment period (1st-2nd week, 20 CBCTs), middle (3rd-4th week, 20 CBCTs), and late (5th-7th week, 30 CBCTs) period. In the present study, all of reference plan generation in treatment emulator were created on the initial plans of two-step method using 12 equidistant field IMRT. The prescribed dose was 70 Gy in 35 fractions and normalized to the dose of 68.6 Gy (98% dose) to 95% of the planning target volume (PTV). The adaptation process on treatment emulator includes auto-segmentation of daily anatomy, calculation of the dose in scheduled plans using the same monitor units and optimization and calculation of the dose in adapted plan. Dose-volume histogram (DVH) parameters between adapted and scheduled plans in terms of PTV (D98%, D95%, D50% and D2%), spinal cord (Dmax and D1cc), brain stem (Dmax), ipsilateral and contralateral parotid glands (Dmedian and Dmean) were evaluated in each period.

RESULTS

D98% of PTV of adapted plan was significantly higher than that of scheduled plan in early and middle period (p = 0.02 and <0.01, respectively). D95% of PTV of adapted plan was significantly higher than that of scheduled plan in all periods (p<0.01). D2% of PTV of adapted plan was significantly lower than that of scheduled plan in all periods (p = 0.04, 0.04 and 0.02 in each period, respectively). There was not significant difference in D50% of PTV between adapted and scheduled plan in all periods. In terms of OARs, Dmax of spinal cord of adapted plan was significantly lower than that of scheduled plan in all periods (p<0.01). Similarly, D1cc of spinal cord of adapted plan was lower than that of scheduled plan. Dmean of ipsilateral and contralateral parotid glands of adapted plan were lower than those of scheduled plan in the late period (p<0.01 and 0.03, respectively).

CONCLUSION

The present study revealed that adapted plan with AI driven work flow could create dosimetrically better plans for pharyngeal cancer compared to scheduled plan. It was suggested that online adaptive radiotherapy could be necessary to maintain PTV coverage while reducing the dose to OARs in all periods for pharyngeal cancer.

Cardioprotective effect of empagliflozin in acute myocardial infarction: the role of ketone bodies availability

Background

The cardio-renal benefits of SGLT2i have been clearly established by clinical trials. Of interest, despite not having any effect on the incidence of classic atherothrombotic events (MI and strokes), patients receiving SGLT2i treatment had a higher chance of surviving myocardial infarction (MI).

Purpose

We aim to evaluate the cardioprotective potential of empagliflozin on acute myocardial infarction.

We postulate that the benefits of SGLT2-I are mediated via an increase in circulating ketone bodies (KBs) induced by SGLT2i, and its preferential myocardial utilization energetically benefits the heart to better withstand an ischemic event.

Methods

The study was undertaken in our non-diabetic porcine model of ischemia/reperfusion. Animals were allocated to either one-week pre-treatment with empagliflozin or placebo before MI-induction. A third group received IV infusion of KBs at the time of the MI- induction to serve as positive-control. The acute effects of the treatments were studied 24 hours after MI-induction by Cardiac Magnetic Resonance (CMR). Immediately post-CMR, animals were sacrificed and heart samples collected for molecular analysis.

Results

(see Table and Figure): Despite similar initial ischemic injury (area at risk) in all groups, empagliflozin was associated with a significantly higher myocardial salvage (MSI 23.7±9.7 vs 4.5±3.6%, p&lt;0.001) and better preserved cardiac function (LVEF 41.3±3.1 vs 33±5.5%, p&lt;0.009) compared with placebo. The infusion of KBs replicated in part the beneficial profile of the empagliflozin group (MSI 16.7±8.8 and LVEF 39.1±3.6%). Histological analysis showed less cardiomyocyte apoptosis and less oxidative stress

Conclusions

To the best of our knowledge, this is the first study evaluating in vivo the cardioprotective potential of a SGLT2 inhibitor in a well-stablished porcine translational model. Furthermore, effects are evaluated using the gold standard for visualization and quantification of MI, Cardiac Magnetic Resonance (CMR). Three are the main conclusions:

1. One-week treatment with empagliflozin raises circulating KBs levels and confers significant cardio-protection during a myocardial infarction. Acute post-MI benefits (greater myocardial salvage and better preserved cardiac function) are already seen within 24 hours as compared with placebo.

2. Periprocedural IV infusion of KBs induces similar benefits than the SGLT2-I group.

3. These observations strongly support our hypothesis that SGLT2 inhibition is associated with increased circulating KBs and its selective use as preferential myocardial source of energy as a potential mechanism of action involved in the cardio-renal benefits observed with SGLT2i.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Spanish Society of Cardiology. Research Fellowship Grant.

