Does regional quota status affect the performance of undergraduate medical students in Japan? A 10-year analysis

OBJECTIVES

This study aims to determine whether there is a difference in the academic performance of medical students based on admission type and examine the extent to which entrance examinations predict their performance.

METHODS

This observational study utilized existing data from Asahikawa Medical University. Participants were 1057 medical students who had enrolled between 2010 and 2019. Analysis of variance and Tukey's test were utilized to identify differences between admission types. The multiple linear regression explored predictors of cumulative grade point average for each type.

RESULTS

Analysis of variance showed significant differences in the National Center Test (F_{(3, 1053)} =70.78, p <0.001) and cumulative grade point average (F_{(3, 1053)} =3.93, p <0.01). Tukey's post hoc test revealed that two types of general admission students (M=83.52, SD=3.22; M=85.57, SD=3.01) were significantly higher on the National Center Test than two types of regional quota students (M=81.61, SD=3.93; M=80.65, SD=3.61). The cumulative grade point average of a regional quota group (M=2.23, SD=0.34) was significantly higher than two types of general admissions (M=2.11, SD=0.36; M=2.12, SD=0.34). High school grade point averages and females were significant in predicting cumulative grade point averages for each admission (16.0-28.3% variance).

CONCLUSIONS

Regional quota students earned a higher cumulative grade point average than those from general admissions, despite their significantly lower scores on the National Center Test. Enhanced utilization of regional quota admissions could become an effective strategy to increase the rural physician workforce.

Non-recovery of vancomycin-associated nephrotoxicity is related to worsening survival outcomes-combined retrospective analyses of two real-world databases

There has been growing concern in worsening survival and renal outcomes following vancomycin-associated nephrotoxicity (VAN) onset, but the factors associated with these phenomena remain unclear. To examine these factors, we performed a retrospective study combining the analysis of two real-world databases. Initially, the FDA Adverse Event Reporting System (FAERS) was used to evaluate the relationship between VAN and mortality using odds ratios (ORs) and 95% confidence intervals (CIs). Next, electronic medical records (EMRs) were examined in a more robust cohort for evaluation of the association between renal outcomes and worsening survival using Cox proportional hazards regression models. FAERS analysis revealed a significant correlation between VAN occurrence and increased mortality (OR: 1.30; 95% CI: 1.17-1.46). EMR analysis showed that non-recovery of VAN was associated with increased hospital mortality (hazard ratio [HR]: 4.05; 95% CI: 2.42-6.77) and one-year mortality (HR: 3.03, 95% CI: 1.98-4.64). The HR for VAN recovery was lower for patients with acute kidney injury (AKI) stage ≥ 2 (HR: 0.09; 95% CI: 0.02-0.40). Thus, worsening survival outcomes were associated with non-recovery of VAN, whereby AKI stage ≥ 2 was a significant risk factor. Progression to severe VAN should be prevented for better survival outcomes.

Impact of the catechol-O-methyltransferase Val158Met polymorphism on the pharmacokinetics of L-dopa and its metabolite 3-O-methyldopa in combination with entacapone

In the pharmacotherapy of patients with Parkinson's disease (PD), entacapone reduces the peripheral metabolism of L-dopa to 3-O-methyldopa (3-OMD), thereby prolonging the half-life (t_1/2) of L-dopa and increasing the area under the concentration curve (AUC). The effect of entacapone on the pharmacokinetics of L-dopa differs between patients with high-activity (H/H) and low-activity (L/L) catechol-O-methyltransferase (COMT) Val158Met polymorphisms, but the effects are unclear in heterozygous (H/L) patients. 3-OMD has a detrimental effect and results in a poor response to L-dopa treatment in patients with PD; however, the influence of this polymorphism on the production of 3-OMD remains unknown. Therefore, the present study aimed to clarify the effect of the COMT Val158Met polymorphism on the concentrations of L-dopa and 3-OMD in the presence of entacapone. We performed an open-label, single-period, single-sequence crossover study at two sites in Japan. The study included 54 Japanese patients with PD, who underwent an acute L-dopa administration test with and without 100 mg entacapone on two different days. Entacapone increased L-dopa AUC_0-infinity by 1.59 ± 0.26-fold in the H/H group, which was significantly higher than that in the H/L (1.41 ± 0.36-fold) and L/L (1.28 ± 0.21-fold) groups (p < 0.05). The concurrent administration of L-dopa with entacapone suppressed the increase in 3-OMD levels compared with L-dopa alone in all genotypes. Our results suggest that the COMT Val158Met polymorphism may be an informative biomarker for individualized dose adjustment of COMT inhibitors in the treatment of PD.

