Prevalence of Double Incontinence and Lower Urinary Tract Symptoms in Patients with Fecal Incontinence: A Single-center Observational Study

Objectives

Double incontinence (DI), which is the co-occurrence of fecal incontinence (FI) and urinary incontinence (UI), increases with age and has a greater negative impact on the quality of life (QOL) than either incontinence alone. We aimed to assess lower urinary tract symptoms (LUTS) in patients with FI to elucidate the prevalence and characteristics of DI.

Methods

This study enrolled consecutive patients who visited our hospital with FI symptoms. FI was evaluated using the Cleveland Clinic Florida Fecal Incontinence Score (CCFIS). LUTS were assessed using the International Prostate Symptom Score (IPSS), QOL score (IPSS-QOL) and Overactive Bladder Symptom Score (OABSS).

Results

This study evaluated 140 patients (96 women [mean age: 70.7 years] and 44 men [mean age: 74.4 years]). The mean IPSS was significantly higher in men than in women (12.0 vs. 7.5, p = 0.003). A positive correlation was found between IPSS and CCFIS in women (r = 0.256, p = 0.012) but not in men. For both sexes, the older group (aged ≥70 years) had higher OABSS scores and more urge UI instances than the younger group (aged ≤69 years). Of the 140 patients with FI, 78 (55.7%) had DI, and DI was more common in women than in men (63.5% vs. 38.6%, p = 0.006).

Conclusions

The characteristics of LUTS and UI in patients with FI were comparable to those in the general population for both sexes; however, the prevalence of DI was much higher among patients with FI than that in the general population.

Long-term Efficacy and Safety of Controlled Manual Anal Dilatation in the Treatment of Chronic Anal Fissures: A Single-center Observational Study

Objectives

Conventional anal dilatation for anal fissures has long been abandoned because of the high incidence of anal incontinence. However, less invasive and more precise dilation techniques have been developed that have shown high healing and low incontinence rates. This study aimed to evaluate the efficacy and safety of controlled anal dilatation (CAD) using a standardized maximum anal diameter.

Methods

This study included 523 patients who underwent CAD for chronic anal fissures between January 2010 and December 2014. CAD was performed under sacral epidural anesthesia. The index fingers of both hands were placed in the anus and dilated evenly in various directions. CAD was completed when the anus was dilated to the sixth scale (35 mm in diameter) using a caliber ruler.

Results

The mean anal scale size expanded from 3.1 to 5.8 (p<0.001). Non-healing was observed in nine patients (1.7%) at 1 month postoperatively, six of whom underwent additional CAD. The mean maximal anal resting pressure (mmHg) decreased from 90.2 to 79.7 at three months postoperatively (p<0.001). Postoperative complications were observed in 11 (2.1%) patients, of whom three patients with thrombosed hemorrhoids underwent resection. None of the patients complained of anal incontinence during the mean follow-up period of 16.6 months. The cumulative recurrence-free rates at three and five years were 87.9% and 69.2%, respectively.

Conclusions

CAD is technically simple and safe and can achieve reasonable long-term outcomes. Thus, CAD appears to be the preferred procedure for patients with chronic anal fissures who do not respond to conservative treatments.

Are There Sex Differences in Defecation Patterns in Patients with Defecation Disorders? - A Single-center Observational Study

Objectives

Defecation disorders (DD) are characterized by impaired rectal evacuation due to inadequate defecatory propulsion and/or dyssynergic defecation. DD are assessed by rectal and anal pressures during attempted defecation using anorectal manometry (ARM). Thus far, at least four types of dyssynergic patterns have been recognized on ARM. This study aimed to compare the manometric parameters and dyssynergic patterns between men and women with DD.

Methods

This study enrolled consecutive patients undergoing anorectal tests for symptoms of DD. Anorectal pressure was measured using a waveform ARM system. DD were diagnosed based on the results of ARM, balloon expulsion tests, and barium defecography. Dyssynergic patterns were defined as a paradoxical increase in anal pressure with (type I) or without (type II) an adequate increase in rectal pressure and failure of a reduction in anal pressure with (type III) or without (type IV) an adequate increase in rectal pressure.

Results

This study evaluated 324 women and 234 men. Based on anorectal tests, 73.1% men and 54.6% women were diagnosed with DD. Rectal and anal pressures during attempted defecation in patients with DD were significantly higher in men than in women. Type I patterns were more common in men (64.9%) than in women (28.2%). Conversely, type II (42.9% vs. 24.0%) and IV (20.9% vs. 5.8%) patterns were observed more frequently in women than in men.

Conclusions

Men were more likely to experience dyssynergic defecation whereas women were more likely to experience inadequate defecatory propulsion. However, future studies are warranted to confirm these results.

Effects of Age and Sex on the Anorectal Sensory Threshold to Electrical Stimulation: A Single-center Observational Study

Objectives

Anorectal sensation is an essential component for maintaining normal defecation and continence. This study aimed to investigate changes in anorectal sensation with age and sex using the anorectal sensory threshold to electrical stimulation in a large population with a broad age spectrum.

Methods

This study enrolled consecutive adult patients (20-89 years old) who underwent anorectal physiology tests to screen for functional or organic anorectal disease. Anorectal sensitivity was measured using an endoanal electrode with a 45-mm long bipolar needle. A constant electrical current was delivered to the lower end of the rectum and the anal canal. The minimum current in milliamperes at which the initial sensation was felt was defined as the sensory threshold.

Results

Overall, 888 patients were included in this study. The most frequent comorbidities were constipation and hemorrhoids. The median sensory threshold for all patients was 0.5 (interquartile range, 0.2-1.5) mA, and the overall sensory threshold was significantly higher in men than in women. The 95% confidence interval of the sensory threshold for men and women were 0.1-6.8 and 0.1-5.1 mA, respectively. The sensory threshold increased significantly with age in both sexes (men, r = 0.384; women, r = 0.410). There was no sex difference in the sensory threshold between ages 20 and 40 years; however, between ages 50 and 70 years, men had a higher sensory threshold than women.

