Medial Patellofemoral Ligament Reconstruction With or Without Tibial Tubercle Osteotomy in Carefully Selected Patients Results in a 5% Revision Rate: A Preliminary Analysis

PURPOSE

The purpose was to assess the outcomes of medial patellofemoral ligament (MPFL) allograft reconstruction with or without tibial tubercle osteotomy (TTO) in adolescents, with a focus on evaluating demographic and imaging characteristics on outcomes.

METHODS

A single-institution retrospective study was performed of patients ages 12 to 19 years who underwent MPFL reconstruction +/- TTO for the treatment of lateral patellar instability. Demographic, clinical, surgical, and postoperative information was collected. All x-ray and magnetic resonance imaging measurements were completed independently by 2 surgeons. Patients were contacted to complete patient-reported outcomes at a minimum of 2 years following surgery. The primary outcome measure was recurrent instability resulting in revision surgery.

RESULTS

Seventy-eight knees in 74 patients, with a median age of 15.3 years (interquartile range: 14.4, 16.1), were included. Forty-five knees underwent isolated MPFL reconstruction and 33 knees had a combined MPFL + TTO. The knees that underwent MPFL + TTO had significantly greater tibial tubercle-trochlear groove distance (19.0 mm vs. 15.4 mm, P =0.015) and patellar tendon-lateral trochlear ridge distance (10.9 mm vs. 5.9 mm, P =0.018) than the knees treated with isolated MPFL reconstruction. Four knees (5.1%) underwent revision stabilization surgery, including 3 knees in the MPFL cohort (6.7%) and 1 knee in the MPFL + TTO cohort (3.0%). The rate of failure between the MPFL and MPFL + TTO knees was not significantly different, P =0.634. There were no differences in age, sex, body mass index, number of dislocations, or any imaging characteristics in patients who underwent revision versus those who did not. Patient-reported outcomes were collected on 50 knees at a median of 36 months (interquartile range: 24, 54) after surgery, and no differences were noted between cohorts.

CONCLUSIONS

Patellar stabilization surgery, including MPFL reconstruction and TTO in carefully selected patients, had excellent revision-free outcomes in 95% of this adolescent cohort. In this case series, those patients whose treatment included TTO had greater tibial tubercle-trochlear groove and patellar tendon-lateral trochlear ridge as compared to the isolated MPFL cohort. Despite previous literature suggesting demographic and imaging characteristics as risks for recurrent instability, we identified no characteristics within these two distinct surgical treatment groups to be predictive of the need for revision stabilization, regardless of the treatment group.

LEVEL OF EVIDENCE

Level III-retrospective comparison study.

Opioid Use in Pediatric Patients After Common Orthopaedic Surgeries

BACKGROUND

The use and misuse of opioid medications is an epidemic and public health emergency. There are currently no standard guidelines for treating perioperative pain in the pediatric population. The purpose of this study is to describe opioid use among pediatric patients after common orthopaedic surgeries.

METHODS

Patients between 5 and 20 years of age undergoing one of 7 common orthopaedic surgeries between the years 2018 to 2020 were prospectively studied. Patients and their families completed a medication logbook to track all doses of pain medication and associated pain scores.

RESULTS

Three hundred forty-two patients completed the study, including 174 females and 168 males with a mean age of 14.0 years (range, 5 to 20 y). A total of 4351 tablets or liquid doses of the narcotic medication, 44% of the total prescribed, were consumed. Of the prescribed medication,56% remained unused. Nonsteroidal anti-inflammatory drug use was identified to be the only independent predictor of less narcotic use, with a mean of 5.1 tablets (P = 0.003) and 1.7 days (P < 0.01) less opioid consumed among these patients. Thirty-two (9.4%) patients consumed 100% of their prescriptions. Nonmedicinal methods of pain control, most commonly ice, were used by 77% of patients, and this was highly variable between procedures. Physicians were cited as a source of medication information by only 50% of patients, with high variability between procedures.

CONCLUSIONS

Opioid medication use in children and adolescents after orthopaedic surgery is significantly less than the number of tablets prescribed, with 56% of the medication prescribed remaining unused in the postoperative period. Duration of narcotic use was longer than anticipated with a wide SD (4.7 d +/-3 d).We recommend orthopaedic surgeons responsibly prescribe pain medications using evidence-based data or the results of their own experience monitoring medication consumption. In addition, and important in the setting of the "opioid epidemic," physicians must counsel patients and families on postoperative pain expectations and appropriate medication use.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Transosseous Meniscus Root Repair in Pediatric Patients and Association With Durable Midterm Outcomes and High Rates of Return to Sports

BACKGROUND

Injuries to the meniscus root attachments result in extrusion of the meniscus, impaired distribution of hoop stresses, and progressive degenerative articular wear. As a result of these deleterious effects, there has been increasing emphasis on repairing meniscus root injuries to restore structure and function.