An early return-to-work program for COVID-19 close contacts in healthcare during the Omicron wave in Japan

During the coronavirus disease 2019 (COVID-19) pandemic, maintaining adequate staffing in healthcare facilities is important to provide a safe work environment for healthcare workers (HCWs). Japan's early return-to-work (RTW) program may be a rational strategy at a time when there is an increased demand for the services of HCWs. We assessed whether the early RTW program for HCWs who have been in close contact with a COVID-19 case in our hospital was justified. Close contacts were identified according to the guidance document of the World Health Organization. HCWs who met all of the following conditions were eligible to apply to an early RTW program: (1) difficult to replace with another HCW, (2) received the third dose of a COVID-19 mRNA vaccine, (3) a negative COVID-19 antigen test before each work shift, and (4) consent from relevant HCWs and their managers to participate in the program. Between January and March 2022, 256 HCWs were identified as close contacts (median age, 35 years; 192 female). Thirty-seven (14%) secondary attack cases of COVID-19 were detected. Among 141 HCWs (55%) who applied to the early RTW program, nurses and physicians comprised about three-quarters of participants, with a higher participation rate by physicians (78%) than nurses (59%). Eighteen HCWs tested positive for COVID-19 by the sixth day after starting the early RTW program. No COVID-19 infection clusters were reported during the observation period. These findings suggest that the early RTW program for COVID-19 close contacts was a reasonable strategy for HCWs during the Omicron wave.

Emergence of paraelectric, improper antiferroelectric, and proper ferroelectric nematic phases in a liquid crystal composed of polar molecules

We have elaborated a theoretical approach for the description of polar nematic phases observed by Nishikawa et al. [Adv. Mater. 29, 1702354 (2017)0935-964810.1002/adma.201702354], their structures, and transitions between them. Specific symmetry contributions to the pair molecular potentials provide the molecular mechanisms responsible for the formation of proper and improper polarity on the macroscopic level. An improper antiferroelectric nematic M2 phase can arise between paraelectric nematic M1 and proper ferroelectric nematic MP in the temperature scale. The local polarization in M2 arises mostly due to the local splay deformation. The director distribution in M2 represents the conjugation of cylindrical waves with opposite splay and polarization signs. The director and polarization are parallel to the cylindrical domain axes in the middle of each cylinder but exhibit considerable (mostly radial) deformation on the periphery of each cylinder. Polarization vectors are mostly stacked antiparallel on the borders between the domains without the director disruption. The domain size decreases with the decreasing temperature, the percentage of the antiferroelectric decouplings increases, and M2 exhibits the first-order phase transition into proper ferroelectric MP. With the increasing temperature the domain size in the M2 phase increases, the domination of particular polar orientation of molecules reduces, and finally, the domain size diverges at particular temperature corresponding to the second-order phase transition from M2 to paraelectric M1. Variations of the polar and nonpolar orientational order parameters are estimated within each phase and between the phases. Our experimental and computer simulation results (also presented in the paper) fully support our theoretical findings.

A Clinical Trial Evaluating the Usefulness of Tailored Antimicrobial Prophylaxis Using Rectal-culture Screening Media Prior to Transrectal Prostate Biopsy: A Multicenter, Randomized Controlled Trial

The aim of this report is to introduce an on-going, multicenter, randomized controlled trial to evaluate whether tailored antimicrobial prophylaxis guided by rectal culture screening prevents acute bacterial prostatitis following transrectal prostate biopsy (TRPB). Patients will be randomized into an intervention or non-intervention group; tazobactam-piperacillin or levofloxacin will be prophylactically administered according to the results of rectal culture prior to TRPB in the intervention group whereas levofloxacin will be routinely given in the non-intervention group. The primary endpoint is the occurrence rate of acute bacterial prostatitis after TRPB. Recruitment begins in April, 2021 and the target total sample size is 5,100 participants.

Nationwide surveillance of the antimicrobial susceptibility of Chlamydia trachomatis from male urethritis in Japan: Comparison with the first surveillance report

