Serum autotaxin is a prognostic indicator of liver-related events in patients with non-alcoholic fatty liver disease

BACKGROUND

Circulating autotaxin (ATX) levels have been reported to correlate with liver inflammation activity and liver fibrosis severity in patients with non-alcoholic fatty liver disease (NAFLD). The objective of this study is to investigate whether serum ATX could predict liver-related events (LRE) in NAFLD patients.

METHODS

This retrospective investigation includes 309 biopsy-proven NAFLD patients registered at Shinshu University Hospital. All patients are followed for at least 1 year, during which time the prevalence of LRE, including newly developing hepatocellular carcinoma, hepatic encephalopathy, ascites, and esophagogastric varices, is investigated in relation to ATX levels at the time of liver biopsy.

RESULTS

During the median follow-up period of 7.0 years, LRE are observed in 20 patients (6.5%). The area under the receiver operating characteristic curve and cut-off value of serum ATX for predicting LRE are 0.81 and 1.227 mg/l, respectively. Multivariate Cox proportional hazards models for LRE determine ATX and advanced fibrosis as independently associated factors. Furthermore, in a competing risk analysis that considered non-liver-related death as a competing event, ATX (HR 2.29, 95% CI 1.22-4.30, p = 0.010) is identified as an independent factor associated with LRE, along with advanced fibrosis (HR 8.01, 95% CI 2.10-30.60, p = 0.002). The predictive utility of ATX for LRE is validated in an independent cohort.

CONCLUSIONS

Serum ATX may serve as a predictive marker for LRE in patients with NAFLD.

Efficacy of surgical staple line reinforcement in Glissonean stapling: A single-center pilot study

Vascular staplers are routinely used in laparoscopic liver resection, which has become a standard procedure in advanced medical facilities. Although previous reports have outlined the benefits of staple line reinforcement (SLR), its application in Glissonean pedicle transection during hepatic resection remains poorly studied. This study investigated surgical SLR as a tool to enhance staple line strength and improve perioperative hemostasis. Here, 10 patients who underwent laparoscopic liver resection using the Tri-StapleTM2.0 Reinforced Reload were included. Patient characteristics, surgical details, and outcomes were assessed. The results demonstrated successful outcomes with no complications related to bile leakage or injuries during staple insertion. Overall, our findings suggest that SLR can be safely utilized in Glissonean pedicle transection during laparoscopic liver resections. Further studies are required to comprehensively evaluate its benefits compared with conventional surgical staplers.

Effect of lower-extremity muscle power training on muscle strength, balance function and walking ability in older adults with heart failure: a randomized controlled trial

PURPOSE

This study investigated the combined effect of lower-extremity muscle power training and regular cardiac rehabilitation on muscle strength, balance function, and walking ability of older adults with heart failure.

METHODS

Thirty-one patients, comprising 17 males and 14 females, aged between 66 and 89 years and diagnosed with non-severe heart failure, were randomly assigned to either the intervention group (n = 15) or control group (n = 16). Both groups participated in a 12-week regular rehabilitation program, with the intervention group receiving additional lower-extremity muscle power training. Various outcome measures, including muscle strength (the five-times-sit-to-stand test and knee extensor peak torque), balance function (Berg balance scale and functional reach test), and walking ability (4-m walk and Timed Up-and-Go tests) were assessed at baseline and 12 weeks after the intervention.

RESULTS

Of the 31 participants, 27 completed the study protocol. The intervention group demonstrated significantly greater improvement in the five-times-sit-to-stand test time, indicating enhanced lower-extremity muscle power compared to the control group. Both groups showed significant differences in the Berg balance scale, functional reach test, 4-m walk test, and Timed Up-and-Go test between baseline and 12 weeks. However, the effect sizes for the changes during the study period were larger in the intervention group (d = 0.74-1.19) than the control group (d = 0.57-0.96).

CONCLUSION

Combining lower-extremity muscle power training with regular cardiac rehabilitation may lead to additional improvements in muscle function for older adults with heart failure, resulting in enhanced dynamic balance and walking ability.

TRIAL REGISTRATION NUMBER/DATE OF REGISTRATION

UMIN000032087/April 4, 2018.

Distribution of internal medicine rotations among resident physicians in Japan: a nationwide, multicenter, cross-sectional study

BACKGROUND

In Japan, postgraduate clinical training encompasses a 2-year residency program, including at least 24 weeks of internal medicine (IM) rotations. However, the fragmented structure of these rotations can compromise the training's quality and depth. For example, a resident might spend only a few weeks in cardiology before moving to endocrinology, without sufficient time to deepen their understanding or have clinical experience. This study examined current patterns and lengths of IM rotations within the Japanese postgraduate medical system. It scrutinized the piecemeal approach-whereby residents may engage in multiple short-term stints across various subspecialties without an overarching, integrated experience-and explored potential consequences for their clinical education.

METHODS

This nationwide, multicenter, cross-sectional study used data from self-reported questionnaires completed by participants in the 2022 General Medicine In-Training Examination (GM-ITE). Data of 1,393 postgraduate year (PGY) one and two resident physicians who participated in the GM-ITE were included. We examined the IM rotation duration and number of IM subspecialties chosen by resident physicians during a 2-year rotation.

RESULTS

Approximately half of the participants chose IM rotation periods of 32-40 weeks. A significant proportion of participants rotated in 5-7 internal medicine departments throughout the observation period. Notable variations in the distribution of rotations were observed, characterized by a common pattern where resident physicians typically spend 4 weeks in each department before moving to the next. This 4-week rotation is incrementally repeated across different subspecialties without a longer, continuous period in any single area. Notably, 39.7% of participants did not undertake general internal medicine rotations. These results suggest a narrowed exposure to medical conditions and patient care practices.

CONCLUSIONS

Our study highlights the need to address the fragmented structure of IM rotations in Japan. We suggest that short, specialized learning periods may limit the opportunity to gain broad in-depth knowledge and practical experience. To improve the efficacy of postgraduate clinical education, we recommend fostering more sustained and comprehensive learning experiences.

EGFR signaling and pharmacology in oncology revealed with innovative BRET-based biosensors

Mutations of receptor tyrosine kinases (RTKs) are associated with the development of many cancers by modifying receptor signaling and contributing to drug resistance in clinical settings. We present enhanced bystander bioluminescence resonance energy transfer-based biosensors providing new insights into RTK biology and pharmacology critical for the development of more effective RTK-targeting drugs. Distinct SH2-specific effector biosensors allow for real-time and spatiotemporal monitoring of signal transduction pathways engaged upon RTK activation. Using EGFR as a model, we demonstrate the capacity of these biosensors to differentiate unique signaling signatures, with EGF and Epiregulin ligands displaying differences in efficacy, potency, and responses within different cellular compartments. We further demonstrate that EGFR single point mutations found in Glioblastoma or non-small cell lung cancer, impact the constitutive activity of EGFR and response to tyrosine kinase inhibitor. The BRET-based biosensors are compatible with microscopy, and more importantly characterize the next generation of therapeutics directed against RTKs.

Development of a Clinical Simulation Video to Evaluate Multiple Domains of Clinical Competence: Cross-Sectional Study

BACKGROUND

Medical students in Japan undergo a 2-year postgraduate residency program to acquire clinical knowledge and general medical skills. The General Medicine In-Training Examination (GM-ITE) assesses postgraduate residents' clinical knowledge. A clinical simulation video (CSV) may assess learners' interpersonal abilities.

OBJECTIVE

This study aimed to evaluate the relationship between GM-ITE scores and resident physicians' diagnostic skills by having them watch a CSV and to explore resident physicians' perceptions of the CSV's realism, educational value, and impact on their motivation to learn.

METHODS

The participants included 56 postgraduate medical residents who took the GM-ITE between January 21 and January 28, 2021; watched the CSV; and then provided a diagnosis. The CSV and GM-ITE scores were compared, and the validity of the simulations was examined using discrimination indices, wherein ≥0.20 indicated high discriminatory power and >0.40 indicated a very good measure of the subject's qualifications. Additionally, we administered an anonymous questionnaire to ascertain participants' views on the realism and educational value of the CSV and its impact on their motivation to learn.

RESULTS

Of the 56 participants, 6 (11%) provided the correct diagnosis, and all were from the second postgraduate year. All domains indicated high discriminatory power. The (anonymous) follow-up responses indicated that the CSV format was more suitable than the conventional GM-ITE for assessing clinical competence. The anonymous survey revealed that 12 (52%) participants found the CSV format more suitable than the GM-ITE for assessing clinical competence, 18 (78%) affirmed the realism of the video simulation, and 17 (74%) indicated that the experience increased their motivation to learn.

CONCLUSIONS

The findings indicated that CSV modules simulating real-world clinical examinations were successful in assessing examinees' clinical competence across multiple domains. The study demonstrated that the CSV not only augmented the assessment of diagnostic skills but also positively impacted learners' motivation, suggesting a multifaceted role for simulation in medical education.

