Quality of Palliative Radiation Therapy Assessed Using Quality Indicators: A Multicenter Survey

PURPOSE/OBJECTIVE(S)

Clinical practice is not always performed in accordance with guideline recommendations. Quality indicators (QIs) are valuable tools for evaluating the quality of healthcare systems. We sought to identify potential gaps between clinical practice and evidence using QIs previously developed using a modified Delphi method.

MATERIALS/METHODS

We used seven QIs (Table 1) to assess the quality of radiation therapy for bone (BoM) and brain metastases (BrM) at 29 centers; 13 (45%) were academic (12 university hospitals and 1 cancer center) and 16 (55%) were nonacademic hospitals. Compliance rate was calculated as the percentage of patients for whom recommended medical care was conducted. Random effects models were used to estimate pooled compliance rates. Mixed effects models with a Q test were used to compare compliance rates between academic and nonacademic centers.

RESULTS

The estimates of the compliance rates with 95% confidence intervals are presented in Table 1. For BoM-1, the compliance rate was higher in academic hospitals (100% [100-100%]) than in non-academic hospitals (96% [89-100%]) (P = 0.021). For BrM-3, the compliance rate was lower in academic hospitals (92% [81-99%]) than in nonacademic hospitals (100% [98-100%]) (P = 0.016).

CONCLUSION

A quality assessment based on these seven QIs is feasible. Overall, compliance rates were high; however, for BoM-3, the practice remains to be improved in some centers. Based on BoM-4 compliance rates, steroids are infrequently used concurrently with radiation therapy for malignant spinal cord compression. Extended fractionation for BoM was less frequently performed in academic than in nonacademic centers. The initiation of radiation therapy for brain metastases was more frequently delayed in academic than in nonacademic centers.

Temporal Profiles of Symptom Scores After Palliative Radiotherapy for Bleeding Gastric Cancer With Adjustment for the Palliative Prognostic Index: An Exploratory Analysis of a Multicentre Prospective Observational Study (JROSG 17-3)

AIMS

Although palliative radiotherapy for gastric cancer may improve some symptoms, it may also have a negative impact due to its toxicity. We investigated whether symptoms improved after radiotherapy with adjustment for the Palliative Prognostic Index (PPI) considering that patients with limited survival tend to experience deterioration of symptoms.

MATERIALS AND METHODS

This study was an exploratory analysis of the Japanese Radiation Oncology Study Group study (JROSG 17-3). We assessed six symptom scores (nausea, anorexia, fatigue, shortness of breath, pain at the irradiated area and distress) at registration and 2, 4 and 8 weeks thereafter. We tested whether symptoms linearly improved after adjusting for the baseline PPI. Shared parameter models were used to adjust for potential bias in missing data.

RESULTS

The present study analysed all 55 patients enrolled in JROSG 17-3. With time from registration as the only explanatory variable in the model, a significant linear decrease was observed in shortness of breath, pain and distress (slopes, -0.26, -0.22 and -0.19, respectively). Given that the interaction terms (i.e. PPI × time) were not significantly associated with symptom scores in any of the six symptoms, only PPI was included as the main effect in the final multivariable models. After adjusting for the PPI, shortness of breath, pain and distress significantly improved (slope, -0.25, -0.19 and -0.17; P < 0.001, 0.002 and 0.047, respectively). An improvement in fatigue and distress was observed only in patients treated with a biologically effective dose ≤14.4 Gy.

CONCLUSION

Shortness of breath, pain and distress improved after radiotherapy. Moreover, a higher PPI was significantly associated with higher symptom scores at all time points, including baseline. In contrast, PPI did not seem to influence the improvement of these symptoms. Regardless of the expected survival, patients receiving radiotherapy for gastric cancer can expect an improvement in shortness of breath, pain and distress over 8 weeks. Multiple-fraction radiotherapy might hamper the improvement in fatigue and distress by its toxicity or treatment burden.

Pathological analysis of struts coverage after second- and third-generation drug-eluting stents implantation for duration of dual anti-platelets therapy; an autopsy study

Background

Strut coverage of drug-eluting stents (DES) is one of the important factors for the duration of dual anti-platelets therapy (DAPT) after percutaneous coronary intervention. Several studies have reported percent coverage of struts assessed by optical coherence tomography (OCT), however, the timing of endothelial coverage of the latest second- and third-generation DES has not been revealed histologically.

Methods and results

From CVHills stent autopsy registry of 171 stented lesions, a total of 56 lesions from 39 autopsy cases with less than 370 days after second- and/or third-generation DES implantation was evaluated histologically. The lesions were stratified by duration: 1–30 days (n=39), 31–60 days (n=4), 61–90 days (n=5), 91–180 days (n=2), and 181–370 days (n=6), and percent coverage of struts, which was defined as neointimal coverage overlying with endothelial cells, was evaluated for each lesion. In addition, difference of coverage within 90 days after implantation between second-generation DES with circumferentially coated polymer and third-generation DES with abluminally coated polymer was also evaluated.

Percent strut coverage increased with time [1–30 days vs. 31–60 days vs. 61–90 days vs. 91–180 days vs. 181–370 days: median (interquartile range) 0.0% (0.0–0.3), 6.3% (1.0–11.7), 16.7% (8.0–32.6), 64.2% (55.6–72.9), and 86.5% (63.5–92.5), respectively, p&lt;0.0001]. When the coverage at the earlier time point was compared between second- and third-generation DES, prevalence of coverage with &gt;25% per section was higher in third-generation DES and the difference was more obvious in 61–90 days after stent implantation (0.0 vs. 1.0%, p=0.15 in 1–30 days, 7.7 vs. 14.3%, p=0.65 in 31–60 days, and 10.0 vs. 36.3%, p=0.04 in 61–90 days).

