AB0332 EVALUATION OF THE RABBIT RISK SCORE IN JAPANESE PATIENTS WITH RHEUMATOID ARTHRITIS NEWLY TREATED WITH BIOLOGIC DMARDS: DATA FROM THE IORRA COHORT

Background

Serious infection is one of the most critical adverse events in patients with rheumatoid arthritis (RA) using biologic disease-modifying antirheumatic drugs (bDMARDs). During the first year, infections occur more frequently. Therefore, estimating the risk of developing a serious infection is important for the safe use of bDMARDs. The Rheumatoid Arthritis Observation of Biologic Therapy (RABBIT) risk score predicted the incidence rate of serious infection during 1 year in patients with RA taking DMARDs. Moreover, it has been validated using data from various observational cohort studies and nationwide registries with favorable results, with a reported area under the receiver operating characteristic curve (AUROC) of 0.68–0.871–5. However, the RABBIT risk score has not been validated in RA patients starting a first bDMARD.

Objectives

To investigate the discriminatory ability of the RABBIT risk score for predicting the development of serious infection during 1 year after starting first bDMARDs in Japanese patients with RA using data from the Institute of Rheumatology, Rheumatoid Arthritis (IORRA) cohort.

Methods

The IORRA cohort is a large observational cohort at the Institute of Rheumatology, Tokyo Women’s Medical University. Japanese patients with RA visiting our institute were registered and clinical parameters were assessed biannually. This study enrolled patients with RA who were registered in the IORRA cohort and treated with a first bDMARD. Patients who were missing data needed to calculate the RABBIT risk score were excluded. The RABBIT risk score was calculated using the patient’s age, comorbidities, Japanese-Health Assessment Questionnaire score, history of previous infections, and types of DMARDs used. Serious infections were defined as those requiring hospitalization or treatment with intravenous antibiotics. The occurrence of serious infection during 1 year after starting the first bDMARDs was identified using data from the biannual IORRA cohort and confirmed using medical records. The discriminatory ability of the RABBIT risk score was analyzed by the AUROC.

Results

A total of 1,081 patients with RA and a median age of 55.3 years, in which females were the majority (88.2%), were included. Serious infection occurred in eight patients during 1 year before starting their first bDMARDs. The number of patients starting a TNF inhibitor, IL-6 inhibitor, and abatacept were 830 (76.8%), 170 (15.7%), and 81 (7.5%), respectively. A total of 23 patients (1.7%) had serious infections during 1 year after starting the first bDMARD; the most frequent infection was pneumonia (n=16, 69.6%). The median RABBIT score was 2.3 (IQR 1.6–5.4) in patients with serious infections during the follow-up period, and 1.6 (IQR 1.2–2.5) in patients without serious infections. The discriminatory ability of the RABBIT risk score was slightly poor, with an AUROC of 0.67 (95% CI, 0.52– 0.79).

Conclusion

The RABBIT risk score is highly practical; however, our present study suggested that some adjustments may be required to predict the risk of serious infection in Japanese patients with RA starting a first bDMARD.

Figure 1.

ROC curve of serious infection and RABBIT score with an AUROC of 0.67 (95% CI, 0.52– 0.79).

Disclosure of Interests

Tomoaki Higuchi: None declared, Eiichi Tanaka Speakers bureau: Abbvie, Asahi Kasei pharma co., Bristol Myers Squibb, Chugai Pharmaceutical, Daiichi Sankyo Co., Eisai Pharmaceutical, Janssen Pharmaceutical K.K., Nippon Kayaku, Pfizer, Takeda Pharmaceutical, Taisho Toyama Pharmaceutical Co., and UCB Pharma., Paid instructor for: Abbvie, Asahi Kasei pharma co., Bristol Myers Squibb, Chugai Pharmaceutical, Daiichi Sankyo Co., Eisai Pharmaceutical, Janssen Pharmaceutical K.K., Nippon Kayaku, Pfizer, Takeda Pharmaceutical, Taisho Toyama Pharmaceutical Co., and UCB Pharma., Eisuke Inoue Speakers bureau: Bristol-Meyers and Pfizer, Consultant of: Nippontect systems, Mai Abe: None declared, Kumiko Saka: None declared, Eri Sugano: None declared, Naohiro Sugitani: None declared, Yoko Shimizu: None declared, Moeko Ochiai: None declared, Rei Yamaguchi: None declared, Katsunori Ikari Speakers bureau: Asahi Kasei Pharma Corp., Astellas Pharma Inc., AbbVie Japan GK, Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., Janssen Pharmaceutical K.K., Kaken Pharmaceutical Co. Ltd., Mitsubishi Tanabe Pharma Corp. Pfizer Japan Inc., Takeda Pharmaceutical Co. Ltd., Teijin Pharma Ltd and UCB Japan Co. Ltd., Yamanaka Hisashi: None declared, Masayoshi Harigai Speakers bureau: AbbVie Japan, Ayumi, Boehringer Ingelheim Japan, Bristol-Myers Squibb, Chugai, Eisai, Eli Lilly Japan, GlaxoSmithKline, Kissei, Pfizer Japan Inc, Takeda, Teijin, Consultant of: AbbVie Japan, Boehringer Ingelheim Japan, Bristol-Myers Squibb, Kissei, Teijin, Grant/research support from: AbbVie Japan, Asahi Kasei, Astellas, Ayumi, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Kissei, Mitsubishi Tanabe, Nippon Kayaku, Sekiui Medical, Shionogi, Taisho, Takeda, Teijin.

THU0144 DESCRIPTIVE ANALYSIS OF PREGNANCY, DELIVERY, AND LACTATION IN PATIENTS WITH RHEUMATOID ARTHRITIS FROM THE IORRA COHORT

Background:

Rheumatoid Arthritis (RA) is common in women with reproductive age. For this reason, RA treatment during pregnancy and lactation is very important. In recent years, the use of biologic disease-modifying antirheumatic drugs (bDMARDs) has become common in RA treatment (1), treatment during pregnancy and lactation has changed drastically (2,3).

Objectives:

To investigate the pregnancy, delivery and lactation status of RA patients and treatment during that period in daily practice.

Methods:

The IORRA cohort is a large, single institute-based, observational cohort of RA patients established at Institute of Rheumatology, Tokyo Women’s Medical University, in 2000. We identified female RA patients aged 20-49 years who answered ‘pregnant’ or ‘delivered’ in the IORRA survey in 2010-2016 and whose pregnancies were confirmed in the medical records. We examined the Disease Activity Score with 28 joint count (DAS28)-CRP, medication use situation, the outcome of pregnancy, and lactation in those patients.

Results:

A total of 101 patients and 143 pregnancies were confirmed, of which 136 outcomes of pregnancy could be confirmed in the medical records. Among 136 confirmed pregnancy cases, there were 106 births and 30 miscarriages. Among 106 births, 4 cases (3.8%) were birth defects that could be confirmed in the medical records. The average age at pregnancy was 34.2±3.7 years and 36.1±3.3 years in delivered and miscarried cases, respectively. Miscarried cases were significantly older pregnancies (p=0.01). Of the 106 births, 65 birth weeks were confirmed, with an average of 37.9±1.8 weeks. The number of preterm delivery was 11 cases (16.9%). The average birth weight of 59 babies whose birth weight could be confirmed was 2699±517 g. There were 21 cases (35.6%) of low birth weight infants. The proportion of patients in DAS28-CRP remission was 73.1% before pregnancy, 61.6% during pregnancy, and 68.0% 1 year after delivery. Drugs used before pregnancy were glucocorticoid (48.8%), non-steroidal anti-inflammatory drugs (14.2%), conventional synthetic DMARDs (24.8%), and bDMARDs (48.0%). Etanercept accounted for 90% of bDMARDs. Among taking bDMARDs patients, 73.8% were discontinued after the pregnancy, and 26.2% were continued during pregnancy. Among those patients who continued bDMARDs, lactating patients were 12/26 (46.2%) cases after delivery, 10/30 (33.3%) cases in six months after delivery, and 7/36 (19.4%) cases in 1 year after delivery, respectively.

Conclusion:

The actual situation of pregnancy, delivery, and lactation in RA patients was revealed. Especially, bDMARDs were used at relatively high rates in RA patients who wish to have a child.

References:

[1]Lancet. 2017;10;389:2338-2348.

[2]Semin Arthritis Rheum. 2019;49:S32-S35.

[3]Rheumatology. 2016;55:1693-7.

