Assessment of locomotive syndrome in patients with visceral cancer, the comparison with non-cancer patients using propensity score matching

BACKGROUND

When treating cancer patients, the progression of symptoms is accompanied by the deterioration of systemic conditions and motor function. From a risk-benefit perspective, a certain level of physical function must be maintained to continue cancer treatment. Recently, outpatient cancer treatment has become more common. Motor function is important to determine the feasibility of continuing cancer treatment. The study aimed to evaluate the motor function of patients with visceral cancer using locomo tests established by Japanese Orthopaedic Association.

METHODS

Locomo tests were performed, and the results were compared with data from non-cancer individuals. Background data were matched by propensity score matching. Data from 53 cancer patients (group C) were compared with that of 75 non-cancer patients (group N).

RESULTS

The average score in the two-step test of group C was lower than that of group N (1.27: 1.37, p = 0.004). The average function in the stand-up test of group C was worse than that of group N (p = 0.001). The average score in the 25-question geriatric locomotive function scale (GLFS) of group C was significantly higher than that of group N (19.92: 5.29, SE 2.21, p < 0.001). Higher 25-question GLFS scores indicate reduced mobility. The proportion of the locomo stage 2 in group C was significantly higher than in group N (51%: 13%, p < 0.001). The results of the two field tests revealed a clinically minimal difference between the two groups, but a statistically significant difference. Locomo tests may be detect potential motor dysfunction in outpatient cancer patients with apparently maintained motor function.

CONCLUSIONS

Even in cancer patients who attend outpatient clinics, their motor functions could be potentially impaired. Therapeutic interventions to maintain and enhance motor function for cancer patients could be useful for continuing cancer treatment, and furthermore, improving prognosis.

Recovery of Forearm Bone Strength After Plate Removal: A Finite Element Analysis Study

PURPOSE

The purpose of this study was to estimate the bone strength after plate removal over time and to investigate the progression of bone strength recovery.

METHODS

A consecutive series of 31 patients was investigated to evaluate bone strength before and after forearm plate removal. Patients who were included underwent plate fixation for forearm diaphyseal fractures and were scheduled for plate removal. Computed tomography (CT) scans of the entire length of the bilateral forearms were taken before plate removal and at 1, 3, and 6 months after surgery. Patient-specific CT-based finite element analysis was used to predict the forearm bone fracture strength against an axial load (N), defined as the bone strength. Bone strength was estimated by patient-specific CT-based finite element analysis at each time point.

RESULTS

The mean age of the patients was 40.4 years. The mean time between plate fixation and removal was 27.5 months. Bone strength before the removal was estimated as reduced to 47% of that of the uninjured side. This was constant regardless of age group, involvement of the radius or ulna, Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification, open fracture, or type of plate. Bone strength at 1, 3, and 6 months after removal was estimated to be 66%, 85%, and 97%, respectively. The bone strength of the distal ulna was weaker than that at the other sites in the forearm and showed delayed recovery.

CONCLUSIONS

Bone strength after plate removal showed recovery within 3-6 months and was fully recovered by 6 months. The degree of recovery of bone atrophy varies from site to site, and patients should be careful about refracture after removal.

CLINICAL RELEVANCE

Clinicians should be aware that bone strength may not be sufficiently restored even 6 months after plate removal of forearm fractures.

Diagnosis of Atrial Fibrillation Using Machine Learning With Wearable Devices After Cardiac Surgery: Algorithm Development Study

Background

Some attempts have been made to detect atrial fibrillation (AF) with a wearable device equipped with photoelectric volumetric pulse wave technology, and it is expected to be applied under real clinical conditions.

Objective

This study is the second part of a 2-phase study aimed at developing a method for immediate detection of paroxysmal AF, using a wearable device with built-in photoplethysmography (PPG). The objective of this study is to develop an algorithm to immediately diagnose AF by an Apple Watch equipped with a PPG sensor that is worn by patients undergoing cardiac surgery and to use machine learning on the pulse data output from the device.

Methods

A total of 80 patients who underwent cardiac surgery at a single institution between June 2020 and March 2021 were monitored for postoperative AF, using a telemetry-monitored electrocardiogram (ECG) and an Apple Watch. AF was diagnosed by qualified physicians from telemetry-monitored ECGs and 12-lead ECGs; a diagnostic algorithm was developed using machine learning on the pulse rate data output from the Apple Watch.

Results

One of the 80 patients was excluded from the analysis due to redness caused by wearing the Apple Watch. Of 79 patients, 27 (34.2%) developed AF, and 199 events of AF including brief AF were observed. Of them, 18 events of AF lasting longer than 1 hour were observed, and cross-correlation analysis showed that pulse rate measured by Apple Watch was strongly correlated (cross-correlation functions [CCF]: 0.6-0.8) with 8 events and very strongly correlated (CCF>0.8) with 3 events. The diagnostic accuracy by machine learning was 0.9416 (sensitivity 0.909 and specificity 0.838 at the point closest to the top left) for the area under the receiver operating characteristic curve.

