Lipoteichoic acid composed of poly-glycerolphosphate containing l-lysine and involved in immunoglobulin A-inducing activity in Apilactobacillus genus.

Lipoteichoic acid (LTA) in the gram-positive bacterial cell wall acts as an immunomodulatory factor in host cells. The chemical structures vary among bacterial species and strains, and may be related to biological activities. In our previous work, much higher immunoglobulin A (IgA)-inducing activity was observed in cells of the Apilactobacillus genus (Apilactobacillus kosoi 10HT, Apilactobacillus apinorum JCM 30765T, and Apilactobacillus kunkeei JCM 16173T) than other lactic acid bacteria, and their LTA was responsible for the activity. In the present study, we elucidated the chemical structures of LTA from these Apilactobacillus strains to explore the structure-function relationship of the IgA-inducing activity. The 1H-nuclear magnetic resonance spectra suggested that their LTA structures were similar. All have a poly-glycerolphosphate main chain, which comprised 12 to 20 average number of the repeating units, with partial substitutions of glucose(α1-, glucosyl(α1-2)glucose(α1- (α-linked-kojibiose), and l-lysine at the C-2 hydroxy group of the glycerol residue. l-Lysine is a substituent never seen before in LTA, and is a probable characteristic of the Apilactobacillus genus. Removal of l-lysine residue from LTA by mild alkaline treatment decreased IgA induction in murine Peyer's patch experiments. The novel l-lysine residue in Apilactobacillus LTA plays a crucial role in the remarkably high IgA-inducing activity.

Prebiotic effect of galacto-N-biose on the intestinal lactic acid bacteria as enhancer of acetate production and hypothetical colonization.

Galacto-N-biose (GNB) is an important core structure of glycan of mucin glycoproteins in the gastrointestinal (GI) mucosa. Because certain beneficial bacteria inhabiting the GI tract, such as bifidobacteria and lactic acid bacteria, harbor highly specialized GNB metabolic capabilities, GNB is considered a promising prebiotic for nourishing and manipulating beneficial bacteria in the GI tract. However, the precise interactions between GNB and beneficial bacteria and their accompanying health-promoting effects remain elusive. First, we evaluated the proliferative tendency of beneficial bacteria and their production of beneficial metabolites using gut bacterial strains. By comparing the use of GNB, glucose, and inulin as carbon sources, we found that GNB enhanced acetate production in Lacticaseibacillus casei, Lacticaseibacillus rhamnosus, Lactobacillus gasseri, and Lactobacillus johnsonii. The ability of GNB to promote acetate production was also confirmed by RNA-seq analysis, which indicated the upregulation of gene clusters that catalyze the deacetylation of N-acetylgalactosamine-6P and biosynthesize acetyl-CoA from pyruvate, both of which result in acetate production. To explore the in vivo effect of GNB in promoting acetate production, antibiotic-treated BALB/cA mice were administered with GNB with L. rhamnosus, resulting in a fecal acetate content that was 2.7-fold higher than that in mice administered with only L. rhamnosus. Moreover, 2 days after the last administration, a 3.7-fold higher amount of L. rhamnosus was detected in feces administered with GNB with L. rhamnosus than in feces administered with only L. rhamnosus. These findings strongly suggest the prebiotic potential of GNB in enhancing L. rhamnosus colonization and converting L. rhamnosus into higher acetate producers in the GI tract. IMPORTANCE: Specific members of lactic acid bacteria, which are commonly used as probiotics, possess therapeutic properties that are vital for human health enhancement by producing immunomodulatory metabolites such as exopolysaccharides, short-chain fatty acids, and bacteriocins. The long residence time of probiotic lactic acid bacteria in the GI tract prolongs their beneficial health effects. Moreover, the colonization property is also desirable for the application of probiotics in mucosal vaccination to provoke a local immune response. In this study, we found that GNB could enhance the beneficial properties of intestinal lactic acid bacteria that inhabit the human GI tract, stimulating acetate production and promoting intestinal colonization. Our findings provide a rationale for the addition of GNB to lactic acid bacteria-based functional foods. This has also led to the development of therapeutics supported by more rational prebiotic and probiotic selection, leading to an improved healthy lifestyle for humans.

Psychiatric Features of Children with Chronic Functional Constipation: Focusing on Individuals with Autism Spectrum Disorder.