PURPOSE

To describe meniscus root tear patterns, associated injuries, and outcomes of transosseous meniscus root repair in a series of pediatric patients.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A single-institution retrospective review approved by the institutional review board was performed on consecutive adolescent patients aged <19 years with a meniscus posterior root tear treated with transosseous root repair over 4 years. All patients had a minimum 24-month clinical follow-up. The primary outcomes were revision meniscal surgery, and Lysholm, patient satisfaction, and Tegner activity scores.

RESULTS

A total of 20 patients (11 male and 9 female patients), with a mean age of 15.6 years (range, 13-18 years), met the inclusion criteria. There were 14 lateral meniscus root tears and 6 medial meniscus root tears. Seventeen patients (85%) had an associated ligament tear: 12 anterior cruciate ligament (ACL) tears and 5 posterior cruciate ligament tears. Two root tears occurred in isolation and both were the posterior root of the medial meniscus. The majority of meniscus root tears (n = 14 patients; 70%) were root avulsions (type 5). The mean follow-up was 42 months (range, 25-71 months). One patient underwent secondary surgery on the affected meniscus after a new injury 4 years postoperatively. Patient-reported outcomes were obtained for 16 patients (80%) at a mean 54-month follow-up. The median Lysholm score was 95 (interquartile range [IQR], 90-100). The median patient satisfaction score was 10 (IQR, 8-10). Thirteen of 16 patients (81%) reported returning to the same or higher level of sports after surgery.

CONCLUSION

Meniscus root tears most commonly occur in pediatric patients as root avulsions of the posterior root of the lateral meniscus and in association with ACL tears. This is unique compared with the adult population, in which the medial meniscus posterior root is often injured in isolation from a radial tear adjacent to the root. In our pediatric case series, transosseous root repair resulted in successful outcomes in the majority of patients, with durable results at the midterm follow-up.

Rates of Concomitant Meniscal Tears in Pediatric Patients With Anterior Cruciate Ligament Injuries Increase With Age and Body Mass Index

Background

Anterior cruciate ligament (ACL) tears are frequently associated with meniscal injury. Risk factors for concomitant meniscal injuries have been studied in the adult population but less so in pediatric patients.

Purpose

To evaluate the relationship between age and body mass index (BMI) and the presence of a concomitant meniscal tear at the time of ACL reconstruction (ACLR) in pediatric patients.

Study Design

Case-control study; Level of evidence, 3.

Methods

A single-institution retrospective review was performed of patients aged <19 years who underwent primary ACLR over a 3.5-year period. Revision ACLR and multiligament knee reconstructions were excluded. Logistic regression was used to identify risk factors associated with having a meniscal tear at the time of surgery. Subgroup analysis was performed for medial and lateral meniscal tears.

Results

Included in this study were 453 patients (230 males, 223 females; median age, 15 years). Of these, 265 patients (58%) had a meniscal tear, including 150 isolated lateral meniscal tears, 53 isolated medial meniscal tears, and 62 patients with both lateral and medial meniscal tears. Median time from injury to surgery was 48 days. For every 1-year increase in age, there was a 16% increase in the adjusted odds of having any meniscal tear (odds ratio [OR], 1.16; 95% confidence interval [CI], 1.05-1.27; P = .002), with a 20% increase in the odds of having a medial meniscal tear (OR, 1.20; 95% CI, 1.07-1.35; P = .002) and a 16% increase in the odds of having a lateral meniscal tear (OR, 1.16; 95% CI, 1.05-1.27; P = .003). For every 2-point increase in BMI, there was a 12% increase in the odds of having any meniscal tear (OR, 1.12; 95% CI, 1.02-1.22; P = .016) and a 10% increase in the odds of having a lateral meniscal tear (OR, 1.10; 95% CI, 1.01-1.19; P = .028).

Conclusion

Pediatric patients undergoing ACLR had a 58% incidence of concomitant meniscal pathology. Increasing age and BMI were independent risk factors for these injuries, while no association was found between time to surgery and meniscal pathology.

P269 Mid-term clinical outcomes of biodegradable polymer everolimus-eluting stents compared with durable polymer everolimus-eluting stents: a propensity-matched study

Background

Introduction: Several studies have reported that durable polymer drug-eluting stents could cause delayed healing and late catch-up. Although biodegradable polymer everolimus-eluting stents (BP-EES) might solve these problems, there is few data about mid-term clinical outcomes of BP-EES compared with durable polymer everolimus-eluting stents (DP-EES).

Purpose

This study aimed to compare mid-term clinical outcomes between BP-EES and DP-EES.

Methods

Between January to December 2016, 206 consecutive patients were treated with BP-EES and 177 consecutive patients were treated with DP-EES in our Heart Center. The primary endpoint was 3-year cumulative incidence of target lesion failure (TLF) defined as cardiac death, target vessel-related myocardial infarction and clinical-driven target lesion revascularization. Moreover, clinical-driven target vessel revascularization (TVR) and definite stent thrombosis (ST) were also evaluated. 

Results

After propensity score matching, 160 patients were selected in each group. At 3 years, the cumulative incidences of TLF were 4.1% in BP-EES group vs. 7.9% in DP-EES (p = 0.12). Similarly, those of clinical-driven TVR were not different between the 2 groups (10.9% vs. 8.0%, p = 0.39). The incidence of definite ST in BP-EES tended to be higher than in that of DP-EES (BP-EES vs. DP-EES; 0% vs. 1.8%, p = 0.06).