Conclusions

The anorectal sensory threshold to electrical stimulation increased with age, and the influence of aging was more significant in men than in women.

Injection of aluminum potassium sulfate and tannic acid in the treatment of fecal incontinence: a single-center observational study

PURPOSE

Perianal injection of bulking agents is an attractive treatment option for patients with mild to moderate fecal incontinence (FI). Various bulking agents have been used for injection therapy, but the optimal injection materials and methods are yet to be standardized. This study aimed to evaluate the effects of injection therapy using aluminum potassium sulfate and tannic acid (ALTA) in the management of FI.

METHODS

This study included consecutive patients who underwent ALTA injection therapy for FI at our institution. The procedure was performed with the patient in the jackknife position, under caudal epidural anesthesia. The procedure consisted of a 4-step injection to the 3 main cushions and a multipoint injection to the remaining submucosa of the anal canal.

RESULTS

Seventy-seven patients (mean age, 76 years) were enrolled in the study. The mean Cleveland Clinic incontinence score of 11.9 ± 4.1 at baseline significantly improved to 7.3 ± 5.2 at 3 months following treatment. The mean maximal resting pressure also increased significantly 3 months after the intervention. Postoperative complications were observed in 3 patients (3.9%), and all events were mild. The mean duration of postoperative follow-up was 17.5 months. The cumulative recurrence-free rate at 3 years was 72.4%.

CONCLUSION

ALTA injection for FI is safe, easy to perform, and provides reasonable mid-term outcomes. Moreover, concomitant anorectal diseases that may be contraindicated by other injectable bulking agents could be treated simultaneously. Therefore, ALTA injection is a promising alternative in the absence of other injectable agents.

Simple Anal Reinforcement with Anal Encirclement Using an Artificial Ligament in Patients with fecal Incontinence: A Single-center Observational Study

Objectives:

Surgical repair of anal sphincter defects in patients with fecal incontinence (FI) has been associated with excellent or good short-term results; however, its benefits have been shown to deteriorate over long-term follow-up. When sphincteroplasty fails or is not feasible, the subsequent surgical options are limited. This study aimed to evaluate the efficacy of anal encirclement using the Leeds-Keio ligament in patients with FI.

Methods:

The inclusion criteria for the procedure were failure of or unsuitability for sphincteroplasty and the presence of a patulous anus (diameter, ≥35 mm). The artificial ligament was routed outside the external anal sphincter at the depth of the middle anal canal under caudal epidural anesthesia.

Results:

Fourteen patients (mean age, 79.4 years; 8 females) with FI were included. Of these, seven (50%) showed a ≥50% reduction in the Cleveland Clinic Florida Fecal Incontinence Score (CCFIS). The mean CCFIS of 13.6 at baseline significantly improved to 7.9 3 months after surgery. The mean maximal anal resting pressure significantly increased from 16.8 mmHg to 22.6 mmHg. Postoperatively, temporary fecal impaction was observed in one patient (7%). None of the cases required removal of the artificial ligament or additional operative interventions for FI during the mean follow-up period of 31.9 months.

Conclusions:

Anal encirclement using the Leeds-Keio ligament was technically simple and safe and achieved good short-term outcomes. Therefore, this technique appears to be a simple solution for sphincter defects and may become an important surgical option for patients with FI and a patulous anus.

A novel telerehabilitation with an educational program for caregivers using telelecture is feasible for fall prevention in elderly people: A case series

BACKGROUND

The importance of fall prevention rehabilitations has been well recognized. Recently telerehabilitation was developed, however, there have been no reports on telerehabilitation with direct support from specialists for fall prevention among the elderly. We herein reported telerehabilitation by caregivers educated by our novel educational program.

METHODS

Caregivers were educated with our educational program using a telelecture system and supported telerehabilitation following instructions from rehabilitation specialists in our university using the telemedicine system every two to four weeks for three months. Caregivers were assessed with our original questionnaire before and after the telelecture. Participants were assessed by the Berg Balance Scale (BBS), Timed Up & Go test (TUG test), Hand-held dynamometer (HHD) and Mini-Mental State Examination (MMSE) before and after telerehabilitation. Wilcoxon's signed-rank test was used for the statistical analyses. A value of P<.05 was considered statistically significant.

RESULTS

Nine elderly people were enrolled. The mean age was 84.7 (78-90) years old and the sex ratio was 1:8 (males:females). The average number of telerehabilitation sessions was 4.7. The average score of nineteen caregivers before the lecture was 15.3, while that after the lecture was 18.3. Caregivers' understanding was significantly increased after the telelecture (P<.001). No adverse events occurred during the study period. The median values of the BBSs, TUG test, right and left HHD and MMSE before and after 3 months' telerehabilitation were 43 (95% confidence interval [CI]: 40.10, 49.01) and 49 (95% CI: 41.75, 50.91), 17.89 (95% CI: 15.51, 23.66) and 18.53 (95% CI: 14.56, 25.67), 7.95 (95% CI: 4.38, 10.14) and 11.55 (95% CI: 7.06, 13.55), 9.85 (95% CI: 6.79, 12.59) and 13.20 (95% CI: 7.96, 14.42), and 19 (95% CI: 12.34, 21.66) and 16 (95% CI: 10.81, 21.00), respectively. Although approximately half of the participants showed improvement in the BBS, TUG test, right and left HHD and MMSE, no significant changes were observed (P=.7239, P=.3446, P=.1023, P=.3538 and P=.8253, respectively).

CONCLUSIONS

Our telerehabilitation program exhibited significant effects in elderly people and improved the degree of understanding concerning rehabilitation among caregivers in facilities for elderly people.