The Urogenital Sub-committee and the Surveillance Committee of the Japanese Society of Chemotherapy, The Japanese Association for Infectious Diseases, and the Japanese Society for Clinical Microbiology conducted the second nationwide surveillance of the antimicrobial susceptibility of Chlamydia trachomatis. In this second surveillance study, clinical urethral discharge specimens were collected from patients with urethritis in 26 hospitals and clinics from May 2016 to July 2017. Based on serial cultures, the minimum inhibitory concentration (MIC) could be determined for 41 isolates; the MICs (MIC₉₀) of ciprofloxacin, levofloxacin, tosufloxacin, sitafloxacin, doxycycline, minocycline, erythromycin, clarithromycin, azithromycin and solithromycin were 2 μg/ml (2 μg/ml), 1 μg/ml (0.5 μg/ml), 0.25 μg/ml (0.25 μg/ml), 0.125 μg/ml (0.063 μg/ml), 0.125 μg/ml (0.125 μg/ml), 0.25 μg/ml (0.25 μg/ml), 0.031 μg/ml (0.031 μg/ml), 0.25 μg/ml (0.125 μg/ml), and 0.016 μg/ml (0.008 μg/ml), respectively. In summary, this surveillance project did not identify any strains resistant to fluoroquinolone, tetracycline, or macrolide agents in Japan. In addition, the MIC of solithromycin was favorable and lower than that of other antimicrobial agents. However, the MIC of azithromycin had a slightly higher value than that reported in the first surveillance report, though this might be within the acceptable margin of error. Therefore, the susceptibility of azithromycin, especially, should be monitored henceforth.

Guidelines for Infection Control in the Urological Field, including Urinary Tract Management (revised second edition)

The Committee for the Development of Guidelines for Infection Control in the Urological Field, including Urinary Tract Management of the Japanese Urological Association, together with its systematic review team and external reviewers, have prepared a set of practice guidelines, an abridged version of which is published herein. These guidelines cover the following topics: (i) foundations of infection control, standard precautions, route-specific precautions, and occupational infection control (including vaccines); (ii) the relationship between urologists and infection control; (iii) infection control in urological wards and outpatient clinics; (iv) response to hepatitis B virus reactivation; (v) infection control in urological procedures and examinations; (vi) prevention of infections occurring in conjunction with medical procedures and examinations; (vii) responses to urinary tract tuberculosis and bacillus Calmette-Guérin; (viii) aseptic handling, cleaning, disinfection, and sterilization of urinary tract endoscopes (principles of endoscope manipulation, endoscope lumen cleaning, and disinfection); (ix) infection control in the operating room (principles of hand washing, preoperative rubbing methods, etc.); (x) prevention of needlestick and blood/bodily fluid exposure and response to accidental exposure; (xi) urinary catheter-associated urinary tract infection and purple urinary bag syndrome; and (xii) urinary catheter-associated urinary tract infections in conjunction with home care. In addressing these topics, the relevant medical literature was searched to the extent possible, and content was prepared for the purpose of providing useful information for clinical practice.

AB0065 HGF/C-MET SIGNALING PROMOTE ANGIOGENESIS THROUGH CXCL16 IN RHEUMATOID ARTHRITIS

Background:

Hepatocyte growth factor (HGF) binds to the receptor tyrosine kinase c-Met and is a multifunctional cytokine that promotes processes such as cell proliferation, survival, differentiation, migration and angiogenesis [1]. We previously reported that HGF is produced by inflammation in the RA synovium, and activates monocyte migration to the synovium and promotes bone destruction through its own chemotactic effect and enhanced chemokine production in the synovium [2].

Objectives:

Therefore, we next aimed to determine the role of HGF in RA angiogenesis.

Methods:

The expression of HGF / c-Met in the serum and synovial tissues (STs) of RA patients and controls and human umbilical vein endothelial cells (HUVECs) was evaluated by ELISA and immunostaining. The effect of HGF/c-Met signaling on the promotion of CXCL16 production from HUVECs and RA fibroblast-like synoviocytes (FLSs) was determined by ELISA. To examine the role of HGF in angiogenesis, we performed in vitro Matrigel assays using HUVECs treated with HGF.

Results:

HGF in serum in treatment-naive RA patients was significantly higher than that in controls and HGF in serum in treatment-resistant RA showed a significant positive correlation with CXCL16. c-Met were expressed on vascular endothelial cells of RA STs and HUVECs. Stimulation of HUVECs with HGF dose-dependently increased CXCL16 production. c-Met signal inhibition by SU11274 suppressed TNF-α stimulation-enhanced CXCL16 production by RA FLSs in a dose-dependent manner. Furthermore, HGF induced HUVEC tube formation by 1.8-fold.

Conclusion:

HGF is produced by inflammation in the RA synovium, and activates angiogenesis through its own potent angiogenic effect and enhanced production of CXCL16 in the synovium. These results indicate that a strategy targeting c-Met signalling may be important for resolving treatment-resistant RA.

References:

[1]Nakamura T, Nishizawa T, Hagiya M, et al. Molecular cloning and expression of human hepatocyte growth factor. Nature. 1989 Nov 23;342(6248):440-3.

[2]Hosonuma M, Sakai N, Furuya H, et al. Inhibition of hepatocyte growth factor/c-Met signalling abrogates joint destruction by suppressing monocyte migration in rheumatoid arthritis. Rheumatology (Oxford). 2021 Jan 5;60(1):408-419.

