Effect of a single warm compress prior to ophthalmic surgery on ocular surface and intraoperative visibility: a randomised controlled study

PURPOSE

We investigated the effects of a warm compress immediately before surgery on the ocular surface and intraoperative visibility during surgery.

METHODS

A randomised controlled quasi-experiment at Saitama Medical University Hospital. From November 2020 to September 2021, 200 patients scheduled for endophthalmic surgery were randomly assigned to a group that received a hot compress with a spontaneously heating eye mask (HM group) or a group that received only an eye mask (control group). The eye masks were applied for 20 min from 2 hours before surgery, and before and after mask application in the non-invasive tear break-up time (NIBUT), tear meniscus height (TMH) and obstruction score of the meibomian gland (meiboscore) were evaluated. The time from wetting to dry blurring of the corneal surface (corneal blurring time, CBT) was also compared before and after the warm compress.

RESULTS

We enrolled 100 patients in the HM group (mean age 69.0±13.3 years) and 99 patients in the control group (mean age 69.5±16.2 years). In the control group, there were no significant changes in the NIBUT, meiboscore or TMH before and after eye mask use, whereas in the HM group, the NIBUT increased from 6.7±5.1 to 9.5±5.6 s (p<0.001), the meiboscore improved from 0.71±0.93 to 0.63±0.96 (p=0.03) and the TMH significantly improved from 0.22±0.08 to 0.24±0.08 mm (p<0.001). The CBT was longer the HM group than control group (33.5±13.4 s, 25.7±14.9 s, respectively, p=0.01).

CONCLUSIONS

The condition of the ocular surface and intraoperative visibility improved after a single warm compress.

TRIAL REGISTRATION NUMBER

UMIN R000047286.

The influence of vulnerability on depression among Japanese university athletes

Objective

This study examined the estimated causal relationship between vulnerability and depressive symptoms in Japanese university athletes and how the degree of vulnerability affects depressive symptoms.

Materials and methods

In Study 1, 248 Japanese university athletes completed a continual survey from Time 1 to Time 3. In Study 2, 562 Japanese university athletes responded to another survey during the same period. Structural equation modeling was performed to estimate the causal relationship using the cross-lagged effects model for the three waves. Next, a binomial logistic regression analysis was performed to examine the influence of vulnerability on depression.

Results

Results of the cross-lagged effects model showed that all paths from vulnerability to depressive symptoms were significant, and all paths from depressive symptoms to vulnerability were not significant. Thus, vulnerability was the causative variable and depressive symptoms were the outcome variables within the causal relationship. The logistic regression results showed that those with high vulnerability were 1.7 times more likely to have moderate or higher depressive symptoms than those with low vulnerability. Vulnerable individuals are at a higher risk for developing depressive symptoms. By verifying the causal relationship between vulnerability and depressive symptoms, we can contribute to the enhancement of mental health care in accordance with the weakest link model. Appropriate psychological support for athletes can decrease depression and improve their mental health.

Effect of High-radiant Emittance and Short Curing Time on Polymerization Shrinkage Vectors of Bulk Fill Composites

PURPOSE

To evaluate the effect of short curing time using a high-radiant emittance light on polymerization shrinkage vectors in different consistency bulk-fill composites (BFRCs) using micro-computed tomography.

METHODS AND MATERIALS

Radiopaque zirconia fillers were homogeneously incorporated and functioned as radiopaque tracers into two regular-paste: TBFill (Tetric EvoCeram Bulk Fill) and TPFill (Tetric PowerFill), and two flowable (n=6): TBFlow (Tetric EvoFlow Bulk Fill) and TPFlow (Tetric PowerFlow) resin composites. Class I cavities (4 mm depth × 4 mm length × 4 mm width) were 3D-printed and filled in a single increment: TBFill and TBFlow were light-activated using a Bluephase Style 20i (10 seconds in high-mode); TPFill and TPFlow were light-activated using a Bluephase PowerCure (three seconds). The same adhesive system (Adhese Universal) was used for all groups. Microcomputed tomography scans were obtained before and after light-activation. Filler particle movement was identified by polymerization shrinkage vectors at five depths (from 0-4 mm): top, top-middle, middle, middle-bottom and bottom.

RESULTS

TPFlow showed the lowest total vector displacement, followed by TBFlow, TBFill and TPFill, significantly different among each other (p<0.05). Generally, BFRCs showed decreased vector displacement with increased depth, and higher displacement at the top-surface (p<0.05). Qualitative analysis showed a similar pattern of vector magnitude and displacement for groups TBFill and TPFill, with displacement vectors on occlusal (top) surfaces toward the center of the restoration from the top to middle areas, and relatively limited displacement at the bottom. TBFlow and TPFlow showed more displacement on the occlusal (top).

CONCLUSIONS

Short curing time with high-radiant emittance on fast-curing BFRCs was shown to be a feasible option in terms of vector displacement. Flowable BFRCs presented lower vector displacement than their regular-viscosity versions.

A Case of Dellen Formation following 27-Gauge Vitrectomy with Rapid Improvement by Scleral and Conjunctival Sutures

Introduction

Dellen is a corneal disease characterized by shallow, saucer-like excavations at the corneal margin. Herein, we presented a case of dellen formation that developed following a 27-gauge pars plana vitrectomy (PPV) and was rapidly resolved using scleral and conjunctival sutures.

Case Presentation

A 73-year-old woman underwent a 27-gauge PPV for the epiretinal membrane of the right eye. Intraoperatively, owing to coexisting diabetic retinopathy, the peripheral vitreous was shaved, and retinal photocoagulation was performed on the peripheral retina. The intraocular pressure (IOP) was 15 mm Hg on 1 day after the PPV and on postoperative day 4; however, on day 14, the IOP decreased to 10 mm Hg, and conjunctival bleb formation was observed. By day 18, the bleb height remained unchanged, and dellen formation was noted at the corneal periphery. Because of marked corneal thinning, conjunctival and scleral sutures were placed 20 days following the PPV. Intraoperative findings revealed leakage from the scleral wound at the trocar puncture site. The IOP increased to 20 mm Hg at 19 h following the suture, resulting in the disappearance of the bleb and dellen. Since then, the bleb or dellen did not recur.

Conclusion

We encountered a case of late-onset scleral wound cleavage 2 weeks following microincision vitreous surgery, resulting in bleb and dellen formation, which was immediately managed by the scleral and conjunctiva suturing.