Disclosure of Interests:

Moeko Ochiai: None declared, Eiichi Tanaka Consultant of: ET has received lecture fees or consulting fees from Abbvie, Asahi Kasei pharma co., Bristol Myers Squibb, Chugai Pharmaceutical, Daiichi Sankyo Co., Eisai Pharmaceutical, Janssen Pharmaceutical K.K., Nippon Kayaku, Pfizer, Takeda Pharmaceutical, Taisho Toyama Pharmaceutical Co., and UCB Pharma., Speakers bureau: ET has received lecture fees or consulting fees from Abbvie, Asahi Kasei pharma co., Bristol Myers Squibb, Chugai Pharmaceutical, Daiichi Sankyo Co., Eisai Pharmaceutical, Janssen Pharmaceutical K.K., Nippon Kayaku, Pfizer, Takeda Pharmaceutical, Taisho Toyama Pharmaceutical Co., and UCB Pharma., Eisuke Inoue Speakers bureau: EI has received speaker fee from Bristol-Meyers, Pfizer, Merck serono., Mai Abe: None declared, Eri Sugano: None declared, Naohiro Sugitani: None declared, Kumiko Saka: None declared, higuchi yoko: None declared, Rei Yamaguchi: None declared, Naoki Sugimoto: None declared, Ikari Katsunori Speakers bureau: KI has received speaker’s fee from Asahi Kasei Pharma Corp., Astellas Pharma Inc., AbbVie Japan GK, Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eis, ai Co., Ltd., Eli Lilly Japan K.K., Janssen Pharmaceutical K.K., Kaken Pharmaceutical Co. Ltd., Mitsubishi Tanabe Pharma Corp.Pfizer Japan Inc., Takeda Pharmaceutical Co. Ltd., Teijin Pharma Ltd and UCB Japan Co. Ltd., Ayako Nakajima Grant/research support from: AN has received research grants from Chugai Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Pfizer Japan Inc., Consultant of: AN has consultant fee from Nippon Kayaku Co. Ltd., Speakers bureau: AN has received speaker’s fee from AbbVie Japan GK, Actelion Pharmaceuticals Japan LTD., Asahi Kasei Pharma Co., Astellas Pharma Inc., Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Hisamitsu Pharmaceutical Co. Inc., Kyorin Pharmaceutical Co. Ltd., Mitsubishi Tanabe Pharma Co., Otsuka Pharmaceutical Co. Ltd., Pfizer Japan Inc., and Teijin Pharma Ltd., Atsuo Taniguchi: None declared, Hisashi Yamanaka Grant/research support from: HY has received research grant or speaker fee from AbbVie, Astellas, Ayumi, Behringer, Bristol-Meyers, Chugai, Daiichi-Sankyo, Eisai, Kaken, Nippon-Shinyaku, Novartis, Ono, Pfizer, Taisyo-Toyama, Takeda, Tanabe-Mitsubishi, Teijin Pharma, Torii, UCB, YLbio., Speakers bureau: HY has received research grant or speaker fee from AbbVie, Astellas, Ayumi, Behringer, Bristol-Meyers, Chugai, Daiichi-Sankyo, Eisai, Kaken, Nippon-Shinyaku, Novartis, Ono, Pfizer, Taisyo-Toyama, Takeda, Tanabe-Mitsubishi, Teijin Pharma, Torii, UCB, YLbio., masayoshi harigai Grant/research support from: AbbVie Japan GK, Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Eisai Co., Ltd., Mitsubishi Tanabe Pharma Co., Nippon Kayaku Co., Ltd., and Teijin Pharma Ltd. MH has received speaker’s fee from AbbVie Japan GK, Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Kissei Pharmaceutical Co., Ltd., Oxford Immuotec, Pfizer Japan Inc., and Teijin Pharma Ltd. MH is a consultant for AbbVie, Boehringer-ingelheim, Kissei Pharmaceutical Co., Ltd. and Teijin Pharma.

AB0257 ASSESSMENT OF PHYSICAL DYSFUNCTION IN PATIENTS WITH RHEUMATOID ARTHRITIS WHO PLANNED PREGNANCY FROM THE IORRA COHORT

Background:

It has been reported that female rheumatoid arthritis (RA) patients have a longer time to pregnancy than healthy women (1), and that high Disease Activity Score with 28 joint count (DAS28) -CRP in preconception increases the frequency of infertility (2). Before the era of biologics, RA treatment tended to be inadequate from pregnancy planning to the end of lactation. And it was not uncommon for female RA patients to be unable to get pregnant or develop physical dysfunction as a result of insufficient control of the disease. There are some reports of disease activity during pregnancy and postpartum in RA patients, and the effects of RA disease activity on pregnancy and childbirth outcomes (3-5), but there are few reports focusing on the physical function during pregnancy planning of RA patients.

Objectives:

To investigate disease activity and physical function in female patients with RA who planned and didn’t plan pregnancy.

Methods:

The IORRA cohort is a large, single institute-based, observational cohort of RA patients established at the Institute of Rheumatology, Tokyo Women’s Medical University, in 2000. We identified female RA patients aged 20-49 years who answered ‘pregnant’ or ‘delivered’ in the IORRA survey in 2010-2015 and whose pregnancy and the pregnancy planning time was confirmed in the medical records, and defined them as the pregnancy planning (PP) group. Matched control was extracted at 1:3 ratio from patients without pregnancy plan based on entry time, age, RA disease duration, DAS28-CRP, Japanese version of Health Assessment Questionnaire (J-HAQ) score, and comorbidities. The primary endpoint was J-HAQ at 3years from the baseline, which was defined as the most recent IORRA survey before planning pregnancy. The mixed-effect model for repeated measures was used to analyze group difference.

Results:

There were 40 patients in the PP group (average 32.2 years, disease duration 5.7 years, DAS28-CRP 1.7, J-HAQ 0.26), and 120 patients in the control group (average 32.4 years, disease duration 5.9 years, DAS28-CRP 1.7, J-HAQ 0.21). The proportion of user and dosage of MTX and glucocorticoid (GC) and bDMARDs user at baseline were comparable between the groups (MTX: PP 87.5% [9.8 mg/week], control 85.0% [8.8 mg/week]; GC: PP 32.5% [3.6 mg/day], control 27.5% [4.4 mg/day]; bDMARDs: PP 40.0%, control 27.5%). DAS28-CRP at year 3 of the PP group elevated and was higher than the control group (PP 2.3, control 1.7, p<0.01), while J-HAQ was stable over the observation period and did not differ significantly at year 3 (PP 0.21, control 0.22, p=0.92). At year 3, the proportion of patients taking MTX was lower and taking GC was higher in the PP group than those in the control group (MTX: PP 36.7%, control 76.7%, p<0.01; GC: PP 70.0%, control 25.6%, p<0.01). The proportion of patients taking bDMARDs was not different in both groups (PP 36.7%, control 32.6%, p=0.68).

Conclusion:

Physical function in pregnancy planning patients with RA did not deteriorate as well as the control patients in clinical settings.

References:

[1]Arthritis Rheum. 2011;63:1517-1521.

[2]Ann Rheum Dis. 2015;10:1836-1841.

[3]J Rheumatol. 2015;42:1376-1382.

[4]J Rheumatol. 2019;46:245-250.

[5]Arthritis Care Res. 2017;69:1297-1303.