Voiding time as a predictor for urinary tract function and health status

AIM

In this study, we investigated self-measured voiding time in the Japanese population.

METHODS

A survey questionnaire was used to determine self-measured voiding time in Japanese participants aged ≥20 years. In addition to demographic data such as age and sex, relevant medical conditions, including hypertension, diabetes mellitus, renal impairment and other disorders, were also recorded. Voiding time was measured whenever the participant had the urge to void.

RESULTS

In total, 2493 healthy individuals (1347 men, mean ± SD, age 60.50 ± 12.16 years, and 1146 women, 51.16 ± 12.97 years) participated in the survey. Self-measured voiding time was 27.71 ± 20.25 s for men, and 17.49 ± 11.87 s for women. Additionally, 1227 participants with certain diseases were included (1026 men, aged 67.12 ± 9.93 years, and 201 women, 60.26 ± 11.02 years). In this group, self-measured voiding time was significantly longer at P < 0.01 (30.71 ± 20.98 s in men, 21.28 ± 15.56 s in women). In men whose international prostate symptom score (IPSS) was >7, voiding time was significantly longer (healthy men: IPSS ≤7 n = 868, 23.9 ± 14.88 s, IPSS ≥8 n = 479, 34.6 ± 26.05 s, P < 0.05, men with comorbidities: IPSS ≤7: n = 504, 25.64 ± 15.63 s, IPSS ≥8: n = 522, 35.6 ± 24.11 s, P < 0.05).

CONCLUSIONS

This self-reported internet survey revealed that self-measured voiding time was longer in men than women regardless of age, and was significantly prolonged with age regardless of sex. Furthermore, self-measured voiding time could be a good screening tool to predict urinary function and health status. Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2020; ••: ••-••.

Real-world pharmacological treatment patterns of patients with young-onset Parkinson's disease in Japan: a medical claims database analysis

INTRODUCTION

Young-onset Parkinson's disease is reported to comprise 5-10% of all Parkinson's disease cases; however, as physicians encounter a limited number of these patients, their treatment patterns are still unclear.

METHODS

We performed a descriptive study using the large Japanese medical claims database to describe the epidemiology and real-world pharmacological treatment patterns of newly diagnosed patients with young-onset Parkinson's disease. Patients aged 21-50 years in whom Parkinson's disease was newly diagnosed between January 1, 2005 and March 31, 2016 were included. We excluded individuals with Parkinson's-related diseases and those using antipsychotics to eliminate the possibility of drug-induced parkinsonism. The patients' demographics, comorbidities, prescribing patterns, and changes in levodopa equivalent daily dose were analyzed.

RESULTS

We identified 131 newly diagnosed young-onset Parkinson's disease patients (median age, 44.2 years). The most common comorbidities were depression (23.7%), hypertension (23.7%), and insomnia (22.9%). Of these patients, 122 were prescribed antiparkinson drugs. During the study period, the proportion of patients who were prescribed dopamine agonists, levodopa, and anticholinergics were 77.1%, 44.3%, and 27.5%, respectively. Dopamine agonists (49.2%) were most commonly prescribed initially, followed by anticholinergics (23.8%), levodopa (19.7%), and others (4.1%). The levodopa equivalent daily dose increased steadily with longer disease duration.

CONCLUSIONS

Dopamine agonists were most frequently prescribed during the study period and were the initial treatment of choice. We also observed a change in levodopa equivalent daily dose over the disease course. This study provides a descriptive overview of real-world prescribing patterns in young-onset Parkinson's disease patients.

[The prognostic factors in astrocytic tumors: analysis by the Kaplan-Meier method and the Weibull log-linear model]