Technical skills simulation in transplant surgery: a systematic review

Purpose

 Transplant surgery is a demanding field in which the technical skills of the surgeon correlates with patient outcomes. As such, there is potential for simulation-based training to play an important role in technical skill acquisition. This study provides a systematic assessment of the current literature regarding the use of simulation to improve surgeon technical skills in transplantation.

Methods

 Data were collected by performing an electronic search of the PubMed and Scopus database for articles describing simulation in transplant surgery. The abstracts were screened using the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Three reviewers analyzed 172 abstracts and agreed upon articles that met the inclusion criteria for the systematic review.

Results

 Simulators can be categorized into virtual reality simulators, cadaveric models, animal models (animate or inanimate) and synthetic physical models. No virtual reality simulators in transplant surgery are described in the literature. Three cadaveric models, seven animal models and eight synthetic physical models specific to transplant surgery are described. A total of 18 publications focusing on technical skills simulation in kidney, liver, lung, pancreas, and cardiac transplantation were found with the majority focusing on kidney transplantation.

Conclusions

 This systematic review identifies currently reported simulation models in transplant surgery. This will serve as a reference for general surgery and transplant surgery professionals interested in using simulation to enhance their technical skills.

OP0008 A NOVEL SITE-SPECIFIC PEGYLATED IL-2 WITH POTENT AND TREG-SELECTIVE ACTIVITY IN VIVO

Background

Decreased regulatory T cells (Tregs) and Treg dysfunction are hallmarks of a various autoimmune and inflammatory diseases. While low-dose IL-2 therapy induces Treg expansion in vivo and has clinical benefits in some diseases (e.g., SLE and chronic graft-versus-host disease [GvHD]), there are many concerns about adverse events due to low Treg-selectivity. Furthermore, frequent dosing is needed due to the short half-life.

Objectives

We discovered a novel site-specific PEGylated IL-2 variant, KKC80, with high Treg selectivity and a long half-life in vivo, which overcomes the issues of low-dose IL-2 therapy.

Methods

Based on the co-crystal structure of wild-type IL-2 and its heterotrimeric receptor (PBD ID: 2ERJ), amino acid residues that were to be PEGylation sites were substituted with oAzZLys, an azide-containing lysine derivative. The PEG molecule was site-specifically attached to oAzZLys-incorporated IL-2 by copper-free click chemistry. The binding property to the IL-2 receptors were measured by surface plasmon resonance (SPR). In vitro, Treg selectivity was evaluated by the IL-2-dependent proliferation activity of Tregs and NK cells from human peripheral blood mononuclear cells (PBMCs). In vivo pharmacological activity after the single subcutaneous administration in cynomolgus monkeys was measured by changes in Treg count and Treg activation status in peripheral blood by flow cytometry. Pharmacokinetic parameters were calculated according to serum PEGylated IL-2 concentration. Efficacy in mouse xenogeneic GvHD model using human PBMC-transplanted NOG mice and in monkey DTH model were evaluated.

Results

A novel PEGylated IL-2, KKC80 (human IL-2 desA1/C125S /I129oAzZLys_W-shaped 80 kDa PEG) was discovered by optimizing the PEGylation site and PEG structure based on Treg selectivity and PK. SPR analysis showed that the binding affinity of KKC80 to CD25 was moderately decreased from wild-type IL-2, while binding affinity of KKC80 to IL-2Rβγ was remarkably decreased due to a significant change of the association rate constant. In vitro, wild-type IL-2 activated both Tregs and NK cells in the same concentration range, whereas KKC80 selectively activated Tregs. The Treg selectivity of KKC80 was comparable to another IL-2 mutein, Fc.IL-2 V91K. KKC80, but not Fc.IL-2 V91K, retained its biological activity, even in the presence of a large amount of recombinant soluble CD25, which mimicked the endogenous decoy receptor for IL-2. In monkeys, KKC80 selectively increased peripheral blood Tregs in a dose-dependent manner; the average maximum rate of increase of Treg count in animals treated with 0.01, 0.03, 0.1, 0.3 and 1 mg/kg was 1.5, 3.5, 28, 50 and 154-fold, respectively. In contrast to Tregs, the rates of increase of conventional CD4+ T, CD8+ T and NK cells were low. The Treg increase peaked on day 8 or 11 and lasted for over day 29. KKC80 showed a more sustained upregulation of functional Treg markers (e.g., Foxp3 and CD25) in comparison to Fc.IL-2 V91K. The half-life of KKC80 was calculated as 83.5 to 150 h. At high doses, inflammation-related adverse effects, including increased CRP (≥0.3 mg/kg) and deterioration of general conditions (1 mg/kg) were observed. In the mouse xenogenic GvHD model, KKC80 ameliorated GvHD symptoms and suppressed multiple tissue inflammation markers. Decreased soluble CD25 and IFN-γ were also confirmed, suggesting Treg-mediated anti-inflammatory effect by KKC80 administration were exerted in vivo. In the monkey DTH model, KKC80 suppressed skin inflammation and antibody production.

Conclusion

Among next-generation IL-2 variants, KKC80 showed a best-in-class biological profile for Treg activation. A drastic and sustained increase of Tregs with high Treg-selectivity and anti-inflammatory effects were observed in vivo. These data suggest that in comparison to current IL-2 therapy, KKC80 provides superior therapeutic index and efficacy in patients with autoimmune and inflammatory diseases.

Figure 1.

Disclosure of Interests

Masahiro Ikeda Employee of: Kyowa Kirin Co., Ltd., Shinpei Yamaguchi Employee of: Kyowa Kirin Co., Ltd., Masumi Murakami Employee of: Kyowa Kirin Co., Ltd., Shigeki Takaoka Employee of: Kyowa Kirin Co., Ltd., Yasuko Sakaguchi Employee of: Kyowa Kirin Co., Ltd., Shunki Yasui Employee of: Kyowa Kirin Co., Ltd., Kousuke Iijima Employee of: Kyowa Kirin Co., Ltd., Kenichiro Nanya Employee of: Kyowa Kirin Co., Ltd., Hideyuki Onodera Employee of: Kyowa Kirin Co., Ltd., Toru Amano Employee of: Kyowa Kirin Co., Ltd.