PURPOSE: The present study aimed to assess the psychiatric characteristics of children with chronic functional constipation using the Aberrant Behavior Checklist-Japanese version and the Pervasive Developmental Disorders/Autism Society Japan Rating Scale, and to examine the frequency of autism spectrum disorder in children with chronic functional constipation. We also investigated differences in treatment duration between children with and without autism spectrum disorder. METHODS: Treatment outcomes were examined retrospectively for 55 participants (chronic functional constipation group: n = 30, mean age 3.4 years; control group: n = 25, mean age, 4.5 years). The association between chronic functional constipation and autism spectrum disorder was evaluated using multivariable logistic regression analysis. RESULTS: The mean Aberrant Behavior Checklist score and frequency of individuals with autism spectrum disorder were significantly higher in the chronic functional constipation group. After adjusting for age and sex, chronic functional constipation was significantly associated with autism spectrum disorder. In the chronic functional constipation group, the frequency of onset was significantly higher in children with autism spectrum disorder under 1 year of age. When treated, the mean duration of constipation was significantly longer in children with autism spectrum disorder. CONCLUSION: Pediatricians, pediatric surgeons, and child psychiatrists should work closely to ensure appropriate treatment of chronic functional constipation in children with autism spectrum disorder.

Characteristics of mental disorders among information technology workers in 238 compensated cases in Japan.

This study aimed to investigate the circumstances, characteristics, and background factors of mental disorders within the information technology (IT) industry, which is known for the frequent occurrence of mental disorders from overwork and poor psychosocial work environment. The study analyzed 238 cases of mental disorders and suicides in the IT industry from fiscal years 2010 to 2018 on the database constructed by the Japan Research Center for Overwork-Related Disorders. The results showed a higher number of cases among men (n=178, 74.8%) and an increasing number among women. The data for diagnosis of mental diseases indicated a high number of depressive episodes (150 cases, 63.0%). Regarding work-induced psychological burden, 37 cases (15.5%) reported "extremely long working hours" for "special events" and 65 cases (27.3%) reported "constantly long working hours". For "specific events", 87 cases (36.6%) reportedly "caused (major) changes in the content and amount of work". Among women, 13 cases (21.7%) of "sexual harassment" (SH), which showed an increasing trend. Therefore, in the IT industry, the working hours must be properly managed. Mental health measures should also accompany improved psychosocial environment in the workplace, and prohibition of SH at work in particular.

Prescribing Patterns in Child and Adolescent Outpatient Psychiatry: A Retrospective Cohort Study of Prescriptions in the First Year.

OBJECTIVE: Recently, excessive and off-label prescribing of psychotropic drugs for children and adolescents have become a problem. Child and adolescent psychiatric patients receive treatment in many departments and department-specific psychotropic drug use has not been analyzed. We surveyed prescriptions for child and adolescent psychiatric outpatients during their first year of treatment. METHODS: The participants were 302 patients, 15 years or younger, who made their first visit to the outpatient psychiatry department of Tokai University Hospital from September 1, 2015 to September 1, 2016. Prescription details and patient profiles were retrospectively investigated using medical records. RESULTS: Medication was prescribed for 20.9% of patients (63/302) with the prescription rate increasing with age. Psychotropic drugs were prescribed for 15.6% of patients (48/302), with attention-deficit/hyperactivity disorder (ADHD) medications being most frequently prescribed (20 cases). Other than psychotropic drugs, iron pills (25 cases) and herbal medicines (21 cases) were prescribed frequently. CONCLUSIONS: The pharmacotherapy and psychotropic prescription rates were low. This may be due to the use of non-pharmacological interventions and the lack of inpatient facilities. With the publication of guidelines for pharmacotherapy in child psychiatry in Japan, measuring the patterns of psychotropic drug prescription in children and adolescents is important, and would make treatment more transparent.

Psychosocial factors predicting symptoms of depression and anxiety in allogeneic hematopoietic stem cell transplant recipients in Japan.

