Comparison of the Effects of OPRM1 A118G Polymorphism Using Different Opioids: A Prospective Study

CONTEXT

μ-opioid receptor gene (OPRM1) A118G polymorphism (rs1799971) causes loss of N-glycosylation sites at the extracellular domain of μ-opioid receptors. G-allele carriers show a limited response to morphine; however, studies investigating the impact of A118G polymorphism on the efficacy of opioids other than morphine are limited.

OBJECTIVE

To compare the impact of A118G polymorphism on the efficacy of various opioids.

METHODS

This prospective cohort study enrolled 222 in-patients administered one of the following opioid therapies for cancer pain as part of an opioid introduction or rotation strategy: tapentadol extended-release tablets, methadone tablets, hydromorphone controlled-release tablets, oxycodone controlled-release tablets, or transdermal fentanyl patches. The impact of A118G polymorphism on the difference in the Brief Pain Inventory-Short Form score on days three, seven, and 14 from baseline was compared among the groups.

RESULTS

Overall, 81, 74, and 67 patients had the AA, AG, and GG genotypes, respectively, with an OPRM1 A118G G-allele variant frequency of 0.47. The reduction in the Brief Pain Inventory-Short Form score after opioid therapy initiation did not differ significantly among the patients with the three A118G genotypes treated with tapentadol (p = 0.84) or methadone (p = 0.97), whereas it was significantly smaller in G-allele carriers than that in AA homozygous patients treated with hydromorphone (p < 0.001), oxycodone (p = 0.031), or fentanyl (p < 0.001).

CONCLUSION

Tapentadol and methadone may be more suitable than hydromorphone, oxycodone, and fentanyl for G-allele carriers due to their dual mechanism of action and low susceptibility to OPRM1 A118G polymorphism.

A revision of JPOS/JASCC clinical guidelines for delirium in adult cancer patients: a summary of recommendation statements

OBJECTIVE

The Japanese Psycho-Oncology Society and the Japanese Association of Supportive Care in Cancer have recently revised the clinical practice guidelines for delirium in adult cancer patients. This article reports the process of developing the revised guidelines and summarizes the recommendations made.

METHODS

The guidelines were developed in accordance with the Medical Information Network Distribution Service creation procedures. The guideline development group, consisting of multi-disciplinary members, created three new clinical questions: non-pharmacological intervention and antipsychotics for the prevention of delirium and trazodone for the management of delirium. In addition, systematic reviews of nine existing clinical questions have been updated. Two independent reviewers reviewed the proposed articles. The certainty of evidence and the strength of the recommendations were graded using the grading system developed by the Medical Information Network Distribution Service, following the concept of The Grading of Recommendations Assessment, Development, and Evaluation system. The modified Delphi method was used to validate the recommended statements.

RESULTS

This article provides a compendium of the recommendations along with their rationales, as well as a short summary.

CONCLUSIONS

These revised guidelines will be useful for the prevention, assessment and management of delirium in adult cancer patients in Japan.

Differences in the Analgesic Effect of Opioids on Pain in Cancer Patients With Spinal Metastases

Background

Spinal metastasis pain includes both inflammatory and neuropathic pain, and opioids, which have only a μ-opioid receptor-stimulating effect, are generally less effective in neuropathic pain. However, no previous study has been conducted for the comparisons of the efficacy of opioids in treating spinal metastasis pain.

Objective

To compare the efficacy of tapentadol and methadone with other opioids for back pain caused by a metastatic spinal tumor.

Design

Retrospective cohort study.

Setting/Subjects

A total of 274 patients were enrolled, who started a tapentadol extended-release tablet, methadone tablet, hydromorphone extended-release tablet, oxycodone extended-release tablet, or transdermal fentanyl patch for cancer pain due to spinal metastasis in Japan from January 1, 2013 to October 31, 2021.

Measurements

The primary endpoint, the difference in the numerical rating scale (NRS) scores before and seven days after each opioid administration, was compared among the five groups.

Results

In patients with numbness, a decrease of the NRS score on day seven compared with before starting each opioid was significantly higher in the tapentadol group than those in the hydromorphone, oxycodone, and fentanyl groups and comparable to that in the methadone group. In patients without numbness, no significant differences were observed in decreases of the NRS scores on day seven among the five groups.

Conclusions

Tapentadol and methadone may be more effective than hydromorphone, oxycodone, and fentanyl for cancer pain due to spinal metastasis with numbness.

Adherence to inhaled corticosteroids and long-acting β2-agonists in asthma: A MASK-air study

INTRODUCTION

Adherence to controller medication is a major problem in asthma management, being difficult to assess and tackle. mHealth apps can be used to assess adherence. We aimed to assess the adherence to inhaled corticosteroids+long-acting β2-agonists (ICS+LABA) in users of the MASK-air® app, comparing the adherence to ICS+formoterol (ICS+F) with that to ICS+other LABA.

MATERIALS AND METHODS

We analysed complete weeks of MASK-air® data (2015-2022; 27 countries) from patients with self-reported asthma and ICS+LABA use. We compared patients reporting ICS+F versus ICS+other LABA on adherence levels, symptoms and symptom-medication scores. We built regression models to assess whether adherence to ICS+LABA was associated with asthma control or short-acting beta-agonist (SABA) use. Sensitivity analyses were performed considering the weeks with no more than one missing day.

RESULTS

In 2598 ICS+LABA users, 621 (23.9%) reported 4824 complete weeks and 866 (33.3%) reported weeks with at most one missing day. Higher adherence (use of medication ≥80% of weekly days) was observed for ICS+other LABA (75.1%) when compared to ICS+F (59.3%), despite both groups displaying similar asthma control and work productivity. The ICS+other LABA group was associated with more days of SABA use than the ICS+F group (median=71.4% versus 57.1% days). Each additional weekly day of ICS+F use was associated with a 4.1% less risk in weekly SABA use (95%CI=-6.5;-1.6%;p=0.001). For ICS+other LABA, the percentage was 8.2 (95%CI=-11.6;-5.0%;p<0.001).

CONCLUSIONS

In asthma patients adherent to the MASK-air app, adherence to ICS+LABA was high. ICS+F users reported lower adherence but also a lower SABA use and a similar level of control.