Interpretable AI Explores Effective Components of CAD/CAM Resin Composites

High flexural strength of computer-aided manufacturing resin composite blocks (CAD/CAM RCBs) are required in clinical scenarios. However, the conventional in vitro approach of modifying materials’ composition by trial and error was not efficient to explore the effective components that contribute to the flexural strength. Machine learning (ML) is a powerful tool to achieve the above goals. Therefore, the aim of this study was to develop ML models to predict the flexural strength of CAD/CAM RCBs and explore the components that affect flexural strength as the first step. The composition of 12 commercially available products and flexural strength were collected from the manufacturers and literature. The initial data consisted of 16 attributes and 12 samples. Considering that the input data for each sample were recognized as a multidimensional vector, a fluctuation range of 0.1 was proposed for each vector and the number of samples was augmented to 120. Regression algorithms—that is, random forest (RF), extra trees, gradient boosting decision tree, light gradient boosting machine, and extreme gradient boosting—were used to develop 5 ML models to predict flexural strength. An exhaustive search and feature importance analysis were conducted to analyze the effective components that affected flexural strength. The R2 values for each model were 0.947, 0.997, 0.998, 0.983, and 0.927, respectively. The relative errors of all the algorithms were within 15%. Among the high predicted flexural strength group in the exhaustive search, urethane dimethacrylate was contained in all compositions. Filler content and triethylene glycol dimethacrylate were the top 2 features predicted by all models in the feature importance analysis. ZrSiO4 was the third important feature for all models, except the RF model. The ML models established in this study successfully predicted the flexural strength of CAD/CAM RCBs and identified the effective components that affected flexural strength based on the available data set.

First-line antibiotic prescription patterns for acute otitis media in children: A descriptive study using Japanese claims data (2014-2018)

INTRODUCTION

Acute otitis media is a highly prevalent disease in children. Although guidelines in many countries recommend amoxicillin as the first-line treatment for acute otitis media, the prescribing pattern in Japan is not clear. Our objective was to clarify the amoxicillin prescriptions as first-line antibiotics for acute otitis media and factors associated with amoxicillin prescriptions. Also, changes in amoxicillin prescriptions during the study period by medical facilities were investigated.

METHODS

Using an administrative claims database, we included new episodes of acute otitis media prescribed antibiotics in children under seven years of age between 2014 and 2018. The proportion of amoxicillin prescription was described. Using multivariate logistic regression analysis, factors associated with amoxicillin prescription were evaluated. Rate differences were calculated to describe changes in amoxicillin prescription by medical facilities.

RESULTS

207,213 episodes in 149,929 patients were identified. Amoxicillin prescription was 24.0% and increased over the study period (P for trend <0.001). Characteristics of medical facilities were associated with amoxicillin prescriptions, and hospitals were more likely to prescribe amoxicillin (adjusted odds ratio: 1.71, 95% confidence intervals: 1.63 to 1.79). Compared to 2014, the range of increase in amoxicillin prescription in 2018 was greater in hospitals (14.9%) and pediatric clinics (10.5%) than in otolaryngology clinics (5.9%) and other specialty clinics (6.0%).

CONCLUSIONS

During the study period, amoxicillin prescriptions had increased compared to 2014, but the proportion was still low. Clinics prescribed less amoxicillin than hospitals, and the range of increase was small. Our results suggested that some interventions focused on clinics are needed.

The prognostic impact of right ventricular dysfunction in patients with septic cardiomyopathy

Background

Sepsis is a systemic condition of profoundly impaired health in which an infection leads to a dysregulated host response, and consecutively causes organ dysfunction, shock, and even death. Septic cardiomyopathy (SCM) is one of the multiple organ dysfunctions. SCM is typically defined as left ventricular (LV) dysfunction, presented by decreased LV ejection fraction (LVEF). However, it remains unclear about the detailed mechanism of cardiac dysfunction. In addition, the prognostic impact of right heart dysfunction in SCM patients has not been fully investigated.

Purpose

The purpose of this study was to investigate the prognostic impact of right heart dysfunction in patients with SCM.

Methods

We used the MIMIC-III (Medical Information Mart for Intensive Care III) critical care database, which is a large, freely-available database comprising deidentified health-related data associated with over forty thousand patients who stayed in critical care units of the Beth Israel Deaconess Medical Center between 2001 and 2012. We retrospectively analyzed data of patients with septic shock on admission to intensive care unit (ICU). Septic shock was defined as the presence of any suspected infections, the need for vasopressors, and the lactate level exceeding 2 mmol/L, based on the Sepsis-3 criteria. Patients were performed portable transthoracic echocardiography (TTE) during hospitalization. LVEF and right ventricular (RV) function were determined predominately by visual estimation in the parasternal long-axis view. SCM was defined as having a minimum LVEF of 50% or less during hospitalization. Patients with hyperdynamic motion of LVEF &gt;70% were excluded.

Results

In total, there were 2254 patients with septic shock. Of these, 604 patients who underwent TTE were enrolled, and 314 patients were diagnosed with SCM. At baseline, age, gender, Sequential Organ Failure Assessment (SOFA) score, maximum lactate levels, and maximum norepinephrine dosage were 70 [59–79] years, 194 males, 13 [11–15], 4.0 [2.7–6.2] mmol/L, and 0.20 [0.10–0.31] mcg/kg/min, respectively. All patients were treated with vasopressors. In Kaplan-Meier survival analysis, patients with SCM had increased 28-day mortality compared with those without SCM (log-rank, p=0.09). In addition, we divided SCM patients into two groups; SCM with and without RV dysfunction. SCM patients with RV dysfunction had significant increased 28-day mortality compared with those without RV dysfunction (log-rank, p=0.01) (Figure). In Cox proportional hazard regression analysis adjusted for age, male sex, SOFA score, and maximum lactate levels, RV dysfunction was an independent determinant of 28-day mortality (hazard ratio, 1.59; 95% confidence interval, 1.03–2.46; p=0.03).

Conclusions

The presence of RV dysfunction increased 28-day mortality in patients with SCM. It might be useful for predicting the prognosis of SCM to evaluate not only left heart function but also right heart function.

Kaplan-Meier survival curves

Funding Acknowledgement

Type of funding source: None

Associations between spleen volume and exercise capacity in advanced heart failure patients with left ventricular assist device

Background

The spleen has been recognized as an important organ with several functions such as a reservoir of blood volume, and an involvement in iron metabolism by processing of aged red blood cells and recycling iron. During exercise, spleen contracts, and red blood cells pooled in the spleen are recruited into the systemic circulation. So far, we reported that spleen size changed in advanced heart failure (HF) with left ventricular assist device (LVAD). In addition, spleen volume was related to pulmonary capillary wedge pressure (PCWP) or right atrial pressure (RAP) as parameters of cardiac preload. However, it remains unclear about the relationship between spleen volume and exercise capacity in advanced HF with LVAD.