Conclusions

There were no significant differences of TLF between BP-EES and DP-EES within 3 years. In this study, BP-EES seems to prevent definite ST and be safer than DP-EES in mid-term.

Abstract P269 Figure.

P974Efficacy of plaque debulking for bifurcated or ostial lesion by directional coronary atherectomy before 2nd generation drug eluting stent (PERFECT2)

Objectives

We sought to evaluate the efficacy of plaque debulking by directional coronary atherectomy (DCA) before 2nd generation drug-eluting stent (DES) implantation for bifurcated coronary lesions.

Background

Percutaneous coronary intervention (PCI) for bifurcated lesions still remains complex and challenging in terms of restenosis or stent thrombosis regardless of whether simple or complex stenting used.

Methods

Patients with bifurcated lesions were enrolled in this prospective multicenter registry. Pre-2nd generation DES plaque debulking with a novel DCA was conducted. All patients were scheduled to perform a follow up (9–12 months) angiography (coronary angiography or coronary computed tomography). The primary end point was the target vessel failure (TVF) at follow-up. Secondary end points were procedure-related events and major adverse cardiac events at 1 year.

Results

A total of 77 patients with bifurcated lesions were enrolled. PCI with DCA was performed successfully in all without any major procedure-related event and only 1 case needed complex stenting. TVF rate at 9–12 months follow up was 3.9% (3 of 77) and those were all associated with revascularization of the target vessel. Restenosis was only observed at ostial of main-branch in 3cases. No death, no coronary artery bypass grafting, and no myocardial infarction were reported in the patients within the first year.

Figure1

Conclusion

DCA before 2nd generation DES implantation can possibly avoid complex stenting and provide a good mid-term outcome in patients with bifurcated lesions.

Acknowledgement/Funding

None

P2796Biodegradable polymer everolimus-eluting stents versus durable polymer everolimus-eluting stents in diabetic patients: a 3-year propensity-matched study

Background and introduction

Diabetic patients are at high risk of adverse cardiovascular events after percutaneous coronary intervention (PCI) even with durable polymer drug-eluting stents. A biodegradable polymer everolimus-eluting stents (BP-EES) might improve clinical outcomes in patients with diabetes mellitus.

Purpose

This study aimed to compare the mid-term clinical outcomes between BP-EES and durable polymer everolimus-eluting stents (DP-EES) in diabetic patients.

Methods

We investigated consecutive 383 patients treated with BP-EES or DP-EES at our Heart Center between January and December 2016. Among these patients, 155 (40.5%) patients had diabetes mellitus. The primary endpoint was 3-year cumulative incidence of target lesion failure (TLF) defined as target vessel-related myocardial infarction (MI) and clinical-driven target lesion revascularization (TLR). Moreover, the incidence of definite stent thrombosis (ST) was also evaluated.

Results

After propensity score matching, 148 patients were divided into 2 groups (BP-EES; N=74, DP-EES; N=74). The 3-year cumulative incidences of TLF were significantly lower in BP-EES group than in DP-EES group (BP-EES vs. DP-EES; 1.4% vs. 11.4%, p=0.01). The incidence of cardiac death, target vessel-related MI, and definite ST were none in the both group.

Figure 1

Conclusions

In diabetic patients, the incidence of TLR within 3 years was significantly lower in BP-EES than in DP-EES. In PCI for diabetic patients, BP-EES might improve clinical outcomes compared to DP-EES.

Impact of obesity on outcomes of paediatric acute pancreatitis based on a national administrative database

BACKGROUND

Insufficient information is available on the relationship between obesity and outcome of paediatric patients with acute pancreatitis.

OBJECTIVES

This study aimed to investigate the effect of obesity on outcomes of paediatric patients with acute pancreatitis based on a national administrative database.

METHODS

A total of 500 cases in 416 paediatric patients with acute pancreatitis (aged 5-17 years) were referred from 260 hospitals between 2010 and 2012 in Japan. Patients were divided into two groups according to the presence of obesity: with obesity (n = 65) and without obesity (n = 435). Patient data were collected from the administrative database to compare the prevalence of severe acute pancreatitis, in-hospital mortality, length of stay (LOS) and medical costs between the groups.

RESULTS

Both prevalence of severe acute pancreatitis and in-hospital mortality were significantly higher in paediatric patients with obesity than those without (36.9% vs. 16.3% and 3.1% vs. 0.0%; P < 0.001, respectively). Longer LOS and higher medical costs were also observed in paediatric patients with obesity (25.7 vs. 15.2 days, P < 0.001 and 14 169.5 vs. 7457.7 US dollars, P < 0.001, respectively).

CONCLUSION

This study demonstrated that obesity significantly influenced the outcomes of paediatric acute pancreatitis.