OBJECTIVE: We explored whether a patient's psychosocial background before allogeneic hematopoietic stem cell transplantation (allo-HSCT) could predict the occurrence of psychiatric symptoms during treatment and after hospital discharge. METHOD: Logistic regression analysis was performed using INTERMED, a scale that comprehensively evaluates psychological factors such as psychiatric history, current mental status, and coping skills, and social factors such as social participation status, relationships with others, and living environment, which were used as independent variables. The Center for Epidemiologic Studies Depression Scale was used to measure depression, while the Profile of Mood States was used to measure anxiety and other symptoms. Both measures were used as dependent variables and were administered upon clean room admission, during clean room stay, at clean room discharge, and at 3, 6, and 12 months after hospital discharge. RESULTS: Participants included 70 patients (45 males and 25 females, mean age 53.3 ± 12.3 years). Thirty-eight patients participated in the program for the entire period, up to 12 months after hospital discharge. The total score on the Japanese version of the INTERMED and psychological factor scores assessed at baseline were significant predictors of depressed mood on discharge; however, there were no significant predictors of scores on the Profile of Mood States. CONCLUSIONS: A comprehensive pretransplant evaluation of psychosocial background can help predict the appearance of psychiatric symptoms after allo-HSCT. In patients who are expected to develop psychiatric symptoms after allo-HSCT, it is important to consider early intervention by a specialist and close monitoring by a medical team.

Mucin glycans and their degradation by gut microbiota.

The human intestinal tract is inhabited by a tremendous number of microorganisms, which are collectively termed "the gut microbiota". The intestinal epithelium is covered with a dense layer of mucus that prevents penetration of the gut microbiota into underlying tissues of the host. Recent studies have shown that the maturation and function of the mucus layer are strongly influenced by the gut microbiota, and alteration in the structure and function of the gut microbiota is implicated in several diseases. Because the intestinal mucus layer is at a crucial interface between microbes and their host, its breakdown leads to gut bacterial invasion that can eventually cause inflammation and infection. The mucus is composed of mucin, which is rich in glycans, and the various structures of the complex carbohydrates of mucins can select for distinct mucosa-associated bacteria that are able to bind mucin glycans, and sometimes degrade them as a nutrient source. Mucin glycans are diverse molecules, and thus mucin glycan degradation is a complex process that requires a broad range of glycan-degrading enzymes. Because of the increased recognition of the role of mucus-associated microbes in human health, how commensal bacteria degrade and use host mucin glycans has become of increased interest. This review provides an overview of the relationships between the mucin glycan of the host and gut commensal bacteria, with a focus on mucin degradation.

Impact of Gut Microbiota on Host Aggression: Potential Applications for Therapeutic Interventions Early in Development.

Aggression in the animal kingdom is a necessary component of life; however, certain forms of aggression, especially in humans, are pathological behaviors that are detrimental to society. Animal models have been used to study a number of factors, including brain morphology, neuropeptides, alcohol consumption, and early life circumstances, to unravel the mechanisms underlying aggression. These animal models have shown validity as experimental models. Moreover, recent studies using mouse, dog, hamster, and drosophila models have indicated that aggression may be affected by the "microbiota-gut-brain axis." Disturbing the gut microbiota of pregnant animals increases aggression in their offspring. In addition, behavioral analyses using germ-free mice have shown that manipulating the intestinal microbiota during early development suppresses aggression. These studies suggest that treating the host gut microbiota during early development is critical. However, few clinical studies have investigated gut-microbiota-targeted treatments with aggression as a primary endpoint. This review aims to clarify the effects of gut microbiota on aggression and discusses the therapeutic potential of regulating human aggression by intervening in gut microbiota.

Managing postoperative atrial fibrillation after open-heart surgery using transdermal ß1 blockers.

BACKGROUND: Postoperative atrial fibrillation (POAF) after open-heart surgery is a non-negligible complication. We aimed to describe the efficacy of a transdermal patch of bisoprolol for managing POAF and flutter in thoracic surgical procedures. METHODS: We analyzed the data of 384 patients who underwent open-heart surgery at our hospital and received oral bisoprolol to prevent POAF. Among them, 65 patients (16.9%) also received a 4-mg transdermal patch of bisoprolol to control the heart rate due to POAF. We applied the bisoprolol transdermal patch when the heart rate was > 80 bpm and removed it at ≤ 60 bpm; an additional patch was applied when the heart rate was > 140 bpm. Heparin calcium injections were administered twice daily for anticoagulation between 2 and 6 days postoperatively. RESULTS: The average number of prescriptions for transdermal patches of bisoprolol during hospitalization was 1.8 ± 1.1 (1-5). The median first prescription date was on postoperative day 2 (range: days 0-37). Sinus rhythm recovered within 24 h in 18 patients (27.7%). Eight patients (12.3%) were switched to continuous landiolol infusion because of persistent tachycardia. In three patients, the transdermal patch was removed owing to severe bradycardia. Fifteen patients experienced persistent atrial fibrillation and were treated with electrical cardioversion during hospitalization. We did not observe any serious complications that could be directly attributed to bisoprolol transdermal patch use. CONCLUSIONS: Single-use bisoprolol transdermal patch may help control the heart rate during the initial treatment of POAF after open-heart surgery.