Conclusions

The current pathological analysis has demonstrated that the process of endothelial strut coverage in second- and third-generation DES proceeds over time, however, the speed was slower than reported in the previous studies evaluated with OCT. Furthermore, endothelial strut coverage of third-generation DES was faster than that of second-generation DES, suggesting a positive roll of abluminal coating on healthy endothelial coverage and safety de-escalation of DAPT at earlier timepoint.

Funding Acknowledgement

Type of funding sources: None.

Impact of poor below-the-knee run-off on stent failure of femoro-popliteal arteries in healthy swine model

Background

Poor below-the-knee (BTK) run-off is reported to be one of the predictors of stent failure after endovascular treatment to femoro-popliteal arteries (1), however, the mechanism of stent failure has never been characterized before. The aim of the current study was to evaluate impact of poor BTK run-off on stent failure in healthy swine femoro-popliteal (FP) lesions, and to compare the outcome of a bare-metal stent (BMS) and two drug-eluting stents (DES) in the arteries with poor BTK run-off.

Method

Fluoropolymer-coated paclitaxel-eluting stents (FP-PES, Eluvia) and BMS were implanted in bilateral femoral arteries of 6 healthy swine following coil embolization in both tibial arteries to induce poor BTK run-off. FP-PES and polymer-free paclitaxel-coated stents (PF-PCS, Zilver-PTX) were also implanted in 6 swine with the same fashion. Angiography with an optical coherence tomography (OCT) at one month followed by histological analysis was performed for each lesion.

Result

Angiography demonstrated that in-stent restenosis was observed exclusively in BMS, and percent stenosis was significantly less in FP-PES compared with BMS (FP-PES vs. BMS, median [interquartile range (IQR)], 17.8% [16.6–28.7] vs. 79.3% [64.2–87.2], respectively, p=0.03). FP-PES also demonstrated significantly less percent stenosis compared with PF-PCS (FP-PES vs. PF-PCS, 8.9% [4.7–44.7] vs. 31.2% [23.3–51.2], respectively, p=0.03). Histopathological evaluation demonstrated that organizing and/or organized fibrin thrombus was the main feature of the restenotic lesions, suggesting a risk of thrombus attachment in the FP lesions with poor BTK run-off. Biologic drug effect such as medial smooth muscle cell (SMC) loss score was significantly greater in FP-PES compared with BMS (4.0 [3.3–4.0] vs. 2.0 [1.0–3.0], respectively, p&lt;0.01), whereas, similar between FP-PES and PF-PCS (4.0 [3.0–4.0] vs. 4.0 [3.0–4.0], respectively, p=0.88).

Conclusion

Thrombus attachment would be the main causes of restenosis in FP lesions with poor BTK runoff. The results of the current study suggest that not only paclitaxel drug effect, but also anti-thrombotic effect of fluoropolymer might be needed to prevent stent failure.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This study is supported by Boston Scientific.

POS1196 SARS-CoV-2 VACCINE ACCEPTANCE AND ASSOCIATED PSYCHOLOGICAL FACTORS IN PATIENTS WITH RHEUMATIC AND MUSCULOSKELETAL DISEASES

Background

The mortality rate of coronavirus disease 2019 (COVID-19) in patients with rheumatic and musculoskeletal disease (RMD) is as high as approximately 10% [1]. Therefore, vaccination promotion is a critical issue. However, there are few reports on the psychological aspects of patient vaccine acceptance.

Objectives

To investigate the intention of patients with RMD to receive the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine and explore the psychological factors related to vaccine acceptance.

Methods

We conducted a questionnaire-based survey of 406 outpatients with RMD at Shiga General Hospital from July to October 2021. The questionnaire included the following sections: (1) vaccination status; (2) expectation of susceptibility to severe COVID-19; (3) expectation of vaccine efficacy; and (4) anxiety about the vaccine, which included concerns on I) the diminishing effect of the vaccine due to current treatment and II) the influence of vaccination on: i) primary disease status, ii) treatment, and iii) adverse reaction.

Results

There were 305 vaccinated and 101 unvaccinated individuals. Unvaccinated individuals were classified into the acceptance group (n=60) and hesitancy group (n=41) according to their vaccination status (Figure 1).

Figure 1.

SARS-CoV-2 vaccination status (n=406)

We compared the backgrounds and awareness of the patients on vaccination between the two groups. Univariate analysis did not show any difference in the backgrounds. The expectation of susceptibility to severe COVID-19 was similar in both groups. There were also no significant differences in the vaccine-related anxiety levels. However, the expectation of vaccine efficacy was higher in the acceptance group and significantly influenced vaccination intention as revealed by multivariate analyses (Table 1).

Table 1.

Awareness towards COVID-19 and SARS-CoV-2 vaccine associated with vaccination intention

Awareness towards COVID-19 and SARS-CoV-2 vaccineAcceptance(N=60)Hesitancy(N=41)UnivariateAnalysis§Multivariate Analysis||Median[IQR]Median[IQR]p-valuep-valueExpectation of susceptibility to severe COVID-19*2.0[1.0-3.0]2.0[1.5-2.5]0.84720.3440Expectation of vaccine efficacy†3.0[3.0-3.0]2.0[1.0-3.0]<0.0001¶<0.0001**Concerns about the diminishing effect of the vaccine due to current treatment‡2.0[1.0-3.0]3.0[2.0-3.0]0.04750.3600Concerns about the effect of vaccination on treatment‡3.0[1.0-3.0]3.0[2.0-4.0]0.01280.6232Concern about the effect of vaccination on primary disease status‡3.0[1.0-3.0]3.0[2.0-3.0]0.05760.7134Concern about the effect of vaccination on adverse reaction‡3.0[3.0-3.0]3.0[3.0-4.0]0.00930.8335

*0: Less likely to become severe~3: Very likely to become severe, †0: Not expected at all~4: Highly expected, ‡0: Not concerned at all ~4:Very concerned

§Pearson’s chi-square test or Wilcoxon test, ||Nominal logistic regression analysis, ¶ p<0.008 (after Bonferroni correction), ** p<0.05.