A randomized phase III trial comparing S-1 versus UFT as adjuvant chemotherapy for stage II/III rectal cancer (JFMC35-C1: ACTS-RC)

This phase III study is the first study to demonstrate the superiority of new oral fluoropyrimidine S-1 over tegafur–uracil as adjuvant chemotherapy for stage II/III rectal cancer patients with no preoperative treatment in terms of relapse-free survival. S-1 can be considered an important option, especially for patients who have not received preoperative treatment.

Backgrounds

Preventing distant recurrence and achieving local control are important challenges in rectal cancer treatment, and use of adjuvant chemotherapy has been studied. However, no phase III study comparing adjuvant chemotherapy regimens for rectal cancer has demonstrated superiority of a specific regimen. We therefore conducted a phase III study to evaluate the superiority of S-1 to tegafur–uracil (UFT), a standard adjuvant chemotherapy regimen for curatively resected stage II/III rectal cancer in Japan, in the adjuvant setting for rectal cancer.

Patients and methods

The ACTS-RC trial was an open-label, randomized, phase III superiority trial conducted at 222 sites in Japan. Patients aged 20–80 with stage II/III rectal cancer undergoing curative surgery without preoperative therapy were randomly assigned to receive UFT (500–600 mg/day on days 1–5, followed by 2 days rest) or S-1 (80–120 mg/day on days 1–28, followed by 14 days rest) for 1 year. The primary end point was relapse-free survival (RFS), and the secondary end points were overall survival and adverse events.

Results

In total, 961 patients were enrolled from April 2006 to March 2009. The primary analysis was conducted in 480 assigned to receive UFT and 479 assigned to receive S-1. Five-year RFS was 61.7% [95% confidence interval (CI) 57.1% to 65.9%] for UFT and 66.4% (95% CI 61.9% to 70.5%) for S-1 [P = 0.0165, hazard ratio (HR): 0.77, 95% CI 0.63–0.96]. Five-year survival was 80.2% (95% CI 76.3% to 83.5%) for UFT and 82.0% (95% CI 78.3% to 85.2%) for S-1. The main grade 3 or higher adverse events were increased alanine aminotransferase and diarrhea (each 2.3%) in the UFT arm and anorexia, diarrhea (each 2.6%), and fatigue (2.1%) in the S-1 arm.

Conclusion

One-year S-1 treatment is superior to UFT with respect to RFS and has therefore become a standard adjuvant chemotherapy regimen for stage II/III rectal cancer following curative resection.

Japanese traditional medicine, Senn-kinn-naidaku-sann up-regulates Toll-like receptor 4 and reduces murine allergic rhinitis

OBJECTIVE

To determine the mechanisms by which a traditional herbal medicine, Senkinnaidakusan (SKNS), controls Th2 responses, we examined the production of IL-12 by murine macrophages treated with SKNS.

RESULTS

Treatment with SKNS significantly increased TLR4 mRNA in macrophages. Furthermore, pre-treatment with SKNS enhanced the production of IL-12 by macrophages stimulated with LPS. When SKNS was orally administered to C3H/HeN mice at the induction phase after OVA sensitization, the serum levels of OVA-specific immunoglobulin (Ig)E and IgG1 decreased, Interleukin (IL)-4 production by spleen T cells in response to OVA was significantly suppressed, while interferon (IFN)-gamma production was increased. After nasal challenge of OVA, eosinophilic infiltration in the nasal mucosa and the number of sneezes were significantly inhibited in SKNS-treated mice compared with control mice. Besides, expression of IL-5 in the nasal mucosa was also inhibited. Using another strain of mice, C3H/HeJ (TLR4 negative), there was no difference in OVA-specific Igs or splenic cytokine production between the SKNS treatment and non-treatment groups. The eosinophilic infiltration in the nasal mucosa, the number of sneezes and IL-5 expression in the nasal mucosa were also not effected even after SKNS treatment.

CONCLUSION

These results suggest that oral administration of SKNS inhibits Th2 responses by enhancement of IL-12 release from macrophages via up-regulation of TLR4 expression.

Search for bosonic superweakly interacting massive dark matter particles with the XMASS-I detector

Bosonic superweakly interacting massive particles (super-WIMPs) are a candidate for warm dark matter. With the absorption of such a boson by a xenon atom, these dark matter candidates would deposit an energy equivalent to their rest mass in the detector. This is the first direct detection experiment exploring the vector super-WIMPs in the mass range between 40 and 120 keV. With the use of 165.9 day of data, no significant excess above background was observed in the fiducial mass of 41 kg. The present limit for the vector super-WIMPs excludes the possibility that such particles constitute all of dark matter. The absence of a signal also provides the most stringent direct constraint on the coupling constant of pseudoscalar super-WIMPs to electrons. The unprecedented sensitivity was achieved exploiting the low background at a level 10(-4)  kg-1 keVee-1 day-1 in the detector.

Methylation levels of LINE-1 in primary lesion and matched metastatic lesions of colorectal cancer

Background:

LINE-1 methylation level is a surrogate marker of global DNA methylation. LINE-1 methylation in primary colorectal cancers (CRCs) is highly variable and strongly associated with a poor prognosis. However, no study has examined LINE-1 methylation levels of metastatic CRCs in relation to prognosis or assessed the heterogeneity of LINE-1 methylation level within the primary CRCs.