Conclusions

We were able to safely monitor pulse rate in patients who wore an Apple Watch after cardiac surgery. Although the pulse rate measured by the PPG sensor does not follow the heart rate recorded by telemetry-monitored ECGs in some parts, which may reduce the accuracy of AF diagnosis by machine learning, we have shown the possibility of clinical application of using only the pulse rate collected by the PPG sensor for the early detection of AF.

Comparison of short-term clinical outcomes between low-dose prasugrel and clopidogrel as part of triple antithrombotic therapy in patients requiring oral anticoagulant therapy and percutaneous coronary intervention

BACKGROUND

Triple antithrombotic therapy, including dual antiplatelet therapy and oral anticoagulant (OAC), is recommended for a short-term period after percutaneous coronary intervention (PCI) in patients requiring anticoagulation therapy. The purpose of this study was to compare in-hospital clinical outcomes between low-dose prasugrel (3.75 mg/day) and clopidogrel, as part of triple antithrombotic therapy, using a large database in Japan.

METHODS

Patients with ischemic heart disease who underwent PCI between January 2015 and December 2019, and were prescribed triple therapy with aspirin, a P2Y12 inhibitor (clopidogrel or low-dose prasugrel), and OAC (direct oral anticoagulant: DOAC or vitamin K antagonist: VKA), were selected from the Diagnosis Procedure Combination database. The primary outcome was in-hospital mortality. The secondary outcomes were myocardial infarction, ischemic stroke, bleeding stroke, gastrointestinal bleeding, and blood transfusion.

RESULTS

Overall, 5,777 patients were eligible in this analysis. The patients were divided into 4 subgroups according to the type of P2Y12 inhibitor and OAC: clopidogrel/DOAC (n = 1,628), clopidogrel/VKA (n = 1,334), prasugrel/DOAC (n = 1,607), and prasugrel/VKA (n = 1,208). There was no significant difference in the incidence of death and gastrointestinal bleeding among the 4 subgroups. The prasugrel/DOAC group had significantly lower incidence of MI (OR 0.566, 95% CI 0.348-0.921). The incidence of ischemic stroke was significantly lower in the prasugrel/DOAC group (OR 0.701, 95% CI 0.502-0.979), and significantly higher in the clopidogrel/VKA group (OR 1.680, 95% CI 1.273-2.216). Need for blood transfusion was less frequent in the prasugrel/DOAC group (OR 0.729, 95% CI 0.598-0.890), and more frequent in both the clopidogrel/VKA group (OR 1.424, 95% CI 1.187-1.708) and the prasugrel/VKA group (OR 1.633, 95% CI 1.367-1.950).

CONCLUSIONS

Combination of low-dose prasugrel and DOAC was associated with lower incidence of MI, ischemic stroke, and blood transfusion. Low-dose prasugrel may be feasible as part of triple therapy in patients undergoing PCI.

Relationship Between Clinical Symptoms and Skin Autofluorescence in Hemodialysis Patients as a Measure of Advanced Glycation End-Product Accumulation

Background

The purpose of this study was to investigate the relationship between skin autofluorescence (SAF), as a measure of advanced glycation end-product (AGE) accumulation and osteoporosis and clinical symptoms in hemodialysis patients.

Methodology

The study participants were 156 hemodialysis patients (97 males, 59 females, mean = 66.9 years, range = 25-92 years) who visited our hospital between October 2019 and March 2020. The average dialysis period was 10.4 years (range = 1-40 years). Age, years of dialysis, bone mineral density, bone metabolism markers (Ca, P, intact parathyroid hormone, total N-terminal propeptide of type 1 collagen, tartrate-resistant acid phosphatase-5b), clinical symptoms, and SAF were evaluated. Clinical symptoms were evaluated using the visual analog scale (VAS) score for low back pain (LBP) and leg pain ranging from 10 mm (extreme amount of pain) to 0 mm (no pain); the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ; 0-100 points); and the Roland-Morris Disability Questionnaire (RDQ; 0-24 points). We calculated Pearson correlation coefficients to assess the correlation of SAF with age, years of hemodialysis, bone density, bone metabolism markers, clinical symptoms, and biochemical markers.

Results

The SAF of dialysis patients averaged 4.11, higher than previous reports for non-dialysis patients. Age (r = 0.435, p = 0.0001) was moderately positively correlated and hemodialysis period (r = 0.214, p = 0.00907) was weakly positively correlated with SAF. Among the clinical symptoms measured by the JOABPEQ, social life dysfunction (r = -0.257, p = 0.0108) had a weak negative correlation with SAF.