A Case of Radiation-Associated Vertebral Compression Fracture Mimicking Solitary Bone Metastasis of Lung Cancer

Radiation therapy plays an important role in the treatment of lung cancer. Although adverse effects of radiation are well known, they are sometimes difficult to be diagnosed. We report a case of a radiation-associated vertebral compression fracture which mimicked bone metastasis of lung cancer. The patient was a 57-year-old man diagnosed with lung squamous cell carcinoma (cT1aN2M0, c-stage IIIA). He received concurrent chemoradiotherapy (CRT) in combination with 6 weeks of weekly carboplatin plus paclitaxel and thoracic radiation of 60 Gy/30 fractions, followed by bi-weekly durvalumab for 12 months. On the last day of the 12-month durvalumab regimen, he complained of backache. Magnetic resonance imaging showed compression fracture of the seventh thoracic vertebra with the spinal cord compressed, and fluorine-18 fluorodeoxyglucose positron emission tomography and computed tomography demonstrated weak focal uptake only at the seventh thoracic vertebra. Although the fracture had been suspected to be bone metastasis, surgical biopsy revealed no evidence of malignancy. Since the seventh thoracic vertebra was included in the irradiation area, the patient was diagnosed with a radiation-associated fracture. Dual-energy X-ray absorptiometry of the lumbar vertebrae (L2 - 4) after the surgery revealed osteopenia. In conclusion, we successfully diagnosed the radiation-associated vertebral fracture caused by radical CRT. The fracture mimicked bone metastasis in preoperative imaging tests. Thus, surgical biopsy was useful for diagnosis.

Identification of Factors Contributing to Methadone-Induced Daytime Sleepiness in Cancer Patients and Proposal of the Conversion Ratio from Other Opioids to Oral Methadone: A Retrospective Cohort Study

Background

When methadone is used to treat cancer pain, the Japanese health insurance system recommends to determine the starting dose according to the equivalency conversion table based on the morphine-equivalent daily dose (MEDD) of prior opioids proposed by the National Comprehensive Cancer Network. Owing to the wide range in variability of the conversion table, methadone increases the incidence of daytime sleepiness.

Objective

To identify the factors associated with daytime sleepiness and propose a conversion ratio from pretreatment MEDD to oral methadone that decreases the risk of daytime sleepiness.

Design

Retrospective cohort study.

Setting/Subjects

One hundred patients who started oral methadone to relieve cancer pain at Ashiya Municipal Hospital (Hyogo, Japan) from January 1, 2013, to August 31, 2022, were enrolled.

Measurements

The primary endpoint, the conversion ratio from pretreatment MEDD to oral methadone without daytime sleepiness, was determined using receiver operator characteristic (ROC) curve analysis.

Results

The incidence of daytime sleepiness within seven days of methadone initiation was 40.0%. The factors identified as contributing to daytime sleepiness were pretreatment MEDD (odds ratio [OR]: 0.941, 95% confidence interval [CI]: 0.916-0.966, p <0.001) and methadone dose (OR: 1.395, 95% CI: 1.178-1.652, p <0.001). The conversion ratio from pretreatment MEDD to oral methadone was 0.24, with an area under the ROC curve of 0.909 (p <0.001).

Conclusions

Daytime sleepiness developed when methadone dose is high relative to pretreatment MEDD. To the best of our knowledge, this is the first study to suggest the conversion ratio from pretreatment MEDD to oral methadone without causing daytime sleepiness.

Combined Exercise and Education Program: Effect of Smaller Group Size and Longer Duration on Physical Function and Social Engagement among Community-Dwelling Older Adults

Background

Exercise, education, and social engagement are critical interventions for older adults for a healthy life expectancy and to improve their physical function.

Objective

To conduct a combined exercise and education (CEE) program for improved social engagement and physical function of older adults.

Design

Based on a short-term program we conducted in our previous study, in this study, the program was conducted for half the number of participants of the earlier study but for a longer duration.

Setting

A community of older adults in Ami, Japan, was the setting of the study.

Participants

23 healthy older adults >65 years living in the community were the participants in the study.

Interventions

Five 80-minute sessions conducted once in two weeks comprised 60-min exercise instruction and 20-min educational lectures per session on health. We examined the improvement in physical and social engagement before and after participation. Physical function and health-related questionnaire data were collected before and after the program.

Results

Data analysis from 15 participants showed improved physical performance but no effect on social engagement.

Conclusions

A higher program frequency, rather than program duration, may be vital to improving exercise performance and social engagement and maximizing the effects of high group cohesion in small groups. Further studies are needed to develop more effective interventions to extend healthy life expectancy.

Neutron resonance absorption imaging of simulated high-level radioactive waste in borosilicate glass

We performed a preliminary study of neutron resonance absorption imaging to investigate the spatial distribution of constituent elements in borosilicate glasses containing simulated high-level radioactive waste, in which elemental inhomogeneities affect the physical and chemical stabilities of the glass. Dips generated by the resonance absorptions of Rh, Pd, Na, Gd, Cs, and Sm were observed in the neutron transmission spectra of the glass samples. The spatial distributions of these elements were obtained from the neutron transmission images at the resonance energies. The distributions of Rh and Pd visualized the sedimentation of these platinum group elements. In contrast, the lanthanides (Gd and Sm) and Cs were uniformly dispersed. These results show that neutron resonance absorption imaging is a promising tool for characterizing borosilicate glasses and investigating the vitrification mechanism of high-level radioactive waste.

Utility of 5-aminolaevulinic acid fluorescence-guided endoscopic biopsy for malignant mesothelioma in a cat and dog

Malignant mesothelioma (MM) is uncommon in cats and dogs and can be challenging to diagnose. Adequate tissue sampling is required for superior diagnostic accuracy. Protoporphyrin IX, a metabolite of 5-aminolaevulinic acid (5-ALA), is a photosensitiser for photodynamic diagnosis (PDD). To the best of our knowledge, no study has reported the use of 5-ALA-PDD to detect MM in veterinary medicine. The present study describes the use of 5-ALA-PDD for MM diagnosis in a cat and dog, as well as the effectiveness of intracavitary chemotherapy. We evaluated the use of PDD with 5-ALA hydrochloride (5-ALA-PDD) in two cases of MM. A 12-year-old cat presented with a 1-month history of respiratory distress, and a 9-year-old dog presented with a 3-month history of mild abdominal distention. We endoscopically biopsied lesions in both the cases using 5-ALA-PDD. Histopathological examination revealed mesothelioma, and immunohistochemical staining was positive for calretinin. Both patients were treated with carboplatin. The cat died of respiratory failure. Although, the dog's condition improved 21 days after the first chemotherapeutic drug administration, the dog died on day 684 owing to cardiac-related issues. 5-ALA-PDD is thus, safe and feasible for the diagnosis of MM in veterinary medicine.

