Baseline tumour necrosis factor alpha levels predict the necessity for dose escalation of infliximab therapy in patients with rheumatoid arthritis

Objectives: To investigate the possible role of baseline plasma tumour necrosis factor alpha levels (baseline-TNF) on the clinical response to infliximab in patients with rheumatoid arthritis (RA). Methods: Patients with RA refractory to methotrexate received 3, 6, or 10 mg/kg of infliximab every 8 weeks, in a randomised, double-blind manner: the RISING study. Clinical response (disease activity score in 28 joints based on C-reactive protein or American College of Rheumatology core set) at week 54 and serum infliximab levels were compared in three patient groups with low, intermediate, or high baseline-TNF (TNF-low, TNF-int, or TNF-high). Results: In TNF-low patients, the clinical response to different doses of infliximab was comparable, whereas TNF-int patients exhibited a dose-dependent trend. In contrast, TNF-high patients (approximately 13% of the total patients) had a clinical response to 10 mg/kg significantly better than the response to 3 and 6 mg/kg of infliximab. In TNF-high patients, the median trough serum levels of infliximab were below the detection limit (<0.1 μg/ml) at 3 and 6 mg/kg but were greater than 2 μg/ml at 10 mg/kg, whereas the levels were approximately 1 μg/ml for each dosage group in TNF-low patients. Conclusion: In patients with RA, baseline-TNF is significantly associated with the clinical response to infliximab in patients with a high baseline-TNF. A higher dose of infliximab may be necessary in these patients, whereas lower doses of infliximab are sufficient for those with a low baseline-TNF. Baseline-TNF may be a useful measure for personalising the treatment of RA using infliximab

Assessment of the Period for Administration of Antibiotics for Primary Atypical Pneumonia

We assessed adequate period for administration of antibiotics for primary atypical pneumonia (PAP). The subjects were patients with PAP admitted to our hospital from January, 1986 to December, 1988. For treatment, 100 mg of minocycline (MINO) was dissolved into 100 ml of solution and infused intravenously for 1 hour twice a day. The patients were divided into two treatment periods: a 6 day-administration group (Group A), and a 9 day-administration group (Group B). Group A: 23 cases (which included 8 cases of mycoplasmal pneumonia) and Group B: 22 cases (which included 10 cases of mycoplasmal pneumonia). A comparative assessment was made between Groups A and B regarding body temperature, WBC, erythrocyte sedimentation rate, CRP and chest X-ray on the 3rd, 6th and 9th days of treatment but no significant difference was observed. Residual shadows at the discontinuance of treatment were present in 61% of Group A and in 36% of Group B but they disappeared gradually in both groups. No recurrent cases were observed in either Group A or B within 1 month after treatment was finished. As for the PAP treatment period using an intravenous drip infusion of minocycline, no significant clinical difference was observed between administration for 6 and 9 days, suggesting that the 6 days administration suffices for treatment. Even though the possible bacterial residue was unknown as no separation of mycoplasma pneumoniae was attempted, there were no recurrent cases

Intracorporeal semi‐hand‐sewn Billroth I reconstruction in total laparoscopic distal gastrectomy

Introduction Intracorporeal Billroth I (B‐I) reconstruction using an endoscopic linear stapler (ELS) is widely performed in total laparoscopic distal gastrectomy. However, conventional procedures require many ELSs for anastomosis. Here, we introduce the novel intracorporeal semi‐hand‐sewn (SHS) B‐I reconstruction. Materials and surgical technique After the transection of stomach and duodenum using ELS following adequate lymph node dissection, small entry holes were made on the anterior wall in the greater curvature of the stomach and the duodenal stump. The posterior walls of both the remnant stomach and the duodenum were attached with the ELS and fired to create the posterior wall of the B‐I anastomosis. All the transection line of the duodenum and one‐third of the transection line of the stomach were dissected; finally the anterior wall suturing at the anastomotic site was performed by the laparoscopic hand‐sewn technique. Discussion SHS procedure was performed for 17 gastric cancer patients. There were no intraoperative complications or conversions to open surgery. One intra‐abdominal abscess was observed although there was no anastomotic leakage. The median reconstruction time was 48 minutes (32‐63). The SHS procedure was safe, feasible, and economical, although it requires sufficient laparoscopic suturing and ligation skill

