Predictors of renal function deterioration at one year after off-clamp non-renorrhaphy partial nephrectomy

BACKGROUND

Preservation of renal function is an important goal in renal cell carcinoma-related surgery. Although several case-dependent techniques for renal pedicle clamping and hemostasis have been used, their effects on long-term renal function are controversial.

METHODS

The clinical records of 114 patients who underwent off-clamp non-renorrhaphy open partial nephrectomy at our hospital were retrospectively reviewed. Perioperative estimated glomerular filtration rate (eGFR) preservation was calculated, and predictors of eGFR decline 12 months post-surgery and overtime deterioration of renal function were identified using a multivariate regression analysis.

RESULTS

The median patient age was 65 years, and the median tumor size was 27 mm. The mean eGFR preservation at 1, 3, and 12 months post-surgery were 90.1%, 89.0%, and 86.9%, respectively. eGFR decline at 1 and 3 months were associated with poor eGFR preservation at 12 months with the odds ratio (95% confidence interval (CI)) of 1.97 and 3.157, respectively. Multivariate regression analyses revealed that tumor size was an independent predictor of eGFR decline at 12 months. Among 65 patients with eGFR preservation over 90% at 1 month post-surgery, eGFR value of 28 patients deteriorated below 90% at 12 months post-surgery compared with preoperative eGFR. Tumor size and eGFR preservation at 1 month were independent predictors of long-term renal function deterioration.

CONCLUSION

Tumor size predicted eGFR decline 12 months post-surgery. Only a mild decline in eGFR was observed between 3 and 12 months after open partial nephrectomy. Tumor size and eGFR preservation at 1 month predicted the deterioration of renal function over time.

Effectiveness and safety of sarilumab in patients with rheumatoid arthritis: A multicenter, retrospective, inverse probability of treatment-weighted analysis based on the FRAB-registry

OBJECTIVE

The efficacy and safety of sarilumab (SARI) were investigated in real-world clinical practice in Japan.

METHOD

Subjects were 121 rheumatoid arthritis (RA) patients in 23 medical institutions in Fukuoka Prefecture, Japan, who started treatment with SARI between May 2018 and November 2021. Data on the SARI starting dose, patients' baseline characteristics, disease activity, and blood test data at the start of treatment, as well as follow-up data on the SARI dose, disease activity, and adverse events until Week 52. Safety and the continuation rate calculated by the Kaplan-Meier method were evaluated, and the effectiveness of treatment at 1 year was assessed using the clinical disease activity index (CDAI). Patients' baseline characteristics for which significant differences were evident were adjusted with a propensity score by using the inverse probability of treatment-weighting (IPTW) method.

RESULTS

The continuation rate at Week 52 was 66.1%. The CDAI showed significant improvement from Week 4 that was maintained until Week 52. Comparisons conducted after IPTW adjustment for patients' baseline characteristics for which significant differences were evident revealed no significant differences at Week 52 between the groups classified by higher or lower body mass index (BMI) (p = 0.231), serious comorbidities (p = 0.973), MTX use (p = 0.321), or prior treatment with ≤ 1 or ≥ 2 biologic and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) (p = 0.765).

CONCLUSIONS

The results showed that the efficacy of SARI is not affected by BMI, comorbidities, MTX use, or the number of prior b/tsDMARDs, and no new safety concerns were apparent. Key Points • This is the first real-world clinical study to report on the efficacy and safety of SARI in Japan. The results of this study indicate that the efficacy of SARI was not affected by BMI, comorbidities, MTX use, or number of previous b/tsDMARDs. • It was shown that SARI can be used in a Japanese population without any new side effects.

Presenteeism and sleep duration on workdays and days off

BACKGROUND

Presenteeism refers to being present at work but experiencing reduced productivity due to health problems, and has been known to be related to sleep loss. Workers commonly sleep longer on days off than on workdays, and presenteeism may be reduced with extended sleep on days off.

AIMS

This study aimed to determine the association between sleep duration both on workdays and days off and presenteeism.

METHODS

The participants were 1967 workers who engaged in work for 5 days and rested for 2 days weekly. Sleep duration was classified into less than 6 hours (short; S), 6-8 hours (medium; M), and 9 hours or longer (long; L), for workdays and days off, respectively. Presenteeism was assessed using the World Health Organization Health and Work Performance Questionnaire.

RESULTS

On both workdays and days off, compared to medium sleep duration, short sleep duration was significantly associated with increased odds of presenteeism. The odds of presenteeism were significantly increased for S-S (odds ratio [OR] 2.17, 95% confidence interval [CI]1.40-3.37), S-M (OR 1.59, 95% CI 1.14-2.22), S-L (OR 2.71, 95% CI 1.05-7.00), and M-S (OR 6.82, 95% CI 2.71-17.17) combined sleep duration for workdays and days off, respectively, compared to an M-M (reference).

CONCLUSIONS

Sleep loss on workdays cannot be compensated for with longer sleep on days off. This study suggests that sufficient sleep duration on both workdays and days off is important for reducing presenteeism.

Cluster analysis defines four groups of Japanese patients with adult-onset Still's disease

OBJECTIVES

To define groups and characterize differences in the prognosis of patients with adult-onset Still's disease (AOSD).

METHODS

We performed a retrospective cohort study. Patients with AOSD were grouped using hierarchical unsupervised cluster analysis according to age, sex, clinical features, and laboratory data. The primary endpoints were overall survival and drug-free remission rate.

RESULTS

A total of 153 patients with AOSD were placed into four clusters. Those in Cluster 1 had a young onset, tended to be female, and had fewer complications and moderate ferritin concentrations. Those in Cluster 2 had a young onset and had more complications and higher ferritin concentrations. Those in Cluster 3 had a young onset, tended to be male, and had no lymphadenopathy and fewer complications. Those in Cluster 4 had an older onset, tended to be female, and had more complications and higher ferritin concentrations. Overall survival tended to be lower (P = .0539) in Cluster 4, and drug-free remission was higher in Clusters 1, 2, and 3 [hazard ratios (HRs) 2.19, 3.37, and 3.62 vs. Cluster 4, respectively].

CONCLUSIONS

Four groups of AOSD that have distinct clinical manifestations, ferritin concentrations, severity, and drug-free remission rate were identified, which were lowest in Cluster 4. Graphical Abstract.

Recent advances in the treatment strategy for AAV improved outcomes with intensive GC tapering

OBJECTIVE

To evaluate trends in results of care and management for antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV).

METHODS

We employed multicenter cohort data collected during 2011-2021, recruiting 43 patients with granulomatosis with polyangiitis (GPA) and 91 with microscopic polyangiitis (MPA). According to the median registration date of September 2015, patients have split into two groups: an early group and a late group (both of them, n = 67). To prevent bias, a propensity score according to numerous baseline characteristics variables was calculated; 50 matching members of each group were statistically extracted. Their treatments and clinical outcomes were examined at 6, 12, and 24 months after initial remission therapy.

RESULTS

Statistics demonstrated that the baseline characteristics were similar. The late group used rituximab (RTX) more often for both remission induction and maintenance therapy, compared with the early group. The mean daily PSL doses of the late group were significantly lower than those of early group at each time point. The late group discontinued PSL 14.0% at 12 months and 23.3% at 24 months. Despite their intensive glucocorticoids (GC) tapering, the remission rates and the relapse rates were significantly fairer in the late group. The Vasculitis Damage Index (VDI) and VDI due to GC at each time point were lower in the late group, and those differences had become wider over time.

CONCLUSION

Recent developments in AAV treatment have allowed efficient remission and prevention of relapses, which in turn enabled extensive GC tapering causing fewer sequelae.