Rhinitis associated with asthma is distinct from rhinitis alone: The ARIA-MeDALL hypothesis

Asthma, rhinitis and atopic dermatitis (AD) are interrelated clinical phenotypes that partly overlap in the human interactome. The concept of "one-airway-one-disease", coined over 20 years ago, is a simplistic approach of the links between upper- and lower-airway allergic diseases. With new data, it is time to reassess the concept. This article reviews (i) the clinical observations that led to Allergic Rhinitis and its Impact on Asthma (ARIA), (ii) new insights into polysensitisation and multimorbidity, (iii) advances in mHealth for novel phenotype definition, (iv) confirmation in canonical epidemiologic studies, (v) genomic findings, (vi) treatment approaches and (vii) novel concepts on the onset of rhinitis and multimorbidity. One recent concept, bringing together upper- and lower-airway allergic diseases with skin, gut and neuropsychiatric multimorbidities, is the "Epithelial Barrier Hypothesis". This review determined that the "one-airway-one-disease" concept does not always hold true and that several phenotypes of disease can be defined. These phenotypes include an extreme "allergic" (asthma) phenotype combining asthma, rhinitis and conjunctivitis. Rhinitis alone and rhinitis and asthma multimorbidity represent two distinct diseases with the following differences: (i) genomic and transcriptomic background (Toll-Like Receptors and IL-17 for rhinitis alone as a local disease; IL-33 and IL-5 for allergic and non-allergic multimorbidity as a systemic disease), (ii) allergen sensitisation patterns (mono- or pauci-sensitisation versus polysensitisation), (iii) severity of symptoms and (iv) treatment response. In conclusion, rhinitis alone (local disease) and rhinitis with asthma multimorbidity (systemic disease) should be considered as two distinct diseases, possibly modulated by the microbiome, and may be a model for understanding the epidemics of chronic and auto-immune diseases.

14 EXAMINING THE IMPACT OF SAFETY MONITORING DEVICES ON CARE WORK AND PROCESSES IN JAPANESE NURSING HOMES

Background

Although the impact of new technology on the workplace has been discussed for many years, little has been reported regarding the effect of new technology in nursing homes. The aim of the research was to test the effect of a safety monitoring device on night-time work patterns.

Methods

A monitoring sensor with an infrared camera was installed in Tokyo-based residential nursing homes in April 2020. A pre/post intervention and observation study was conducted before and after the introduction of the device. Four care professionals worked each night in pairs (one person providing care, and the other observing and keeping minute-by-minute records of task and time allocated to each task. The tasks were divided into 33 items). The data were collected by two pairs at three different nights for pre-intervention and from two pairs at two nights for post-intervention. Ten care professionals participated in the study, and they were looking after 30 older adults (86.8 +/- 6.8 years old).

Results

The total time for executing various tasks marginally increased from 978 mins to 1033 mins. However, statistically significant changes were found mainly among items related to medical care and safety. While nurse call response time decreased significantly, the proportion of time allocated to personal care such as vital checks (from 1 to 2 percent) and mobility (from 4 to 9 percent) assistance doubled. Break time also increased significantly.

Conclusion

While the introduction of a safety monitoring system did not radically reduce the workload, it changed the patterns of caregiving during the night shift. Some behavioural changes were directly caused by functions of the system, while others were by-products. Staff’s break length also increased. The findings suggest that the introduction of Information and Communication Technology (ICT) in nursing homes has the potential to release time to care.

Comparison of the Effects of Diuretics on Pedal Edema in Patients with Cancer

Background:

The effectiveness of tolvaptan (T) for treating pedal edema remains unknown.

Objective:

We aimed to clarify the effectiveness of diuretics, including T, on pedal edema in advanced cancer patients, and to compare patients' versus physicians' assessments of the effects.

Methods:

Participants comprised 88 hospitalized cancer patients treated with T, loop diuretics (L), or spironolactone (S). Patient characteristics, initial doses of diuretics, reason for discontinuation, side effects, evaluation of pedal edema, and effects of diuretics on pedal edema were investigated retrospectively using electronic medical records.

Results:

The rates of improvement of pedal edema according to patients (Pt) and physicians (MD) were T: Pt 83.3% (n = 6), MD 71.4% (n = 14); L: Pt 57.1% (n = 14), MD 50.0% (n = 26); S: Pt 0% (n = 1), MD 57.1% (n = 7); L+S: Pt 83.3% (n = 12), MD 69.0% (n = 29); T+L: Pt 90.9% (n = 22), MD 71.8% (n = 39); T+S: Pt 0% (n = 1), MD 0% (n = 2); T+L+S: Pt 62.5% (n = 8), MD 69.2% (n = 13). In 57.1%–90.9% and 50.0%–71.8% of episodes, patients and physicians, respectively, observed some effectiveness of diuretics on pedal edema in advanced cancer, except for in the S (Pt) and T + S (Pt, MD) groups.

Conclusions:

The treatment of pedal edema improves patient symptoms, enhancing quality of life. Further verification and evaluation of the effect of T on pedal edema are needed.

Joint integrity evaluation of laser beam welded additive manufactured Ti6Al4V sheets

The feasibility of joining laser metal deposited Ti6Al4V sheets using laser beam welding was investigated in this article. The additive manufactured sheets were joined using a 3 kW CW YLS-2000-TR ytterbium laser system. The mechanical properties and microstructure of the welded additive manufactured parts (AM welds) were compared with those of the wrought sheets welded using the same laser process. The welds were characterized and compared in terms of bead geometry, microhardness, tensile strength, fractography, and microstructure. The differences in characteristics are majorly found in the width of the bead and tensile strength. The bead width of AM welds appear wider than the wrought welds, and the wrought welds exhibited higher tensile strength and ductility than the AM welds.

Sterile inflammation through Ca2+/ Calmodulin-dependent protein kinase II signaling is essential for adverse cardiac remodeling

Introduction and hypothesis

Sterile inflammation is associated with cardiac remodeling in response to non-ischemic stress, but how it is initiated in the absence of cell death and how it is propagated are not well elucidated. We tested the hypothesis that activation of CaMKII in cardiomyocytes and macrophages in response to pressure overload initiates inflammatory responses leading to adverse cardiac remodeling.

Methods and results

Cardiomyocyte specific CaMKIIδ knockout (CKO) mice were subjected to transverse aortic constriction (TAC). CaMKII and NFkB activation were significantly increased in control fl/fl (CTL) but not in CKO hearts. Cardiac mRNA levels for pro-inflammatory cytokines also increased vs sham. These responses were significantly attenuated in the CKO mice. Activated NLRP3 inflammasome was shown by elevated caspase-1 activity in isolated cardiomyocytes of CTL while attenuated in CKO. Macrophage accumulation was attenuated in the CKO and NLRP3 inhibitor MCC950 treated mice. Cardiac fibrosis and subsequent cardiac dysfunction were less impaired in the CKO vs CTL (ejection fraction 43±3% vs 33±5%). Upregulated NLRP3 gene expression, elevated CaMKII and caspase-1 activity were observed in neonatal mouse cardiomyocytes (NMCMs) in response to osmotic stretch. Increased caspase-1 activity was observed in macrophages cultured with media from osmotic-stretched NMCMs and it was attenuated by pretreatment of CaMKII inhibitor KN-93. Coincubation with stretched NMCMs induced inflammatory responses in isolated macrophages from wild-type mice but not in isolated macrophages from KN-93 pretreated mice.

Conclusions

Activated CaMKIIδ in response to pressure overload triggers inflammatory signals including NLRP3 inflammasome cascade in cardiomyocytes. CaMKII could also contribute amplification of inflammasome signal in macrophages leading fibrosis and consequent cardiac dysfunction. CaMKII in cardiomyocytes and macrophages could be a therapeutic target to prevent progression of non-ischemic heart failure.