プラスミド性キノロン耐性遺伝子を保有するIMP-6産生腸内細菌科細菌でのイノカラムサイズ効果の比較

Almost all cases of carbapenemase-producing Enterobacteriaceae infections in Japan are caused by blaIMP-positive Enterobacteriaceae (especially blaIMP-6) and infections caused by other types of carbapenemase-producing Enterobacteriaceae are quite rare. We examined drug resistance genes co-harboring with blaIMP-6 and their inoculum size effects. We screened β-lactamase genes, plasmid-mediated quinolone resistance (PMQR) genes, and aminoglycoside-modifying enzyme genes by PCR and performed sequencing for 14 blaIMP-6-positive Enterobacteriaceae. Further, all PMQR-positive isolates were submitted to conjugation and inoculum effect evaluation. Our data showed that 13 of the 14 isolates harbored CTX-M-2 and one co-harbored CTX-M-2 and CTX-M-1 as extended-spectrum β-lactamases. All isolates carried one or more PMQRs; aac(6’)-Ib-cr was the most prevalent (92.8%), and was followed by oqxA (64.3%), qnrS (50%), oqxAB (21.4%), and qnrB (14.3%). However, Klebsiella pneumoniae contains chromosomal OqxAB. Inoculum size effects were significant in all strains for meropenem, 13 strains for imipenem, 7 for levofloxacin, and 3 for amikacin. We observed that 11 of the experimental strains (100%), 8 strains (72.7%), and 1 strain showed inoculum size effects for meropenem, imipenem, and amikacin, respectively. However, four strains harbored qnr genes and two strains harbored qnr genes and QRDR mutations concurrently; no inoculum size effect was seen for levofloxacin. The blaIMP-6-positive Enterobacteriaceae that we studied was found to harbor at least one plasmid-mediated drug resistance gene. The inoculum size effect for carbapenems was thought to be mainly due to IMP-6-type metallo-β-lactamase; however qnrB and qnrS also had a minimal impact on the inoculum size effect for levofloxacin.博士（医学）・乙第1463号・令和2年6月30日Copyright: © 2019 Ogawa et al. This is an open access article distributed under the terms of the Creative Commons Attribution License(https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

奈良における侵襲性GBS感染症における臨床的特徴と分子疫学的特徴(2007～2016年)

Invasive Streptococcus agalactiae (GBS) infections are increasingly common among neonates and the elderly. Therefore, GBS surveillance for better antibiotic treatment and prophylaxis strategies are needed. We retrospectively evaluated the clinical aspects of invasive infections and the phenotypic and genetic diversity of infectious isolates from Nara, Japan, collected between 2007 and 2016, by using information from hospital records. GBS strains collected from the blood and cerebrospinal fluid cultures were evaluated for capsular types, multi-locus sequence typing (MLST), antibiotic susceptibility, antibiotics resistance gene, and pulsed-field gel electrophoresis. Forty GBS isolates (10 from children and 30 from adults) were analyzed, and the distribution of molecular serotype and allelic profiles varied between children and adults. We found the rates of early-onset disease in neonates with birth complications to be higher than that of previous reports, indicating that there could be relevance between complications at birth and early-onset disease. Standard antibiotic prophylaxis strategies may need to be reconsidered in patients with birth complications. In adults, the mean age of the patients was 68 years (male: 63%). Primary bacteremia was the most common source of infection. In the neonates, six had early-onset diseases and four had late-onset diseases. The most frequently identified strains were molecular serotype Ia ST23 (40%) and molecular serotype Ib ST10 (20%) in children and molecular serotype Ib ST10 (17%), molecular serotype VI ST1 (13%), and molecular serotype V ST1 (13%) in adults. Levofloxacin-resistant molecular serotype Ib strains and molecular serotypes V and VI ST1 were common causes of GBS infection in adults but were rarely found in children. Furthermore, pulsed-field gel electrophoresis in our study showed that specific clone isolates, that tend to have antibiotics resistance were widespread horizontally for a decade. Continuous surveillance and molecular investigation are warranted to identify the transmission route and improve antibiotic treatment strategies.博士（医学）・甲第773号・令和3年3月15日Copyright: © 2020 Hirai et al. This is an open access article distributed under the terms of the Creative Commons Attribution License(https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

再灌流後急性心筋梗塞患者におけるリバースリモデリングと非造影T1低信号梗塞コア

Background: Non-contrast T1 hypointense infarct cores (ICs) within infarcted myocardium detected using cardiac magnetic resonance imaging (CMR) T1 mapping may help assess the severity of left ventricular (LV) injury. However, because the relationship of ICs with chronic LV reverse remodeling (LVRR) is unknown, this study aimed to clarify it. Methods and Results: We enrolled patients with reperfused AMI who underwent baseline CMR on day-7 post-primary percutaneous coronary intervention (n=109) and 12-month follow-up CMR (n=94). Correlations between ICs and chronic LVRR (end-systolic volume decrease ≥15% at 12-month follow-up from baseline CMR) were investigated. We detected 52 (47.7%) ICs on baseline CMR by non-contrast-T1 mapping. LVRR was found in 52.1% of patients with reperfused AMI at 12-month follow-up. Patients with ICs demonstrated higher peak creatine kinase levels, higher B-type natriuretic peptide levels at discharge, lower LV ejection fraction at discharge, and lower incidence of LVRR than those without ICs (26.5% vs. 73.3%, P<0.001) at follow-up. Multivariate logistic regression analysis showed that the presence of ICs was an independent and the strongest negative predictor for LVRR at 12-month followup (hazard ratio: 0.087, 95% confidence interval: 0.017–0.459, P=0.004). Peak creatine kinase levels, native T1 values at myocardial edema, and myocardial salvaged indices also correlated with ICs. Conclusions: ICs detected by non-contrast-T1 mapping with 3.0-T CMR were an independent negative predictor of LVRR in patients with reperfused AMI.博士（医学）・乙第1529号・令和5年3月15