Disclosure of Interests:

Moeko Ochiai: None declared, Eiichi Tanaka Consultant of: ET has received lecture fees or consulting fees from Abbvie, Asahi Kasei pharma co., Bristol Myers Squibb, Chugai Pharmaceutical, Daiichi Sankyo Co., Eisai Pharmaceutical, Janssen Pharmaceutical K.K., Nippon Kayaku, Pfizer, Takeda Pharmaceutical, Taisho Toyama Pharmaceutical Co., and UCB Pharma., Speakers bureau: ET has received lecture fees or consulting fees from Abbvie, Asahi Kasei pharma co., Bristol Myers Squibb, Chugai Pharmaceutical, Daiichi Sankyo Co., Eisai Pharmaceutical, Janssen Pharmaceutical K.K., Nippon Kayaku, Pfizer, Takeda Pharmaceutical, Taisho Toyama Pharmaceutical Co., and UCB Pharma., Eisuke Inoue Speakers bureau: EI has received speaker fee from Bristol-Meyers, Pfizer, Merck serono., Mai Abe: None declared, Eri Sugano: None declared, Naohiro Sugitani: None declared, Kumiko Saka: None declared, higuchi yoko: None declared, Rei Yamaguchi: None declared, Naoki Sugimoto: None declared, Ikari Katsunori Speakers bureau: KI has received speaker’s fee from Asahi Kasei Pharma Corp., Astellas Pharma Inc., AbbVie Japan GK, Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eis, ai Co., Ltd., Eli Lilly Japan K.K., Janssen Pharmaceutical K.K., Kaken Pharmaceutical Co. Ltd., Mitsubishi Tanabe Pharma Corp.Pfizer Japan Inc., Takeda Pharmaceutical Co. Ltd., Teijin Pharma Ltd and UCB Japan Co. Ltd., Ayako Nakajima Grant/research support from: AN has received research grants from Chugai Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Pfizer Japan Inc., Consultant of: AN has consultant fee from Nippon Kayaku Co. Ltd., Speakers bureau: AN has received speaker’s fee from AbbVie Japan GK, Actelion Pharmaceuticals Japan LTD., Asahi Kasei Pharma Co., Astellas Pharma Inc., Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Hisamitsu Pharmaceutical Co. Inc., Kyorin Pharmaceutical Co. Ltd., Mitsubishi Tanabe Pharma Co., Otsuka Pharmaceutical Co. Ltd., Pfizer Japan Inc., and Teijin Pharma Ltd., Atsuo Taniguchi: None declared, Hisashi Yamanaka Grant/research support from: HY has received research grant or speaker fee from AbbVie, Astellas, Ayumi, Behringer, Bristol-Meyers, Chugai, Daiichi-Sankyo, Eisai, Kaken, Nippon-Shinyaku, Novartis, Ono, Pfizer, Taisyo-Toyama, Takeda, Tanabe-Mitsubishi, Teijin Pharma, Torii, UCB, YLbio., Speakers bureau: HY has received research grant or speaker fee from AbbVie, Astellas, Ayumi, Behringer, Bristol-Meyers, Chugai, Daiichi-Sankyo, Eisai, Kaken, Nippon-Shinyaku, Novartis, Ono, Pfizer, Taisyo-Toyama, Takeda, Tanabe-Mitsubishi, Teijin Pharma, Torii, UCB, YLbio., masayoshi harigai Grant/research support from: AbbVie Japan GK, Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Eisai Co., Ltd., Mitsubishi Tanabe Pharma Co., Nippon Kayaku Co., Ltd., and Teijin Pharma Ltd. MH has received speaker’s fee from AbbVie Japan GK, Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Kissei Pharmaceutical Co., Ltd., Oxford Immuotec, Pfizer Japan Inc., and Teijin Pharma Ltd. MH is a consultant for AbbVie, Boehringer-ingelheim, Kissei Pharmaceutical Co., Ltd. and Teijin Pharma.

OP0221 HAVE 5-YEAR SURVIVAL RATE AND MORTALITY CHANGED IN PATIENTS WITH EARLY RHEUMATOID ARTHRITIS IN THE PAST TWENTY YEARS?-RESULTS FROM THE IORRA COHORT

Background:

The mortality of patients with rheumatoid arthritis (RA) had been reported as being worse than that of the general population [1, 2], but is expected to have improved over time because the progress in treatment of RA during the past twenty years has been actively adopted to RA management [3, 4]. However, the change in the mortality still remains controversial in patients with early RA [5, 6].

Objectives:

To investigate whether the vital prognosis of patients with early RA has changed in the past twenty years.

Methods:

The IORRA cohort is a large observational cohort established in 2000 at the Institute of Rheumatology, Tokyo Women’s Medical University. Essentially, all Japanese patients diagnosed with RA at our institute were registered and clinical parameters were assessed biannually. As there is no National Death Registry in Japan, we obtained death report from residual families who responded to our mail query to patients who failed to conduct the subsequent IORRA survey, from physicians of affiliated hospitals and from police in case they found dead patient outside of a hospital. In this study, the patients with early RA (less than 2 years of disease duration) who participated in the survey for the first time from 2001 to 2012 were included and observed for five years from the date of the initial survey. We classified patients into group A (enrolled in 2001-2006) and B (enrolled in 2007-2012). Five-year survival rate and standardized mortality ratio (SMR) were calculated for each group. SMR was calculated using the life tables in Japanese general population reported by the Ministry of Health, Labour and Welfare, Japan. The effects of loss to follow-up cases were evaluated by multiple imputation method as a sensitivity analysis of SMR.

Results:

A total of 3,217 patients with early RA were analyzed. The number of patients was 1,609 (79.4% female) in the group A and 1,608 (81.8% female) in B. The median age at baseline was 55 in both groups. Among a total of 3,217 patients, 486 (15.1%) patients were lost during 5-year follow-up; 213 (13.2%) in the group A and 273 (17.0%) in B, respectively. During the observational period, deaths were confirmed in 47 cases (2.9%) in the group A and 45 (2.8%) in B. Major causes of death included malignancies (28% in the group A, 38% in B), respiratory involvement (23% in the group A, 40% in B), cerebrovascular disorders (11% in the group A, 2% in B), and cardiovascular disorders (11% in the group A, 0% in B). The five-year survival rate was 88.8% for the group A and 87.8% for B, and the SMR was 0.81 (95%CI: 0.59-1.08) for the group A and 0.78 (0.57-1.04) for B when assuming all the lost to follow-up patients were alive for 5 years. In the sensitivity analysis assuming that the mortality rate of patients who were lost to follow-up was twice as that of the general population, the SMR was 0.90 (0.68-1.19) for the group A and 0.92 (0.68-1.23) for B.

Conclusion:

The mortality of patients with early RA in the past twenty years has been comparable to that of the Japanese general population. In addition, the SMR and the five-year survival rate did not change overtime.

References:

[1]Cobb, S., et al. N Engl J Med 1953; 249(14): 553-556.

[2]Nakajima, A., et al. Scand J Rheumatol 2010; 39(5): 360-367.

[3]Smolen, J. S., et al. Ann Rheum Dis 2014; 73(3): 492-509.

[4]Singh, J. A., et al. Arthritis Care Res 2016; 68(1): 1-25.

[5]Lacaille, D., et al. Ann Rheum Dis 2017; 76(6): 1057-1063.

[6]Humphreys, J. H., et al. Arthritis Care Res 2014; 66(9): 1296-1301.

Disclosure of Interests:

Naohiro Sugitani: None declared, Eiichi Tanaka Consultant of: Abbvie, Asahi Kasei pharma co., Bristol Myers Squibb, Chugai Pharmaceutical, Daiichi Sankyo Co., Eisai Pharmaceutical, Janssen Pharmaceutical K.K., Nippon Kayaku, Pfizer, Takeda Pharmaceutical, Taisho Toyama Pharmaceutical Co., and UCB Pharma., Eisuke Inoue Speakers bureau: EI has received speaker fee from Bristol-Meyers, Pfizer, Merck serono., Mai Abe: None declared, Eri Sugano: None declared, Kumiko Saka: None declared, Moeko Ochiai: None declared, Yoko Shimizu: None declared, Rei Yamaguchi: None declared, Naoki Sugimoto: None declared, Katsunori Ikari Speakers bureau: Asahi Kasei Pharma Corp., Astellas Pharma Inc., AbbVie Japan GK, Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eis, ai Co., Ltd., Eli Lilly Japan K.K., Janssen Pharmaceutical K.K., Kaken Pharmaceutical Co. Ltd., Mitsubishi Tanabe Pharma Corp.Pfizer Japan Inc., Takeda Pharmaceutical Co. Ltd., Teijin Pharma Ltd and UCB Japan Co. Ltd., Ayako Nakajima Grant/research support from: AN has received research grants from Chugai Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Pfizer Japan Inc., Consultant of: AN has consultant fee from Nippon Kayaku Co. Ltd., Speakers bureau: AN has received speaker’s fee from AbbVie Japan GK, Actelion Pharmaceuticals Japan LTD., Asahi Kasei Pharma Co., Astellas Pharma Inc., Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Hisamitsu Pharmaceutical Co. Inc., Kyorin Pharmaceutical Co. Ltd., Mitsubishi Tanabe Pharma Co., Otsuka Pharmaceutical Co. Ltd., Pfizer Japan Inc., and Teijin Pharma Ltd., Atsuo Taniguchi: None declared, Hisashi Yamanaka Grant/research support from: HY has received research grant or speaker fee from AbbVie, Astellas, Ayumi, Behringer, Bristol-Meyers, Chugai, Daiichi-Sankyo, Eisai, Kaken, Nippon-Shinyaku, Novartis, Ono, Pfizer, Taisyo-Toyama, Takeda, Tanabe-Mitsubishi, Teijin Pharma, Torii, UCB, YLbio., Speakers bureau: HY has received research grant or speaker fee from AbbVie, Astellas, Ayumi, Behringer, Bristol-Meyers, Chugai, Daiichi-Sankyo, Eisai, Kaken, Nippon-Shinyaku, Novartis, Ono, Pfizer, Taisyo-Toyama, Takeda, Tanabe-Mitsubishi, Teijin Pharma, Torii, UCB, YLbio., masayoshi harigai Grant/research support from: AbbVie Japan GK, Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Eisai Co., Ltd., Mitsubishi Tanabe Pharma Co., Nippon Kayaku Co., Ltd., and Teijin Pharma Ltd. MH has received speaker’s fee from AbbVie Japan GK, Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Kissei Pharmaceutical Co., Ltd., Oxford Immuotec, Pfizer Japan Inc., and Teijin Pharma Ltd. MH is a consultant for AbbVie, Boehringer-ingelheim, Kissei Pharmaceutical Co., Ltd. and Teijin Pharma.