Purpose

The purpose of this study was to investigate the associations between spleen volume and exercise capacity in advanced HF patients with LVAD.

Methods

We enrolled 27 HF patients (21 males, 45±12 years) with LVAD (HeartMate II™; Abbott, Chicago, IL, USA) for use as a bridge to heart transplantation. All patients underwent blood test, echocardiography, right heart catheterization, computed tomography (CT) and cardiopulmonary exercise testing (CPET). Spleen size was measured by CT volumetry. We excluded patients with splenic infarction or aortic valve closure surgery.

Results

At baseline, body mass index, blood brain natriuretic peptide levels, hemoglobin levels, left ventricular ejection fraction were 21.4±3.1 kg/m2, 73.8 (51.9–165.8) pg/mL, 12.1 (10.6–13.4) g/dL, 24.8±14.7%, respectively. Total cardiac output (CO), the sum of pump flow and CO of native heart was 4.6±0.9 L/min, and spleen volume was 184.9±48.8 mL. As for parameters of CPET, peak heart rate (HR), peak VO2, and peak O2 pulse were 128±25 beats/min, 14.2±3.3 mL/kg/min, and 6.6±1.9 mL/beat. At rest, there were significant correlations between spleen volume and PCWP (r=0.382, p=0.049), RAP (r=0.406, p=0.035) or pulsatility index (r=0.384, p=0.047), despite no correlations with total CO or pump flow. During exercise, there were significant interrelations of spleen volume with peak VO2 (r=0.451, p=0.018) and peak O2 pulse (r=0.427, p=0.026). Furthermore, peak VO2 was interrelated with peak HR (r=0.481, p=0.011) or hemoglobin levels (r=0.649, p&lt;0.001). Remarkably, spleen volume was significantly correlated with hemoglobin levels (r=0.391, p=0.043) (Figure). Interpreting these results based on Fick's formula, the proportion of native CO to total CO is very small at rest, but increases during exercise. The spleen during exercise may contribute to increased native CO, especially stroke volume. Moreover, the spleen may be related to both cardiac preload and oxygen carrying capacity, resulting in a significant association between spleen volume and peak VO2.

Conclusion

Spleen volume could be a useful predictor of exercise capacity in advanced HF patients with LVAD, reflecting splenic function to modulate cardiac preload and blood hemoglobin levels.

Spleen volume and exercise parameters

Funding Acknowledgement

Type of funding source: None

Efficacy of right ventricular dysfunction estimated by pulmonary artery pulsatility index in stable phased dilated cardiomyopathy

Background

Dilated cardiomyopathy (DCM) is characterized by a reduction in left and/or right ventricular myocardial contraction, dilatation of biventricular cavity and major cause of heart failure with high morbidity and mortality rates. Right ventricular dysfunction (RVD) recently have been received attention because of 34% of DCM had RVD and considered as a powerful predictor of impaired prognosis in DCM. Pulmonary Artery Pulsatility index (PAPi) is a novel hemodynamic index shown to predict RVD in advanced heart failure, however, it is unknown that even at early phase, PAPi can reflects latent right myocardial damage and predict long-term prognosis in stable DCM patients.

Methods

From April 2000 to March 2018, we enrolled 566 consecutive patients with cardiomyopathy. All patients underwent laboratory measurement, echocardiography, and cardiac catheterization to evaluate their general conditions. After excluded secondary cardiomyopathy, ischemic cardiomyopathy, and valvular heart disease, finally 162 DCM patients were enrolled. All enrolled patients had NYHA I/II/III and NYHA I/II were 150 patients (92.6%). PAPi was calculated as (systolic pulmonary artery pressure – diastolic pulmonary artery pressure (Pulmonary artery pulse pressure: PAPP)) / right atrial pressure. Median followed up for 4.85 years. In this study 149 patients were performed endomyocardial biopsy in order to exclude secondary cardiomyopathies and 95 patients were assessed using Sirius red staining. Myocardial fibrosis in biopsy specimen was assessed using Sirius red staining, and the positive region was quantified as the collagen volume fraction (CVF).

Results

The mean age and LV ejection fraction (EF) was 50.9±12.6 years and 30.5±8.3%, respectively. When divided into two groups by median PAPi value [PAPi &lt;3.06 (L-PAP) and PAPi ≥3.06 (H-PAP)], even though there were no significant difference in BNP, pulmonary vascular resistance and right ventricular stroke work index between two groups, the probability of cardiac event-survival was significantly higher in L-PAP than H-PAP by Kaplan-Meier analysis (P=0.012). Furthermore, cox proportional hazard regression analysis revealed that PAPi was independent predictor of cardiac events (hazard ratio: 0.624, P=0.025). In pathological analysis, there was no difference between H-PAPi and L-PAPi in CVF.

Conclusion

In the calculation of PAPi, PAPP reflects both RV contractility and left atrial filling pressure and this index considered as RV adaptive response to afterload. The denominator of the PAPP is defined by RA pressure, which serves as a marker of RV preload. Thus, PAPi reflect both preload and afterload of RV at the same time and even though estimated patients at early phase, RVD exists in DCM patients without severe myocardial fibrosis, and PAPi may help stratify DCM and predict cardiac events.

Kaplan-Meier analysis

Funding Acknowledgement

Type of funding source: None

Genetic parameters for conception rate and milk production traits within and across Holstein herds with different housing types and feeding systems during the first 3 lactations