Conclusion

The perception of vaccine efficacy is strongly correlated with vaccine acceptance. In order to promote vaccination in patients with RMDs, this study suggests that emphasizing the efficacy of the vaccine may be more effective than alleviating anxiety about the adverse effects of the vaccine.

References

[1]Strangfeld, A. et al. Ann. Rheum. Dis. 2021; 80: 930–942.

Disclosure of Interests

Haruka Sugawara: None declared, Hiroshi Doi: None declared, Takeshi Iwasaki: None declared, Yoichi Nakayama: None declared, Yuri Nishida: None declared, Yoshie Gon: None declared, Masaki Kamakura: None declared, Kenshi Ohbori: None declared, Naoko Sakane: None declared, Naomi Nakamura: None declared, Takahiko Utsumi: None declared, Akio Morinobu Speakers bureau: Eli Lilly Japan K.K., Ono Pharmaceutical Co., Pfizer Inc., UCB Japan, AbbVie G.K., Asahi Kasei Pharma., and Chugai Pharmaceutical Co. Ltd., Grant/research support from: Eli Lilly Japan K.K., Ono Pharmaceutical Co., Pfizer Inc., UCB Japan, AbbVie G.K., Asahi Kasei Pharma., and Chugai Pharmaceutical Co. Ltd.

Screening of Fabry disease in patients with chronic kidney disease in Japan

BACKGROUND

Fabry disease (FD), an X-linked lysosomal storage disorder caused by a deficiency in alfa-galactosidase A (α-Gal A) activity due to mutations in the GLA gene, has a prevalence of 0-1.69% in patients undergoing haemodialysis; however, its prevalence in patients with chronic kidney disease (CKD) Stages 1-5 is unknown.

METHODS

Serum α-Gal A activity analysis and direct sequencing of GLA were used to screen for FD in 2122 male patients with CKD, including 1703 patients with CKD Stage 5D and 419 with CKD Stages 1-5. The correlation between serum α-Gal A activity and confounding factors in patients with CKD Stages 1-5 was evaluated.

RESULTS

FD prevalence rates in patients with CKD Stage 5D and CKD Stages 1-5 were 0.06% (1/1703) and 0.48% (2/419), respectively. A patient with CKD Stage 5D exhibited a novel GLA mutation, p.Met208Arg, whereas two patients with CKD Stages 1-5 had c.370delG and p.Met296Ile. p. Met208Arg caused moderate structural changes in the molecular surface region near the substituted amino acid residue but did not affect the catalytic residues Asp170 and Asp231 in α-Gal A. Serum α-Gal A activity in patients with CKD Stages 1-5 was inversely correlated with age (P < 0.0001) but directly correlated with estimated glomerular filtration rate (P < 0.0001).

CONCLUSIONS

FD prevalence was much higher in male patients with CKD Stages 1-5 than in those with CKD Stage 5D. FD screening in patients with CKD Stages 1-5 may improve patient survival, decreasing the number of patients with CKD Stage 5D.

Investigating links between thermal tolerance and oxygen supply capacity in shark neonates from a hyperoxic tropical environment

Temperature and oxygen limit the distribution of marine ectotherms. Haematological traits underlying blood-oxygen carrying capacity are thought to be correlated with thermal tolerance in certain fishes, and this relationship is hypothesised to be explained by oxygen supply capacity. We tested this hypothesis using reef shark neonates as experimental models because they live near their upper thermal limits and are physiologically sensitive to low oxygen conditions. We first described in situ associations between temperature and oxygen at the study site (Moorea, French Polynesia) and found that the habitats for reef shark neonates (Carcharhinus melanopterus and Negaprion acutidens) were hyperoxic at the maximum recorded temperatures. Next, we tested for in situ associations between thermal habitat characteristics and haematological traits of neonates. Contrary to predictions, we only demonstrated a negative association between haemoglobin concentration and maximum habitat temperatures in C. melanopterus. Next, we tested for ex situ associations between critical thermal maximum (CT_Max) and haematological traits, but only demonstrated a negative association between haematocrit and CT_Max in C. melanopterus. Finally, we measured critical oxygen tension (p_crit) ex situ and estimated its temperature sensitivity to predict oxygen-dependent values of CT_Max. Estimated temperature sensitivity of p_crit was similar to reported values for sharks and skates, and predicted values for CT_Max equalled maximum habitat temperatures. These data demonstrate unique associations between haematological traits and thermal tolerance in a reef shark that are likely not explained by oxygen supply capacity. However, a relationship between oxygen supply capacity and thermal tolerance remains to be demonstrated empirically.

Amino Acid-Mediated Intracellular Ca2+ Rise Modulates mTORC1 by Regulating the TSC2-Rheb Axis through Ca2+/Calmodulin

Mechanistic target of rapamycin complex 1 (mTORC1) is a master growth regulator by controlling protein synthesis and autophagy in response to environmental cues. Amino acids, especially leucine and arginine, are known to be important activators of mTORC1 and to promote lysosomal translocation of mTORC1, where mTORC1 is thought to make contact with its activator Rheb GTPase. Although amino acids are believed to exclusively regulate lysosomal translocation of mTORC1 by Rag GTPases, how amino acids increase mTORC1 activity besides regulation of mTORC1 subcellular localization remains largely unclear. Here we report that amino acids also converge on regulation of the TSC2-Rheb GTPase axis via Ca²⁺/calmodulin (CaM). We showed that the amino acid-mediated increase of intracellular Ca²⁺ is important for mTORC1 activation and thereby contributes to the promotion of nascent protein synthesis. We found that Ca²⁺/CaM interacted with TSC2 at its GTPase activating protein (GAP) domain and that a CaM inhibitor reduced binding of CaM with TSC2. The inhibitory effect of a CaM inhibitor on mTORC1 activity was prevented by loss of TSC2 or by an active mutant of Rheb GTPase, suggesting that a CaM inhibitor acts through the TSC2-Rheb axis to inhibit mTORC1 activity. Taken together, in response to amino acids, Ca²⁺/CaM-mediated regulation of the TSC2-Rheb axis contributes to proper mTORC1 activation, in addition to the well-known lysosomal translocation of mTORC1 by Rag GTPases.