Optimal cutoff value of the dry eye-related quality-of-life score for diagnosing dry eye disease

This retrospective study aimed to determine the optimal cutoff values of the Dry Eye-Related Quality-of-Life Score (DEQS) questionnaire for diagnosing dry eye disease (DED) and classifying DED severities. Participants completed the DEQS questionnaire, the Japanese version of the Ocular Surface Disease Index (J-OSDI) questionnaire, and DED examinations. DED was diagnosed according to the 2016 Asia Dry Eye Society diagnostic criteria based on DED symptoms (J-OSDI ≥ 13 points) and tear film breakup time ≤ 5 s. Receiver operating characteristic (ROC) analysis was used to calculate the optimal cutoff values of the DEQS summary score for detecting DED and grading its severity. Among 427 patients, 296 (69.3%) and 131 (30.7%) were diagnosed with DED and non-DED, respectively. ROC analysis determined an optimal cutoff value of 15.0 points for DED diagnosis, with 83.5% sensitivity, 87.0% specificity, and an area under the curve of 0.915. The positive and negative predictive values for DEQS ≥ 15.0 points were 93.6% and 69.9%, respectively. DEQS cutoff values of 15.0, 20.0, and 26.8 points could be accepted for severity classification of DED subjective symptoms in clinical use and represent mild, moderate, and severe DED, respectively. Conclusively, the optimal cutoff values of DEQS enable DED detection and subjective symptom severity classification.

High-risk Features for Recurrence in Patients With Stage III Colorectal Cancer: A Retrospective Cohort Study

BACKGROUND/AIM

Risk classification for recurrence in stage III colorectal cancer (CRC) is not as well established as it is for stage II. This study aimed to identify high-risk factors for stage III colorectal cancer and to investigate their clinical significance.

PATIENTS AND METHODS

We retrospectively analyzed data from 120 patients with stage III CRC who had undergone curative colectomy at our institution between 2014 and 2020. We used logistic regression analysis to identify risk factors for recurrence and subsequently explored their clinical significance.

RESULTS

We identified three high-risk factors in stage III CRC: preoperative bowel obstruction [odds ratio (OR)=5.39; 95% confidence interval (CI)=1.61-18.03; p=0.007], N2 disease (OR=3.12; 95%CI=1.05-9.29; p=0.041), and having fewer than 17 examined lymph nodes (OR=3.17; 95%CI=1.11-8.99; p=0.031). The prognosis of patients was clearly stratified by the number of these risk factors, and furthermore, the effectiveness of adjuvant therapy depended on their number.

CONCLUSION

Tumor obstruction, N-stage, and the number of lymph nodes examined are important high-risk features for recurrence. This study provides clinicians with valuable insights to predict and stratify patient outcomes in stage III CRC.

Suppressive effect of Yokukansan on glutamate released from canine keratinocytes

Background

Canine atopic dermatitis (CAD) is caused by skin barrier dysfunction due to allergen exposure. Excessive glutamate release in the skin is associated with delayed skin barrier function recovery and epidermal thickening and lichenification. Treatment with Yokukansan (YKS), a traditional Japanese medicine, reduces dermatitis severity and scratching behavior in NC/Nga mice by decreasing epidermal glutamate levels. However, the association between canine keratinocytes and glutamate and the mechanism by which YKS inhibits glutamate release from keratinocytes remains unknown.

Aim

We aimed to investigate glutamate release from canine progenitor epidermal keratinocytes (CPEKs) and the inhibitory effect of YKS on this release. We also explored the underlying mechanism of YKS to enable its application in CAD treatment.

Methods

Glutamate produced from CPEKs in the medium at 24 hours was measured. The measurement conditions varied in terms of cell density and YKS concentration. CPEKs were treated with a glutamate receptor antagonist (MK-801), a glutamate transporter antagonist (THA), and a glutamate dehydrogenase inhibitor (epigallocatechin gallate; EGCG), and the inhibitory effect of YKS, YKS + THA, MK-801, and EGCG on this release was determined. MK-801 and glutamate dehydrogenase inhibitor were tested alone, and THA was tested in combination with YKS. Finally, glutamine incorporated into CPEKs at 24 hours was measured using radioisotope labeling.

Results

CPEKs released glutamate in a cell density-dependent manner, inhibited by YKS in a concentration-dependent manner. Moreover, YKS reduced the intracellular uptake of radioisotope-labeled glutamine in a concentration-dependent manner. No involvement of glutamate receptor antagonism or activation of glutamate transporters was found, as suggested by previous studies. In addition, EGCG could inhibit glutamate release from CPEKs.

Conclusion

Our findings indicated that glutamate release from CPEKs could be effectively inhibited by YKS, suggesting the utility of YKS in maintaining skin barrier function during CAD. In addition, CPEKs are appropriate for analyzing the mechanism of YKS. However, we found that the mechanism of action of YKS differs from that reported in previous studies, suggesting that it may have had a similar effect to EGCG in this study. Further research is warranted to understand the exact mechanism and clinical efficacy in treating CAD.

Effectiveness of warm-up and dynamic balance training in preventing anterior cruciate ligament injuries in college gymnasts: a 3-year prospective study for one team

BACKGROUND

The effect of trunk stability and dynamic balance warm-up exercises on physical functional improvement remains unelucidated. This study examined whether exercises could prevent anterior cruciate ligament (ACL) injury and improve trunk muscle activation and dynamic balance in gymnasts.

METHODS

This comparison study, involving gymnastics practice sessions, included 31 university gymnasts and was conducted in two periods: 1 year of observation followed by 2 years of intervention. Participants performed a trunk and dynamic balance warm-up exercise program during the intervention. The effect of exercise on the incidence of ACL injury was evaluated. In addition, the paired t-test was used to compare the Y-balance distance and the changes in muscle thickness associated with trunk muscle activation at rest and during plank.

RESULTS

ACL injury risk during the intervention was significantly lower, with a relative risk of 0.23 (P=0.02, 95% CI: 0.06-0.88). Changes in muscle thickness with activation of the transversus abdominis (P<0.01, mean difference 4.1, 95% CI: 9.97-28.07, Cohen's d=0.52), internal oblique (P<0.01, mean difference 5.2, 95% CI: 9.72-21.55, Cohen's d=0.65), and external oblique (P<0.01, mean difference 5.5, 95% CI: 20.44-39.09, Cohen's d=0.71) muscles were significantly higher during the intervention. The Y-balance distance was also significantly greater in the posterior medial reach (P<0.01, mean difference 3.3, 95% CI: 1.56-6.26, Cohen's d=0.46) during the intervention.

CONCLUSIONS

Exercise-based warm-up programs may decrease ACL injuries. It can improve physical functions, such as the rate of change in trunk muscle thickness and the posterior medial distance during Y balance.

Association of sleep quality with duty hours, mental health, and medical errors among Japanese postgraduate residents: a cross-sectional study

Long duty hours (DH) impair sleep and negatively affect residents' health and medical safety. This cross-sectional study investigated the association among residents' DH, sleep duration, insomnia, sleep impairment, depressive symptoms, and self-reported medical errors among 5579 residents in Japan who completed the General Medicine In-Training Examination (2021) and participated in the training-environment survey. Weekly DH was classified under seven categories. Sleep duration and insomnia symptoms, from the Athens Insomnia Scale, were analysed to determine sleep impairment; depressive symptoms and medical errors were self-reported. Among 5095 residents, 15.5% slept < 5 h/day, and 26.7% had insomnia. In multivariable analysis, compared with ≥ 60 and < 70, DH ≥ 90 h/week associated with shorter sleep duration and worsen insomnia symptoms. Shorter durations of sleep and more intense symptoms of insomnia were associated with increased depressive symptoms. Medical errors increased only among residents with insomnia, but were not associated with sleep duration. DH > 90 h/week could lead to shorter sleep duration, worsen insomnia symptoms, and negatively impact well-being and medical safety. There was no significant association between sleep duration and medical errors; however, insomnia conferred an increased risk of medical errors. Limiting DH for residents to avoid excessive workload can help improve resident sleep, enhance resident well-being, and potentially reduce insomnia-associated medical errors.

The Impact of 5-Aminolevulinic Acid Supplementation on Redox Balance and Aerobic Capacity

We examined the impact of 5-aminolevulinic acid (5-ALA) and sodium-ferrous-citrate supplementation on aerobic capacity and redox balance through a placebo-controlled, double-blind trial. Fourteen healthy volunteers were randomly assigned to Pla + ALA (4-week placebo followed by 4-week 5-ALA supplementation) or ALA + Pla (4-week 5-ALA supplement followed by a 4-week placebo) group and administered 5-ALA (25 mg/day) or placebo once daily. The participants underwent submaximal incremental cycling tests at weeks 0, 2, 4, 6, and 8. In the cycling test at week 0, individual load-intensity stages required for blood lactate levels >2 mmol/L (lactate threshold, LT) and 4 mmol/L (onset of blood lactate accumulation, OBLA) were determined. The heart rate (HR), blood lactate (La), and oxidative stress markers (diacron reactive oxygen metabolite, d-ROMs; biological antioxidant potential, BAP) were measured at resting, LT, and OBLA states in each cycling test. Marker values were not significantly different between the groups. HR, La, and d-ROMs at resting, LT, and OBLA states were not significantly different among the conditions. BAP and BAP/d-ROMs ratios were significantly different in the OBLA state at week 4 of the 5-ALA group compared with that of the placebo group (p < 0.05). In conclusion, 5-ALA supplementation might improve redox balance during high-intensity aerobic exercise.