Efficacy and Safety of Anal Encirclement Combining the Leeds-Keio Artificial Ligament With Injection Sclerotherapy Using Aluminum Potassium Sulfate and Tannic Acid in the Management of Rectal Prolapse: A Single-Center Observational Study

Purpose

Perineal procedures are an important surgical option for frail and high-risk patients with rectal prolapse. This study aimed to evaluate the efficacy and safety of combined therapy using injection sclerotherapy, with aluminum potassium sulfate and tannic acid (ALTA), and the Thiersch procedure, using the Leeds-Keio ligament (ALTA-Thiersch).

Methods

This study included 106 consecutive patients (mean age, 81.2 years) who underwent ALTA-Thiersch for rectal prolapse. The procedure was performed under caudal epidural anesthesia. ALTA was injected into the submucosa from the tip of the prolapsed rectum down to the dentate line, circumferentially, at 20 to 40 locations. The ligament tape was placed outside the external sphincter muscle and at an approximate depth of 2 cm into the middle anal canal.

Results

Of 106 patients, rectal prolapse was cured shortly after surgery in 105 patients. An additional tape was inserted in 1 patient who had persistent prolapse. Postoperative complications were observed in 27 patients (25.5%). Fecal impaction occurred in 12 patients; however, since it was temporary, no tape removal was required. Of the 12 cases in which the tape was infected or exposed, 11 required tape removal. There were 18 cases of recurrence at a mean follow-up of 22.1 months. Cumulative recurrence rates at 3 and 5 years were 21.3% and 38.6%, respectively.

Conclusion

ALTA-Thiersch is a simple and safe procedure for rectal prolapse, having reasonable outcomes. The use of the Leeds-Keio ligament for anal encircling can help compensate for the disadvantages of the Thiersch operation.

Rectosigmoid Localization of Radiopaque Markers for Identifying Defecation Disorders in Patients With Chronic Constipation: A Retrospective Cohort Study

BACKGROUND/AIMS

Defecation disorders (DD) are part of the spectrum of chronic constipation with outlet obstruction. Although anorectal physiologic tests are required for the diagnosis of DD, these tests are not available in many institutions. This study aims to investigate the predictivity of DD using rectosigmoid localization of radiopaque markers in a colonic transit study.

METHODS

A total of 169 patients with refractory constipation with a mean age of 67 years were studied. All patients underwent anorectal manometry, a balloon expulsion test, and a colonic transit study. Barium defecography was performed if needed. The relationship between DD diagnosed by these anorectal tests and the rectosigmoid accumulation of markers was examined.

RESULTS

Seventy-nine (46.7%) patients were identified to have DD based on anorectal test combinations. Rectosigmoid accumulation of markers was observed in 39 (23.1%) patients. The sensitivity and positive predictive value of rectosigmoid accumulation for identifying DD were 31.6% and 64.1%, respectively. Rectosigmoid accumulation provided poor discrimination of DD from normal transit constipation, at a specificity of 82.1% but with a sensitivity of only 10.6%. In discriminating DD from slow transit constipation, rectosigmoid accumulation was found to be useful with a positive likelihood ratio of 5.3.

CONCLUSION

s Rectosigmoid accumulation of markers can differentiate DD from slow transit constipation. However, non-rectosigmoid accumulation does not exclude the presence of DD.

Tolerance and Efficacy of Polyethylene Glycol 4000 in Elderly Patients with Chronic Constipation: A Retrospective, Single-center, Observational Study

Objectives:

This retrospective, observational study aimed to evaluate the tolerance and efficacy of polyethylene glycol 4000 plus electrolytes (PEG 4000) in elderly patients with chronic constipation.

Methods:

PEG 4000 powder was orally administered once daily at a dose of one or two 6.9 g sachets as the initial dose. The outcome measures were changes in the Cleveland Clinic Constipation Score (CCCS) and the Bristol Stool Form Scale (BSFS) value before and 2 weeks after drug administration.

Results:

This study included 324 patients aged ≥65 years (mean age: 78.6 ± 7.6 years, range: 65-100 years) with chronic constipation. The total CCCS was noted to significantly improve from 11.5 ± 4.6 at baseline to 7.4 ± 5.2 after drug administration. All CCCS sub-scores also improved significantly. The average BSFS value at baseline (2.5 ± 1.6) significantly improved to 4.3 ± 1.1 after treatment. Side effects (16 events) were observed in 13 patients (4.0%), with the most common being diarrhea (6 patients, 1.9%). All events were mild in severity, with none of the symptoms being serious. The cumulative treatment continuation rate at 1 year was 83.1%.

Conclusions:

PEG 4000 treatment was safe, effective, and well tolerated in elderly patients with chronic constipation. Thus, it appears to be a promising drug that can be continued for a long time.

Quality of walleye pollack frozen surimi by adding carboxylic acid salt in place of sugar compounds

Sugar compounds and polyphosphates are typically added to frozen surimi for the maintenance of its quality. To create healthier, low-calorie frozen surimi, frozen surimi using carboxylic acid and amino acid salts as preservatives in place of sugar compounds was prepared. After thawing, the surimi was salted, followed by preheating at 30°C for either 40 min or between 0 and 40 min, and then heating it at 90°C for 30 min. The breaking strength (BS) and breaking strain (bs) of the heat-induced gels of the surimi were then measured using a rheometer, and the gel strength (Gs = BS / bs) and jelly strength (JS = BS × bs) were calculated. The quality of the surimi was evaluated by assessing the physical properties of the heat-induced gels made from it, as well as the relationship between the BS and Gs during preheating for two-step heated gels. Results showed that the frozen surimi preparations made with 5% sodium gluconate and 3% sodium gluconate + 2% sodium glutamate, each with the addition of 0.1% Na3PO4, were comparable in quality to the typical preparation with 5.7% sugar compounds, remaining stable at -23°C for seven months or at -45°C for ten months. It was also found that, when comparing samples with equal BS values, the heat-induced gels of the 5% sodium gluconate and 3% sodium gluconate + 2% sodium glutamate preparations had slightly lower bs values as compared to typical frozen surimi with sugar compounds, thus exhibiting a slightly more brittle texture.