Conclusions

The level of AGEs implied by SAF was elevated in hemodialysis patients. SAF correlated with social life disorders, suggesting that SAF may be involved in disorders of activities of daily living in hemodialysis dialysis patients.

Mixed venous oxygen tension is a crucial prognostic factor in pulmonary hypertension: a retrospective cohort study

BACKGROUND

The prognostic value of mixed venous oxygen tension (PvO2) at pulmonary hypertension diagnosis treated with selective pulmonary vasodilators remains unclear. This study sought to investigate the association of PvO2 with long-term prognosis in pulmonary arterial hypertension (PAH) and medically treated chronic thromboembolic pulmonary hypertension (CTEPH) and to identify the distinct mechanisms influencing tissue hypoxia in patients with CTEPH or PAH.

METHODS

We retrospectively analyzed data from 138 (age: 50.2 ± 16.6 years, 81.9% women) and 268 (age: 57.4 ± 13.1 years, 72.8% women) patients with PAH and CTEPH, respectively, diagnosed at our institution from 1983 to 2018. We analyzed the survival rates of patients with/without tissue hypoxia (PvO2 < 35 mmHg) and identified their prognostic factors based on the pulmonary hypertension risk stratification guidelines.

RESULTS

Survival was significantly poorer in patients with tissue hypoxia than in those without it for PAH (P = 0.001) and CTEPH (P = 0.017) treated with selective pulmonary vasodilators. In patients with PAH, PvO2 more strongly correlated with prognosis than other hemodynamic prognostic factors regardless of selective pulmonary vasodilators usage. PvO2 was the only significant prognostic factor in patients with CTEPH treated with pulmonary hypertension medication. Patients with CTEPH experiencing tissue hypoxia exhibited significantly poorer survival than those in the intervention group (P < 0.001). PvO2 more strongly correlated with the cardiac index (CI) than the alveolar-arterial oxygen gradient (A-aDO2) in PAH; whereas in CTEPH, PvO2 was more strongly correlated with A-aDO2 than with CI.

CONCLUSIONS

PvO2 may represent a crucial prognostic factor for pulmonary hypertension. The prognostic impact of tissue hypoxia affects different aspects of PAH and CTEPH, thereby reflecting their distinct pathogenesis.

Influence of sarcopenia as defined by EWGSOP2 on complications after pancreaticoduodenectomy and on the prognosis of pancreatic head cancer: A prospective cohort study

OBJECTIVES

It has been reported that sarcopenia is associated with higher postoperative complication rates in various surgeries and with a poorer prognosis in various carcinomas. However, many of these reports did not strictly follow the definition of sarcopenia. Therefore, we prospectively evaluated the influence of sarcopenia, as defined by the European Working Group on Sarcopenia in Older People 2 (EWGSOP2), on complications after pancreaticoduodenectomy (PD) and on the prognosis of pancreatic head carcinoma.

METHODS

We prospectively investigated 180 patients who underwent PD at Chiba University Hospital from January 2016 to March 2020. The skeletal muscle mass, grip strength, and gait speed of the patients were measured preoperatively. Sarcopenia was defined in accordance with the EWGSOP2 definition. We evaluated the frequency and severity of postoperative complications in infectious, non-infectious, and overall complications. We analyzed the prognosis of 83 patients with pancreatic head carcinoma who underwent PD.

RESULTS

There were no differences in the severity and frequency of infectious, non-infectious, and overall complications between patients with and without sarcopenia. In patients with pancreatic head carcinoma, the recurrence-free and overall survival rates were significantly lower in patients with sarcopenia than in those without sarcopenia (P = 0.017 and P = 0.011, respectively). In multivariate analysis, sarcopenia was an independent risk factor for poor recurrence-free survival and overall survival (HR, 4.48; 95% CI, 1.68-11.98; P = 0.003 and HR, 3.25; 95% CI, 1.19-8.86; P = 0.021, respectively).

CONCLUSIONS

Sarcopenia, as defined by EWGSOP2, did not affect complications after PD. Sarcopenia is an important prognostic factor for surgically resected pancreatic head carcinoma.

Mental foramen in panoramic radiography can be a reference for discrimination of punched-out lesions in the mandible in patients with symptomatic multiple myeloma: A cross-sectional study

Multiple myeloma (MM) is a hematopoietic malignancy characterized by monoclonal proliferation of plasma cells. MM features bony radiolucencies called punched-out lesions (POLs), which require appropriate diagnosis due to increased risk of surgically-related adverse events. Although dental surgeons can identify dental focal infections (DFIs) in MM patients, the prevalence and characteristics of POLs in the jawbone of MM patients have not been investigated. We examined the prevalence of POLs in the mandible of MM patients, evaluated its relationship with MM International Staging System progression, and examined panoramic radiographs as a diagnostic reference for POLs in a single center in Japan. We identified 98 patients (55 men, 43 women) with a median age of 63 (range, 34 to 91) years. Of these, 18 patients (18.4%) had POLs in the mandible, including two patients in stage I (2/37; 5.4%), six in stage II (6/43; 14.0%), and ten in stage III (10/18; 55.6%). The prevalence of POLs significantly increased with MM stage progression (p < 0.0001). POLs confirmed on computed tomography (CT) were also detected on panoramic radiographs. The Hounsfield unit value at the site of POLs was nearly the same or lower than that of the mental foramen. Although the prevalence of POLs in the mandible is low, dental surgeons need to differentiate POLs as radiological findings when examining DFIs in MM patients. Confirmation of POLs in the mandible is possible by CT and panoramic radiography, and the mental foramen is likely to be a reference for discrimination.