A surgical case of anti-coagulant ileus mimicking small-bowel tumors: a case report

BACKGROUND

Anti-coagulant ileus, characterized by intramural hematoma due to excessive anti-coagulant therapy, presents a diagnostic challenge. Although previously considered uncommon, recently, reporting cases of anti-coagulant ileus have become more frequent. Herein, we report a rare surgical case of anti-coagulant ileus mimicking small-bowel tumors.

CASE PRESENTATION

A 79-year-old man was admitted to our hospital for fatigue. He had been administered warfarin for 5 months for atrial fibrillation. On admission, the patient exhibited mild epigastric tenderness. Laboratory test results revealed anemia (hemoglobin, 8.4 g/dL); unmeasurably prolonged prothrombin time (PT) with international normalized ratio (INR) > 8; and elevated soluble interleukin 2 receptor (sIL-2R) levels (849 IU/mL; normal range, 122-496 IU/mL). Abdominal plain computed tomography (CT) showed a circumferentially thickened intestinal wall at one site in the jejunum and two in the ileum. After hospitalization, bowel obstruction did not improve with conservative treatment. Suspecting small-bowel tumors such as lymphoma, the patient subsequently underwent open surgery on day 3 after admission. No obvious tumor mass was observed intra-operatively. However, only thickened and hemorrhagic segments were identified at the suspected sites. We performed partial jejunal and ileal resections of 12 and 27 cm, respectively. Histopathology confirmed submucosal congestion, edema, and hemorrhage in each area without tumor components, leading to the final diagnosis of intramural hematoma. The postoperative course was uneventful, and he was discharged on postoperative day 9. No recurrence occurred during the 5-year follow-up period.

CONCLUSIONS

We encountered a surgical case of anti-coagulant ileus, which was difficult to differentiate from malignant lymphoma based on CT findings and high sIL-2R levels. The possibility of anti-coagulant ileus should always be considered in patients on long-term anticoagulation medication and bowel obstruction with high PT-INR values.

Clinical Utility of Smartphone Applications in Ophthalmology: A Systematic Review

Topic

Numerous smartphone applications have been devised for diagnosis, treatment, and symptom management in ophthalmology. Despite the importance of systematic evaluation of the purpose, target disease, effectiveness, and utility of smartphone applications to their effective utilization, few studies have formally evaluated their validity, reliability, and clinical utility.

Clinical Relevance

This report identifies smartphone applications with potential for clinical implementation in ophthalmology and summarizes the evidence on their practical utility.

Methods

We searched PubMed and EMBASE on July 28, 2022, for articles reporting original data on the effectiveness of treatment, disease detection, diagnostic accuracy, disease monitoring, and usability of smartphone applications in ophthalmology published between January 1, 1987, and July 25, 2022. Their quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklist.

Results

The initial search yielded 510 articles. After removing 115 duplicates and 285 articles based on inclusion and exclusion criteria, the full texts of the remaining 110 articles were reviewed. Furthermore, 71 articles were included in the final qualitative synthesis. All studies were determined to be of high (87.3%) or moderate (12.7%) quality. In terms of respective application of interest, 24 (33.8%) studies assessed diagnostic accuracy, 17 (23.9%) assessed disease detection, and 3 (4.2%) assessed intervention efficacy. A total of 48 smartphone applications were identified, of which 27 (56.3%) were publicly available. Seventeen (35.4%) applications included functions for ophthalmic examinations, 13 (27.1%) included functions aimed at disease detection, 10 (20.8%) included functions to support medical personnel, five (10.4%) included functions related to disease education, and three (6.3%) included functions to promote treatment adherence for patients. The largest number of applications targeted amblyopia (18.8%), followed by retinal disease (10.4%). Two (4.2%) smartphone applications reported significant efficacy in treating diseases.

Conclusion

In this systematic review, a comprehensive appraisal is presented on studies related to diagnostic accuracy, disease detectability, and efficacy of smartphone applications in ophthalmology. Forty-eight applications with potential clinical utility are identified. Appropriate smartphone applications are expected to enable early detection of undiagnosed diseases via telemedicine and prevent visual dysfunction via remote monitoring of chronic diseases.

Financial Disclosures

Proprietary or commercial disclosure may be found after the references.

Prognostic Significance of C-Reactive Protein in Lenvatinib-Treated Unresectable Hepatocellular Carcinoma: A Multi-Institutional Study

BACKGROUND

Serum C-reactive protein (CRP) is an established biomarker for acute inflammation and has been identified as a prognostic indicator for hepatocellular carcinoma (HCC). However, the significance of the serum CRP level, specifically in HCC patients treated with lenvatinib, remains unclear.

METHODS

We retrospectively analyzed 125 HCC patients who received lenvatinib treatment at six centers. Clinical characteristics were assessed to identify clinical associations between serum CRP and HCC prognosis.

RESULTS

The median overall serum CRP level was 0.29 mg/dL. The cohort was divided into two groups: the low-CRP group with a serum CRP < 0.5 mg/dL and the high-CRP group with a serum CRP ≥ 0.5 mg/dL. The low-CRP group exhibited significantly longer overall survival (OS) than the high-CRP group (22.9 vs. 7.8 months, p < 0.001). No significant difference was observed for progression-free survival (PFS) between the high- and low-CRP groups (9.8 vs. 8.4 months, p = 0.411), while time-to-treatment failure (TTF) was significantly longer in the low-CRP group (8.5 vs. 4.4 months, p = 0.007). The discontinuation rate due to poor performance status was significantly higher in the high-CRP group (p < 0.001).

CONCLUSION

A baseline serum CRP level exceeding 0.5 mg/dL was identified as an unfavorable prognostic factor in HCC patients receiving lenvatinib treatment.

The effects of resident work hours on well-being, performance, and education: A review from a Japanese perspective

This article examines the impact of working-hour restrictions on the well-being, performance, and education of medical residents in Japan. Despite Japan's plan to introduce new regulations for resident working hours by 2024, there is still an ongoing debate regarding their appropriateness. This review provides a comprehensive overview of the current regulations of resident working hours worldwide, with a specific focus on weekly hours. The varying regulations are highlighted, including the 80-hour-per-week regulation in the United States and the 48-h-per-week regulation in the European Union influencing other regions. The article also discusses the effectiveness of working-hour restrictions on residents' mental health, with shorter working hours having potentially greater benefits. However, the impacts on medical safety and resident education are mixed, and further reduction in working hours must be carefully considered to avoid adverse effects. The planned changes to working-hour limits for residents in Japan offer a unique opportunity to gain new evidence on the impact of such regulations, which will be of interest to policymakers and researchers worldwide.

Symptom-based stratification algorithm for heterogeneous symptoms of dry eye disease: a feasibility study

BACKGROUND/OBJECTIVE

To test the feasibility of a dry eye disease (DED) symptom stratification algorithm previously established for the general population among patients visiting ophthalmologists.

SUBJECT/METHODS

This retrospective cross-sectional study was conducted between December 2015 and October 2021 at a university hospital in Japan; participants who underwent a comprehensive DED examination and completed the Japanese version of the Ocular Surface Disease Index (J-OSDI) were included. Patients diagnosed with DED were stratified into seven clusters using a previously established symptom-based stratification algorithm for DED. Characteristics of the patients in stratified clusters were compared.

RESULTS

In total, 426 participants were included (median age [interquartile range]; 63 [48-72] years; 357 (83.8%) women). Among them, 291 (68.3%) participants were diagnosed with DED and successfully stratified into seven clusters. The J-OSDI total score was highest in cluster 1 (61.4 [52.2-75.0]), followed by cluster 5 (44.1 [38.8-47.9]). The tear film breakup time was the shortest in cluster 1 (1.5 [1.1-2.1]), followed by cluster 3 (1.6 [1.0-2.5]). The J-OSDI total scores from the stratified clusters in this study and those from the clusters identified in the previous study showed a significant correlation (r = 0.991, P < 0.001).

CONCLUSIONS

The patients with DED who visited ophthalmologists were successfully stratified by the previously established algorithm for the general population, uncovering patterns for their seemingly heterogeneous and variable clinical characteristics of DED. The results have important implications for promoting treatment interventions tailored to individual patients and implementing smartphone-based clinical data collection in the future.