Impact of body mass index on the clinical outcomes in heart failure patients undergoing cardiac rehabilitation

Background

Increased body mass index (BMI) has recently shown to have a favorable effect on the prognosis in heart failure (HF) patients. However, the impact of BMI on clinical events and mortality in HF patients who underwent cardiac rehabilitation (CR) remains unclear.

Purpose

This study aimed to investigate whether the obesity paradox is present in HF patients who have undergone CR.

Methods

This study enrolled 238 consecutive HF patients who had undergone CR at our university hospital between November 2015 and October 2017. The clinical characteristics and anthropometric data of these patients, including BMI, were collected at the beginning of the CR. The major adverse cardiovascular event (MACE) was defined as a composite of all-cause mortality and unplanned hospitalization for HF. Follow-up data regarding the primary endpoints were collected until November 2018.

Results

Patients (mean age 68.7 years, male 61%) were divided into four groups as per BMI quartiles. More patients in the highest BMI group were women, were significantly younger, and had a higher prevalence of hypertension, dyslipidemia, and diabetes mellitus; however, no significant differences were observed in the prevalence of chronic kidney disease, left ventricular ejection fraction, and brain natriuretic peptide levels of the four groups. During a median follow-up duration of 583 days, 28 patients experienced all-cause mortality, and 42 were hospitalized for HF. Kaplan–Meier analysis showed that patients in the highest BMI quartiles had lower rates of MACE (Log-rank P&lt;0.05) (Figure 1). After adjusting for confounding factors, Cox regression multivariate analysis revealed that BMI was negatively and independently associated with the incidence of MACE (hazard ratio: 0.89, 95% confidence interval: 0.83–0.96, P&lt;0.05).

Conclusion

Increased BMI was associated with better clinical prognosis even in HF patients who have undergone CR Therefore, BMI assessment may be useful for risk stratification in HF patients who have undergone CR.

Figure 1. Kaplan-Meier survival curve

Funding Acknowledgement

Type of funding source: None

Efficacy and Safety of Elobixibat in Elderly Patients with Chronic Constipation: A Single-center, Observational Study

Objectives:

A retrospective, observational study was conducted to examine the efficacy and safety of elobixibat, a novel therapeutic agent for chronic constipation, in Japanese elderly patients aged ≥ 65 years with chronic constipation.

Methods:

The study was conducted at Kunimoto Hospital. Patients who visited the hospital from April 2018 to March 2019 due to symptoms of chronic constipation and who took elobixibat were enrolled. The outcome measures were changes in the Constipation Scoring System (CSS) score and the Bristol stool form scale (BSFS) before and after elobixibat administration.

Results:

The study included 150 patients. The total CSS score significantly improved from 11.7±4.5 at baseline to 9.3±5.2 two weeks after drug administration. The improvement was confirmed in six out of eight CSS items. The BSFS at baseline of 2.5±1.8 was improved to 3.4±1.7 two weeks after treatment, nearly close to the normal stool consistency of 4. Adverse reactions were observed in 18 of 150 patients (12.0%) with 21 events, most commonly diarrhea in nine patients (6.0%) and abdominal pain in eight patients (5.3%).

Conclusions:

Elobixibat improved not only the frequency of bowel movements but also alleviated various symptoms of constipation, such as difficulty with evacuation and sensations of incomplete evacuation in elderly patients with chronic constipation. All adverse drug reactions were mild in severity with no safety concerns.

Clinical efficacy of Japanese herbal medicine daikenchuto in the management of fecal incontinence: A single-center, observational study

Objectives: The purpose of this study was to investigate whether the symptoms of fecal incontinence (FI) or anal sphincter dysfunction are improved by daikenchuto (DKT). Methods: This is a retrospective observational study that analyzes the effects of DKT. The study was conducted at Kunimoto Hospital. Patients who visited the hospital from January 2012 to December 2016 due to symptoms of FI with a certain degree of chronic constipation and who took DKT were enrolled. The drug to be evaluated was “Tsumura Daikenchuto Extract Granules for Ethical Use (TJ-100)” manufactured by Tsumura & Co., Tokyo, Japan. The primary outcome measures were changes in the scores of the Cleveland Clinic Incontinence Score (CCIS) and Constipation Scoring System (CSS) before and after the administration of DKT. Results: A total of 157 patients were enrolled. On the CCIS, “leakage of solid stool,” “leakage of liquid stool,” “pad use,” and “total score” were significantly improved. On the contrary, on the CSS, the score of “type of assistance” was significantly improved after the administration of DKT, but no significant difference was found in the total score. On the Bristol Stool Form Scale, the administration of DKT showed a tendency to normalize stool consistency. Maximum resting anal pressure and maximum squeeze anal pressure significantly increased after the administration of DKT. No side effects caused by DKT were observed during the study. Conclusions: DKT appears to be a safe and useful agent for the management of FI in patients with defecation disorders and internal anal sphincter dysfunction.

P629Voluntary exercise associated with myokine production ameliorates cardiac remodeling and inflammation in a myocardial infarction mouse model

Background

Left ventricular (LV) remodeling, through excessive inflammation, leads to heart failure. Exercise (Ex) training is associated with a risk reduction in heart failure through direct and indirect mechanisms by which Ex contributes an anti-inflammatory effect. During Ex, contracting muscle fibers release myokines, including interleukins (ILs), tumor necrosis factor α (TNF-α), follistatin-like protein 1 (FSTL-1), and fibroblast growth factor 21 (FGF-21), into the bloodstream. These myokines may have beneficial effects on other damaged organs, such as an infarcted myocardium, through anti-inflammatory effects. However, the exact mechanisms of the anti-inflammatory effects of voluntary Ex in myocardial infarction (MI) are poorly understood. Therefore, we investigated the effect of voluntary Ex on cardiac remodeling and inflammation, the relationship between cardiac remodeling and skeletal muscle (SKM) response, and circulating myokine levels in a mouse model of MI.

