Prediction of Nursing Home Admission Using the FRAIL-NH Scale Among Older Adults in Post-Acute Care Settings

OBJECTIVES

The FRAIL-NH scale was developed to identify frailty status in nursing home residents. The purpose of this study was to examine the utility of the FRAIL-NH scale for predicting nursing home admission among patients in post-acute care settings. Design/ Setting/ Participants: This single-center, prospective, observational cohort study included participants aged 65 years or older who were admitted to a community-based integrated care ward (CICW) between July 2015 and November 2020.

MEASUREMENTS

Using the CICW database, we retrospectively classified participants as robust, prefrail, or frail based on the FRAIL-NH scale the score by identifying variables from our database that were most representative of each component. The following data were collected: examination findings, CICW admission and discharge information, length of CICW stay, and nursing home admission. The participants were divided into two groups based on whether or not they were admitted to a nursing home after CICW discharge. The hazard ratios (HRs) and 95% confidence intervals (CIs) for nursing home admission were calculated according to the FRAIL-NH categories using the Cox proportional hazards models with reference to the robust group. In the multivariate adjusted model, we adjusted for age, sex, nutritional status, cognitive function, living status, and economic status.

RESULTS

Data of 550 older adults were analyzed, of which 118 were admitted and 432 were not admitted to a nursing home. The frail group had a higher risk of nursing home admission (HR, 2.22; 95% CI 1.32-3.76) than the robust group.

CONCLUSIONS

This study showed that the FRAIL-NH scale was beneficial for predicting nursing home admission among older adults in the post-acute care setting. Thus, assessment using the FRAIL-NH scale may help to consider preparation and support for life after discharge.

Impact of Frailty on Dietary Habits among Community-Dwelling Older Persons during the COVID-19 Pandemic in Japan

Background

The coronavirus disease (COVID-19) pandemic has resulted in reduced physical activity and social interaction. These restrictions may have affected the food intake habits of frail older people more than non-frail older people.

Objectives

To investigate the association between frailty and change in dietary habit during the pandemic.

Design

Cross-sectional mail survey

Setting

Community-based

Participants

The study questionnaire was mailed to 4,436 older residents of Higashiura, Aich Japan, who were aged ≥75 years and who did not need care as of April 1, 2020. Of these, 2,738 participants provided complete answers to the questionnaires (75–96 years old, 49.3% males).

Measurements

The participants’ frailty status and changes in food consumption during social isolation were assessed. Frailty status was assessed using the five-item frailty screening index (i.e., weight loss, low physical function, low physical activity, cognition, and exhaustion). Any participant who reported an increase or a decrease in ≥1 of the 12 food categories was defined as having change in dietary habit. Using multivariate logistic regression analysis, the odds ratios (ORs) and 95% confidence intervals (CIs) of frailty for changes in diet were estimated by adjusting for age, sex, BMI, and living alone. In each of the 12 food categories, the proportion of participants with increased and decreased food intake was compared between the groups.

Results

Among the participants, 470 (17.2%) were frail, and 1,097 (40.1%) experienced a change in dietary habit under social restriction. The adjusted OR (95% CI) of the frail group for a change in dietary habit was 2.01 (1.63–2.47, p<0.001). Participants with decreased consumption of meat, fish, seaweed and mushroom, and fruits and those with increased consumption of eggs, bread, and noodles tended to be frail.

Conclusion

The nutritional intervention for frail older people should be strengthened during the pandemic.

Impact of Magnetic Field Configuration on Heat Transport in Stellarators and Heliotrons

We assess the magnetic field configuration in modern fusion devices by comparing experiments with the same heating power, between a stellarator and a heliotron. The key role of turbulence is evident in the optimized stellarator, while neoclassical processes largely determine the transport in the heliotron device. Gyrokinetic simulations elucidate the underlying mechanisms promoting stronger ion scale turbulence in the stellarator. Similar plasma performances in these experiments suggests that neoclassical and turbulent transport should both be optimized in next step reactor designs.

Dietary Patterns and Muscle Mass, Muscle Strength, and Physical Performance in the Elderly: A 3-Year Cohort Study

OBJECTIVES

Nutritional support effectively prevents and treats sarcopenia; however, the influence of overall dietary patterns on sarcopenia parameters is less investigated. This study aimed to determine the association between adherence to Mediterranean-style diet (MD), Dietary Approaches to Stop Hypertension (DASH), Japanese Food Guide Spinning Top (JFG-ST), and modified JFG-ST (mJFG-ST) and muscle mass, muscle strength, and physical performance in community-dwelling Japanese elderly.