THU0086 FACTORS ASSOCIATED WITH TREATMENT RESPONSE IN PATIENTS WITH ELDERLY-ONSET RHEUMATOID ARTHRITIS: 3-YEAR OBSERVATION USING THE IORRA COHORT

Background:

Patients with elderly-onset rheumatoid arthritis (EORA) are on the rise in the aging or super-aging society, especially in Japan. Patients with EORA have more comorbidities than those with younger-onset RA, a higher risk of adverse drug reactions due to reduced drug metabolism, and a higher risk of infections1). Therefore, patients with EORA tend to receive suboptimal treatment, resulting in insufficient control of disease activity2). Although several studies reported treatment responsiveness in patients with EORA, many of them have a limited observation period3-8), and long-term treatment responses and their associated factors need to be clarified.

Objectives:

We retrospectively evaluated treatment responses of patients with EORA for 3 years and their associated factors in a clinical setting.

Methods:

The Institute of Rheumatology Rheumatoid Arthritis (IORRA) cohort is a large, single institute-based, observational cohort of RA patients established at Institute of Rheumatology, Tokyo Women’s Medical University, in 2000. The subjects were RA patients who first enrolled in the IORRA cohort from 2010 to 2014, were over 60 years old with less than 1-year disease duration, and had a DAS28-ESR over 3.2 at entry. The primary endpoint was DAS28-ESR <3.2 after 3-year observation. A multivariate logistic regression analysis was conducted to identify factors at baseline associated with the primary endpoint. The missing values of DAS28-ESR were imputed by using the last observation carried forward method.

Results:

Among a total of 250 patients in this study, 152 patients (60.8%) achieved DAS28-ESR <3.2 after 3-year observation (remission/low disease activity (RL) group), and 98 patients did not (moderate/high disease activity (MH) group). Baseline characteristics of the patients were as follows (average ± SD or %): the RL group, age 69.9 ± 6.5, female 77%, DAS28-ESR 4.3 ± 0.8, J-HAQ 0.9 ± 0.7, PSL user 23.7%, MTX user 64.5%, and biologics user 4.0%; the MH group, age 69.4 ± 6.7, female 80.6%, DAS28-ESR 4.4 ± 0.8, J-HAQ 1.0 ± 0.7, PSL user 36.7%, MTX user 64.3%, and biologics user 6.1%. Proportions of the patients with cardiovascular disease and malignancy were 13.3% and 11.2% in the MH group and 5.9% and 1.3% in the RL group, respectively. DAS28-ESR and J-HAQ score after 3-year observation of the RL group were 2.3±0.5 and 0.4±0.5, respectively, and those of the MH group were 3.4±0.9 and 1.0±0.8, respectively. Corticosteroid use and having malignancy at baseline were associated with not achieving DAS28-ESR <3.2 after 3-year observation using multivariate analysis (Table 1). Similar results were obtained when MTX use and corticosteroid use were replaced by the average dose of each drug.

Conclusion:

The majority of the patients with EORA achieved DAS28-ESR <3.2 after 3-year observation, and no use of corticosteroid and absence of malignancy at baseline were associated with the good outcome.

References:

[1]Nat Rev Rheumatol 2013;9:604-613

[2]Ann Rheum Dis 2006;65:1226-1229

[3]Ann Rheum Dis 2009;68:1470–1473

[4]Joint Bone Spine 2015;82:25-30

[5]J Rheumatol 2016;43:1974-1983

[6]Rheumatology 2015;54:798-807

[7]Rheumatology 2014;53:1075-1086

[8]Japanese Journal of Geriatrics 2018;55:251-258

Acknowledgments:

We thank all patients who participated in the IORRA survey and all of the members of the Institute of Rheumatology, Tokyo Women’s Medical University, for the successful management of the IORRA cohort.

Disclosure of Interests:

Mai Abe: None declared, Eiichi Tanaka Consultant of: Abbvie, Asahi Kasei pharma co., Bristol Myers Squibb, Chugai Pharmaceutical, Daiichi Sankyo Co., Eisai Pharmaceutical, Janssen Pharmaceutical K.K., Nippon Kayaku, Pfizer, Takeda Pharmaceutical, Taisho Toyama Pharmaceutical Co., and UCB Pharma., Eisuke Inoue Speakers bureau: EI has received speaker fee from Bristol-Meyers, Pfizer, Merck serono., Eri Sugano: None declared, Naohiro Sugitani: None declared, Kumiko Saka: None declared, Moeko Ochiai: None declared, Yoko Shimizu: None declared, Rei Yamaguchi: None declared, Naoki Sugimoto: None declared, Katsunori Ikari Speakers bureau: Asahi Kasei Pharma Corp., Astellas Pharma Inc., AbbVie Japan GK, Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eis, ai Co., Ltd., Eli Lilly Japan K.K., Janssen Pharmaceutical K.K., Kaken Pharmaceutical Co. Ltd., Mitsubishi Tanabe Pharma Corp.Pfizer Japan Inc., Takeda Pharmaceutical Co. Ltd., Teijin Pharma Ltd and UCB Japan Co. Ltd., Ayako Nakajima Grant/research support from: AN has received research grants from Chugai Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Pfizer Japan Inc., Consultant of: AN has consultant fee from Nippon Kayaku Co. Ltd., Speakers bureau: AN has received speaker’s fee from AbbVie Japan GK, Actelion Pharmaceuticals Japan LTD., Asahi Kasei Pharma Co., Astellas Pharma Inc., Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Hisamitsu Pharmaceutical Co. Inc., Kyorin Pharmaceutical Co. Ltd., Mitsubishi Tanabe Pharma Co., Otsuka Pharmaceutical Co. Ltd., Pfizer Japan Inc., and Teijin Pharma Ltd., Atsuo Taniguchi: None declared, Hisashi Yamanaka Grant/research support from: HY has received research grant or speaker fee from AbbVie, Astellas, Ayumi, Behringer, Bristol-Meyers, Chugai, Daiichi-Sankyo, Eisai, Kaken, Nippon-Shinyaku, Novartis, Ono, Pfizer, Taisyo-Toyama, Takeda, Tanabe-Mitsubishi, Teijin Pharma, Torii, UCB, YLbio., Speakers bureau: HY has received research grant or speaker fee from AbbVie, Astellas, Ayumi, Behringer, Bristol-Meyers, Chugai, Daiichi-Sankyo, Eisai, Kaken, Nippon-Shinyaku, Novartis, Ono, Pfizer, Taisyo-Toyama, Takeda, Tanabe-Mitsubishi, Teijin Pharma, Torii, UCB, YLbio., masayoshi harigai Grant/research support from: AbbVie Japan GK, Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Eisai Co., Ltd., Mitsubishi Tanabe Pharma Co., Nippon Kayaku Co., Ltd., and Teijin Pharma Ltd. MH has received speaker’s fee from AbbVie Japan GK, Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Kissei Pharmaceutical Co., Ltd., Oxford Immuotec, Pfizer Japan Inc., and Teijin Pharma Ltd. MH is a consultant for AbbVie, Boehringer-ingelheim, Kissei Pharmaceutical Co., Ltd. and Teijin Pharma.

