What can cause cancer patients to attempt suicide? Thiamine deficiency mimicking the symptoms of major depressive disorder

OBJECTIVES

Thiamine deficiency (TD) presents with various physical and psychiatric symptoms, but no cases with depression-like symptoms have been reported.

METHODS

We report a patient with cancer who appeared to attempt suicide as a consequence of depressive mood likely related to TD.

RESULTS

The patient was a 58-year-old woman diagnosed with recurrent endometrial cancer, with lung metastasis and pelvic dissemination. The patient apparently attempted suicide was referred to the psycho-oncology department. At the time of the examination, major depressive disorder was suspected based on her mental symptoms, but when thiamine was administered intravenously in response to her poor dietary intake, her palpitations, dyspnea, anorexia, and insomnia improved, and her suicidal ideation disappeared at her reexamination 1 hour later after thiamine administration.

SIGNIFICANCE OF RESULTS

It is likely that the observed palpitations, dyspnea, anorexia, and insomnia, as well as the severe depression and the attempted suicide, which were thought to be physical symptoms associated with depression, were actually related to TD. Suicidal ideation and attempted suicide are conspicuous as psychiatric symptoms. However, in such cases, rather than simply starting treatment for depression, it is necessary to consider reversible TD as a cause of these symptoms and perform differential diagnosis to confirm the physical illness.

Features and prognosis of patients with lupus nephritis receiving glucocorticoid treatment: a descriptive study using a Japanese claims database

OBJECTIVE

To evaluate the status of lupus nephritis treatment particularly regarding the need for intensification of treatment in Japan from 2010 to 2019 using a large-scale claims database.

METHODS

This descriptive study included adult lupus nephritis patients who were administered glucocorticoid equivalent to ≥15 mg prednisolone as the initial dose. After summarizing patient characteristics, we assessed the rate of treatment intensification using the Kaplan-Meier method among six groups based on initial dose of glucocorticoid.

RESULTS

We identified 403 patients (mean age, 42.7 years; 68.5% women) with the median initial glucocorticoid dose of 30 mg/day prednisolone equivalent. We observed 56 treatment intensifications; the incidence rate was 71.3 per 1,000 person-years (95% confidence interval: 52.6-90.0). The rate in higher glucocorticoid dose groups was higher than that in lower glucocorticoid dose groups.

CONCLUSIONS

We found that the rate of treatment intensification was higher in the high-dose glucocorticoid groups than in the low-dose glucocorticoid groups. Further studies are needed to clarify the relationship between the initial dose of glucocorticoids and the prognosis of lupus nephritis patients.

Impact of immediate general anesthesia in the emergency room on prevention of rebleeding after subarachnoid hemorrhage

BACKGROUND

Aneurysm rebleeding is fatal in patients with aneurysmal subarachnoid hemorrhage (aSAH). We aimed to investigate whether immediate general anesthesia (iGA) management in the emergency room, upon arrival, prevents rebleeding after admission and reduces mortality following aSAH.

METHODS

The clinical data of 3033 patients with World Federation of Neurosurgical Societies (WFNS) grade 1, 2, or 3 aSAH from the Nagasaki SAH Registry Study between 2001 and 2018 were retrospectively analyzed. iGA was defined as sedation and analgesia using intravenous anesthetics and opioids combined with intubation induction. We calculated crude and adjusted odds ratios to evaluate the associations between iGA and the risk of rebleeding/death using multivariable logistic regression models with fully conditional specification for multiple imputations. In the analysis of the relationship between iGA and death, we excluded patients with aSAH who died within 3 days after the onset of symptoms.

RESULTS

Of the 3033 patients with aSAH who met the eligibility criteria, 175 patients (5.8%) received iGA (mean age, 62.4 years; 49 were male). Heart disease, WFNS grade, and lack of iGA were independently associated with rebleeding in the multivariable analysis with multiple imputations. Among the 3033 patients, 15 were excluded due to death within 3 days after the onset of symptoms. After excluding these cases, our analysis revealed that age, diabetes mellitus, history of cerebrovascular disease, WFNS grade, Fisher grade, lack of iGA, rebleeding, postoperative rebleeding, no shunt operation, and symptomatic spasm were independently associated with mortality.

CONCLUSIONS

Management by iGA was associated with a 0.28-fold decrease in the risks of both rebleeding and mortality in patients with aSAH, even after adjusting for the patient's history of diseases, comorbidities, and aSAH status. Thus, iGA can be a treatment for the prevention of rebleeding before aneurysmal obliteration treatment.

Impact of intraoperative fluid restriction on renal outcomes in patients undergoing robotic-assisted laparoscopic prostatectomy

Robotic-assisted laparoscopic prostatectomy (RALP) requires intraoperative fluid restriction to maintain the optimal view of the operative field during vesicourethral anastomosis and to prevent upper airway edema that may occur due to the steep Trendelenburg position. The aim of this study was to demonstrate that our fluid restriction regimen would not increase postoperative serum creatinine (sCr) levels in patients undergoing RALP. The fluid regimen involved maintaining a crystalloid infusion at 1 ml/kg/h until completion of vesicourethral anastomosis, then rapid infusion of 15 ml/kg within 30 min, followed by maintenance at 1.5 ml/kg/h until post-operative day (POD) 1. The primary outcome of this study was the change in the sCr level from baseline to POD7. Secondary outcomes were the sCr levels on PODs 1 and 2, the surgical view during vesicourethral anastomosis, and the incidences of re-intubation and acute kidney injury (AKI). Sixty-six patients were eligible for the analysis. The paired t test for non-inferiority showed no significant difference in sCr levels between baseline and POD7 (mean ± standard deviation, 0.79 ± 0.14 vs. 0.80 ± 0.18 mg/dl, p < 0.001). Seven patients developed AKI on POD1, but all but one recovered on POD2. Ninety-seven percent of operations were rated as having a good view of the operative field. There were no cases of re-intubation. This study demonstrated that the fluid restriction regimen of 1 ml/kg/h until completion of vesicourethral anastomosis created a good view of the operative field during vesicourethral anastomosis without increasing postoperative sCr levels in patients undergoing RALP. Trial registration: This trial was registered in the University Hospital Medical Information Network under registration number UMIN000018088 (registration date; July 1, 2015).

A patient with Marchiafava-Bignami disease type A transported by ambulance with impaired consciousness and malnutrition was successfully treated after early diagnosis by MRI

Marchiafava-Bignami disease (MBD) is a very rare disorder characterized by demyelination and necrosis of the corpus callosum. A 53-year-old male was transported to the emergency room with impaired consciousness. On his arrival, he was quite emaciated. CT examination revealed no hemorrhagic lesions whereas MR images showed hyperintense areas throughout the corpus callosum, leading to a diagnosis of MBD. His impaired consciousness improved with treatment, including parenteral thiamine administration. When examining patients with impaired consciousness because of malnutrition, MBD should be taken in consideration and the incorporation of head MR imaging into the examination protocol enables early diagnosis and treatment, and may improve the prognosis.