Funding Acknowledgement

Type of funding sources: None.

Tapentadol in Cancer Patients with Neuropathic Pain: A Comparison of Methadone, Oxycodone, Fentanyl, and Hydromorphone

Tapentadol has μ-opioid receptor stimulating and noradrenaline reuptake inhibiting properties, and should be effective for neuropathic pain (NP). However, the efficacy of tapentadol for NP in cancer patients is unclear. Ashiya Municipal Hospital (Hyogo, Japan) enrolled five groups of Japanese cancer patients between January 1, 2013, and December 31, 2019. Patients with NP were administered tapentadol (n = 29), methadone (n = 32), oxycodone (n = 20), fentanyl (n = 26), or hydromorphone (n = 20). The primary endpoint was the difference in the verbal rating scale (VRS) scores between days 0 and 7. The secondary endpoint was the tolerability of each opioid. Before administering opioids among the five groups, there was no significant difference in the VRS score (p = 0.99). The mean reduction in the VRS score on day 7 was significantly greater in the tapentadol group than in the oxycodone group (p = 0.0024) and was larger than that of the methadone, fentanyl, and hydromorphone groups. Regarding safety, the discontinuation rate in the tapentadol group was the lowest of all groups (tapentadol vs. methadone vs. oxycodone vs. fentanyl vs. hydromorphone, 0.0% vs. 6.3% vs. 5.0% vs. 3.8% vs. 10.0%, respectively). This study suggests that tapentadol could be efficacious for cancer patients with NP, and a preferred option in cases that require immediate dose adjustment or for those at high risk for adverse effects. However, the pain intensity was evaluated without pain assessment scales specific to NP. Thus, we think that it is desirable to validate our findings using assessment scales, such as the painDETECT questionnaire in future.

Factors influencing the prescribed dose of opioid analgesics in cancer patients

The dose of opioids prescribed for cancer pain does not always correlate with the actual pain severity. However, there is little evidence to explain this observation. In the present study, we sought to determine factors that influence the dose of opioid analgesics. A total of 227 patients who were administered opioids between August 2012 and May 2016 and later expired within the Department of Palliative Care at Ashiya Municipal Hospital were included, and the following variables were examined: age, sex, type of cancer, Verbal Rating Scale before and after the administration of the maximum pre-scribed dose of opioids, type of opioids and route of administration, blood test results, pain severity, and use of adju-vants. Data were analyzed using step-wise multiple linear regression. Median of the maximum prescribed dose of opioids, expressed in oral morphine equivalent, was 68.6, 60.0, and 39.2 mg for patients aged <65, 65-74, and ≥75 years, respectively. Step-wise multiple linear regression analysis further demonstrated that an increase in age by 1 year decreased the maximum prescribed dose of opioids by 0.98-fold (p = 0.006). Other factors that influenced the maximum prescribed dose of opioids included the use of analgesic adjuvants (1.91-fold, p = 0.001), oral administration (0.54-fold, p = 0.016), and elevated level of bilirubin (0.95-fold by 0.1 mg/dL increase, p = 0.013). Opioids examined in the study are metabolized in the liver by cytochromes P450 or by glucuronidation. Thus, if reduced drug metabolism causes the reduction in the maximum prescribed dose of opioids, liver function may contribute to this effect. Based on our findings that old age is associated with a lower prescribed dose of opioids, future studies should examine additional variables included in laboratory tests in more detail and measure hepatic blood flow to determine the cause of this as-sociation.

Local fungus-specific Immunoglobulin E production in chronic rhinosinusitis with nasal polyps

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a heterogeneous disease, and its pathogenesis remains controversial. This study aimed to examine the involvement of fungi in CRSwNP pathogenesis.

METHODS

We enrolled 29 controls and 111 CRSwNP patients. We analyzed fungi in the nasal secretions, serum fungus-specific immunoglobulin E (IgE) levels, and nasal polyp (NP) IgE levels. Moreover, we evaluated the correlation between patients' IgE levels and computed tomography (CT) scores.

RESULTS

There was no difference in fungal detection rate between CRSwNP patients with and without asthma. Specific IgEs against various antigens were highly detectable in NPs of CRSwNP patients. In CRSwNP patients, fungus-specific IgE levels in NPs were correlated with CT scores. Serum fungus-specific IgEs became undetectable after operation in more than half of the CRSwNP patients without asthma but not in those with asthma. Other serum airborne antigen-specific IgEs did not become undetectable after operation.

CONCLUSIONS

Fungus-specific IgEs were highly detectable in NPs of CRSwNP patients, and NPs comprised a major region of specific IgE production. Fungi may therefore play an important role in CRSwNP pathogenesis by inducing Th2 immune responses, including IgE synthesis.

Elucidation of gastrointestinal dysfunction in response to irradiation using metabolomics

Gastrointestinal toxicity is frequently observed secondary to accidental or therapeutic radiation exposure. However, the variation in the intestinal metabolites after abdominal radiation exposure remains ambiguous. In the present study, C57BL/6 mice were exposed to 0, 2, and 20 Gy irradiation dose. The Head and chest of each mouse were covered with a lead shield before x-ray irradiation. 24 h post-irradiation treatment, intestinal tissue of each mouse was excised and prepared for metabolites measurement using gas chromatography-mass spectrometry (GC-MS). Our comprehensive analysis of metabolites in the intestinal tissues detected 44 metabolites after irradiation, including amino acids, carbohydrates, organic acids, and sugars. Amino acid levels in the intestinal tissue gradually rose, dependent on the radiation dose, perhaps as an indication of oxidative stress. Our findings raise the possibility that amino acid metabolism may be a potential target for the development of treatments to alleviate or mitigate the harmful effects of oxidative stress-related gastrointestinal toxicity due to radiation exposure.

•

Gastrointestinal damage frequently results from radiation exposure.

•

We analyzed the metabolic profile after local irradiation to the intestine.

•

Amino acid levels in the intestinal tissue rose dependent on the radiation dose.

•

Amino acid metabolism may be a good target for future therapies.

The Adequateness of Methadone for Japanese Terminal Cancer Patients Can Be Determined Earlier than 7 Days: A Preliminary Retrospective Study

Introduction:

The Japanese packaging instructions for methadone prohibit dose escalation within 7 days of administration initiation as this may result in overdose and subsequent adverse events. However, for terminal cancer patients, evaluation of the effects of methadone may be desirable within 7 days because they have limited prognoses. We aimed to determine the possibility of estimating the adequateness of methadone earlier than the 7th day by investigating the onset timing of analgesic effects and adverse events of methadone in Japanese terminal cancer patients.

Methods:

Japanese terminal cancer patients who started taking methadone in Ashiya Municipal Hospital were enrolled from January 1, 2013 to February 28, 2019. Verbal rating scale (VRS) scores on pain and adverse events before and after methadone administration (on days 3, 5, and 7) were retrospectively investigated from medical records.