P6503Impact of ascending aortic disease categories on the histopathological degenerative changes in relation to aorta dimensions

Background

Recently a consensus statement on surgical pathology of the aorta was published to improve pathological assessment of non-inflammatory aortic diseases.

Purpose

We used data of the ascending aorta surgical specimens for aneurysm or dissection to better understand the relationship between the histological medial degenerative changes (MDC) and aortic size assessed by computed tomography.

Methods

In this retrospective single center study we retrieved 719 ascending aorta surgical specimens from January 2010 until June 2018 and analyzed them according to the consensus statement and scored MDC [elastic fiber fragmentation and/or loss (EFFL), smooth muscle nuclei loss (SMNL), mucoid extracellular matrix accumulation (MEMA); intralamellar (I) or translamellar (T)] and measured medial wall thickness on correlation with imaging data and the status [thoracic aorta aneurysm (TAA), dissection (TAD), bicuspid aortic valve (BAV) or non-BAV].

Results

We analyzed 517 patients with degenerative aortic diseases (mean age, 61 years) whose imaging data were obtained, with BAV in 203 (TAD 4%, TAA 96%) and with non-BAV in 314 (TAD 44%, TAA 56%). In TAA subset, scores of EFFL, SMNL and MEMA-T were lower in BAV than in non-BAV (p<0.01). Maximum aortic diameters averaged 50 mm in TAD and 53 mm in TAA. In relation to the aortic diameter, the scores of EFFL, SMNL and MEMA-T were more important in non-BAV subset than in BAV, and in TAD subset than in TAA particularly at the small aortic diameters (<50mm) (Figure). Independent predictors of aortic dissection included thicker medial wall (odds ratio [OR], 6.5; 95% confidence interval [CI], 2.6 to 17.6; p<0.0001) and greater SMNL (OR, 1.2; 95% CI, 1.1 to 1.3; p=0.003).

Conclusions

Non-BAV aortas were associated with higher scores of MDC than BAV aortas. Advanced MDC was correlated with increased aortic diameter in the ascending aortic diseases. However, in even smaller aortic diameters, MDC in patients with TAD was important.

Iodoarene-catalyzed oxidative transformations using molecular oxygen

Molecular oxygen serves as an oxidant for the glycol scission of diols and the Hofmann rearrangement of amides using an iodoarene catalyst.

Ghrelin enhancer, rikkunshito, improves postprandial gastric motor dysfunction in an experimental stress model

BACKGROUND

Functional dyspepsia (FD) is one of the most common disorders of gastrointestinal (GI) diseases. However, no curable treatment is available for FD because the detailed mechanism of GI dysfunction in stressed conditions remains unclear. We aimed to clarify the association between endogenous acylated ghrelin signaling and gastric motor dysfunction and explore the possibility of a drug with ghrelin signal-enhancing action for FD treatment.

METHODS

Solid gastric emptying (GE) and plasma acylated ghrelin levels were evaluated in an urocortin1 (UCN1) -induced stress model. To clarify the role of acylated ghrelin on GI dysfunction in the model, exogenous acylated ghrelin, an endogenous ghrelin enhancer, rikkunshito, or an α2 -adrenergic receptor (AR) antagonist was administered. Postprandial motor function was investigated using a strain gauge force transducer in a free-moving condition.

KEY RESULTS

Exogenous acylated ghrelin supplementation restored UCN1-induced delayed GE. Alpha2 -AR antagonist and rikkunshito inhibited the reduction in plasma acylated ghrelin and GE in the stress model. The action of rikkunshito on delayed GE was blocked by co-administration of the ghrelin receptor antagonist. UCN1 decreased the amplitude of contraction in the antrum while increasing it in the duodenum. The motility index of the antrum but not the duodenum was significantly reduced by UCN1 treatment, which was improved by acylated ghrelin or rikkunshito.

CONCLUSIONS & INFERENCES

The UCN1-induced gastric motility dysfunction was mediated by abnormal acylated ghrelin dynamics. Supplementation of exogenous acylated ghrelin or enhancement of endogenous acylated ghrelin secretion by rikkunshito may be effective in treating functional GI disorders.

Genetic variation of vascular endothelial growth factor pathway does not correlate with the severity of retinopathy of prematurity

OBJECTIVE

The aim of this study was to assess the genetic effects of the vascular endothelial growth factor (VEGF) pathway on retinopathy of prematurity (ROP).

STUDY DESIGN

A prospective study from a tertiary center that enrolled 204 Japanese infants (<35 weeks of gestational age (GA)) having no anomalies. ROP developed in 127, but not in 77 infants. The relative severity was defined as non-severe, moderate and severe ROP for GA, based on the staging criteria. VEGF (g.-634G>C, g.+13553C>T) and VEGF-receptor (KDR g.+4422(AC)11 to 14, Flt-1 c.+6724(TG)13 to 23) gene polymorphisms and clinical variables were assessed by uni/multivariate analyses.

RESULT

The frequency of polymorphisms did not differ between ROP and non-ROP patients. The TT genotype of g.+13553 showed a higher odds ratio for non-severe ROP than CC genotype (P=0.006). Multivariate analyses indicated that low birth weight, blood transfusion and respiratory distress syndrome, but not polymorphisms, were the risk factors of advanced ROP (≥ stage 3).

CONCLUSION

A genotype of the VEGF pathway weakly affects the severity of ROP compared with other clinical factors.

Congenital multiple pituitary hormone deficiency associated with hyperammonemia: a case report with a short review of the literature

We herein report a case study of a female newborn with multiple pituitary hormone deficiencies who presented with generalized seizures, hypoglycemia and hyperammonemia at 18 h after birth. In addition, we review the association of hyperammonemia in neonates with multiple pituitary hormone deficiencies reported in the previous literature. This unrecognized association should be taken into account for the early diagnosis and treatment of these patients.

Development of LC-MS method for detection of mutant uromodulin protein

Mutations in the uromodulin gene cause the autosomal disorders familial juvenile hyperuricemic nephropathy (FJHN) and medullary cystic kidney disease type 2 (MCKD2). However, methods to detect the mutant form of the uromodulin protein have not been developed. In this study, we developed a liquid chromatography-mass spectrometry (LC-MS) method for detection of the mutated uromodulin peptide (C148W). Our method can distinguish the mutant peptide, GWHWE, from wildtype peptide, GWHC*E. Using MS/MS analysis with a selected reaction monitoring (SRM) mode, peptide-specific fragment ions (m/z 714 --> 381, 471, 567, and 679 for GWHWE and m/z 688 --> 381, 445, 541, and 653 for GWHC*E) were detected.

Development of improved SNAP25 endopeptidase immuno-assays for botulinum type A and E toxins

Botulinum neurotoxins contain proteases that cleave specific intra-neural proteins essential for neurotransmitter release. Toxin types A, E and C1 intra-cellularly cleave SNAP25 resulting in a flaccid paralysis. As a consequence, various different endopeptidase assays have been developed to specifically detect the toxins enzymatic activity, however, many of these suffer from variability, low sensitivity or unwanted interference exerted by product specific excipients. The current studies utilised solid phase synthesized SNAP25(137-206) peptide substrate, and specific antibody to either the SNAP25(190-197) or (173-180) octapeptide epitopes that become exposed following cleavage by toxin types A or E respectively. Assay sensitivity was increased 50 fold by the use of an optimal 0.5% Tween 20 concentration in tandem to 0.1% albumin together with an improved, simplified assay design without a pre-activation / reduction step. Sensitivities capable of detecting 0.01 LD50/ml (40fg/ml or 0.3fM) of type A toxin was achieved with a linear dose response between 0.1 and 1 LD50/ml. This provides sufficient sensitivity and precision (inter assay GCV of < 2%) for monitoring activity within any current or newly marketed therapeutic products containing less units per vial and may also make it applicable for other applications. Both purified haemagglutinin free and complexed toxins could be detected equally. Unlike type A, type E activity could unexpectedly be detected in the complete absence of reducing conditions and the optimal assay had a limit of detection of 0.2LD50/ml (4.8pg/ml) with a linear dose response between 1 and 10LD50/ml. The principle of using a detecting antibody to a substrate sequence buried within the native substrates alpha-helix may be further expanded to other specific enzyme cleavage reactions in the future.

