Optimal biological dose selection in dose-finding trials with model-assisted designs based on efficacy and toxicity: a simulation study

With the emergence of molecular targeted agents and immunotherapies in anti-cancer treatment, a concept of optimal biological dose (OBD), accounting for efficacy and toxicity in the framework of dose-finding, has been widely introduced into phase I oncology clinical trials. Various model-assisted designs with dose-escalation rules based jointly on toxicity and efficacy are now available to establish the OBD, where the OBD is generally selected at the end of the trial using all toxicity and efficacy data obtained from the entire cohort. Several measures to select the OBD and multiple methods to estimate the efficacy probability have been developed for the OBD selection, leading to many options in practice; however, their comparative performance is still uncertain, and practitioners need to take special care of which approaches would be the best for their applications. Therefore, we conducted a comprehensive simulation study to demonstrate the operating characteristics of the OBD selection approaches. The simulation study revealed key features of utility functions measuring the toxicity-efficacy trade-off and suggested that the measure used to select the OBD could vary depending on the choice of the dose-escalation procedure. Modelling the efficacy probability might lead to limited gains in OBD selection.

Feasibility, Acceptability, and Potential Efficacy of a Mobile Health Application for Community-Dwelling Older Adults with Frailty and Pre-Frailty: A Pilot Study

Smartphone applications aimed at enhancing physical, cognitive, and social activities through mobile health (mHealth) technology are of increasing interest. Their feasibility and acceptability, alongside impacts on frailty phenotype scores and step counts among older adults with frailty, remain to be fully validated. This study presents a 13-week preliminary intervention trial assessing an mHealth app's feasibility in a cohort of 34 eligible older adults, including 5 frail and 29 pre-frail participants. The intervention entailed a 6-week course on app usage, followed by 7 weeks of observation, with four participants withdrawing early. Feasibility was determined by login and active use rates, with a target login rate of 60% or higher. Post-intervention, 100% session attendance and a median login rate of 88.4% were observed. Acceptability was high, with 73% affirming the app's health benefits. Notably, frailty scores and step counts improved post-intervention, underscoring the app's potential for supporting older adults with frailty.

An analysis of muscle growth after proton beam therapy for pediatric cancer

Retardation of growth and development is a well-known late effect after radiotherapy for pediatric patients. The goal of the study was to examine the effect of proton beam therapy (PBT) on the growth of muscles included in the irradiated area. The subjects were 17 pediatric patients (age ≤ 5 years) who received PBT with a treatment field including a muscle on only one side out of a pair of symmetrical bilateral muscles and had imaging evaluations for at least 1 year after PBT. The thicknesses of the irradiated and non-irradiated (contralateral) muscles were measured retrospectively on CT or MRI axial images collected before and after PBT. The change of thickness divided by the period (years) for each muscle was compared between the irradiated and contralateral sides. Correlations of muscle growth with irradiation dose and age at the start of treatment were also evaluated. The median observation period was 39.2 months. The measurement sites included the erector spinae (n = 9), gluteus maximus (n = 5) and rhomboids + trapezius (n = 3) muscles. The average changes in muscle thickness were 0.24 mm/year on the irradiated side and 1.19 mm/year on the contralateral side, showing significantly reduced growth on the irradiated side (P = 0.001). Younger patients had greater muscle growth. Irradiation dose was not significant, but muscle growth tended to decrease as the dose increased, and muscles irradiated at >50 Gy (RBE) showed little growth. These results show that muscle growth is affected by PBT and that long-term follow-up is needed to evaluate muscle growth retardation.

A systematic review and meta-analysis of radiotherapy and particle beam therapy for skull base chondrosarcoma: TRP-chondrosarcoma 2024

Introduction

Chondrosarcoma is a rare malignant bone tumor. Particle beam therapy (PT) can concentrate doses to targets while reducing adverse events. A meta-analysis based on a literature review was performed to examine the efficacy of PT and photon radiotherapy for skull base chondrosarcoma.