The housing types (HST) in which dairy cows are kept and the feeding systems (FDS) used differ among farmers in Japan. Here, we investigated the genetic relationships among conception rate at first insemination (CR) and milk production traits (PROD) during the first 3 lactations of Holstein cows by using a multiple-trait model that considered the trait values of herds with different HST [tiestall (TSL) barn, freestall (FS) barn, or grazing (GZ)] and FDS as separate traits. Milk production and conception records of Holstein cows in the Hokkaido region of Japan (283,611 records for first lactation, 253,902 for second, and 181,197 for third) were analyzed. We categorized herds with TSL or FS into 2 types of FDS for cows: separate feeding (SF) of roughage plus concentrate or feeding of total mixed ration, in which roughage and concentrates were mixed before feeding. The PROD analyzed were cumulative milk, fat, and protein yields within 305 d and lactation persistency, which we defined as the difference between milk yields at 240 and 60 d in milk. We estimated the heritabilities for CR or PROD within each HST or HST × FDS group and the genetic correlations between these traits within each group or across different groups within each lactation by using a 3-HST (TSL, FS, and GZ) × 2-trait (CR and each PROD) or 2-HST (TSL and FS) × 2-FDS × 2-trait animal model. Heritability estimates for CR in GZ were higher than those in TSL or FS, and genetic correlations for CR between GZ and TSL or FS barns were weaker than those between TSL and FS barns. In addition, genetic correlations between CR and PROD in GZ were weaker than those in TSL and FS barns. In the comparison among the 4 HST × FDS except GZ, heritability estimates for CR in FS × SF were higher than those in the others, and genetic correlations for CR between FS × SF and the other systems were relatively weak. These results indicated that differences in the production system for Holstein cows influence genotypic effects in terms of the cows' ability to conceive and the genetic relationships between fertility traits and milk production traits.

Novel method for endovascular fenestration using radiofrequency transseptal needle for aortic dissection with malperfusion syndrome

Malperfusion syndrome is considered one of the most significant adverse events in aortic dissection disease and often requires invasive strategies to improve ischemia. We report the case of a patient who was presented with worsening claudication and leg rest pain due to malperfusion syndrome of type B aortic dissection. We successfully performed endovascular fenestration therapy to relieve the symptom by using a NRG radiofrequency transseptal needle (Baylis Medical, Montreal, Canada). We suggest that this novel method would be available for the patients with malperfusion syndrome of aortic dissection

Dissociation of the AhR/ARNT complex by TGF-β/Smad signaling represses CYP1A1 gene expression and inhibits benze[a]pyrene-mediated cytotoxicity

Cytochrome P450 1A1 (CYP1A1) catalyzes the metabolic activation of polycyclic aromatic hydrocarbons (PAHs) such as benzo[a]pyrene (B[a]P) and is transcriptionally regulated by the aryl hydrocarbon receptor (AhR)/AhR nuclear translocator (ARNT) complex upon exposure to PAHs. Accordingly, inhibition of CYP1A1 expression reduces production of carcinogens from PAHs. Although transcription of the CYP1A1 gene is known to be repressed by transforming growth factor-β (TGF-β), how TGF-β signaling is involved in the suppression of CYP1A1 gene expression has yet to be clarified. In this study, using mammalian cell lines, along with shRNA-mediated gene silencing, CRISPR/Cas9-based genome editing, and reporter gene and quantitative RT-PCR assays, we found that TGF-β signaling dissociates the B[a]P-mediated AhR/ARNT heteromeric complex. Among the examined Smads, Smad family member 3 (Smad3) strongly interacted with both AhR and ARNT via its MH2 domain. Moreover, hypoxia-inducible factor 1α (HIF-1α), which is stabilized upon TGF-β stimulation, also inhibited AhR/ARNT complex formation in the presence of B[a]P. Thus, TGF-β signaling negatively regulated the transcription of the CYP1A1 gene in at least two different ways. Of note, TGF-β abrogated DNA damage in B[a]P-exposed cells. We therefore conclude that TGF-β may protect cells against carcinogenesis because it inhibits CYP1A1-mediated metabolic activation of PAHs as part of its anti-tumorigenic activities.

The mechanical and chemical stability of the interfaces in bioactive materials: The substrate-bioactive surface layer and hydroxyapatite-bioactive surface layer interfaces

Bioactive materials should maintain their properties during implantation and for long time in contact with physiological fluids and tissues. In the present research, five different bioactive materials (a bioactive glass and four different chemically treated bioactive titanium surfaces) have been studied and compared in terms of mechanical stability of the surface bioactive layer-substrate interface, their long term bioactivity, the type of hydroxyapatite matured and the stability of the hydroxyapatite-surface bioactive layer interface. Numerous physical and chemical analyses (such as Raman spectroscopy, macro and micro scratch tests, soaking in SBF, Field Emission Scanning Electron Microscopy equipped with Energy Dispersive Spectroscopy (SEM-EDS), zeta potential measurements and Fourier Transformed Infra-Red spectroscopy (FTIR) with chemical imaging) were used. Scratch measurements evidenced differences among the metallic surfaces concerning the mechanical stability of the surface bioactive layer-substrate interface. All the surfaces, despite of different kinetics of bioactivity, are covered by a bone like carbonate-hydroxyapatite with B-type substitution after 28 days of soaking in SBF. However, the stability of the apatite layer is not the same for all the materials: dissolution occurs at pH around 4 (close to inflammation condition) in a more pronounced way for the surfaces with faster bioactivity together with detachment of the surface bioactive layer. A protocol of characterization is here suggested to predict the implant-bone interface stability.

Bioactive materials: In vitro investigation of different mechanisms of hydroxyapatite precipitation

Bioactive materials, able to induce hydroxyapatite precipitation in contact with body fluids, are of great interest for their bone bonding capacity. . The aim of this paper is to compare bioactive materials with different surface features to verify the mechanisms of action and the relationship with kinetics and type of precipitated hydroxyapatite over time. Four different surface treatments for Ti/Ti6Al4V alloy and a bioactive glass were selected and a different mechanism of bioactivity is supposed for each of them. Apart from the conventional techniques (FESEM, XPS and EDX), less common characterizations (zeta potential measurements on solid surfaces and FTIR chemical imaging) were applied. The results suggest that the OH groups on the surface have several effects: the total number of the OH groups mainly affects hydrophilicity of surfaces, while the isoelectric points, surface charge and ions attraction mainly depend on OH acidic/basic strength. Kinetics of hydroxyapatite precipitation is faster when it involves a mechanism of ion exchange while it is slower when it is due to electrostatic effects . The electrostatic effect cooperates with ion exchange and it speeds up kinetics of hydroxyapatite precipitation. Different bioactive surfaces are able to differently induce precipitation of type A and B of hydroxyapatite, as well as different degrees of crystallinity and carbonation. STATEMENT OF SIGNIFICANCE: The bone is made of a ceramic phase (a specific type of hydroxyapatite), a network of collagen fibers and the biological tissue. A strong bond of an orthopedic or dental implant with the bone is achieved by bioactive materials where precipitation and growth of hydroxyapatite occurs on the implant surface starting from the ions in the physiological fluids. Several bioactive materials are already known and used, but their mechanism of action is not completely known and the type of precipitated hydroxyapatite not fully investigated. In this work, bioactive titanium and bioglass surfaces are compared through conventional and innovative methodologies. Different mechanisms of bioactivity are identified, with different kinetics and the materials are able to induce precipitation of different types of hydroxyapatite, with different degree of crystallinity and carbonation.