Methods:

Pyrosequencing was used to quantify LINE-1 methylation level in 42 liver metastases, 26 matched primary tumours, and 6 matched lymph node (LN) metastases. KRAS, BRAF, and PIK3CA mutation status and microsatellite instability (MSI) status were also examined.

Results:

The distribution of LINE-1 methylation level in liver metastases was as follows: mean, 67.3; range, 37.1–90.1. Primary tumours showed LINE-1 methylation levels similar to those of matched liver and LN metastases. The difference in LINE-1 methylation level between superficial areas and invasive front areas was within 7.0 in all six cases evaluated. Prognostic impact of LINE-1 hypomethylation in liver metastases on overall survival was not observed. The concordance rate was 94% for KRAS, 100% for BRAF, 88% for PIK3CA, and 97% for MSI.

Conclusion:

Alteration of LINE-1 methylation level may occur in early CRC tumorigenesis, and the LINE-1 methylation level is relatively stable during CRC progression.

Perceived chewing ability and need for long-term care in the elderly: a 5-year follow-up study

Increasing need for long-term care in older adults is expected with the ageing of Japan's population. The aim of the present study was to show the relationship between perceived chewing ability and long-term care needs for over 5 years in elderly persons. The chewing ability of 812 elderly persons living independently was evaluated at baseline using self-assessed masticatory ability, and it was classified into one of three categories: ability to chew all foods (good masticatory ability), ability to chew only slightly hard food (fair masticatory ability), and ability to only chew soft or pureed food (poor masticatory ability). Participants' care needs were then followed through Japan's long-term care insurance system for over 5 years. The log-rank test and Cox proportional hazard model were used to examine statistical differences in the frequency of care-needs certification between participants with good and fair or poor masticatory ability. Among participants aged 65-79 years, the frequency of care-needs certification was significantly higher in those with fair or poor masticatory ability than in those with good masticatory ability, and the relative hazard ratio was significantly higher in those with fair or poor masticatory ability than in those with good masticatory ability, after adjusting for age, gender, current employment status, educational background, social interaction, chronic medical conditions and dentition status. These relationships were not found among those aged 80-93 years. Impairment in perceived chewing ability may be associated with higher incidence of certification in Japan's long-term care insurance system among elderly persons aged 65-79.

Factors associated with self-assessed masticatory ability among community-dwelling elderly Japanese

Self-assessed masticatory ability has been shown to be significantly related to general health among elderly persons.

OBJECTIVE

To identify oral factors associated with the self-assessed masticatory ability.

BASIC RESEARCH DESIGN

Cross-sectional study.

PARTICIPANTS

A total of 736 community-dwelling elderly persons.

MAIN OUTCOME MEASURES

Data on background factors and the self-assessed masticatory ability were collected by questionnaire. An intraoral examination examined the pattern of posterior occluding pairs of natural teeth (POPs), the WHO Community Periodontal Index of Treatment Needs (CPI) and denture-related factors such as use of dentures, pain when using dentures and stability and retention of dentures. Chi-squared tests examined the relationships between the self-assessed masticatory ability and the background factors and oral conditions. Ordinal regression models were constructed with the self-assessed masticatory ability as the dependent variable and oral conditions as the principal independent variables, to adjust for the potential confounding variables.

RESULTS

Self-assessed impairment of masticatory ability was associated with lost POPs (p < 0.001) and CPI (p = 0.012). In the participants with lost POPs, self-assessed impairment of masticatory ability was associated with not using dentures and pain when using dentures (p < 0.001). In the totally edentulous subjects, impairment of masticatory ability was not associated with stability and retention of dentures (p = 0.070).

CONCLUSIONS

Factors affecting self-assessed masticatory ability include the pattern of POPs, periodontal status, denture use and pain when using dentures.

Associations between self-assessed masticatory ability and higher brain function among the elderly

Among the elderly, the quality of higher brain function is a contributing factor in performing activities of daily living. The aim of the study is to elucidate, epidemiologically, associations between mastication and higher brain function. A total of 208 community-dwelling elderly persons, aged 70-74 years, were enrolled. Self-assessed masticatory ability (masticatory ability) was classified into one of three categories: ability to chew all kinds of food, ability to chew only slightly hard food, or ability to chew only soft or pureed food. Brain function was assessed by four neuropsychological tests: Raven's Colored Progressive Matrices (RCPM) test, the Verbal Paired Associates 1 (VerPA) task and the Visual Paired Associates 1 task (from the Wechsler Memory Scale Revised Edition), and the Block Design subtest (from the Wechsler Adult Intelligence Scales-Third Edition). Correlations between masticatory ability and each test were examined using Spearman rank correlation coefficients. Multinominal logistic regression models were conducted with the neuropsychological tests as the dependent variables and masticatory ability as the principal independent variable to adjust for age, gender, educational background, social activity, drinking/smoking habits, chronic medical conditions and dental status. Significant correlations were found between the RCPM test, the VerPA task, the Block Design test and masticatory ability. In multinominal logistic regression models, poor masticatory ability was significantly and independently related to the categories under the mean-s.d. points compared with those of the mean ± s.d. ranges for RCPM test and the VerPA task. Significant associations may exist between mastication and higher brain function among the elderly.