Multi-mode resistive spectroscopy for precisely controlling morphology of extremely narrow gap palladium nanocluster array

During the deposition of a metallic material on a substrate, a nanocluster-array structure with an extremely narrow gap is formed transiently at the transition between isolated clusters and the continuous film. It is known that the nanocluster array shows a unique electrical property different from that of isolated clusters and the continuous film. The electrical property of the nanocluster array changes significantly depending on its morphology, and precise control of the deposition time is indispensable to obtain a desired electrical property. However, the detection of the transition is not straightforward. To overcome this problem, we develop the multi-mode resistive spectroscopy. It evaluates the morphological change during deposition using resonant vibrations of a piezoelectric material and enables the fabrication of nanocluster arrays with a slightly different morphology. Palladium nanocluster arrays with different morphologies are fabricated using this method, and the availability of the multi-mode resistive spectroscopy is demonstrated by evaluating their electrical response to hydrogen gas.

Convergence of stakeholders' environmental threat perceptions following mass coral bleaching of the Great Barrier Reef

Managing human use of ecosystems in an era of rapid environmental change requires an understanding of diverse stakeholders' behaviors and perceptions to enable effective prioritization of actions to mitigate multiple threats. Specifically, research examining how threat perceptions are shared or diverge among stakeholder groups and how these can evolve through time is increasingly important. We investigated environmental threat perceptions related to Australia's Great Barrier Reef and explored their associations before and after consecutive years of mass coral bleaching. We used data from surveys of commercial fishers, tourism operators, and coastal residents (n = 5254) conducted in 2013 and 2017. Threats perceived as most serious differed substantially among groups before bleaching but were strongly aligned after bleaching. Climate change became the most frequently reported threat by all stakeholder groups following the coral bleaching events, and perceptions of fishing and poor water quality as threats also ranked high. Within each of the 3 stakeholder groups, fishers, tourism operators, and coastal residents, the prioritization of these 3 threats tended to diverge in 2013, but convergence occurred after bleaching. These results indicate an emergence of areas of agreement both within and across stakeholder groups. Changes in perceptions were likely influenced by high-profile environmental-disturbance events and media representations of threats. Our results provide insights into the plasticity of environmental-threat perceptions and highlight how their convergence in response to major events may create new opportunities for strategic public engagement and increasing support for management.

Effect of switching from cinacalcet to etelcalcetide on secondary hyperparathyroidism in patients undergoing hemodialysis: an ESCORT trial

Background

Etelcalcetide is the first intravenously administered calcimimetic agent used to manage secondary hyperparathyroidism (SHPT) in hemodialysis (HD) patients. We evaluated the safety and efficacy of replacing cinacalcet with etelcalcetide in HD patients.

Methods

One hundred and thirty-three patients HD on cinacalcet were screened, and 93 patients with serum-intact parathyroid hormone (iPTH) level of ≥ 60 pg/mL and serum albumin-corrected calcium (cCa) level of ≥ 8.4 mg/dL were enrolled. The patients were divided into three groups based on the dose of cinacalcet (i.e., 25, 50, and ≥ 75 mg) and switched to etelcalcetide. Etelcalcetide was administered three times per week for 24 weeks. The primary and secondary endpoints were etelcalcetide conversion dose and etelcalcetide effectiveness for iPTH levels (target range: 60–240 pg/mL), respectively.

Results

Of the 68 patients whose iPTH level was within the management target at screening, 60 patients maintained the target level at the end of the study. Among patients whose iPTH level exceeded 240 pg/mL at screening, it decreased from 401 ± 246 pg/mL to 220 ± 209 pg/mL (p < 0.001) at the end of the study. Among 22 patients with the iPTH level of ≥ 240 pg/mL, 17 achieved the target level. The mean dose of cinacalcet was 41.4 ± 22.2 mg/day and that of etelcalcetide at the end of the study was 6.4 ± 3.7 mg/session in all patients. In 45 patients whose iPTH level was within the management target throughout the study and active vitamin D agent and calcium-based phosphate binder doses were constant, the mean dose of cinacalcet was 45.0 ± 22.4 mg/day and that of etelcalcetide at the end of the study was 6.1 ± 3.1 mg/session. The spKt/V might affect the ratio of etelcalcetide per session to oral cinacalcet per day (45 patients, p = 0.087; 90 patients, p < 0.05) in the generalized linear model. Etelcalcetide-induced severe adverse events were not observed.

Conclusions

This study reports the conversion dose of etelcalcetide and demonstrates its safety and efficacy in HD patients with SHPT previously treated with cinacalcet.

Trial registration

UMIN, UMIN000027637; Registered on June 5, 2017.

Effect of tolvaptan on renal involvement in patients with autosomal dominant polycystic kidney disease according to different gene mutations

BACKGROUND

Autosomal dominant polycystic kidney disease (ADPKD) is an inherited disorder caused by mutations in the polycystic kidney disease (PKD) gene. Although tolvaptan has benefits for renal involvement, the different effects depending on the gene mutation type are unknown. Thus, we explore the different effects of tolvaptan on the annual changes in total kidney volume (%TKV) and estimated glomerular filtration rate (eGFR) according to the gene mutation type in ADPKD patients.