14- and 17-Membered Macrocycles Containing Amide, Amino, and Carbamate Groups in The Monocyclic Skeleton: An Accidental Byproduct Obtained from a Residue after Separation

A 14-membered cyclic compound (3) containing amide, amino, and carbamate groups, which was serendipitously obtained in the oily residue after the separation of 4-benzyl-1,4,7,10-tetraazacyldododecane-2,6-dione (2a) and 4,16-dibenzyl-1,4,7,10,13,16,19,22-octaazacyclo-tetracosane-2,6,14,18-tetraone (2b), is reported. The structure of 3 is formally a CO₂ insertion between positions 3 and 4 of the 12-membered ring in 2a. The CO₂ insertion was confirmed in the synthesis of diethyl 2,2'-(benzylazanediyl)diacetate (1) by the reaction of benzylamine with ethyl bromoacetate using K₂CO₃ as the base. In addition, the selective synthesis of 3 and ethyl N-benzyl-N-((2-ethoxy-2-oxoethoxy)carbonyl)glycinate (5) and their kinetic behavior are reported. The reaction of 5 with triethylenetetramine afforded a 17-membered macrocycle (7), which was obtained in an 18% yield. Compounds 6 and 8 were prepared from 3 and 7 by introducing benzyl groups to improve their solubility in organic solvents. Titration experiments using ¹H NMR showed that both 6 and 8 exhibit Li⁺ selectivity.

Investigation of Whole Blood Thiamine Concentration in Independently Ambulatory Residents of a Provincial Town in Japan: A Cross-Sectional Study

Background Thiamine deficiency (TD) is an important public health problem in nutrition, occurring in 2-6% of the population in Europe and the US, whereas thiamine levels are reported to be significantly reduced by 36.6-40% in some populations of East Asia. However, there is little information available at present, regarding factors such as age, despite the continued aging of society. Further, studies such as those mentioned above have not yet been undertaken in Japan, the country in which population aging is most advanced. Objective To investigate TD in the Japanese community-dwelling individuals who are independently ambulatory. Methods We undertook an examination of TD in blood samples obtained from 270 citizens in a provincial town, aged 25-97 years, who were able to walk to the venue and provide informed consent for inclusion in this research and of whom 8.9% had a history of cancer. We summarized the demographic characteristics of the subjects. The whole-blood thiamine concentrations were measured using the high-performance liquid chromatography method. A value of 21.3 ng/ml or less was taken as low and a borderline value was set as less than 28 ng/ml. Results The mean (±SD) whole blood thiamine concentration was 47.6 ± 8.7 ng/ml. No TD was observed to exist participating in this study, with no subjects even showing show borderline values. Further, there was no significant difference in thiamine level between those aged 65 or older and those aged less than 65. Conclusions No cases of TD were observed among the subjects in this study, nor was the concentration of thiamine found to be related to age. It is possible that the frequency of TD might be very low in citizens who have a certain level of activity. In the future, it is necessary to expand the prevalence of TD to a wider range of subjects.

Thiamine Deficiency in a Patient With Schizophrenia: Precautions and Countermeasures for Subclinical Thiamine Deficiency

Patients with schizophrenia often experience problems associated with ordinary exercises of life due to their mental symptoms. Those experiencing problems related to feeding behavior, in particular, are considered to be susceptible to developing Wernicke encephalopathy due to a deficiency in thiamine, the physiological stores of which are limited; however, there are few reported cases, and most of them were accompanied by the classical triad of signs. We report our experience with asymptomatic thiamine deficiency (TD) in a schizophrenia patient. A 73-year-old female was receiving medication for schizophrenia as an outpatient. No symptoms such as hallucinations or delusions were observed, the patient had a sociable personality and was able to function at a level where she could live alone. Although there were no active complaints about eating by the patient, we investigated the situation due to reports of TD in schizophrenia patients. As results revealed a significant decrease in whole blood thiamine to 19 ng/mL (reference range: 24-66 ng/mL), we administered a large dose of thiamine. No changes were observed in psychosomatic symptoms before and after administration. Patients with schizophrenia experience problems that may lead to TD, such as dietary imbalances and disturbed feeding habits. Therefore, even if patients with schizophrenia do not actively complain about their feeding behavior, it may be necessary to take medical measures such as blood sampling in consideration of the potential for developing TD.

Pseudoprogression during induction treatment with nivolumab plus ipilimumab combined with chemotherapy for metastatic lung adenocarcinoma: A case report

The incidence rate of pseudoprogression during immune checkpoint inhibitor monotherapy for non-small cell lung cancer is reportedly 3.6%-6.9%, while pseudoprogression during chemoimmunotherapy is rare. Reports on pseudoprogression during dual immunotherapy combined with chemotherapy are lacking. Herein, a 55-year-old male with invasive mucinous adenocarcinoma (cT2aN2M1c [OTH, PUL], stage IVB, and programmed death-ligand 1 expression <1%), renal dysfunction, and disseminated intravascular coagulation was treated with carboplatin, solvent-based paclitaxel, nivolumab, and ipilimumab. After treatment initiation, computed tomography (CT) on day 14 showed disease progression. The patient was diagnosed with pseudoprogression because of a lack of symptoms, improved platelet count, and decreased fibrin/fibrinogen degradation product levels. CT on day 36 showed a reduction in the primary lesion size, multiple lung metastases, and mesenteric metastases. Therefore, pseudoprogression should be considered during dual immunotherapy with chemotherapy.

Recent Trend of Using Computed Tomography to Diagnose Pediatric Appendicitis at the First Hospital Visit: A Descriptive Study Using a Medical Claims Database

OBJECTIVE

We recognize that computed tomography (CT) should not be used to diagnosis pediatric appendicitis due to radiation exposure. However, few studies have recently shown a trend in its use. This study aimed to investigate the annual use of CT for the diagnosis of pediatric appendicitis at the first hospital visit.

METHODS

This was a descriptive study using nationwide claims data. We extracted the data of children younger than 15 years who underwent imaging tests to diagnose acute and suspected appendicitis at the first visit between January 2008 and September 2018. We summarized the patient characteristics and the percentage of CT, ultrasonography (US), or CT/US utilization by year, age, and department.

RESULTS

We identified 6658 children who underwent CT (2349 [35.8%]), US (53,57 [54.5%]), and CT/US (634 [9.7%]). The annual CT use dropped from 43.1% in 2012 to 29.4% in 2018. According to age group, the highest percentage of CT use in 2018 was 84.6% in preschool children, followed by adolescents (40.3%), upper-grade (26.0%), and lower-grade (15.0%) children. Data of annual CT use by department revealed that CT usage was much higher in internal and emergency medicine than in pediatrics. Furthermore, adolescents accounted for approximately 50% of CT use in internal medicine.

CONCLUSIONS

The percentage of CT use for pediatric appendicitis at the first visit declined annually. However, CT use still tended to be higher in preschool- and adolescent-aged children, or in departments other than pediatrics. Further studies are required to clarify the clinical benefits of CT use to diagnose pediatric appendicitis.