Results:

We enrolled 25 patients, of which 20 (80.0%) received methadone until day 7. The VRS score (mean ± standard deviation) on pain was significantly reduced to 0.90 ± 0.55 on day 3, compared with 1.65 ± 0.67 before the administration of methadone (p < 0.05). The mean VRS scores did not differ significantly on days 3, 5, and 7. Additionally, of the 23 patients who received methadone until day 3, 20 (87.0%) showed an analgesic effect on day 3 and 17 (85.0%) received methadone without experiencing serious adverse events until day 7.

Conclusions:

The adequateness of methadone in Japanese terminal cancer patients could be determined before day 7, considering the high analgesia incidence and few adverse events 3 days after the methadone administration under careful observation by a physician experienced in methadone administration. However, as this is a preliminary study, the relationship between pharmacokinetic parameters and analgesic effects was not evaluated. Further studies involving pharmacokinetics and multicenter prospective studies are required to support these findings.

JPOS/JASCC clinical guidelines for delirium in adult cancer patients: a summary of recommendation statements

BACKGROUND

The Japanese Psycho-Oncology Society and Japanese Association of Supportive Care in Cancer recently launched the clinical practice guidelines for delirium in adult cancer patients. The aim of the guidelines was to provide evidence-based recommendations for the clinical assessment and management of delirium in cancer patients. This article reports the process of developing the guideline and summarizes the recommendations made.

METHODS

The guidelines were developed in accordance with the Medical Information Network Distribution Service creation procedures. The guideline development group, consisting of multidisciplinary members, formulated nine clinical questions. A systematic literature search was conducted to identify relevant articles published prior to through 31 May 2016. Each article was reviewed by two independent reviewers. The level of evidence and the strength of the recommendations were graded using the grading system developed by the Medical Information Network Distribution Service, following the concept of The Grading of Recommendations Assessment, Development and Evaluation system. The modified Delphi method was used to validate the recommendation statements.

RESULTS

This article provides a summary of the recommendations with rationales for each, as well as a short summary.

CONCLUSIONS

These guidelines will support the clinical assessment and management of delirium in cancer patients. However, additional clinical studies are warranted to further improve the management of delirium.

Correlation between work impairment, scores of rhinitis severity and asthma using the MASK-air® App

BACKGROUND

In allergic rhinitis, a relevant outcome providing information on the effectiveness of interventions is needed. In MASK-air (Mobile Airways Sentinel Network), a visual analogue scale (VAS) for work is used as a relevant outcome. This study aimed to assess the performance of the work VAS work by comparing VAS work with other VAS measurements and symptom-medication scores obtained concurrently.

METHODS

All consecutive MASK-air users in 23 countries from 1 June 2016 to 31 October 2018 were included (14 189 users; 205 904 days). Geolocalized users self-assessed daily symptom control using the touchscreen functionality on their smart phone to click on VAS scores (ranging from 0 to 100) for overall symptoms (global), nose, eyes, asthma and work. Two symptom-medication scores were used: the modified EAACI CSMS score and the MASK control score for rhinitis. To assess data quality, the intra-individual response variability (IRV) index was calculated.

RESULTS

A strong correlation was observed between VAS work and other VAS. The highest levels for correlation with VAS work and variance explained in VAS work were found with VAS global, followed by VAS nose, eye and asthma. In comparison with VAS global, the mCSMS and MASK control score showed a lower correlation with VAS work. Results are unlikely to be explained by a low quality of data arising from repeated VAS measures.

CONCLUSIONS

VAS work correlates with other outcomes (VAS global, nose, eye and asthma) but less well with a symptom-medication score. VAS work should be considered as a potentially useful AR outcome in intervention studies.

Attenuated relationship between salivary oxytocin levels and attention to social information in adolescents and adults with autism spectrum disorder: a comparative study

BACKGROUND

Previous research studies have assessed the relationship between attention to social information and peripheral (e.g., plasma and salivary) oxytocin (OT) levels in typically developing (TD) children and children with autism spectrum disorder (ASD). A relationship between them was observed in TD children, but not in children with ASD. However, this relationship remains unexamined in other age groups. To clarify whether this lack of association is maintained throughout development in individuals with ASD, we aimed to assess the relationship between salivary OT levels and attention to social information in adolescents and adults with and without ASD.

METHODS

We recruited male adolescents and adults with ASD (n = 17) and TD participants (n = 24). Using the all-in-one eye-tracking system Gazefinder, we measured the percentage fixation time allocated to social information. We also measured the salivary OT levels and Autism Spectrum Quotient (AQ) of participants. Subsequently, we confirmed group differences and conducted a correlation analysis to investigate the relationships between these three measures.

RESULTS

Salivary OT levels did not show any significant difference between the ASD and TD groups and were negatively correlated with the AQ in the whole-group analysis, but not in within-group analysis. Individuals with ASD had significantly lower percentage fixation times than did TD individuals for eye regions in human faces with/without mouth motion, for upright biological motion, and for people regions in the people and geometry movies. The percentage of fixation for geometric shapes in the people and geometry movies was significantly higher in the ASD than in the TD group. In the TD group, salivary OT levels were positively correlated with percentage fixation times for upright biological motion and people and negatively correlated with inverted biological motion and geometry. However, no significant correlations were found in the ASD group.

CONCLUSIONS

Our exploratory results suggest that salivary OT levels in adolescents and adults with ASD are less indicative of attention to social stimuli than they are in TD adolescents and adults. It is suggested that their association is slightly weaker in adolescents and adults with ASD and that this attenuated relationship appears to be maintained throughout development.

[Collaboration of Diagnostic Test Results by Palliative Care Certified Nurses and Clinical Laboratory Technicians]

As part ofthe medical system in Japan, one ofthe initial steps in palliative care involves cancer patient guidance management feeⅠ(counselingⅠ)by a nurse. However, due to poor cooperation between doctors and nurses, the rate ofcounseling Ⅰ is currently low. Therefore, at our hospital, we collaborated with clinical laboratory technicians to inform, at the same time, both the certified nurse and doctor of the patient's diagnostic test results regarding any malignant findings in the pathological tissue examination. Then, we initiated efforts to inform the doctor about the implementation of counselingⅠ positively by certified nurses. As a result, it was possible to set a reliable list oftarget patients, and the number ofcounseling Ⅰ sessions increased by 1.5 times. In addition, these findings suggest the possibility ofreducing the burden ofdoctors by counselingⅠ.