P6452Circulating human epididymis protein 4 is a novel prognostic predictor in ambulatory patients with non-ischemic dilated cardiomyopathy

Background

Myofibroblasts, which are activated fibroblasts, play an important role in interstitial fibrosis in non-ischemic dilated cardiomyopathy (NIDCM). Recently, human epididymal body protein 4 (HE4) has attracted attention as a marker specific to myofibroblasts. However, the prognostic impact of HE-4 on cardiovascular events in NIDCM patients has not been reported.

Purposes

The purpose of this study was to investigate the impact of circulating serum HE4 on the prognosis in patients with NIDCM.

Methods

Forty-four NIDCM patients underwent echocardiography, laboratory measurements, cardiac catheterization, and endomyocardial biopsy within one week under stable heart failure condition. Patients with cancer were excluded from this study. We collected blood samples from peripheral vain, ascending aorta, and coronary sinus during cardiac catheterization and measured serum HE4 level. They were divided into two groups at the median of HE4 level: High-HE4 group (HE4 >69 pmol/L); n=22, Low-HE4 group (HE4 <69 pmol/L); n=22. Cardiac composite event was defined as cardiac related deaths and hospitalization due to worsening heart failure.

Results

The mean age, left ventricular ejection fraction (LVEF), and plasma brain natriuretic peptide level were 56 years, 32%, and 205 pg/mL. Between two groups, there were no significant differences in age, gender, LVEF, left ventricular end-diastolic diameter, cardiac index, and pulmonary capillary wedge pressure. However, estimated glomerular filtration rate was significantly lower in the High-HE4 group (p=0.025). Kaplan-Meier survival analysis revealed that the High-HE group had a higher rate of cardiac composite event (p=0.011, see Figure). However, as for the pathological analysis, not only the peripheral HE4 level but also HE4 value subtracting coronary sinus from ascending aorta did not significantly correlate with collagen volume fraction in biopsy samples.

Circulating HE4 level and prognosis

Conclusion

Elevated circulating HE4 is associcated with poor prognosis in ambulatory patients with NIDCM.

P5417Splenic volume changes as a hemodynamic parameter in advanced heart failure with left ventricular assist device

Background

The spleen has been recognized as an important organ to reserve 20–30% of the total blood volume. Generally, splenomegaly has been thought to be related to congestion. However, in the setting of hypovolemic shock or hypoxemia, it has been reported that spleen contracted and splenic volume decreased. On the other hand, in advanced heart failure (HF), the hemodynamics is characterized by both low cardiac output (LO) and systemic congestion, and patients sometimes need support of left ventricular assist device (LVAD). However, it remains unclear about the association between spleen size and hemodynamic parameters in patients with LO who need LVAD support.

Purpose

The purpose of this study was to investigate the relationship between spleen size and hemodynamic parameters in advanced HF before and after LVAD implantation.

Methods

We enrolled 12 advanced HF patients with LVAD (11 males, 45±10 years). All patients underwent blood test, echocardiography, right heart catheterization, and computed tomography (CT) before and after LVAD implantation. Spleen size was measured by CT volumetry. We excluded patients with splenic infarction, or any infections, or mean right atrial pressure (RAP) <5mmHg because of a possibility of hypovolemic status. LO was defined as CI less than 2.2L/min/m2.

Results

At pre- and post-LVAD implantation, cardiac output, cardiac index (CI), mean RAP, and mean pulmonary capillary wedge pressure were 3.1±0.6 vs. 4.9±0.9L/min, p=0.002; 1.7±0.3 vs. 2.8±0.3L/min/m2, p=0.002; 14±5 vs. 9±3mmHg, p=0.059; and 30±7 vs. 10±3mmHg, p=0.002, respectively. The serum brain natriuretic peptide level had significantly decreased (1101 [517–1446] vs 74 [35–216] pg/mL, p=0.002). In all patients, CI had increased to over 2.2L/min/m2. The splenic volume significantly increased from pre- to post-LVAD implantation (172±48 vs. 233±78mL, p=0.002) (Figure). Furthermore, all patients were divided into two groups; elevated RAP group (n=4) and non-elevated RAP group (n=8) after LVAD support. In elevated RAP group, there were no significant changes in the spleen size between pre- and post-LVAD implantation (167±45 vs. 223±111mL, p=0.068). On the other hand, in non-elevated RAP group, the spleen volume had significantly increased from pre- to post-LVAD support (172±53 vs. 231±62mL, p=0.011). In addition, there was one patient whose hemodynamic state had changed to LO again because of LVAD failure due to pump thrombosis. In this case, the splenic volume was 212mL before LVAD implantation with LO, and increased to 418mL after LVAD implantation with non-LO, although decreased to 227mL after LVAD pump failure with LO again.

Splenic volume changes

Conclusions

The spleen may change its size in order to keep cardiac output by regulating cardiac preload depending on the systemic perfusion in advanced HF with LVAD.

Acknowledgement/Funding

None

P1581Early blood pressure reduction by intravenous vasodilators associates with acute kidney injury in patients with hypertensive acute decompensated heart failure

Background

In patients with hypertensive acute decompensated heart failure (ADHF), intravenous vasodilators are commonly used. However, little is known about optimal use in blood pressure (BP) management to avoid acute kidney injury (AKI).

Purpose

To investigate the association between systolic BP (SBP) changes in first 6 h and incidence of AKI within 48 h in patients with hypertensive ADHF.

Methods

Post-hoc analysis was performed on a prospectively enrolled cohort. We investigated 245 patients with ADHF and SBP >140 mmHg on arrival (mean age, 76 years; 40% female). We defined “SBP-fall” as maximum percent reduction in SBP 6h after intravenous treatment. AKI was defined as serum creatinine (SCr) ≥0.3 mg/dL, or urine output <0.5 mL/kg/h at 48 h.