Methods

The meta-analysis was conducted using 21 articles published from 1990 to 2022.

Results

After PT, the 3- and 5-year overall survival (OS) rates were 94.1% (95% confidence interval [CI]: 91.0-96.2%) and 93.9% (95% CI: 90.6-96.1%), respectively, and the 3- and 5-year local control rates were 95.4% (95% CI: 92.0-97.4%) and 90.1% (95% CI: 76.8-96.0%), respectively. Meta-regression analysis revealed a significant association of PT with a superior 5-year OS rate compared to three-dimensional conformal radiotherapy (p < 0.001). In the studies used in the meta-analysis, the major adverse event of grade 2 or higher was temporal lobe necrosis (incidence 1-18%, median 7%).

Conclusion

PT for skull base chondrosarcoma had a good outcome and may be a valuable option among radiotherapy modalities. However, high-dose postoperative irradiation of skull base chondrosarcoma can cause adverse events such as temporal lobe necrosis.

Proton Beam Therapy for Hepatocellular Carcinoma: Multicenter Prospective Registry Study in Japan

PURPOSE

A prospective multicenter registry study was started May 2016 in Japan to evaluate the efficacy and safety of proton beam therapy (PBT) for hepatocellular carcinoma (HCC).

METHODS AND MATERIALS

Patients who received PBT for HCC from May 2016 to June 2018 were registered in the database of the Particle Beam Therapy Committee and Subcommittee of the Japanese Society for Radiation Oncology. Overall survival (OS), progression-free survival (PFS), and local recurrence were evaluated.

RESULTS

Of the 755 registered patients, 576 with initial PBT and no duplicate cancer were evaluated. At final follow-up, 322 patients were alive and 254 had died. The median follow-up period for survivors was 39 months (0-58 months). The median OS time of the 576 patients was 48.8 months (95% CI, 42.0-55.6 months) and the 1-, 2-, 3-, and 4-year OS rates were 83.8% (95% CI, 80.5%-86.6%), 68.5% (64.5%-72.2%), 58.2% (53.9%-62.2%), and 50.1% (44.9%-55.0%), respectively. Recurrence was observed in 332 patients, including local recurrence in 45 patients. The median PFS time was 14.7 months (95% CI, 12.4-17.0 months) and the 1-, 2-, 3-, and 4-year PFS rates were 55.2% (95% CI, 51.0%-59.2%), 37.5% (33.5%-41.5%), 30.2% (26.3%-34.2%), and 22.8% (18.5%-27.4%), respectively. The 1-, 2-, 3-, and 4-year OS rates were significantly higher for tumor size <5 versus 5 to 10 cm (P < .001) and <5 versus ≥10 cm (P < .001); Child-Pugh score A/B versus C (P < .001); and distance of the tumor from the gastrointestinal tract <1 versus 1 to 2 cm (P < .008) and <1 versus >2 cm (P < .001). At final follow-up, 27 patients (4.7%) had late adverse events of grade 3 or higher, with liver failure (n = 7), and dermatitis (n = 7) being most common.

CONCLUSIONS

This multicenter prospective data registry indicated that PBT for HCC gives good therapeutic effects (3-year local control rate of 90%) with a low risk of severe late adverse events.

A novel predictive formula for highly accurate discrimination between truly Helicobacter pylori-uninfected and currently infected/spontaneously eradicated individuals for gastric cancer screening

