Relationship between critical care nutrition and post-intensive care syndrome in surviving ventilated patients with COVID-19: a multicenter prospective observational study

The impact of nutrition therapy in the acute phase on post-intensive care syndrome (PICS) remains unclear. We conducted a multicenter prospective study on adult patients with COVID-19 who required mechanical ventilation for more than three days. The questionnaire was mailed after discharge. Physical PICS, defined as less than 90 points on the Barthel index (BI), was assigned as the primary outcome. We examined the types of nutrition therapy in the first week that affected PICS components. 269 eligible patients were evaluated 10 months after discharge. Supplemental parenteral nutrition (SPN) >400 kcal/day correlated with a lower occurrence of physical PICS (10% vs 21.92%, p = 0.042), whereas the amounts of energy and protein provided, early enteral nutrition, and a gradual increase in nutrition delivery did not, and none correlated with cognitive or mental PICS. A multivariable regression analysis revealed that SPN had an independent impact on physical PICS (odds ratio 0.33, 95% CI 0.12-0.92, p = 0.034), even after adjustments for age, sex, body mass index and severity. Protein provision ≥1.2 g/kg/day was associated with a lower occurrence of physical PICS (odds ratio 0.42, 95% CI 0.16-1.08, p = 0.071). In conclusion, SPN in the acute phase had a positive impact on physical PICS for ventilated patients with COVID-19.

Post-intensive care syndrome: Recent advances and future directions

Post-intensive care syndrome comprises physical, cognitive, and mental impairments in patients treated in an intensive care unit (ICU). It occurs either during the ICU stay or following ICU discharge and is related to the patients' long-term prognosis. The same concept also applies to pediatric patients, and it can greatly affect the mental status of family members. In the 10 years since post-intensive care syndrome was first proposed, research has greatly expanded. Here, we summarize the recent evidence on post-intensive care syndrome regarding its pathophysiology, epidemiology, assessment, risk factors, prevention, and treatments. We highlight new topics, future directions, and strategies to overcome post-intensive care syndrome among people treated in an ICU. Clinical and basic research are still needed to elucidate the mechanistic insights and to discover therapeutic targets and new interventions for post-intensive care syndrome.

Resurgence of human metapneumovirus infection and influenza after three seasons of inactivity in the post-COVID-19 era in Hokkaido, Japan, 2022-2023

Following the coronavirus disease 2019 (COVID-19) outbreak in February 2020, incidences of various infectious diseases decreased notably in Hokkaido Prefecture, Japan. However, Japan began gradually easing COVID-19 infection control measures in 2022. Here, we conducted a survey of children hospitalized with human metapneumovirus (hMPV), influenza A and B, and respiratory syncytial virus infections in 18 hospitals across Hokkaido Prefecture, Japan, spanning from July 2019 to June 2023. From March 2020 to June 2022 (28 months), only 13 patients were hospitalized with hMPV, and two patients had influenza A. However, in October to November 2022, there was a re-emergence of hMPV infections, with a maximum of 27 hospitalizations per week. From July 2022 to June 2023 (12 months), the number of hMPV-related hospitalizations dramatically increased to 317 patients, with the majority aged 3-6 years (38.2%, [121/317]). Influenza A also showed an increase from December 2022, with a peak of 13 hospitalizations per week in March 2023, considerably fewer than the pre-COVID-19 outbreak in December 2019, when rates reached 45 hospitalizations per week. These findings suggest the possibility of observing more resurgences in infectious diseases in Japan after 2023 if infection control measures continue to be relaxed. Caution is needed in managing potential outbreaks.

Changing Patterns of Infectious Diseases Among Hospitalized Children in Hokkaido, Japan, in the Post-COVID-19 Era, July 2019 to June 2022

BACKGROUND

Many reports have reported a reduction in respiratory infectious diseases and infectious gastroenteritis immediately after the coronavirus disease 2019 (COVID-19) pandemic, but data continuing into 2022 are very limited. We sought to understand the current situation of various infectious diseases among children in Japan as of July 2022 to improve public health in the post-COVID-19 era.

METHODS

We collected data on children hospitalized with infectious diseases in 18 hospitals in Japan from July 2019 to June 2022.

RESULTS

In total, 3417 patients were hospitalized during the study period. Respiratory syncytial virus decreased drastically after COVID-19 spread in early 2020, and few patients were hospitalized for it from April 2020 to March 2021. However, an unexpected out-of-season re-emergence of respiratory syncytial virus was observed in August 2021 (50 patients per week), particularly prominent among older children 3-6 years old. A large epidemic of delayed norovirus gastroenteritis was observed in April 2021, suggesting that the nonpharmaceutical interventions for COVID-19 are less effective against norovirus. However, influenza, human metapneumovirus, Mycoplasma pneumoniae , and rotavirus gastroenteritis were rarely seen for more than 2 years.

CONCLUSIONS

The incidence patterns of various infectious diseases in Japan have changed markedly since the beginning of the COVID-19 pandemic to the present. The epidemic pattern in the post-COVID-19 era is unpredictable and will require continued careful surveillance.

Anticoagulant therapies against sepsis-induced disseminated intravascular coagulation

Disseminated intravascular coagulation (DIC) is a frequent but lethal complication in sepsis. Anticoagulant therapies, such as heparin, antithrombin, activated protein C, and recombinant human-soluble thrombomodulin, were expected to regulate the progression of coagulopathy in sepsis. Although a number of randomized controlled trials (RCTs) have evaluated the survival effects of these therapies over the past few decades, there remains no consistent evidence showing a significant survival benefit of anticoagulant therapies. Currently, anticoagulant therapies are not conducted as a standard treatment against sepsis in many countries and regions. However, most of these RCTs were performed overall in patients with sepsis but not in those with sepsis-induced DIC, who were theoretically the optimal target population of anticoagulants. Actually, multiple lines of evidence from observational studies and meta-analyses of the RCTs have suggested that anticoagulant therapies might reduce mortality only when used in septic DIC. In addition, the severity of illness is another essential factor that maximally affects the efficacy of the therapy. Therefore, to provide evidence on the true effect of anticoagulant therapies, the next RCTs must be designed to enroll only patients with sepsis-induced overt DIC and a high severity of illness. To prepare these future RCTs, a novel scientific infrastructure for accurate detection of patients who can receive maximal benefit from anticoagulant therapies also needs to be established.