Disclosure of Interests:

None declared

POS0429 INTERLEUKIN-4 ACTIVATES EOSINOPHILS AND CCR3-POSITIVE T HELPER CELLS MIGRATION TO FASCIA AND PROMOTES FIBROSIS IN EOSINOPHILIC FASCIITIS

Background:

Eosinophilic fasciitis (EF) is a rare disease that causes inflammation and fibrosis mainly in the fascia of the extremities with eosinophilia. It has been reported that the hypertrophied fascia in EF shows inflammatory cell infiltration by the lymphocytes and eosinophils and increased expression of fibrosis-related cytokines genes in fibroblast [1]. However, its pathophysiology in the fascia remains unresolved.

Objectives:

Therefore, we focused on fascial fibroblasts and aimed to determine the role of interleukin-4 (IL-4) in eosinophil and helper T cell infiltration and fibrosis in fascial fibroblast in EF.

Methods:

Fascial fibroblasts were obtained from fascia biopsy of a patient with EF, and were stimulated with pre- and post-treatment serum of a patient with EF and healthy control, followed by microarray to analyze gene expression. Fascial fibroblasts were stimulated with IL-4 10 ng/mL, and gene expression of IL-4 receptor and CCR3 ligands, CCL7 and CCL11 were measured by qPCR. Transforming growth factor (TGF) -β and periostin in the pre- and post-treatment serum of a patient with EF and conditioned medium of fascial fibroblasts stimulated with IL-4 were measured by ELISA. To examine the role of IL-4 in proliferation, we performed in proliferation assays using fascial fibroblasts treated with IL-4. CCR3-positive T cells in the fascial tissue of EF, dermatomyositis, and polymyositis patients were evaluated by immunostaining.

Results:

By microarray analysis, CCL7 and CCL11 expression of fascial fibroblasts stimulated with pre-treatment EF serum was higher than that in post-treatment EF serum and control serum. CCL7 and CCL11 mRNA in IL-4 stimulated facial fibroblasts were increased by 5.1-fold and 7.3-fold, respectively. TGF-β and periostin in IL-4 stimulated facial fibroblast conditioned medium were also increased. In addition, TGF-β and periostin in EF serum were gradually decreased by treatment for 4 and 10 weeks, compared to before treatment. Finally, fascial fibroblast proliferation was significantly increased by stimulation with IL-4. Furthermore, infiltration of CCR3-positive T cells was specific to the fascial tissue of EF.

Conclusion:

In EF, IL-4 enhances the production of CCR3 ligands, TGF-β, and periostin from fascial fibroblasts. As a result, it promotes the migration of eosinophils and CCR3-positive T helper cells to the fascia and fibrosis. These results suggest that inhibition of IL-4 pathway could be a novel strategy for eosinophilic fasciitis.

References:

[1]Igarashi A, Nashiro K, Kikuchi K, et al. Connective tissue growth factor gene expression in tissue sections from localized scleroderma, keloid, and other fibrotic skin disorders. J Invest Dermatol. 1996 Apr;106(4):729-33.

Disclosure of Interests:

None declared

Nationwide surveillance of bacterial pathogens isolated from patients with acute uncomplicated cystitis in 2018: Conducted by the Japanese Research Group for Urinary Tract Infections (JRGU)

INTRODUCTION

The aim of this study was to monitor the development of drug-resistant bacteria isolated from acute uncomplicated cystitis (AUC) and to evaluate methodology of the survey conducted by collecting only clinical data.

METHODS

We enrolled female patients at least 16 years of age diagnosed with AUC in 2018. Patient information including age, menopausal status, and results of bacteriological examination were collected and analyzed regardless of bacterial identification, antimicrobial susceptibility testing or extended-spectrum β-lactamase (ESBL) detection method.

RESULTS

A total of 847 eligible cases were collected. Escherichia coli (E. coli) was the most frequently isolated bacterial species at about 70%, with proportions of fluoroquinolone-resistant E. coli (QREC) and ESBL-producing E. coli isolates at 15.6% and 9.5% of all E. coli isolates, respectively. The proportion of Staphylococcus saprophyticus (S. saprophyticus) was significantly higher in premenopausal women. Regarding the drug susceptibility of E. coli, isolates from Eastern Japan had significantly higher susceptibility to cefazolin, cefotiam and cefpodoxime and lower susceptibility to levofloxacin in postmenopausal women. ESBL-producing E. coli isolates had a high susceptibility to tazobactam-piperacillin, cefmetazole, carbapenems, aminoglycosides, and fosfomycin. In S. saprophyticus, the susceptibility to β-lactams including carbapenems was 40-60%.