The Association Between Hypouricemia and Cardiometabolic Diseases: Analyzing Nationwide Data From Medical Checkup and Health Insurance Records

OBJECTIVES

The aims of this study were to evaluate the association between hypouricemia and cardiometabolic diseases, such as hypertension, dyslipidemia, and reduced kidney function, and to explore the sex-specific optimal range for serum uric acid (sUA) associated with the lowest risk for these diseases.

METHODS

In this cross-sectional study, we identified individuals with sUA data between April 2018 and March 2019 and recorded the frequency of cardiometabolic comorbidities according to sUA. Univariable and multivariable logistic regression analyses were performed for the overall population and after classifying by sex to assess the association between sUA and cardiometabolic comorbidities.

RESULTS

Among 796,508 individuals, a J-shaped association was observed between the sUA level and cardiometabolic diseases in the overall population. The adjusted odds ratios (95% confidence interval) for hypertension, dyslipidemia, and reduced renal function in individuals with sUA ≤1.0 mg/dL compared with those with sUA ranging between 2.1 and 3.0 mg/dL were 1.38 (1.13-1.69), 1.52 (1.30-1.78), and 2.17 (1.47-3.20), respectively. A J-shaped association between sUA and hypertension was observed only in women. The optimal range of sUA associated with the lowest risk for hypertension was assumed to be <6 mg/dL in men and 1-4 mg/dL in women. A J-shaped association between the sUA and dyslipidemia and reduced renal function was observed in both men and women. The optimal range of sUA for dyslipidemia and reduced renal function was approximately 2-5 mg/dL in men and 1-4 mg/dL in women.

CONCLUSIONS

Excess and extremely low uric acid levels may be related to an increased cardiometabolic risk.

A long-acting anti-IL-8 antibody improves inflammation and fibrosis in endometriosis

Current pharmacological treatments for endometriosis are limited to hormonal agents that can relieve pain but cannot cure the disease. Therefore, the development of a disease-modifying drug for endometriosis is an unmet medical need. By studying human endometriotic samples, we found that the progression of endometriosis was associated with the development of inflammation and fibrosis. In addition, IL-8 expression was highly up-regulated in endometriotic tissues and closely correlated with disease progression. We created a long-acting recycling antibody against IL-8 (AMY109) and evaluated its clinical potency. Because rodents do not produce IL-8 and do not experience menstruation, we analyzed the lesions in cynomolgus monkeys that spontaneously developed endometriosis and in a surgically induced endometriosis monkey model. Both spontaneously developed and surgically induced endometriotic lesions demonstrated pathophysiology that was highly similar to that of human endometriosis. Once-a-month subcutaneous injection of AMY109 to monkeys with surgically induced endometriosis reduced the volume of nodular lesions, lowered the Revised American Society for Reproductive Medicine score as modified for monkeys, and ameliorated fibrosis and adhesions. In addition, experiments using cells derived from human endometriosis revealed that AMY109 inhibited the recruitment of neutrophils to endometriotic lesions and the production of monocyte chemoattractant protein-1 from neutrophils. Thus, AMY109 may represent a disease-modifying therapy for patients with endometriosis.

Incidence and factors associated with newly implemented do-not-attempt-resuscitation orders among deteriorating patients after rapid response system activation: A retrospective observational study using a Japanese multicenter database

Aim

The rapid response system (RRS) was initially aimed to improve patient outcomes. Recently, some studies have implicated that RRS might facilitate do-not-attempt-resuscitation (DNAR) orders among patients, their families, and healthcare providers. This study aimed to examine the incidence and factors independently associated with DNAR orders newly implemented after RRS activation among deteriorating patients.

Methods

This observational study assessed patients who required RRS activation between 2012 and 2021 in Japan. We investigated patients' characteristics and the incidence of new DNAR orders after RRS activation. Furthermore, we used multivariable hierarchical logistic regression models to explore independent predictors of new DNAR orders.

Results

We identified 7904 patients (median age, 72 years; 59% male) who required RRS activation at 29 facilities. Of the 7066 patients without pre-existing DNAR orders before RRS activation, 394 (5.6%) had new DNAR orders. Multivariable hierarchical logistic regression analyses revealed that new DNAR orders were associated with age category (adjusted odds ratio [aOR], 1.56; 95% confidence interval, 1.12-2.17 [65-74 years old reference to 20-64 years old], aOR, 2.56; 1.92-3.42 [75-89 years old], and aOR, 6.58; 4.17-10.4 [90 years old]), malignancy (aOR, 1.82; 1.42-2.32), postoperative status (aOR, 0.45; 0.30-0.71), and National Early Warning Score 2 (aOR, 1.07; 1.02-1.12 [per 1 score]).

Conclusion

The incidence of new DNAR orders was one in 18 patients after RRS activation. The factors associated with new DNAR orders were age, malignancy, postoperative status, and National Early Warning Score 2.

Recurrence of Large-Vessel Vasculitis Induced by Multiple Types of Granulocyte Colony-Stimulating Factor Preparation in Patient with Large-Cell Neuroendocrine Lung Carcinoma: A Case Report

With the increased use of granulocyte colony-stimulating factor (G-CSF) preparations, there is concern about the increase in G-CSF-associated large-vessel vasculitis; however, there have been no previous reports of vasculitis caused by multiple types of G-CSF preparations. We experienced a case of drug-induced large-vessel vasculitis caused by two different G-CSF products, which was difficult to diagnose. When treating patients with a history of large-vessel vasculitis caused by pegfilgrastim, we need to pay attention to its recurrence when using other G-CSF preparations.

Efficacy of a breastfeeding support education program for nurses and midwives: a randomized controlled trial

BACKGROUND

Nutritional support influences the growth and development of late preterm infants (LPIs) and their long-term health status. However, healthy LPIs have a shorter hospital stay and may not receive adequate care after discharge. In this study, we developed and evaluated the effectiveness of an educational program for nurses and midwives to enable them to support breastfeeding of healthy LPIs.

METHODS

A randomized controlled trial was conducted in Japan from July 2018 to April 2019. The participant pool consisted of nurses and midwives working at midwiferies and obstetric centers in Tokyo, Japan. A total of 395 candidates were recruited for participation across 79 facilities. The final participants were assigned to two groups: the breastfeeding support for LPIs program (BSLPI group; n = 36) or the non-technical skills program (NTS group; n = 33). The measures included the Self-Efficacy of Breastfeeding Support scale (SBS), the Social Skills in Nursing Interactions with Mothers (SS) scale, and the Knowledge and Skills Necessary for Breastfeeding Support for LPIs test (K-S). Scores for each measure were collected before, after, and one-month after the intervention. Repeated-measures ANOVA was used to identify differences (main effects) according to program (BSLPI and NTS) and time (before, immediately after, and one month after intervention).

RESULTS

All 69 participants attended the program. Main effects of the program were observed only for K-S scores (F[1,58] = 78.57, p = 0.01). No significant differences were found for SBS (F[1,58] = 0.63, p = 0.43) or SS scores (F[1,58] = 1.51, p = 0.23).