Randomized clinical trial comparing intravitreal aflibercept combined with subthreshold laser to intravitreal aflibercept monotherapy for diabetic macular edema

To compare the efficacy and safety of intravitreal aflibercept with three loading doses + pro re nata regimen combined with subthreshold laser application to that of IVA monotherapy on eyes with diabetic macular edema. This was a phase 4 clinical trial with a prospective, randomized, and parallel investigator-driven protocol. Patients with DME were randomly assigned to the IVA monotherapy group (n = 25) or the IVA + SL combination therapy group (n = 26). The main outcome measures were the number of IVA injections and the changes in the best-corrected visual acuity (BCVA) and the central retinal thickness (CRT) at the final evaluation at 96 weeks. The mean number of IVA injections in the monotherapy group was 5.86 ± 2.43 and it was 6.05 ± 2.73 in the IVA + SL group at 96 weeks, and this difference was not significant (P = 0.83). The differences in the mean changes of the CRT (P = 0.17) and the BCVA (P = 0.31) were also not significant between the two groups throughout the follow-up period. We conclude that adjunct of SL to anti-VEGF therapy does not reduce the number of necessary intravitreal injections.

Automated detection of anterior cruciate ligament tears using a deep convolutional neural network

Background

The development of computer-assisted technologies to diagnose anterior cruciate ligament (ACL) injury by analyzing knee magnetic resonance images (MRI) would be beneficial, and convolutional neural network (CNN)-based deep learning approaches may offer a solution. This study aimed to evaluate the accuracy of a CNN system in diagnosing ACL ruptures by a single slice from a knee MRI and to compare the results with that of experienced human readers.

Methods

One hundred sagittal MR images from patients with and without ACL injuries, confirmed by arthroscopy, were cropped and used for the CNN training. The final decision by the CNN for intact or torn ACL was based on the probability of ACL tear on a single MRI slice. Twelve board-certified physicians reviewed the same images used by CNN.

Results

The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of the CNN classification was 91.0%, 86.0%, 88.5%, 87.0%, and 91.0%, respectively. The overall values of the physicians’ readings were similar, but the specificity was lower than the CNN classification for some of the physicians, thus resulting in lower accuracy for the human readers.

Conclusions

The trained CNN automatically detected the ACL tears with acceptable accuracy comparable to that of human readers.

Oral antibiotics and a low-residue diet reduce the incidence of anastomotic leakage after left-sided colorectal surgery: a retrospective cohort study

PURPOSE

Anastomotic leakage is a potential complication after colorectal surgery. We investigated the effects of oral antibiotics and a low-residue diet on the incidence of anastomotic leakage after left-sided colorectal surgery.

METHODS

Outcomes were retrospectively compared between 64 patients who underwent mechanical bowel preparation alone (group A) and 183 patients who underwent mechanical bowel preparation with addition of oral kanamycin and metronidazole (group B) on the day before left-sided colorectal surgery. After surgery, patients in group A received a normal diet containing dietary fiber and those in group B received a low-residue diet. The primary outcome was the incidence of anastomotic leakage. Secondary outcomes were rates of other postoperative complications, length of postoperative hospital stay, and laboratory data.

RESULTS

Anastomotic leakage, surgical site infection, and diarrhea were less common in group B than in group A (4.9% vs 18.8%, 6.6% vs 23.4%, and 25.7% vs 43.8%, respectively). Postoperative C-reactive protein levels were significantly lower in group B. The median postoperative hospital stay was significantly shorter in group B than in group A (8 days vs 9 days, P = 0.010). Adaptive double least absolute shrinkage and selection operator regression revealed that use of preoperative oral antibiotics and a postoperative low-residue diet were associated with lower incidence of anastomotic leakage (odds ratio 0.163, 95% confidence interval 0.062-0.430; P < 0.001).

CONCLUSION

Oral antibiotics and a low-residue diet reduced the incidence of anastomotic leakage and shortened the postoperative hospital stay by 1 day.

