Fact-finding survey on diagnostic procedures and therapeutic interventions for parkinsonism accompanying dementia with Lewy bodies

BACKGROUND

We performed a questionnaire survey of medical doctors engaged in the management of dementia to identify the actual status of treatment for dementia with Lewy bodies (DLB) in Japan.

METHODS

Among participating medical doctors, we selected neurologists (Group N) and psychiatrists (Group P) because these physicians are usually involved in the management of DLB patients. The two groups were compared based on their diagnosis and treatment of DLB and in particular, parkinsonism.

RESULTS

Neurological examinations and biomarker tests were less frequently performed by Group P than Group N. Antipsychotics and other psychotropics excluding anti-dementia drugs were significantly more frequently administered by Group P than Group N. The proportion of physicians who selected L-dopa as a first-line therapy for parkinsonism was significantly higher in Group N than in Group P. Despite these between-group differences, the following findings were common to the two groups: there was a discrepancy between the symptom that patients expressed the greatest desire to treat, and the awareness of physicians regarding the treatment of these symptoms; the initial agent was L-dopa; and physicians exercised caution against the occurrence of hallucinations, delusions, and other adverse drug reactions.

CONCLUSIONS

The results of the present survey offer valuable insight for the formulation of future DLB therapeutic strategies.

A survey of doctors on diagnosis and treatment of dementia with Lewy bodies: examination and treatment of behavioural and psychological symptoms

BACKGROUND

Dementia with Lewy bodies (DLB) is a progressive form of dementia, accompanied by a range of behavioural and psychological symptoms. The aim of this study was to identify current clinical practice for the treatment of DLB in Japan.

METHODS

We conducted a survey of medical doctors engaged in the management of dementia in Japan. Participants were divided into two groups: psychiatrists (Group P) and neurologists or neurosurgeons (Group NS). Doctors completed a questionnaire and we analysed their responses to compare the two groups with regard to diagnosis and treatment of DLB, and in particular the treatment of behavioural and psychological symptoms of dementia (BPSD).

RESULTS

Responses suggested that Group P conducted biomarker examinations less frequently and decided on their own therapeutic strategies more frequently than did Group NS. Both groups most frequently selected hallucinations/delusions as the symptoms given highest treatment priority. More than 70% of respondents in both groups reported having difficulties in treating BPSD. Atypical antipsychotics were more frequently prescribed by Group P, but were also prescribed in 70% of patients in Group NS. A third of patients received atypical antipsychotics for more than 1 year.

CONCLUSIONS

The responses to this survey highlighted the difficulties faced by clinicians managing patients with DLB and identified the need to effectively treat BPSD in such patients.

What are the risk factors for postoperative infections of third molar extraction surgery: A retrospective clinical study?

BACKGROUND

This study aimed to identify (1) the predilection site of postoperative infection after third molar extraction surgery, (2) risk factors associated with postoperative infection, and (3) the cause of the difference between delayed- and early-onset infections.

MATERIALS AND METHODS

This retrospective study included 1010 patients (396 male, 614 female) who had ≥1 third molars extracted (2407; 812 maxilla, 1595 mandible). The risk factors were classified as attributes, general health, anatomic, and operative. Outcome variables were delayed- and early-onset infections.

RESULTS

Postoperative infection was completely absent in the maxilla, and all infections occurred in the mandible, with a probability of 1.94% (31/1595). Bivariate analysis for postoperative infection showed depth of inclusion and intraoperative hemostatic treatment to be significantly associated with the development of infections. Bivariate analysis for delayed- and early-onset infections showed simultaneous extraction of the left and right mandibular third molars to be prominent risk factors.

CONCLUSIONS

Postoperative infection occurs mainly in the mandible, and that in the maxilla is very rare. The risk of postoperative infection in the mandible was found to be related to the depth of inclusion and intraoperative hemostatic treatment. Simultaneous extraction of the left and right mandibular third molars appear to increase the risk of delayed-onset postoperative infection.