Self-assessed masticatory ability and hospitalisation costs among the elderly living independently

The escalating medical costs are a social problem in many countries. Masticatory ability is thought to be related to the general health conditions. The purpose of this study was to show relationships between self-assessed masticatory ability and medical costs among the elderly living independently in community. Data on background factors and self-assessed masticatory ability were collected from 702 Japanese elderly persons by questionnaires. An intra-oral examination was performed to examine the number of remaining teeth. Self-assessed masticatory ability was classified into one of three categories: ability to chew all kinds of food (Good), ability to chew only slightly hard food (Fair) or ability to chew only soft or pureed food (Poor). Data on the annual medical excluding dental costs were obtained from the Japanese National Health Insurance system. The Kruskal-Wallis test was used to examine differences in outpatient costs and hospitalisation costs among the three groups of self-assessed masticatory ability. Univariate unconditional logistic regression models and multivariate logistic regression models were used with medical costs as the dependent variable and self-assessed masticatory ability as the principal independent variable. A significant difference (P=0·039) in hospitalisation costs but not outpatient costs was found among the three groups of self-assessed masticatory ability. The multivariate logistic regression analysis showed that severely impaired masticatory ability (Poor) was significantly related to higher costs of hospitalisation. Self-assessed impairment of masticatory ability may be a significant and independent indicator of higher costs of hospitalisation among community-dwelling elderly persons.

[Huge right atrial myxoma]

Myxomas are account for approximately half of primary cardiac tumors, and 75% cases originate in left atrium. We report our experience of a right atrial myxoma. A 68-year-old woman was referred to us due to anorexia, general fatigue and facial edema. Echocardiogram, computed tomography (CT), magnetic resonance imaging (MRI), and catheter angiocardiogram revealed a huge tumor in right atrium. The tumor was resected completely with the attached right atrial free wall under cardiopulmonary bypass. Pathological examination showed myxomatous tissue. Postoperative course was uneventful. She discharged the hospital on the 37th day after the operation, and is now doing well without any symptoms.

Endoscopic submucosal dissection using a novel grasping type scissors forceps

Endoscopic submucosal dissection (ESD) with a knife is a technically demanding procedure that is associated with a high complication rate. The shortcoming of this method is the difficulty in fixing the knife to the target lesion. This difficulty can lead to unexpected incision, resulting in major complications such as perforation and bleeding. To reduce the risk of complications related to ESD, we developed a new grasping type scissors forceps (GSF), which can grasp and incise the targeted tissue using an electrosurgical current. The ESD procedure using the GSF was carried out in an animal model (resected porcine stomachs in vitro). After marking the lesion and injecting a solution into the submucosa, the lesion was separated from the surrounding normal mucosa following complete incision around the lesion using the GSF. A piece of submucosal tissue was grasped and cut with the GSF using an electrosurgical current to achieve submucosal exfoliation. ESD using the GSF was carried out safely and easily without unintentional incision. ESD using GSF appears to be an easy, safe, and technically efficient method for resecting gastrointestinal neoplasms.

Altered Postural Regulation of Foot Skin Oxygenation and Blood Flow in Patients with Type 2 Diabetes Mellitus

AIMS

Although skin oxygenation is an important factor in the development and healing of foot ulcers, its regulation was not fully understood. We studied changes in foot skin oxygenation and blood flow during postural changes in patients with type 2 diabetes mellitus.

METHODS

Skin oxygenation was measured using transcutaneous oxygen pressure (TcPO(2)) and skin blood flow by laser Doppler flowmetry in 40 patients with type 2 diabetes mellitus without evidence of peripheral arterial disease and 13 healthy control subjects.

RESULTS

TcPO(2) in the supine position was significantly lower in patients with type 2 diabetes mellitus compared with control, although skin blood flow was not different. In the sitting position, TcPO(2) significantly increased in control and diabetic patients. The postural change-related increase in TcPO(2) was significantly enhanced in diabetic patients. On the other hand, skin blood blow significantly decreased in the sitting position from the supine position in control subjects but remained stable in diabetic patients. Orthostatic drop in systolic blood pressure correlated negatively with TcPO(2) in the supine position while correlated positively with %change in TcPO(2) and blood flow by postural changes.

CONCLUSIONS

The present study demonstrated the dissociated regulation of skin oxygenation and blood flow in response to leg dependency. Impaired postural vasoconstriction was associated with altered regulation of skin oxygenation probably due to sympathetic vascular dysfunction in diabetic patients.