Intra-articular injection of monoiodoacetate induces diverse hip osteoarthritis in rats, depending on its dose

BACKGROUND

Monoiodoacetate (MIA)-induced arthritis models are used widely in osteoarthritis (OA) research to develop effective conservative treatments for hip OA, as an alternative to joint replacement surgery. In joint OA models, such as the MIA-induced knee OA model, various doses of MIA are utilized, depending on the purpose of the research. So far, only 2 mg of MIA has been used for MIA-induced hip OA research. We hypothesized that the amount of MIA should be adjusted according to the osteoarthritis model under investigation. We performed radiographic and histological evaluations in rats for hip OA models induced by different doses of MIA.

METHODS

One hundred and eighty right hips of six-week-old, male Sprague-Dawley rats (n = 30 rats per group) were treated with either a single intra-articular injection of various doses of MIA (0.25, 0.5, 1.0, 2.0, and 4.0 mg) dissolved in 25 μl of sterile saline (MIA group), or with 25 μl of sterile saline alone (Sham group). Radiographic and histological evaluations of the hip joint were performed at one, two, four, eight, and 12 weeks after administration (n = 6 rats per group per time point).

RESULTS

OA changes progressed from 1 week after administration in the 1.0-mg, 2.0-mg, and 4.0-mg MIA groups. The degree of OA changes increased as the dose of MIA increased. The 0.25-mg and 0.5-mg MIA groups presented fewer OA changes than the 2.0-mg and 4.0-mg MIA groups during the entire study period (up to 12 weeks). The administration of 0.25 mg and 0.5 mg of MIA-induced both radiographic and histological OA changes in a time-dependent manner, whereas more than 2 mg of MIA provoked end-stage OA at 8 weeks after injection. Absolute, dose-dependent histopathological OA changes were observed 4 weeks after MIA administration.

CONCLUSIONS

Intra-articular MIA injection to the hip joints of rats induced diverse OA changes dose-dependently. Research for developing novel conservative treatments for hip OA and intractable pain should consider the pathological condition when determining the dose of MIA to be employed.

Sodium-Glucose Co-Transporter 2 Inhibitors Reduce Macular Edema in Patients with Diabetes mellitus

Purpose: To determine the efficacy of systemic sodium-glucose co-transporter 2 inhibitors (SGLT2i) on diabetic macular edema (DME). Methods: The medical records of patients with DME with a central retinal thickness (CRT) ≥320 µm in men and 305 µm in women, more than 6 months after the initiation of diabetes mellitus treatment, were reviewed. The CRT and best-corrected visual acuity (BCVA) were evaluated before and after the initiation of systemic SGLT2i and non-SGLT2i treatments. Results: There were 24 eyes of 19 patients with DME that were treatment naïve or had not received treatments for the DME within four months before the initiation of SGLT2i. In these patients, the BCVA had a 0.31 ± 0.39 logarithm of the minimum angle of resolution (logMAR) units at the baseline, and it did not improve significantly at 0.26 ± 0.29 logMAR units after the initiation of SGLT2i (p = 0.56). However, the SGLT2i treatment significantly reduced the CRT from 423.3 ± 79.8 µm to 379.6 ± 69.5 µm (p = 0.0001). In the same evaluation of 19 eyes of 14 patients with DME that were initiated with non-SGLT2i agents, there was no significant difference between the baseline BCVA and the BCVA after the initiation of non-SGLT2i (p = 0.47). The CRT increased significantly after the initiation of non-SGLT2i (p = 0.0011). In three eyes in which the SGLT2i treatments were administered at the time of anti-vascular endothelial growth factor (VEGF) treatments, the anti-VEGF treatment alone had only a limited effect on the DME, but the reduction in the DME was enhanced after the addition of SGLT2i. Conclusions: These findings indicate that systemic SGLT2i can reduce DMEs, and they suggest that SGLT2i may be an additional treatment option to anti-VEGF treatments for eyes with DMEs.

Evaluating the efficacy and safety of transdermal electrical stimulation on the visual functions of patients with retinitis pigmentosa: a clinical trial protocol for a prospective, multicentre, randomised, double-masked and sham-controlled design (ePICO trial)

INTRODUCTION

Previously, we conducted a clinical trial to evaluate the safety and efficacy of transdermal electrical stimulation (TdES) with skin electrodes to improve the visual functions in patients with retinitis pigmentosa (RP). No adverse events were related to the treatment during follow-up examinations, and TdES significantly improved the mean visual acuity and visual field sensitivity.

METHODS AND ANALYSIS

We developed a study protocol for a prospective, multicentre, randomised, double-masked and sham-controlled clinical trial, planned to commence on June 2021. We intend to compare the maintenance or improvement in best-corrected visual acuity, and safety of TdES using skin electrodes between patients with RP and the sham group. The primary endpoint comprises the superiority of the logarithm of the minimum angle of resolution (logMAR) visual acuity change at week 24 from baseline in the treatment and sham groups. Secondary endpoints involve the comparison of the treatment and sham groups at week 24 for the logMAR visual acuity, early treatment diabetic retinopathy study visual acuity, the mean deviation value of Humphrey field analyser 10-2, monocular Humphrey Esterman visual field test score, ellipsoid zone length, central foveal thickness and 25-item National Eye Institute Visual Function Questionnaire score. We intend to enrol 50 patients from three Japanese institutions within 1 year and follow them up for 1 years.