High Thermoelectric Performance in Polycrystalline GeSiSn Ternary Alloy Thin Films

Group IV materials are promising candidates for highly reliable and human-friendly thin-film thermoelectric generators, used for micro-energy harvesting. In this study, we investigated the synthesis and thermoelectric applications of a Ge-based ternary alloy thin film, Ge_1-x-ySi_xSn_y. The solid-phase crystallization of the highly densified amorphous precursors allowed the formation of high-quality polycrystalline Ge_1-x-ySi_xSn_y layers on an insulating substrate. The small compositions of Si and Sn in Ge_1-x-ySi_xSn_y (x < 0.15 and y < 0.05) lowered the thermal conductivity (3.1 W m^-1 K^-1) owing to the alloy scattering of phonons, while maintaining a high carrier mobility (approximately 200 cm² V^-1 s^-1). The solid-phase diffusion of Ga and P allowed us to control the carrier concentration to the order of 10¹⁹ cm^-3 for holes and 10¹⁸ cm^-3 for electrons. For both p- and n-type Ge_1-x-ySi_xSn_y, the power factor peaked at x = 0.06 and y = 0.02, reaching 1160 μW m^-1 K^-2 for p-type and 2040 μW m^-1 K^-2 for n-type. The resulting dimensionless figure of merits (0.12 for p-type and 0.20 for n-type) are higher than those of most environmentally friendly thermoelectric thin films. These results indicate that group IV alloys are promising candidates for high-performance, reliable thin-film thermoelectric generators.

Hyodeoxycholic Acid (HDCA) Prevents Development of Dextran Sulfate Sodium (DSS)-Induced Colitis in Mice: Possible Role of Synergism between DSS and HDCA in Increasing Fecal Bile Acid Levels

Secondary bile acids (SBAs) with high hydrophobicity are abundant in the colonic lumen. However, both aggravating and protective roles of SBAs have been proposed in the pathogenesis of inflammatory bowel diseases (IBDs). We observed that oral administration of hyodeoxycholic acid (HDCA), a hydrophilic bile acid, prevented the development of dextran sulfate sodium (DSS)-induced colitis in mice. We then examined the individual effects of DSS and HDCA as well as their combined effects on fecal bile acid profile in mice. HDCA treatment increased the levels of most of fecal bile acids, whereas DSS treatment had limited effects on the levels of fecal bile acids. The combined treatment with DSS and HDCA synergistically increased the levels of fecal chenodeoxycholic acid (CDCA) and deoxycholic acid (DCA) in feces, which are potent activators of the farnesoid X receptor (FXR) and Takeda G-protein-coupled receptor 5 (TGR5). The overall hydrophobicity of fecal bile acids was not modified by any treatments. Our data suggest that the preventive effect of HDCA on DSS-induced colitis in mice is due to the synergism between DSS and HDCA in increasing the levels of the fecal bile acids with potencies to activate FXR and TGR5.

Pimitespib in patients with advanced gastrointestinal stromal tumor (CHAPTER-GIST-301): a randomized, double-blind, placebo-controlled phase 3 trial

BACKGROUND

Prognosis of advanced gastrointestinal stromal tumors (GIST) refractory to tyrosine kinase inhibitors (TKIs) is poor. This randomized, placebo-controlled, phase 3 trial evaluated the efficacy and safety of pimitespib, a novel heat shock protein 90 inhibitor, in advanced GIST refractory to standard TKIs.

PATIENTS AND METHODS

Patients with histologically confirmed GIST refractory to imatinib, sunitinib, and regorafenib were randomized 2:1 to oral pimitespib 160 mg/day or placebo for five consecutive days per week in 21-day cycles. Following disease progression by blinded central radiological review (BCRR), crossover to open-label pimitespib was permitted. The primary endpoint was progression-free survival (PFS) by BCRR in the full analysis set. Secondary endpoints included overall survival (OS) adjusted using the rank preserving structural failure time method to reduce the expected confounding impact of crossover.

RESULTS

From Oct 31, 2018 to Apr 30, 2020, 86 patients were randomized to pimitespib (n=58) or placebo (n=28). Median PFS was 2.8 months (95% CI 1.6-2.9) with pimitespib versus 1.4 months (0.9-1.8) with placebo (hazard ratio [HR] 0.51 [95% CI 0.30-0.87]; one-sided p=0.006). Pimitespib showed an improvement in crossover-adjusted OS compared with placebo (HR 0.42 [0.21-0.85], one-sided p=0.007). Seventeen (60.7%) patients receiving placebo crossed-over to pimitespib; median PFS after crossover was 2.7 (95% CI 0.7-4.1) months. The most common (≥30%) treatment-related adverse events (AEs) with pimitespib were diarrhea (74.1%) and decreased appetite (31.0%); the most common (≥10%) grade ≥3 treatment-related AE was diarrhea (13.8%). Treatment-related AEs leading to pimitespib discontinuation occurred in 3 (5.2%) patients.

CONCLUSION

Pimitespib significantly improved PFS and crossover-adjusted OS compared with placebo and had an acceptable safety profile in patients with advanced GIST refractory to standard TKIs.

Relation between nutrition therapy in the acute phase and outcomes of ventilated patients with COVID-19 infection: a multicenter prospective observational study

BACKGROUND

Optimal nutrition therapy has not yet been established for the acute phase of severe coronavirus disease 2019 (COVID-19) infection.

OBJECTIVES

We aimed to examine the effects of nutrition delivery in the acute phase on mortality and the long-term outcomes of post-intensive care syndrome (PICS).

METHODS

A multicenter prospective study was conducted on adult patients with COVID-19 infection requiring mechanical ventilation during an intensive care unit (ICU) stay. Daily total energy (kcal/kg) and protein (g/kg) deliveries in the first week of the ICU stay were calculated. The questionnaire for PICS evaluation was mailed within a median of 6 mo after hospital discharge. The primary outcome was in-hospital mortality, and secondary outcomes were the PICS components of physical impairment, cognitive dysfunction, and mental illness.