CONCLUSIONS

The proportions of QREC and ESBL-producing E. coli were increasing trends and lower susceptibility to LVFX in postmenopausal women was observed. Such surveillance, consisting of the collecting only clinical data, could be conducted easily and inexpensively. It is expected to be continuously performed as an alternative survey to conventional one collecting bacterial strains.

The effects of wheel-running using the upper limbs following immobilization after inducing arthritis in the knees of rats

This study investigated the effects of wheel-running using the upper limbs following immobilization after inducing arthritis in the knees of rats. Forty male Wistar rats (aged 8 weeks) divided into four groups randomly: arthritis (AR), immobilization after arthritis (Im), wheel-running exercise with the upper limbs following immobilization after arthritis induction (Im+Ex) and sham arthritis induction (Con). The knee joints of the Im and Im+Ex groups were immobilized with a cast for 4 weeks. In the Im+Ex group, wheel-running exercise was administered for 60 min/day (5 times/week). The swelling and the pressure pain threshold (PPT) of the knee joint were evaluated for observing the condition of inflammatory symptoms in affected area, and the paw withdraw response (PWR) was evaluated for observing the condition of secondary hyperalgesia in distant area. Especially, in order to evaluate histological inflammation in the knee joint, the number of macrophage (CD68-positive cells) in the synovium was examined. The expression of calcitonin gene-related peptide (CGRP) in the spinal dorsal horn (L2-3 and L4-5) was examined to evaluate central sensitization. The Im+Ex group showed a significantly better recovery than the Im group in the swelling, PPTs, and PWRs. Additionally, CGRP expression of the spinal dorsal horn (L2-3 and L4-5) in the Im+Ex group was significantly decreased compared with the Im group. According to the results, upper limb exercise can decrease pain in the affected area, reduce hyperalgesia in distant areas, and suppress the central sensitization in the spinal dorsal horn by triggering exercise-induced hypoalgesia (EIH).

Long-term outcomes and recurrence-free interval after the treatment of keloids with a standardized protocol

BACKGROUND

Recurrence rates of keloids have generally been reported at one time point. However, the longer the duration after treatment, the greater the likelihood that such lesions will recur. In this study, we analysed the time to recurrence during long-term follow-up.

MATERIAL AND METHODS

We retrospectively reviewed recurrence-free interval in 52 patients with keloid (age 8-79 years) who had been treated between June 2006 and January 2011 using a standardised protocol developed by our group.

RESULTS

Mean duration of follow-up was 37.5 (range, 7-120) months in patients with keloid. Kaplan-Meier survival curves revealed a statistically significant difference in recurrence-free interval between ear keloids and keloids excluding ear keloids. Recurrence rate for keloids was high in the first 2 years after treatment.

CONCLUSIONS

Kaplan-Meier analysis was useful for understanding the tendency of recurrence of keloids after treatment using a standardised protocol.

Short-term risk stratification using CADILLAC risk score in patients with ST elevation myocardial infarction

Background

The recent reperfusion therapy for ST-elevation myocardial infarction (STEMI) has made the length of hospital stay shorter without adverse events. CADILLAC risk score is reportedly one of the risk scores predicting the long-term prognosis in STEMI patients.

Purpose

To invenstigate the usefulness of CADILLAC risk score for predicting short-term outcomes in STEMI patients.

Methods

Consecutive patients admitted to our university hospital and our medical center with STEMI (excluding shock, arrest case) who underwent primary PCI between January 2012 and April 2018 (n=387) were enrolled in this study. The patients were classified into 3 groups according to the CADILLAC risk score: low risk (n=176), intermediate risk (n=87), and high risk (n=124). Data on adverse events within 30 days after hospitalization, including in-hospital death, sustained ventricular arrhythmia, recurrent myocardial infarction, heart failure requiring intravenous treatment, stroke, or clinical hemorrhage, were collected.

Results

In the low risk group, adverse events within 30 days were significantly less observed, compared to the intermediate and high risk groups (n=13, 7.4% vs. n=13, 14.9% vs. n=58, 46.8%, p&lt;0.001). In particular, all adverse events occurred within 3 days in the low risk group, although adverse events, such as heart failure (n=4), recurrent myocardial infarction (n=1), stroke (n=1), and gastrointestinal bleeding (n=1), were substantially observed after day 4 of hospitalization in the intermediate and high risk groups.

Conclusions

In STEMI patients with low CADILLAC risk score, better short-term prognosis was observed compared to the intermediate and high risk groups, and all adverse events occurred within 3 days of hospitalization, suggesting that discharge at day 4 might be safe in this study population. CADILLAC risk score may help stratify patient risk for short-term prognosis and adjust management of STEMI patients.