As the prognosis of astrocytic tumors depends on various factors, identifying prognostic factors should be useful for developing strategies to cope with them. Between 1975 and 1994, more than 200 patients with astrocytic tumors were treated in Kagoshima University. Of these patients, 149 (grade I: 17, grade II: 42, grade III: 41, grade IV: 42, unproven: 7) have been followed up. Records of these patients were retrospectively reviewed for age at the time of initial symptoms, gender, histological grade (WHO), extent of tumor resection, radiation therapy, and administration of anticancer agents. We used the Kaplan-Meier method and the Weibull log-linear model to analyze the relation between survival time and these prognostic factors. Survival time was counted from onset of symptoms, and age of initial treatment was used as a covariant. The mean age of males at the initial diagnosis was 40.8 years (n = 77), and that of females was 39 years (n = 72). Using the Kaplan-Meier method, the mean survival time of the 149 patients was 101 months (males; 72.7 months, females; 134.5 months). Mean survival time of grade II was 144.3 months, that of grade III was 95.2 months, and grade IV (glioblastoma) was 15.9 months. Histological grades and mean ages of the groups showed a positive correlation. Among grades II, III and IV, the Kaplan-Meier survival curves were significantly different (p < 0.0001) according to the log-rank test. By the extent of surgical resection (subtotal or greater resection, partial resection, and less than partial resection), the mean survival time showed a significant difference (p < 0.05) on the log-rank test. However, we could not detect a significant difference in survival time between the group that received chemotherapy and the group which did not. The Weibull log-linear analysis indicated that gender, age, histological grade (WHO), extent of surgery, and dose of radiation therapy were prognostic factors. Covariants of grades II, III, and IV made survival time 0.314, 0.179, and 0.069 times as long as that of grade I. The survival time after "partial resection" became 1.415 times as long as the survival time after "less than partial resection". The covariant of "greater than subtotal resection" showed a prolonged survival time of 2.916 compared with that of "less than partial resection". As for age at treatment, the older the patient was, the shorter the survival time. The rate was 0.986 for each year of age. Irradiation of one Gy increased survival time by 1.015 times. Chemoimmunotherapy (dose of ACNU and interferon beta) could not be confirmed as an effective covariant.

[Ventilatory insufficiency due to upper cervical injury treated by diaphragm pacing: a case report]

A 33-year-old man suffered chronic ventilatory insufficiency with tetraplegia after an operation for atlantoaxial dislocation. He was alert and his tetraplegia gradually improved. However, continuous mechanical ventilation was necessary for him. Thirteen months after the operation, a diaphragm pacer (Avery Laboratory Inc.) was implanted on the right phrenic nerve in the cervical region. Nineteen days after the implantation of the right side pacer, a left side diaphragm pacer was also implanted. Diaphragm pacing was started two weeks after the second implantation. The pacing period was gradually prolonged and continuous pacing for 9 hours by the right side pacer and three hours by the left side pacer was able to be obtained. One year after implantation, twelve continuous hours of diaphragm pacing became possible. During diaphragm pacing, blood gas analysis was satisfactory and the patient could move sitting on a wheel chair, watch television and write letters using a word processor. We were unable to achieve total ventilatory support for him using these diaphragm pacers. We thought that the main cause of our partial failure originated from the procedure used in implanting the electrode onto the phrenic nerve. Left side pacing needs higher amplitude than that used on the right side to obtain sufficient tidal volume. The patient refused our continuing the left side pacing because of pain around the anterior chest and shoulder. Another problem to be watched is diaphragm fatigue. However, diaphragm pacing has been continued for six years and it has been useful in improving his quality of life.(ABSTRACT TRUNCATED AT 250 WORDS)

Extra-axial ependymoma--case report

A 13-year-old boy presented with a very unusual ependymoma extending extra-axially. Computed tomography demonstrated a tumor with a cyst and calcification adjacent to the dura and extending over the right occipital and parietal lobes. The cyst wall and solid tumor were enhanced postcontrast. Magnetic resonance imaging revealed that the solid tumor was isointense on T1-weighted images and a mixed iso- and high-intensity on T2-weighted images. The solid tumor and tissue surrounding the cyst were enhanced markedly by gadolinium-diethylenetriaminepentaacetic acid. Sagittal and coronal images demonstrated a multilocular tumor shadow. Cerebral angiography demonstrated a tumor fed by a posterior branch of the right middle meningeal artery but no feeders from the internal carotid and vertebral arteries. The tumor was removed en bloc. The histological diagnosis was clear cell-type ependymoma.

[Trigeminal neurinoma in the cavernous sinus revealed by intratumoral hemorrhage: a case report]

A case of trigeminal neurinoma located in the left cavernous sinus and revealed by intratumoral hemorrhage is reported. Preoperatively, magnetic resonance imaging provided the accurate localization of the lesion, allowing precise planning of the surgical approach. The neurinoma inside the cavernous sinus wall was removed successfully, and the patient developed no new neurological deficits except for anesthesia in the 1st division of the trigeminal nerve. The characteristic findings of magnetic resonance imaging of the trigeminal neurinoma in the cavernous sinus are reported.