RESULTS

Among 414 eligible patients, 297 who received mechanical ventilation for 7 d or longer were examined. PICS was evaluated in 175 patients among them. High protein delivery on days 4-7 correlated with a low in-hospital mortality rate. In contrast, high protein delivery on days 1-3 correlated with physical impairment. A multivariate logistic regression analysis adjusted for age, sex, BMI, and severity revealed that average energy and protein deliveries on days 4-7 correlated with decreased in-hospital mortality (OR: 0.94; 95% CI: 0.89, 0.99; P = 0.013 and OR: 0.40; 95% CI: 0.17, 0.93; P = 0.031, respectively). Nutrition delivery did not correlate with PICS outcomes after adjustments. In the multivariate regression using a restricted cubic spline model, in-hospital mortality monotonically decreased with increases in average nutrition delivery on days 4-7.

CONCLUSIONS

In patents with COVID-19 on mechanical ventilation for ≥7 d, nutrition delivery in the late period of the acute phase was monotonically associated with a decrease in in-hospital mortality. Adequate protein delivery is needed on days 4-7.This trial was registered at https://www.umin.ac.jp as UMIN000041276.

Interleukin-32 regulates downstream molecules and promotes the invasion of pancreatic cancer cells

Pancreatic cancer is a malignant neoplasm with high invasiveness and poor prognosis. In a previous study, a highly invasive pancreatic cancer cell line was established and found to feature enhanced interleukin-32 (IL-32) expression. However, whether IL-32 promotes the invasiveness by enhancing or suppressing the expression of IL-32 through regulating downstream molecules was unclear. To investigate the effect of IL-32, cells were established with high levels of expression or downregulated IL-32; their invasive ability was measured using a real-time measurement system and the expression of some candidate downstream molecules involved in invasion was evaluated in the two cell types. The morphological changes in both cell types and the localization of IL-32 expression in pancreatic cancer tissues were studied using immunohistochemistry. Among the several splice variants of IL-32, cells transfected with the ε isoform had increased invasiveness, whereas the IL-32-suppressed cells had reduced invasiveness. Several downstream molecules, whose expression was changed in the two cell types, were monitored. Notably, changes of E-cadherin, CLDN1, CD44, CTGF and Wnt were documented. The morphologies of the two cell types differed from the original cell line. Immunohistochemically, the expression of IL-32 was observed only in tumor cells and not in normal pancreatic cells. In conclusion, IL-32 was found to promote the invasiveness of pancreatic cancer cells by regulating downstream molecules.

Accurate axillary staging by superparamagnetic iron oxide-enhanced MRI at 1.5 T with fat-suppression sequence as an alternative to sentinel node biopsy in breast cancer

Superparamagnetic iron oxide (SPIO)-enhanced MRI at 1.5 T with fat-suppression sequence is useful for the detection of metastases in sentinel nodes localized by CT lymphography in patients with breast cancer. SPIO-enhanced MRI may offer an alternative to sentinel node biopsy and avoid axillary surgery itself for patients with breast cancer who have negative sentinel nodes on SPIO-enhanced MRI.

Utility of Ethylene-Diamine-Tetraacetic Acid Buffer Solution With Boric Acid for Immunostaining of Specimens Stored for an Extended Period

Antigen modification and denaturation are recognized causes of false negatives in immunostaining. Specimens that have been stored for an extended period at room temperature show decreased immunoreactivity and may mislead the diagnosis. Studies of the molecular targeting of drugs often involve immunostaining of previous samples and, in some situations, only unstained specimens can be used. The present study aimed to develop an effective staining method to recover antigen activation in unstained specimens stored for an extended period by using ethylene-diamine-tetraacetic acid (EDTA) buffer solution with boric acid. We compared several commonly used antigen retrieval solutions and found that Tris-borate-EDTA (TBE) buffer solution with a pH ≥8.3 provided sufficient antigen retrieval. However, pH values higher than 8.3 (9.0, 10.0, and 11.0) frequently caused severe tissue damage. Thus, TBE with pH 8.3 was the most suitable antigen retrieval solution for recovering the antigenicity of specimens stored for an extended period. This procedure may allow useful immunohistochemical information, even from sections that have been stored for an extended period.

The potential diagnostic significance of crypt differentiation in gastric dysplasia

AIMS

This study investigated the relationship between the differentiation of tumour cells into crypts, which is determined by cell differentiation into Paneth and neuroendocrine cells, and tumour infiltration in gastric dysplasia.

METHODS AND RESULTS

The lesions were endoscopically biopsied low-grade dysplasia (LGD), endoscopically resected high-grade dysplasia (HGD), or cancer with submucosal invasion. LGD (n = 32) displayed crypt differentiation across the entire width of the tumour in all cases. Crypt differentiation was identified as a characteristic of tumours with low biological malignancy. HGD (n = 40) included tumours with a mixture of areas with and without crypt differentiation (n = 25) and tumours with crypt differentiation throughout the entire width (n = 15). Of the cancers with submucosal invasion (n = 30), the morphological progression of HGD area with crypt differentiation, HGD area without crypt differentiation and invasive cancer without crypt differentiation was confirmed for 23 samples. In two lesions, invasive cancer without crypt differentiation developed from HGD without crypt differentiation throughout the tumour width. In five samples, well-differentiated tubular adenocarcinoma with crypt differentiation developed from HGD with crypt differentiation and invaded with lamina propria-like stroma.

CONCLUSIONS

Loss of crypt differentiation could be an objective indicator of infiltration in the progression of HGD to invasive cancer. The invasive potential of dysplasia depends on the presence or absence of crypt differentiation.

Impact of beta-lactamase detection reagent on rapid diagnosis of ESBL-producing pathogens using urine samples of patients with Gram-negative bacteriuria

INTRODUCTION

The rapid increase of extended-spectrum beta-lactamase (ESBL)-producing pathogens makes it difficult to choose appropriate antimicrobials in patients with Gram-negative bacterial infection. The Cica-beta reagent (Kanto Chemical, Tokyo, Japan) is a chromogenic test that detects ESBLs from bacterial colonies. This study aimed to reveal whether Cica-beta reagent could detect ESBLs directly from urine samples to facilitate rapid diagnosis of antibiotic susceptibility.

METHODS

A prospective study was conducted from July 2019 to November 2019. Patients in whom urine culture tests were performed were eligible. Each urine sample was centrifuged, and the pellet was mixed with Cica-beta reagent. The test was considered positive when the enzymatic reaction turned from yellow to red or orange.