DESIGN AND SETTINGS

This prospective cohort study recruited individuals aged over 60 years from a community college in Nagoya, Japan.

PARTICIPANTS AND MEASUREMENTS

A total of 666 participants were followed up annually from 2014 to 2017. Demographic data, anthropometric measurements, and sarcopenia parameters including walking speed (WS), hand grip strength in the dominant hand (HGS), and skeletal mass index (SMI) were recorded. Self-recall dietary intake was assessed using a validated food frequency questionnaire comprising 29 food groups. Adherence to MD, DASH, JFG-ST, and mJFG-ST was determined by tertiles.

RESULTS

At baseline, the mean age of all participants (56.5% women) was 69.4±4.4 years. WS, HGS, and SMI were 1.4±0.2 (m/s), 28.9±8.1 (kg), and 6.7±1.0 (kg/m2), respectively. In longitudinal analysis, participants with higher JFG-ST adherence scores were more likely to have higher SMI (Q3 vs. Q1: mean difference, 0.048; p=0.04) after adjustment, and its benefits were more evident in men (Q2 vs. Q1: mean difference, 0.098; p=0.047; Q3 vs. Q1: mean difference, 0.091; p=0.017) than in women. WS and HGS were not associated with any type of dietary pattern.

CONCLUSIONS

Adherence to JFG-ST was positively associated with SMI in Japanese community-dwelling elderly adults aged over 60 years, specifically in men. The country-specific dietary recommendations are required to be developed for sarcopenia prevention.

More Active Participation in Voluntary Exercise of Older Users of Information and Communicative Technology even during the COVID-19 Pandemic, Independent of Frailty Status

OBJECTIVES

The aim of this study was to examine whether older users of information and communicative technology (ICT) participate in active behaviors, such as voluntary exercise, to maintain health, even under community containment to suppress the coronavirus disease 2019 (COVID-19) pandemic.

DESIGN

Cross-sectional study.

SETTING

Community setting.

PARTICIPANTS

Independent community-dwelling older residents aged ≥75 years.

MEASUREMENTS

The municipality sent the Kihon Checklist (KCL) and Simplified Nutritional Appetite Questionnaire (SNAQ) with several questions on lifestyle and health conditions under social restriction.

RESULTS

Among 3199 responders (72.1%), we analyzed the data of 2304 residents who provided complete answers to the KCL and SNAQ and on ICT use, voluntary exercise, polypharmacy, and families. The mean age was 79.7 years (51.3% male). The percentages of frailty assessed by the KCL, voluntary exercise, and low SNAQ scores (≤14) were 16.0%, 61.4%, and 43.8% in 808 ICT users and 30.3%, 47.2%, and 54.1% in 1496 ICT non-users, respectively (p<0.001). ICT use was significantly associated with voluntary exercise even during social restriction, independent of age, sex, polypharmacy, low SNAQ scores, and frailty status (odds ratio, 1.503; 95% confidential interval, 1.246-1.813).

CONCLUSION

Older ICT users are more active to maintain health even during social restriction, independent of frailty status.

Quantifying Muscle Mass by Adjusting for Body Mass Index Is the Best for Discriminating Low Strength and Function in Japanese Older Outpatients

OBJECTIVES

To investigate the association of three muscle mass adjustment methods with low muscle strength (MS) and low physical function (PF) defined by the Asian Working Group for Sarcopenia (AWGS) 2019 criteria.

DESIGN

Cross-sectional study.

SETTING

Clinical setting.

PARTICIPANTS

We included 361 outpatients (77.9 ± 5.9 years) without scheduled orthopedic surgery or activities of daily living disability.

MEASUREMENTS

Appendicular skeletal muscle mass (ASM) was measured by dual-energy X-ray absorptiometry, then divided by height-square (ht2), body weight, and body mass index (BMI) to calculate the ASM indexes. We assessed grip strength, gait speed, short physical performance battery, and five-time chair stand test. Low MS and low PF were defined by the AWGS2019 criteria. To compare the association of three muscle mass adjustments with low MS and low PF, multiple logistic regression analysis was performed, adjusted for age in each sex.