Shoseiryuto Promotes the Formation of a Tight-Junction Barrier in Cultured Human Bronchial Epithelial Cells

Shoseiryuto (SST) (Xiao-Qing-Long-Tang in Chinese) is an effective treatment for respiratory diseases, such as bronchial asthma and allergic rhinitis, but its effects on the bronchial tight-junction (TJ) barrier have not been clarified. This study aimed to evaluate the effect of SST on TJ-barrier function in human bronchial epithelial (16HBE) cells. The 16HBE cells were cultured in a culture medium without (control) and with SST in the absence and presence of bacterial endotoxin lipopolysaccharide (LPS) in transwell chambers. Transepithelial electrical resistance (TEER) and sodium fluorescein (Na-F) permeability of the cultured-cell monolayer were measured as TJ integrity markers. In addition, immunofluorescence staining and quantitative real-time polymerase chain reaction analysis were used to measure the expression of the TJ protein, occludin. SST increased TEER and decreased Na-F permeability of the 16HBE cell monolayers. Furthermore, SST increased both occludin mRNA and immunostained protein expressions, suggesting that SST has the effect of directly promoting epithelial TJ-barrier function. LPS decreased TEER, increased Na-F permeability, and decreased both occludin mRNA and protein expression. LPS-induced barrier dysfunction was completely blocked by pre/co- and posttreatment with SST. These results suggest that SST has protective and therapeutic effects against LPS-induced TJ-barrier damage. To our knowledge, these are the first results to demonstrate the protective and therapeutic effects conferred by TJ-barrier promoting, which may be a novel mechanism contributing to the efficacy of SST for respiratory diseases.

Association between regional quota program in medical schools and practical clinical competency based on General Medicine In-Training Examination score: a nationwide cross-sectional study of resident physicians in Japan

PURPOSE

A regional quota program (RQP) was introduced in Japan to ameliorate the urban-rural imbalance of physicians. Despite concerns about the low learning abilities of RQP graduates, the relationship between the RQP and practical clinical competency after initiating clinical residency has not been evaluated.

METHODS

We conducted a nationwide cross-sectional study to assess the association between the RQP and practical clinical competency based on General Medicine In-Training Examination (GM-ITE) scores. We compared the overall and category GM-ITE results between RQP graduates and other resident physicians. The relationship between the RQP and scores was examined using multilevel linear regression analysis.

RESULTS

There were 4978 other resident physicians and 1119 RQP graduates out of 6097 participants from 593 training hospitals. Being younger; preferring internal, general, or emergency medicine; managing fewer inpatients; and having fewer ER shifts were all characteristics of RQP graduates. In multilevel multivariable linear regression analysis, there was no significant association between RQP graduates and total GM-ITE scores (coefficient: 0.26; 95% confidence interval: -0.09, 0.61; P = .15). The associations of RQP graduates with GM-ITE scores in each category and specialty were not clinically relevant. However, in the same multivariable model, the analysis did reveal that total GM-ITE scores demonstrated strong positive associations with younger age and GM preference, both of which were significantly common in RQP graduates.

CONCLUSION

Practical clinical competency evaluated based on the GM-ITE score showed no clinically relevant differences between RQP graduates and other resident physicians. Key messages What is already known on this topic Many countries offer unique admission processes to medical schools and special undergraduate programs to increase the supply of physicians in rural areas. Concerns have been raised about the motivation, learning capabilities, and academic performance of the program graduates. What this study adds This nationwide cross-sectional study in Japan revealed clinical competency based on the scores from the General Medicine In-Training Examination showed no clinically relevant differences between graduates of regional quota programs and other resident physicians. How this study might affect research, practice, or policy The study provides evidence to support the Japanese regional quota program from the perspective of clinical competency after initiating clinical practice.

Alternative Bypass Technique Using Radial Artery Graft between V3 Segment of Vertebral Artery and Middle Cerebral Artery: Technical Note

BACKGROUND

 There are some cases where a radial artery (RA) graft is needed for a high-flow extracranial to intracranial (EC-IC) bypass as the external carotid artery (ECA) cannot be utilized as a donor artery. In this report, we describe two cases of extracranial vertebral artery (VA) to middle cerebral artery (MCA) high-flow bypass using an RA graft with an artificial vessel as an alternative bypass technique.

METHODS

 The patient was placed supine with a head rotation of 80 degrees. After frontotemporal craniotomy, another C: -shaped skin incision was made at the retroauricular region and the V3 portion of the VA was exposed at the suboccipital triangle. Prior to attempting the high-flow bypass, the superficial temporal artery (STA) was anastomosed to the M4 portion of the MCA as an insurance bypass. The RA graft was anastomosed to the V3 portion of the VA that traveled under the periosteum at the supra-auricular region through an artificial vessel. After RA-M2 anastomosis, an alternative EC-IC bypass, the V3-RA-M2 bypass, was achieved.

RESULTS

 Postoperative angiography demonstrated successful graft patency and no perioperative complications were observed in both cases.

CONCLUSIONS

 In the cases where a high-flow bypass is required, the V3 portion of the VA is a suitable alternative proximal anastomosis site when the ECA is not a candidate donor. Furthermore, an artificial vessel shows satisfactory protection against graft complications.

Association between prolonged weekly duty hours and self-study time among residents: a cross-sectional study

PURPOSE

In 2024, the Japanese government will enforce a maximum 80-hour weekly duty hours (DHs) regulation for medical residents. Although this reduction in weekly DHs could increase the self-study time (SST) of these residents, the relationship between these two variables remains unclear. The aim of the study was to investigate the relationship between the SST and DHs of residents in Japan.

METHODS

In this nationwide cross-sectional study, the subjects were candidates of the General Medicine In-Training Examination in the 2020 academic year. We administered questionnaires and categorically asked questions regarding daily SST and weekly DHs during the training period. To account for hospital variability, proportional odds regression models with generalized estimating equations were used to analyse the association between SST and DHs.

RESULTS

Of the surveyed 6117 residents, 32.0% were female, 49.1% were postgraduate year-1 residents, 83.8% were affiliated with community hospitals, and 19.9% worked for ≥80 hours/week. Multivariable analysis revealed that residents working ≥80 hours/week spent more time on self-study than those working 60-70 hours/week. Conversely, residents who worked <50 hours/week spent less time on self-study than those who worked 60-70 hours/week. The factors associated with longer SST were sex, postgraduate year, career aspiration for internal medicine, affiliation with community hospitals, academic involvement, and well-being.

CONCLUSION

Residents with long DHs had longer SSTs than residents with short DHs. Future DH restrictions may not increase but rather decrease resident SST. Effective measures to encourage self-study are required, as DH restrictions may shorten SST.

Correction: Ishihara et al. Association between Daily Physical Activity and Locomotive Syndrome in Community-Dwelling Japanese Older Adults: A Cross-Sectional Study. Int. J. Environ. Res. Public Health 2022, 19, 8164

There was an error in the "d-value of the first paragraph in Section 3 (Results)" in the original publication (Page 5, Line 41) [...].

Measurements of neutrino oscillation parameters from the T2K experiment using 3.6×1021 protons on target

The T2K experiment presents new measurements of neutrino oscillation parameters using 19.7 ( 16.3 ) × 10 20 protons on target (POT) in (anti-)neutrino mode at the far detector (FD). Compared to the previous analysis, an additional 4.7 × 10 20 POT neutrino data was collected at the FD. Significant improvements were made to the analysis methodology, with the near-detector analysis introducing new selections and using more than double the data. Additionally, this is the first T2K oscillation analysis to use NA61/SHINE data on a replica of the T2K target to tune the neutrino flux model, and the neutrino interaction model was improved to include new nuclear effects and calculations. Frequentist and Bayesian analyses are presented, including results on sin 2 θ 13 and the impact of priors on the δ CP measurement. Both analyses prefer the normal mass ordering and upper octant of sin 2 θ 23 with a nearly maximally CP-violating phase. Assuming the normal ordering and using the constraint on sin 2 θ 13 from reactors, sin 2 θ 23 = 0 . 561 - 0.032 + 0.021 using Feldman-Cousins corrected intervals, and Δ m 32 2 = 2 . 494 - 0.058 + 0.041 × 10 - 3 eV 2 using constant Δ χ 2 intervals. The CP-violating phase is constrained to δ CP = - 1 . 97 - 0.70 + 0.97 using Feldman-Cousins corrected intervals, and δ CP = 0 , π is excluded at more than 90% confidence level. A Jarlskog invariant of zero is excluded at more than 2 σ credible level using a flat prior in δ CP , and just below 2 σ using a flat prior in sin δ CP . When the external constraint on sin 2 θ 13 is removed, sin 2 θ 13 = 28 . 0 - 6.5 + 2.8 × 10 - 3 , in agreement with measurements from reactor experiments. These results are consistent with previous T2K analyses.