Results

Mean SBP, SBP-fall and SCr level at arrival were 180 mmHg, 29.4%, and 1.21 mg/dL, respectively. Sixty-six patients experienced AKI. There were no significant differences in age, NYHA functional class, SBP and SCr at admission between AKI and Non-AKI group. AKI group had the greater SBP-fall compared with Non-AKI (36.7%versus 27.2%, p≤0.0001). Logistic regression analyses revealed that SBP-fall had an independent predictor of AKI (Table). In addition, SBP-fall had positive association with the number of concomitant used intravenous vasodilators in first 6 h (Figure).

Logistic regression analyses for AKI Univariate Multivariate AUC OR 95% CI P OR 95% CI P Ages, years, per 10 years 1.04 0.82–1.33 0.17 0.75 SBP at arrival, per 10 mmHg 1.01 0.93–1.11 0.77 SBP-fall, per 10% 1.49 1.22–1.81 <0.001 1.54 1.24–1.91 <0.001 HR, per 10 beat/min 1.12 1.00–1.25 0.049 1.07 0.95–1.21 0.28 COPD 2.95 1.06–8.21 0.04 3.06 0.99–9.43 0.054 SCr, per 1 mg/dL 1.40 0.83–2.37 0.21 Furosemide i.v. 1.12 0.42–2.95 0.82 Carperitide 3.22 1.69–6.13 0.0002 4.39 2.16–8.93 <0.001 NTG/ISDN i.v. 0.97 0.54–1.74 0.92 CCB i.v. 1.86 0.76–4.53 0.18 OR, odds ratio; CI, confidence interval; AUC, area under the curve; SBP, systolic blood pressure; COPD, chronic obstructive pulmonary disease; SCr, serum creatinine; i.v., intravenous; NTG, nitroglycerin; ISDN, isosorbide dinitrate; CCB, calcium channel blocker.

SBP-fall odds ration for AKI

Conclusion

In the first 6h of management for hypertensive ADHF patients, aggressive SBP reduction by the combination use of vasodilator agents predicted the incidence of AKI.

Predicting the Debonding of CAD/CAM Composite Resin Crowns with AI

A preventive measure for debonding has not been established and is highly desirable to improve the survival rate of computer-aided design/computer-aided manufacturing (CAD/CAM) composite resin (CR) crowns. The aim of this study was to assess the usefulness of deep learning with a convolution neural network (CNN) method to predict the debonding probability of CAD/CAM CR crowns from 2-dimensional images captured from 3-dimensional (3D) stereolithography models of a die scanned by a 3D oral scanner. All cases of CAD/CAM CR crowns were manufactured from April 2014 to November 2015 at the Division of Prosthodontics, Osaka University Dental Hospital (Ethical Review Board at Osaka University, approval H27-E11). The data set consisted of a total of 24 cases: 12 trouble-free and 12 debonding as known labels. A total of 8,640 images were randomly divided into 6,480 training and validation images and 2,160 test images. Deep learning with a CNN method was conducted to develop a learning model to predict the debonding probability. The prediction accuracy, precision, recall, F-measure, receiver operating characteristic, and area under the curve of the learning model were assessed for the test images. Also, the mean calculation time was measured during the prediction for the test images. The prediction accuracy, precision, recall, and F-measure values of deep learning with a CNN method for the prediction of the debonding probability were 98.5%, 97.0%, 100%, and 0.985, respectively. The mean calculation time was 2 ms/step for 2,160 test images. The area under the curve was 0.998. Artificial intelligence (AI) technology-that is, the deep learning with a CNN method established in this study-demonstrated considerably good performance in terms of predicting the debonding probability of a CAD/CAM CR crown with 3D stereolithography models of a die scanned from patients.

Significance and potential of self-management research for HTLV-1 associated myelopathy: review of self-management for people with multiple sclerosis

Objective and Methods: A total of 21 published studies on self-management for people with multiple sclerosis (MS) were reviewed to explore the significance and potential of self-management for people with HTLV-1 associated myelopathy (HAM). These studies were classified based on three concepts: self-management regimen and preferences, context of self-management, and outcomes of self-management. Results: Self-management regimens for people with MS include medical, role, and emotional management. Moreover, self-management regimens are closely associated with the context of self-management, emphasizing the importance of investigating contextual factors and regimens concurrently. Quality of life (QOL) has been evaluated as an outcome of self-management, and self-management has been shown to have both positive and negative effects on the QOL of people with MS. However, insufficient studies focus on self-management regimens and patient preferences; further investigation is necessary to develop effective self-management interventions that reflect the often unique nature of the disease for each individual. The characteristics of HAM are also unique to individual patients. Therefore, investigation of people with HAM in particular is required. Conclusion: This literature review examined the significance of investigating self-management for people with HAM.

Influence of the anatomical form of the posterior maxilla on the reliability of superior maxillary repositioning by Le Fort I osteotomy

Certain patients with facial deformities require superior repositioning of the maxilla via Le Fort I osteotomy; however, the magnitude of superior repositioning of the maxilla is often less than expected. In this study, the correlation between the accuracy of superior repositioning of the maxilla and the anatomical form of the maxillary posterior region was examined. Seventy-five patients who underwent Le Fort I osteotomy without forward movement of the maxilla but with superior repositioning of the maxilla were included in this study. The bone volume around the descending palatine artery (DPA), the angle of the junction between the pterygoid process and the tuberosity, and the distance between the upper second molar and the pterygoid process were measured via three-dimensional analysis. A significant negative correlation (r=-0.566) was found between the bone volume around the DPA and the ratio of repositioning (actual movement divided by expected movement). It is possible that the superior repositioning of the maxilla expected prior to surgery was not sufficiently attained because of the large volume of bone around the DPA. The results of this study show that in some patients, superior repositioning was not achieved at the expected level because of bone interference attributable to the anatomical form of the maxillary posterior region.

The effect of femoral bone tunnel configuration on tendon-bone healing in an anterior cruciate ligament reconstruction: An animal study

Objectives

To compare the effect of femoral bone tunnel configuration on tendon-bone healing in an anterior cruciate ligament (ACL) reconstruction animal model.

Methods

Anterior cruciate ligament reconstruction using the plantaris tendon as graft material was performed on both knees of 24 rabbits (48 knees) to mimic ACL reconstruction by two different suspensory fixation devices for graft fixation. For the adjustable fixation device model (Socket group; group S), a 5 mm deep socket was created in the lateral femoral condyle (LFC) of the right knee. For the fixed-loop model (Tunnel group; group T), a femoral tunnel penetrating the LFC was created in the left knee. Animals were sacrificed at four and eight weeks after surgery for histological evaluation and biomechanical testing.