RESULTS

In total, 350 urine samples were analysed. Urinary tract infection (UTI) was diagnosed in 214 patients. ESBL-producing Enterobacterales were isolated from 79 samples. The Cica-beta test showed sensitivity of 79.8% and specificity of 99.3% in patients with Gram-negative bacteriuria. Sensitivity and specificity improved to 90.2% and 100%, respectively, in patients with UTI.

CONCLUSION

The Cica-beta test could be an efficient test for the detection of ESBL-producing pathogens in urine. By providing immediate information about ESBLs, it might be a useful point-of-care test to guide appropriate antimicrobial use in patients with UTI.

Post-Intensive Care Syndrome and Its New Challenges in Coronavirus Disease 2019 (COVID-19) Pandemic: A Review of Recent Advances and Perspectives

Intensive care unit survivors experience prolonged physical impairments, cognitive impairments, and mental health problems, commonly referred to as post-intensive care syndrome (PICS). Previous studies reported the prevalence, assessment, and prevention of PICS, including the ABCDEF bundle approach. Although the management of PICS has been advanced, the outbreak of coronavirus disease 2019 (COVID-19) posed an additional challenge to PICS. The prevalence of PICS after COVID-19 extensively varied with 28-87% of cases pertaining to physical impairments, 20-57% pertaining to cognitive impairments, and 6-60% pertaining to mental health problems after 1-6 months after discharge. Each component of the ABCDEF bundle is not sufficiently provided from 16% to 52% owing to the highly transmissible nature of the virus. However, new data are emerging about analgesia, sedation, delirium care, nursing care, early mobilization, nutrition, and family support. In this review, we summarize the recent data on PICS and its new challenge in PICS after COVID-19 infection.

Establishment of highly invasive pancreatic cancer cell lines and the expression of IL-32

Compared to tumors of other organs, pancreatic cancer is highly aggressive; with one of its biological features being that, despite a prominent fibrotic stroma, there is remarkable infiltration of tumor cells. This characteristic is considered to be the main reason for the poor prognosis of patients with pancreatic cancer. Therefore, in order to elucidate the factors that contribute to this high invasiveness, a selective invasion method was used to establish four highly invasive subclones from six human pancreatic cancer cell lines. The results demonstrated that two cell lines did not exhibit enhanced invasiveness. Microarray analysis revealed that, in the highly invasive cell lines, several genes were expressed at high levels, compared with the original cell lines. These highly expressed genes were recognized only in highly invasive cells. Among them, IL-32 was most strongly upregulated in the highly invasive cells, compared with cells with a low invasive potential, as well as the original cells. RT-qPCR and western blot analysis confirmed the high levels of expression of IL-32 in highly invasive cells at the RNA and protein levels. In addition, immunohistochemical analysis of resected surgical materials revealed that the tumor cells expressed IL-32 and, in particular, many IL-32 positive cells were seen at the invasive front of the tumor tissue. IL-32 is a cytokine that is widely involved in the development of cancer and has recently received considerable attention. This cytokine has multiple splice variants and shows a wide variety of behaviors, depending on the tumor type and primary organ. Although some hypotheses have been proposed to explain the activity of IL-32, a unified view has not been agreed. In the present study, through the establishment of highly invasive cells from pancreatic cancer and a comprehensive gene analysis, it is suggested that IL-32 may serve an important role as a molecule involved in the invasiveness of this neoplasm.

Application of ultra-high voltage electron microscope tomography to 3D imaging of microtubules in neurites of cultured PC12 cells

Electron tomography methods using the conventional transmission electron microscope have been widely used to investigate the three-dimensional distribution patterns of various cellular structures including microtubules in neurites. Because the penetrating power of electrons depends on the section thickness and accelerating voltage, conventional TEM, having acceleration voltages up to 200 kV, is limited to sample thicknesses of 0.2 µm or less. In this paper, we show that the ultra-high voltage electron microscope (UHVEM), employing acceleration voltages of higher than 1000 kV (1 MV), allowed distinct reconstruction of the three-dimensional array of microtubules in a 0.7-µm-thick neurite section. The detailed structure of microtubules was more clearly reconstructed from a 0.7-µm-thick section at an accelerating voltage of 1 MV compared with a 1.0 µm section at 2 MV. Furthermore, the entire distribution of each microtubule in a neurite could be reconstructed from serial-section UHVEM tomography. Application of optimised UHVEM tomography will provide new insights, bridging the gap between the structure and function of widely-distributed cellular organelles such as microtubules for neurite outgrowth. LAY DESCRIPTION: An optimal 3D visualisation of microtubule cytoskeleton using ultra-high voltage electron microscopy tomography The ultra-high voltage electron microscope (UHVEM) is able to visualise a micrometre-thick specimen at nanoscale spatial resolution because of the high-energy electron beam penetrating such a specimen. In this study, we determined the optimal conditions necessary for microtubule cytoskeleton imaging within 0.7-µm-thick section using a combination with UHVEM and electron tomography method. Our approach provides excellent 3D information about the complex arrangement of the individual microtubule filaments that make up the microtubule network.

Utility of the Eating Assessment Tool-10 (EAT-10) in Evaluating Self-Reported Dysphagia Associated with Oral Frailty in Japanese Community-Dwelling Older People

OBJECTIVES

The aim of the present study was to verify the associations between dysphagia as screened by the Eating Assessment Tool-10 (EAT-10) and indicators in the 100-mL water swallowing test (WST) or medical history among community-dwelling older people.

STUDY DESIGN

A cross-sectional study.

SETTING AND PARTICIPANTS

The study participants were 202 community-dwelling older Japanese adults aged ≥65 years.

MEASUREMENTS

We investigated the participants' basic attributes, including age, sex, body mass index, medical history (cerebrovascular disease, respiratory disease: chronic obstructive pulmonary disease [COPD], and history of pneumonia within the previous year), and number of prescribed medications. Dysphagia assessment was performed using the EAT-10 and the 100-mL WST as subjective and objective examinations, respectively. The 100-mL WST used four indicators (SC: swallowing capacity, VS: volume per swallow, TS: time per swallow, and choking signs). Patients with and without dysphagia according to the EAT-10 were divided into two groups according to a cutoff score of 3, and the two groups were then compared in terms of their characteristics including medical history and 100-mL WST indicators. A multiple logistic regression model was used to determine whether the indicators of the 100-mL WST or medical history were independently associated with dysphagia in the EAT-10.