Process Intensification of a Napabucasin Manufacturing Method Utilizing Microflow Chemistry.

Microflow chemistry is one of the newest and most efficient technologies used today for the safe and effective production of medicines. In this paper, we show the use of this technology in the development of a manufacturing method for napabucasin, which has potential in the treatment of colorectal and pancreatic cancers. In conventional "batch-type" reactor systems, the generation of side products can be controlled with traditional techniques such as reagent reverse-addition and temperature control. However, there is a limitation to which the yield and purity can be improved by these methods, as both are constrained by the efficiency of heat/mass transfer. Applying microflow chemistry technology alters the parameters of the constraint through the use of precise mixing in a microchannel, which offers increased possibility for improving yields and process intensification of the napabucasin process. Reported herein is a proof-of-concept study for the scale-up production of napabucasin using microflow chemistry techniques for manufacturing at the kilogram scale.

Host metabolic benefits of prebiotic exopolysaccharides produced by Leuconostoc mesenteroides.

Fermented foods demonstrate remarkable health benefits owing to probiotic bacteria or microproducts produced via bacterial fermentation. Fermented foods are produced by the fermentative action of several lactic acid bacteria, including Leuconostoc mesenteroides; however, the exact mechanism of action of these foods remains unclear. Here, we observed that prebiotics associated with L. mesenteroides-produced exopolysaccharides (EPS) demonstrate substantial host metabolic benefits. L. mesenteroides-produced EPS is an indigestible α-glucan, and intake of the purified form of EPS improved glucose metabolism and energy homeostasis through EPS-derived gut microbial short-chain fatty acids, and changed gut microbial composition. Our findings reveal an important mechanism that accounts for the effects of diet, prebiotics, and probiotics on energy homeostasis and suggests an approach for preventing lifestyle-related diseases by targeting bacterial EPS.

A fluorogenic probe for core-fucosylated glycan-preferred ENGase.

A fluorescence-quenching-based assay system to determine the hydrolytic activity of endo-ß-N-acetylglucosaminidases (ENGases), which act on the innermost N-acetylglucosamine (GlcNAc) residue of the chitobiose segment of core-fucosylated N-glycans, was constructed using a dual-labeled fluorescent probe with a hexasaccharide structure. The fluorogenic probe was evaluated using a variety of ENGases, including Endo-M W251N mutant, Endo-F3, and Endo-S, which recognize core fucosylated N-glycans. The occurrence of a hydrolysis reaction was detected by observing an increased fluorescence intensity, ultimately allowing the ENGase activities to be easily and quantitatively evaluated, with the exception of Endo-S. The obtained results clearly indicated the substrate specificities of the examined ENGases.

Draft Genome Sequence of Lentilactobacillus kosonis NBRC 111893, Isolated from a Japanese Sugar-Vegetable Fermented Beverage called Kôso.

Lentilactobacillus kosonis NBRC 111893 is a species of heterolactic acid bacteria isolated from kôso, a Japanese sugar-vegetable fermented beverage. The draft genome sequence of L. kosonis NBRC 111893 is useful for understanding the features of the genus Lentilactobacillus and its possible uses in fermented foods.

A Case of Nocturnal Enuresis Associated with Attention-deficit/hyperactivity Disorder Successfully Treated with Guanfacine Monotherapy.

Nocturnal enuresis (NE) is a syndrome associated with abnormal nocturnal urine production, urination mechanism, and sleep arousal. NE is strongly associated with attention-deficit/hyperactivity disorder (ADHD), and it has been reported that NE occurs in approximately 30% of children with ADHD. There have been several reports on the efficacy of atomoxetine as treatment for NE with ADHD, while the efficacy of guanfacine is still limited. We report our experience of treating an 10-year-old girl with NE with ADHD with a single dose of guanfacine. The patient first visited our hospital because of difficulty concentrating, restlessness at home and school, and nocturnal incontinence. She was diagnosed with NE with ADHD based on a review of her personal history from her mother. Her NE symptoms improved with guanfacine monotherapy (1 mg/day. The patient weighed 28 kg).