CONCLUSIONS

Participation in the BSLPI was related to improved breastfeeding support knowledge and skills but was not related to improvements in nurses' self-efficacy or social skills.

TRIAL REGISTRATION

Registered 12 December 2018, https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000040145 (UMIN: UMIN000035227).

Atezolizumab in combination with carboplatin plus nab‐paclitaxel for managing combined large‐cell neuroendocrine carcinoma: A case report

Large‐cell neuroendocrine carcinomas (LCNECs), categorized as high‐grade neuroendocrine carcinomas, account for approximately 3% of resected lung cancers. LCNECs containing other components are called ‘combined LCNECs’ and have no standard treatment. A 73‐year‐old male with a metastatic brain tumour from a combined LCNEC of the lung containing adenocarcinoma and sarcomatoid components was referred to our department. The patient was treated with chemotherapy consisting of carboplatin and nanoparticle albumin‐bound (nab)‐paclitaxel in combination with atezolizumab, which was decided in accordance with the histological evaluation of the components. This treatment resulted in partial response and remained durable for 12 months with an ongoing regimen. The current case suggests that the constituents of chemoimmunotherapy should be selected in accordance with the reported efficacy of relevant regimens for each component of the combined LCNEC.

Is a decrease in activities of daily living in the elderly irreversible? A case report of Wernicke encephalopathy in home medical care

The patient was an 83-year-old male who, after being hospitalized for 70 days for suffocation due to aspiration, was provided with home medical care (HMC) as his physical condition did not allow him to climb stairs. Wernicke encephalopathy (WE) was suspected based on his disorientation and a continued loss of appetite. This diagnosis was supported by abnormal serum thiamine and the disappearance of delirium after thiamine administration. In addition, he became able to use stairs. Patients who receive HMC should undergo active screening and receive treatment with WE in mind.

Trends and patterns in the practice of pediatric sedation for magnetic resonance imaging in Japan: A longitudinal descriptive study from 2012 to 2019

BACKGROUND

Worldwide, pediatric sedation for magnetic resonance imaging is a standard practice; however, there are few studies on its trends and patterns.

AIMS

This study aimed to investigate the trends and patterns of pediatric sedation for magnetic resonance imaging in Japan and determine the incidence of and risk factors for adverse events/interventions.

METHODS

This longitudinal descriptive study assessed children (age < 15 years) who underwent sedation for magnetic resonance imaging between April 2012 and December 2019 in Japan using a nationwide claims database. We assessed the patients' demographic characteristics, time trends in sedatives, sedative patterns by age, and adverse events/interventions within two post-sedation days. Further, we used multivariable logistic regression models to explore factors related to the incidence of adverse events/interventions.

RESULTS

We identified 29 187 cases (median age, 2.0 years; 55.2% males). The most common sedative was triclofos sodium (n = 18 812, 51.7%). There was an increasing trend in barbiturate use (17.0% [2012] to 25.0% [2019]) and decreasing trends in the use of triclofos sodium (56.4% [2012] to 47.7% [2019]) and chloral hydrate (15.6% [2012] to 10.8% [2019]). We identified 534 adverse events/interventions in 460 cases (1.5%). Multivariable logistic regression analyses revealed that the incidence of adverse events/interventions mainly increased with the number of sedatives (≥3; adjusted odds ratio, 5.10; 95% confidence interval, 3.67-7.10) and unscheduled setting (adjusted odds ratio, 6.28; 95% confidence interval, 4.85-8.61); further, it decreased with high hospital procedure volume (adjusted odds ratio, 0.62; 95% confidence interval, 0.49-0.78).

CONCLUSIONS

Based on a Japanese real-world setting, there is an increasing trend in barbiturate use and decreasing trends in the use of triclofos sodium and chloral hydrate in pediatric sedation for magnetic resonance imaging. Low hospital procedure volumes were associated with an increased risk of adverse events/interventions.

Epidural Blood Patch Using a Racz Catheter for Spontaneous Intracranial Hypotension With Unclear Leak Points

Using a Racz catheter (Brevi-XL™, Epimed Inc., NY, USA) to insert an epidural blood patch (EBP) may be an effective method of reaching the target epidural space in the cervical region. We would like to present a case, wherein a targeted EBP via Racz catheter was used in the management of spontaneous intracranial hypotension. When the leak point is clear via imaging, EBP should be performed exactly at that point. However, if the leak point is unclear, with only a contrast agent pool detected via imaging, EBP should be performed to mask the entire region of the pool. In both cases, EBP via Racz catheter is a convenient and effective method for the management of spontaneous intracranial hypotension. Further cases may be needed to verify our results.

Entrectinib for ROS1-rearranged non-small cell lung cancer after crizotinib-induced interstitial lung disease: A case report

Chromosomal rearrangements involving the c-ros oncogene 1 (ROS1) are identified in approximately 1% of non-small cell lung cancer (NSCLC) patients. Crizotinib is the first tyrosine kinase inhibitor (TKI) against ROS1-rearranged NSCLC. G2032R, a secondary resistant mutation, is observed in 41% of patients treated with crizotinib. Entrectinib, a TKI against neurotrophic tropomyosin receptor kinase, is reportedly efficacious against ROS1-rearranged NSCLC. However, ROS1-G2032R is resistant to entrectinib both in vitro and in vivo. We report an 85-year-old female patient with ROS1-rearranged NSCLC, who developed drug-induced interstitial lung disease (DI-ILD) 2 months after crizotinib treatment, and was treated with prednisolone followed by entrectinib. Entrectinib treatment resulted in stable disease with a marginal response after a partial response to crizotinib. Entrectinib treatment following crizotinib cessation due to DI-ILD was efficacious, which suggested that ROS1-G2032R gatekeeper mutation, frequently observed in crizotinib-resistant disease, was absent.

High proportion of thiamine deficiency in referred cancer patients with delirium: a retrospective descriptive study

BACKGROUND/OBJECTIVES

Recent studies have revealed thiamine deficiency (TD) as a cause of delirium in cancer patients. However, the extent to which Wernicke encephalopathy is present and in what patients is not well understood.

SUBJECTS/METHODS

In this retrospective descriptive study, we investigated referred cancer patients who were diagnosed with delirium by a psycho-oncologist to clarify the proportion of TD, the therapeutic effect of thiamine administration, and the factors involved in its onset.

RESULTS

Among 71 patients diagnosed with delirium by a psycho-oncologist, TD was found in 45% of the patients. Intravenous administration of thiamine led to a recovery in about 60% of these patients. We explored the factors associated with TD using a multivariable regression model with a Markov chain Monte Carlo imputation procedure. We found an association between TD and chemotherapy (adjusted odds ratio, 1.98 [95% confidence interval, 1.04-3.77]); however, there were no significant associations between TD and the other factors we considered.