A case in which baricitinib was effective for both rheumatoid arthritis and essential thrombocythemia

We experienced a case of rheumatoid arthritis and JAK2V617F mutation-positive essential thrombocythemia treated with baricitinib. The patient was a 72-year-old male. He was diagnosed with rheumatoid arthritis at a local clinic in April 2018. Methotrexate (MTX) was started and the dose was increased to 16 mg/week. In October of the same year, anaemia was observed and MTX was reduced, but anaemia progressed. Blood tests showed pancytopenia, and he was referred to Rheumatology on suspicion of drug-induced pancytopenia. Pancytopenia improved with discontinuation of MTX and administration of folic acid. His platelet count was markedly increased to 1,400,000/μl at one point, decreased to 400,000/μl, and then gradually increased to 700,000-1,000,000/μl. Despite taking an antiplatelet drug, he developed cerebral infarction in June 2019. The JAK2V617F mutation was noted, and he was diagnosed with essential thrombocythemia. Hydroxycarbamide was started, but the effect was insufficient. Baricitinib, a JAK1/2 inhibitor indicated for rheumatoid arthritis, was started in August with the expectation that it would also be effective for essential thrombocythemia. The platelet count decreased to ∼400,000-600,000 cells/μl, and a decrease in the C-reactive protein level and the improvement of arthritis were noted. We report this case because it is considered to be a valuable case, suggesting that baricitinib may be effective for essential thrombocythemia.

Multi-Institutional Fact-Finding Study: Association between Geriatric Assessment and Reduction in Intensity of Radiotherapy for Elderly Cancer Patients without Metastasis

PURPOSE/OBJECTIVE(S)

Vulnerable patients receive a low-intensity, palliative treatment rather than the standard treatment. Defining vulnerability in terms of standard or reduced radiation intensity can result in appropriate radiotherapy for elderly cancer patients without excessive adverse events and poor outcomes. However, it is difficult to define vulnerability, because radiation oncologists hesitate to include vulnerable patients in clinical trials involving radical radiotherapy. We hypothesized that for elderly cancer patients without metastasis, vulnerability scores, obtained by geriatric assessment (GA), could help in predicting the reduction in radiation intensity determined by radiation oncologists based on their experience.

MATERIALS/METHODS

In this multicenter prospective study, we enrolled cancer patients (70 years or older) without metastasis. The reduction in radiation intensity was categorized into 3 groups as follows: i) standard schedule of radiotherapy, but conversion of irradiation fields, ii) standard irradiation fields, but converted schedule of radiotherapy, and iii) conversion of radiotherapy schedule and irradiation fields. Standard radiotherapy was defined as recommended doses and radiation fields according to the guidelines for the primary tumors analyzed. GA was performed by calculating geriatric 8 (G8) and vulnerable elders survey (VES-13) scores before radiotherapy and 3-5 and 8-16 weeks after completion of radiotherapy. The primary endpoint was to evaluate the correlation between vulnerability assessed by G8 and change in radiation intensity.

RESULTS

Between November 2020 and February 2022, 317 patients were included in this study at 13 centers in Japan. The median age was 77 (range, 70-90) years. The primary cancer sites were head and neck, esophagus, lungs, breasts, pancreas, bladder, uterus, and prostate in 63, 22, 62, 48, 6, 5, 26, and 85 patients, respectively. High-precision radiotherapy was performed for 199 patients (63%). Of the 31 patients (10%) whose radiation intensity was reduced, 14, 9, and 8 patients were provided i, ii, and iii category, respectively. Planned radiotherapy was completed for 312 patients (98%). G8 and VES-13 vulnerability scores were obtained for 201 and 61 patients, respectively, before radiotherapy. The mean G8 and VES-13 scores were 13.3 ± 2.4 and 1.8 ± 1.8, 12.9 ± 2.6 and 2.0 ± 2.0, and 13.4 ± 2.4 and 2.0 ± 1.9 before radiotherapy and 3-5 and 8-16 weeks after completion of radiotherapy, respectively. Multivariate analysis revealed that reduction in radiation intensity was significantly associated with vulnerability assessed using VES-13 (p < 0.001) but not G8 (p = 0.06).

CONCLUSION

An excellent completion rate was obtained for planned radiotherapy, and vulnerability assessed using VES-13, not G8, was associated with the reduction in intensity of radiotherapy.

Advantages of enhanced recovery after surgery program in robot-assisted radical cystectomy

Radical cystectomy is a gold-standard treatment for muscle-invasive bladder cancer. We recently introduced robot-assisted radical cystectomy (RARC) with perioperative enhanced recovery after surgery (ERAS). The medical records of patients with bladder cancer who underwent open radical cystectomy (ORC) or RARC/ERAS at NTT Medical Center Tokyo were retrospectively reviewed to compare the surgical outcomes, hospital stay, and medical costs between groups. Multidisciplinary full ERAS items were provided for the RARC/ERAS group. The median estimated blood losses in the ORC and RARC/ERAS groups were 650 and 100 mL, and the median operative times were 312 and 445 min, respectively. In addition, the median times to liquid food intake in these groups were 6 and 0 days, the median times to first flatus and first defecation were 2 and 1 day, and 3 and 1.5 days, respectively. The rates of postoperative ileus in the ORC and RARC/ERAS groups were 27.5% and 4.5%, and the median postoperative hospital stays was 26.5 and 12 days, respectively. Medical costs excluding surgery were significantly lower in the RARC/ERAS group. In conclusion, RARC/ERAS represents a safe treatment option for muscle-invasive bladder cancer with decreased perioperative complications and lower medical costs.

Development of advanced photon calibrator for Kamioka gravitational wave detector (KAGRA)

The Kamioka Gravitational wave detector (KAGRA) cryogenic gravitational-wave observatory has commenced joint observations with the worldwide gravitational wave detector network. Precise calibration of the detector response is essential for accurately estimating parameters of gravitational wave sources. A photon calibrator is a crucial calibration tool used in laser interferometer gravitational-wave observatory, Virgo, and KAGRA, and it was utilized in joint observation 3 with GEO600 in Germany in April 2020. In this paper, KAGRA implemented three key enhancements: a high-power laser, a power stabilization system, and remote beam position control. KAGRA employs a 20 W laser divided into two beams that are injected onto the mirror surface. By utilizing a high-power laser, the response of the detector at kHz frequencies can be calibrated. To independently control the power of each laser beam, an optical follower servo was installed for power stabilization. The optical path of the photon calibrator's beam positions was controlled using pico-motors, allowing for the characterization of the detector's rotation response. Additionally, a telephoto camera and quadrant photodetectors were installed to monitor beam positions, and beam position control was implemented to optimize the mirror response. In this paper, we discuss the statistical errors associated with the measurement of relative power noise. We also address systematic errors related to the power calibration model of the photon calibrator and the simulation of elastic deformation effects using finite element analysis. Ultimately, we have successfully reduced the total systematic error from the photon calibrator to 2.0%.

Five-Year Clinical Outcomes of Low-Add-Power Segmented Rotationally Asymmetrical Intraocular Lens

INTRODUCTION

This study assessed 5-year results of rotationally asymmetric multifocal intraocular lens (IOL) with +1.5 diopters (D) near addition (Lentis Comfort LS-313 MF15, Teleon Surgical B.V., Spankeren, Netherlands).

METHODS

In 38 eyes of 20 patients (76.8 ± 4.6 years) who were examined at both 1 and 5 years after surgery, clinical data were retrospectively collected.

RESULTS

Corrected and uncorrected distance visual acuity (5 m) and uncorrected and distance-corrected intermediate visual acuity (70 cm) were excellent, with no significant differences between 1 and 5 years after surgery. Uncorrected and distance-corrected near visual acuity (30 cm) remained lower. Contrast sensitivity was within the normal range at both 1 and 5 years. The percentage of patients who reported "never or hardly use spectacles" for far, intermediate, and near vision was 95.0%, 85.0%, and 35.0%, respectively. Glare and halo were slightly increased from 1 to 5 years after surgery, but the severity remained none or mild. All patients reported "very high" or "high" level of overall satisfaction. There were no notable postoperative complications.

CONCLUSIONS

During 5 years after surgery, low-add-power segmented multifocal IOL maintained excellent distance and intermediate visual acuity as well as good contrast sensitivity. Glare and halo symptoms were mild, and patients' satisfaction level was high.

TRIAL REGISTRATION

University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) identifier UMIN000048353.