Enhanced head-twitch response to 5-HT-related agonists in thiamine-deficient mice

While many studies suggest an involvement of brain serotonergic systems in neuro-psychiatric disorders such as schizophrenia and depression, their role in Wernicke-Korsakoff syndrome (WKS) remains unclear. Since dietary thiamine deficiency (TD) in mice is considered as a putative model of WKS, it was used in the present study to investigate the function of serotonergic neurons in this disorder. After 20 days of TD feeding, the intensity of tryptophan hydroxylase immunofluorescence was found to be significantly decreased in the dorsal and medial raphe nuclei. In addition, the head-twitch response (HTR) elicited by the intracerebroventricular administration of the 5-HT(2A) agonist 2,5-dimethoxy-4-iodoamphetamine hydrochloride (DOI) was significantly increased in TD versus control mice, whereas the injection of ketanserin, a 5-HT(2A) receptor antagonist, prevented this enhancement. A single injection of thiamine HCl on the 19th day of TD feeding did not reduce the enhanced DOI-induced HTR. On the other hand, the administration of d-fenfluramine, a 5-HT releaser, did not enhance the HTR in TD mice. Together, our results indicate that TD causes a super-sensitivity of 5-HT(2A) receptors by reducing presynaptic 5-HT synthesis derived from degenerating neurons projecting from the raphe nucleus.

Data Processing for Radioimmunoassay Standard Curve Using Microcomputer: A New Basic Program for Weighted Logit-Log Transformation

A new BASIC program of the weighted linear, quadratic and cubic logit-log regression methods for data processing of radioimmunoassay standard curve was developed using a microcomputer. Using this program, three regression analyses are calculated and the table for root mean square of residuals in each regression are shown for the selection of the regression method. The data of three radioimmunoassays of human pancreatic enzymes and pancreatic secretory trypsin inhibitor were examined by this program and compared with those processed by the four parameter logistic method. The weighted cubic logit-log regression showed better fit in radioimmunoassays of human pancreatic enzymes with larger molecular weights. The present program is useful and practicable for its simplicity and accuracy.

[Severe tracheal compression resulting from atherosclerotic aortic arch aneurysm; report of a case]

A 70-year-old woman presented with severe respiratory insufficiency similar to an asthma attack. Computed tomography (CT) revealed an atherosclerotic aneurysm (maximum diameter 106 mm) on the aortic arch which resulted in a severe tracheal compression. We performed an aortic arch replacement. After the operation, we tried to manage breathing without a respirator twice without success. We then performed a tracheotomy on the 12th day after operation. The patient could breathe independently on the 19th day after the first operation. Peri-and postoperative respiratory management was difficult but the patient was discharged on the 86th day after operation without further complication.

[De Bakey type I aortic dissection complicating systemic lupus erythematosus; report of a case]

We report a 43-year-old patient of De Bakey type I aortic dissection [DA (I)] with a 2-year-history of systemic lupus erythematosus (SLE). He had had no treatment for SLE before the onset of dissection. Computed tomography (CT) on admission revealed DA (I), and he underwent emergency operation. Since the aortic valve and the left main coronary artery were severely damaged, aortic root replacement was performed. Coronary buttons were prepared in Carrel method and coronary reconstruction was performed in Piehler modification. After surgery, he suffered from repetitive hemolytic anemia. Corticosteroid therapy and rinsed blood transfusion were very effective for anemia. The combination with SLE and DA (I) was rare and this report of successful aortic root replacement is the second literature among English and Japanese papers.

Colonic muco-submucosal elongated polyp: diagnosis with endoscopic ultrasound

Colonic muco-submucosal elongated polyp is a new clinical entity first reported in 1998. The purpose of this report is to determine the value of endoscopic ultrasound in the diagnosis of this condition. We reviewed the endosonographic and histological findings of seven colonic muco-submucosal elongated polyps that were removed completely by endoscopic resection or surgery. The lesions appeared as pedunculated submucosal tumours, measuring 1-4 cm in maximal diameter. Endosonographically, all lesions consisted of mucosal and submucosal layers, and microcystic components were found in the submucosal layer. There were no echogenic masses or muscularis propria within the polyps. These endosonographic features corresponded to histological findings of this type of polyp which was covered with normal mucosa and composed of submucosal layer alone. The submucosal layer consisted of oedematous, loose, connective tissue and/or fibrous tissue, accompanied by dilated blood vessels and lymphatics. Endoscopic ultrasound enabled differentiation of colonic muco-submucosal elongated polyp from other submucosal lesions.

Attenuation of canine warm ischemic small bowel injury by novel combination of nitric oxide donor, FK409, and cytokine suppressive anti-inflammatory agent FR167653

Organ ischemia-reperfusion injury is caused by two consecutive steps, microcirculatory disturbance and neutrophil-endothelial cell interactions, which are caused by inflammatory cytokines. We examined the hypothesis that combination therapy with a donor (FK409) of nitric oxide, one of the potent mediators with diverse roles as a vosodilator and a platelet inhibitor, together with the cytokine suppressor agent (FR167653) attenuates warm ischemic injury in canine small bowel. Small bowel ischemia was initiated by clamping the superior mesenteric artery and vein. Animals were divided into two groups: a control group (n = 5) subjected to 2-hour small bowel ischemia only, and a combination therapy group (FK/FR group, n = 5) that received FK409 (300 mcg/kg/h) plus FR167653 (1 mg/kg/h) intravenously before and after the ischemic event. We evaluated animal survival, small bowel tissue blood flow, and enzyme release from the small bowel. All controls died from severe acidosis within 2 days and all the FK/FR animals survived 7 days (P < .05). The FK/FR group recovered more than 70% of blood flow immediately after the revascularization, while the flow was less than 40% among the controls. Serum creatine phosphokinase values in the control group after reperfusion were significantly higher than those in the FK/FR group. In conclusion improvement of the microcirculation by FK409 and inhibition of cytokine release by FR167653 together attenuated warm ischemic small bowel injury.