Initial event occurrence timing

Funding Acknowledgement

Type of funding source: None

Serum immunoglobulin G antibody titer to Fusobacterium nucleatum is associated with unfavorable outcome after stroke

Stroke can be a cause of death, while in non-fatal cases it is a common cause of various disabilities resulting from associated brain damage. However, whether a specific periodontal pathogen is associated with increased risk of unfavorable outcome after stroke remains unknown. We examined risk factors for unfavorable outcome following stroke occurrence, including serum antibody titers to periodontal pathogens. The enrolled cohort included 534 patients who had experienced an acute stroke, who were divided into favorable (n = 337) and unfavorable (n = 197) outcome groups according to modified ranking scale (mRS) score determined at 3 months after onset (favorable = score 0 or 1; unfavorable = score 2-6). The associations of risk factors with unfavorable outcome, including serum titers of IgG antibodies to 16 periodontal pathogens, were examined. Logistic regression analysis showed that the initial National Institutes of Health stroke scale score [odds ratio (OR) = 1·24, 95% confidence interval (CI) = 1·18-1·31, P < 0·001] and C-reactive protein (OR = 1·29, 95% CI = 1·10-1·51, P = 0·002) were independently associated with unfavorable outcome after stroke. Following adjustment with those, detection of the antibody for Fusobacterium nucleatum ATCC 10953 in serum remained an independent predictor of unfavorable outcome (OR = 3·12, 95% CI = 1·55-6·29, P = 0·002). Determination of the antibody titer to F. nucleatum ATCC 10953 in serum may be useful as a predictor of unfavorable outcome after stroke.

P599Native T1 mapping is useful for detection of myocardial fibrosis in cases with ischemic and non-ischemic myocardial diseases

Background

Evaluation of myocardial fibrosis (MF) as late gadolinium enhancement (LGE) on MRI is useful for differential diagnosis of various myocardial diseases and prediction of future adverse cardiac events in some specific myocardial diseases. Gadolinium contrast is contraindicated for cases with severe renal dysfunction, therefore non contrast MRI is necessary for detection of MF in cases with both myocardial disease and severe renal dysfunction.

Purpose

We aimed to evaluate diagnostic accuracy of native T1 mapping for detection of MF compared with LGE in cases with various myocardial diseases, including ischemic and non-ischemic myocardial diseases.

Methods

We selected consecutive 40 patients who were suspected of having various myocardial diseases and underwent cardiac MRI, using 1.5T MRI (Ingenia, Philips) in 10 cases (25%) or 3T MRI (Ingenia, Philips) in 30 cases (75%), including native T1 mapping (without contrast) and LGE using contrast media from Jan 2018 to Feb 2019 in our institution. We evaluated diagnostic accuracy for detection of MF in left ventricular myocardium (LVM) of native T1 mapping image compared with LGE as the gold standard, in a patient-based and segment-based analysis. In T1 mapping images, segmental high T1 lesions were defined as MF. In a segment-based analysis, MF was evaluated using 17 LVM segments model in American Heart Association.

Results

MF was detected in 139 LVM segments in 25 (63%) cases. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of native T1 mapping for detection of MF were 90%, 89%, 95%, 80% and 90% in a patient-based analysis, and 63%, 96%, 84%, 89% and 88% in a segment-based analysis (left figure). Native T1-values of LVM with MF were significantly higher than LVM without LGE (1351±79 vs 1093±124 in 1.5T and 1562±131 vs 1291±43 in 3T) (p<0.05 and p<0.01). Interobserver agreement of native T1 mapping and LGE were not significantly different (0.88 and 0.89, P=0.70). Overall diagnostic accuracy of native T1 mapping for detection of MF in a patient-based analysis, was not significantly different in between the cases with ischemic (n=18) and non-ischemic (n=22) myocardial disease (90% and 83.3%, P=0.10).

Conclusion

Native T1 mapping (without contrast) is useful for detection of MF in various myocardial diseases and high diagnostic accuracy is expected especially in a patient-based analysis.

P6182Combination of a new iterative reconstruction technique with low tube voltage and high tube current has important role of detection of late enhancement on 320 slice CT

Background

New iterative reconstruction tecniques, including Adaptive Iterative Dose Reduction 3D (AIDR 3D) and Forward Projected Model-based Iterative Reconstruction SoluTion (FIRST), have been recently available on new generation 320 slice CT, and they can provide high-quality CT images.

Purpose

The aim of this study was to evaluate the diagnostic performance of detection of abnormal late enhancement (LE) in left ventricular (LV) myocardium (LVM) using 320-slice CT with new iterative reconstruction techiniques, AIDR 3D (Figure A) and FIRST (Figure B).