RESULTS

The multiple logistic regression analysis revealed that dysphagia in the EAT-10 was independently associated with male sex (odds ratio [OR] = 2.78; 95% confidence interval [CI] = 0.98-7.90), COPD (OR = 14.68; 95% CI = 3.14-68.85), and VS and TS in the 100-mL WST (OR = 0.85; 95% CI = 0.80-0.90 and OR = 3.03; 95% CI = 1.78-5.16, respectively).

CONCLUSIONS

Our results revealed that the EAT-10 was independently associated with the 100-mL WST and respiratory disease. We propose that swallowing rehabilitation incorporating respiratory training could be effective for older people screened using the EAT-10.

1044 Simple echocardiographic scoring in screening for aortic stenosis by emergency physicians in the emergency department

Background; Aortic stenosis (AS) is one of the important critical diseases and may influence hemodynamics in cardiovascular or non-cardiovascular emergency, however, there is no established methodology to diagnose AS in a focused cardiac ultrasound (FOCUS). We have previously reported that our developed visual AS score was a simple index for AS screening using rapid echocardiography and it could successfully diagnose clinically significant AS. The purpose of the present study was to evaluate the diagnostic accuracy of visual AS score assessed by emergency physicians in the emergency department. Methods; Visual AS score was calculated as the sum of the scores of each three aortic cusp’s opening in a short-axis view scored as follows: 0 = not restricted, 1 = restricted, or 2 = severely restricted; and classified in 0 – 6 as we previously reported. Emergency physicians who did not specialize in cardiology or ultrasonography underwent basic 30 minutes training to visualize aortic valve in a short-axis view and to assess visual AS score beforehand. They performed echocardiography and evaluated visual AS score in emergency outpatients with suspected cardiovascular diseases such as chest symptom, consciousness disorder, abnormal vital signs, heart murmur or abnormal electrocardiogram in the emergency department. Then, another assessment of visual AS score and complete echocardiography including quantitative assessment of AS was performed by expert sonographers. Aortic valve area index (AVAI) was calculated using continuity equation and body surface area, and an AVAI &gt; 0.85 cm/m2, 0.6 - 0.85 cm/m2, and &lt; 0.6 cm/m2 were defined as none or mild, moderate and severe AS, respectively. Results: Sixty patients underwent evaluations of visual AS score by emergency physicians. Visual AS score could not be assessed in 5 patients and continuity equation could not be evaluated in 2 patients, both due to poor echocardiographic imaging quality. Visual AS scores assessed by emergency physicians and expert sonographers showed strong positive correlation (R = 0.94, P &lt; 0.0001). Fourteen patients (26 %) including 6 with shock or hypotension, 3 with congestive heart failure, 2 with syncope, 1 with acute myocardial infarction, 1 with suspected cardiac tamponade and 1 with abnormal electrocardiogram had moderate or more degree of AS in complete echocardiography performed by expert sonographers. Visual AS score 3 or more assessed by emergency physicians had 86 %, 100 %, 100 % and 95 % of a diagnostic sensitivity, specificity, positive predictive value and negative predictive value, respectively. Conclusion: Visual AS score in FOCUS is useful to screen for AS for emergency physicians who do not specialize in cardiology.

P1358 New insights into cardiac dysfunction assessed by left atrial function in patients with type 1 diabetes mellitus

BACKGROUND

There have been many reports of heart failure due to diabetic cardiomyopathy and decreased left ventricular (LV) function with increasing age in patients with type 1 diabetes mellitus (T1DM). Recently, although left atrial (LA) function has been occasionally reported to be a more useful prognostic indicator than LV function in acquired heart diseases, LA function in patients with T1DM has not yet been studied.

PURPOSE

To investigate LA dysfunction in patients with T1DM.

METHODS

Fifty patients with T1DM were recruited (age, 5–41 years). We excluded patients who had a history of heart disease, hypertension, and those taking cardioprotective agents. The patients and 50 age-matched controls were classified into 3 age groups (D1, C1, 5–14 years; D2, C2, 15–29 years; D3, C3, 30–41 years). The LA phasic function serving as the reservoir, conduit, and pump strains; the LA strain rate (SR) in the systole, early diastole, and late diastole; and the LV global longitudinal strain (LV-LS) as determined via 2-dimensional speckle tracking imaging were measured from the apical four- and two-chamber views. We also calculated the LA stiffness index as the ratio of E/e’ to the LA reservoir strain.

RESULTS

There was no significant difference in left ventricular ejection fraction in each age group. The LA reservoir strains in D2 and D3 were significantly lower than those in C2 (40.8 ± 5.7% vs. 47.2 ± 5.5%, p = 0.005) and C3 (39.2 ± 5.5% vs. 47.3 ± 5.7%, p = 0.004), respectively. The LA conduit strain in D2 was significantly lower than that in C2 (28.9 ± 5.8% vs. 35.0 ± 5.0%, p = 0.006). The LA pump strain and the three phases of LA SR were not significantly different among the age groups. The LA stiffness index in D3 increased significantly compared to that in N3 (0.18 ± 0.05 vs. 0.13 ± 0.01, p &lt;0.001). The LV-LS in D2 and D3 was significantly lower than that in C2 (-15.7 ± 1.7% vs. -18.7 ± 2.1%, p &lt;0.001) and C3 (-15.3 ± 1.8% vs. -19.3 ± 2.0%, p &lt;0.001), respectively. The LA reservoir strain significantly correlated with LV-LS (r = -0.468, p &lt; 0.001). Both the LA reservoir strain and LV-LS in patients with T1DM decreased significantly (p = 0.028, p &lt; 0.042, respectively) and correlated with increasing age (r = -0.323, r = 0.286, respectively). The LV stiffness index did not correlate with age or LV-LS.

CONCLUSIONS

The LA reservoir strain might be as useful as LV-LS as an early marker of cardiac dysfunction in patients with T1DM. The correlation coefficient between the LA reservoir strain and LV-LS was not strong. Therefore, although LV-LS might affect the LA reservoir strain, it might represent other aspects of cardiac dysfunction. The increase of LA stiffness might represent the changes in LA wall properties and could be another useful indicator of cardiac dysfunction during long-term follow-ups, which is independent of LV-LS. Overall, these findings provide new insights into cardiac dysfunction in patients with T1DM.