METHODS

In total, 135 ADPKD patients were screened, and 22 patients taking tolvaptan for at least a year were retrospectively studied at the Kurume University Hospital. We examined the decline in renal function and %TKV by computed tomography and analyzed the gene mutation. Patients were classified into the following four groups according to gene mutation type: PKD1-truncated, PKD1-non-truncated, PKD2, and mutation not found. Patients were treated with tolvaptan, and the effects of tolvaptan were analyzed according to the gene mutation type.

RESULTS

Patients (age: 52.3 ± 11.2 years) were administered tolvaptan at a dose of 45 or 60 mg. No variation was observed in the annual changes in eGFR (%eGFR) (before: - 10.5% ± 13.9%, after: - 14.4% ± 8.1%, P = 0.139), whereas %TKV was significantly improved after the tolvaptan treatment (before: 14.9% ± 8.0%, after: - 5.4% ± 7.6%, P < 0.001). Unlike %eGFR, tolvaptan treatment significantly improved %TKV, regardless of the type of gene mutation.

CONCLUSIONS

A year treatment with tolvaptan significantly improved %TKV in patients with ADPKD, regardless of the gene mutation type.

The clinical and pathological features of intraplaque hemorrhage in coronary artery -insights from Japan DCA registry-

Introduction

Intraplaque hemorrhage (IPH) is known to play an important role in plaque vulnerability in coronary artery. However, the biological reaction in IPH and clinical features of patients with IPH remain unknown, since most histological studies of IPH in coronary artery were performed on autopsy cases. Directional coronary atherectomy (DCA) enables the direct pathological evaluation of collected tissue from “living” patients.

Purpose

We aimed to clarify the clinical presentations and histopathologic features of IPH using specimens obtained by DCA.

Method

This multicentral prospective observational study included consecutive patients who underwent percutaneous coronary intervention for de novo lesions using DCA from June 2015 to February 2018. Histopathological sections that were collected from coronary plaques by DCA were evaluated and classified by the presence of IPH. IPH in DCA specimens was defined as clusters of hemosiderin (Figure A, arrows), erythrocytes (Figure B, arrow heads) and fibrin (Figure C, arrows) within the coronary plaque. A total of 154 de novo lesions from 154 patients were ultimately analyzed, and were divided into IPH group (n=37) and non-IPH group (n=117).

Result

Clinical profiles of patients in the two groups were comparable, except that unstable angina rather than chronic coronary syndrome was significantly more prevalent in the IPH group (32.4% vs. 16.2%, P=0.04). Histopathological analysis showed a significantly higher incidence of cellular-rich plaque (46.0% vs. 25.6%, P=0.02) and spindle-shaped cells (18.9% vs. 6.0%, P=0.02), which indicate active cell proliferations, in the IPH group. The prevalence of necrotic core was also higher in IPH group compared to non-IPH group (48.7% vs. 13.7%, P&lt;0.01).

Conclusion

Pathohistological analysis revealed that coronary plaques with IPH had an active cell proliferation, and patients with IPH likely to had clinical presentations of unstable angina.

Figure 1

Funding Acknowledgement

Type of funding source: None

Effectiveness of immunosuppressive therapy for nephrotic syndrome in a patient with late-onset Fabry disease: a case report and literature review

BACKGROUND

Fabry disease (FD) is an X-linked lysosomal storage disorder caused by mutations of the GLA gene, followed by deficiency in α-galactosidase A (α-gal) activity. Nephrotic syndrome, as the renal phenotype of FD, is unusual. Here, we report the rare case of a patient with FD with nephrotic syndrome whose proteinuria disappeared by immunotherapy.

CASE PRESENTATION

A 67-year-old Japanese man was admitted to our hospital because of emesis, abdominal pain, and facial edema due to nephrotic syndrome. The patient was diagnosed with focal segmental glomerulosclerosis (FSGS) by renal biopsy before being diagnosed with FD, and immunotherapy was initiated. After treatment, the kidney biopsy results showed typical glycosphingolipid accumulation in the podocytes of this patient. The white blood cell α-gal activity was very low, and genetic analysis revealed a GLA gene variant (M296I), which is known as a late-onset genetic mutation of FD. Immunotherapy (steroids and cyclosporine A) dramatically improved the massive proteinuria. Currently, he has been undergoing enzyme replacement therapy, and his proteinuria has further decreased. There is the possibility that other nephrotic syndromes, such as minimal change nephrotic syndrome or FSGS, may co-exist in this patient.

CONCLUSIONS

We experienced the rare case of a FD patient whose nephrotic syndrome disappeared by immunotherapy. These findings suggest that immunosuppressive treatment may be considered if nephrotic syndrome develops, even in patients with FD.

OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis

OBJECTIVE

To update and expand upon prior Osteoarthritis Research Society International (OARSI) guidelines by developing patient-focused treatment recommendations for individuals with Knee, Hip, and Polyarticular osteoarthritis (OA) that are derived from expert consensus and based on objective review of high-quality meta-analytic data.

METHODS

We sought evidence for 60 unique interventions. A systematic search of all relevant databases was conducted from inception through July 2018. After abstract and full-text screening by two independent reviewers, eligible studies were matched to PICO questions. Data were extracted and meta-analyses were conducted using RevMan software. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Evidence Profiles were compiled using the GRADEpro web application. Voting for Core Treatments took place first. Four subsequent voting sessions took place via anonymous online survey, during which Panel members were tasked with voting to produce recommendations for all joint locations and comorbidity classes. We designated non-Core treatments to Level 1A, 1B, 2, 3, 4A, 4B, or 5, based on the percentage of votes in favor, in addition to the strength of the recommendation.