CONCLUSIONS

TD is not particularly rare in delirium patients undergoing psychiatric consultation. The delirium was resolved in more than half of these patients by intravenous administration of thiamine. Oncologists should consider TD as a cause of delirium in cancer patients. Further prospective study is needed to clarify the relationship between TD and delirium in cancer patients.

A case of Wernicke encephalopathy in a dementia caregiver: The need for nutritional evaluation in family caregivers

A 63‐year‐old woman had started caring for her mother with dementia 6 months previously. A loss of appetite had appeared 2 months prior to her visit. Neurologically, she experienced mild unsteadiness, but she was fully conscious and had no ocular symptoms. MRI examination of her head did not reveal any notable findings. From these symptoms, the possibility of thiamine deficiency was considered, and her unsteadiness disappeared within a few days after an intravenous injection of thiamine. The burden of caring for a dementia patient may affect the nutritional status of the family caregiver.

UCP1 and TRPM8 Expression in the Brown Fat Did Not Affect the Restriction of Menthol-Induced Hyperthermia by Estradiol in Ovariectomized Rats

Estradiol (E₂) modulates the central and peripheral thermoregulatory responses to cold. Menthol is an agonist of transient receptor potential melastatin type 8 (TRPM8), which is a peripheral cold receptor. E₂ suppresses menthol-induced elevation of body temperature (T_b) in ovariectomized rats, but the mechanism is unknown. The aim of the present study is to investigate the effect of E₂ on uncoupling protein 1 (UCP1), a thermogenic gene, and TRPM8 mRNA levels in ovariectomized rats applied menthol. A silastic tube was implanted in ovariectomized rats with and without E₂ underneath the dorsal skin (E₂(+) and E₂(-) groups), and data loggers for T_b measurement into peritoneal cavity. After application of 10% L-menthol or vehicle to the skin of the whole trunk of rats, T_b was measured for 2 h. The interscapular brown adipose tissue (BAT) and spinal ganglia of cervical, thoracic, and lumbar parts were obtained for RT-qPCR assay. In the menthol application, T_b in the E₂(+) group was lower than that in the E₂(-) group. The UCP1 mRNA in the BAT, TRPM8 mRNA in the BAT and spinal ganglia in all areas did not differ between the E₂(+) and E₂(-) groups. In conclusion, the UCP1 and TRPM8 expression in the brown fat did not affect the restriction of the menthol-induced hyperthermia by estradiol in ovariectomized rats.

Nasogastric administration of osimertinib suspension for an epidermal growth factor receptor-mutated lung cancer causing an esophageal stricture: case report

An esophageal stricture is an abnormal esophageal narrowing, usually caused by esophageal diseases and rarely by lung cancer. They cause malnutrition, performance status (PS) deterioration, and difficulty in the oral administration of antitumor drug tablets. A 78-year-old female patient with lung adenocarcinoma, harboring an epidermal growth factor receptor (EGFR)-sensitizing mutation, experienced dysphagia due to an esophageal stricture caused by retrotracheal lymph node metastases. Osimertinib is a third-generation EGFR-tyrosine kinase inhibitor that is efficacious against EGFR-sensitizing mutations. The esophageal stricture hampered food intake and oral administration of osimertinib, causing severe malnutrition and deterioration to PS 3. Esophagogastroduodenoscopy (EGD) revealed severe and entire circumferential stenosis (7 cm in length) of the upper esophagus without mucosal abnormality. A nasogastric tube was inserted under EGD guidance, and an osimertinib suspension was administered accordingly: a tablet containing 80 mg of osimertinib was suspended in 50 mL of sterile hot water (55 ℃) for ten minutes, and the suspension was administered through a nasogastric tube once daily. Dysphagia improved 15 days after the introduction of osimertinib. After 21 days, the patient could take foods and drugs orally, and her PS improved to 1. Administering an osimertinib suspension via a nasogastric tube was a viable option in managing esophageal strictures in patients with EGFR-sensitizing mutations.

Proximity Proteomics Has Potential for Extracellular Vesicle Identification

Extracellular vesicles (EVs) are biomarkers and mediators of intercellular communication. In biological samples, EVs are secreted by various types of cells. The proteomic identification of proteins expressed in EVs has potential to contribute to research and clinical applications, particularly for cancer. In this study, the proximity-labeling method-based proteomic approach was used for EV identification, labeling membrane components proximal to a given molecule on the EV membrane surface. Due to the small labeling range, proteins on the surface of the same EVs are likely to be labeled by selecting a given EV surface antigen. The protein group of cancer cell-secreted EV (cEV), which abundantly expresses a close homologue of L1 (CHL1), was examined using a model mouse for lung cancer (LC). cEV-expressed proteins were identified by proteomic analysis of enzyme-mediated activation of radical sources by comparing serum EVs from wild-type and LC mice. SLC4A1 was found to be co-expressed in CHL1-expressing EVs, highlighting EVs expressing both CHL1 and SLC4A1 as candidates for cEVs. Serum EVs expressing both CHL1 and caspase 14 were significantly elevated in LC patients compared with healthy individuals. Thus, the combination of proximity labeling and proteomic analysis allows for effective EV identification.

MicroRNA Let-7c Contributes to Paclitaxel Resistance via Aurora-B in Endometrial Serous Carcinoma

The incidence of endometrial cancer has rapidly risen over recent years. Paclitaxel, a key drug for endometrial cancer treatment, inhibits microtubule depolymerization and induces apoptosis in cancer cells. Endometrial serous carcinoma (ESC) accounts for < 10% of all endometrial carcinomas, but its aggressive nature makes it responsible for close to 40% of cancer deaths. Thus, novel therapeutic targets are required for ESC. To identify microRNAs that promote paclitaxel resistance, we established two paclitaxel-resistant cell lines from USPC1 human ESC cells by exposing paclitaxel to parental cells for 12 weeks. Paclitaxel concentrations were increased every 2 weeks, and after 12 weeks of paclitaxel exposure, two replicate paclitaxel-resistant cell lines were established (USPC1-PTSR1 and USPC1-PTXR2). The microarray analysis was performed using USPC1 cells and USPC1-PTXR1 cells, and eight candidate microRNAs were thus selected as potential mediators of paclitaxel sensitivity. Among these candidate microRNAs, let-7c precursor treatment of paclitaxel-resistant USPC1-PTXR1 cells caused the greatest increase in paclitaxel-mediated cytotoxicity. Let-7c inhibition conversely decreased paclitaxel-induced apoptosis. It is known that let-7a microRNA, a member of the let-7 family, inhibits growth of endometrial carcinoma cells targeting Aurora-B that controls progression through each phase of mitosis. We thus studied whether let-7c mediates Aurora-B expression in ESC cells. The expression levels of Aurora-B mRNA and protein were higher in USPC-PTXR1 cells compared with USPC1 cells. Let-7c inhibition increased Aurora-B expression in USPC1 cells but decreased Aurora-B expression in USPC1-PTXR1 cells. These results indicate that let-7c mediates paclitaxel resistance via inhibition of Aurora-B expression in ESC cells.