Adverse effects of COVID-19 vaccines and measures to prevent them.

Recently, The Lancet published a study on the effectiveness of COVID-19 vaccines and the waning of immunity with time. The study showed that immune function among vaccinated individuals 8 months after the administration of two doses of COVID-19 vaccine was lower than that among the unvaccinated individuals. According to European Medicines Agency recommendations, frequent COVID-19 booster shots could adversely affect the immune response and may not be feasible. The decrease in immunity can be caused by several factors such as N1-methylpseudouridine, the spike protein, lipid nanoparticles, antibody-dependent enhancement, and the original antigenic stimulus. These clinical alterations may explain the association reported between COVID-19 vaccination and shingles. As a safety measure, further booster vaccinations should be discontinued. In addition, the date of vaccination should be recorded in the medical record of patients. Several practical measures to prevent a decrease in immunity have been reported. These include limiting the use of non-steroidal anti-inflammatory drugs, including acetaminophen to maintain deep body temperature, appropriate use of antibiotics, smoking cessation, stress control, and limiting the use of lipid emulsions, including propofol, which may cause perioperative immunosuppression. In conclusion, COVID-19 vaccination is a major risk factor for infections in critically ill patients.

A strategy to enable rapid healing and prevent recurrence of venous ulcers.

INTRODUCTION: Venous ulcers are often intractable. OBJECTIVE: The aim of this study was to retrospectively analyze the effectiveness of endovenous ablation, compression therapy, moist wound healing, and skin care in the management of venous ulcers. MATERIALS AND METHODS: Twenty-eight consecutive patients (10 male, 18 female; mean age, 70.1 years) with Clinical-Etiology-Anatomy-Pathophysiology (CEAP) class C6 venous ulcer underwent endovenous ablation between December 2014 and August 2020. The main treatment strategies were radiofrequency ablation and varicectomy (including stab avulsion of incompetent perforating veins), use of compression therapy until complete healing was achieved, moist wound healing (washing the ulcer site and covering it with dressings twice daily), and skin care, taking into consideration the balance of the microbiome. RESULTS: Active venous leg ulcers (CEAP class C6) were diagnosed in 36 patients at the first visit. In 7 of these patients, compression therapy and use of strategies to promote moist wound healing resulted in ulcer healing by the day of the planned surgery. One patient was unable to quit smoking and, therefore, could not undergo surgery. After excluding these 8 patients, the authors analyzed the data from 28 patients who underwent endovenous ablation. The mean surgical time was 38.9 minutes, and the mean number of stab avulsion incision sites was 9.7. All ulcers healed within a median of 55.5 days (range, 13-365 days). Ulcer healing was achieved by 1 year in all 28 patients (100%). No ulceration recurred as of the final follow-up (median, 24.5 months [range, 3-66 months]). CONCLUSIONS: Endovenous ablation, adequate varicectomy (stab avulsion [maximum number of sites in 1 patient, 43]), compression therapy, moist wound healing, and skin care are effective in treating and preventing recurrence of venous ulcers.

Role of Lipoteichoic Acid from the Genus Apilactobacillus in Inducing a Strong IgA Response.