Kinetics of serum O-glycosylated M-hepatitis B surface antigen with hepatocellular carcinoma history and nucleos(t)ide analogue therapy in hepatitis B patients

A newly developed O-glycosylated M-hepatitis B surface antigen (HBsAgGi) measurement system can detect hepatitis B surface antigen (HBsAg) associated with infectious particles. We investigated the association of HBsAgGi levels with clinical parameters and a history of hepatocellular carcinoma (HCC) development in a cross-sectional cohort analysis (Study 1) as well as the quantitative changes in HBsAgGi during nucleos(t)ide analogue (NA) therapy in a longitudinal cohort analysis (Study 2). A total of 124 patients with genotype C chronic HBV infection were analysed in Study 1 to evaluate correlations of HBsAgGi with conventional HBV markers and HCC history. Among those, 36 patients receiving NA therapy were enrolled in Study 2 for quantitative comparisons between pre-treatment baseline and 48 weeks of NA therapy. In Study 1, serum HBsAgGi was significantly associated with HBsAg (r = .5857, p < .00001) and weakly but significantly correlated with HBV DNA (r = .2936, p = .001). Although HBsAgGi (p = .111) was comparable between HCC history (+) group and HCC history (-) group, the HBsAgGi/HBsAg ratio (p = .011) was significantly higher in HCC history (+) patients. In Study 2, HBsAgGi was significantly decreased after 48 weeks of NA therapy (p < .001). HBsAg findings were similar (p = .005) along with an HBV DNA reduction (p < .001). In the baseline hepatitis B e antigen (HBeAg) (+) subgroup, HBsAgGi decreased significantly between baseline and 48 weeks of NA (p = .005), while HBsAg was comparable (p = .051). Low HBsAg and high HBsAgGi were associated with a history of HCC development. HBsAgGi decreased significantly by 48-week NA therapy.

Clinical utility of maximum blink interval measured by smartphone application DryEyeRhythm to support dry eye disease diagnosis

The coronavirus disease (COVID-19) pandemic has emphasized the paucity of non-contact and non-invasive methods for the objective evaluation of dry eye disease (DED). However, robust evidence to support the implementation of mHealth- and app-based biometrics for clinical use is lacking. This study aimed to evaluate the reliability and validity of app-based maximum blink interval (MBI) measurements using DryEyeRhythm and equivalent traditional techniques in providing an accessible and convenient diagnosis. In this single-center, prospective, cross-sectional, observational study, 83 participants, including 57 with DED, had measurements recorded including slit-lamp-based, app-based, and visually confirmed MBI. Internal consistency and reliability were assessed using Cronbach's alpha and intraclass correlation coefficients. Discriminant and concurrent validity were assessed by comparing the MBIs from the DED and non-DED groups and Pearson's tests for each platform pair. Bland-Altman analysis was performed to assess the agreement between platforms. App-based MBI showed good Cronbach's alpha coefficient, intraclass correlation coefficient, and Pearson correlation coefficient values, compared with visually confirmed MBI. The DED group had significantly shorter app-based MBIs, compared with the non-DED group. Bland-Altman analysis revealed minimal biases between the app-based and visually confirmed MBIs. Our findings indicate that DryEyeRhythm is a reliable and valid tool that can be used for non-invasive and non-contact collection of MBI measurements, which can assist in accessible DED detection and management.

Smartphone App-Based and Paper-Based Patient-Reported Outcomes Using a Disease-Specific Questionnaire for Dry Eye Disease: Randomized Crossover Equivalence Study

BACKGROUND

Using traditional patient-reported outcomes (PROs), such as paper-based questionnaires, is cumbersome in the era of web-based medical consultation and telemedicine. Electronic PROs may reduce the burden on patients if implemented widely. Considering promising reports of DryEyeRhythm, our in-house mHealth smartphone app for investigating dry eye disease (DED) and the electronic and paper-based Ocular Surface Disease Index (OSDI) should be evaluated and compared to determine their equivalency.

OBJECTIVE

The purpose of this study is to assess the equivalence between smartphone app-based and paper-based questionnaires for DED.

METHODS

This prospective, nonblinded, randomized crossover study enrolled 34 participants between April 2022 and June 2022 at a university hospital in Japan. The participants were allocated randomly into 2 groups in a 1:1 ratio. The paper-app group initially responded to the paper-based Japanese version of the OSDI (J-OSDI), followed by the app-based J-OSDI. The app-paper group responded to similar questionnaires but in reverse order. We performed an equivalence test based on minimal clinically important differences to assess the equivalence of the J-OSDI total scores between the 2 platforms (paper-based vs app-based). A 95% CI of the mean difference between the J-OSDI total scores within the ±7.0 range between the 2 platforms indicated equivalence. The internal consistency and agreement of the app-based J-OSDI were assessed with Cronbach α coefficients and intraclass correlation coefficient values.

RESULTS

A total of 33 participants were included in this study. The total scores for the app- and paper-based J-OSDI indicated satisfactory equivalence per our study definition (mean difference 1.8, 95% CI -1.4 to 5.0). Moreover, the app-based J-OSDI total score demonstrated good internal consistency and agreement (Cronbach α=.958; intraclass correlation=0.919; 95% CI 0.842 to 0.959) and was significantly correlated with its paper-based counterpart (Pearson correlation=0.932, P<.001).

CONCLUSIONS

This study demonstrated the equivalence of PROs between the app- and paper-based J-OSDI. Implementing the app-based J-OSDI in various scenarios, including telehealth, may have implications for the early diagnosis of DED and longitudinal monitoring of PROs.

Symptom-based portopulmonary hypertension screening questionnaire in Japanese patients with chronic liver disease

Background and Aim

As the exact prevalence of portopulmonary hypertension (PoPH) and the etiology of chronic liver disease (CLD) remain unknown, the present study aimed to clarify these points in Japanese patients with CLD using symptom-based questionnaire screening.

Methods

Patients with CLD were asked to complete an eight-item written questionnaire on pulmonary hypertension (PH) symptoms. If at least one item response was "yes," the patient was offered ultrasonic echocardiography (UCG). Patients identified as having an intermediate or high risk of PH by UCG were referred to a cardiologist for further evaluation, whereby a definitive diagnosis of PoPH was made using right heart catheterization (RHC) findings.

Results

A total of 1111 patients with CLD completed the survey. Of the 566 symptomatic patients with at least one question answered as "yes," approximately half agreed to undergo UCG (n = 267). Compared with asymptomatic patients, symptomatic patients were significantly older, predominantly female, and more frequently exhibited cirrhosis. Based on UCG findings, 228, 12, and 8 patients had a low, intermediate, or high risk for PH, respectively. Intermediate-/high-risk patients showed significantly more advanced disease progression status than low-risk patients. The frequencies of answer to the eight questions were comparable. Ultimately, three patients were diagnosed as having PoPH (1.1% of UCG cases), one with underlying hepatitis C virus (HCV) infection and two with primary biliary cholangitis (PBC).

Conclusion

This symptom-based PoPH screening study clarified the prevalence of PoPH in CLD patients according to a PH symptom questionnaire, UCG, and RHC. Patients with HCV and PBC may have a higher risk of PoPH.

HLA-G susceptibility to hepatitis B infection and related hepatocellular carcinoma in the Japanese population

AIMS

Human leukocyte antigen (HLA)-G plays a role in various physiological immunomodulatory functions. Aberrant HLA-G expression is observed in various disease states, including tumors, autoimmune disorders, and viral infections. The present study investigated the association between HLA-G functional gene polymorphisms (rs1736933 [-486 C > A], rs1049033 [+2018 C > T], 14 bp Insertion [Ins]/Deletion [Del] [+2961 Del > Ins], and rs1063320 [+3142 C > G]) and disease susceptibility, hepatocellular carcinoma (HCC) development, and hepatitis B surface antigen (HBsAg) clearance.

METHODS

Allele discrimination of the 3 SNPs (-486 C > A, +2018 C > T, +3142 C > G) was determined by a TaqMan 5' exonuclease assay, while the 14 bp Ins/Del polymorphism was typed by fragment analysis using Genetic Analyzer and GeneMapper software. The above polymorphisms were analyzed for 325 Japanese hepatitis B virus (HBV) patients, 355 Japanese healthy subjects (Controls) as healthy controls, and 799 Japanese hepatitis C virus (HCV) patients as disease controls, respectively.

RESULTS

The 14 bp Insertion allele was significantly more frequent in HBV patients than Controls (27.1 % vs 20.6 %, odds ratio [OR] 1.43, P = 0.005) but did not differ between HCV patients and Controls. Similar results were found for the rs1063320 G allele (38.9 % vs 26.3 %, OR 1.78, P < 0.001) and the rs1736933 T allele (32.2 % vs 26.9 %, OR 1.29, P = 0.034) between HBV and Controls. The rs1049033 T allele showed a weak but significant association with HCC development in the dominant model (OR 1.95, P = 0.04). Regarding HBsAg clearance, the A allele at rs1736933 was significantly correlated in the recessive model (OR 3.23, P = 0.003).

CONCLUSIONS

This study revealed significant associations of HLA-G gene polymorphisms with disease susceptibility, HCC development, and HBsAg clearance in HBV patients.