The ABC classification, which categorizes gastric cancer risk based on serum Helicobacter pylori (H pylori) antibody and pepsinogen levels, has a limitation of potentially misclassifying high-risk individuals as low risk. To overcome the problem, we previously developed a 4-parameter predictive formula (age, serum H pylori antibody, PGI, and PGII) using logistic regression analysis to accurately identify low-risk truly H pylori-uninfected status. Our predictive formula demonstrated superior sensitivity and specificity in distinguishing between low-risk truly uninfected individuals and high-risk currently/spontaneously eradicated status individuals, compared to the modified ABC classification based on latex immunoassay kits (traditional 3-parameter model). This study aimed to revalidate the diagnostic accuracy of the predictive formula in a new and different study population. We applied the predictive formula to the target population and compared the sensitivity and specificity with those of the traditional 3-parameter model. A total of 788 enrollees were analyzed: 703 were classified as truly uninfected, 45 as currently infected, and 40 as spontaneously eradicated according to the results of stool antigen testing and endoscopic findings. The sensitivities and specificities of the predictive formula and the traditional 3-parameter model were 89.5% and 87.1% versus 89.8% and 80.0%, respectively. The specificity of the predictive formula was superior in the 70 to 89 age range and H pylori antibody < 3 U/mL groups. The predictive formula had higher specificity than the traditional 3-parameter model. The results should contribute to efficient gastric cancer screening by predicting H pylori infection status.

Effects of Radio-Taiso on Health-Related Quality of Life in Older Adults with Frailty: A Randomized Controlled Trial

BACKGROUND

Radio-Taiso could be a sustainable public health strategy for maintaining quality of life (QoL) in older adults with frailty. This study aimed to investigate whether Radio-Taiso provided greater benefits for health-related quality of life (HR-QoL) and to identify the mechanisms underlying the effectiveness in this population.

METHODS

A 12-week randomized controlled trial enrolled 226 older Japanese adults with pre-frailty or frailty, assessed using the modified frailty phenotype. Participants were randomly allocated to the intervention (Radio-Taiso + nutrition program) or control (nutrition program) groups. The Radio-Taiso program comprised five 60-min group sessions and daily practice at the participants' homes. The primary outcome was the change in the mental domain of HR-QoL, assessed using the SF-36®. The secondary outcomes included six physical fitness items and exercise self-efficacy.

RESULTS

Overall, 104 and 105 participants in the intervention and control groups, respectively, were analyzed based on the intention-to-treat principle. The median (interquartile range) daily practice rate of Radio-Taiso was 94.1% (73.2-98.8%). Although general linear models adjusted for baseline values and allocation stratification factors showed that the intervention group obtained greater benefits (adjusted mean differences [95% confidence intervals]) in the up-and-go (0.3 [0.1, 0.6] s), 2-min step-in-place (-3.2 [-6.2, -0.2] steps) tests, and exercise self-efficacy scale (-1.4 [-2.6, -0.1] points) than the control group, there were no group differences in changes in the mental domain score of HR-QoL.

CONCLUSIONS

Radio-Taiso provided greater benefits for agility/dynamic balance, aerobic endurance, and exercise self-efficacy in older adults with frailty; however, these changes do not improve HR-QoL.

Multivariate generalized mixed-effects models for screening multiple adverse drug reactions in spontaneous reporting systems

Introduction: For assessing drug safety using spontaneous reporting system databases, quantitative measurements, such as proportional reporting rate (PRR) and reporting odds ratio (ROR), are widely employed to assess the relationship between a drug and a suspected adverse drug reaction (ADR). The databases contain numerous ADRs, and the quantitative measurements need to be calculated by performing the analysis multiple times for each ADR. We proposed a novel, simple, and easy-to-implement method to estimate the PRR and ROR of multiple ADRs in a single analysis using a generalized mixed-effects model for signal detection. Methods: The proposed method simultaneously analyzed the association between any drug and numerous ADRs, as well as estimated the PRR and ROR for a specific combination of drugs and suspected ADRs. Furthermore, the proposed method was applied to detect drug-drug interactions associated with the concurrent use of two or more drugs. Results and discussion: In our simulation studies, the false-positive rate and sensitivity of the proposed method were similar to those of the traditional PRR and ROR. The proposed method detected known ADRs when applied to the Food and Drug Administration Adverse Event Reporting System database. As an important advantage, the proposed method allowed the simultaneous evaluation of several ADRs using multiple drugs.