Intracranial vascular stenosis in giant cell arteritis successfully treated by two balloon angioplasty procedures

Intracranial vascular stenosis is rarely associated with giant cell arteritis (GCA), and the prognosis for stroke caused by GCA is poor. Despite its unfavourable outcome, the strategy to manage this involvement and the indication of endovascular treatment are not well defined in the latest guidelines or recommendations. Here, we present a case in a 68-year-old woman, which was refractory to medical therapy, but successfully treated by two balloon angioplasty procedures. She was admitted to our department with lower extremity stiffness and left visual disturbance. GCA was clinically diagnosed by the wall thickening of the temporal artery and the aorta. Hemiparesis and motor aphasia developed shortly after intravenous methylprednisolone pulse therapy, and magnetic resonance imaging revealed acute cerebral infarction with severe stenosis at the end of the left internal carotid artery. Balloon angioplasty was tried initially with improvement in her symptoms and additionally performed to treat restenosis without any significant adverse events. Her symptoms markedly improved with no recurrence until 8 months after discharge. We also review 10 similar cases reported in the literature. Although further evidence is needed to confirm the usefulness and safety of balloon angioplasty for intracranial GCA, this case report provides valuable information about the endovascular therapy for GCA.

Real-world effects of once-daily inhaled steroid (fluticasone furoate) combined with long-acting beta-2 agonist (vilanterol) and long-acting muscarinic antagonist (umeclidinium) on lung function tests of asthma patients in Japan

Background: The Japanese drug use system allowed the once-daily use of inhaled corticosteroid fluticasone furoate (FF) combined with a long-acting beta-2 agonist vilanterol (VI) and a long-acting muscarinic antagonist umeclidinium (UMEC) against asthma on 18 February 2021. We investigated the real-world effects of these drugs (FF/UMEC/VI) mainly on lung function tests. Methods: This was an open-label, uncontrolled, within-group time-series (before-after) study. Prior asthma treatment (inhaled corticosteroid with/without a long-acting beta-2 agonist with/without a long-acting muscarinic antagonist) was switched to FF/UMEC/VI 200/62.5/25 μg. Subjects were evaluated by lung function tests prior to, and 1-2 months after, initiation of FF/UMEC/VI 200/62.5/25 μg. Patients were asked questions regarding the asthma control test and preference for drugs. Results: Overall, 114 asthma outpatients (97% Japanese) were enrolled from February 2021 to April 2022: 104 subjects completed the study. Forced expiratory volume in 1 s, peak flow, and asthma control test score of FF/UMEC/VI 200/62.5/25 μg-treated subjects were significantly increased (p < 0.001, p < 0.001, and p < 0.01, respectively). In contrast with FF/VI 200/25 μg, instantaneous flow at 25% of the forced vital capacity and expiratory reserve volume were significantly increased by FF/UMEC/VI 200/62.5/25 μg (p < 0.01, p < 0.05, respectively). Sixty-six percent of subjects declared they wanted to continue FF/UMEC/VI 200/62.5/25 μg in the future. Adverse effects, mainly local, were seen in 30% of patients, but no serious adverse effects were seen. Conclusion: Once-daily FF/UMEC/VI 200/62.5/25 μg was effective against asthma without serious adverse events. This is the first report that demonstrated FF/UMEC/VI dilated peripheral airways using lung function tests. This evidence on drug effects may improve our understanding of pulmonary physiology and the pathophysiology of asthma.

Predictive factors for postoperative renal function after off-clamp, non-renorrhaphy partial nephrectomy

Background

There is limited information on perioperative renal function during off-clamp, non-renorrhaphy open partial nephrectomy. Therefore, this retrospective study aimed to identify predictive factors of perioperative decline in renal function after off-clamp, non-renorrhaphy open partial nephrectomy.

Methods

Clinical records of 138 patients with renal tumors who underwent off-clamp, non-renorrhaphy open partial nephrectomy at our institution were reviewed. Off-clamp, non-renorrhaphy partial nephrectomy was performed using a soft coagulation system. Perioperative estimated glomerular filtration rate (eGFR) preservation was calculated, and predictors were identified using multivariate regression analysis at 5 days, 1 month, and 3 months after surgery.

Results

The median operation time was 122 minutes, and the median volume of estimated blood loss was 155 mL. The mean eGFR preservation at 5 days, 1 month, and 3 months after surgery was 95.3%, 91.0%, and 90.7%, respectively. Estimated blood loss was an independent predictor of perioperative decline in eGFR 5 days after surgery [odds ratio (OR): 0.97; 95% confidence interval (CI): 0.96, 0.98; P<0.001]. Preoperative eGFR and estimated blood loss were independent predictors of perioperative decline in eGFR 1 month after surgery (OR: 0.86; 95% CI: 0.77, 0.95; P=0.007 and OR: 0.98; 95% CI: 0.97, 0.99; P<0.001, respectively). Age, preoperative eGFR, and estimated blood loss were independent predictors of perioperative decline in eGFR 3 months after surgery (OR: 0.64; 95% CI: 0.54, 0.81; P<0.001, OR: 0.72; 95% CI: 0.61, 0.85; P<0.001; and OR: 0.98; 95% CI: 0.97, 0.99; P=0.004, respectively).

Conclusions

Estimated blood loss during surgery was a predictor of perioperative decline in eGFR within 3 months after off-clamp, non-renorrhaphy open partial nephrectomy. Age was a predictor of perioperative decline in eGFR 3 months after surgery.

Clinical course of patients with rheumatoid arthritis who continue or discontinue biologic therapy after hospitalization for infection: a retrospective observational study

Background

To analyse the subsequent clinical course of patients with rheumatoid arthritis (RA) who either continued or discontinued biologic agents after hospitalization for infections.

Methods

We retrospectively reviewed the clinical records of 230 RA patients with 307 hospitalizations for infections under biologic therapy between September 2008 and May 2014 in 15 institutions for up to 18 months after discharge. The risks of RA flares and subsequent hospitalizations for infections from 61 days to 18 months after discharge were evaluated.

Results

Survival analyses indicated that patients who continued biologic therapy had a significantly lower risk of RA flares (31.4% vs. 60.6%, P < 0.01) and a slightly lower risk of subsequent infections (28.7% vs. 34.5%, P = 0.37). Multivariate analysis showed that discontinuation of biologic therapy, diabetes, and a history of hospitalization for infection under biologic therapy were associated with RA flares. Oral steroid therapy equivalent to prednisolone 5 mg/day or more and chronic renal dysfunction were independent risk factors for subsequent hospitalizations for infections.

Conclusions

Discontinuation of biologic therapy after hospitalization for infections may result in RA flares. Continuation of biologic therapy is preferable, particularly in patients without immunodeficiency.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02820-y.

Long-term outcomes of cataract surgery with toric intraocular lens implantation by the type of preoperative astigmatism

Surgical outcomes of toric intraocular lens (IOL) implantation for 8 years after surgery were analyzed. Data were retrospectively collected in 176 eyes of 176 patients before and 1 month, 1, 3, 5, and 8 years after phacoemulsification and implantation of a toric IOL. Preoperative corneal and postoperative manifest astigmatism was analyzed by converting to power vector notations; horizontal/vertical (J₀) and oblique (J₄₅) astigmatism components. Toric IOL implantation significantly reduced pre-existing astigmatism by decreasing J₀ in eyes with preoperative with-the-rule (WTR) astigmatism, increasing J₀ in eyes with against-the-rule (ATR) astigmatism, and correcting J₄₅ in eyes with oblique astigmatism. After surgery, the eyes with preoperative ATR astigmatism showed a significant ATR astigmatic shift, and J₀ at 5 and 8 years was significantly smaller than that at 1 month postoperatively. Uncorrected distance visual acuity was also significantly worse at 5 and 8 years than at 1 month postoperatively. In eyes with WTR and oblique astigmatism, the effects of toric IOLs on astigmatism and visual acuity were sustained for 8 years. The long-term astigmatism-correcting effects did not differ among the models of toric IOL used in this study, SN6AT3–8 (Alcon Laboratories). In eyes with preoperative ATR astigmatism, astigmatism-correcting effects of toric IOLs decreased at 5 years and later postoperatively, indicating that overcorrection may be considered at the time of cataract surgery. In eyes with WTR and oblique astigmatism, the effects of toric IOLs were maintained throughout the 8-year follow-up period.

Long-term outcomes of transsclerally sutured intraocular lens correctly fixed in the ciliary sulcus

Objective

To report the long-term postoperative outcomes of transsclerally sutured intraocular lenses (IOLs), in which the haptics were correctly fixated into the ciliary sulcus using an auxiliary device and endoscope.