RESULTS

Participants with low MS was 31.5%, low PF was 50.1%. After adjustment, only ASM/BMI was significantly associated with all independent variables, such as low MS, low PF, and either of these, with the odds ratios of 2.09, 2.08, and 2.50 for males; and 1.87, 2.43, and 2.71 for females, respectively.

CONCLUSION

Our findings suggest that ASM/BMI is best associated with low MS and low PF in older Japanese outpatients. Longitudinal outcome studies are needed to confirm our findings.

Association between Sarcopenia and Fall Risk According to the Muscle Mass Adjustment Method in Japanese Older Outpatients

We investigated whether the association between sarcopenia and fall risk (FR) differs according to the muscle mass adjustment method in 357 outpatients who were not disabled in the activities of daily living or indicated for orthopedic surgery. Sarcopenia was diagnosed by the Asian Working Group for Sarcopenia (AWGS) 2019 criteria, using adjusting methods of muscle mass by height squared (ht2), body mass index (BMI), or any of these (i.e., ht2-adjusted Sarc", "BMI-adjusted Sarc", or "ht2 and/or BMI-adjusted Sarc, respectively). FR was defined by FR index ≥10. There were 111, 105, and 157 participants with ht2-adjusted, BMI-adjusted, and ht2 and/or BMI-adjusted Sarc, respectively. After multivariable adjustment, ht2 and/or BMI-adjusted Sarc was the most closely associated with FR [odds ratio and 95% confidence interval: 2.94, 1.75-4.93]. Our data suggest that the sarcopenia definition using low ASM/ht2 and/or ASM/BMI muscle mass might better predict adverse outcomes in older patients.

Measurements of radial profile of hydrogen and deuterium density in isotope mixture plasmas using bulk charge exchange spectroscopy

A bulk charge exchange spectroscopy system has been applied to measure the radial profiles of the hydrogen (H) and deuterium (D) density ratio in the isotope mixture plasma in a large helical device. Charge exchange lines of H_α and D_α are fitted by 4 Gaussian of H and D cold components and H and D hot components with 5 parameters by combining the measurement of plasma toroidal rotation velocity with carbon charge exchange spectroscopy. The radial profiles of the relative density of hydrogen and deuterium ions are derived from H and D hot components measured and the beam density calculated from beam attenuation calculation. A proof-of-principle experiment is performed by the H pellet and the D pellet injections into the H-D mixture plasma.

Predictive Ability of Seven Domains of the Kihon Checklist for Incident Dependency and Mortality

The Kihon Checklist (KCL) is a structured questionnaire consisting of 7 domains to assess seniors' function in daily living. The aim of this study was to examine which domains of the KCL can predict incident dependency and mortality. The municipality sent a KCL questionnaire to independent seniors in Higashi-ura Town and collected the answers of the 5542 seniors who provided complete answers. Their incident dependency and mortality were followed-up for 2.5 years. A Cox proportional hazard model indicated that meeting any of the criteria in instrumental activities of daily living, physical, nutrition, and mood domains significantly predicted the risk of dependency, whereas meeting any of the criteria in physical, nutrition and socialization domains significantly predicted the risk of mortality. Category assessment by the KCL could be useful to predict incident dependency and all-cause mortality.

Giant appendiceal mucocele: report of a case

Mucoceles of the appendix are a group of mucus-filled lesions causing obstructive dilation of the ileocecal appendix. We report a rare case of giant appendiceal mucocele. A 48-year-old woman, with no discomfort, was admitted to our hospital after a mass was detected in the right lower quadrant of the abdomen. The patient underwent right hemicolectomy on the basis of the clinical diagnosis of a possible appendiceal tumor. The final pathologic diagnosis was mucocele of the appendix.

Implementation of the fifth link of the chain of survival concept for out-of-hospital cardiac arrest

BACKGROUND

The American Heart Association 2010 resuscitation guidelines recommended adding a fifth link (multidisciplinary postresuscitation care in a regional center) to the previous 4 in the chain of survival concept for out-of-hospital cardiac arrest. Our study aimed to determine the effectiveness of this fifth link.