Bevacizumab-Containing Chemoimmunotherapy for Recurrent Non-Small-Cell Lung Cancer after Chemoradiotherapy: Case Report

Chemoimmunotherapy has become the standard of care as the first-line treatment of advanced or recurrent non-small-cell lung cancer (NSCLC). The bevacizumab-containing chemoimmunotherapy regimen is theoretically more effective than a non-bevacizumab-containing regimen via two mechanisms: a superior outcome of bevacizumab-containing chemothrerapy than the standard platinum doublet regimen, and the synergistic effect of bevacizumab with an immune checkpoint inhibitor (ICI). Bevacizumab effectively normalizes vascularization, especially when the vascular bed is damaged by previous treatment. Bevacizumab promotes immunomodulation when used with ICI. We describe a patient with nonsquamous NSCLC who returned 2.5 years after definitive chemoradiotherapy for postoperative locoregional recurrence in the right supraclavicular lymph node. Considering the destroyed vascular bed due to prior chemoradiotherapy, attaining vascular normalization was critical for effective drug delivery. The patient was treated with a bevacizumab-containing chemoimmunotherapy regimen, which resulted in a complete metabolic response. The patient responded well for 23 months and is receiving ongoing treatment. Thus, bevacizumab-containing chemoimmunotherapy could be advantageous in some recurrent cases after chemoradiotherapy.

Early responders within seven days of dupilumab treatment for severe asthma evaluated by patient-reported outcome: a pilot study

Background

The management of severe asthma-associated symptoms is essential since they are distressing to the affected patients, and also greatly impair their quality of life. Dupilumab, a monoclonal antibody, blocks interleukin (IL)-4 and IL-13 signaling, both of which are crucial in acquired and innate immunity pathways through fast signal transduction, leading to an early response to treatment. Although rapid improvement within 1–3 days after dupilumab treatment was observed in moderate-to-severe atopic dermatitis, an early response within 7 days of dupilumab treatment in severe asthma has not been reported.

Methods

Twelve consecutive patients with severe asthma who were newly treated with dupilumab between July 2019 and April 2020 were retrospectively investigated. We evaluated the early response (within 7 days) of patients with severe asthma receiving dupilumab therapy. Asthma control test (ACT) and the daily ACT, which was modified from the ACT to evaluate daily symptoms associated with asthma, were adopted as patient-reported outcomes (PROs) at week 8 and within 7 days, respectively. Patients were stratified into early responders (7 days), late responders (week 8), and non-responders without significant improvement in PROs. Descriptive statistics were adopted due to the limited number of patients.

Results

Four of these 12 patients were early responders, with the following baseline characteristics: body mass index, <25 kg/m²; without depression; baseline forced expiratory volume in 1 second, <1.50 L; and more than one exacerbation in 1 year. On the other hand, five were late responders, and 44.4% of the nine responders were early responders. The higher the eosinophilic count and/or FeNO did not show any relationship between the early responder and nonresponder.

Conclusions

The effect of dupilumab on severe asthma in patients with atopic features could be started earlier than 2 weeks, similar to atopic dermatitis. Daily ACT may be useful in monitoring the early efficacy of dupilumab in treating severe asthma.

Subclinical thiamine deficiency identified by pretreatment evaluation in an esophageal cancer patient

Despite the fact that both thiamine deficiency (TD) and Wernicke encephalopathy (WE) have been observed to some degree in cancer patients, such cases of TD and/or WE reported to date have all been diagnosed after the initiation of treatment. We here report a case of TD that presented without the commonly accepted triad of WE symptoms based on a total nutritional evaluation prior to the onset of treatment for cancer. The patient was a 71-year-old man with esophageal cancer who was referred to the oncology outpatient clinic for evaluation to determine the treatment plan. Although he did not present with delirium, cerebellar signs, or ocular symptoms, TD was suspected based on a reduction in appetite lasting 2 months as thiamine stores in the body are depleted in as few as 18 days. Blood findings showed a marked decline in serum thiamine level supported, which the diagnosis of TD. This case revealed the existence of a cancer patient with subclinical TD prior to the onset of treatment for cancer. Due to the fact that TD can occur without the characteristic symptoms as in this case, we believe it is important that total nutritional evaluation of cancer patients always be considered.

Characteristics of Mandibular Canal Branches Related to Nociceptive Marker

It is difficult to correlate the direction of mandibular canal branches (MCBs) with altered sensation in dental treatments. In contrast, calcitonin gene-related peptide (CGRP) is related to vasodilation, bone formation, and the interaction with the peripheral nervous system. Therefore, we investigated the detailed morphological characteristics of MCBs using cone-beam computed tomography (CBCT) and observation of the CGRP distribution around the MCB. The MCB measurements were evaluated using principal component analysis (PCA) to identify morphological correlations. A total of 168 sides of mandibles from 84 cadavers were analyzed in this study. Most of the MCBs were primarily in the direction of the clock model from X to XI in sagittal sections and XII to I in coronal sections of the mandible. The structure of the MCB was divided into the fine canal branch (60.4%, 223/369), partial branch (24.4%, 90/369), and no canal branch (15.2%, 56/369). PCA indicated that the measurement element with the MCB and its structures were correlated in contrast to tooth factors. Positive CGRP reactions were clearly observed in the no-canal branch group compared to other groups. These data provide useful suggestions for MCB dynamics and information for clinical dental treatment.

Predictors of survival among Japanese patients receiving first-line chemoimmunotherapy for advanced non-small cell lung cancer

Background

First‐line chemoimmunotherapy (CIT) has improved overall survival (OS) and progression‐free survival (PFS) outcomes among patients with non‐small cell lung cancer (NSCLC). The immunological and nutritional statuses of patients fluctuate during treatment using immune checkpoint inhibitors, and are closely related to treatment outcomes. However, it is unclear whether these markers are significant in patients who are receiving CIT.

Methods

This retrospective single‐center study evaluated 34 consecutive Japanese patients with NSCLC who were treated using first‐line CIT. Previously reported markers that reflect immunological and nutritional statuses were evaluated at three time points: at the start of CIT, after three weeks, and at the end of induction therapy.

Results

The median PFS was 7.2 months (95% confidence interval: 6.3 months–not reached) and the median OS was not reached (95% confidence interval: 9.6 months–not reached). The PFS duration was significantly associated with the baseline neutrophil‐to‐lymphocyte ratio and the three‐week values for the modified Glasgow prognostic score, C‐reactive protein‐albumin ratio, prognostic nutrition index, and advanced lung cancer inflammation index. The OS duration was significantly associated with the pre‐treatment values for the neutrophil‐to‐lymphocyte ratio and advanced lung cancer inflammation index, as well as the prognostic nutrition index at the end of induction therapy.

Conclusions

Immunological and nutritional markers could be useful for predicting the outcomes of CIT for Japanese patients with advanced non‐small cell lung cancer. The timing of their evaluation may also be important.