Methods and analysis

Data were collected from eyes that were followed up for at least 12 months after ciliary sulcus suture fixation of an IOL using an auxiliary device for securely placing the IOL haptics to the ciliary sulcus, which was confirmed using intraoperative endoscopy in all cases. The corrected distance visual acuity (CDVA), refractive error, anterior chamber depth (ACD), IOL decentration and tilt, corneal endothelial cell density (CECD) and postoperative complications were recorded. ACD and IOL deviations were compared with those of normal controls after standard cataract surgery.

Results

A total of 146 eyes of 142 patients were included, with a mean follow-up period of 56.0±35.3 (range 12–174) months. Postoperative CDVA from 1 month to 8 years and final CDVA were significantly better, and the mean refraction error, ACD and CECD decline rate were −0.71±0.75 dioptre, 4.01±0.37 mm and −7.4%±16.0%, respectively. Compared with normal controls, ACD was not significantly different but the tilt and decentration were significantly different. The main postoperative complications included vitreous haemorrhage (24.0％), suture thread exposure (19.2%) and corectopia (18.5%). There were no cases of IOL dislocation due to suture breakage or postoperative endophthalmitis

Conclusion

Long-term postoperative outcomes were favorable with good CDVA and without IOL dislocation and endophthalmitis. The significance and value of fixing haptics to the ciliary sulcus should be re-evaluated.

Factors affecting patient satisfaction related to cost and treatment effectiveness in rheumatoid arthritis: results from the multicenter observational cohort study, FRANK Registry

Background

To further improve rheumatoid arthritis (RA) treatment, it is necessary to understand each RA patient’s satisfaction and to identify the factors affecting their satisfaction. Despite the rise in medical costs for RA, little is known about the factors that influence patient satisfaction with the cost of treatment in RA patients.

Methods

This is a multicenter observational study of Japanese RA patients from the FRANK Registry with data analyzed from March 2017 to August 2020. We collected data on demographic characteristics, clinical data, quality of life which was evaluated using the EuroQol 5-dimensional questionnaire (EQ5D), and patient satisfaction. The four categories of patient satisfaction were evaluated individually (i.e., cost, treatment efficacy, activities of daily living [ADL], and global treatment satisfaction). We analyzed the factors that affected each patient’s satisfaction, such as age, sex, EQ5D, disease duration, disease activity, and treatment.

Results

This study included 2235 RA outpatients (406 males, 1829 females). In RA patients, “very satisfied” and “satisfied” were given for nearly half of each satisfaction aspect (cost 49%; efficacy 72%; ADL 58%; global treatment 66%) at the time of the initial registration. To investigate the factors influencing each satisfaction, multivariate analysis has revealed that the use of b/tsDMARDs increased satisfaction of treatment effect (odds ratio [OR] 0.66) and ADL (OR 0.78) but decreased cost satisfaction (OR 2.21). Age (50–64 years; OR 0.91; 65–74 years, 0.55: ≥ 75 years, 0.35), female (OR 0.81), and history of musculoskeletal surgery (OR 0.60) all increased cost satisfaction. Patients with lower disease activity and higher EQ5D scores had higher levels of satisfaction in all areas.

Conclusions

In this study, patient satisfaction in terms of cost, treatment effect, ADL, and overall treatment was generally higher, but some patients were dissatisfied. The cost of satisfaction increased with age and a history of musculoskeletal surgery, while it decreased with a lower EQ5D score and the use of b/tsDMARDs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02746-5.

Pleuroparenchymal Fibroelastosis with a Predominantly Airway-centered Distribution: A Late Complication of Chemotherapy

Airway-centered fibroelastosis is a distinct entity characterized by prominent airway-centered elastosis of the upper lobe with little or no pleural involvement. Little is known regarding its etiology; however, it was reported to have an idiopathic or asthma-associated etiology. We document, for the first time, 2 women (19 and 60 years old) who developed pleuroparenchymal fibroelastosis with a predominantly airway-centered distribution as a late complication (6 and 9 years later, respectively) of chemotherapy. The disease rapidly progressed following the manifestation of symptoms, and they subsequently died (3 and 2 years later, respectively). Therefore, post-chemotherapy long-term monitoring for this disease is warranted.

Immune-related dermatitis during combined treatment with pembrolizumab and axitinib in a patient with metastatic renal cell\x92carcinoma with stasis dermatitis

INTRODUCTION

The combination of pembrolizumab and axitinib has recently been approved as a first-line treatment for previously untreated metastatic renal cell carcinoma. However, immune-related adverse events are not well known.

CASE PRESENTATION

A 65-year-old male was diagnosed with renal cell carcinoma with metastases to the brain and lungs. The patient had a medical history of stasis dermatitis. During the combined treatment of pembrolizumab and axitinib, blisters appeared on the lower extremities. Skin biopsy revealed septal panniculitis, pustules, and perivascular lymphocytic and neutrophilic infiltration of the skin, and the patient was diagnosed with immune-related dermatitis. The dermatitis improved with oral prednisolone treatment.

CONCLUSION

A case of immune-related dermatitis during combinatorial treatment with pembrolizumab and axitinib for renal cell carcinoma has been reported. Preexisting stasis dermatitis may have affected the onset and deterioration of immune-related dermatitis.

Usefulness of the severity classification for predicting drug-free remission in Japanese patients with adult-onset Still's disease

OBJECTIVES

To investigate the usefulness of severity classification for predicting outcomes in patients with adult-onset Still's disease (AOSD).

METHODS

This was a multi-centre retrospective cohort study. AOSD patients were classified into mild, moderate, and severe groups based on severity classification (Japanese Ministry of Health, Labour and Welfare) during the initial treatment, and clinical features were compared among these groups. The primary endpoints were the AOSD-related mortality and drug-free remission rate. For comparison, the same analysis was performed in parallel for patient groups stratified by the modified Pouchot systemic score.

RESULTS

According to severity classification, 49 (35%), 37 (26%), and 56 patients (39%) were classified into mild, moderate, and severe groups, respectively. Patients in the severe group showed higher frequency of severe complications and the use of biological agents. Although AOSD-related survival was not significantly different (p = .0776), four of the five fatal cases were classified into the severe group. The severe group showed a reduced rate of drug-free remission (p = .0125). Patient groups classified by systemic score did not correlate with survival or drug-free remission.

CONCLUSIONS

Severity classification is useful for predicting outcomes in patients with AOSD.

Impact of dietary compositions and patterns on the prevalence of nonalcoholic fatty liver disease in Japanese men: a cross-sectional study

BACKGROUND

This study aimed to examine the impact of dietary compositions and patterns on nonalcoholic fatty liver disease (NAFLD) morbidity in Japanese men.

METHODS

We conducted a cross-sectional study of 281 individuals who underwent comprehensive medical examinations during health screening. Dietary intake was assessed using a semi-quantitative food frequency questionnaire, and factor analysis was performed to detect dietary patterns. NAFLD was diagnosed by the presence of fatty liver on abdominal ultrasonography in nondrinkers (< 30 g/day), and patients were categorized into control (n = 192) and NAFLD groups (n = 89).

RESULTS

Compared with the control group, the NAFLD group consumed fewer mushrooms. Three dietary patterns were identified, namely, a healthy pattern, a western pattern, and a snack pattern. The score of healthy pattern was negatively correlated with the risk of NAFLD. Compared with the lowest tertile of the healthy pattern, the middle tertile was associated with a lower risk of NAFLD after adjusting for age, physical activity, and smoking (odds ratio: 0.47, 95% confidence interval: 0.25-0.91). After further adjustments for body mass index, the middle tertile was associated with a lower risk of NAFLD (odds ratio: 0.46, 95% confidence interval: 0.23-0.92).

CONCLUSIONS

A healthy dietary pattern comprising frequent intake of seaweeds, vegetables, mushrooms, pulses, and potatoes and starches was associated with a lower risk of NAFLD in Japanese men. In our opinion, this healthy pattern closely resembles the Japanese Washoku diet, indicating that adherence to Washoku may help prevent NAFLD.

Role of the Water Gradient Structure in Inhibiting Thin Aqueous Layer Break in Silicone Hydrogel-Soft Contact Lens

Purpose

Soft contact lenses (SCLs) are effective for refractive error correction, but prolonged wear triggers discomfort and discontinuation. This study investigates whether water gradient technology of delefilcon A-based SCLs improve tear film dynamics.