RESULTS

Core Treatments for Knee OA included arthritis education and structured land-based exercise programs with or without dietary weight management. Core Treatments for Hip and Polyarticular OA included arthritis education and structured land-based exercise programs. Topical non-steroidal anti-inflammatory drugs (NSAIDs) were strongly recommended for individuals with Knee OA (Level 1A). For individuals with gastrointestinal comorbidities, COX-2 inhibitors were Level 1B and NSAIDs with proton pump inhibitors Level 2. For individuals with cardiovascular comorbidities or frailty, use of any oral NSAID was not recommended. Intra-articular (IA) corticosteroids, IA hyaluronic acid, and aquatic exercise were Level 1B/Level 2 treatments for Knee OA, dependent upon comorbidity status, but were not recommended for individuals with Hip or Polyarticular OA. The use of Acetaminophen/Paracetamol (APAP) was conditionally not recommended (Level 4A and 4B), and the use of oral and transdermal opioids was strongly not recommended (Level 5). A treatment algorithm was constructed in order to guide clinical decision-making for a variety of patient profiles, using recommended treatments as input for each decision node.

CONCLUSION

These guidelines offer comprehensive and patient-centered treatment profiles for individuals with Knee, Hip, and Polyarticular OA. The treatment algorithm will facilitate individualized treatment decisions regarding the management of OA.

A Novel Diagnostic System for Infectious Diseases Using Solid-State Nanopore Devices

Nanopore-based diagnostic systems are a promising tool for counting viruses in a specimen one by one. However, despite intensive R&D efforts, it remains difficult to recognize virus subtypes by nanopore devices. We thus propose a novel diagnostic system that combines a specialized virus recognition procedure with a nanopore detection procedure. This recognition procedure consists of three steps: 1) capture target viruses using specific probes for recognition; 2) release captured targets; and 3) detect released targets by nanopore. Proof-of-concept tests are conducted using avidin-modified fluorescent particles (as a model for viruses) and biotin-modified alkane thiol (as a model for probes). The avidin-modified particles are confirmed to be captured on electrode by biotin-modified probes and then, the particles are electrochemically released from the electrode. Consequently, the released particles are successfully detected by nanopore devices. Furthermore, the concept is also proved by using human influenza viruses (H1N1, A/PR/8/34) and sugar chain (6'-sialyllactose)-modified probes. This suggests that our concept is applicable to various infectious diseases by changing probes (ligands).

P838Is multi-biomarker combination approach comparable to the GRACE risk score for short-term mortality prediction in acute myocardial infarction cases?

Introduction

The Global Registry of Acute Coronary Events (GRACE) score is said to be a superior predictor of mortality in acute myocardial infarction (AMI) patients, and same applies to biochemical parameters as N-terminal pro-B-type natriuretic peptide (N-BNP), Troponin-T (TnT) and high-sensitivity C- reactive protein (hs-CRP) levels.

Purpose

We validated that whether each or combination of biochemical parameters are comparable to GRACE score or not for mortality prediction in AMI patients.

Method

We investigated about clinical background including The GRACE score, above parameters and in-hospital mortality in 754 AMI patients (mean age 66±13y/o, 609 ST-elevated AMI cases) received emergency percutaneous coronary intervention (PCI) successfully during 8 years in a single center retrospectively. Combination of biochemical parameters are derived from N-BNP, TnT and hs-CRP by logistic regression analyses. We compared The GRACE score with each or combination of biochemical parameters between survival (SG) and non-survival group (nSG) on receiver operating characteristic (ROC) analysis.

Result

In-hospital mortality was 6.8%. The GRACE score (106±33 versus 161±32; p<0.005) and N-BNP level (2458±7058 versus 8880±11331pg/ml; p<0.005) were significantly lower in SG than nSG. Area under the ROC curve about in-hospital mortality of The GRACE score were higher (0.868) than N-BNP (0.787; p=0.007), TnT (0.613; p<0.005), hs-CRP levels (0.614; p<0.005) and multi-biomarker combination (0.742; p=0.016) as Figure 1.

Area under the curve of the composite with the GRACE score and multi-biomarker is not increased compared with the GRACE score alone (0.868 versus 0.865; p=n.s.).

Figure 1

Conclusion

The GRACE score is a superior predictor about in-hospital mortality than each or combination of biochemical parameters in AMI patients. Multi-biomarker combination dose not refine the accuracy of the GRACE score.

Our Environmental Value Orientations Influence How We Respond to Climate Change

People variably respond to global change in their beliefs, behaviors, and grief (associated with losses incurred). People that are less likely to believe in climate change, adopt pro-environmental behaviors, or report ecological grief are assumed to have different psycho-cultural orientations, and do not perceive changes in environmental condition or any impact upon themselves. We test these assumptions within the context of the Great Barrier Reef (GBR), a region currently experiencing significant climate change impacts in the form of coral reef bleaching and increasingly severe cyclones. We develop knowledge of environmental cultural services with the Environmental Schwartz Value Survey (ESVS) into four human value orientations that can explain individuals’ environmental beliefs and behaviors: biospheric (i.e., concern for environment), altruistic (i.e., concern for others, and intrinsic values), egoistic (i.e., concern for personal resources) and hedonic values (i.e., concern for pleasure, comfort, esthetic, and spirituality). Using face-to-face quantitative survey techniques, where 1,934 residents were asked to agree or disagree with a range of statements on a scale of 1–10, we investigate people’s (i) environmental values and value orientations, (ii) perceptions of environmental condition, and (iii) perceptions of impact on self. We show how they relate to the following climate change responses; (i) beliefs at a global and local scale, (ii) participation in pro-environmental behaviors, and (iii) levels of grief associated with ecological change, as measured by respective single survey questions. Results suggest that biospheric and altruistic values influenced all climate change responses. Egoistic values were only influential on grief responses. Perception of environmental change was important in influencing beliefs and grief, and perceptions of impact on self were only important in influencing beliefs. These results suggest that environmental managers could use people’s environmental value orientations to more effectively influence climate change responses toward environmental stewardship and sustainability. Communications that target or encourage altruism (through understanding and empathy), biospherism (through information on climate change impacts on the environment), and egoism (through emphasizing the benefits, health and wellbeing derived from a natural resource in good condition), could work.