A novel "permanent" acid-type hair color made possible with dye-metal ion complex technology

The advantages and disadvantages of oxidative permanent and acid-type semi-permanent hair colors are evident. The former provides a longlasting "permanent" color, while the latter imparts less damage to the hair. We developed a novel acid-type hair color technology that can allow an acid dye and a metal ion to form a complex inside the hair similar to the oxidative hair color. It is well known that acid dye diffuses into the hair and creates an ionic bond with the positively charged amino acid residues of hair protein. However, the dye can be extracted easily from the hair by daily shampooing due to the weakness of the bond. In order to strengthen this bond and to prevent the extraction of the dye by shampooing, an aluminum chloride ion was chosen as the metal ion component to form the dye-metal complex. A proper composition of penetration enhancers, benzyl alcohol and ethyl alcohol, was required to allow acid dyes to interact with the aluminum chloride ion after each component penetrates deeply into the hair to form a complex inside the hair. To provide color brightness and a color longevity effect to hair color, glycolic acid was also selected due to the observation that a weak acid with a small molecular weight would enhance those effects.

Existence of phenol oxidase in the argasid tick Ornithodoros moubata

Phenol oxidase (PO, EC 1.10.3.1) activity was detected in the hemolymph of the fourth instar nymphs of the argasid tick, Ornithodoros moubata, with peak levels corresponding to the days before the majority of the nymphs had molted, suggestive of a protective role of PO during the ecdysial phase. Higher PO activity was detected in plasma relative to the hemolymph and was negligible in hemocytes. The concentration of the hemolymph and plasma assayed clearly influenced the level of PO activity, and was significantly reduced ( P<0.005) after treatment with 1-phenyl-2 thiourea, a specific PO inhibitor. This is the first report of the existence of PO in the hemolymph and plasma of a soft tick species. The regulation of PO activity and its precise role in soft tick immunity, particularly during the ecdysial phase, are interesting and need to be examined further.

Increased leukocyte activity as a predictor for flow-limiting coronary lesions in patients with angina pectoris

Myocardial ischemia initiates an acute inflammatory response, in which polymorphonuclear leukocytes (PMNs) are major participants. We investigated whether increased PMN activity in the peripheral blood is a marker for high-grade coronary artery stenosis in patients with angina pectoris. PMN activity was examined in 45 patients by measuring the luminol-dependent chemiluminescence (CL) response of the peripheral blood upon addition of phorbol myristate acetate (PMA). The CL of patients with angiographic filling delay was 1.6-fold higher than in patients without delay (480+/-54 vs. 302+/-33 counts/PMN, P<0.01). The CL of patients with a filling delay of the left anterior descending artery (LAD) was 1.7-fold higher than in patients without an LAD filling delay (537+/-79 vs. 317+/-27 counts/PMN, P<0.01). With the CL cut-off at 400 counts/PMN, the sensitivity and specificity for detecting an angiographic filling delay of the LAD were 69 and 75%, respectively. These data indicate that PMN activity in the peripheral blood is increased with the presence of a flow-limiting coronary lesion showing an angiographic filling delay. Measuring PMN activity may be a useful approach to assess indications for and timing of angiography and/or adjunctive invasive therapies in patients with angina pectoris.

Quality control of diphtheria tetanus acellular pertussis combined (DTaP) vaccines in Japan

Diphtheria tetanus acellular pertussis combined (DTaP) vaccines have been successfully used in Japan by controlling their potencies and toxicities with animal models. In accordance with the recent practical introduction of DTaP vaccines of various formulations, a question has been raised in other nations as to the efficacy of a quality control system based on animal tests and standard preparations. The World Health Organization issued its guidelines on the production and quality control of acellular pertussis vaccines in 1998 along with the concept of quality control by ensuring that production lots were consistent with clinical trial lots, rather than by comparing them with standard preparations in traditional laboratory tests. However, because it is not feasible to evaluate the combined use of vaccines from different manufacturers in a clinical study, the alternative trend of quality control may give rise to a difficulty in rationalizing the practical immunizations to use vaccines of different brands in a mixed consequence. A standardized national regulation system to ensure the equivalence of approved products would be essential for such an immunization practice. The success of the Japanese DTaP vaccination suggests the possibility of an effective quality control of DTaP vaccines by means of standardized test systems.

Limitations of successive transradial approach in the same arm: the Japanese experience

The transradial approach (TRA) has been used for diagnostic and interventional cardiology. It has not previously been determined how many times the same radial artery can be cannulated without complications. A total of 812 patients (502 men and 310 women) underwent angiography or angioplasty via the TRA between 1997 and 1999 at our institution with a total of 1,438 procedures. Sheaths were 5 (55%) or 6 Fr (45%). Dropout rates of 3.5% and 7.9% were found at the second TRA attempt in the men and the women, respectively. Of the 62 TRA failures, 56 (90%) were due to narrowing or occlusion of the radial artery after the previous TRA procedure. A third TRA procedure was possible in 90% of the men and 80% of the women. A fifth TRA procedure was possible in 70% of the men and 50% of the women. The dropout rates for TRA increased as successive punctures were performed. This was primarily due to vessel narrowing and occlusion occurring as a function of multiple punctures.

Thermal and photochemical solvolysis of (E)- and (Z)-2-phenyl-1-propenyl(phenyl)iodonium tetrafluoroborate: benzenium and primary vinylic cation intermediates

The thermal and photochemical solvolysis of the two stereoisomeric 2-phenyl-1-propenyl(phenyl)iodonium tetrafluoroborates has been investigated in alcoholic solvents of varying nucleophilicity. The product profiles and rates of product formation in the thermal reaction are all compatible with a mechanism involving cleavage of the vinylic C-I bond assisted by the group in the trans position (methyl or phenyl), always leading to rearranged products. Depending on the nucleophilicity of the solvent, the primarily formed cations may or may not further rearrange to more stable isomers. The less reactive Z compound also yields some unrearranged vinyl ether product in the more nucleophilic solvents via an in-plane S(N)2 mechanism. The mechanism of the photolysis involves direct, unassisted cleavage of the vinylic, and aromatic, C-I bond in an S(N)1 mechanism. This produces a primary vinyl cation, which is partially trapped prior to rearrangement in methanol. The unrearranged vinyl ethers are mainly formed with retention of configuration via a lambda3-iodonium/solvent complex in an S(N)i mechanism. Thermal and photochemical solvolyses of iodonium salts are complementary techniques for the generation of different cation intermediates from the same substrate.

High susceptibility of Scid mice to colon carcinogenesis induced by azoxymethane indicates a possible caretaker role for DNA-dependent protein kinase

Severe combined immunodeficiency (Scid) mice have defects in V(D)J recombination and DNA double-strand breaks repair caused by an inherited genetic defect in the catalytic subunit of DNA-dependent protein kinase (DNA-PKcs). Scid mice are highly susceptible to development of T-cell lymphomas, and because of the nature of its association with DNA repair and recombination, DNA-PKcs is considered to belong to the caretaker class of tumor suppressor genes. In the present study, the susceptibility of Scid mice to colon carcinogenesis due to administration of azoxymethane (AOM) was investigated. Significantly higher susceptibility in terms of induction of both aberrant crypt foci (ACFs), putative pre-cancerous lesions of the colon and colon cancers was observed as compared with the isogenic strain, C.B-17 mice. The incidences of colon tumors, either adenomas or adenocarcinomas, in Scid and C.B-17 mice after administration of AOM (10 mg/kg body weight/week) for 6 weeks were 87% (26 of 30) and 50% (15 of 30), respectively, by experimental week 22 (P < 0.01). The multiplicity of colon tumors in Scid mice was also significantly higher than in C.B-17 mice, being 2.2 +/- 1.5 and 0.9 +/- 1.2, respectively (P < 0.001). The present study clearly demonstrated high susceptibility of Scid mice to colon carcinogenesis, which might be attributable to disruption of the caretaker role of DNA-PK in colonic epithelial cells.

Psoas abscess and cellulitis of the right gluteal region resulting from carcinoma of the cecum

Although retroperitoneal or psoas abscess is an unusual clinical problem, the insidious and occult characteristics of this abscess sometimes cause diagnostic delays, resulting in considerably high morbidity and mortality. In particular, psoas abscess caused by perforated colon carcinoma is uncommon. We report a case of psoas abscess caused by a carcinoma of the cecum. A 72-year-old Japanese woman was admitted to our hospital, with pain in the right groin and buttock. The pain had appeared 6 months before admission, and the symptoms had then been relieved by oral antibiotics. On March 25, 1999, inflammatory signs in the right buttock indicated localized cellulitis, and incision and drainage was performed at a local hospital. The patient was referred to our hospital on the same day. On admission to our hospital, computed tomography (CT) scan revealed a thick right-sided colonic wall and enlargement of the right ileopsoas muscle. Barium enema and colonofiberscopy revealed an ulcerated tumor occupying the entire circumference of the cecum. A retroperitoneal abscess and fistula had been formed by the retroperitoneal perforation of cecum carcinoma: surgical resection was performed after remission of the local inflammatory signs. Operative findings indicated that the cancerous lesion and its surrounding tissues were firmly attached to the right iliopsoas and major psoas muscle, and en-bloc resection, including adjacent muscular tissue, was performed. The fact that carcinoma of the colon could be a cause of psoas abscess and cellulitis in the gluteal region should be considered when an unexplained psoas abscess is diagnosed.