Methods

This retrospective observational study included 50 asymptomatic delefilcon A or narafilcon A users. Data on thin aqueous layer break (TALB; %), noninvasive tear break-up time (NIBUT), tear meniscus height (TMH; mm), subjective dryness, and higher-order aberrations (HOAs) were collected. Measurements of the bare eye, the SCL-worn eye after 15 minutes (visit 1 [v1]) and 30 ± 5 days after v1 after SCL was worn for ≥5 hours (visit 2 [v2]) were recorded.

Results

TALB was significantly reduced in the delefilcon A group compared to the narafilcon A group (33.3% vs. 85.5% at v1; P < 0.0001 and 31.7% vs. 80.4% at v2; P < 0.0001). The NIBUT was also significantly higher in the former (4.2 ± 2.1 seconds vs. 2.9 ± 1.5 at v1; P < 0.01 and 4.1 ± 2.3 seconds vs. 2.7 ± 1.6 seconds at v2; P < 0.01) across both visits. The TMH was significantly reduced in the former in both v1 and v2. The total ocular HOAs were significantly lower in the former at v1 (P < 0.001) and v2 (P < 0.05) compared to the bare eye.

Conclusions

The water gradient technology of delefilcon A reduces TALB and increases NIBUT.

Translational Relevance

The use of water gradient technology improves tear film dynamics and alleviate pathological break-up pattern, improving lens performance.

Eccrine sweat glands' maximum ion reabsorption rates during passive heating in older adults (50-84 years)

PURPOSE

We examined whether eccrine sweat glands ion reabsorption rate declined with age in 35 adults aged 50-84 years. Aerobic fitness (VO_2max) and salivary aldosterone were measured to see if they modulated ion reabsorption rates.

METHODS

During a passive heating protocol (lower leg 42 °C water submersion) the maximum ion reabsorption rates from the chest, forearm and thigh were measured, alongside other thermophysiological responses. The maximum ion reabsorption rate was defined as the inflection point in the slope of the relation between galvanic skin conductance and sweat rate.

RESULTS

The maximum ion reabsorption rate at the forearm, chest and thigh (0.29 ± 0.16, 0.33 ± 0.15, 0.18 ± 0.16 mg/cm²/min, respectively) were weakly correlated with age (r ≤  - 0.232, P ≥ 0.05) and salivary aldosterone concentrations (r ≤  - 0.180, P ≥ 0.179). A moderate positive correlation was observed between maximum ion reabsorption rate at the thigh and VO_2max (r = 0.384, P = 0.015). Salivary aldosterone concentration moderately declined with age (r =  - 0.342, P = 0.021). Whole body sweat rate and pilocarpine-induced sudomotor responses to iontophoresis increased with VO_2max (r ≥ 0.323, P ≤ 0.027) but only moderate (r =  - 0.326, P = 0.032) or no relations (r ≤  - 0.113, P ≥ 0.256) were observed with age.

CONCLUSION

The eccrine sweat glands' maximum ion reabsorption rate is not affected by age, spanning 50-84 years. Aldosterone concentration in an aged cohort does not appear to modulate the ion reabsorption rate. We provide further support for maintaining cardiorespiratory fitness to attenuate any decline in sudomotor function.

Granulomatous prostatitis with high suspicion of prostatic adenocarcinoma on radiological imaging

INTRODUCTION

Granulomatous prostatitis is a benign inflammatory condition of the prostate that may mimic prostatic adenocarcinoma on magnetic resonance imaging findings. Even in the era of multiparametric magnetic resonance imaging, the differential diagnosis of granulomatous prostatitis from malignancy remains difficult.

CASE PRESENTATION

A 69-year-old man with abnormal magnetic resonance imaging and positron emission tomography/magnetic resonance imaging findings, and a prostate-specific antigen value of 2.48 ng/mL underwent prostate needle biopsy. He had a history of urinary tract infection 3 months prior to presentation. Multiparametric magnetic resonance imaging showed low-intensity signals on T2-weighted images, slightly high-intensity signals on diffusion-weighted images, and low values on apparent diffusion coefficients. The prostate imaging-reporting and data system version 2 score was 3. Histological examination revealed granulomatous prostatitis.

CONCLUSION

For patients with preceding urinary tract infections, granulomatous prostatitis should be considered as a differential diagnosis, even when magnetic resonance imaging and positron emission tomography suggest prostatic adenocarcinoma.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Assessment of surgical outcomes of off-clamp open partial nephrectomy without renorrhaphy for ≥T1b renal tumours

PURPOSE

To assess the surgical outcomes of off-clamp open partial nephrectomy without renorrhaphy. In the era of robot-assisted surgeries, open partial nephrectomy remains a surgical option for  ≥ T1b renal tumours. Although the necessity of renal pedicle clamping and renorrhaphy in open partial nephrectomy for larger tumours remains to be discussed, reports on this issue are rare.

METHODS

Twenty-seven open partial nephrectomies for  ≥ T1b renal tumours were performed without renal pedicle clamping or renorrhaphy. A soft coagulation system was used to control bleeding from the resection bed. Surgical results, complications, and predictors of perioperative estimated glomerular filtration rate (eGFR) preservation at 1 month and 3 months after surgery were analysed.

RESULTS

The median estimated volume of blood loss was 420 mL. The rates of perioperative eGFR preservation were 88.9 and 87.3% at 1 and 3 months after surgery, respectively. Tumour size was an independent predictor of perioperative eGFR preservation at 1 month after surgery, whereas age and exophytic/endophytic properties of the tumour were independent predictors of perioperative eGFR preservation at 3 months after surgery.

CONCLUSION

Open partial nephrectomy without renal pedicle clamping or renorrhaphy could be safely performed for  ≥ T1b renal tumours, even when tumours were entirely endophytic and located close to the renal pedicle. Mild perioperative eGFR reduction was observed. Although surgical indications should be carefully considered in these cases, off-clamp open partial nephrectomy without renorrhaphy is a feasible procedure for patients with  ≥ T1b renal tumours.

POS1396 DAMAGE PROGRESSION OF FINGER JOINT CARTILAGE EVALUATED BY ULTRASOUND AND X-RAY IN PATIENTS WITH RHEUMATOID ARTHRITIS (RA)

Background:

Cartilage damage in RA has been evaluated by joint space narrowing (JSN) in X-ray, while it is not a direct evaluation of cartilage. Previously we have confirmed the usefulness of the direct imaging of finger joint cartilage by ultrasound (US) in patients with RA [1].

Objectives:

We aimed to examine the temporal changes of US cartilage thickness in RA patients.

Methods:

We enrolled 53 RA patients in whom the cartilage thickness of finger joints was measured by US and had radiographs of both hands at baseline and 1-year later. The cartilage of metacapophalangeal and proximal interphalangeal joints of 2nd to 5th fingers were bilaterally visualized at the middle portion from a longitudinal dorsal view. Cartilage thickness was measured from the base of the cartilage to the interface artefact at the cartilage surface by static images. In addition, the JSN of the corresponding joints was scored using a hand X-ray by van der Heijde-modified Sharp method. Continuous variables from the two groups were analyzed using the Mann-Whitney U test or Wilcoxon signed-rank test. The relationships among the continuous variables were assessed using the Spearman’s rank correlation coefficient.

Results:

The median age of the patients was 68 years and the median disease duration was 6.3 years. The sum of total cartilage thickness from 16 joints per patient ranged from 3.1 to 9.1mm (median 6.5 mm) at baseline, and it was significantly correlated with total JSN score of the same joints (ρ=-0.63, p<0.001). The cartilage thickness was inversely correlated with disease duration (rho=-0.40, p=0.003), but not associated with age nor height. The decrease in cartilage thickness over 1 year was evident in patients with persistent moderate to high disease activity by the DAS28-CRP (n=10; median -6.2%) as compared with other patients (n=43; median -1.2%, p=0.004 versus active patients).

Conclusion:

This pilot study demonstrated the progression of cartilage damage by sustained RA activity, supporting the validity and usefulness of joint cartilage thickness evaluation by ultrasound in patients with RA.

References:

[1]Ogura T, et al. Arthritis Care Res 2019 Oct 25.

Table 1.