Effectiveness of cryofiltration and mizoribine combination with oral steroid therapy in a patient with membranoproliferative glomerulonephritis due to essential cryoglobulinemia

A 65-year-old male patient with nephrotic syndrome was admitted to our hospital due to worsening systemic edema and purpura on the limbs. He had an impaired renal function, low serum complement level, and elevated rheumatoid factor level. He was positive for cryoglobulin (monoclonal IgM-κ and polyclonal mixed-type IgG), and the results of his kidney biopsy showed a tissue profile of membranoproliferative glomerulonephritis (MPGN). Due to the fact that the secondary cause was unclear, he was diagnosed with MPGN due to essential mixed cryoglobulinemia. On hospital day 20, he was initiated on 50 mg/day prednisolone (PSL). On hospital day 43, oral mizoribine (MZR) at a dose of 150 mg/day was prescribed. On hospital day 49, cryofiltration was performed because the disease was steroid resistant. The treatment promptly decreased urine protein levels. Serum albumin and serum complement levels increased, and complete remission was achieved approximately three months after the initiation of treatment. The PSL and MZR doses were gradually reduced to 2 mg/day and 100 mg/day, respectively, without any reemergence of the symptoms of cryoglobulinemia or relapse of the nephrotic syndrome for three years. Here, we report this case with essential mixed cryoglobulinemia in whom we could achieve complete remission of the disease by adding cryofiltration to the oral corticosteroid and immunosuppressant therapy with mizoribine and could maintain for a long time.

Retrospective Assessment of Exposures to Ionising Radiation: Abstract

Basic dose quantities used in dose reconstruction are defined. The following dose reconstruction methods based on measurements performed for individual persons are reviewed: electron paramagnetic resonance (EPR) measurements with tooth enamel, analyses of dicentric chromosomes and chromosome translocations, counting of micronuclei in lymphocytes, somatic-mutation assays, and measurements of radionuclide activities in the human body. Methods based on measurements in environmental media include luminescence methods applied to minerals to determine absorbed doses in ceramics such as bricks or porcelain, accelerator mass spectrometry (AMS) to determine small quantities of man-made long-lived radionuclides, methods based on existing measurements of absorbed dose rates in air, and modelling based on radionuclide activities in the environment. The application of different methods of dose reconstruction to the same individuals is reviewed for the atomic-bomb survivors of Hiroshima and Nagasaki (dosimetry system DS86, EPR with teeth, chromosomal aberrations in lymphocytes, and somatic-mutation assays) and the workers of the Mayak Production Association (occupational film badge dosimetry, EPR with teeth, and fluorescence in situ hybridisation (FISH) with lymphocytes). Examples of reconstruction of absorbed doses in environmental media are Hiroshima and Nagaski (luminescence measurements, AMS and the DS86 system), the Nevada test site (measurements of 137Cs activity in the soil, thermoluminescence of bricks and gamma dose rate in air), and settlements contaminated by the Chernobyl accident (luminescence methods and modelling based on measured 137Cs activity in the ground). The report concludes with an overview the conditions under which the various methods of the dose reconstruction are best applied.

Ultra-sensitive Trace-Water Optical Sensor with In situ- synthesized Metal-Organic Framework in Glass Paper

Monitoring of trace water in industrial gases is strongly recommended because contaminants cause serious problems during use, especially in the semiconductor industry. An ultra-sensitive trace-water sensor was developed with an in situ-synthesized metal-organic framework as the sensing material. The sample gas is passed through the sensing membrane and efficiently and rapidly collected by the sensing material in the newly designed gas collection/detection cell. The sensing membrane, glass paper impregnated with copper 1,3,5-benzenetricarboxylate (Cu-BTC), is also newly developed. The amount and density of the sensing material in the sensing membrane must be well balanced to achieve rapid and sensitive responses. In the present study, Cu-BTC was synthesized in situ in glass paper. The developed system gave high sensing performances with a limit of detection (signal/noise ratio = 3) of 9 parts per billion by volume (ppbv) H₂O and a 90% response time of 86 s for 200 ppbv H₂O. The reproducibility of the responses within and between lots had relative standard deviations for 500 ppbv H₂O of 0.8% (n = 10) and 1.5% (n = 3), respectively. The long-term (2 weeks) stability was 7.3% for 400 ppbv H₂O and one-year continuous monitoring test showed the sensitivity change of <∼3% before and after the study. Furthermore, the system response was in good agreement with the response achieved in cavity ring-down spectroscopy. These performances are sufficient for monitoring trace water in industrial gases. The integrated system with light and gas transparent structure for gas collection/absorbance detection can also be used for other target gases, using specific metal-organic frameworks.