METHODS AND RESULTS

This multicenter prospective cohort study involved all eligible out-of-hospital cardiac arrest patients in the Aizu region (n=1482, suburban/rural, Fukushima, Japan). Proportions of favorable neurological outcomes were evaluated before (January 2006-April 2008) and after (January 2009-December 2010) the implementation of the fifth link. After implementation, all patients were transported directly from the field to the tertiary-level hospital or secondarily from an outlying hospital to the tertiary-level hospital after restoration of circulation. The tertiary hospital provided intensive postresuscitation care, including appropriate hemodynamic and respiratory management, therapeutic hypothermia, and percutaneous coronary intervention. One-month survival with a favorable neurological outcome among all patients treated by emergency medical services providers improved significantly after implementation (4 of 770 [0.5%] versus 21 of 712 [3.0%]; P<0.001). The adjusted odds ratios of favorable neurological outcome were 0.9 (95% confidence interval, 0.7-1.1) for early access to emergency medical care, 3.1 (95% confidence interval, 0.7-14.2) for bystander resuscitation, 14.7 (95% confidence interval, 3.2-67.0) for early defibrillation, 1.0 (95% confidence interval, 1.0-1.1) for early advanced life support, and 7.8 (95% confidence interval, 1.6-39.0) for the fifth link.

CONCLUSION

The proportion of out-of-hospital cardiac arrest patients with a favorable neurological outcome improved significantly after the implementation of the fifth link, which may be an independent predictor of outcome.

CLINICAL TRIAL REGISTRATION

URL: http://www.apps.who.int/trialsearch. Unique identifier: UMIN000001607.

Neoclassical toroidal viscosity calculations in tokamaks using a δf Monte Carlo simulation and their verifications

Neoclassical toroidal viscosities (NTVs) in tokamaks are investigated using a δf Monte Carlo simulation, and are successfully verified with a combined analytic theory over a wide range of collisionality. A Monte Carlo simulation has been required in the study of NTV since the complexities in guiding-center orbits of particles and their collisions cannot be fully investigated by any means of analytic theories alone. Results yielded the details of the complex NTV dependency on particle precessions and collisions, which were predicted roughly in a combined analytic theory. Both numerical and analytic methods can be utilized and extended based on these successful verifications.

De-escalation of antimicrobials in the treatment of bacteraemia due to antibiotic-sensitive pathogens in immunocompetent patients

BACKGROUND

The aim of this study was to examine the safety and efficacy of de-escalating antimicrobial therapy in immunocompetent patients presenting with bacteraemia due to antibiotic-sensitive pathogens.

METHODS

We screened 1,350 positive blood cultures identified in a single, 1,065-bed university hospital over 5 years, and retained 310 cases of bacteraemia due to antibiotic-sensitive pathogens, including (1) methicillin-sensitive staphylococci, (2) penicillin-sensitive streptococci, (3) β-lactam-sensitive (a) Escherichia coli, and (b) Klebsiella species. The efficacy of appropriate initial empirical antimicrobial therapy, the performance of de-escalated pathogen-directed therapy, and the safety and efficacy of de-escalated therapy were evaluated.

RESULTS

Among 270 appropriately treated patients, 16 (6%) died, versus 6 (15%) among 40 who were inappropriately treated (p = 0.04). While 201 of 270 patients (74%) who received appropriate initial empirical therapy were candidates for de-escalation, the treatment was de-escalated in only 79 (39%). De-escalation was associated with (1) a trend toward a lower (a) death rate (1 vs. 5%) and (b) treatment failure (4 vs. 10%), and (2) (a) a 4-day longer median duration and (b) a $50 higher median cost of antimicrobial therapy (p < 0.001).

CONCLUSIONS

When the pathogen was sensitive to antimicrobial therapy and the initial empirical treatment was effective, de-escalation of antimicrobial therapy in immunocompetent patients with bacteraemia was safe and associated with acceptable outcomes. The rate of de-escalation of antimicrobial therapy was low.