Key points

Significant findings of the study

Overall survival in patients receiving first‐line chemoimmunotherapy for advanced lung cancer were associated with pretreatment values of neutrophil‐to‐lymphocyte ratio, advanced lung cancer inflammation index, and the prognostic nutrition index at the end of induction therapy.

What this study adds

Repetitive evaluation of immunological and nutritional markers may be useful for guiding prognostication and treatment selection for Japanese patients with advanced lung cancer.

Systemic acyl-ghrelin increases tail skin temperature in rats without affecting their thermoregulatory behavior in a cold environment

Fasting increases ghrelin that is a peptide hormone with two circulating isoforms, acyl and des-acyl ghrelin. We reported that fasting or des-acyl ghrelin facilitates behavioral thermoregulation in the cold in rats assessed by tail-hiding behavior that was the indicator of rats' thermoregulatory behavior in the cold; however, the effect of acyl-ghrelin on the same process remains to be elucidated. We investigated the effect of acyl-ghrelin on thermoregulatory behavior in the cold in rats. The animals received an intraperitoneal saline or 24 μg acyl-ghrelin injection and were exposed to 27 °C or 15 °C for 2 h, while their body temperature, tail skin temperature, and tail-hiding behavior were constantly monitored. cFos immunoreactive (cFos-IR) cells in the median preoptic area, medial preoptic area, paraventricular nucleus (PVN), and arcuate nucleus were counted. Body temperature and the duration of thermoregulatory behavior did not show a significant difference between the acyl-ghrelin-treated and control groups at 15 °C; however, tail skin temperature in the acyl-ghrelin-treated group was higher than that in the control group. The number of cFos-IR cells in the PVN was greater in the control group than that in the acyl-ghrelin-treated group at 27 °C. These results indicate that acyl-ghrelin did not affect behavioral thermoregulation but might affect tail skin temperature in rats in the cold.

IgG4-related lung disease progressing to respiratory failure

Immunoglobulin G4 (IgG4)-related disease (IgG4-RD) is a systemic immune-mediated, fibroinflammatory disorder categorized as proliferative or fibrotic depending on the responsiveness of corticosteroid treatment. IgG4-related lung disease (IgG4-RLD) accounts for 13-14% of IgG4-RD cases, but respiratory failure is quite rare. A 71-year-old man diagnosed with interstitial lung disease was referred to our department after a 10-month observational period. He presented with respiratory failure at the first visit, with significant elevations in serum IgG4 levels and histopathological findings meeting the criteria of IgG4-positive plasma cells and IgG4/IgG-positive plasma cell ratio in transbronchial lung biopsy and inguinal lymph node biopsy, resulting in a diagnosis of IgG4-RD. Systemic corticosteroid treatment promptly ameliorated the respiratory failure. 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography showed significant FDG accumulation in the lung fields, indicating the proliferative and reversible status of IgG4-RLD, which responded well to corticosteroid treatment. The patient recovered from respiratory failure even after a 10-month observational period.

Drug-induced interstitial lung disease associated with dasatinib coinciding with active tuberculosis

A 69-year-old woman was diagnosed with a breakpoint cluster region-Abelson-positive chronic myeloid leukaemia and treated with dasatinib for 14 months. She presented with one month of high-grade fever and persistent dry cough. Chest computed tomography revealed non-segmental subpleural consolidation, ground-glass opacities, and interlobular septal thickening. The bronchoalveolar lavage (BAL) and transbronchial lung biopsy confirmed a diagnosis of drug-induced interstitial lung disease (ILD) associated with dasatinib. Then, systemic corticosteroid treatment was initiated, which was effective and the interstitial shadow disappeared after two weeks. The acid-fast bacilli culture test of BAL fluid after three weeks was positive for Mycobacterium tuberculosis, and combination therapy with four antituberculosis drugs was added. It is known that drug-induced ILD and susceptibility to infection associated with dasatinib occur in a dose-dependent manner. This is the first case of dasatinib-induced ILD which coincided with active tuberculosis.

Exacerbation of psychotic symptoms as clinical presentation of Wernicke encephalopathy in an Alzheimer's disease patient

Although there have been recent reports of nonalcoholic thiamine deficiency (TD), no association has been reported between the exacerbation of the psychiatric symptoms of Alzheimer's disease patient and TD. An 89-year-old woman with dementia visited our hospital because of acute deterioration in behavioral and psychological symptoms of dementia (BPSD). Her medical history revealed a decrease in oral food intake lasting more than 2 weeks, so that TD was suspected and abnormal behavior improved significantly after thiamine administration. Thiamine deficiency should be suspected in patients with dementia who demonstrate acute deterioration in BPSD possibly related to poor oral food intake.

Atezolizumab in combination with carboplatin and etoposide for heavily treated small cell lung cancer

Atezolizumab was the first immune checkpoint inhibitor (ICI) to be introduced as a first-line treatment option for extensive-stage small cell lung cancer (ES-SCLC), in combination with carboplatin and etoposide (CE) chemotherapy. However, SCLC treatment options after progression to first-line chemotherapy are limited, warranting the readministration of previously used drugs. In combination with atezolizumab, CE readministration may theoretically be effective, based on two tentative mechanisms: its additive and synergistic effects on cytotoxic chemotherapy. The additive effect is based on the IFCT-1603 trial in which the Kaplan-Meier estimates of both progression-free survival (PFS) and overall survival (OS) in the atezolizumab group exhibited a tail plateau in the selected population. Conversely, an anti-PD-L1 antibody synergistic effect on platinum compounds was assessed in a preclinical study, which was reinforced by clinical data. Thus, atezolizumab in combination with CE may be a treatment option in heavily treated patients. Here, we describe the first case of a heavily treated ES-SCLC patient treated with chemoimmunotherapy, resulting in a partial response and a durable PFS. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY AND WHAT THIS STUDY ADDS: CE readministration with atezolizumab may be effective based on two tentative mechanisms. Additive and synergistic effects of atezolizumab on CE have been previously suggested via a clinical trial and preclinical study, respectively. This is reflected in the current case in clinical settings.

Comparison of intrathecal morphine with continuous patient-controlled epidural anesthesia versus intrathecal morphine alone for post-cesarean section analgesia: a randomized controlled trial

Background

Several neuraxial techniques have demonstrated effective post-cesarean section analgesia. According to previous reports, it is likely that patient-controlled epidural analgesia (PCEA) without opioids is inferior to intrathecal morphine (IM) alone for post-cesarean section analgesia. However, little is known whether adding PCEA to IM is effective or not. The aim of this study was to compare post-cesarean section analgesia between IM with PCEA and IM alone.

Methods

Fifty patients undergoing elective cesarean section were enrolled in this prospective randomized study. Patients were randomized to one of two groups: IM group and IM + PCEA group. All patients received spinal anesthesia with 12 mg of 0.5% hyperbaric bupivacaine, 10 μg of fentanyl, and 150 μg of morphine. Patients in IM + PCEA group received epidural catheterization through Th11–12 or Th12-L1 before spinal anesthesia and PCEA (basal 0.167% levobupivacaine infusion rate of 6 mL/h, bolus dose of 3 mL in lockout interval of 30 min) was commenced at the end of surgery. A numerical rating scale (NRS) at rest and on movement at 4,8,12,24,48 h after the intrathecal administration of morphine were recorded. In addition, we recorded the incidence of delayed ambulation and the number of patients who requested rescue analgesics. We examined NRS using Bonferroni’s multiple comparison test following repeated measures analysis of variance; p < 0.05 was considered as statistically significant.