Methods

Twelve-week-old male C57BL/6J mice were used and divided into the following 4 groups: sham operation (Sham), MI, Sham+Ex, and MI+Ex. MI was induced by ligation of the left anterior descending coronary artery. Ex groups began voluntary wheel running for 4 weeks after the operation. An echocardiography was performed at baseline and 4 weeks after the operation. The mRNA levels in the LV infarcted area and SKM were measured with RT-PCR and western blot analysis. Plasma levels of myokines were also measured with immunoassays.

Results

Four weeks after MI induction, echocardiographic evaluation showed that the MI mice had a larger LV end-diastolic diameter (LVEDD) and end-systolic diameter (LVESD) than the Sham mice. The MI mice also showed higher mRNA levels of TNF-α, IL-1β, IL-6, and IL-10 in the LV tissue when compared to the Sham mice. These changes were significantly ameliorated in the MI+Ex mice. Interestingly, in the MI+Ex mice, mRNA levels of IL-6, IL-1β, FSTL-1, and FGF-21 in the SKM were significantly higher than in the MI mice, while there were no significant differences in TNF-α and IL-10 levels in all groups. Similarly, protein expression levels of peroxisome proliferator-activated receptor gamma coactivator 1-alpha, sirtuin-1, and mitochondrial transcriptional factor A of mitochondrial function markers in SKM were also significantly higher in the MI+Ex mice than in the MI mice. Furthermore, there were significant correlations between plasma levels of IL-1β, but not other myokines, and LVEDD, and LVESD. In addition, there was also a significant correlation between the SKM IL-1β level and LVESD in the Sham+Ex mice (all, P<0.05).

Conclusions

Amelioration of cardiac remodeling and inflammation by voluntary Ex is associated with increased myokines, especially IL-1β, in a MI mouse model. These results suggest that increased myokine levels, through voluntary exercise, may play an important role in the prevention of cardiac remodeling after MI.

P6209Relationship between skin autofluorescence levels and clinical outcomes in heart failure patients undergoing cardiac rehabilitation

Background

Advanced glycation end-products, indicated by skin autofluorescence (SAF) levels, could be prognostic predictors of all-cause and cardiovascular mortality in patients with diabetes mellitus (DM) and renal disease. However, the clinical usefulness of SAF levels in patients with heart failure (HF) who underwent cardiac rehabilitation (CR) remains unclear.

Purpose

The purpose of this study was to investigate the prognostic value of SAF levels in patients with HF who underwent CR.

Methods

This study enrolled 204 consecutive patients with HF who had undergone CR at our university hospital between November 2015 and October 2017. Clinical characteristics and anthropometric data were collected at the beginning of CR. SAF levels were noninvasively measured with an autofluorescence reader. The major adverse cardiovascular event (MACE) was a composite of all-cause mortality and unplanned hospitalization for HF. Follow-up data concerning primary endpoints were collected until November 2018.

Results

Patients' mean age was 68.1 years, and 61% were males. Patients were divided into two groups according to the median SAF levels (high and low SAF groups). Patients in the high SAF group were significantly older, had a higher prevalence of chronic kidney disease, and histories of coronary artery bypass surgery; however, there were no significant between-group differences in sex, prevalence of DM, left ventricular ejection fraction, and physical function. During a median follow-up period of 623 days, 25 patients experienced all-cause mortality and 34 were hospitalized for HF. Kaplan–Meier analysis showed that patients in the high SAF group had a higher incidence of MACE (log-rank P<0.05), whereas when patients were divided into two groups according to the median hemoglobin A1c level, no significant between-group difference was observed for the incidence of MACE (Figure). After adjusting for confounding factors, Cox regression multivariate analysis revealed that SAF levels were independently associated with the incidence of MACE (hazard ratio: 1.74, 95% confidence interval: 1.12–2.65, P<0.05).

Figure 1

Conclusion

SAF levels were significantly associated with the incidence of MACE in patients with HF and may be useful for risk stratification in patients with HF who undergo CR.

Diagnosis of Aneurysm of Superior Thyroid Artery by CT and Mr Imaging

A 51-year-old man presented with a nonpulsatile anterior neck mass which suggested a thyroglossal duct cyst. At CT a small cystic mass was revealed. The mass contained a well-defined, crescent-shaped, low-density area with homogeneous contrast enhancement. On MR T2-weighted spin-echo and gradient-echo images the mass was as hyperintense as the neck vessels. Angiography and operation confirmed an aneurysm of the left superior thyroid artery with a mural thrombus.

[Clinical usefulness of oral aprepitant for alleviation of delayed nausea and vomiting induced by mFOLFOX6--report of a case]

A 50-year-old-woman underwent high anterior resection for sigmoid colon adenocarcinoma. Modified oxaliplatin/l / -LV/ 5-FU(mFOLFOX6)was started as adjuvant treatment due to final-stage III b. Granisetron 3 mg and dexamethasone 8 mg for prophylaxis chemotherapy-induced nausea and vomiting (CINV) were administered intravenously 30 min before oxaliplatin administration. Grade 3 delayed CINV was observed at course 4. CINV could not be controlled by any rescue medications. We adopted a neurokinin-1 receptor antagonist (aprepitant) that alleviated the emetic effects of substance P. The oral aprepitant dose was 125 mg on day 1 and 80 mg on days 2 and 3. Afterward, delayed vomiting was completely controlled and chemotherapy could be continued to course 12. Aprepitant is a very active antiemetic drug for the prevention of delayed nausea and vomiting induced by mFOLFOX6 regimen.