Impact of intravenous injection of glucagon on anastomotic leakage in esophagectomy

Background

Anastomotic leakage after esophagectomy affects the early postoperative state and prognosis. However, effective measures to prevent anastomotic leakage in esophagogastric anastomosis have not been established.

Methods

This single-center, retrospective, observational study included 147 patients who underwent esophagectomy for esophageal cancer between 2010 and 2020. Glucagon was administered to extend the gastric tube in patients who underwent esophagectomy from January 2016. The patients were divided into two groups: a glucagon-treated group (2016-2020) and a control group (2010-2015). The incidence of anastomotic leakage was compared between the two groups for evaluation of the preventive effects of glucagon administration on anastomotic leakage.

Results

The length of the gastric tube from the pyloric ring to the final branch of the right gastroepiploic artery was extended by 2.8 cm after glucagon injection. The incidence of anastomotic leakage was significantly lower in the glucagon-treated group (19% vs. 38%; p = 0.014). Multivariate analysis showed that glucagon injection was the only independent factor associated with a reduction in anastomotic leakage (odds ratio, 0.26; 95% confidence interval, 0.07-0.87). Esophagogastric anastomosis was performed proximal to the final branch of the right gastroepiploic artery in 37% patients in the glucagon-treated group, and these cases showed a lower incidence of anastomotic leakage than did those with anastomosis distal to the final branch of the right gastroepiploic artery (10% vs. 25%, p = 0.087).

Conclusions

Extension of the gastric tube by intravenous glucagon administration during gastric mobilization in esophagectomy for esophageal cancer may be effective in preventing anastomotic leakage.

Crowned dens syndrome: A case series of 72 patients at eight teaching hospitals in Japan

Background

Crowned dens syndrome (CDS) is characterized by calcification around the odontoid process, accompanied by neck pain. Although CDS is supposedly rare, we regularly diagnose and manage this condition, indicating a perception gap between previous studies and our experience. The purpose of this study was to determine the annual incidence of CDS, time to diagnosis in CDS, as well as the features of CDS.

Methods

The study design was a retrospective case series study conducted at eight teaching hospitals in Japan. We identified CDS cases from April 2013-March 2015. CDS was diagnosed when patients had acute onset of neck pain and CT showed calcification around the dens and when other diagnoses were unlikely.

Results

Seventy-two CDS cases were identified. Mean annual incidence was 4.6 ± 2.3 cases at each hospital. Among those with available data, 57 of 64 had limited rotation (89.1%). The diagnosis of CDS was made in general internal medicine or the emergency medicine department in 61 cases (84.7%). A total of 62 cases (86.1%) were diagnosed within 1 day of presentation, and the median time from initial presentation at the hospital to diagnosis was 0.0 days (25th-75th percentiles, 0.0-1.0). For treatment, NSAIDs were used in 56cases (77.8%) and acetaminophen in 20 cases (27.8%).

Conclusion

CDS might be more common than has been reported to date. Time to diagnosis of CDS was within 1 day of visiting a teaching hospital. Cervical motion restriction is common in CDS and may be useful in establishing the diagnosis.

The minimal clinically important difference of app-based electronic patient-reported outcomes for hay fever

BACKGROUND

Hay fever is a common allergic disease, with an estimated worldwide prevalence of 14.4% and a variety of symptoms. This study assessed the minimal clinically important difference (MCID) of nasal symptom score (NSS), non-nasal symptom score (NNSS), and total symptoms score (TSS) for app-based hay-fever monitoring.

METHODS

MCIDs were calculated based on the data from a previous large-scale, crowdsourced, cross-sectional study using AllerSearch, an in-house smartphone application. MCIDs were determined with anchor-based and distribution-based methods. The face scale score of the Japanese Allergic Conjunctival Disease Standard Quality of Life Questionnaire Domain III and the daily stress level due to hay fever were used as anchors for determining MCIDs. The MCID estimates were summarized as MCID ranges.

RESULTS

A total of 7590 participants were included in the analysis (mean age: 35.3 years, 57.1% women). The anchor-based method produced a range of MCID values (median, interquartile range) for NSS (2.0, 1.5-2.1), NNSS (1.0, 0.9-1.2), and TSS (2.9, 2.4-3.3). The distribution-based method produced two MCIDs (based on half a standard deviation, based on a standard error of measurement) for NSS (2.0, 1.8), NNSS (1.3, 1.2), and TSS (3.0, 2.3). The final suggested MCID ranges for NSS, NNSS, and TSS were 1.8-2.1, 1.2-1.3, and 2.4-3.3, respectively.

CONCLUSIONS

MCID ranges for app-based hay-fever symptom assessment were obtained from the data collected through a smartphone application, AllerSearch. These estimates may be useful for monitoring the subjective symptoms of Japanese patients with hay fever through mobile platforms.

Identification of SARS-CoV-2 variants in wastewater using targeted amplicon sequencing during a low COVID-19 prevalence period in Japan

Wastewater-based epidemiology is expected to be able to identify SARS-CoV-2 variants at an early stage via next-generation sequencing. In the present study, we developed a highly sensitive amplicon sequencing method targeting the spike gene of SARS-CoV-2, which allows for sequencing viral genomes from wastewater containing a low amount of virus. Primers were designed to amplify a relatively long region (599 bp) around the receptor-binding domain in the SARS-CoV-2 spike gene, which could distinguish initial major variants of concern. To validate the methodology, we retrospectively analyzed wastewater samples collected from a septic tank installed in a COVID-19 quarantine facility between October and December 2020. The relative abundance of D614G mutant in SARS-CoV-2 genomes in the facility wastewater increased from 47.5 % to 83.1 % during the study period. The N501Y mutant, which is the characteristic mutation of the Alpha-like strain, was detected from wastewater collected on December 24, 2020, which agreed with the fact that a patient infected with the Alpha-like strain was quarantined in the facility on this date. We then analyzed archived municipal wastewater samples collected between November 2020 and January 2021 that contained low SARS-CoV-2 concentrations ranging from 0.23 to 0.43 copies/qPCR reaction (corresponding to 3.30 to 4.15 log₁₀ copies/L). The targeted amplicon sequencing revealed that the Alpha-like variant with D614G and N501Y mutations was present in municipal wastewater collected on December 4, 2020 and later, suggesting that the variant had already spread in the community before its first clinical confirmation in Japan on December 25, 2020. These results demonstrate that targeted amplicon sequencing of wastewater samples is a powerful surveillance tool applicable to low COVID-19 prevalence periods and may contribute to the early detection of emerging variants.

Purulent Pericarditis Due to Pneumococcal Bacteremia Caused by Acupuncture: An Autopsy Case Report

Purulent pericarditis is an infection of the pericardial cavity that produces purulent fluid and is commonly caused by Streptococcus pneumoniae. We herein report an autopsy case that is unique in two respects: the patient had pneumococcal bacteremia from a skin and soft tissue infection associated with acupuncture as well as purulent pericarditis from pneumococcal bacteremia. This case suggests that bloodstream infection should be included in the differential diagnosis on observing pneumococcal pericarditis. Furthermore, it is necessary to recognize that S. pneumoniae may be the organism responsible for skin and soft tissue infections caused by trauma in immunosuppressed patients.

Near-white light emission from single crystals of cationic dinuclear gold(I) complexes with bridged diphosphine ligands

Three cationic dinuclear Au(I) complexes containing acetonitrile (AN) as an ancillary ligand were synthesized: [μ-L_Me(AuAN)₂]·2BF₄ (1), [μ-L_Et(AuAN)₂]·2BF₄ (2), and [μ-L_iPr(AuAN)₂]·2BF₄ (3) (L_Me = {1,2-bis[bis(2-methylphenyl)phosphino]benzene}, L_Et = {1,2-bis[bis(2-ethylphenyl)phosphino]benzene}, and L_iPr = {1,2-bis[bis(2-isopropylphenyl)phosphino]benzene}). The unique structures of complexes 1-3 with two P-Au(I)-AN rods bridged by rigid diphosphine ligands were determined through X-ray analysis. The Au(I)-Au(I) distances observed for complexes 1-3 were as short as 2.9804-3.0457 Å, indicating an aurophilic interaction between two Au(I) atoms. Unlike complexes 2 and 3, complex 1 incorporated CH₂Cl₂ into the crystals as crystalline solvent molecules. Luminescence studies in the crystalline state revealed that complexes 1 and 2 mainly exhibited bluish-purple phosphorescence (PH) at 293 K: the former had a PH peak wavelength at 415 nm with the photoluminescence quantum yield Φ_PL = 0.12, and the latter at 430 nm with Φ_PL = 0.13. Meanwhile, complex 3 displayed near-white PH, that is dual PH with two PH bands centered at 425 and 580 nm with Φ_PL = 0.44. The PH spectra and lifetimes of complexes 2 and 3 were measured in the temperature range of 77-293 K. The two PH bands observed for complex 3 were suggested to originate from the two emissive excited triplet states, which were in thermal equilibrium. From theoretical calculations, the dual PH observed for complex 3 is explained to occur from the two excited triplet states, T_1H and T_1L: the former exhibits a high-energy PH band (bluish-purple) and the latter exhibits a low-energy PH band (orange). The T_1H state is considered ³ILCT with a structure similar to that of the S₀-optimized structure. Conversely, the T_1L state is assumed to be a ³MLCT with a T₁-optimized structure, which has a short Au(I)-Au(I) bond and two bent rods (Au-AN). The thermal equilibrium between the two excited states is discussed based on computational calculations and photophysical data in the temperature range of 77-293 K. With regard to the crystal of complex 1, we were unable to precisely measure the temperature-dependent emission spectra and lifetimes, particularly at low temperatures, because the cooled crystals became irreversibly turbid over time.