Etude système de diodes lasers à verrouillage de modes pour la radio-sur-fibre en bande millimétrique

Ce travail de thèse s inscrit dans la recherche des solutions économiquementviables pour des réseaux personnels à hauts débits (plusieurs Gbps à plusieursdizaines de Gbps) opérationnels en bande millimétrique autour de 60 GHz. Aucas où ces réseaux servent un nombre élevé d utilisateurs, ils comprendront unemultitude d antennes afin d assurer l accès sans fil rapide. Afin de réduire aumaximum le coût d un module d antenne, les réseaux doivent fournir un signalanalogue à des porteuses millimetriques. Une solution prometteuse pour les systèmesde distribution qui correspond à ces besoins sont des structures à fibreoptique, laquelle permet une transmission à faibles pertes et à haute bande passante.On parle de l approche "radio-sur-fibre" (en anglais, radio-over-fiber). Laproblématique est de pouvoir générer et moduler un signal aux fréquences millimétriqueslors de la transmission optique - et ce avec des composant bas coûts.La technique utilisée dans le cadre de cette thèse est l emploi des diodes laser àverrouillage de modes. Ces derniers vont pouvoir générer des hautes fréquencestout en ne nécessitant qu une alimentation continue, et ils peuvent être modulésde manière directe ou externe. Les lasers à semi-conducteurs employés ici sontd une génération encore à l état d étude puisqu il s agit des lasers à boites (ouîlots) quantiques. Ces lasers ont montrés de très bonnes capacités à générer dessignaux électriques aux fréquences autour de 60 GHz, bien qu ayant encore, pourl instant, à une stabilité de fréquence (ou de phase) limitée. Dans le cadre des systèmesde communication opto/micro-ondes, peu de travaux approfondis ont étémenés sur ces structures.Au cours de cette thèse, plusieurs études ont été effectuées. La première portesur les propriétés générales d un système construit à partir de ce type de laser(puissances disponibles, figure de bruit, linéarité etc.). Une deuxième étude aété consacrée aux effets de la propagation des signaux dans les systèmes baséssur les lasers à verrouillage de modes, notamment de la dispersion chromatiquelaquelle a un effet considérable sur les distances de transmission. Les deux étudesmettent en avant l importance d une limitation du nombre de modes générés parla diode laser afin d optimiser non seulement le gain du lien et la puissance RFrécupérée, mais aussi la figure de bruit du système. Lors d une troisième étude, lastabilité en fréquence/phase s est révélée critique, car le bruit de fréquence/phaselimite la qualité de la transmission en introduisant un plancher d erreur mêmepour des rapports signal-a-bruit très élevés. Des différentes générations de lasersà boites (îlots) quantiques et à verrouillage de modes ont été testées. Le problèmedu bruit de fréquence et de phase persiste et ne peut pas être résolu en utilisantles techniques classiques comme les boucles à verrouillage de phase conventionnelles.Une solution pour ce problème a été développée pour les systèmes detransmission; elle permet simultanément un ajustement de fréquence supérieure(précision de quelques Hz à quelques kHz) à celle donnée par le processus de fabricationdes diodes lasers (précision de quelques GHz), ainsi qu une stabilisationde fréquence et de phase.This dissertation is related to the search for an economically sustainable solutionfor high data rate (several Gbps to several tens of Gbps) personal area networksoperating in the millimeter-wave region around 60 GHz. If such networks supplya large number of users, they need to encompass a multitude of antenna pointsin order to assure wireless access to the network. With the aim of reducing thecost of an antenna module, the networks should at best provide quasi "readyto-radiate" signals to the modules, i.e. at millimeter-wave carrier frequencies.Thanks to their low transmission loss and their high bandwidth, optical fiber distributionarchitectures represent a promising solution. The technique is referredto as the so-called "radio-over-fiber" approach whereby the analog radio signalwill be transported to the access point by an optical wave. The challenge herebyis the generation and modulation of an optical signal by a millimeter-wave radiosignal using preferably cost-efficient system components. The technique proposedherein is based on the use of mode-locked laser diodes which can generatesignals at very high frequencies under the condition of continuous current supply.Mode-locked laser diodes can be modulated both directly and externally. Thediodes employed in this work are based on so-called quantum dots (or quantumdashes); these are material structures which are themselves still subject to intensivephysical research. Signals at millimeter-wave frequencies (around 60 GHz)can easily be generated by such lasers. However, their frequency and phase stabilityis as yet limited. In the context of radio-over-fiber communication systems,these structures have not yet been studied in detail.In the course of this dissertation, several aspects are considered. A first systemstudy treats the basic properties of a system built from this type of laser source(available signal power, system noise figure, linearity etc.). A second study isdevoted to an investigation of propagation effects like dispersion, which considerablyinfluence the attainable transmission distances. An essential result of bothstudies is the importance of limiting the laser spectrum to a small number of lasermodes for an optimization of link gain, generated RF power, and system noisefigure. A third study deals with the limited frequency and phase stability whichturn out to be critical factors for transmission quality. The study of several generationsof quantum dot/dash lasers has revealed that the problems of frequencyand phase noise persist and cannot be solved using classical techniques involvinge.g. conventional phase-locked loops. In this dissertation, a solution is presentedwhich not only allows a more precise adjustment of the laser frequency (precisionin the order of Hz to kHz) than that given by the manufacturing process of thelaser (precision in the order of GHz), but also enables a stabilization of frequencyand phase.SAVOIE-SCD - Bib.électronique (730659901) / SudocGRENOBLE1/INP-Bib.électronique (384210012) / SudocGRENOBLE2/3-Bib.électronique (384219901) / SudocSudocFranceF