Aluminum potassium sulfate and tannic acid injection in the treatment of total rectal prolapse: early outcomes

PURPOSE

No surgical method for repair of total rectal prolapse has been established as optimal. We describe a new technique that uses ALTA (aluminum potassium sulfate and tannic acid) injection as a simple perianal procedure for total rectal prolapse.

METHODS

Fourteen patients with total rectal prolapse were treated with sclerosing therapy by using ALTA injection. Via a perianal approach, 0.5 to 1 ml of ALTA solution was injected along a linear track into the submucosa at 30 to 80 different sites, totaling 20 to 60 ml.

RESULTS

All 14 patients treated with injection sclerotherapy were cured, with no intraoperative or postoperative complications. One patient required a repeat injection after two months to be cured. No exacerbation of constipation has resulted, and no stenosis has been evident on rectal examination. In seven of ten patients presenting with fecal incontinence, this complaint resolved after therapy.

CONCLUSIONS

ALTA sclerotherapy yielded satisfactory results in total rectal prolapse, causing no alteration in neurophysiology of bowel function. Injection sclerotherapy should be recommended as the first procedure for treatment of total rectal prolapse.

Toxicity assessment of treated wastewater using cultured human cell lines

Bioassay using cultured human cell lines was applied to an effluent of a wastewater treatment plant (WWTP) in Sapporo to assess their toxicity, and in order to investigate the fate of toxicity in the WWTP, bioassay of the water samples from several points in WWTP (influent, effluent, return flow from thickener, from dewatering process and from incineration process) was performed. We also applied bioassay to the mixture of the activated sludge from the investigated plant and artificial sewage. These results showed that the toxicity of the effluent was more intensive than the influent, and organic matter released from activated sludge bacteria during their decay process contributed to the increase of toxicity in the effluent.

Toxicity assessment of the extract of compost as a final product from Bio-Toilet

Bio-Toilet is the name of a dry closet or composting toilet using sawdust as an artificial soil matrix for bioconversion of human excrement into compost. Since feces and urine contain several chemicals such as pharmaceutical residues and endocrine disruptors and they may still remain in compost after biological reaction in the Bio-Toilet, it is required to examine the possibility of soil and/or groundwater pollution by applying compost to a soil system in farmland. In this study, toxicity of Bio-Toilet compost was evaluated by measuring the viability of human neuroblast (NB-1). The bio-assay was applied to the water extract of compost from the Bio-Toilets which are in practical use in Japan. The assay results showed that (1) the extract of feces showed no toxicity, and the extracts of unused sawdust had no or low level toxicity and (2) the extracts of composts had heavier toxicity than unused sawdust. These results implied that some chemicals that have toxicity were generated by biological reactions or accumulated in toilet system. The bioassay results with fractionated organic matter by its molecular weight showed that the small molecular weight fraction had stronger toxicity than other fractions. The effect of inorganic matter on toxicity was examined by comparing the dose-response relationship of the extracts of compost with positive control with 1M of sodium chloride solution. The comparison showed that sodium concentration in the extract was too low to develop the toxicity and the effect of inorganic matter could be neglected in this study.

Role of hydrophilic organic matter on developing toxicity in decay process of activated sludge

It is known that the toxicity of effluent is more intensive than that of influent in the activated sludge process. In this study, we applied bioassay using cultured human cell lines to the decay process of activated sludge to evaluate the toxicity of organic matter generated and/or released from activated sludge bacteria. We also applied this bioassay to hydrophilic fraction of samples. The bioassay results showed that: (1) the variation in the dose-response relation obtained from assay with original samples was observed during decay; (2) on the other hand, the response curves of only hydrophilic fraction at each time show the same relationship between TOC and viability of MCF7 cells; (3) this trend was confirmed by plotting the time course of EC50. These results imply that: (1) the hydrophilic organic matter controlled for developing toxicity during decay process of activated sludge; and (2) the character of hydrophilic organic matter is not changed during the experimental period.

Inhibitory effect of 2,3,7,8-tetrachlorodibenzo-p-dioxin on cAMP-induced differentiation of rat C6 glial cell line

Dioxin is suspected to cause adverse effects on the development of the central nervous system (CNS). To investigate the neurotoxic effects of dioxin on the differentiation of astrocytes, rat C6 glial cell line was used as a model, because these cells are induced to express astrocyte markers and to change the cell morphology toward an astrocytic phenotype by increasing intracellular cAMP levels. When C6 cells were simultaneously exposed to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) and N(6),O(2')-dibutylyl cAMP (dbcAMP), the expression of cytochrome P-450 1A1 (CYP1A1) was dramatically increased, and the expression of aryl hydrocarbon receptor (AhR) was moderately decreased in a dose-dependent manner. In addition, extension of astrocytic processes was inhibited by 1 nM TCDD that did not reduce cell viability. TCDD also inhibited the induction of glial fibrillary acidic protein (GFAP) expression in a dose-dependent manner, until the end of a 72-hr exposure period. This inhibition was restored by the addition of an antagonist of AhR, alpha-naphthoflavone. These results indicate that TCDD inhibits astrocytic differentiation of C6 cells, which may be mediated by an AhR-dependent pathway.

Polymorphism of the promoter region of prostacyclin synthase gene is not related to essential hypertension

An impaired synthesis of prostacyclin has been implicated in the development of essential hypertension (EH). We therefore investigated whether there is an association between the prostacyclin synthase (PGIS) gene and EH using a variable number of tandem repeats (VNTR) polymorphism in the promoter region that influences transcriptional activity of this gene. A total of 125 patients with EH and 125 age-matched subjects with normal blood pressure were studied. The number of VNTR of the five alleles ranged from 3 to 7 repeats in the 250 unrelated Japanese subjects. The allele frequency distribution in the two groups were not significantly different. Thus, this VNTR polymorphism in the PGIS gene is not associated with EH.