Reliability of ultrasonographic measurements of bovine sole structures in relation to sole horn thickness, measured by computed tomography, and sole horn hardness

The goal of the present study was to determine the effect of sole horn thickness (SHT) and sole horn hardness (SHD) on ultrasonographic visualization of sole structures in the inner and outer claws of 150 Holstein-Friesian cows, and to evaluate different ultrasound frequencies for this purpose. Ultrasonographic views of the sole structure were considered complete when 3 echogenic lines, representing the ventral surface of the sole horn, the borders of the sole horn and soft-tissue layer, and the ventral surface of the distal phalanx, were seen. The proportion of complete ultrasonographic views of the sole structures, designated as the ultrasonographic visualization proportion (UVP), and the measurement errors of SHT were evaluated by comparing images from computed tomography (CT) and ultrasonography. The latter images were generated using 3 different probes, frequencies of 6.5 and 5.0 MHz, and 2 different ultrasound machines (#1 and #2) to assess the apex, middle, and heel regions of the claws. The UVP were 60.8 to 77.9% for the 6.5-MHz probe in ultrasound machine #1 (probe A), which were lower than those (>90%) for both the 5.0-MHz probe in ultrasound machine #1 (probe B) and the 5.0-MHz probe in ultrasound machine #2 (probe C). The UVP was significantly lower in claws with an SHD ≥50 units than in claws with an SHD <40 or 40 to <50 units (UVP: 77.1% compared with 93.7 and 91.4%, respectively) when measured with probe B. In claws with an SHT <10 mm, the UVP was significantly lower when SHD was ≥50 units compared with <40 or 40 to >50 units; the values were 69.0% versus 91.3 and 85.9%, respectively, for probe A, and 89.7% versus 100 and 100%, respectively, for probe B. When SHT were measured by either probes A or B in ultrasound machine #1, the proportions of claws in which ultrasonographic values were within a ±1 mm range compared with the values obtained by CT were 84.9 to 91.3% for CT-determined SHT <5 mm, 66.7 to 71.9% for CT-determined SHT 5 to <7 mm, 28.9 to 51.2% for CT-determined SHT 7 to <10 mm, and 6.2 to 19.7% for CT-determined SHT ≥10 mm. The data indicated that increased SHT was associated with a decrease in ultrasonographic measurement accuracy. In claws with an SHT <5 mm, the high proportion of ultrasonographic values that were accurate within a ±1 mm range suggests that this imaging modality would be useful in cows with thin soles.

Guidance to 2018 good practice: ARIA digitally-enabled, integrated, person-centred care for rhinitis and asthma

Aims

Mobile Airways Sentinel NetworK (MASK) belongs to the Fondation Partenariale MACVIA-LR of Montpellier, France and aims to provide an active and healthy life to rhinitis sufferers and to those with asthma multimorbidity across the life cycle, whatever their gender or socio-economic status, in order to reduce health and social inequities incurred by the disease and to improve the digital transformation of health and care. The ultimate goal is to change the management strategy in chronic diseases.

Methods

MASK implements ICT technologies for individualized and predictive medicine to develop novel care pathways by a multi-disciplinary group centred around the patients.

Stakeholders

Include patients, health care professionals (pharmacists and physicians), authorities, patient’s associations, private and public sectors.

Results

MASK is deployed in 23 countries and 17 languages. 26,000 users have registered.

EU grants (2018)

MASK is participating in EU projects (POLLAR: impact of air POLLution in Asthma and Rhinitis, EIT Health, DigitalHealthEurope, Euriphi and Vigour).

Lessons learnt

(i) Adherence to treatment is the major problem of allergic disease, (ii) Self-management strategies should be considerably expanded (behavioural), (iii) Change management is essential in allergic diseases, (iv) Education strategies should be reconsidered using a patient-centred approach and (v) Lessons learnt for allergic diseases can be expanded to chronic diseases.

Amelioration of Radiation Enteropathy by Dietary Supplementation With Reduced Coenzyme Q10

Purpose

Effective methods to ameliorate radiation enteropathy have not been developed. To address this issue, we investigated the reduced form of coenzyme Q10 (rCoQ10) as a potential radioprotector in a mouse model.

Methods and Materials

rCoQ10 was added to a standard laboratory mouse diet at a final concentration of 1.0% 9 days before irradiation and 30 days thereafter or dissolved in corn oil and administered transorally. Accumulated amounts of coenzyme Q10 (CoQ10) or coenzyme Q9 in the intestine were measured by high-performance liquid chromatography. Reactive oxygen species (ROS), apoptosis, and morphologic changes in the intestine were assessed by immunohistochemistry after administration of 13 Gy of x-ray to the mouse abdomen. Body weight and survival were monitored for 30 days after irradiation. Cytotoxicity using 3 human cancer cell lines and the tumor growth–inhibiting effect in a xenograft were investigated to determine whether rCoQ10 interferes with radiation-specific cytotoxic effects on tumor growth.

Results

CoQ10 was greatly accumulated in all sections of the intestine after both massive transoral dosing and dietary administration, whereas coenzyme Q9 was not. Administration of rCoQ10 suppressed ROS production and inhibited apoptosis in the crypts, resulting in preservation of villi structures after irradiation. Notably, 92% of mice fed the rCoQ10-supplemented diet were healthy and alive 30 days after irradiation, whereas 50% of control mice died (P < .05). Moreover, rCoQ10 did not interfere with radiation-specific cytotoxic effects on tumors either in vitro or in vivo.

Conclusions

Administration of rCoQ10 led to its accumulation in the intestine and induced radioprotective effects by inhibiting ROS-mediated apoptosis, thereby preserving intestinal structures. Our results indicated that rCoQ10 supplementation effectively ameliorated radiation enteropathy.

Validation of a Short-Term, Objective, Prognostic Predictive Method for Terminal Cancer Patients in a Palliative Care Unit Using a Combination of Six Laboratory Test Items

Background: There is no established method to objectively predict short-term prognosis. Recently, we proposed objective, short-term, prognostic predictive methods that are combinations of laboratory test items: WPCBAL score, derived from six values (white blood cell, platelet, C-reactive protein, blood urea nitrogen, aspartate aminotransferase, and lactate dehydrogenase). However, that study was conducted in an acute-phase hospital to identify the test items useful for prognostic prediction; thus, whether WPCBAL score could be applied to terminal cancer patients in a palliative care unit was unverified. Objective: To verify the usefulness of WPCBAL score for terminal cancer patients. Design: A retrospective study. Setting/Subjects: Patients admitted to the palliative care unit of Ashiya Municipal Hospital (N = 128) in Japan in 2016. Measurements: The sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and area under the receiver operating characteristic curve (AUROC) were compared between WPCBAL score and the Glasgow prognostic score (GPS). Results: For predicting three-week prognosis, WPCBAL score showed higher AUROC compared with GPS (0.7540 and 0.6573, respectively). WPCBAL score predicting two-week prognosis showed greater AUROC than GPS predicting three-week prognosis (0.7491 and 0.6573, respectively). Conclusion: WPCBAL score was verified to objectively predict the two- or three-week prognosis for terminal cancer patients in a palliative care unit. WPCBAL score may be a new option for prognostic prediction for terminal cancer patients.