ETHICS AND DISSEMINATION

The protocol was approved by the institutional review board at the Chiba University Hospital and two other institutions, and was registered with the Japan Registry of Clinical Trials on 17 May 2021. The trial will be conducted in accordance with the principles of the Declaration of Helsinki, and is in accordance with Good Clinical Practice standards. The findings will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

JRCT2032210094.

A 2-year longitudinal study of skeletal muscle mass in women over 40 years of age with degenerative lumbar scoliosis

PURPOSE

We investigated changes in skeletal muscle mass and bone mineral density in degenerative lumbar scoliosis (DLS) patients during a 2-year follow-up following diagnosis.

METHOD

This study included 418 Japanese women, identifying 50 patients for the DLS group (mean age 76.4 years) and 368 patients for the control group (mean age 73.4 years). Whole-body skeletal muscle mass was measured using a Bioelectrical Impedance Analyzer. Bone mineral density (BMD) was measured using DXA. Skin autofluorescence (SAF), a marker of advanced glycation end products in the skin, was measured using a spectroscope. Spinal alignment, skeletal muscle mass, BMD, grip strength, and SAF were examined and the amount of change 1 and 2 years from the initial examination for each item was compared between groups.

RESULTS

Height, body fat mass, grip strength, upper limb muscle mass, and trunk muscle mass in the DLS group were significantly lower, and lumbar spine BMD was significantly greater compared to controls at the first visit (p < 0.05). There was no significant difference in spinal alignment in the DLS group after 2 years compared with baseline. Trunk muscle mass also decreased significantly more in the DLS group (-2.7%) than in the control group (-1.1%) over the 2-year follow-up (p < 0.05).

DISCUSSION

In this study, trunk muscle mass in the DLS group decreased about 2.4 times more in 2 years compared with the control group (p < 0.05). It may be possible to clarify the mechanism of kyphoscoliosis progression in the future with large-scale longitudinal studies.

Ifenprodil tartrate treatment of adolescents with post-traumatic stress disorder: A double-blind, placebo-controlled trial

BACKGROUND

Several lines of evidence suggest that glutamatergic neurotransmission via the N-methyl-D-aspartate (NMDA) receptor plays a role in certain behavioral manifestations common to Post-Traumatic Stress Disorder (PTSD). Ifenprodil tartrate is a neuroprotective agent that binds to the GluN2B subunit of the NMDA receptor. The aim of this study is to confirm whether ifenprodil tartrate is effective in the adolescent PTSD patients.

METHODS

This is a randomized, double-blind, placebo-controlled trial. Ten adolescent (13 to 18 years old) PTSD patients were randomized into two arms: placebo (n = 4), 40 mg/day ifenprodil tartrate (n = 6) for 4 weeks. All of the patients were assessed by IES-R-J (Primary outcome measure), TSCC-J, CDRS-R, DSRS-C-J and CGI-I.

RESULTS

A comparison of baseline IES-R-J total scores and 4-week end-point scores showed a mild trend of improvement (p = 0.0895) and the difference score was -9.314. A comparison of baseline scores and 2-week intermediate-point scores showed that IES-R-J hyperarousal subscores and TSCC-J subscores (dissociation subscores, sexual concerns subscores) improved significantly. A comparison of baseline TSCC-J sexual concerns subscores and 4-week end-point scores improved significantly.

CONCLUSIONS

Our study may prove to be an short-term effective alternative safe treatment for adolescent patients with PTSD.

Treatment Resistance in Severe Asthma Patients With a Combination of High Fraction of Exhaled Nitric Oxide and Low Blood Eosinophil Counts

Background: Combining a fraction of exhaled nitric oxide (FeNO) and blood eosinophil count (B-EOS) may be a useful strategy for administration of biologics such as anti-IgE or anti-IL-5 to patients with type 2 inflammatory-predominant severe asthma and is important to be elucidated considering the increasing use of biologics.

Methods: This cross-sectional study analyzed the clinical data from 114 adult patients with severe asthma, who were treated at Saitama Medical University Hospital. The eligible patients were stratified into four subgroups defined by thresholds of FeNO and blood eosinophil (B-EOS) counts to detect sputum eosinophilia, using the receiver operating characteristic curve analysis. A total of 75 patients with optimal samples were stratified into four subtypes defined by thresholds of sputum eosinophilia and neutrophilia. Clinical characteristics, pattern of biologics, and distribution of sputum subtypes were analyzed in the stratified subclasses according to the FeNO and B-EOS thresholds. The asthma exacerbation (AE)-free time of the FeNO/B-EOS subgroups and any biologics treatment including anti-IgE or anti-IL-5 use were examined using the Kaplan–Meier method. The hazard ratios (HRs) for AE-free time were examined using the Cox proportional hazard model.