Methods

A total of 100 patients who were suspected of having various myocardial diseases and underwent late phase acquisition both on cardiac CT and CMR within 3 months were analyzed. The first 50 consecutive patients (Group 1) underwent 320-slice CT with AIDR 3D, 120 Kv tube voltage, 519±71 mA tube current. The next 50 consecutive patients (Group 2) underwent 320-slice CT with FIRST, 80 or 100Kv tube voltage, 803±20 mA tube current. We compared diagnostic accuracy of CT for detection of LE in LVM against that of CMR (the gold standard) in between the 2 groups.

Results

On patient-by-patient analysis, sensitivity, specificity, positive (PPV) and negative predictive values (NPV), and overall accuracy for detection of LE on CT vs CMR were 87, 95, 96, 82, and 90% in Group 1, and 97, 83, 91, 88, and 90% in Group 2. There were no significant difference of diagnostic accuracy on patient-by-patient analysis in between the 2 groups (Figure C). However, on a segment-by-segment analysis (using 17 American Heart Association LV segment model), these values for detection of LE on CT vs CMR were 60, 95, 73, 91, and 88% in Group 1, and 85, 95, 86, 95, and 93% in Group 2. Sensitivity, PPV, NPV and overall accuracy were significantly higher in Group 2 than in Group 1 (all P<0.01) (Figure D).

Conclusions

Diagnostic accuracy of detection of LE in LVM on CT combining low tube voltage and high tube current acquisition on a new generation 320-slice CT with FIRST was superior to 320-slice CT with AIDR 3D.

Acknowledgement/Funding

TSUCHIYA MEMORIAL MEDICAL FOUNDATION

P6578Development of the novel program to diagnose atrial fibrillation using automated blood pressure monitor

Background

Atrial fibrillation (AF) is often asymptomatic and contributes to an increased risk of strokes. The development of proper screening device of AF is unmet medical needs worldwide. Recently, we had reported that multiple measurements using Omron automated blood pressure (BP) monitor with irregular heartbeat detection showed high sensitivity and specificity for AF detection in general cardiac patients, however, this method had limitations in discriminating between AF and other arrhythmias.

Purpose

The aim of this study is to develop a novel program that can accurately diagnose AF by discriminating it from other arrhythmias using the pressure pulse waveform data outputted from Omron automated BP monitor.

Methods

In our previous clinical research, BP measurements were performed 3 times each for 303 general cardiac patients (mean age: 72.2 years, 69.8% male) with recording the real-time single lead ECG, and a total of 909 pressure pulse waveforms were obtained. Among them, 840 pressure pulse waveforms from 280 patients (include 40 AF patients) used for further analysis. We developed a program to analyze and visualize uniquely the characteristics of AF waveform through the autocorrelation-based waveform processing system produced by Melody International Ltd, Kagawa, Japan. All visualized results were judged and classified into Sinus, Non-AF and AF by two individuals blinded to the results. For each patient who obtained 3 results, a two by two contingency table was created and sensitivity, specificity, and accuracy for diagnosing AF were calculated.

Results

Among 840 pressure pulse waveforms, only 21 (2 Sinus and 19 Non-AF) out of 720 Sinus and Non-AF waveforms were judged as AF, and 7 out of 120 AF waveforms were judged as Non-AF. None of AF waveforms was absolutely misjudged as Sinus. In analysis for each patient, when one or more AF judgements were found in 3 waveforms, the diagnosis of AF has sensitivity and specificity of 100% and 95.8%, respectively. When two or more AF judgements were found in 3 waveforms, the diagnosis of AF has sensitivity and specificity of 100% and 97.9%, respectively. In this rule, the diagnostic accuracy of AF reached up to 98.8%, and no sinus patients were misjudged as AF.

Conclusion

The novel program, which applied autocorrelation methods uniquely to analysis of the pressure pulse waveforms recorded by automated BP monitor, showed high sensitivity and high specificity for AF diagnosis in general cardiac patients. This program is expected to be useful for early diagnosis for asymptomatic AF patients.

Acknowledgement/Funding

The present research is supported by a grant through the SCOPE from the Ministry of Internal Affairs and Communications, Japan.

Honeycomb blocks composed of carbonate apatite, β-tricalcium phosphate, and hydroxyapatite for bone regeneration: effects of composition on biological responses