Genetic and phenotypic profile of 112 patients with X-linked Charcot-Marie-Tooth disease type 1

BACKGROUND AND PURPOSE

X-linked Charcot-Marie-Tooth disease type 1 (CMTX1), caused by mutations in gap junction protein beta 1 (GJB1), is characterized by various central nervous system symptoms and gender differences of clinical severity. The aim of this study was to identify the frequency and mutation spectrum of CMTX1 patients in Japan and to demonstrate their phenotypic diversities.

METHODS

Using three high-throughput sequencing systems, targeted gene panel sequencing on 1483 unrelated index patients with suspected Charcot-Marie-Tooth (CMT) disease was performed. The peripheral and central nervous system involvements of all patients with GJB1 variants were assessed retrospectively and a detailed gender comparison was conducted with the CMT examination score.

RESULTS

Twenty-three novel and 36 described GJB1 variants were identified from 88 pedigrees, in which 34 female and 78 male patients were enrolled. Mean age at onset of the male patients was much younger than the females, 21.56 ± 17.63 years vs. 35.53 ± 23.72 years (P = 0.007). Male patients presented with more severe phenotypes in every examination item, but statistical differences were observed only in motor dysfunctions of the lower extremities and vibration sensation. No significant sensory difference was identified between genders, either clinically or electrophysiologically. Central nervous system dysfunctions were found in 15 patients from 12 pedigrees. Therein, six patients developed stroke-like phenotypes, with dysarthria as the leading symptom.

CONCLUSIONS

A relatively lower frequency of CMTX1 (5.9%) was demonstrated and a broad mutation spectrum of GJB1 was described. Detailed clinical differences between genders and various central nervous system symptoms were also illustrated, even in the same pedigree.

MASK 2017: ARIA digitally-enabled, integrated, person-centred care for rhinitis and asthma multimorbidity using real-world-evidence

mHealth, such as apps running on consumer smart devices is becoming increasingly popular and has the potential to profoundly affect healthcare and health outcomes. However, it may be disruptive and results achieved are not always reaching the goals. Allergic Rhinitis and its Impact on Asthma (ARIA) has evolved from a guideline using the best evidence-based approach to care pathways suited to real-life using mobile technology in allergic rhinitis (AR) and asthma multimorbidity. Patients largely use over-the-counter medications dispensed in pharmacies. Shared decision making centered around the patient and based on self-management should be the norm. Mobile Airways Sentinel networK (MASK), the Phase 3 ARIA initiative, is based on the freely available MASK app (the Allergy Diary, Android and iOS platforms). MASK is available in 16 languages and deployed in 23 countries. The present paper provides an overview of the methods used in MASK and the key results obtained to date. These include a novel phenotypic characterization of the patients, confirmation of the impact of allergic rhinitis on work productivity and treatment patterns in real life. Most patients appear to self-medicate, are often non-adherent and do not follow guidelines. Moreover, the Allergy Diary is able to distinguish between AR medications. The potential usefulness of MASK will be further explored by POLLAR (Impact of Air Pollution on Asthma and Rhinitis), a new Horizon 2020 project using the Allergy Diary.

Photodynamic detection of a canine glioblastoma using 5-aminolevulinic acid

Photodynamic detection using 5-aminolevulinic acid has been used to identify the surgical margins during resection of human primary brain tumours. Although there are some reports on its use in malignant tumours in veterinary medicine, it has never been used for primary brain tumours. Here we describe a canine glioblastoma that was detected at autopsy with protoporphyrin IX fluorescence induced by orally administered 5-aminolevulinic acid. The fluorescence was strongest towards the centre of the lesion and was absent in normal brain tissue. Moreover, the fluorescence findings were consistent with MRI and histopathological findings. Our findings suggest that photodynamic detection using 5-aminolevulinic acid might be useful for intraoperative fluorescence-guided resection of malignant gliomas in dogs.

Identification of specifically reduced Th2 cell subsets in allergic rhinitis patients after sublingual immunotherapy

BACKGROUND

Although Th2 cells are well known to play important roles in allergic diseases including allergic rhinitis (AR), the factors that induce and sustain the pathogenesis of AR remain unclear. The recent development of sublingual immunotherapy (SLIT) is expected to allow changes to the underlying pathogenesis of AR. However, which Th2 cell subsets are important in house dust mite-induced AR (HDM-AR), the influence of SLIT on the pathogenic Th2 cells, and the association of Th2 cell subsets with SLIT efficacy have not been clarified.

METHODS

The cytokine production and frequency of HDM-reactive T-cell subsets in peripheral blood mononuclear cells (PBMCs) were evaluated using flow cytometry in 89 HDM-AR patients (placebo [n = 43] and HDM 300 IR [n = 46]) who participated in a placebo-controlled study of SLIT with HDM tablets. All patients provided samples both before treatment as a baseline and at the end of the 52-week study. The PBMCs were stained with CellTrace™ Violet (CTV) before culture with HDM extract, and HDM-reactive T cells were detected as the proliferated cells with diminished CTV.

RESULTS

HDM-reactive IL-5⁺ IL-13⁺ CD27^- CD161⁺ CD4⁺ cells and ST2⁺ CD45RO⁺ CD4⁺ cells were observed in the peripheral blood from each patient with HDM-AR; these cells significantly decreased after SLIT in the group treated with active tablets. HDM-reactive ST2⁺ CD45RO⁺ CD4⁺ cells were significantly lower in active-responders.

CONCLUSION

Allergen-reactive ST2⁺ CD45RO⁺ CD4⁺ cells or those combined with IL-5⁺ IL-13⁺ CD27^- CD161⁺ CD4⁺ cells may be useful as markers indicating the successful treatment of SLIT. These cells may play a crucial role in the pathogenesis of AR as pathogenic memory Th2 cells.

Morphology and Physical Properties of Hydrophilic-Polymer-Modified Lipids in Supported Lipid Bilayers

Lipid molecules such as glycolipids that are modified with hydrophilic biopolymers participate in the biochemical reactions occurring on cell membranes. Their functions and efficiency are determined by the formation of microdomains and their physical properties. We investigated the morphology and properties of domains induced by the hydrophilic-polymer-modified lipid applying a polyethylene glycol (PEG)-modified lipid as a model modified lipid. We formed supported lipid bilayers (SLBs) using a 0-10 mol % range of PEG-modified lipid concentration ( C_PEG). We studied their morphology and fluidity by fluorescence microscopy, the fluorescence recovery after photobleaching method, and atomic force microscopy (AFM). Fluorescence images showed that domains rich in the PEG-modified lipid appeared and SLB fluidity decreased when C_PEG ≥ 5%. AFM topographies showed that clusters of the PEG-modified lipid appeared prior to domain formation and the PEG-lipid-rich domains were observed as depressions. Frequency-modulation AFM revealed a force-dependent appearance of the PEG-lipid-rich domain.