Results: The optimal cutoff values for prediction of sputum eosinophilia were defined as ≥2.7% wherein for FeNO as ≥27 ppb and B-EOS as ≥265/µL were considered. The high-FeNO subgroups showed significant high total IgE, compared with the low FeNO. The high-FeNO/high-B-EOS and the high-FeNO/low-B-EOS subgroups showed the largest prevalence of mepolizumab and benralizumab use among the other FeNO/B-EOS, respectively. The high-FeNO/low-B-EOS showed the largest frequency of AEs, high HR, and the shortest AE-free time, among the other FeNO/B-EOS. The sputum eosinophil-predominant subtype was the great majority in the high FeNO/high B-EOS. A diverse distribution of sputum leukocyte-predominant subtype was observed in the other FeNO/B-EOS. The subsequent AE-free time and its HR were comparable among the biologics use groups.

Conclusion: The strategy of classifying severe asthma based on the combination of FeNO and B-EOS proposes particular refractory type 2 severe asthma and underlying airway inflammation as a feasible trait for optimal biologics use.

The cortical silent period in schizophrenia: A systematic review and meta-analysis focusing on disease stage and antipsychotic medication

BACKGROUND

Although numerous studies reported some changes of cortical silent period (CSP), an indicator of gamma-aminobutyric acid (GABA) function in central nervous system, in schizophrenia patients, it has been unknown how the disease stage and antipsychotic medication affect CSP values.

METHODS

The present study conducted a systematic review of previous literature comparing CSP between schizophrenia patients and healthy subjects, and then performed meta-analysis on the effects of (1) the disease stage and (2) antipsychotics on CSP.

RESULTS

(1) In the comparison of the disease stage comprising a total of 17 reports, there was no significant difference in CSP between patients under drug-naïve first-episode psychoses and healthy controls, or between patients with antipsychotic medication and healthy controls. (2) In the comparison of the antipsychotic class, patients treated with clozapine were longer in CSP compared to healthy controls. Patients treated with olanzapine/quetiapine or with other type of antipsychotics were not different from healthy controls. Regarding other type of antipsychotics, the iteration analysis after leaving out one literature showed that patients were shorter in CSP than healthy controls.

CONCLUSION

The results showed that clozapine seems to surely prolong CSP, indicating the enhancement of GABA transmission via GABA_B receptors, suggesting the possible relationship between the CSP prolongation by clozapine and its high efficacy in psychopathology. The finding of shorter CSP in patients with other type of antipsychotics was distinct from clozapine/olanzapine/quetiapine, but was difficult to interpret since this group included a variety of transcranial magnetic stimulation (TMS) methodologies and patients' background.

Pharmacotherapy for elderly patients with delirium in a general ward setting: A retrospective study

Antipsychotic medications are widely used in patients with delirium. However, antipsychotics may lead to various adverse events including cardiac arrythmias, extrapyramidal side effects, and oversedation. This study aimed to investigate whether non-antipsychotic medications including ramelteon, suvorexant, and trazodone are useful for the treatment of elderly inpatients with delirium in a general ward setting. This was a retrospective cohort study using medical chart reviews of all consecutive inpatients with hyperactive forms of delirium who were admitted to a regional general hospital. The primary outcome of this study was to evaluate whether non-antipsychotic medication (ramelteon, suvorexant, and trazodone) is inferior, in terms of efficacy and safety, to antipsychotic medication in delirium treatment. Of 154 patients who consulted psychiatrists during the study period, 33 patients were diagnosed with hyperactive delirium. Of these patients, 21 were categorized into the antipsychotic medication group, and 12 were categorized into the non-antipsychotic medication group. The duration of delirium after pharmacological treatments was not statistically different between the two groups. However, the rates of adverse events related to psychotropic medications in the antipsychotic medication group were significantly higher than that in the non-antipsychotic medication group. This study demonstrated that, in the treatment of elderly patients with delirium, non-antipsychotic drugs, such as suvorexant, ramelteon, and trazodone, could be more useful than antipsychotics in terms of efficacy and safety.