Web survey-based selection of controls for epidemiological analyses of a multi-prefectural outbreak of enterohaemorrhagic Escherichia coli O157 in Japan associated with consumption of self-grilled beef hanging tender

An outbreak of enterohaemorrhagic Escherichia coli O157 occurred in multiple prefectures of Japan in November 2009. We conducted two case-control studies with trace-back and trace-forward investigations to determine the source. The case definition was met by 21 individuals; 14 (66.7%) were hospitalised, but no haemolytic uraemic syndrome, acute encephalopathy or deaths occurred. Median age was 23 (range 12-48) years and 14 cases were male (66.7%). No significant associations with food were found in a case-control study by local public health centres, but our matched case-control study using Internet surveys found that beef hanging tender (or hanger steak), derived from the diaphragm of the cattle, was significantly associated with illness (odds ratio = 15.77; 95% confidence interval, 2.00-124.11). Pulsed-field gel electrophoresis analysis of isolates from patients and the suspected food showed five different patterns: two in faecal and food samples, and another three in patient faecal samples only, although there were epidemiological links to the meat consumed at the restaurants. Trace-back investigation implicated a common food processing company from outside Japan. Examination of the logistics of the meat processing company suggested that contamination did not occur in Japan. We concluded that the source of the outbreak was imported hanging tender. This investigation revealed that Internet surveys could be useful for outbreak investigations.

Hydrated ionic liquids as a liquid chaperon for refolding of aggregated recombinant protein expressed in Escherichia coli

We have succeeded in refolding of aggregated recombinant protein from Escherichia coli in hydrated ionic liquids. In cholinium dihydrogen phosphate containing a limited amount of water molecules, aggregated solid cellulase was dissolved and refolding was successfully carried out without further processing.

Mucocutaneous inflammation in the Ikaros Family Zinc Finger 1-keratin 5-specific transgenic mice

BACKGROUND

Our genomewide association study documented an association between cold medicine-related Stevens-Johnson syndrome/toxic epidermal necrolysis (CM-SJS/TEN) and Ikaros Family Zinc Finger 1 (IKZF1). Few studies examined biological and pathological functions of IKZF1 in mucosal immunity. We hypothesized that IKZF1 contributes to the mucocutaneous inflammation.

METHODS

Human skin and conjunctival tissues were obtained for immunohistological studies. Primary human conjunctival epithelial cells (PHCjECs) and adult human epidermal keratinocytes (HEKa) also used for gene expression analysis. We also generated K5-Ikzf1-EGFP transgenic mice (Ikzf1 Tg) by introducing the Ik1 isoform into cells expressing keratin 5, which is expressed in epithelial tissues such as the epidermis and conjunctiva, and then examined them histologically and investigated gene expression of the epidermis. Moreover, Ikzf1 Tg were induced allergic contact dermatitis.

RESULTS

We found that human epidermis and conjunctival epithelium expressed IKZF1, and in PHCjECs and HEKa, the expression of IKZF1 mRNA was upregulated by stimulation with polyI:C, a TLR3 ligand. In Ikzf1 Tg, we observed dermatitis and mucosal inflammation including the ocular surface. In contact dermatitis model, inflammatory infiltrates in the skin of Ikzf1 Tg were significantly increased compared with wild type. Microarray analysis showed that Lcn2, Adh7, Epgn, Ifi202b, Cdo1, Gpr37, Duoxa1, Tnfrsf4, and Enpp5 genes were significantly upregulated in the epidermis of Ikzf1 Tg compared with wild type.

CONCLUSION

Our findings support the hypothesis that Ikaros might participate in mucocutaneous inflammation.

Salmonella Typhimurium PagP- and UgtL-dependent resistance to antimicrobial peptides contributes to the gut colonization

Mucosal barrier formed by cationic antimicrobial peptides (CAMPs) is believed to be crucial for host protection from pathogenic gut infection. However, some pathogens can develop resistance to the CAMPs to survive in hosts. Salmonella enterica is a common cause of acute diarrhea. During the course of this disease, the pathogen must continuously colonize the gut lumen, which contains CAMPs. However, it is incompletely understood whether the resistance of Salmonella strains to CAMPs contributes to the development of gut infections. PhoPQ two-component system-dependent lipid A modifications confer resistance to CAMPs in S. enterica serovar Typhimurium. Therefore, we introduced mutations into the PhoPQ-regulated genes in an S. Typhimurium strain, obtaining pagP ugtL and pmrA mutant strains. Each mutant strain demonstrated a distinct spectrum of the resistance to CAMPs. Using streptomycin mouse model for Salmonella diarrhea, we show that the pagP ugtL, but not pmrA, mutant strain had a gut colonization defect. Furthermore, the pagP ugtL, but not pmrA, mutant strain had decreased outer membrane integrity and susceptibility to magainin 2, an alpha-helical CAMP. Taken together, the PagP- and UgtL-dependent resistance to CAMPs was demonstrated to contribute to sustained colonization in the gut. This may be due to the robust outer membrane of S. Typhimurium, inducing the resistance to alpha-helical CAMPs such as α-defensins. Our findings indicate that the development of resistance to CAMPs is required for the S. Typhimurium gut infection.

AGEs-RAGE overexpression in a patient with smoking-related idiopathic nodular glomerulosclerosis

We report a case of smoking-related idiopathic nodular glomerulosclerosis (ING) with overexpression of glomerular advanced glycation end products (AGEs) and their receptor (RAGE). A 59-year-old Japanese man with nephrotic syndrome, who had a smoking history of one pack of cigarettes per day for approximately 40 years, presented with a 3-year history of urinalysis abnormalities without clinical evidence of diabetic mellitus. The patient's leg edema progressively worsened over the previous 2 years, and he was admitted to our hospital. Renal biopsy showed mesangial expansion with diabetic Kimmelstiel-Wilson-like nodular lesions, glomerular basement thickening, and arteriosclerosis. No electron-dense deposits, fibrils, or microtubule deposits were seen in the glomeruli on electron microscopy. Skin AGE level measured using AGE reader was higher in this case than the average level in age-matched Caucasians. In addition, immunohistochemical analysis revealed that N-carboxymethyl lysine, one of the major AGEs, and RAGE were overexpressed and podocin expression was decreased in the peripheral area of the glomerular nodular lesions. These observations suggest that AGEs-RAGE system may be activated in smoking-related ING, possibly leading to the progression of renal dysfunction.