Tumor Response on Diagnostic Imaging after Proton Beam Therapy for Hepatocellular Carcinoma

BACKGROUND

Follow-up after treatment for hepatocellular carcinoma (HCC) can be mostly performed using dynamic CT or MRI, but there is no common evaluation method after radiation therapy. The purpose of this study is to examine factors involved in tumor reduction and local recurrence in patients with HCC treated with proton beam therapy (PBT) and to evaluate HCC shrinkage after PBT.

METHODS

Cases with only one irradiated lesion or those with two lesions irradiated simultaneously were included in this study. Pre- and post-treatment lesions were evaluated using Response Evaluation Criteria in Solid Tumors (RECIST) by measuring the largest diameter.

RESULTS

The 6-, 12-, and 24-month CR + PR rates after PBT were 33.1%, 57.5%, and 76.9%, respectively, and the reduction rates were 25.1% in the first 6 months, 23.3% at 6-12 months, and 14.5% at 13-24 months. Cases that reached CR/PR at 6 and 12 months had improved OS compared to non-CR/non-PR cases.

CONCLUSIONS

It is possible that a lesion that reached SD may subsequently transition to PR; it is reasonable to monitor progress with periodic imaging evaluations even after 1 year of treatment.

Three-dimensional analysis reveals a high incidence of lung adenocarcinoma in the upper region

PURPOSE

The lung is a unique organ with a ventilation-perfusion mismatch, which can cause inhomogeneous incidence rates of lung cancer depending on the location in the lung. We aimed to evaluate the incidence of lung adenocarcinoma in each lobe by analyzing the incidence per unit volume, to evaluate the incidence without being affected by differences in the size of each lobe or in the size of the lungs between individuals.

METHODS

The number of adenocarcinomas in each lobe was counted. Lung volumes were measured using a three-dimensional computer workstation. The tumor incidence per unit volume was analyzed based on the number of tumors in each lobe.

RESULTS

The number of tumors per unit volume was 0.467 in the right upper lobe (RUL), 0.182 in the right middle lobe, 0.209 in the right lower lobe, 0.306 in the left upper segment (LUS), 0.083 in the left lingular segment, and 0.169 in the left lower lobe. The tumor incidence rate of RUL + LUS was 2.269 times that of the other lobes, a value that was significantly higher when using the bootstrap method (p < 0.001).

CONCLUSIONS

The incidence of adenocarcinoma per unit volume in both upper lobes was higher than that in other lobes.

Efficacy of Low-Dose Isoproterenol Infusion for the Exclusion of a Left Atrial Appendage Thrombus in Patients With Dense Spontaneous Echo Contrast Caused by Atrial Fibrillation

BACKGROUND

In patients with atrial fibrillation (AF) and severe blood stasis in the left atrial appendage (LAA), dense spontaneous echo contrast (SEC) disturbs the distinct visualization of the LAA interior, thus making thrombus diagnosis inconclusive. We aimed to prospectively assess the efficacy and safety of a protocol for a low-dose isoproterenol (ISP) infusion to reduce SEC to exclude an LAA thrombus.Methods and Results: We enrolled 17 patients with AF and dense SEC (Grade 4 or sludge). ISP was infused with gradually increasing doses of 0.01, 0.02, and 0.03 μg/kg/min at 3-min intervals. After increasing the dose to 0.03 μg/kg/min for 3 min, or when the LAA interior was visible, the infusion was terminated. We reassessed the SEC grade, presence of an LAA thrombus, LAA function, and left ventricular ejection fraction (LVEF) within 1 min of ISP termination. Compared with baseline, ISP significantly increased LAA flow velocity, the LAA emptying fraction, LAA wall velocities, and LVEF (all P<0.01). ISP administration significantly reduced the SEC grade (median) from 4 to 1 (P<0.001). The SEC grade decreased to ≤2 in 15 (88%) patients, and the LAA thrombus was excluded. There were no adverse events.