心不全を合併した心房細動患者のカテーテルアブレーション後の長期予後 : 左室駆出率に基づいた心不全のサブタイプ間における比較

Aims: Heart failure (HF) prognosis has been reported similar in patients with preserved vs. reduced left ventricular ejection fraction (LVEF). This study compared the long-term prognosis of HF patients undergoing radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF). Methods and results: Among 5010 patients undergoing RFCA in Kansai Plus AF registry, 656 patients (13.1%) with a documented history of HF were enrolled in the study before RFCA. The primary endpoint was a composite of all-cause death, HF hospitalization, and stroke or systemic embolism. Patients with reduced (<40%), mid-range (40-49%), and preserved (≥50%) LVEF were 98 (14.9%), 107 (16.3%), and 451 (68.8%) patients, respectively. The prevalence of ischaemic heart disease and cardiomyopathies was higher among patients with reduced as compared with preserved LVEF (27.6% vs. 10.0%, P < 0.05 and 36.7% vs. 15.3%, P < 0.05, respectively). The median follow-up period was 2.9 years. The 3-year cumulative risk for the primary endpoint was higher in patients with reduced LVEF (32.7%) compared to those with mid-range (11.7%) or preserved (11.6%) LVEF (P < 0.001). Reduced LVEF was the most significant independent risk factor for primary endpoint (hazard ratio, 2.83; 95% confidence interval 1.74-4.61, P < 0.001). The 3-year arrhythmia recurrence rate was similar among the groups (48.2%, 42.8%, and 47.3%, respectively, P = 0.75). Conclusion : This study raises hypothesis that patients with HFrEF and AF had approximately three times higher risk for a composite of all-cause death, HF hospitalization, and stroke or systemic embolism after AF ablation compared with patients with HFmrEF or HFpEF.博士（医学）・甲第802号・令和3年12月21日Copyright: © Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021.This is a pre-copyedited, author-produced version of an article accepted for publication in Europace following peer review. The version of record "Europace Online ahead of print (2021 Aug 31;euab201) is available online at: https://doi.org/10.1093/europace/euab201.発行元が定める登録猶予期間終了の後、本文を登録予定（2022.08

Transient IGF-1R inhibition combined with osimertinib eradicates AXL-low expressing EGFR mutated lung cancer

Drug tolerance is the basis for acquired resistance to epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) including osimertinib, through mechanisms that still remain unclear. Here, we show that while AXL-low expressing EGFR mutated lung cancer (EGFRmut-LC) cells are more sensitive to osimertinib than AXL-high expressing EGFRmut-LC cells, a small population emerge osimertinib tolerance. The tolerance is mediated by the increased expression and phosphorylation of insulin-like growth factor-1 receptor (IGF-1R), caused by the induction of its transcription factor FOXA1. IGF-1R maintains association with EGFR and adaptor proteins, including Gab1 and IRS1, in the presence of osimertinib and restores the survival signal. In AXL-low-expressing EGFRmut-LC cell-derived xenograft and patient-derived xenograft models, transient IGF-1R inhibition combined with continuous osimertinib treatment could eradicate tumors and prevent regrowth even after the cessation of osimertinib. These results indicate that optimal inhibition of tolerant signals combined with osimertinib may dramatically improve the outcome of EGFRmut-LC