Association study between the variants of the human ANP gene and essential hypertension

Variants of atrial natriuretic peptide (ANP) are reported to be more common in blacks with hypertension than in normotensive controls and constitute an independent risk factor for cerebral infarction. The purpose of the present study was to investigate the role of ANP in the pathogenesis of essential hypertension (EH) in the Japanese. We investigated 2 previously reported ANP gene markers, G1837A and T2238C, for their possible associations with EH. A total of 233 individuals with EH and 213 age-matched normotensive (NT) control subjects were studied. The frequencies of the G and A alleles were 0.09 (42/466) and 0.91 (424/466), respectively, for the NT group and 0.11 (47/426) and 0.89 (379/426), respectively, for the EH group. These frequencies did not differ significantly between the two groups. The frequencies of the T and C alleles were 0.024 (11/466) and 0.97 (455/466), respectively, for the NT group and 0.03 (13/426) and 0.97 (413/426), respectively, for the EH group. These frequencies also did not differ significantly between the two groups. Neither G1837A nor the T2238C polymorphism of the ANP gene was associated with EH. Our findings do not support the hypothesis that the G1837A and T2238C polymorphisms of the ANP gene are markers for EH in the Japanese.

Relationship between the fecal occult blood test and benign anal disorders

BACKGROUND/AIMS

The fecal occult blood test is a very useful method for mass screening for colorectal cancer. The possibility of the fecal occult blood test being positive is high even in benign anal disorders, but the relationship between anal disorders and the fecal occult blood test has not been fully studied.

METHODOLOGY

During the period from November 1995 to April 1996, we performed both fecal occult blood test and sigmoid colonofiberscopy for 440 patients with anal disorders who visited our hospital for the first time.

RESULTS

The positive fecal occult blood test rate was 18.8% (77/409) for those who had only anal disorders and no findings in the colon and rectum. The positive fecal occult blood test rate was significantly high in the cases with polyps (42.3%) and in those with colorectal cancer (60%).

CONCLUSIONS

These findings suggested the need to analyze fecal occult blood test, keeping in mind that fecal occult blood test might be positive even without any malignant findings in the large intestine in about 20% of cases of patients have anal disorders when fecal occult blood test is performed.

Association of 5' upstream promoter region of prostacyclin synthase gene variant with cerebral infarction

The aim of this study was to investigate whether there is an association between the promoter region of the prostacyclin synthase gene and cerebral infarction (CI). Using the polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP) method, we found a variable-number tandem repeat polymorphism in the 5'-upstream promoter region of the prostacyclin synthase gene. This region contains transcriptional factors-binding sites of Spl (CCCGCC) and AP-2 (CCGCCAGCCCC). The alleles varied in size from three to seven repeats of nine base pairs (bp). We performed an association study using the polymorphism in 111 patients and 152 control subjects. The transcriptional activity of the abnormal promoter region allele was determined by luciferase assay. The overall distribution of alleles differed significantly between both groups. Logistic linear regression analysis revealed the small number repeat allele to be found more frequently with CI. Transcriptional activity increased with increasing numbers of repeats. This study provides consistent support for the association between CI and the PGIS gene.

Nitric oxide inactivates glyoxalase I in cooperation with glutathione

We previously found that glyoxalase I (Glo I) is inactivated upon exposure of human endothelial cells to extracellular nitric oxide (NO), and this event correlates with an increase in its pI on two-dimensional gels. In this study, we demonstrate that NO can modulate Glo I activity in cooperation with cellular glutathione (GSH). Severe depletion of intracellular GSH prevents the inactivation of Glo I in response to NO, although such depletion enhances the inactivation of glyceraldehyde-3-phosphate dehydrogenase (G3PDH), a well-known enzyme susceptible to NO-induced oxidation. S-Nitrosoglutathione (GSNO), an adduct of GSH and NO, lowers the activity of purified human Glo I, while S-nitrosocysteine (CysNO) inactivates the enzyme only in the presence of GSH. This indicates that a dysfunction in Glo I would require the formation of GSNO in situ. Competitive inhibitors of Glo I, S-(4-bromobenzyl)glutathione and its membrane-permeating form, completely abolish the NO action in vitro and inside cells, respectively. Taken together, these results reveal that Glo I can interact directly with GSNO, and that the interaction converts Glo I into an inactive form. Moreover, the data suggest that the substrate recognition site of Glo I might be involved in the interaction with GSNO.

Antiepileptic effect of nefiracetam on kainic acid-induced limbic seizure in rats

Nefiracetam is being studied as a novel cognition-enhancing agent; however, it has been suggested from studying its chemical structure that it has a potential anticonvulsive effect. We examined the antiepileptic effect of nefiracetam on kainic acid (KA)-induced seizures. KA was infused into the left basolateral amygdaloid nucleus and focal limbic seizures were induced in 43 male Wistar rats. During status epilepticus, 10, 50, 100 or 200 mg/kg of nefiracetam was intravenously injected. Nefiracetam inhibited KA-induced limbic seizures at doses over 100 mg/kg while it had a sedative effect on the animals. In (14C) deoxyglucose autoradiographic studies, the propagation of seizure-induced hypermetabolic areas was also suppressed dose-dependently. From the results, it was indicated that nefiracetam has an antiepileptic effect and that its application may suppress seizure propagation. Further study is required, whether this agent is available as a novel anticonvulsant.