Impact of duty hours on competency-related knowledge acquisition among community hospital residents

Background

The effect of duty hour (DH) restrictions on postgraduate residents' acquisition of clinical competencies is unclear. We evaluated the relationship between DHs and competency-related knowledge acquisition using the General Medicine In-training Examination (GM-ITE).

Methods

We conducted a multicenter, cross-sectional study of community hospital residents among 2019 GM-ITE examinees. Self-reported average DHs per week were classified into five DH categories and the competency domains were classified into four areas: symptomatology and clinical reasoning (CR), physical examination and clinical procedure (PP), medical interview and professionalism (MP), and disease knowledge (DK). The association between these scores and DHs was examined using random-intercept linear models with and without adjustment for confounding factors.

Results

We included 4753 participants in the analyses. Of these, 31% were women, and 49.1% were in the postgraduate year (PGY) 2. Mean CR and MP scores were lower among residents in Category 1 (<50 h) than in residents in Category 3 (≥60 and <70 h; reference group). Mean DK scores were lower among residents in Categories 1 and 2 (≥50 and <60 h) than in the reference group. PGY-2 residents in Categories 1 and 2 had lower CR scores than those in Category 3; however, PGY-1 residents in Category 5 showed higher scores.

Conclusions

The relationship between DHs and each competency area is not strictly linear. The acquisition of knowledge of physical examination and clinical procedures skills in particular may not be related to DHs.

Relationship between COVID-19 care and burnout among postgraduate clinical residents in Japan: a nationwide cross-sectional study

OBJECTIVE

The relationship between the care of patients with COVID-19 and mental health among resident physicians in Japan is imperative for ensuring appropriate care of patients with COVID-19 and should be clarified. We herein assessed the relationship between the care of patients with COVID-19 and mental health among postgraduate year 1 (PGY-1) and PGY-2 resident physicians and factors associated with mental health.

DESIGN

This nationwide cross-sectional study analysed data obtained using the clinical training environment self-reported questionnaire.

SETTING

An observational study across Japan among resident physicians (PGY-1 and PGY-2) from 583 teaching hospitals.

PARTICIPANTS

Examinees who took the general medicine in-training examination of academic year 2020.

PRIMARY AND SECONDARY OUTCOME MEASURES

The Patient Health Questionnaire and Mini-Z 2.0 were used to assess mental health, and experience of caring for patients with COVID-19 was divided into three groups (none, 1-10 and ≥11). The prevalence of mental conditions in the three groups was compared using the 'modified' Poisson generalised estimating equations by adjusting for prefecture-level, hospital-level and resident-level variables.

RESULTS

Of the 5976 participants analysed, 50.9% were PGY-1. The prevalence of burnout was 21.4%. Moreover, 47.0% of all resident physicians had no experience in the care of patients with COVID-19. The well-experienced group accounted for only 7.9% of the total participants. A positive association was found between the number of caring patients with COVID-19 and burnout (prevalence ratio 1.25; 95% CI 1.02 to 1.53). Moreover, the shortage of personal protective equipment was identified as a major contributor to burnout (prevalence ratio 1.60; 95% CI 1.36 to 1.88).

CONCLUSIONS

Resident physicians who experienced more care of patients with COVID-19 had slightly greater burnout prevalence than those who did not. Approximately half of resident physicians did not participate in the care of patients with COVID-19, which posed a challenge from an educational perspective.

Neonatal bilateral whisker trimming in male mice age-dependently alters brain neurotransmitter levels and causes adolescent onsets of social behavior abnormalities

Tactile perception via whiskers is important in rodent behavior. Whisker trimming during the neonatal period affects mouse behaviors related to both whisker-based tactile cognition and social performance. However, the molecular basis of these phenomena is not completely understood. To solve this issue, we investigated developmental changes in transmitters and metabolites in various brain regions of male mice subjected to bilateral whisker trimming during the neonatal period (10 days after birth [BWT10 mice]). We discovered significantly lower levels of 3-methoxy-4-hydroxyphenyl glycol (MHPG), the major noradrenaline metabolite, in various brain regions of male BWT10 mice at both early/late adolescent stages (at P4W and P8W). However, reduced levels of dopamine (DA) and their metabolites were more significantly identified at P8W in the nuclear origins of monoamine (midbrain and medulla oblongata) and the limbic system (frontal cortex, amygdala, and hippocampus) than at P4W. Furthermore, the onset of social behavior deficits (P6W) was observed later to the impairment of whisker-based tactile cognitive behaviors (P4W). Taken together, these findings suggest that whisker-mediated tactile cognition may contribute toprogressive abnormalities in social behaviors in BWT10 mice accompanied by impaired development of dopaminergic systems.

Genome-Wide Association Study Identifies CDKN1A as a Novel Locus Associated with Muscle Fiber Composition

Muscle fiber composition is associated with physical performance, with endurance athletes having a high proportion of slow-twitch muscle fibers compared to power athletes. Approximately 45% of muscle fiber composition is heritable, however, single nucleotide polymorphisms (SNP) underlying inter-individual differences in muscle fiber types remain largely unknown. Based on three whole genome SNP datasets, we have shown that the rs236448 A allele located near the cyclin-dependent kinase inhibitor 1A (CDKN1A) gene was associated with an increased proportion of slow-twitch muscle fibers in Russian (n = 151; p = 0.039), Finnish (n = 287; p = 0.03), and Japanese (n = 207; p = 0.008) cohorts (meta-analysis: p = 7.9 × 10−5. Furthermore, the frequency of the rs236448 A allele was significantly higher in Russian (p = 0.045) and Japanese (p = 0.038) elite endurance athletes compared to ethnically matched power athletes. On the contrary, the C allele was associated with a greater proportion of fast-twitch muscle fibers and a predisposition to power sports. CDKN1A participates in cell cycle regulation and is suppressed by the miR-208b, which has a prominent role in the activation of the slow myofiber gene program. Bioinformatic analysis revealed that the rs236448 C allele was associated with increased CDKN1A expression in whole blood (p = 8.5 × 10−15) and with greater appendicular lean mass (p = 1.2 × 10−5), whereas the A allele was associated with longer durations of exercise (p = 0.044) reported amongst the UK Biobank cohort. Furthermore, the expression of CDKN1A increased in response to strength (p < 0.0001) or sprint (p = 0.00035) training. Accordingly, we found that CDKN1A expression is significantly (p = 0.002) higher in the m. vastus lateralis of strength athletes compared to endurance athletes and is positively correlated with the percentage of fast-twitch muscle fibers (p = 0.018). In conclusion, our data suggest that the CDKN1A rs236448 SNP may be implicated in the determination of muscle fiber composition and may affect athletic performance.

Pneumococcal lactational mastitis in a healthy woman

We report a case of lactational mastitis complicated by Streptococcus pneumoniae bacteraemia in a breast feeding, healthy woman in her 20s. Numerous investigations showed that mastitis was the probable source of S. pneumoniae bacteraemia. While S. pneumoniae is known to cause non-lactational mastitis in patients with underlying diseases, such as systemic lupus erythematosus, reports of lactating mastitis in healthy individuals are scarce, with only six cases reported in the scientific literature published in English since 1995. Similar to previous reports, our patient had a good clinical course with antimicrobial therapy, and the infection was presumably transmitted from the asymptomatic child to the mother. Although the exact mechanisms that establish transmission from a child remain unclear, both host and pathogen factors, such as stagnant milk or bacterial virulence factors, are thought to play a key role. Caution should be exercised because serotypes not currently covered by pneumococcal vaccines are emerging.