Results

Twenty-three patients in each group were finally analyzed. Mean NRS at rest was significantly higher in IM group than in IM + PCEA group at 4 (2.7 vs 0.6), 8 (2.2 vs 0.6), and 12 h (2.5 vs 0.7), and NRS during mobilization was significantly higher in IM group than in IM + PCEA group at 4 (4.9 vs 1.5), 8 (4.8 vs 1.9), 12 (4.9 vs 2), and 24 h (5.7 vs 3.5). The number of patients who required rescue analgesics during the first 24 h was significantly higher in IM group compared to IM + PCEA group. No significant difference was observed between the groups in incidence of delayed ambulation.

Conclusions

The combined use of PCEA with IM provided better post-cesarean section analgesia compared to IM alone.

Trial registration

UMIN-CTR (Registration No. UMIN000032475). Registered 6 May 2018 – Retrospectively registered.

Neuroleptic malignant syndrome in patients with cancer: a systematic review

BACKGROUND

Antipsychotics potentially cause a low incidence of the side effect called neuroleptic malignant syndrome (NMS), which has a high mortality rate. However, few studies on NMS among patients with cancer exist.

AIMS

We aimed to examine the characteristics of antipsychotic-induced NMS among patients with cancer.

METHODS

We conducted a systematic review of published reports on NMS described during the treatment of patients with any type of cancer. Articles were identified by a comprehensive search of PubMed, Web of Science, the Cochrane Library and reference lists from relevant articles published until 25 December 2019. Original articles or case reports on humans published in English were included. This review summarises the symptoms, characteristics, treatment course and prognosis of patients with cancer with NMS.

RESULTS

Eleven patients with various cancer types from ten case reports published from 1988 to 2013 met the eligibility criteria. Mean age of the 11 patients was 52.5 (range, 32-83) years. NMS developed mostly during the postoperative period, and haloperidol and D2 receptor antagonists were determined as the common causative drugs. Ten patients survived following treatment that mostly involved discontinuing the causative drugs and administering dantrolene, if necessary.

CONCLUSION

Although NMS intrinsically has a low incidence and high mortality, only few reports were available, with most patients surviving after early detection and appropriate treatment. Healthcare providers should consider NMS development while prescribing antipsychotics to ensure prompt recognition of the condition and rapid treatment for preventing unnecessary deaths.

Effect of the menstrual cycle phase on foot skin temperature during menthol application in young women

According to the literature, the arteriovenous anastomoses in the peripheral parts (ex. hands and feet) respond thermal stimulation susceptibly. Thus, the feet are sensitive to cold stimulation. The aim of the present study was to investigate the effect of menstrual cycle on skin temperature (T_sk) of the foot during menthol application in young women. T_sk and partial cutaneous blood flow in the foot, tympanic temperature, blood pressure, heart rate, thermal sensation and pleasantness during the preovulatory (P), luteal (L), and menstrual (M) phases during menthol application in young women using thermography, laser Doppler flowmetry, a digital blood pressure monitor, and VAS scale were examined at 25 °C. After application of the 0.5% menthol solution to the right foot, the measurements were continued for 20 min. The T_sk of the second and third right toes in the P phase were lower than that in the L phase. The T_sk of the little right toe in the P phase was lower than that in the L and M phases. No significant differences were observed in the T_sk of the dorsum of right foot, cutaneous Laser-Doppler flow in the right great toe, tympanic temperature, blood pressure, heart rate, thermal sensation and pleasantness among the phases. The menstrual cycle phase did not affect T_sk in the dorsum of the foot, but it affected T_sk in some toes during menthol application.

Seasonality of acute kidney injury incidence and mortality among hospitalized patients

Background

Understanding disease seasonality is important for improving clinical practice, hospital resource utilization and community-based preventive care. However, no studies have investigated the seasonality of acute kidney injury (AKI).

Methods

In the Tokushukai Medical Database, which includes 38 Japanese community hospitals, we identified hospitalized patients with AKI based on the Kidney Disease: Improving Global Outcomes serum creatinine criteria from January 2012 to December 2014. We plotted the number and proportion of patients with AKI among hospitalized patients by month of hospital admission. Subgroup analyses were conducted by the admission diagnosis category, timing of AKI diagnosis and age. We also examined the association between month of hospital admission and AKI, adjusting for patient characteristics and AKI risk factors. Finally, we assessed seasonal variations in disease severity and 30-day mortality of patients with AKI.

Results

We identified 81 279 (14.6%) patients with AKI among 555 940 hospitalized patients. The proportion of patients with AKI was highest in January (16.7%) and lowest in June (13.4%). Subgroup analyses suggested that the seasonality of AKI incidence was driven by community-acquired AKI associated with the admission diagnosis of cardiovascular and pulmonary diseases among older patients. The adjusted odds ratio for AKI (January versus June) was 1.24 (95% confidence interval, 1.17-1.31). Patients with AKI showed a larger number of failing organs in winter, and their 30-day mortality was 16.4% in spring, 14.5% in summer, 15.6% in autumn and 18.4% in winter.

Conclusion

AKI is more common among hospitalized patients and patients with AKI are more severely ill in winter.

Regulatory T cells and M2-polarized tumour-associated macrophages are associated with the oncogenesis and progression of oral squamous cell carcinoma

Regulatory T cells (Tregs) and tumour-associated macrophages (TAMs) contribute to the tumour microenvironment by inhibiting anti-tumour immune responses. This study was performed to investigate the roles of Tregs and TAMs in oral squamous cell carcinoma (OSCC) and oral epithelial precursor lesions (OEPL). The expression of Treg markers CD25 and FoxP3 and TAM markers CD163 and CD204 was investigated in 82 OSCC and 45 OEPL specimens, and their associations with clinicopathological parameters were analyzed. Correlations were found among CD25, FoxP3, CD163, and CD204 levels (P <  0.001), and these targets were up-regulated in OSCC compared to OEPL (P <  0.001). In OSCC, infiltration of Tregs and/or M2 TAMs was associated with sex and clinicopathological features, such as tumour size, nodal metastasis, tissue differentiation, stromal reaction, invasive behaviour, and invasive depth. In OEPL, CD25, FoxP3, CD163, and CD204 immunoreactivities were significantly associated with sex, postoperative recurrence, and cancerization to OSCC. This study is novel in showing that the infiltration of Tregs and M2 TAMs is significantly associated with the progression of premalignant lesions to OSCC. This suggests that these cells represent prognostic biomarkers for premalignant lesion progression and that immunotherapeutic approaches to control Treg/M2 TAM numbers could protect against progression to malignancy.