Volume-Outcome Relationships for Percutaneous Coronary Intervention in Acute Myocardial Infarction

Background Lower primary percutaneous coronary intervention (PCI) volume is known to be associated with worse outcomes in patients with acute myocardial infarction (MI) at hospital level. The present study aimed to evaluate the relations of primary, elective, and total PCI volume and primary/total PCI volume ratio per hospital to in-hospital mortality in patients with acute MI undergoing primary PCI. Methods and Results Using a large nationwide administrative database, we included a total of 83 076 patients from 154 hospitals in Japan undergoing PCI for either acute MI or elective cases. Relations of annual procedural volumes for primary, elective, and total PCI to in-hospital mortality after acute MI at hospital level were evaluated. The ratio of primary to total PCI volume per hospital was also assessed. The primary end point was the ratio of observed to predicted mortality. Of 83 076 patients, 26 913 (32.4%) underwent primary PCI for acute MI, among whom 1561 (5.8%) died during hospitalization. Overall, observed in-hospital mortality after acute MI and observed/predicted mortality ratio were higher in hospitals with lower primary, elective, and total PCI volumes. Observed/predicted in-hospital mortality ratio was higher in hospitals with low primary/total PCI volume ratio, even in those with high total PCI volume. Conclusions Primary, elective, and total PCI volume at hospitals were inversely associated with in-hospital mortality in patients with acute MI undergoing primary PCI. Lower ratio of primary to total PCI volume were related to higher in-hospital mortality, suggesting primary/total PCI volume ratio as an institutional indicator of quality of care for acute MI.

Two Cases of Liver Transplantation With a High Ionized Magnesium to Total Magnesium Ratio

Magnesium (Mg), an important cation, is involved in the activation of enzymes important for life support. The incidence of hypomagnesemia in critically ill patients admitted to the intensive care unit (ICU) is high and has been reported to be a factor in worsening prognosis. Ionized magnesium (iMg) is physiologically active, although total magnesium (tMg) is often used to evaluate the concentration of magnesium because of the limited availability of instruments that can measure iMg. However, the changes in tMg and iMg are not correlated in critically ill patients. We obtained considerable data on the simultaneous measurements of iMg and tMg in two patients with severe liver disease who underwent liver transplantation. In both patients, the iMg/tMg values were high, suggesting the influence of hypoalbuminemia associated with liver dysfunction. Mg correction using tMg as a guide may lead to overdose. Furthermore, when considering the data for each case, the correlation between iMg and tMg was very high, which suggested that the iMg/tMg ratio may be a value unique to each individual or disease. Investigating in a large-scale study the correlation between iMg levels and clinical symptoms and prognosis is necessary in the future.

Guided internet-based cognitive behavioral therapy for obsessive-compulsive disorder: A multicenter randomized controlled trial in Japan

Few studies have compared the effectiveness of internet-based cognitive behavior therapy (ICBT) for obsessive-compulsive disorder (OCD) with treatment as usual (TAU). We investigated the effectiveness of guided ICBT for patients with OCD. This prospective, randomized, controlled, assessor-blinded, multicenter clinical trial was conducted at three facilities in Japan from January 2020 to March 2021. Thirty-one patients with OCD as the primary diagnosis participated in the trial and were randomly assigned to either the intervention group or the control group. The primary outcome was the Yale-Brown obsessive-compulsive scale score; the assessors were blinded. Results of the analysis of covariance among the groups were significantly different between the groups (p < 0.01, effect size Cohen's d = 1.05), indicating the superiority of guided ICBT. The results suggest that guided ICBT is more effective than TAU for treating OCD.

RCT REGISTRATION

UMIN Clinical Trials Registry (UMIN000039375).

Feasibility of guided internet-based cognitive behavioral therapy for patients with anorexia nervosa

OBJECTIVE

The objective of the present study was to investigate the feasibility of guided internet cognitive behavioral therapy (ICBT) for anorexia nervosa.

METHODS

We conducted a prospective single-arm study between January 2020 and March 2021. The intervention was built using videos, web programs, and chat tools. The intervention program was largely based on metacognitive training. Participants performed the self-help program once a week for 12 consecutive weeks. The primary outcome was the global Eating Disorder Examination Questionnaire (EDE-Q) score. Secondary outcomes included clinical symptoms of eating disorders, metacognitive function, body mass index, depression, and generalized anxiety. The main statistical analysis examined whether the EDE-Q score and other outcomes at the end of the intervention differed from the baseline.

RESULTS

Fourteen participants underwent the trial treatment, and 13 completed the intervention. There was a significant reduction in the global EDE-Q score from 3.48 (SD = 1.4) to 2.54 (SD = 1.5, p = 0.02, Cohen's d = 0.75) from baseline to post-intervention. Some EDE-Q subscales and body checking questionnaire scale demonstrated statistically significant improvements, with moderate to large effect sizes. Although there was no significant improvement in body mass index, metacognitive function, or depressive symptoms, there was a significant improvement in the severity of generalized anxiety (M = -4.0, p = 0.01, Cohen's d = 0.95). No adverse events were observed.

DISCUSSION

Our findings suggest that guided ICBT for anorexia nervosa is well accepted by female patients and practical as a telemedicine approach that improves symptoms. In the future, tightly controlled randomized controlled trials should be conducted for efficacy verification.