The detectability and removal efficiency of SARS-CoV-2 in a large-scale septic tank of a COVID-19 quarantine facility in Japan

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is known to be present in sewage, and wastewater-based epidemiology has attracted much attention. However, the physical partitioning of SARS-CoV-2 in wastewater and the removal efficiency of treatment systems require further investigation. This study aimed to investigate the detectability and physical partitioning of SARS-CoV-2 in wastewater and assess its removal in a large-scale septic tank employing anaerobic, anoxic, and oxic processes in a sequential batch reactor, which was installed in a coronavirus disease 2019 (COVID-19) quarantine facility. The amount of SARS-CoV-2 RNA in wastewater was determined with polyethylene glycol (PEG) precipitation followed by quantitative polymerase chain reaction (qPCR), and the association of SARS-CoV-2 with wastewater solids was evaluated by the effect of filtration prior to PEG precipitation (pre-filtration). The amount of SARS-CoV-2 RNA detected from pre-filtered samples was substantially lower than that of samples without pre-filtration. These results suggest that most SARS-CoV-2 particles in wastewater are associated with the suspended solids excluded by pre-filtration. The removal efficiency of SARS-CoV-2 in the septic tank was evaluated based on the SARS-CoV-2 RNA concentrations in untreated and treated wastewater, which was determined by the detection method optimized in this study. Escherichia coli and pepper mild mottle virus (PMMoV) were also quantified to validate the wastewater treatment system's performance. The mean log₁₀ reduction values of SARS-CoV-2, E. coli, and PMMoV were 2.47 (range, 2.25-2.68), 2.81 (range, 2.45-3.18), and 0.66 (range, 0.61-0.70), respectively, demonstrating that SARS-CoV-2 removal by the wastewater treatment system was comparable to or better than the removal of fecal indicators. These results suggest that SARS-CoV-2 can be readily removed by the septic tank. This is the first study to determine the removal efficiency of SARS-CoV-2 in a facility-level sequencing batch activated sludge system.

Higher Responsiveness for Women, High Transaminase Levels, and Fat Percentage to Pemafibrate Treatment for NAFLD

Aim: Pemafibrate (PEM) is a novel selective peroxisome proliferator-activated receptor alpha modulator that is effective for hypertriglyceridemia accompanying non-alcoholic fatty liver disease (HTG-NAFLD). This study aimed to identify the predictors of PEM efficacy for HTG-NAFLD in clinical practice. Methods: We retrospectively enrolled 88 HTG-NAFLD patients treated with PEM for 6 months for the analysis of routine blood and body composition testing. A PEM response was defined as a decrease in serum alanine aminotransferase (ALT) of >30% compared with pre-treatment level. The clinical features related to PEM responsiveness were statistically tested between responders and non-responders. Results: All 88 patients completed the 6 month drug regimen without any adverse effects. PEM treatment significantly decreased liver enzymes, triglycerides, and total cholesterol levels, without any detectable impact on body weight or body composition. Comparisons of baseline clinical features revealed female and greater aspartate aminotransferase (AST), ALT, and fat mass % levels to be significantly associated with a PEM response. The optimal cut-off values to predict responders as determined by receiver operating characteristic analysis were AST 45 U/L, ALT 60 U/L, and fat mass 37%. Conclusions: Female HTG-NAFLD patients with higher transaminase and fat mass % levels may be preferentially indicated for PEM treatment. Additional large-scale prospective studies are warranted to verify our results.

A Smartphone Healthcare Application, CALO mama Plus, to Promote Weight Loss: A Randomized Controlled Trial

Mobile applications are increasingly used in healthcare. We have developed a smartphone healthcare application, CALO mama Plus, that can register daily diet, exercise, mood, and sleep quality, calculate dietary intake, and provide advice using artificial intelligence technology. This 3-month randomized controlled trial tested the hypothesis that CALO mama Plus could promote body weight reduction in Japanese adults with overweight or obesity. We recruited office workers as participants. The key eligibility criteria were an age of 20–65 years and a body mass index of 23–40 kg/m². The primary outcome was body weight change over 3 months. We enrolled 141 participants and randomly assigned them to the intervention (n = 72) and control (n = 69) groups. The intervention group used CALO mama Plus, and the control group did not receive any intervention. The change in body weight was −2.4 ± 4.0 kg and −0.7 ± 3.3 kg in the intervention and control groups, respectively. An analysis of covariance adjusted for related variables showed a significant between-group difference in body weight change (−1.60 kg; 95% confidence interval −2.83 to −0.38; p = 0.011). The present study suggests that CALO mama Plus effectively promotes weight loss.

The Efficient and Practical virus Identification System with ENhanced Sensitivity for Solids (EPISENS-S): A rapid and cost-effective SARS-CoV-2 RNA detection method for routine wastewater surveillance

Wastewater-based epidemiology has attracted attention as a COVID-19 surveillance tool. Here, we developed a practical method for detecting SARS-CoV-2 RNA in wastewater (the EPISENS-S method), which employs direct RNA extraction from wastewater pellets formed via low-speed centrifugation. The subsequent multiplex one-step RT-preamplification reaction with forward and reverse primers for SARS-CoV-2 and a reverse primer only for pepper mild mottle virus (PMMoV) allowed for qPCR quantification of the targets with different abundances in wastewater from the RT-preamplification product. The detection sensitivity of the method was evaluated using wastewater samples seeded with heat-inactivated SARS-CoV-2 in concentrations of 2.11 × 10³ to 2.11 × 10⁶ copies/L. The results demonstrated that the sensitivity of the EPISENS-S method was two orders of magnitude higher than that of the conventional method (PEG precipitation, followed by regular RT-qPCR; PEG-QVR-qPCR). A total of 37 untreated wastewater samples collected from two wastewater treatment plants in Sapporo, Japan when 1.6 to 18 new daily reported cases per 100,000 people were reported in the city (March 4 to July 8, 2021), were examined using the EPISENS-S method to confirm its applicability to municipal wastewater. SARS-CoV-2 RNA was quantified in 92 % (34/37) of the samples via the EPISENS-S method, whereas none of the samples (0/37) was quantifiable via the PEG-QVR-qPCR method. The PMMoV concentrations measured by the EPISENS-S method ranged from 2.60 × 10⁶ to 1.90 × 10⁸ copies/L, and the SARS-CoV-2 RNA concentrations normalized by PMMoV ranged from 5.71 × 10^-6 to 9.51 × 10^-4 . The long-term trend of normalized SARS-CoV-2 RNA concentration in wastewater was consistent with that of confirmed COVID-19 cases in the city. These results demonstrate that the EPISENS-S method is highly sensitive and suitable for routine COVID-19 wastewater surveillance.

Association between Daily Physical Activity and Locomotive Syndrome in Community-Dwelling Japanese Older Adults: A Cross-Sectional Study

This study aimed to evaluate the association between locomotive syndrome (LS) and daily physical activity (PA) in community-dwelling older adults. This cross-sectional study included 80 healthy Japanese older adults (40 men and 40 women; age: 60-79 years). Habitual daily PA was evaluated using a triaxial wrist accelerometer. Participants were divided into two groups based on the results of the two-step test, stand-up test, and 25-question geriatric locomotive function scale. Binomial logistic regression analysis was conducted to examine the statistical relationships between daily PA and category of LS, adjusting for age from adjusted odds ratio (adjusted OR) with the 95 percent confidence intervals (95%CI) and bootstrap 95%CI. The mean step count and time spent on moderate to vigorous physical activity (MVPA) were significantly higher among non-LS participants than among LS participants in women, but not in men. Logistic regression analyses indicated that spending longer than 28 min/day on MVPA was significantly associated with a lower likelihood of LS relative to short time category under 28 min/day in women (adjusted OR = 0.12, 95%CI = 0.02-0.59, bootstrap 95%CI = 0.01-0.43), but not in men. This study suggests that in community-dwelling older women, those with higher MVPA had lower odds of LS, and daily MVPA was associated with LS, but not in men. Therefore, the associations between LS and daily physical activity were partly dependent on sex differences.

High-throughput muscle fiber typing from RNA sequencing data

Background

Skeletal muscle fiber type distribution has implications for human health, muscle function, and performance. This knowledge has been gathered using labor-intensive and costly methodology that limited these studies. Here, we present a method based on muscle tissue RNA sequencing data (totRNAseq) to estimate the distribution of skeletal muscle fiber types from frozen human samples, allowing for a larger number of individuals to be tested.

Methods

By using single-nuclei RNA sequencing (snRNAseq) data as a reference, cluster expression signatures were produced by averaging gene expression of cluster gene markers and then applying these to totRNAseq data and inferring muscle fiber nuclei type via linear matrix decomposition. This estimate was then compared with fiber type distribution measured by ATPase staining or myosin heavy chain protein isoform distribution of 62 muscle samples in two independent cohorts (n = 39 and 22).

Results

The correlation between the sequencing-based method and the other two were r_ATPas = 0.44 [0.13–0.67], [95% CI], and r_myosin = 0.83 [0.61–0.93], with p = 5.70 × 10^–3 and 2.00 × 10^–6, respectively. The deconvolution inference of fiber type composition was accurate even for very low totRNAseq sequencing depths, i.e., down to an average of ~ 10,000 paired-end reads.

Conclusions

This new method (https://github.com/OlaHanssonLab/PredictFiberType) consequently allows for measurement of fiber type distribution of a larger number of samples using totRNAseq in a cost and labor-efficient way. It is now feasible to study the association between fiber type distribution and e.g. health outcomes in large well-powered studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13395-022-00299-4.