Results

Histologically, both groups showed a mixture of direct and indirect healing patterns at four weeks, whereas only indirect healing patterns were observed in both groups at eight weeks. No significant histological differences were seen between the two groups at four and eight weeks in the roof zone (four weeks, S: mean 4.8 sd 1.7, T: mean 4.5 sd 0.5, p = 0.14; eight weeks, S: mean 5.8 sd 0.8, T: mean 4.8 sd 1.8, p = 0.88, Mann-Whitney U test) or side zone (four weeks, S: mean 5.0 sd 1.2, T: mean 4.8 sd 0.4, p = 0.43; eight weeks, S: mean 5.3 sd 0.8,T: mean 5.5 sd 0.8, p = 0.61, Mann-Whitney U test) . Similarly, no significant difference was seen in the maximum failure load between group S and group T at four (15.6 sd 9.0N and 13.1 sd 5.6N) or eight weeks (12.6 sd 3.6N and 17.1 sd 6.4N, respectively).

Conclusion

Regardless of bone tunnel configuration, tendon-bone healing after ACL reconstruction primarily occurred through indirect healing. No significant histological or mechanical differences were observed between adjustable and fixed-loop femoral cortical suspension methods.

Cite this article: Y. Sato, R. Akagi, Y. Akatsu, Y. Matsuura, S. Takahashi, S. Yamaguchi, T. Enomoto, R. Nakagawa, H. Hoshi, T. Sasaki, S. Kimura, Y. Ogawa, A. Sadamasu, S. Ohtori, T. Sasho. The effect of femoral bone tunnel configuration on tendon-bone healing in an anterior cruciate ligament reconstruction: An animal study. Bone Joint Res 2018;7:327–335. DOI: 10.1302/2046-3758.75.BJR-2017-0238.R2.

Analysis of masticatory muscle coordination during unilateral single-tooth clenching using muscle functional magnetic resonance imaging

In a previous study, we used muscle functional magnetic resonance imaging to show that the anterior movement of the occlusal point increased the activity of the superior head of the ipsilateral lateral pterygoid muscle (ipsilateral SHLP) during unilateral single-tooth clenching. The purpose of this study was to verify the hypothesis that the increased activity of the ipsilateral SHLP described above serves to antagonise the occlusal force acting on the condyle. In total, 9 healthy volunteers were requested to perform left unilateral clenching at the first molar or first premolar region for 1 minute at 20% or 40% maximum voluntary clenching force. Changes in the mean proton transverse relaxation time (∆T2) were examined from the magnetic resonance images obtained before and after each clenching act as an index of the activity in all masticatory muscles. Correlation analyses of the mean ΔT2 for each volume of interest were performed with the first molar or premolar clenches to analyse the correlation between the activities in each muscle. A statistically significant correlation was exhibited between the ipsilateral temporal and ipsilateral SHLP (r = .651, P = .003) during first premolar clenching. However, no significant correlations were observed in the ipsilateral SHLP during first molar clenching. The results of this study suggest that the ipsilateral SHLP may contribute to the pulling of the mandibular condyle forward against the occlusal force generated by the ipsilateral temporal muscle.

A randomized controlled phase II clinical trial comparing ONO-4053, a novel DP1 antagonist, with a leukotriene receptor antagonist pranlukast in patients with seasonal allergic rhinitis

Background

Prostaglandin D₂ (PGD₂) is primarily produced by mast cells and is contributing to the nasal symptoms including nasal obstruction and rhinorrhea.

Objective

This study aimed to evaluate the efficacy and safety of a novel PGD₂ receptor 1 (DP1) antagonist, ONO‐4053, in patients with seasonal allergic rhinitis (SAR).

Methods

This study was a multicenter, randomized, double‐blind, parallel‐group study of patients with SAR. Following a one‐week period of placebo run‐in, patients who met the study criteria were randomized to either the ONO‐4053, leukotriene receptor antagonist pranlukast, or placebo group for a two‐week treatment period. A total of 200 patients were planned to be randomly assigned to receive ONO‐4053, pranlukast, or placebo in a 2:2:1 ratio. Nasal and eye symptoms were evaluated.

Results

Both ONO‐4053 and pranlukast had higher efficacy than placebo on all nasal and eye symptoms. ONO‐4053 outperformed pranlukast in a total of three nasal symptom scores (T3NSS) as well as in individual scores for sneezing, rhinorrhea, and nasal itching. For T3NSS, the Bayesian posterior probabilities that pranlukast was better than placebo and ONO‐4053 was better than pranlukast were 70.0% and 81.6%, respectively, suggesting that ONO‐4053 has a higher efficacy compared with pranlukast. There was no safety‐related issue in this study.

Conclusions

We demonstrated that the efficacy of ONO‐4053 was greater than that of pranlukast with a similar safety profile. This study indicates the potential of ONO‐4053 for use as a treatment for SAR (JapicCTI‐142706).

Setting Ideal Lubricant Mixing Time for Manufacturing Tablets by Evaluating Powder Flowability

We investigated the effectiveness of using Carr's flowability index (FI) and practical angle of internal friction (Φ) as indexes for setting the target Mg-St mixing time needed for preparing tablets with the target physical properties. We used FI as a measure of flowability under non-loaded conditions, and Φ as a measure of flowability under loaded conditions for pharmaceutical powders undergoing direct compression with varying concentrations of Mg-St and mixing times. We evaluated the relationship between Mg-St mixing conditions and pharmaceutical powder flowability, analyzed the correlation between the physical properties of the tablets (i.e., tablet weight variation, drug content uniformity, hardness, friability, and disintegration time of tablets prepared using the pharmaceutical powder), and studied the effect of Mg-St mixing conditions and pharmaceutical powder flowability on tablet properties. Mg-St mixing time highly correlated with pharmaceutical powder FI (R ² = 0.883) while Mg-St concentration has low correlation with FI, and FI highly correlated with the physical properties of the tablet (R ² values: weight variation 0.509, drug content variation 0.314, hardness 0.525, friability 0.477, and disintegration time 0.346). Therefore, using pharmaceutical powder FI as an index could enable prediction of the physical properties of a tablet without the need for tableting, and setting the Mg-St mixing time by using pharmaceutical powder FI could enable preparation of tablets with the target physical properties. Thus, the FI of the intermediate product (i.e., pharmaceutical powder) is an effective index for controlling the physical properties of the finished tablet.