Stereoselective synthesis of (Z)-enethiols and their derivatives: vinylic S(N)2 reaction of (E)-alkenyl(phenyl)-lambda3-iodanes with thioamides

[reaction: see text]. Exposure of (E)-beta-alkylvinyl(phenyl)-lambda3-iodanes to thioamides in dichloromethane at room temperature was found to result in a bimolecular nucleophilic substitution (S(N)2) at the vinylic carbon atom to give inverted (Z)-enethiols and/or (Z)-S-vinylthioimidonium salts. Vinylic S(N)2 reactions with thioureas are also discussed.

Spontaneous necrosis of gallbladder carcinoma in patient with pancreaticobiliary maljunction

While gallbladder carcinoma is occasionally associated with pancreaticobiliary maljunction, spontaneous necrosis of carcinoma is extremely rare. We herein present a case of spontaneous necrosis of gallbladder carcinoma associated with direct invasion of viable cancer cell nests to the muscularis propria and subserosal layer located beneath the primary nodules. A 65-year-old Japanese man was admitted to a local hospital, complaining of repeated discomfort in the right hypochondrium. Ultrasonography and computed tomography scanning revealed cholecystitis associated with gallstones. Cholecystectomy was performed, and operative cholangiography demonstrated pancreaticobiliary maljunction. The resected gallbladder showed multiple mixed stones filled with necrotic debris and bile sludge. Scrutiny of the mucosal surface revealed multiple small necrotic nodules in the fundus, which were histologically confirmed to be necrotic remnants of a cancerous glandular structure. Small nests of papillary adenocarcinoma were found beneath the nodules in the muscularis propria and in the venous structure located in the connective tissues next to the divided margin of the gallbladder bed. Resection of S4a and S5 of the liver and resection of the extrahepatic bile duct was then performed to remove the remaining cancerous tissues and/or micrometastasis in the liver and bile duct. The biliary tree was reconstructed with a hepaticoduodenostomy. No cancer nests or any precancerous lesions were found in the additionally resected specimens. This case indicates a unique morphological feature of gallbladder carcinoma associated with pancreaticobiliary maljunction, which provides some insight into the pathogenesis of spontaneous necrosis of gallbladder carcinoma.

A quantitative in vitro assay for detecting biological activity of endotoxin using rabbit peripheral blood

The pyrogen test or the endotoxin test has been playing a crucial role in detecting endotoxin in parenteral drugs. The current test methods, however, have disadvantages such as requiring a relatively high number of animals or an inadequacy in direct evaluation of in vivo activity. We made an attempt to establish a new in vitro assay method that can overcome the shortcomings of the current assay methods. We standardized the system of tumor necrosis factor-alpha (TNF-alpha) induction from the peripheral blood of rabbits for assaying endotoxin activity. This in vitro assay showed a linear dose-response regression between 0.1 and 5.0 endotoxin units per milliliter of endotoxin and a definite homogeneity of variance by logarithmically transforming the endotoxin and TNF-alpha concentrations in the reaction mixtures at 5 h of incubation at 37 degrees C. The assay showed a definite correlation with the pyrogen test but not with the endotoxin test when endotoxins from various bacteria were tested.

Oxidative ring cleavage of cyclic acetals with hypervalent tert-butylperoxy-lambda(3)-iodanes

[reaction: see text] Exposure of cyclic acetals to 1-tert-butylperoxy-1,2-benziodoxol-3(1H)-one in the presence of tert-butyl hydroperoxide and potassium carbonate in benzene at room temperature results in oxidative ring cleavage to glycol monoesters via intermediate tert-butylperoxy ortho esters.

LacI transgenic animal study: relationships among DNA-adduct levels, mutant frequencies and cancer incidences

In the processes of carcinogenesis caused by genotoxic carcinogens, DNA-adduct formation and resultant genetic changes are crucially important. In this report, the relationship between DNA-adduct levels and mutant frequencies (MFs), DNA-adduct levels and cancer incidences, and MFs and cancer incidences induced by heterocyclic amines (HCAs), to which humans are exposed on daily basis were investigated. There was no direct correlation between adduct levels and MFs detected after feeding Big Blue mice with 2-amino-3,4-dimethylimidazo[4,5-f]quinoline (MeIQ), in a comparison among various organs. Further, there was no direct correlation between DNA-adduct levels and cancer incidences, in a comparison among various organs of F344 rats. Since DNA-adducts are fixed as mutations after cell proliferation, and mutations in cancer-related genes result in cancer development, it is expected that MFs directly correlate with cancer incidences. However, there was no direct correlation between MFs and cancer incidences. Possible mechanisms involved in the discordance between DNA damage markers and cancer incidences are discussed.

Pancreatic ductal adenocarcinoma associated with Potter type III cystic disease

Although polycystic liver disease (PLD) is known to be associated with autosomal dominant polycystic kidney disease, a finding of PLD with pancreatic ductal adenocarcinoma is extremely rare. We have experienced one such case of a ductal adenocarcinoma of the pancreas in a patient with Potter type III cystic disease of the liver and kidney. A 63-year-old man was admitted to our hospital because of obstructive jaundice. Six months previously, on admission to a local hospital for treatment of diabetes mellitus, he had been found to have polycystic disease of the liver and kidney. Ultrasound examination revealed dilatation of the intrahepatic bile duct and the common bile duct. Blood tests showed an elevated total bilirubin level. Abdominal computed tomography scans and magnetic resonance imaging demonstrated polycystic lesions in the liver and the bilateral kidneys. Percutaneous transhepatic cholangio-drainage was performed, and fluorography of the biliary tree revealed obstruction of the lower common bile duct, causing jaundice. This appears to be a case of independent association of pancreatic ductal adenocarcinoma with polycystic disease of the liver and kidney. The patient's sister, who also had polycystic disease of the liver and kidney, had died of squamous cell carcinoma of the tongue. Although familial associations of carcinomas with polycystic liver disease may be extremely rare, they provide a perspective for the etiology of polycystic liver disease.

Hyperplastic polyp of the gallbladder in a child

We report a case of hyperplastic polyp of the gallbladder in a 6-year-old girl, successfully treated by laparoscopic cholecyctectomy after a 2-year follow-up from the original diagnosis. On her first admission, serum amylase level was very high, so that congenital pancreaticobiliary maljunction (PBM) was suspected. Although it became clear afterwards that the high serum amylase level was derived from a mumps infection, the diagnosis of PBM was not excluded until intraoperative cholangiography was conducted. The tumor in the gallbladder had doubled in size in 2 years. It was not possible to obtain biopsy specimens for histological diagnosis, so the risk of the tumor being malignant could not be completely excluded until surgical resection had been carried out. In spite of the rapid tumor growth, no neoplastic features were seen in the tumor by histopathological examination of the resected specimen; thus, a diagnosis of a hyperplastic polyp of the gallbladder was made.

Platelet aggregability under shear is enhanced in patients with unstable angina pectoris who developed acute myocardial infarction

The study investigated whether patients hospitalized for unstable angina pectoris (UAP), who subsequently develop complete coronary thrombosis (acute transmural myocardial infarction (AMI)) despite medical treatment, exhibit platelet hyperaggregability in an assay system that does not employ agonist stimulation. The study comprised 89 patients with UAP (Braunwald type B). Unfractionated heparin and nitrate were administered to all patients via continuous intravenous drip together with aspirin taken orally. Citrated platelet-rich plasma (230-250x 10(3)/microl) was obtained on admission and again, in some patients, following the AMI. Platelet aggregability was measured in an optically modified cone-plate viscometer that enables the detection of platelet aggregation without agonist stimulation. A continuous shear rate of 1,200/s was employed. Of the 89 patients, 85 were finally stabilized, while 4 developed an AMI accompanied by persistent ST-segment elevation with increased levels of plasma creatine kinase within 3 h after starting the treatment. The extent of platelet aggregation on admission was significantly greater in these 4 patients compared with the 85 who were stabilized (87.8+/-6.8%, n=4 vs 26.8+/-9.1%, n=85; mean+/-SD). These data suggest that platelet hyperaggregability mediated mainly by fibrinogen binding to the activated glycoprotein IIb/IIIa complex occurs before a complete thrombotic occlusion and this evaluation may provide important information before the onset of myocardial infarction.