Long-Term Results and Follow-Up Examinations after Endovascular Embolization for Unruptured Cerebral Aneurysms

BACKGROUND AND PURPOSE

The appropriate period of follow-up examinations after endovascular embolization for cerebral aneurysms using time-of-flight MR angiography is not well-known. We retrospectively investigated long-term results after endovascular embolization for unruptured cerebral aneurysms and evaluated the periods from embolization to recanalization and retreatment.

MATERIALS AND METHODS

Between April 2006 and March 2011, one hundred forty-eight unruptured aneurysms were treated with endovascular coil embolization. Among them, we investigated 116 unruptured aneurysms, which were followed up for >5 years. Time-of-flight MR angiography was performed at 1 day, 3-6 months, 1 year after the procedure, and every year thereafter.

RESULTS

The mean follow-up period was 7.0 ± 1.4 years. Recanalization was observed in 19 (16.3%) aneurysms within 2 years. Among them, retreatment for recanalization was performed in 8 (6.8%) aneurysms. No recanalization was detected in any aneurysms that had been stable in the first 2 years after embolization. A larger maximum aneurysm size was significantly correlated with recanalization (P = .019).

CONCLUSIONS

Aneurysms in which recanalization was not observed within 2 years after endovascular coil embolization were stable during a mean follow-up of 7 years. This result may be helpful in considering the appropriate span or frequency of follow-up imaging for embolized cerebral aneurysms.

Trajectory Prediction with a Conditional Variational Autoencoder

Conventional motion planners do not rely on previous experience when presented with a new problem. Trajectory prediction algorithms solve this problem using a pre-existing dataset at runtime. We propose instead using a conditional variational autoencoder (CVAE) to learn the distribution of the motion dataset and hence to generate trajectories for use as priors within the traditional motion planning approaches. We demonstrate, through simulations and by using an industrial robot arm with six degrees of freedom, that our trajectory prediction algorithm generates more collision-free trajectories compared to the linear initialization, and reduces the computation time of optimization-based planners.

Intra-arterial infusion of fasudil hydrochloride to treat post-traumatic cerebral vasospasm

Background

The effect of intra‐arterial infusion of fasudil hydrochloride in patients with post‐traumatic cerebral vasospasm remains unclear. Here we report a case of intra‐arterial infusion of fasudil hydrochloride for post‐traumatic cerebral vasospasm.

Case presentation

A 47‐year‐old man was transferred to our hospital with a fractured skull and traumatic subarachnoid hemorrhage. As rhinorrhea of cerebrospinal fluid had not improved, repair surgery was carried out on day 4. Aphasia appeared on day 13. Magnetic resonance imaging and angiography showed an ischemic region in the left temporal lobe and vasospasm of the left middle cerebral artery. We immediately carried out angiography and diagnosed severe vasospasm of the M1 region of the left middle cerebral artery. After placing a microcatheter into the proximal middle cerebral artery, we injected fasudil hydrochloride intra‐arterially. Vasospasm improved and aphasia resolved.

Conclusion

In this case, intra‐arterial infusion of fasudil hydrochloride was effective against post‐traumatic cerebral vasospasm.

Sarcopenia Is Not a Prognostic Factor of Outcome in Patients With Cervical Cancer Undergoing Concurrent Chemoradiotherapy or Radiotherapy

BACKGROUND/AIM

The objective of this study was to determine if sarcopenia was a predictor of poor prognosis in patients with cervical cancer (CC) undergoing concurrent chemoradiation therapy (CCRT) or radiation therapy (RT).

MATERIALS AND METHODS

A total of 236 patients with CC undergoing CCRT or RT were retrospectively examined. We determined if clinical characteristics and survival were correlated with pretreatment sarcopenia, measured as psoas muscle index (PI) or skeletal muscle index (SMI).

RESULTS

Pretreatment PI and SMI were related to parametrial involvement with CC undergoing CCRT or RT (p=0.002, and, p=0.034, respectively). The median progression-free survival (PFS) and overall survival (OS) times in patients undergoing CCRT or RT were 29.0 and 34.5 months, respectively. Neither PI nor SMI were prognostic predictors in patients with CC undergoing CCRT or RT.

CONCLUSION

Sarcopenia is not a predictive factor of outcome in patients with CC undergoing CCRT or RT.

Outcomes in patients with infections and augmented renal clearance: A multicenter retrospective study

Recently, augmented renal clearance (ARC), which accelerates glomerular filtration of renally eliminated drugs thereby reducing the systemic exposure to these drugs, has started to receive attention. However, the clinical features associated with ARC are still not well understood, especially in the Japanese population. This study aimed to evaluate the clinical characteristics and outcomes of ARC patients with infections in Japanese intensive care unit (ICU) settings. We conducted a retrospective observational study from April 2013 to May 2017 at two tertiary level ICUs in Japan, which included 280 patients with infections (median age 74 years; interquartile range, 64–83 years). We evaluated the estimated glomerular filtration rate (eGFR) at ICU admission using the Japanese equation, and ARC was defined as eGFR >130 mL/min/1.73 m². Multivariable logistic regression analysis was performed to identify the independent risk factors for ARC and to determine if it was a predictor of ICU mortality. In addition, a receiver operating curve (ROC) analysis was performed, and the area under the ROC (AUROC) was determined to examine the significant variables that predict ARC. In total, 19 patients (6.8%) manifested ARC. Multivariable logistic regression analysis identified younger age as an independent risk factor for ARC (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.91–0.96). However, ARC was not found to be a predictor of ICU mortality (OR, 0.57; 95% CI, 0.11–2.92). In addition, the AUROC of age was 0.79 (95% CI, 0.68–0.91), and the optimal cut off age for ARC was ≤63 years (sensitivity, 68.4%; specificity, 78.9%). The incidence of ARC was, therefore, low among patients with infections in the Japanese ICUs. Although younger age was associated with the incidence of ARC, it was not an independent predictor of ICU mortality.