Synthetic scaffolds exhibiting bone repair ability equal to that of autogenous bone are required in the fields of orthopedics and dentistry. A suitable synthetic bone graft substitute should induce osteogenic differentiation of mesenchymal stem cells, osteogenesis, and angiogenesis. In this study, three types of honeycomb blocks (HCBs), composed of hydroxyapatite (HAp), β-tricalcium phosphate (TCP), and carbonate apatite (CO3Ap), were fabricated, and the effects of HCB composition on bone formation and maturation were investigated. The HC structure was selected to promote cell penetration and tissue ingrowth. HAp and β-TCP HCBs were fabricated by extrusion molding followed by sintering. The CO3Ap HCBs were fabricated by extrusion molding followed by sintering and dissolution-precipitation reactions. These HCBs had similar macroporous structures: all harbored uniformly distributed macropores (∼160 ​μm) that were regularly arrayed and penetrated the blocks unidirectionally. Moreover, the volumes of macropores were nearly equal (∼0.15 ​cm3/g). The compressive strengths of CO3Ap, HAp, and β-TCP HCBs were 22.8 ​± ​3.5, 34.2 ​± ​3.3, and 24.4 ​± ​2.4 ​MPa, respectively. Owing to the honeycomb-type macroporous structure, the compressive strengths of these HCBs were higher than those of commercial scaffolds with intricate three-dimensional or unidirectional macroporous structure. Notably, bone maturation was markedly faster in CO3Ap HCB grafting than in β-TCP and HAp HCB grafting, and the mature bone area percentages for CO3Ap HCBs at postsurgery weeks 4 and 12 were 14.3- and 4.3-fold higher and 7.5- and 1.4-fold higher than those for HAp and β-TCP HCBs, respectively. The differences in bone maturation and formation were probably caused by the disparity in concentrations of calcium ions surrounding the HCBs, which were dictated by the inherent material resorption behavior and mechanism; generally, CO3Ap is resorbed only by osteoclastic resorption, HAp is not resorbed, and β-TCP is rapidly dissolved even in the absence of osteoclasts. Besides the composition, the microporous structure of HC struts, inevitably generated during the formation of HCBs of various compositions, may contribute to the differences in bone maturation and formation.

Efficacy of Prophylactic Antimicrobial Administration of Tazobactam/Piperacillin for Radical Cystectomy with Urinary Diversion: A Multicenter Study

OBJECTIVES

The purpose of this study was to investigate the association between prophylactic antibiotic administration (PAA) and postoperative infection after radical cystectomy with urinary diversion in patients with invasive bladder cancer.

METHODS

Forty-nine consecutive cases were analyzed prospectively. Postoperative infections were categorized as surgical site infection (SSI) and remote infection (RI). We used the antibiotics tazobactam/piperacillin (TAZ/PIPC) as PAA (48 h).

RESULTS

A total of 18 (36.7%) patients had postoperative infections, 4/18 (22.2%) patients had wound infections, and 12/18 (66.7%) patients had RI. In the risk factor study for SSI and RI occurrences, we found that the surgical time was significantly shorter in the non-infection group (p = 0.031). Taken together, these results suggest that TAZ/PIPC with shorter PAA duration (48 h) might lead to a lower rate of postoperative infections.

CONCLUSIONS

Our data showed that PAA with TAZ/PIPC with a shorter duration PAA (48 h) might be recommended for RC with urinary diversion. We found that the surgical time was significantly shorter in the non-infection group. A prospective study based on our data is desirable to establish or revise PAA strategy for prophylactic medication to prevent postoperative infection after RC with urinary diversion.

Adjunctive perampanel in partial-onset seizures: Asia-Pacific, randomized phase III study

OBJECTIVES

To evaluate the efficacy, safety, and tolerability of perampanel, a selective, non-competitive, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor antagonist, as an adjunctive treatment for patients with refractory partial-onset seizures (POS) from Asia-Pacific.

MATERIALS & METHODS

This multicenter, randomized, double-blind, placebo-controlled trial (ClinicalTrials.gov identifier: NCT01618695) involved patients aged ≥12 years with refractory POS (receiving 1-3 antiepileptic drugs). Patients were randomized (1:1:1:1) to receive once-daily placebo or perampanel 4, 8, or 12 mg over a 6-week titration and 13-week maintenance double-blind period. Enzyme-inducing antiepileptic drugs were equally stratified between groups. The primary efficacy endpoint was percent change in POS frequency per 28 days (double-blind phase vs baseline). Other efficacy endpoints included ≥50% responder rate and seizure freedom. Treatment-emergent adverse events (TEAEs) were also monitored.

RESULTS

Of 710 randomized patients, seizure frequency data were available for 704 patients. Median percent changes in POS frequency per 28 days indicated dose-proportional reductions in seizure frequency: -10.8% with placebo and -17.3% (P = .2330), -29.0% (P = .0003), and -38.0% (P < .0001) with perampanel 4, 8, and 12 mg, respectively. In total, 108 (15.3%) patients discontinued treatment; 44 (6.2%) due to TEAEs. TEAEs occurring in ≥5% of patients, and reported at least twice as frequently with perampanel vs placebo, included dizziness and irritability.

CONCLUSIONS

Adjunctive perampanel (8 and 12 mg/d) significantly improved seizure control in patients with refractory POS. Safety and tolerability were acceptable at daily doses of perampanel 4-12 mg.