Metastasis to the forearm skeletal muscle from an adenocarcinoma of the colon: report of a case

While the liver and lung are primary targets for distant metastasis from colorectal carcinoma, metastasis in other distant sites is rarely found. We report herein an unusual case of metastasis to the skeletal muscle of the right forearm from an adenocarcinoma of the transverse colon. A 60-year-old man was originally admitted to our hospital for surgical treatment of an intestinal obstruction caused by a transverse colon carcinoma. Transverse colon resection along with lymph node dissection was performed and no evidence of distant metastatic foci was found. Angiography-enhanced computed tomography scanning done 14 months after the first operation revealed multiple hepatic metastases which were resected. A metastasis was subsequently detected in the right extensor carpi ulnaris muscle 2 years after the primary resection, and a major part of the right extensor carpi ulnaris and the extensor digiti minimi muscle were resected, warranting a sufficient margin of 5 cm of normal tissue from the tumor. Reattachment of the residual muscles into the ulna was performed. Metastases to bone and/or soft tissues from colorectal carcinomas are extremely rare and to our knowledge, only eight other cases have been reported in the world literature. This low incidence may be related to the anatomical characteristics and/or the biochemical environment of the skeletal muscle, but it is also possible that the true incidence is underestimated. Recent improvements in interventional radiological procedures may facilitate a diagnosis of skeletal muscle metastasis being made more frequently.

Interfering effect of diphtheria-tetanus-acellular pertussis combined (DTaP) vaccines on the bacterial endotoxin test

We evaluated applicability of the endotoxin test to DTaP vaccines. Although no DTaP vaccine batches showed immediate interference with the activating activity of spiked endotoxin on the clotting of Limulus amaebocyte lysate (LAL), a gradually progressing interference depending on the time after spiking was seen for some of the batches. The interfering DTaP vaccine batches, however, showed no significant effect onin vitro TNF-alpha induction in RAW264.7 cells and pyrogenicity in rabbits of spiked endotoxin. Aluminium hydroxide gel in the vaccines was suggested to be one of the causes of the interference. Accordingly, a careful evaluation of the interfering effect was assumed crucial for the effective application of the endotoxin test to check residual biological activity of endotoxin in DTaP vaccines.

[A case of lung adenocarcinoma showing diffuse air-space consolidation with idiopathic interstitial pneumonia]

Routine chest radiography demonstrated abnormal opacities in the right lower lung field of a 54-year-old man with idiopathic interstitial pneumonia. A high-resolution chest CT scan showed diffuse air-space consolidation in the right lower lung with replacement of a honeycomb area. The diagnosis was adenocarcinoma, and a right lower lobectomy was performed. Histopathologic examination showed moderately differentiated adenocarcinoma and the pathological stage was T3 N0 M0 (Stage IIB). About 1 year later, the cancer recurred with diffuse air-space consolidation in the whole of the right lung and the left middle and lower lung, which resulted in the patient's death. It was difficult to discriminate between an acute change for the worse of idiopathic interstitial pneumonia and a recurrence of lung cancer on the basis of the CT findings in this patient. It is important to elucidate the CT features of lung cancer associated with idiopathic interstitial pneumonia.

Efficacy of a new hemostatic device, Adapty , after transradial coronary angiography and intervention

A novel hemostatic device, Adapty (Medikit, Tokyo, Japan), was developed to achieve effective and comfortable hemostasis following transradial procedures. The device consists of a pad fixed to a transparent plastic plate and a self-adhesive strap. The catheter sheath is removed from the radial artery after the pad has been positioned precisely over the puncture site, with the strap attached to the plate. Compression pressure then is adjusted with the self-adhesive strap, as is required with occlusive clamps. Patients do not need to maintain hyperextension of the wrist after the procedure. The wrist can be mobilized immediately after application. The efficacy of Adapty was evaluated in prospective observations of 200 patients. The device was successfully applied in all patients immediately after sheath removal. No patient required interruption of compression because of pain, congestion or ischemia. Complete hemostasis was obtained in 199 patients (99.5%), and the device caused no vascular complications. This study demonstrates that Adapty is highly effective for achieving hemostasis after transradial procedures.

Clinical experiences of stenting in patients with esophago-bronchial fistula: report of four cases

The esophagorespiratory fistula is difficult to treat, and the patients' quality of life is generally poor due to suffering from dysphagia and dyspnea. We performed stent therapy in four cases of the esophagorespiratory fistula associated with esophageal cancer. Three of four patients showed improved symptoms, enabling oral liquid or food intake, although one died of dyspnea despite the therapy. The findings suggest that stent therapy is an effective method to close the esophagorespiratory fistula and to improve the patients' quality of life, although it is temporary and not a radical treatment.

Unprecedented direct oxygen atom transfer from hypervalent oxido-lambda(3)-iodanes to alpha,beta-unsaturated carbonyl compounds: synthesis of alpha,beta-epoxy carbonyl compounds

Tetra-n-butylammonium oxido-lambda(3)-iodane, prepared from 1-hydroxy-1,2-benziodoxol-3(1H)-one by reaction with tetra-n-butylammonium fluoride, directly undergoes oxygen atom transfer to alpha,beta-unsaturated carbonyl compounds, yielding epoxides.

Evaluation of the applicability of the bacterial endotoxin test to antibiotic products

Fundamental conditions for applying the bacterial endotoxin test to antibiotic products were investigated so as not to affect the level of regulation by the rabbit pyrogen test. According to accuracy evaluation of test methods, the kinetic-turbidimetric and kinetic-colourimetric assays were shown to allow more accurate measurement and, therefore, more sensitive detection of interference to the bacterial endotoxin test than the gel-clot method. In total, 102 antibiotic products were evaluated on their interfering effect to show that the antibiotics could be categorized into three groups depending on intensity of the interference. Although the test was shown to be applicable even to the group showing the strongest interference, it was assumed to be crucial to use appropriate reagents and an accurate test method for avoiding approval of a pyrogenic product. Accordingly, lists of antibiotics are presented to provide limits of concentration for eliminating interference and endotoxin limits for approval to facilitate effective bacterial endotoxin tests.

Purification and characterization of biliverdin-binding protein from larval hemolymph of the swallowtail butterfly, Papilio xuthus L

The biliverdin-binding protein from the larval hemolymph of the swallowtail butterfly, Papilio xuthus L., was purified and characterized. The crude biliverdin-binding protein, obtained by ammonium sulfate fractionation, was purified in two steps, the first one by gel filtration chromatography and the second one by ion-exchange chromatography. The molecular mass of the purified protein was analyzed by SDS-polyacrylamide gel electrophoresis and estimated to be 21 kDa. The Namino terminal sequence of P. xuthus biliverdin-binding protein analyzed up to the 19th residue showed that 42% of the amino acid sequence are sequence similarity to the bilin-binding protein from Pieris brassicae. These results suggest that the P. xuthus biliverdin-binding protein belongs to the insecticyanin-type.

Angiomyomatous hamartoma and associated stromal lesions in the right inguinal lymph node: a case report

Angiomyomatous hamartoma is a rare disease with a predisposition for the inguinal lymph nodes. A 51-year-old male patient visited a local hospital because of a right inguinal mass, measuring 3 x 4 cm in size, which was resected. The resected specimen showed irregularly distributed thick-walled vessels in the hilum, extending into the medulla and focally into the cortex of the node, eventually becoming more dispersed and associated with smooth muscle cells splaying into sclerotic stroma. These findings are compatible with an angiomyomatous hamartoma. Another tumor-like mass appeared shortly after the resection at the same location, but was not an angiomyomatous hamartoma, rather it was composed of edematous stromal tissue with proliferating smooth muscle cells. The stromal component included thick-walled blood vessels and lymphatics. Although it could not be determined whether these associated changes in the surrounding stroma are a cause or an effect of angiomyomatous hamartoma, they indicate the clinical difficulty in determining an appropriate area of resection and may provide clues to the pathogenesis of angiomyomatous hamartoma.