SALIENT FEATURES OF THE 9 PATIENTS PRESENTING WITH RETINAL TOXICITY DUE TO HCQ

Sl.NoAgeGenderWeight(Kg)Primary DiagnosisDoseDuration(Years)Detection Method UsedRecommended Dose(mg/Day)Received Dose(mg/Day)Cumulative Dose(grams)FUNDUSEXAM.SD-OCTHVF10-2FAF147F58SLE2904004383RPE ChangesThinning/Photoreceptor LossDefects seen-220F46SLE2302001462Multiple Small Drusens In Paramacular AreaMultipleDrusensNormalPerifoveal autofluorescence spots-drusens323F50SLE2504001461RPE ChangesRPEDisruptionsDefects seen-430F55SLE275200731NormalNormalParacentral Scotoma-550F49RA2452005117Early Bull’s Eye MaculopathyRPEAtrophyDefects seen-672F60RA30020073010RPE AtrophyFR AbsentRPEAtrophyGeneral reduction in sensitivity-765M57.4RA2872001462RPE ChangesRPEDisruptions & Thinning NotedDefects seen-862F70RA3502002193Chorioretinal AtrophyAlteredRPEMembraneDefects seen-959M71.6RA3582002924RPE ChangesRPEDisruptionsNormal-

F:Female; M:Male; SLE:Systemic Lupus Erythematosus; RA: Rheumatoid Arthritis, FUNDUS EXAM.: Fundus Examination; SD-OCT:Spectral Domain-Optical Coherence Tomography, HVF 10-2:Humphrey Visual Field 10-2; FAF: Fundus Autofluorescence, RPE:Retinal Pigment Epithelium; FR:Foveal Reflex

Disclosure of Interests:

None declared

Staging laparoscopy for pancreatic cancer using intraoperative ultrasonography and fluorescence imaging: the SLING trial

This prospective trial revealed the additional diagnostic value of staging laparoscopy with contrast-enhanced intraoperative ultrasonography and indocyanine green-fluorescence imaging, detecting radiologically occult liver metastases and other occult metastases effectively for patients with high-risk resectable or borderline resectable pancreatic cancer. The 2-year survival rate of patients without occult metastasis was significantly better than that of patients with occult metastasis. These favourable results for patients without occult metastasis indicate that an enhanced screening strategy and modern multidisciplinary treatment may improve the outcome even of patients affected by high-risk advanced pancreatic cancer.

State-of-the-art staging worth the effort

A genetically defined signature of responsiveness to erlotinib in early-stage pancreatic cancer patients: Results from the CONKO-005 trial

Background

high recurrence rates of up to 75% within 2 years in pancreatic ductal adenocarcinoma (PDAC) patients resected for cure indicate a high medical need for clinical prediction tools and patient specific treatment approaches. Addition of the EGFR inhibitor erlotinib to adjuvant chemotherapy failed to improve outcome but its efficacy in some patients warrants predictors of responsiveness.

Patients and Methods

we analysed tumour samples from 293 R0-resected patients from the randomized, multicentre phase III CONKO-005 trial (gemcitabine ± erlotinib) with targeted sequencing, copy number, and RNA expression analyses.

Findings

a total of 1086 mutations and 4157 copy-number aberrations (CNAs) with a mean of 17.9 /tumour were identified. Main pathways affected by genetic aberrations were the MAPK-pathway (99%), cell cycle control (92%), TGFβ signalling (77%), chromatin remodelling (71%), and the PI3K/AKT pathway (65%). Based on genetic signatures extracted with non-negative matrix factorization we could define five patient clusters, which differed in mutation patterns, gene expression profiles, and survival. In multivariable Cox regression analysis, SMAD4 aberrations were identified as a negative prognostic marker in the gemcitabine arm, an effect that was counteracted when treated with erlotinib (DFS: HR=1.59, p = 0.016, and OS: HR = 1.67, p = 0.014). Integration of differential gene expression analysis established SMAD4 alterations with low MAPK9 expression (n = 91) as a predictive biomarker for longer DFS (HR=0.49; test for interaction, p = 0.02) and OS (HR = 0.32; test for interaction, p = 0.001).

Interpretation

this study identified five biologically distinct patient clusters with different actionable lesions and unravelled a previously unappreciated association of SMAD4 alteration status with erlotinib effectiveness. Confirmatory studies and mechanistic experiments are warranted to challenge the hypothesis that SMAD4 status might guide addition of erlotinib treatment in early-stage PDAC patients.

B cell-activating factors in autoimmune pulmonary alveolar proteinosis

Background

Autoimmune pulmonary alveolar proteinosis (APAP) results from the suppression of granulocyte-macrophage colony-stimulating factor (GM-CSF) signaling by a neutralizing autoantibody against GM-CSF. B cell-activating factor (BAFF) and a proliferation-inducing ligand (APRIL) are involved in immunoglobulin G production and are overproduced in various autoimmune disorders. We hypothesized that BAFF and/or APRIL levels would be elevated in serum and bronchoalveolar lavage fluid (BALF) and serum and BALF levels of BAFF and APRIL respond to the treatments (whole lung lavage (WLL) or inhalation of recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSF)) in patients with APAP.

Subjects and methods

BAFF and APRIL levels in serum and BALF from 110 patients with APAP were measured at baseline and during and after treatment, using an enzyme-linked immunosorbent assay kit. We enrolled 34 healthy volunteers as serum cytokine controls, and 13 disease controls for BALF. Associations of BAFF and APRIL levels with clinical measures were assessed to clarify their clinical roles.

Results

In patients with APAP, serum BAFF and APRIL levels were significantly increased relative to healthy volunteers (p < 0.0001 and p < 0.05, respectively), and BALF BAFF and APRIL levels were significantly increased versus disease controls (p < 0.0001 and p < 0.01, respectively). Serum BAFF levels (but not APRIL levels) were significantly correlated with Krebs von den Lungen-6 (KL-6), surfactant protein (SP)-D, SP-A, and lactate dehydrogenase (p < 0.0001). There was no significant correlation between serum BAFF or APRIL levels and anti-GM-CSF autoantibody. BAFF and APRIL were negatively correlated with single-breath diffusion capacity for carbon monoxide (DLco) (p = 0.004) and forced vital capacity (p = 0.04), respectively. BAFF (but not APRIL) in BALF was negatively correlated with vital capacity (p = 0.04) and DLco (p = 0.006). There were significant correlations between disease severity and BAFF levels in serum (p = 0.04) and BALF (p = 0.007). Serum levels of anti-GM-CSF autoantibody, BAFF, and APRIL were not significantly affected by WLL or inhalation of recombinant human GM-CSF.

Conclusions

BAFF and APRIL levels of sera and BALF in APAP were significantly increased compared with healthy volunteer and disease control, and the BAFF and APRIL pathway might have important specific roles in pathogenesis of APAP. Our data suggest a new perspective of future treatment for APAP.

Lymphoplasmacytic lymphoma involving the mediastinum and the lung, followed by amyloidosis: A surgically and genetically proven case

A 60-year-old man was admitted for ground glass opacity in the lower lung field and mediastinal lymphadenopathy. Blood tests revealed elevated serum IgM levels, and the urine test detected Bence-Jones protein. Surgical biopsy from the mediastinal lymph node and lung showed small lymphocytes and plasma cells between follicles, and AL kappa amyloid deposition. Genetic examination detected MYD88 L265P mutation. Our diagnosis was lymphoplasmacytic lymphoma (LPL), involving the mediastinum and the lung, followed by amyloidosis. Mutation analysis, in addition to conventional histological evaluation, was useful for a precise diagnosis.

Ventricular tachycardia in cardiac sarcoidosis -prognosis, characterization of ventricular substrates and outcomes of treatment-

Background

The prognosis, the underlying substrate and clinical outcomes of treatment are unclear in patients with cardiac sarcoidosis (CS)-related ventricular tachycardia (VT).

Objective

This study investigated the prognosis and the relationship between electroanatomical mapping (EAM) and imaging findings in patients with CS-related VT.

Methods

A total of 203 CS patients (Age 68.1±11.6 years, 87 males) were enrolled at two tertiary care medical centers between 2000 and 2018. All met the 2016 Japanese Circulation Society guidelines for diagnosis of CS. They were followed for a composite of major adverse cardiac events (MACE) including cardiac death, heart transplantation, unscheduled hospitalization for heart failure, and life-threatening ventricular arrhythmias. Distribution of late gadolinium enhancement (LGE) on cardiac MRI (CMR) and/or an abnormal myocardial 18F-fluorodeoxyglucose (FDG) uptake on positron emission tomography at diagnosis were examined. The relationship between EAM and the image findings were also analyzed in patients with radiofrequency ablation (RFA) for VT.