Hydrocephalus due to villous hypertrophy of the choroid plexus in the lateral ventricles. Case report

A case is reported of hydrocephalus due to overproduction of cerebrospinal fluid (CSF) caused by villous hypertrophy of the choroid plexus in the lateral ventricles. A 7-year-old girl with mental retardation developed gait disturbance; hydrocephalus and a Dandy-Walker cyst were detected on computerized tomography. She was initially treated with a ventriculoperitoneal shunt; however, shunting failed to control the hydrocephalus. The excessive outflow of CSF suggested choroid plexus abnormality, and magnetic resonance (MR) imaging revealed enlargement of the choroid plexus in both lateral ventricles. The patient was therefore diagnosed as having hydrocephalus induced by overproduction of CSF, which was controlled by resection of the choroid plexus. Histological examination showed the structure typical of normal choroid plexus. This is a rare case of villous hypertrophy of the choroid plexus in which MR imaging assisted in the diagnosis.

31P-magnetic resonance spectroscopic study on the effect of glycerol on cold-induced brain edema

The aim of the present study was to determine the effects of a hyperosmotic agent, 10% glycerol, on both brain energy metabolism and intracellular pH (pHi) in experimental vasogenic brain edema. Vasogenic brain edema was induced by cold injury applied to bilateral parietal portions in 13 mongrel dogs (7 glycerol, 6 control) while, 3 dogs were used as control. Before and at 24 hours after the injury, sequential phosphorous-31 magnetic resonance spectroscopy (31P-MRS) was performed for 2 hours in order to determine phosphocreatine (PCr), beta-adenosine triphosphate (beta-ATP), inorganic phosphate (Pi) levels and pHi. At 24 hours following cold injury, both PCr/Pi and ATP/Pi ratios significantly decreased from 7.75 to 3.97 and from 2.26 to 1.25, respectively. Furthermore, a moderate decrease in pHi of 7.16 to 7.01 was significantly demonstrated during the same experimental period. Administration of glycerol for 30 minutes significantly increased PCr/Pi from 3.97 to 5.06 and ATP/Pi from 1.25 to 1.72, respectively. Also, glycerol administration caused a significant increase in pHi from 7.01 to 7.11. This study indicates that cryogenic injury, in which formation and expansion of vasogenic brain edema a known to occur, results in disturbed brain energy metabolism and in intracellular acidosis; moreover, the administration of glycerol can ameliorate either or both of these derangements.

[Transorbital penetrating brain injury]

Transorbital penetrating brain injury is rare during this time of peace. In our paper, we reported seven cases of these injuries and discussed the mechanism and treatment of intracranial complications. Transorbital penetrating brain injuries were caused by thin, long and relative hard objects such as chop-stick (case 3), pencil (case 6), bamboo stick (case 1, 2, 7) and a piece of metal (case 4, 5). CT scan, MRI and angiography demonstrated a large variety of intracranial complications. For instance, intracerebral hematoma, cerebral contusion, intraventricular hemorrhage, pneumocephalus, brain stem injury and carotid cavernous sinus fistula. We had no case of infectious complications such as meningitis and brain abscess. If the direction of the injuring object runs parallel to the orbital roof, it penetrates the cranial cavity commonly via the superior orbital fissure or the optic canal, which routes provide direct access without bone fracture. This direction will cause critical intracranial complications such as CCF or brain stem injury. If the injuring object runs upward and across the orbital roof which has thin bone and therefore offers little resistance, the frontal lobe will be easily damaged, and it will cause intracerebral hematoma. But the prognosis for this type of injury is not so poor because we can easily remove the hematoma and the foreign body. With our treatment policy of "pull and see", all our cases but one recovered well. The one exception was a case in which a large intracerebral hematoma was over-looked in an ophthalmological clinic. This patient died. Nowadays, CT scan and MRI give clear information about the anatomical location of injuring objects and intracranial complications.(ABSTRACT TRUNCATED AT 250 WORDS)

[Spinal artery aneurysm associated with dural AVM of the posterior fossa]

The incidence of an aneurysm of the spinal artery is extremely rare. Only several cases have been documented previously. Herewith, the authors present a patient with a ruptured aneurysm of the anterior spinal artery associated with dural AVM of the posterior fossa. A 51-year-old male had a sudden onset of occipital headache and left shoulder pain. Lumbar puncture revealed bloody CSF. Angiography showed a saccular aneurysm, filling from the anterior spinal artery and dural AVM of the posterior fossa. Aneurysmal neck clipping and cauterization for nidus of dural AVM was performed successfully through suboccipital craniectomy with laminectomy of C1 and C2. The authors reviewed the literature and discussed the features of the aneurysm of a spinal artery.