Appearance of extracellular glutathione peroxidase (eGPx) in the ascite fluid of casein-elicited rats

Glutathione peroxidase (GPx) activity was detected in the ascite fluid of rats injected intraperitoneally with 2.5% heat-denatured casein solution. Activity in the ascite fluid increased with time after the injection of casein, and reached a maximum at 24 h. The active component was concentrated with successive 35% ammonium sulfate precipitation and Activated Thiol-Sepharose 4B column chromatography from the ascite fluid of rats at 24 h after the injection of casein. No N-terminal amino acid of the protein corresponding to GPx was detected by automatic amino acid sequence analysis following separation with sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) and transfer to a polyvinyl difluoride (PVDF) membrane. Following BrCN treatment of the protein, the N-terminal amino acid sequences of two 14 and 2.6 kDa peptide fragments were found to be S-G-T-I-Y-E-Y-G-A-L and K-I-H-D-I-R-W-N-F-E, respectively. The former and the latter fragments corresponded to sequences beginning at the 37th and 176th amino acid residues of rat extracellular GPx (eGPx), respectively. The exclusive presence of eGPx in the ascite fluid of rats elicited by casein was confirmed immunologically by ELISA, immuno-precipitation and Western blotting assays. No other GPx isozymes such as cytosolic GPx (cGPx), phospholipid hydroperoxide GPx (PHGPx) or intestinal GPx (iGPx) were detected. eGPx activity and protein were also detected in the pleuritic fluid of rats following injection of 2% carrageenan. These findings indicate that eGPx appears at various sites of acute inflammation in rats. This pattern is due to leakage from circulation as a result of the increased capillary permeability at inflammation sites elicited by chemotactic factors.

Correlation of EEG, neuroimaging and histopathology in an epilepsy patient with diffuse cortical dysplasia

The correlation between scalp EEG, intraoperative electrocorticogram, neuroimaging and histopathology was examined in an epileptic child with diffuse cortical dysplasia. The 6-year-old girl with moderate mental retardation had suffered from intractable complex partial and generalized epilepsies since the age of 2 years. MR images demonstrated unilateral large macrogyria/polymicrogyria and schizencephaly in the right occipital lobe. The epileptic focus was detected on the macrogyria by EEG and single photon emission tomography. However, the intraoperative electrocorticogram showed frequent spikes from the polymicrogyria and no paroxysmal activity in the macrogyria. The polymicrogyria and the macrogyric lesion were resected, using an image-guided system. The histological findings revealed that the macrogyria was covered with and separated by glial bundles. It has been reported that epileptogenicity is produced from abnormal neurons and their arrangement in cortical dysplasia; in this case, however, the major dysplastic lesion had no epileptogenicity; rather the focus might be in the polymicrogyria around the lesion.

Glyoxalase I is a novel nitric-oxide-responsive protein

To clarify the molecular mechanisms of nitric oxide (NO) signalling, we examined the NO-responsive proteins in cultured human endothelial cells by two-dimensional (2D) PAGE. Levels of two proteins [NO-responsive proteins (NORPs)] with different pI values responded to NO donors. One NORP (pI 5.2) appeared in response to NO, whereas another (pI 5.0) disappeared. These proteins were identified as a native form and a modified form of human glyoxalase I (Glox I; EC 4. 4.1.5) by peptide mapping, microsequencing and correlation between the activity and the isoelectric shift. Glox I lost activity in response to NO, and all NO donors tested inhibited its activity in a dose-dependent manner. Activity and normal electrophoretic mobility were restored by dithiothreitol and by the removal of sources of NO from the culture medium. Glox I was selectively inactivated by NO; compounds that induce oxidative stress (H(2)O(2), paraquat and arsenite) failed to inhibit this enzyme. Our results suggest that NO oxidatively modifies Glox I and reversibly inhibits the enzyme's activity. The inactivation of Glox I by NO was more effective than that of glyceraldehyde-3-phosphate dehydrogenase (G3PDH), another NO-sensitive enzyme. Thus Glox I seems to be a novel NO-responsive protein that is more sensitive to NO than G3PDH.

[Clinical experiences and problems with home medical treatment in an orthopedic clinic]

Twenty-five patients who received home medical treatment were reviewed. There were 11 males and 14 females, with a mean age of 77 years. In an orthopedic clinic, it is difficult to secure the time for to visit a patient's home. Another problem for doctor is that the medical fee for home treatment is very low. To promote home treatment by orthopedists, it is important to secure the time to visit a patient's home, to improve the fees for home treatment, and to establish a connection with a visiting nurse care station and visiting rehabilitation workers.

Cellular glutathione peroxidase as a predominant scavenger of hydroperoxyeicosatetraenoic acids in rabbit alveolar macrophages

The cytosol of rabbit lung alveolar macrophages contains a high amount of peroxidase, which reduces 5-hydroperoxyeicosatetraenoic acid (5-HPETE) to 5-hydroxyeicosatetraenoic acid (5-HETE) in the presence of glutathione. This peroxidase was purified 69-fold to homogeneity with overall recovery of activity of 18.5%. The molecular mass of the enzyme was approximately 80 kDa by gel filtration, and emerged as a single band at 23.1 kDa under reducing condition by sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE). The amino-terminal sequence of the purified peroxidase was completely identical to the sequence deduced from cellular glutathione peroxidase (cGPx) gene of rabbit liver. No other activity that reduces 5-HPETE to 5-HETE was observed during purification. These results suggest that cGPx plays an important role in metabolism of lipid hydroperoxides, especially HPETE, in lung alveolar macrophages.

Zinc stimulates DNA synthesis during its antiapoptotic action independently with increments of an antiapoptotic protein, Bcl-2, in porcine kidney LLC-PK(1) cells

Cadmium, an environmental pollutant, caused nephroptosis that was inhibitable by zinc. The mechanism of the antiapoptotic action of zinc is poorly understood. In this study, we found the stimulation of DNA synthesis, as assessed by bromodeoxyuridine incorporation, during prevention by zinc of apoptosis, suggesting that the proliferactive nature of zinc contributes to its inhibition of apoptosis. This finding was consistent with the result that the cells driven by dialyzed fetal bovine serum were resistant to apoptotic stimuli of cadmium. Furthermore, zinc activated the expression of endogenous Bcl-2 proteins. However, overexpression of Bcl-2 proteins by transfection did not facilitate zinc-mediated DNA synthesis. Thus, one possible role of zinc in the prevention of apoptosis is to promote DNA synthesis independently with activation of antiapoptotic proteins Bcl-2.