Results

During a median follow-up of 53 months, 87 of the 203 patients (43%) experienced a MACE. Baseline factors associated with MACE were presence of sustained VT (HR, 2.43, 95% CI 1.54–3.85, P&lt;0.001), left ventricular ejection fraction below 50% (HR, 1.95 95% CI 1.07–3.56, P=0.029), and abnormal myocardial FDG uptake (HR, 2.42 95% CI 1.04–5.61, P=0.039). Overall, 69 of the 203 patients (34%) experienced sustained VT. Abnormal myocardial FDG uptake was significantly more prevalent in patients with VT than in those without (92.7% vs. 78.5%, P=0.02). A total of 25 patients (9.9%) required RFA for CS-related VT (Age 64.0±8.7 years, 12 males, 1.32±0.56 RFAs per patient). Abnormal electrocardiograms (EGM) were observed in 22 of the 25 patients (88%). LGE was more frequent than abnormal FDG uptake in areas with an abnormal EGM (77% vs. 41%; P=0.002). Over a mean follow-up period of 67-months, 13 of the 25 patients with RFA (52%) remained free of VT episodes (Figure). VT recurred in nine of the 12 patients with RFA and in 17 of the 47 patients without RFA, but was suppressed by intensive pharmacologic therapy such as the combined use of amiodarone and sotalol. In patients with CS-related VT, survival without experiencing a MACE did not differ in participants with or without RFA.

Conclusions

In our 203 CS patients, sustained VT and abnormal FDG uptake were associated with worse cardiac outcomes. The prevalence of abnormal FDG uptake was significantly higher in patients with CS-related VT, LGE on CMR was more frequent within localized areas of an abnormal EGM, suggesting that both scar itself and the associated inflammation were involved in the pathogenesis of CS-related VT. Successful RFA of CS-related VT is still challenging, and recurrence is common. Preprocedural CMR can be useful in detecting abnormal EGMs that are potential targets for substrate ablation.

Funding Acknowledgement

Type of funding source: None

Prospective assessment of plate-haptic rotationally asymmetric multifocal toric intraocular lens with near addition of + 1.5 diopters

Background

To prospectively evaluate surgical results following implantation of rotationally asymmetric, plate-haptic, refractive segmented multifocal toric intraocular lenses (IOLs) with near addition of + 1.5 diopters (D) (Lentis Comfort LS-313 MF15T, Oculentis GmbH).

Methods

In 59 eyes of 41 patients, ocular examinations were conducted before and 1 day, 1 week, 1, 3, and 6 months after surgery. Uncorrected (UDVA) and corrected (CDVA) distance visual acuity, uncorrected (UIVA) and distance-corrected (DCIVA) intermediate visual acuity at 70 cm, and uncorrected (UNVA) and distance-corrected (DCNVA) near visual acuity at 30 cm were tested. A defocus curve was drawn, and the degree of disturbing photic phenomena were questioned.

Results

The IOL showed excellent rotational stability; the average absolute rotation was 1.66 ± 1.17 degrees from 1 day 1 to 6 months postoperatively, and 98.1 and 100% of eyes yielded rotation of less than 5 and 10 degrees, respectively. Postoperative distance and intermediate visual acuity were highly satisfactory; UDVA, CDVA, UIVA, and DCIVA were about 20/20, 20/16, 20/25, 20/25, respectively. Near visual acuity was suboptimal; UNVA and DCNVA were at approximately 20/60. The defocus curve analysis showed that 20/25 and 20/40 uncorrected visual acuity was attained at as close as 60 and 40 cm, respectively. Contrast sensitivity was within a normal range, and subjective photic phenomena were minimum.

Conclusions

The refractive segmented, rotationally asymmetric multifocal toric IOLs with + 1.5 D near addition showed superb rotational stability and highly satisfactory distance and intermediate vision. Contrast sensitivity was high and incidence of photic symptoms was very low.

Trial registration

This study was registered at JAPIC Clinical Trials Information, ID: JapicCTI-183,877, https://www.clinicaltrials.jp/cti-user/trial/Search.jsp (February 5, 2018).

Cardiac function at diagnosis is important prognostic factor in patients with cardiac sarcoidosis -from Japanese nationwide questionnaire survey-

Background

Sarcoidosis is a systemic non-caseating granulomatous disease of unknown etiology. Cardiac involvement (cardiac sarcoidosis, CS) has been reported to be an important prognostic factor in this disease because of heart failure and/or ventricular arrhythmia, and corticosteroid therapy is usually prescribed to prevent cardiac events. However, little is known about the relationship of cardiac function and concomitant corticosteroid therapy on later cardiac events in CS.

Objective

We evaluated the relationship between prognosis and left ventricular ejection fraction (LVEF) at the time of diagnosis in CS patients from the Japanese nationwide questionnaire survey.

Methods

Total of 757 Japanese patients from 57 hospitals who diagnosed CS were examined. Patients who unsatisfied the criteria of the Japanese new guidelines, or who underwent cardiac transplantations were excluded, and 420 patients (287 females, mean age 60±13 years old, median follow-up periods 1864 days [interquartile range: 845–3159 days]) were analyzed. The relationship of adverse events (all-cause death, cardiovascular death, and appropriate ICD [Implantable Cardioverter Defibrillator] discharge) and LVEF (with corticosteroid 84%) (low LVEF: LVEF≤35% n=98 [with corticosteroid in 78%], moderate LVEF: LVEF 35–50% n=104 [with corticosteroid in 93%], normal LVEF: 50≤LVEF n=218 [with corticosteroid in 83%]) were evaluated respectively.

Results

89 CS patients developed all-cause death (n=50), cardiovascular death (n=30) or appropriate ICD discharge (n=48). The frequency of corticosteroid therapy was not different in the each LVEF group, but Kaplan-Meier analysis revealed that all-cause death, cardiovascular death, and all cardiovascular adverse events were more observed in lower LVEF group (log-rank p&lt;0.0001). Furthermore, multivariate Cox hazard analysis revealed that LVEF was a most important independent prognostic factor in CS.

Conclusion

This Japanese nationwide questionnaire survey data showed that initial LVEF was an independent and strong prognostic predictor in CS, therefore primary prevention would be needed even after starting corticosteroid in patients with decreased cardiac function.

Funding Acknowledgement

Type of funding source: None

Long time clinical course of cardiac sarcoidosis with corticosteroid therapy -from Japanese nationwide questionnaire survey-

Background

Sarcoidosis is a systemic inflammatory syndrome of unknown etiology and cardiac involvement has been reported to be an important prognostic factor in this disease. An autopsy study has reported that the frequency of this cardiac involvement (cardiac sarcoidosis: CS) varies in the different countries and races and very frequent in Japanese patients. We therefore performed the nationwide questionnaire survey and try to clarify the clinical characteristics and corticosteroid effect in CS, especially focused on arrhythmic events in this disease.

Methods

Total of 757 Japanese patients from 57 hospitals who diagnosed CS were examined. Patients who unsatisfied the criteria of the Japanese new guidelines, or who underwent cardiac transplantations were excluded, and 420 patients (287 females, median follow-up periods 1864 days [interquartile range: 845–3159 days]) were analyzed. The clinical outcome and corticosteroid effect were evaluated.

Results

Clinical characteristics at diagnosis was as follows: female dominant (68%), mean age of 60±13 years old, mean left ventricular ejection fraction was 49±16%. Arrhythmic events were very frequently observed as an initial cardiac manifestation in 263 patients (62%) of CS, of which atrioventricular block (AVB) in 174 (41%), ventricular tachycardia (VT) in 73 (17%) and AVB with VT in 17 (4%) (Figure 1A). Pacemaker was implanted in 166 patients (40%) and defibrillators was 137 patients (33%). Corticosteroid was prescribed in 144 (83%) of 174 patients with AVB and in 62 (85%) of 73 patients with VT. Initial dose was mean 47.9 mg and maintenance dose of mean 7.3 mg. Corticosteroid improved VT as good as AVB (27% vs. 29%). However, corticosteroid sometimes worsened VT events compared with AVB (10% vs. 2%) (Figure 1B). During the course of follow-up, 32 patients were needed to increase corticosteroid in 23 of AVB and 10 of VT cases. However, there were no difference in mortality between the groups, whether or not to increase corticosteroid. All survival rate was 92% (5-year mortality), 83% (10-year mortality) and free from all cause death and defibrillator charge was 81% (5 year), 71% (10 year).