Comparison of accuracy of presepsin and procalcitonin concentrations in diagnosing sepsis in patients with and without acute kidney injury

BACKGROUND

Levels of the biomarkers presepsin and procalcitonin are affected by renal function. We evaluated the accuracies of presepsin and procalcitonin levels for diagnosing sepsis in patients with and without acute kidney injury (AKI).

METHODS

We evaluated patients with presepsin and procalcitonin data, and classified them into AKI and non-AKI groups based on the Kidney Disease Improving Global Outcomes criteria. Each group was then subdivided according to sepsis status for each stage of AKI. Receiver operating characteristic curve analyses were used to investigate the accuracies of biomarker levels for diagnosing sepsis.

RESULTS

In the non-AKI group, the area under the curves (AUCs) for procalcitonin and presepsin levels were 0.897 and 0.880, respectively (p = .525) and optimal cut-off values were 0.10 ng/ml (sensitivity: 85.1%, specificity: 79.1%) and 240 pg/ml (sensitivity: 80.9%, specificity: 83.2%), respectively. In the stage 3 subgroup, the AUC for procalcitonin (0.946) was significantly higher than that for presepsin (0.768, p < .001). The optimal cut-off values for diagnosing sepsis were 4.07 ng/ml (sensitivity: 87.2%, specificity: 93.5%) for procalcitonin and 500 pg/ml (sensitivity: 89.7%, specificity: 59.7%) for presepsin.

CONCLUSIONS

In patients with severe AKI, the accuracy of the diagnosis of sepsis with procalcitonin was significantly higher than with presepsin.

Developing a Remotely Operated Portable Mobile Robot

The Tsukuba Challenge is one of the few technical events where it is permitted to conduct demonstrations of autonomous mobile robots on a public road in a city. Thus, when limited trial runs are available several times per year, domestic and foreign teams must bring robots to the venue and conduct experiments using robots and observation instruments. For a team located far away from the venue, the cost of transporting equipment and staff each time becomes prohibitive. In this research, to reduce the cost of transporting robots and personnel, we design and develop a mobile robot platform that is easy to transport and deploy. Additionally, to allow remote experts to generate maps and routes without visiting the site, we construct a remote operating system that operates over the internet. In this paper, we describe the portable mobile robot platform and the software configuration needed for remote operation. Then, we report the results of our verification test.

Clinical impact of endometrial cancer stratified by genetic mutational profiles, POLE mutation, and microsatellite instability

BACKGROUND

The molecular characterization of endometrial cancer (EC) can facilitate identification of various tumor subtypes. Although EC patients with POLE mutations reproducibly demonstrate better prognosis, the outcome of patients with microsatellite instability (MSI) remains controversial. This study attempted to interrogate whether genetic stratification of EC can identify distinct subsets with prognostic significance.

MATERIALS AND METHODS

A cohort of 138 EC patients who underwent surgical resection with curative intent was enrolled. Sanger sequencing was used to evaluate mutations in the POLE and KRAS genes. MSI analysis was performed using four mononucleotide repeat markers and methylation status of the MLH1 promoter was measured by a fluorescent bisulfite polymerase chain reaction (PCR). Protein expression for mismatch repair (MMR) proteins was evaluated by immunohistochemistry (IHC).

RESULTS

Extensive hypermethylation of the MLH1 promoter was observed in 69.6% ECs with MLH1 deficiency and 3.5% with MMR proficiency, but in none of the ECs with loss of other MMR genes (P < .0001). MSI-positive and POLE mutations were found in 29.0% and 8.7% EC patients, respectively. Our MSI analysis showed a sensitivity of 92.7% for EC patients with MMR deficiency, and a specificity of 97.9% for EC patients with MMR proficiency. In univariate and multivariate analyses, POLE mutations and MSI status was significantly associated with progression-free survival (P = 0.0129 and 0.0064, respectively) but not with endometrial cancer-specific survival.

CONCLUSIONS

This study provides significant evidence that analyses of proofreading POLE mutations and MSI status based on mononucleotide repeat markers are potentially useful biomarkers to identify EC patients with better prognosis.

Adjunctive perampanel in partial-onset seizures: Asia-Pacific, randomized phase III study

OBJECTIVES

To evaluate the efficacy, safety, and tolerability of perampanel, a selective, non-competitive, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor antagonist, as an adjunctive treatment for patients with refractory partial-onset seizures (POS) from Asia-Pacific.

MATERIALS & METHODS

This multicenter, randomized, double-blind, placebo-controlled trial (ClinicalTrials.gov identifier: NCT01618695) involved patients aged ≥12 years with refractory POS (receiving 1-3 antiepileptic drugs). Patients were randomized (1:1:1:1) to receive once-daily placebo or perampanel 4, 8, or 12 mg over a 6-week titration and 13-week maintenance double-blind period. Enzyme-inducing antiepileptic drugs were equally stratified between groups. The primary efficacy endpoint was percent change in POS frequency per 28 days (double-blind phase vs baseline). Other efficacy endpoints included ≥50% responder rate and seizure freedom. Treatment-emergent adverse events (TEAEs) were also monitored.

RESULTS

Of 710 randomized patients, seizure frequency data were available for 704 patients. Median percent changes in POS frequency per 28 days indicated dose-proportional reductions in seizure frequency: -10.8% with placebo and -17.3% (P = .2330), -29.0% (P = .0003), and -38.0% (P < .0001) with perampanel 4, 8, and 12 mg, respectively. In total, 108 (15.3%) patients discontinued treatment; 44 (6.2%) due to TEAEs. TEAEs occurring in ≥5% of patients, and reported at least twice as frequently with perampanel vs placebo, included dizziness and irritability.

CONCLUSIONS

Adjunctive perampanel (8 and 12 mg/d) significantly improved seizure control in patients with refractory POS. Safety and tolerability were acceptable at daily doses of perampanel 4-12 mg.

Development of Robot for 3D Measurement of Forest Environment

This paper describes the development of a robot that can move through a forest environment and automatically generates three-dimensional (3D) digital maps. We designed and constructed the robot, equipping it with a rocker-bogie mechanism composed of six drive wheels and four steering motors. This mechanics enables the robot to move damaging a forest as little as possible while negotiating the obstacle in it. This robot is equipped with a 3D light detection and ranging sensor, and it uses the normal distributions transform algorithm to construct 3D digital maps. We tested the generation of a 3D digital map of 50 m2of a sloped forest environment and verified the generated map by comparing it with a map constructed manually by engineers. The comparison revealed an error of less than 0.15 m.