Unusual intra- and extracranial arteriovenous communication--case report

The authors report an unusual case of arteriovenous communication between extracranial and intracranial vessels, accompanied by incidentally detected bilateral arachnoid cysts of the middle cranial fossa. A 52-year-old male was admitted with a sudden onset of headache, vomiting, and conjunctival hyperemia of the right eye followed by progressive chemosis and proptosis. He had undergone a craniotomy for hypertensive right putaminal hemorrhage 4 months previously. Angiography showed the main feeding artery to be the superficial temporal artery and the draining veins to be the superficial Sylvian veins and the basal vein of Rosenthal. Partial obstruction of the right cavernous sinus was also shown. At surgery, granulation tissue continued to the dura mater through the skull aperture of previous craniotomy and adhered to the underlying damaged cerebrum. The extremely unusual nature of the communication, the operative findings, and the atypical fistulous figures suggested that communication had occurred postoperatively via newly generated vessels in granulation tissue.

[A case of systemic lupus erythematosus with subarachnoid hemorrhage due to ruptured aneurysm]

A case of systemic lupus erythematosus (SLE) with subarachnoid hemorrhage due to a ruptured intracranial aneurysm is reported. A 31-year-old woman who had been treated with steroid for SLE was admitted to our department with severe headache, and nausea. CT scan showed subarachnoid hemorrhage and the left carotid angiogram revealed a small aneurysm at the supraclinoid portion of the left internal carotid artery. She had no neurological deficit. Hematological examination on admission showed disseminated intravascular coagulation (DIC), therefore, we decided to perform an intentionally delayed operation. In the meantime we treated the patient for DIC with FOY and methylprednisolone. The operation was performed after two weeks, when DIC had been eliminated completely. Postoperative hematological examination showed severe thrombocytopenia. We considered that SLE had come to the fore again, so we used Danazol in company with FOY and steroid. It seemed that Danazol was very effective for her. She was discharged about two months after admission with no problem. Cerebral apoplexy, such as cerebral infarction and cerebral hemorrhage, has often been seen in SLE, but subarachnoid hemorrhage due to a ruptured aneurysm is very rare. We could find only five reports of this phenomenon. Their prognoses were all, unfortunately, poor. It should be born in mind for therapy that a patient in SLE has a tendency to bleed. It seems that repeated hematological examinations and quick and proper management are important. We think that the aneurysmal formation in SLE is due to lupus vasculitis or the fragility of blood vessels due to a long use of Steroid.

[Posttraumatic cerebrovascular narrowing. A case report and review of the literature]

We, neurosurgeons have sometimes confronted with the case of posttraumatic cerebrovascular narrowing or spasm. However, there have been few reports on the pathophysiology of the posttraumatic narrowing or spasm in comparison with those the spasm following the subarachnoid hemorrhage caused by the rupture of the aneurysm. The authors report here a case of temporal lobe contusion who demonstrated cerebrovascular narrowing angiographically at the 21st days after head injury. This 53-years-old male was examined again by angiography one week after the above-described angiography and the narrowing disappeared. The authors reviewed the literature on the posttraumatic cerebrovascular narrowing or spasm. Thirty seven cases have been reported in detail. Under the conditions of these 38 cases including the present case, the pathophysiology of the posttraumatic cerebrovascular narrowing or spasm was discussed. Two theories had been suggested for a long time: one was vasospasm caused by the traumatic subarachnoid hemorrhage and the other by direct mechanical irritation of cerebral artery. Recently, neurogenic factor is thought to take a part of this to a great extent such as hypothalamic dysfunction or dysfunctioning fragile autoregulation mechanism. It is seemed to be that such spasm caused by these mechanism will exist sure. However, in the posttraumatic cerebrovascular vasospasm, there are other accompanying intracranial lesions such as cerebral swelling, cerebral contusion, fracture of the base of the skull and so on. It is not assumed to be so simple environment as the spasm following the rupture of the aneurysm, and also the mechanism of genesis of the posttraumatic cerebrovascular spasm is not to be so simple. Several factors and their duplication will play a role in the mechanism. Further investigation is necessary for the clearness of the problem.