Expression of thymidine phosphorylase as an effect prediction factor for uterine cervical squamous cell carcinoma after radiotherapy: an immunohistochemical study

Prognoses in cases of uterine cervical squamous cell carcinoma treated with radiotherapy were investigated in association with immunohistochemical expression of an angiogenic factor, thymidine phosphorylase (TP). Forty-six cases of uterine cervical squamous cell carcinoma mainly treated with radiotherapy during 1992-2001 at our clinic were studied. All were diagnosed as stages IIB to IVA. Paraffin-embedded biopsy specimens excised before radiotherapy were stained immunohistochemically using anti-TP monoclonal antibody. The extent of staining in both tumor and interstitial cells was graded as (-), (+/-), (+), and (2+). Specimens with TP expression levels of (2+) and (+) were regarded as positively stained and those with TP expression levels of (+/-) and (-) as negatively stained. The efficacy of radiotherapy in both groups was analyzed by the Kaplan-Meier method. With tumor cells, 5-year survival rates for the positive (n= 38) and negative (n= 8) staining groups were 73.9% and 42.9%, respectively; the rate being significantly higher for the TP-positive group (log rank, P= 0.0096). Contrarily, with staining for interstitial cells, the 5-year survival rates for the positive (n= 20) and negative (n= 26) staining groups were 74.1% and 64.6%, respectively, with no significant difference (log rank, P= 0.406). The efficacy of radiotherapy in the group with positive staining of tumor cells was significantly better than in the negative staining group. Immunohistochemical expression of TP in tumor cells is suggested as a useful prognostic factor for uterine cervical squamous cell carcinomas treated with radiotherapy. Choosing therapy for individual cases by referring to factors including TP expression should contribute to an improved prognosis.

Comparison of Campylobacter isolated from humans and food-producing animals in Japan

AIMS

To compare the antimicrobial resistance, serotypes and flagellin gene types of Campylobacter isolated from humans and food-producing animals and thereby facilitate elucidation of the origin of Campylobacter causing human infection in Japan.

METHODS AND RESULTS

The MIC values of ampicillin, dihydrostreptomycin, gentamicin, erythromycin, oxytetracycline, nalidixic acid and enrofloxacin for Campylobacter isolated from humans (134 isolates), cattle (38 isolates), pigs (69 isolates), layers (84 isolates) and broilers (51 isolates) were compared. The MIC(90) values of ampicillin for Campylobacter jejuni isolates from poultry were higher than those from humans and cattle. Campylobacter coli that was resistant to dihydrostreptomycin and erythromycin was observed at a higher frequency in humans and pigs than in poultry. The restriction fragment profiles of flaA of human, bovine and broiler isolates were analysed by clustering, and the isolates were classified into five clusters. Cluster I contained only human and bovine isolates. Clusters III, IV and V contained human, bovine and broiler isolates.

CONCLUSIONS

Campylobacter isolates from humans included isolates that exhibited characteristics identical to those of the bovine, porcine and poultry isolates.

SIGNIFICANCE AND IMPACT OF THE STUDY

In addition to poultry, cattle and pigs are believed to be sources of campylobacteriosis in Japan.

Expression of thymidine phosphorylase as an effect prediction factor for uterine cervical squamous cell carcinoma after radiotherapy: an immunohistochemical study

Prognoses in cases of uterine cervical squamous cell carcinoma treated with radiotherapy were investigated in association with immunohistochemical expression of an angiogenic factor, thymidine phosphorylase (TP). Forty-six cases of uterine cervical squamous cell carcinoma mainly treated with radiotherapy during 1992–2001 at our clinic were studied. All were diagnosed as stages IIB to IVA. Paraffin-embedded biopsy specimens excised before radiotherapy were stained immunohistochemically using anti-TP monoclonal antibody. The extent of staining in both tumor and interstitial cells was graded as (−), (±), (+), and (2+). Specimens with TP expression levels of (2+) and (+) were regarded as positively stained and those with TP expression levels of (±) and (−) as negatively stained. The efficacy of radiotherapy in both groups was analyzed by the Kaplan–Meier method. With tumor cells, 5-year survival rates for the positive (n = 38) and negative (n = 8) staining groups were 73.9% and 42.9%, respectively; the rate being significantly higher for the TP-positive group (log rank, P = 0.0096). Contrarily, with staining for interstitial cells, the 5-year survival rates for the positive (n = 20) and negative (n = 26) staining groups were 74.1% and 64.6%, respectively, with no significant difference (log rank, P = 0.406). The efficacy of radiotherapy in the group with positive staining of tumor cells was significantly better than in the negative staining group. Immunohistochemical expression of TP in tumor cells is suggested as a useful prognostic factor for uterine cervical squamous cell carcinomas treated with radiotherapy. Choosing therapy for individual cases by referring to factors including TP expression should contribute to an improved prognosis.