The impact of external fixation on mortality in patients with an unstable pelvic ring fracture: a propensity-matched cohort study

AIM

There is not adequate evidence to establish whether external fixation (EF) of pelvic fractures leads to a reduced mortality. We used the Japan Trauma Data Bank database to identify isolated unstable pelvic ring fractures to exclude the possibility of blood loss from other injuries, and analyzed the effectiveness of EF on mortality in this group of patients.

PATIENTS AND METHODS

This was a registry-based comparison of 1163 patients who had been treated for an isolated unstable pelvic ring fracture with (386 patients) or without (777 patients) EF. An isolated pelvic ring fracture was defined by an Abbreviated Injury Score (AIS) for other injuries of < 3. An unstable pelvic ring fracture was defined as having an AIS ≥ 4. The primary outcome of this study was mortality. A subgroup analysis was carried out for patients who required blood transfusion within 24 hours of arrival in the Emergency Department and those who had massive blood loss (AIS code: 852610.5). Propensity-score matching was used to identify a cohort like the EF and non-EF groups.

RESULTS

With the use of propensity-score matching using the completed data, 346 patients were matched. When the propensity-score matching was adjusted, EF was associated with a significantly lower risk of death (p = 0.047). In the subgroup analysis of patients who needed blood transfusion within 24 hours and those who had massive blood loss, EF was associated with a significantly lower risk of death in patients who needed blood transfusion within 24 hours (p = 0.014) and in those with massive blood loss (p = 0.016).

CONCLUSION

The use of EF to treat unstable pelvic ring fractures was associated with a significantly lower risk of death, especially in patients with severe fractures. Cite this article: Bone Joint J 2018;100-B:233-41.

Endoglin (CD105) and SMAD4 regulate spheroid formation and the suppression of the invasive ability of human pancreatic cancer cells

In this study, we investigated the ability of pancreatic cancer cell lines to form spheroids with the aim of identifying factors involved in cell invasiveness, a property that leads to a poor prognosis in pancreatic cancer. For this purpose, 8 cell lines derived from human pancreatic cancer tissues were cultured in non-adherent culture conditions to form spheroids, as well as normal monolayers. The morphology of the cells was observed and spheroid diameters measured. mRNA expression was compared between cells cultured under both culture conditions. The gene knockdown of endoglin (ENG) and SMAD4, components of the transforming growth factor-β (TGF-β) signaling system, using siRNAs was conducted in spheroids in order to identify affected protein signaling factors, determine the morphological changes occurring over time and to measure the invasive capacity of the cells constituting spheroids. The cell lines exhibited differences in their spheroid-forming abilities. The expression of SMAD4 and ENG concomitantly increased in the cells that formed spheroids. SMAD4 was transported into the nucleus when spheroids were formed. The expression of ENG was decreased in the cells in which SMAD4 was knocked down; by contrast, the expression of BMP and activin membrane-bound inhibitor (BAMBI) and noggin (NOG), further components of the TGF-β signaling system, increased. In the cells in which ENG was knocked down, the decreased mRNA expression of TGF-β receptor type 2 (TGFBR2) and SMAD9 was observed, as well as a change in the expression of pSMAD1/5/9, and a tendency of spheroids to decrease in size. Spheroids cultured on Matrigel exhibited a tendency towards a reduction in size over time, as well as a tendency to invade into the Matrigel. In particular, the cells in which ENG was knocked down exhibited spheroids which were reduced in size, and also exhibited an increase in invasiveness, and a decrease in adhesiveness. Thus, our data indicate that in pancreatic cancer cells, the expression of ENG may be controlled by a pathway mediated by SMAD4. In addition, ENG was found to be related to the spheroid-forming ability of cells and to be involved in the invasive capacity of pancreatic cancer cells.

Facilitatory effect of insulin treatment on hepatocellular carcinoma development in diabetes

BACKGROUND

To evaluate the effect of insulin treatment on the incidence and/or severity of hepatocellular carcinoma (HCC) in a mouse model of HCC based on diabetes.

METHODS

We recently reported that neonatal streptozotocin (STZ) treatment causes type 1 diabetes and subsequent HCC in ddY, Institute for Animal Reproduction (DIAR) mice. Newborn male DIAR mice were divided into three groups based on STZ and insulin (INS) treatment. STZ was subcutaneously injected (60 mg/g) into the STZ-treated group (DIAR-nSTZ mice, N = 13) and the STZ/insulin-treated group (DIAR-nSTZ/INS mice, N = 20). A physiologic solution was injected into the control group (DIAR-control mice, N = 8) 1.5 days after birth. Insulin was subcutaneously injected into the DIAR-nSTZ/INS mice according to the following protocol: 2 IU/day at 4-5 weeks of age, 3 IU/day at 5-7 weeks of age, and 4 IU/day at 7-12 weeks of age. All mice were fed a normal diet and were subjected to physiological and histopathological assessments at 12 weeks of age.

RESULTS

DIAR-nSTZ mice had significantly lower body weight and higher blood glucose levels than DIAR-control mice, whereas no significant differences were observed between DIAR-nSTZ/INS mice and control mice. At 12 weeks of age, lower weight of paratesticular fat and higher levels of total cholesterol, triglyceride, and free fatty acids were observed in DIAR-nSTZ mice compared to DIAR-control mice, whereas there were no significant differences between DIAR-nSTZ/INS mice and DIAR-control mice. In the livers of DIAR-nSTZ mice, HCC was observed in 15% of cases, and dysplastic nodules were observed in 77% of cases. In the livers of DIAR-nSTZ/INS mice, HCC was observed in 39% of cases and dysplastic nodules were observed in 61% of cases (p = 0.011). Moreover, the average tumor size was significantly larger in STZ/INS-treated mice than in STZ-treated mice. Immunohistochemical analysis demonstrated that the expression of ERK1/2, downstream substrates of insulin signaling that activate cell proliferation, was significantly higher in STZ/INS-treated mice compared to STZ-treated mice.

CONCLUSIONS

Insulin treatment promoted, rather than inhibited, the progression of liver carcinogenesis in DIAR-nSTZ mice. Hyperinsulinemia rather than hyperglycemia can accelerate the progression of HCC via insulin signaling.