CONCLUSIONS

Low-dose ISP infusion may be effective and safe to reduce SEC and exclude an LAA thrombus by improving LAA function and LVEF.

Efficacy and Safety of Bladder Preservation Therapy in Combination with Atezolizumab and Radiation Therapy (BPT-ART) for Invasive Bladder Cancer: Interim Analysis from a Multicenter, Open-label, Prospective Phase 2 Trial

PURPOSE

To evaluate the safety and pathologic complete response (pCR) rate of radiation therapy with atezolizumab as bladder-preserving therapy for invasive bladder cancer.

METHODS AND MATERIALS

A multicenter, phase 2 study was conducted with patients with clinically T2-3 or very-high-risk T1 bladder cancer who were poor candidates for or refused radical cystectomy. The interim analysis of pCR is reported as a key secondary endpoint ahead of the progression-free survival rate primary endpoint. Radiation therapy (41.4 Gy to the small pelvic field and 16.2 Gy to the whole bladder) was given in addition to 1200 mg intravenous atezolizumab every 3 weeks. After 24 treatment weeks, response was assessed after transurethral resection, and tumor programmed cell death ligand-1 (PD-L1) expression was assessed using tumor-infiltrating immune cell scores.

RESULTS

Forty-five patients enrolled from January 2019 to May 2021 were analyzed. The most common clinical T stage was T2 (73.3%), followed by T1 (15.6%) and T3 (11.1%). Most tumors were solitary (77.8%), small (<3 cm) (57.8%), and without concurrent carcinoma in situ (88.9%). Thirty-eight patients (84.4%) achieved pCR. High pCR rates were achieved in older patients (90.9%) and in patients with high PD-L1-expressing tumors (95.8% vs 71.4%). Adverse events (AEs) occurred in 93.3% of patients, with diarrhea being the most common (55.6%), followed by frequent urination (42.2%) and dysuria (20.0%). The frequency of grade 3 AEs was 13.3%, whereas no grade 4 AEs were observed.

CONCLUSIONS

Combination therapy with radiation therapy and atezolizumab provided high pCR rates and acceptable toxicity, indicating it could be a promising option for bladder preservation therapy.

[Relationship between low back pain and physical activity and sitting time among community-dwelling older adults: A cross-sectional study]

Objectives　Japan has a high prevalence of low back pain among older adults requiring long-term care, which results in increasing expenses; therefore, prevention measures are necessary. This study aimed to examine the relationship between low back pain and physical activity and sitting time according to sex and age (65-74 years [young-old adults]; ≥75 years [old-old adults]) who had not received long-term care certification.Methods　A self-administered survey was mailed to 7,080 adults >65 years of age residing in Tsuru City (Yamanashi Prefecture, Japan) from January to February 2018, and had not received long-term care certification. Demographic information, health status (body mass index and medical history), lifestyle (dietary habits, alcohol consumption, and smoking), presence of low back pain, physical activity, sitting time, and social participation were measured. Low back pain was evaluated by asking, "Did you experience pain in parts of the body other than the knees for the past month?" Those who answered, "experienced low back pain" were categorized as "with low back pain". The short form of the International Physical Activity Questionnaire was used to assess physical activity, which was categorized into three groups: <150, 150-299, and ≥300 min/week. Sitting time was divided into two groups: <480 and ≥480 min/day. Multiple logistic regression analysis was used to determine the association between low back pain and physical activity and sitting time, according to sex and age.Results　Of the 7,080 individuals surveyed, 4,877 responded (2,217 male, 2,660 female), corresponding to a response rate of 68.9%. The number of older adults with low back pain was 1,542 (31.6%) including 673 (30.4%) males and 869 (32.7%) females. The rate of low back pain in young-old adults was 29.8% and 33.6% in old-old adults. There was no significant relationship between lower back pain and physical activity among the young-old adults. In the old-old adults, there was a significant relationship in the male ≥300 min group (odds ratio [OR] 0.66 [95%CI 0.48-0.89]), and in both female 150-299 (OR 0.69 [95%CI 0.48-0.99]) and ≥300 (OR 0.59 [95%CI 0.44-0.80]) min/week groups.Conclusion　The complaint rate for low back pain was approximately 30%, regardless of sex or age. These results suggest that interventions to prevent low back pain are necessary. Moreover, physical activity, but not sitting time, was associated with low back pain in both males and females among the old-old adults.