A new radiofrequency thermal balloon catheter for pulmonary vein isolation

OBJECTIVES

We sought to evaluate whether porcine pulmonary vein (PV) isolation (PVI) can be produced by ablation using our novel radiofrequency (RF) thermal balloon catheter (RBC).

BACKGROUND

It has been proposed that PVI can prevent focal atrial fibrillation (AF) originating in or close to the PV.

METHODS

The RBC is composed of a 12F main shaft, a 4F inner tube and a balloon. Inside the balloon, there is a unipolar coil electrode with a thermocouple sensor mounted along the tube, the former to deliver RF energy (13.56 MHz) and the latter to monitor the temperature. After the presence of a PV potential was confirmed, the RBC was safely inserted into the left atrium (LA) by the trans-septal approach. Once the balloon was inflated and optimally wedged at the junction between the PV and LA, RF energy was applied for 5 min. Radiofrequency catheter ablation (RFA) was repeated up to three times, until elimination of the PV potential or dissociation between the LA and PV was observed. Finally, each heart was examined histologically.

RESULTS

In 18 PVs that had PV potentials, PVI was performed, resulting in success in 15 (success rate 83%, 95% confidence interval [CI] 58.0% to 96.3%; failure rate 17%, 95% CI 3.7% to 42.0%). After successful PVI, the PV potentials completely disappeared and the histologic examination revealed circumferential, transmural necrosis around the PV trunks. No major complications, such as PV stenosis or macroscopic thrombosis, were observed.

CONCLUSIONS

The RBC was useful for PVI.

Development of "Standards for the Evaluation of Hospital Infection Control Policies and Procedures, the Second Version"

The Japan Society for Quality in Health Care (JSQua) created "Standards for the Evaluation of Hospital Infection Control Policies and Procedures, the First Version" in 1998 and carried out third-party surveys. Through the experience of those surveys, we revised the standards and created a second version in 1999. The surveyors felt that in using the second version of the standards it would be easier to evaluate the quality of hospital care and that these standards would be more widely applied.

[All-trans retinoic acid combined with low-dose cytosine arabinoside treatment for acute myelogenous leukemia with trilineage myelodysplasia--a case report]

AML with trilineage myelodysplasia (AML/TMDS) is recognized as having of poor prognosis due to its resistance to chemotherapy in comparison with de novo AML. An AML/TMDS patient who failed to respond to ordinary induction therapy achieved complete remission with combination therapy consisting of all-trans retinoic acid (ATRA) and low-dose Ara-C. No serious toxicity was observed. ATRA combined with low-dose Ara-C could be an alternative treatment for this kind of patient.

Surgical treatment for chronic pleural empyema

Various surgical procedures have been developed in an attempt to alleviate the significant problems caused by chronic pleural empyema. The present study evaluates our 11-year experience of employing a number of therapeutic approaches for chronic empyema. Between 1987 and 1997, 45 consecutive patients underwent treatment for chronic empyema at our hospitals. They comprised 21 patients (47%) presenting with post-tuberculosis, 11 (24%) receiving cancer therapy including pulmonary resection, and 13 (29%) with postpneumonic empyema. Omentopexy, lung resection, and thoracoscopic surgery were performed in 10 (22%), 5 (11%), and 4 (9%) patients, respectively. Poor results of treatment were observed in two of the patients with post-tuberculous empyema, and three of the patients treated for cancer died of recurrence. The other 40 patients remain symptom-free. An improvement in quality of postoperative life was revealed by the exercise test rather than by static spirometry. Optimal therapy for chronic empyema requires selection of the most appropriate first and staged procedures for each patient. Moreover, lung resection should be minimal. In a critical state, open thoracostomy must be performed as the first procedure, while omentopexy or thoracoplasty should be restricted to selected cases. Dead space and minor air leakage may safely be left behind. A video-assisted procedure can be selected for postpneumonia empyema.

beta-adrenergic receptor-mediated presynaptic facilitation of inhibitory GABAergic transmission at cerebellar interneuron-Purkinje cell synapses