Lactic acid bacterium-containing fermentates provide beneficial health effects by regulating the immune response. A naturally fermented vegetable beverage, a traditional Japanese food, reportedly provides health benefits; however, the beneficial function of its bacteria has not been clarified. Apilactobacillus kosoi is the predominant lactic acid bacterium in the beverage. Using murine Peyer's patch cells, we compared the immunoglobulin A (IgA)-inducing activity of A. kosoi 10HT to those of 29 other species of lactic acid bacteria and found that species belonging to the genus Apilactobacillus (A. kosoi 10HT, A. apinorum JCM30765T, and A. kunkeei JCM16173T) possessed significantly higher activity than the others. Thereafter, lipoteichoic acids (LTAs), important immunostimulatory molecules of Gram-positive bacteria, were purified from the three Apilactobacillus species, and their IgA-inducing activity was compared to those of LTAs from Lactiplantibacillus plantarum JCM1149T and a probiotic strain, Lacticaseibacillus rhamnosus GG. The results revealed that LTAs from Apilactobacillus species had significantly higher activity than others. We also compared the LTA structure of A. kosoi 10HT with that of L. plantarum JCM1149T and L. rhamnosus GG. Although d-alanine or both d-alanine and carbohydrate residues were substituents of free hydroxyl groups in the polyglycerol phosphate structure in LTAs from strains JCM1149T and GG, d-alanine residues were not found in LTA from strain 10HT by 1H nuclear magnetic resonance (NMR) analysis. Matrix-assisted laser desorption ionization-time-of-flight mass spectrometry (MALDI-TOF MS) analysis of the glycolipid structure of LTA revealed that LTA from strain 10HT contained dihexosyl glycerol, whereas trihexosyl glycerol was detected in LTAs from other strains. These structural differences may be related to differences in IgA-inducing activity. IMPORTANCE The components of lactic acid bacteria that exert immunostimulatory effects are of increasing interest for therapeutic and prophylactic options, such as alternatives to antibiotics, cognitive enhancements, and vaccine adjuvants. LTAs act as immunostimulatory molecules in the host innate immune system by interacting with pattern recognition receptors. However, as LTA structures differ among species, detailed knowledge of the structure-function relationship for immunostimulatory effects is required. Comparisons of the IgA-inducing activity of LTAs have demonstrated that LTAs from the genus Apilactobacillus possess distinctive activities to stimulate mucosal immunity. The first analysis of the LTA structure from the genus Apilactobacillus suggests that it differs from structures of LTAs of related species of lactic acid bacteria. This knowledge is expected to aid in the development of functional foods containing lactic acid bacteria and pharmaceutical applications of immunostimulatory molecules from lactic acid bacteria.

Feasibility of incompetent perforator vein excision using stab avulsion.

OBJECTIVES: Whether incompetent perforator veins (IPVs) require treatment remains controversial. We retrospectively evaluated the feasibility of IPV excision performed using the stab avulsion technique without ligation and sutures in patients undergoing endovenous ablation (EA). METHODS: This was a single-center, retrospective, observational cohort study. EA was performed in 1503 consecutive patients, including 33 patients with ulcers, between December 2014 and May 2021. Varicectomy was performed using the stab avulsion technique; IPV cases were included. RESULTS: Stab avulsion was performed at a mean number of 11.4 ± 7.8 sites. No deep vein thromboses or pulmonary emboli were noted. The incidence of nerve injury was 0.3%. All 33 (100%) patients with ulcers achieved healing by 1 year (median: 55.5 days; range: 13-365 days). CONCLUSIONS: IPV excision via stab avulsion may be a viable option for treating varicose veins and ulcers. This technique offers multiple advantages, including simplicity, safety, and reduced healthcare costs.

Compassionate open-label use of rituximab following a randomised clinical trial against neuromyelitis optica (RIN-2 study): B cell monitoring-based administration.

OBJECTIVE: The aim of the RIN-2 study was a compassionate use of rituximab (RTX) for patients who completed the RIN-1 study, a multicentre, randomised, double-blind, placebo-controlled trial of RTX. We also investigated the long-term safety and efficacy of RTX. METHODS: A study design was a prospective open-label extension study following the RIN-1 study. RTX was infused repeatedly under monthly monitoring of CD19-positive and CD 20-positive B cell lymphocyte subsets from 24 weeks after an infusion. RESULTS: Thirty-three (87%) of 38 patients of the RIN-1 study were enrolled from February 2016 to March 2019 at six sites in Japan. In RIN-2, RTX was administered three times (median, range 1-5 times), and the interval of RTX administrations were 9.5 [2.5] months (mean [SD]). The observation period was 20.5 [10.1] months. During the trial, three patients dropped out due to two withdrawals and one adverse event. During the study, 28 (90%) of 31 patients were treated with RTX monotherapy. Neuromyelitis optica (NMO) relapses were observed in two patients. The annualized relapse rate (ARR) was 0.035 counts per person-years, ∼1/10th compared with 0.321 in the placebo arm of the RIN-1 study. We observed 14 severe adverse events in six (18%) and 156 adverse events, of which 135 were grade 1, 11 were grade 2 and 10 were grade 3. CONCLUSIONS: Under B cell monitoring, the interval of RTX re-infusion was elongated to nine months, and NMO relapses were suppressed with 0.035 of ARR.