Discovery of a big void in Khufu's Pyramid by observation of cosmic-ray muons

The Great Pyramid, or Khufu's Pyramid, was built on the Giza plateau in Egypt during the fourth dynasty by the pharaoh Khufu (Cheops), who reigned from 2509 bc to 2483 bc. Despite being one of the oldest and largest monuments on Earth, there is no consensus about how it was built. To understand its internal structure better, we imaged the pyramid using muons, which are by-products of cosmic rays that are only partially absorbed by stone. The resulting cosmic-ray muon radiography allows us to visualize the known and any unknown voids in the pyramid in a non-invasive way. Here we report the discovery of a large void (with a cross-section similar to that of the Grand Gallery and a minimum length of 30 metres) situated above the Grand Gallery. This constitutes the first major inner structure found in the Great Pyramid since the nineteenth century. The void, named ScanPyramids' Big Void, was first observed with nuclear emulsion films installed in the Queen's chamber, then confirmed with scintillator hodoscopes set up in the same chamber and finally re-confirmed with gas detectors outside the pyramid. This large void has therefore been detected with high confidence by three different muon detection technologies and three independent analyses. These results constitute a breakthrough for the understanding of the internal structure of Khufu's Pyramid. Although there is currently no information about the intended purpose of this void, these findings show how modern particle physics can shed new light on the world's archaeological heritage.

123I-metaiodobenzylguanidine myocardial scintigraphy with early images alone is useful for the differential diagnosis of dementia with Lewy bodies

123I-metaiodobenzylguanidine cardiac scintigraphy (MIBG) is a useful imaging technique for the diagnosis of dementia with Lewy bodies (DLB). However, MIBG has a serious disadvantage in that it demands a long examination time. The objective of this study was to evaluate statistically the usefulness of the heart/mediastinum ratio (H/M) from the early phase of MIBG for the differential diagnosis of DLB. In total, 113 patients were examined, including 32 non-DLB (19 with Alzheimer's dementia) and 79 DLB patients. The mean early-H/M ratio was 2.83 in the non-DLB group and 1.95 in the DLB group. The mean delayed-H/M ratio was 3.0 in the non-DLB group and 1.76 in the DLB group. With a cutoff point of 2.27 on early images, the sensitivity, specificity, and diagnostic accuracy were 65%, 94%, and 73%, respectively, and the area under the curve was 0.82, indicating moderate accuracy. This analysis indicates that images from the early phase of MIBG alone are sufficient for the differential diagnosis of Alzheimer's disease and DLB.

Increased dosage of donepezil for the management of behavioural and psychological symptoms of dementia in dementia with Lewy bodies

BACKGROUND

As with other types of dementia, the behavioral and psychological symptoms of dementia (BPSD) can make caregiving difficult for patients with dementia with Lewy bodies (DLB). We hypothesized that administration of donepezil at an increased dose of 10 mg/day might dose-dependently improve BPSD in DLB patients with relapse, after their symptoms had been controlled initially by donepezil therapy at the standard dose.

METHODS

The present study was as an open-label trial. We enrolled 24 patients with DLB (diagnosed according to the Consortium on Dementia with Lewy Bodies Guideline-Revised) who experienced a relapse of BPSD despite treatment with donepezil at the standard dose (5 mg/day). The donepezil dose for these patients was increased to 10 mg/day, and we evaluated the efficacy and safety of this dose escalation strategy.

RESULTS

The Neuropsychiatric Inventory (NPI) scores for BPSD showed statistically significant improvements as a result of the increased dosage, except those for anxiety and euphoria, disinhibition, irritability/lability. High-dose donepezil therapy caused gastrointestinal symptoms in 4 patients, but there were no life-threatening adverse events, such as arrhythmias, or no exacerbation of parkinsonian symptoms.

CONCLUSIONS

We found that donepezil dose-dependently improved relapsing BPSD in these patients. Therefore, increasing the dosage of donepezil is a safe and effective treatment for patients with DLB who experience a relapse of BPSD.

Marked lateral deviation of the phrenic nerve due to variant origin and course of the thyrocervical trunk: a cadaveric study

Phrenic nerve impairment can often lead to serious respiratory disorders under various pathological conditions. During routine dissection of an 88-year-old Japanese male cadaver, a victim of heart failure, we recognized an extremely rare variation of the right thyrocervical trunk arising from the subclavian artery laterally to the anterior scalene muscle. In addition to that, the ipsilateral phrenic nerve was drawn and displaced remarkably laterad by this vessel. We examined all of the branches arising from subclavian arteries, phrenic nerves and diaphragm muscles. The embryological background of this arterial variation is considered. The marked displacement with prolonged strain had a potential to cause phrenic nerve impairment with an atrophic change of the diaphragm muscle. Recently many image diagnostic technologies have been developed and are often used. However, it is still possible that rare variations like this case may be overlooked and can only be recognized by intimate regional examination while keeping these rare variations in mind.