Norepinephrine (NE) has been shown to elicit long-term facilitation of GABAergic transmission to rat cerebellar Purkinje cells (PCs) through beta-adrenergic receptor activation. To further examine the locus and adrenoceptor subtypes involved in the NE-induced facilitation of GABAergic transmission, we recorded inhibitory postsynaptic currents (IPSCs) evoked by focal stimulation with paired-pulse (PP) stimuli from PCs in rat cerebellar slices by whole cell recordings and analyzed the PP ratio of the IPSC amplitude. NE increased the IPSC amplitude with a decease in the variance of the PP ratio, which was mimicked by presynaptic manipulation of the transmission caused by increasing the extracellular Ca(2+) concentration, confirming that the presynaptic adrenergic receptors are responsible for the facilitation. Pharmacological tests showed that the beta(2)-adrenoceptor antagonist, ICI118,551, but not the beta(1)-adrenoceptor antagonist, CGP20712A, blocked the NE-induced IPSC facilitation, suggesting that the beta(2)-adrenoceptors on cerebellar interneurons, basket cells (BCs), mediate the noradrenergic facilitation of GABAergic transmission. Double recordings were performed from BCs and PCs to further characterize the regulation of the GABAergic synapses. First, on-cell recordings from BCs showed that the beta-agonist isoproterenol (ISP) increased the frequencies of the spontaneous spikes in BCs and the spike-triggered IPSCs in PCs recorded with the whole cell mode. The amplitude of the spike-triggered IPSCs decreased or increased depending on the individual GABAergic synapses examined. Forskolin invariably increased both the amplitude and the frequency of the spike-triggered IPSCs. Double whole cell recordings from BC-PC pairs showed that ISP mainly caused an increase in the amplitude of the IPSCs evoked in the PCs by an action current in the BCs produced in response to voltage steps from -60 to -10 mV. Our data suggest that the noradrenergic facilitation of GABAergic transmission in the rat cerebellar cortex is mediated, at least in part, by depolarization and action potential discharges in the BCs through activation of the beta(2)-adrenoceptors in BCs coupled to intracellular cyclic AMP formation.

Carbohydrate metabolism during starvation in the silkworm Bombyx mori

The effect of starvation on carbohydrate metabolism in the last instar larvae of the silkworm Bombyx mori was examined. Trehalose concentration in the hemolymph increased slightly during the first 6 h of starvation and decreased thereafter, whereas glucose concentration decreased rapidly immediately after diet deprivation. Starvation-induced hypertrehalosemia was completely inhibited by neck ligation, suggesting that starvation stimulates the release of a hypertrehalosemic factor(s) from the head. The percentage of active glycogen phosphorylase in the fat body increased within 3 h of starvation and its glycogen content decreased gradually. These observations suggest that production of trehalose from glycogen is enhanced in starved larvae. However, hypertrehalosemia during starvation cannot be explained by the increased supply of trehalose into hemolymph alone, as similar changes in phosphorylase activity and glycogen content in the fat body were observed in neck-ligated larvae, in which hemolymph trehalose concentration did not increase but decreased gradually. When injected into larvae, trehalose disappeared from hemolymph at a rate about 40% lower in starved larvae than neck-ligated larvae. The hemolymph lipid concentration increased during starvation, suggesting that an increased supply of lipids to tissues suppresses the consumption of hemolymph trehalose and this is an important factor in hypertrehalosemia.

Glucose stimulates the release of bombyxin, an insulin-related peptide of the silkworm Bombyx mori

The effects of starvation and feeding on the release of bombyxin, a peptide of insulin superfamily in insects, from the larval brain of the silkworm Bombyx mori were investigated. Following starvation, the bombyxin titer in the hemolymph of larvae decreased, whereas its content in the brain increased. On the other hand, refeeding of the starved larvae resulted in an increase in the hemolymph bombyxin titer and a rapid decrease in the hormone level in the brain. These results indicate that the release of bombyxin from the brain is suppressed by starvation and stimulated by feeding. The hemolymph glucose titer also changed sharply upon starvation and refeeding, and a close relationship was observed between the changes in glucose concentrations and bombyxin titers in the hemolymph. The injection of glucose into starved larvae could mimic the effect of refeeding on the release of bombyxin, suggesting that glucose serves as the signal for the "fed" state of the animal. It is likely that glucose is a common nutritional signal for inducing the release of mammalian and insect insulins.