Successful intrauterine treatment with radiofrequency ablation in a case of acardiac twin pregnancy complicated with a hydropic pump twin

Twin reversed arterial perfusion sequence is a serious complication of monochorionic twin pregnancy, as the pump twin that perfuses blood to the acardiac twin may experience heart failure and fetal hydrops resulting in a poor perinatal outcome. A woman with an acardiac twin pregnancy complicated by a hydropic pump twin underwent intrauterine treatment with radiofrequency ablation (RFA) at 27 weeks of gestation. Obliteration of blood flow to the acardiac twin from the pump twin was successful. Fetal hydrops resolved by the time of delivery at 32 weeks of gestation, in spite of transient deterioration, and a good postnatal outcome was achieved for the pump twin. We found that RFA was an effective intrauterine treatment for acardiac twin pregnancy and suggest that it could be introduced in cases complicated by a hydropic pump twin.

Effects of NMDA receptor-related agonists on learning and memory impairment in olfactory bulbectomized mice

A significant impairment of learning and memory-related behavior was induced in mice on the 7th and 14th days after olfactory bulbectomy (OBX), as measured by a passive avoidance task. The involvement of the N-methyl-D-aspartate (NMDA) receptor ion-channel complex for learning and memory-related behavior impairment was examined by the intracerebroventricular administration of several NMDA receptor-related agonists and in combination with antagonists. The NMDA receptor agonist NMDA (1 ng/mouse) and the polyamine site agonist spermidine (1 micro g/mouse) improved learning and memory-related behavior impairment. In contrast, the glycine agonist D-cycloserine (0.2, 1 and 5 micro g/mouse) had no effect on learning and memory-related behavior impairment. The improved effects by NMDA and spermidine were reversed by the coadministration of D-APV, a competitive NMDA receptor antagonist, MK-801, an NMDA ion-channel blocker and ifenprodil, a polyamine site antagonist, respectively. These results suggest that the degeneration of NMDA receptors and polyamine sites in the NMDA receptor ion-channel complex may be involved in the OBX-induced impairment of learning and memory-related behavior.

[A giant left atrial myxoma with severe mitral valve regurgitation: report of a case]

A 76-year-old female underwent operation with a diagnosis of a left atrial myxoma with accompanied mitral regurgitation. Although no clinical findings of mitral regurgitation were noticed preoperatively, degenerative changes to the anterior leaflet as well as chordae tendinae possibly due to mechanical damage by the movement of the giant tumor through the mitral valve complex were observed in operation. Resection of the tumor and mitral valve replacement were successfully performed. Our case suggests that it is indispensable to investigate the mitral valve during operation even in case of the left atrial tumor with no preoperative findings of mitral regurgitation.

Effect of artificial carbon dioxide foot bathing on critical limb ischemia (Fontaine IV) in peripheral arterial disease patients

BACKGROUND

It has been reported that artificial carbon dioxide (CO(2)) foot bathing improves subcutaneous microcirculation in peripheral arterial disease (PAD) patients. However, the effect for critical limb ischemia (CLI) with ulceration or gangrene (Fontaine stage IV) is not identified. The physiological effects of CO(2) bathing and the outcome of limb salvage in such patients were studied.

METHODS

In 18 healthy volunteers (Study I), the dorsal pedis peripheral blood flow was measured by a laser Doppler flow-meter during CO(2) foot bathing (1000 ppm, 37 degrees C) for 10 min. A Holter electrocardiogram was also recording in the same period. Blood flow and cell volume significantly increased during bathing. Eighty-three CLI limbs (Fontaine IV) in 68 PAD patients (Study II) underwent artificial CO(2) foot bathing (for 10 minutes twice daily >2 months) were followed up >6 months.

RESULTS

In Study I, analysis of heart rate variability showed that high frequency amplitude (HFA) considerably increased and the ratio of low frequency amplitude to HFA (LF/HF) noticeably decreased during bathing. In Study II, 69 limbs (83.1%) could be salvaged. Twenty-seven of 28 limbs (96.4%) which have ulcer and gangrene in only one toe, 13/16 limbs (81.2%) in multiple toes and 29/39 limbs (74.4%) in all toes and/or heel respectively were saved.

CONCLUSIONS

The effect of CO(2) enriched water on the subcutaneous microcirculation might be brought about by peripheral vasodilation reflected by increased parasympathetic and decreased sympathetic activity, and the artificial CO(2) foot bathing is clinically effective on salvage of CLI (Fontaine stage IV) limbs.