Chiral Domain Structure in Superfluid ^{3}He-A Studied by Magnetic Resonance Imaging

The existence of a spatially varying texture in superfluid ^{3}He is a direct manifestation of the complex macroscopic wave function. The real space shape of the texture, namely, a macroscopic wave function, has been studied extensively with the help of theoretical modeling but has never been directly observed experimentally with spatial resolution. We have succeeded in visualizing the texture by a specialized magnetic resonance imaging. With this new technology, we have discovered that the macroscopic chiral domains, of which sizes are as large as 1 mm, and corresponding chiral domain walls exist rather stably in ^{3}He-A film at temperatures far below the transition temperature.

Changes in resting-state brain networks after cognitive-behavioral therapy for chronic pain

BACKGROUND

Cognitive-behavioral therapy (CBT) is thought to be useful for chronic pain, with the pathology of the latter being closely associated with cognitive-emotional components. However, there are few resting-state functional magnetic resonance imaging (R-fMRI) studies. We used the independent component analysis method to examine neural changes after CBT and to assess whether brain regions predict treatment response.

METHODS

We performed R-fMRI on a group of 29 chronic pain (somatoform pain disorder) patients and 30 age-matched healthy controls (T1). Patients were enrolled in a weekly 12-session group CBT (T2). We assessed selected regions of interest that exhibited differences in intrinsic connectivity network (ICN) connectivity strength between the patients and controls at T1, and compared T1 and T2. We also examined the correlations between treatment effects and rs-fMRI data.

RESULTS

Abnormal ICN connectivity of the orbitofrontal cortex (OFC) and inferior parietal lobule within the dorsal attention network (DAN) and of the paracentral lobule within the sensorimotor network in patients with chronic pain normalized after CBT. Higher ICN connectivity strength in the OFC indicated greater improvements in pain intensity. Furthermore, ICN connectivity strength in the dorsal posterior cingulate cortex (PCC) within the DAN at T1 was negatively correlated with CBT-related clinical improvements.

CONCLUSIONS

We conclude that the OFC is crucial for CBT-related improvement of pain intensity, and that the dorsal PCC activation at pretreatment also plays an important role in improvement of clinical symptoms via CBT.

Bereaved Family Members' Perceptions of the Distressing Symptoms of Terminal Patients With Cancer

BACKGROUND

Few data are available on bereaved family members' perspective on the frequency of symptoms and degree of distress among terminal patients with cancer.

METHODS

We sent a questionnaire to 1472 bereaved family members of terminal patients with cancer in 20 general hospitals. The questionnaire asked them (1) to indicate which symptoms the patients had, (2) to rate on a 4-point scale the extent to which the symptom was distressing, as follows: 1 = not distressing, 2 = slightly distressing, 3 = quite distressing, and 4 = very distressing at the point of 2 weeks before the patient had died.

RESULTS

We analyzed 805 questionnaires for this study. Anorexia was the commonest symptom among terminal patients with cancer experienced by bereaved family members, followed by somnolence, weight loss, fatigue, and pain. Anorexia was the most distressing symptom among terminal patients with cancer experienced by bereaved family members, followed by weight loss, pain, edema, and dyspnea.

CONCLUSIONS

Anorexia and weight loss were frequent symptoms and bereaved family members felt very distressing. Furthermore, there are not means of effective treatment now. Thus, we think that further study in this field is necessary.

Patellofemoral reconstruction for patellar instability with patella alta in middle-aged patients: Clinical outcomes

INTRODUCTION

Although several surgical treatments for patellar instability with patella alta have been reported, the clinical outcomes and optimal surgical procedures for patellar instability with patella alta in middle-aged patients are still controversial. We hypothesized that optimal surgical procedures for patellar instability with patella alta in middle-aged patients may induce good clinical outcomes with better patellofemoral geometry.

MATERIALS AND METHODS

Twelve middle-aged patients with a mean age of 44 years (range: 40-55 years), who presented with patellar instability and patella alta, were treated with a combination of several surgeries, such as medial patellofemoral ligament (MPFL) reconstruction, trochleoplasty, lateral release, and three-dimensional transfer of the tibial tuberosity, based on a surgical algorithm. Patellar position and clinical outcomes were evaluated postoperatively. The mean follow-up time was 41.5 months (range: 24-72 months).

RESULTS

Patellar position altered from 1.31 (1.21-1.53) preoperatively to 0.88 (0.69-1.06) postoperatively on the Caton-Deschamps Index (p<0.01). The tibial tuberosity-trochlear groove (TT-TG) distance altered from 21.8mm (20.1-25.8mm) to 10.3mm (5.1-14.7mm), and patellar tilt ranged from 28.1° (21-40°) to 14.6° (5-28°), respectively (p<0.01). Clinical outcomes on the Lysholm and Kujala scales improved from 43.1 and 38.4 to 86.7 and 78.3, respectively, at final follow-up (p<0.01). Surgical treatment that included trochleoplasty resulted in better outcomes than other surgical combinations without trochleoplasty (p<0.05). Sulcus angle and postoperative patellar tilt improved more in those who underwent trochleoplasty than in those who did not (p<0.05).

DISCUSSION

Surgical treatment for patellar instability with patella alta in middle-aged patients resulted in improved clinical outcomes. In particular, a combination surgery including trochleoplasty resulted in the greatest improvement in case of severe trochlear dysplasia.

LEVEL OF EVIDENCE

IV. Retrospective case series study.

The analgesic effect of rescue administration of intravenous acetaminophen in cancer patients may be associated with sex and opioid dose, and the effect would appear to patients administered under 45 mg/day opioid (oral morphine equivalents)

There have been no investigations examining the analgesic effect of rescue administration of intravenous acetaminophen (IV APAP) for pain in cancer patients. Fifty cancer patients who received IV APAP for pain at Ashiya Municipal Hospital (Hyogo, Japan) between January 2014 and July 2016 were retrospectively evaluated. The degree of pain was evaluated using a 4-point verbal rating scale. Pain intensity differences ≥ 1 defined the IV APAP effective group, and the patient' characteristics were compared by a medical chart review. Variables were extracted from medical records for logistic regression analyses of factors associated with analgesic effect. The cut-off value of opioid dose (oral morphine equivalent) was determined using receiver operator characteristic (ROC) curve analysis. Thirty eight (76%) patients experienced an analgesic effect of rescue administration of IV APAP. Sex (odds ratio [OR] 5.4014; p = 0.0397) and opioid dose used for pain control (OR 0.9901; p = 0.0147) were found to be associated with the efficacy of rescue administration of IV APAP. The cut-off value of opioid dose (oral morphine equivalent), which may be difficult to match the analgesic effect of IV APAP, was calculated to be more than 45 mg/day. This study demonstrated the efficacy of a rescue administration of IV APAP for pain in cancer patients, and revealed that sex and opioid dose may be associated with the analgesic effect. Furthermore, this study also proposes a criterion for the analgesic effect.