Synaptic activation of AMPA receptors inhibits GABA release from cerebellar interneurons

A single neurotransmitter elicits diverse physiological responses through activation of multiple receptor subtypes and/or heterosynaptic interactions involving distinct synaptic targets. We found that a typical excitatory transmitter released from the climbing fiber (CF) in the cerebellar cortex not only excited Purkinje cells directly but also presynaptically inhibited GABAergic transmission from interneurons converging on the same Purkinje cells. Both homosynaptic and heterosynaptic actions of the CF transmitter (possibly glutamate) were mediated by activation of AMPA receptors. Dual AMPA receptor-mediated functions of excitation and disinhibition may ensure transmission of cerebellar CF signals controlling sensorimotor coordination.

A case of adenoma of the ampulla of Vater

A case of adenoma of the ampulla of Vater is presented in a 48-year-old man who was admitted with epigastric pain. Gastroendoscopy revealed a sessile tumor about 3 cm in diameter at the ampulla of Vater, and the pathological diagnosis of a biopsy specimen was adenoma with moderate atypia. Because of the possibility of a malignant component, pylorus-preserving pancreatoduodenectomy was performed to avoid local recurrence. The final pathological diagnosis was adenoma with severe atypia.

Survival related to lymph node involvement in lung cancer after sleeve lobectomy compared with pneumonectomy

OBJECTIVE

The purpose of this study was to compare the outcomes after sleeve lobectomy and pneumonectomy for patients with non-small cell lung cancer distributed according to their nodal involvement status.

METHODS

Of 1172 patients in whom primary non-small cell lung carcinoma, including mediastinal lymph nodes, was completely excised, 151 patients underwent sleeve lobectomy and 60 underwent pneumonectomy. For bias reduction in comparison with a nonrandomized control group, we paired 60 patients undergoing sleeve lobectomy with 60 patients undergoing pneumonectomy by using the nearest available matching method.

RESULTS

The 30-day postoperative mortality was 2% (1/60) in the pneumonectomy group and 0% in the sleeve lobectomy group. Postoperative complications occurred in 13% of patients in the sleeve lobectomy group and in 22% of those in the pneumonectomy group. Local recurrences occurred in 8% of patients in the sleeve lobectomy group and in 10% of those in the pneumonectomy group. The overall 5- and 10-year survivals for the sleeve lobectomy group were 48% and 36%, respectively, whereas those for the pneumonectomy group were 28% and 19%, respectively (P =.005). Multivariable analysis showed that the operative procedure, T factor, and N factor were significant independent prognostic factors and revealed that survival after sleeve lobectomy was significantly longer than that after pneumonectomy (P =.03).

CONCLUSIONS

These data suggest that sleeve lobectomy should be performed instead of pneumonectomy in patients with non-small cell lung cancer regardless of their nodal status whenever complete resection can be achieved because this is a lung-saving procedure with lower postoperative risks and is as curative as pneumonectomy.

[Usefulness and pitfalls in clinical electrophysiological studies]

Clinical electrophysiological studies(EPS) have become useful tools for specific cardiac arrhythmias. However, these studies are expensive and occasionally cause major as well as minor complications such as serious arrhythmias, cardiac tamponade or thromboembolism. It is important to consider guidelines for clinical application of invasive studies. The indications for clinical electrophysiological studies have been categorized into three classes. Class 1: All experts agree that EPS is useful and important for patients treatment and patients with these condition benefit from EPS. Class 2: There is less certainty about usefulness of the information from EPS. Class 3: EPS does not provide useful information. EPS should be performed by trained cardiologist in adequately equipped laboratory. Such studies are performed either by intracardiac pacing and recording or esophageal pacing and recording, and evaluate electrophysiological properties such as automaticity, conduction and refractoriness; initiate and terminate tachycardias; mechanism of tachycardia by activation mapping and pace mapping; evaluate for antiarrhythmic drug, catheter ablation, and intracardiac defibrillator. EPS is useful tool for analysis of bradyarrhythmias and tachyarrhythmias and bring us useful information for the choice of treatment but has its limitation and pitfalls. In general, EPS is not so important to determine the indication of pacemaker for bradyarrhythmias such as sick sinus syndrome or atrioventricular(AV) block. But, it is very useful to analysis tachyarrhythmias and indicate antiarrhythmic drugs or catheter ablation for patients with Wolf-Parkinson-White(WPW) syndrome, AV nodal reentrant tachycardia, atrial tachycardia, atrial flutter, or ventricular tachycardia to cure the tachyarrhythmias.