Conclusion

Fatal arrhythmia is commonly observed in CS as a primary symptom. Corticosteroid sometimes worsen ventricular arrhythmia and appropriate defibrillator discharge was common. Thus, careful attention for activating ventricular arrhythmia would be needed during the follow-up period even after corticosteroid therapy.

Funding Acknowledgement

Type of funding source: None

Long-term follow up ventricular tachycardia patients with preserved cardiac function -from Japanese cardiac sarcoidosis nationwide questionnaire survey-

Background

Prior ventricular tachycardia (VT) and low left ventricular ejection fraction (LVEF) are the most important prognostic factors in cardiac sarcoidosis (CS). Recently diagnosis of CS was renewed according to Japanese new guidelines. Patients with preserved cardiac function often have VT events, thus new guidelines recommends to assess the implantable cardioverter defibrillator (ICD) implantation for CS patients with preserved LVEF (35%≤LVEF&lt;50%). However, the long-term prognosis of CS patients with preserved LVEF is unclear.

Objective

In CS patients with preserved LVEF, we evaluated the prognosis between VT manifestation and non-VT manifestation groups at CS diagnosis from Japanese nationwide questionnaire survey.

Methods

Total of 757 Japanese patients from 57 hospitals who diagnosed CS were examined. Patients who unsatisfied the criteria of the Japanese new guidelines, who had LVEF≤35%, LVEF&gt;50%, or who underwent cardiac transplantations were excluded. 104 patients with LVEF 35–50% (67 females, mean age 60±15 years old, median follow-up periods 2134 days [interquartile range: 758–2935 days]) were analyzed. The prognosis between VT manifestation and non-VT manifestation groups at CS diagnosis were evaluated.

Results

30 patients had VT manifestation at CS diagnosis and 24 patients (80%) received ICDs. 74 patients had no VT manifestation at CS diagnosis and 19 patients (44%) received ICDs during follow up period. All-cause mortality was not different between two groups (Figure). Appropriate ICD therapy of non-VT manifestation group was significantly lower compared with that of VT manifestation group (log-rank p=0.001), however considerable number (n=7, 15%) of non-VT manifestation group had appropriate ICD therapy event during follow-up period. Cox hazard analysis revealed that concomitant non-sustained VT (NSVT) with atrioventricular block (AVB) was a predictor of appropriate ICD therapy in non-VT manifestation group.

Conclusion

This nationwide survey showed that considerable number of CS patients with preserved LVEF had VT events, independent of VT manifestation. Concomitant NSVT with AVB was a predictor of VT events, and ICD implantation should be assessed.

Funding Acknowledgement

Type of funding source: None

Beneficial effects of balloon pulmonary angioplasty on clinical outcomes in patients with residual pulmonary hypertension after pulmonary endarterectomy

Background

Although pulmonary endarterectomy (PEA) is an established surgical treatment for chronic thromboembolic pulmonary hypertension (CTEPH), a part of patients after PEA show residual pulmonary hypertension, leading to limited exercise capacity. Recently, several studies have indicated that balloon pulmonary angioplasty (BPA) improves hemodynamics, exercise capacity and prognosis in inoperable CTEPH patients. However, the effects of BPA in patients with residual pulmonary hypertension after PEA remain to be elucidated.

Aim

In the present study, we investigated comprehensive efficacy of BPA on hemodynamics, exercise capacity and right ventricular function in those with residual pulmonary hypertension after PEA.

Methods

From October 2010 to February 2019, 227 patients with CTEPH underwent PEA in our institution. Right heart catheterization after PEA (median follow up period from PEA to right heart catheterization 39 [10.5, 90] months) showed that 55 patients showed residual PH (mean pulmonary artery pressure (mPAP)≥25mmHg), and 38 of them referred to BPA (mean age 57 years old, male 8 (21%)) due to residual symptoms. In 29 out of 38 patients (76%) who completed BPA and underwent follow-up right heart catheterization, we examined hemodynamics, exercise capacity and right ventricular function before and after BPA. Follow-up examination was performed 3 months after last BPA session.

Results

In this study population (N=29), PEA significantly improved mPAP (47±7 to 38±10 mmHg), pulmonary vascular resistance (PVR, 14.6±4.6 to 9.2±4.6 WU) and right ventricular ejection fraction measured by magnetic resonance imaging (26.6±11.3 to 38.4±6.8%) (Figure). Median period from PEA to first BPA procedure was 42 [13.5, 94] months. Total session number during study period was 160 sessions, and mean session number of BPA was 5.5±1.5 per patient. Follow-up study revealed that BPA additionally improved mPAP (38±10 to 27±8 mmHg) and PVR (9.2±4.6 to 5.1±2.2 WU) (Figure). Similarly, 6-minute walk distance (393±125 to 452±125 m) and peak VO2 (16.4±3.8 to 18.1±4.6 ml/min/kg, p&lt;0.05) were increased, and WHO functional class also significantly improved by BPA (I/II/III/IV, 0/21/8/ 0 to 1/27/1/0, p&lt;0.01). In addition, right ventricular ejection fraction (38.4±6.8 to 44.2±7.1%) was increased after BPA (Figure). There were no procedure-related deaths and major lung injuries requiring oral intubation during study period. 3-year survival in patients after BPA was 100% (median follow-up period after last BPA session, 32 [18, 46] months).

Conclusion

In CTEPH patients with residual pulmonary hypertension after PEA, additional BPA significantly improved hemodynamics, right ventricular function, exercise capacity and residual symptoms without severe complications, leading to good prognosis. These results suggest that combination therapy of PEA and BPA could be an effective therapeutic option for post PEA patients with residual symptoms and exercise limitation.

Figure 1

Funding Acknowledgement

Type of funding source: None

Micro-embolic risks during radiofrequency and cryoballoon-ablation of atrial fibrillation -analysis from real-time carotid artery doppler monitoring-

Background

Catheter ablation of atrial fibrillation (AF) is associated with risks of silent cerebral events. However, the timing of intraprocedural micro-embolic events or differences between open-irrigated radiofrequency (RF) and cryoballoon (Cryo) ablation are unclear. Newly developed real-time carotid artery Doppler is a simple non-invasive method to detect micro-embolic signals (MESs) during ablation.

Objective

We investigated the timing of detecting MESs during RF and Cryo ablation of AF.

Methods

During the first pulmonary vein isolation (PVI) session of AF, MESs were monitored by real-time carotid artery Doppler monitoring throughout the procedure. The MES counts were collected and evaluated separately during the different steps of the procedure (Figure).

Results

Thirty-three AF patients (RF/Cryo: 22/11 cases, 9 females, 69.5±11.6 y.o) were included. PVI was successfully accomplished in all patients with no major complications. The MES count was significantly greater in the RF group than Cryo group (table). In both groups, left atrial (LA) access (interatrial puncture) and sheaths insertion to the LA generated a significant number of MESs (RF: 1690 of 9116 MESs [18.5% of the total MESs], Cryo: 793 of 2285 MESs [34.7%]). In the RF group, MESs were observed incessantly during PVI (Figure). The LA dwell time was significantly longer in the RF group than Cryo group (table). In the RF group, the MES count was significantly greater in the longer LA dwell time group (LA dwell time &gt;130min) than the shorter group (464.2±179.7 vs 302.6±138.2: P=0.049). During the cryo-applications in the Cryo group, the MESs were greatest during the first cryoballoon application (625 of 2285 MESs [27.4%]).

Conclusions

There were more MESs during RF ablation than cryoablation. MESs were recorded during a variety of steps throughout the procedure. In the RF group, most of MESs were recorded incessantly during radiofrequency ablation and greater number of MESs were recorded in patients with longer LA dwell time. In the Cryo group, most of MESs occurred during phases with a high probability of gaseous emboli.

Funding Acknowledgement

Type of funding source: None