Correlation of motor-auditory cross-modal and auditory unimodal N1 and mismatch responses of schizophrenic patients and normal subjects: an MEG study

Introduction

It has been suggested that the positive symptoms of schizophrenic patients (hallucinations, delusions, and passivity experience) are caused by dysfunction of their internal and external sensory prediction errors. This is often discussed as related to dysfunction of the forward model that executes self-monitoring. Several reports have suggested that dysfunction of the forward model in schizophrenia causes misattributions of self-generated thoughts and actions to external sources. There is some evidence that the forward model can be measured using the electroencephalography (EEG) and magnetoencephalography (MEG) components such as N1 (m) and mismatch negativity (MMN) (m). The objective in this MEG study is to investigate differences in the N1m and MMNm-like activity generated in motor-auditory cross-modal tasks in normal control (NC) subjects and schizophrenic (SC) patients, and compared that activity with N1m and MMNm in the auditory unimodal task.

Methods

The N1m and MMNm/MMNm-like activity were recorded in 15 SC patients and 12 matched NC subjects. The N1m-attenuation effects and peak amplitude of MMNm/MMNm-like activity of the NC and SC groups were compared. Additionally, correlations between MEG measures (N1m suppression rate, MMNm, and MMNm-like activity) and clinical variables (Positive and Negative Syndrome Scale (PANSS) scores and antipsychotic drug (APD) dosages) in SC patients were investigated.

Results

It was found that (i) there was no significant difference in N1m-attenuation for the NC and SC groups, and that (ii) MMNm in the unimodal task in the SC group was significantly smaller than that in the NC group. Further, the MMNm-like activity in the cross-modal task was smaller than that of the MMNm in the unimodal task in the NC group, but there was no significant difference in the SC group. The PANSS positive symptoms and general psychopathology score were moderately negatively correlated with the amplitudes of the MMNm-like activity, and the APD dosage was moderately negatively correlated with the N1m suppression rate. However, none of these correlations reached statistical significance.

Discussion

The findings suggest that schizophrenic patients perform altered predictive processes differently from healthy subjects in latencies reflecting MMNm, depending on whether they are under forward model generation or not. This may support the hypothesis that schizophrenic patients tend to misattribute their inner experience to external agents, thus leading to the characteristic schizophrenia symptoms.

Comparison of the Clinical Outcome of Carotid Artery Stenting Between Institutions With a Treatment Strategy Based on Risk Factors and Those With First-Line Treatment

PURPOSE

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are recommended based on certain risk factors. The volume of an institution's treatment experience may be associated with good clinical outcomes. There is a dilemma between the treatment strategy based on risk factors and the experience volume. Therefore, we investigated the clinical outcomes of CAS performed at institutions that selected the treatment strategy based on risk factors and those that performed CAS at the first-line treatment.

MATERIALS AND METHODS

Patients who underwent CAS at 5 institutions were included in this retrospective case-control study. We defined CEA/CAS institutions as those that selected the treatment option based on risk factors, and CAS-first institutions as those that performed CAS as the first-line treatment. We investigated cases of ischemic stroke, hemorrhagic stroke, myocardial infarction, and deaths within 30 days of the intervention between the CEA/CAS- and CAS-first institution groups. One-to-one propensity score matching was performed to compare rates of ischemic and hemorrhagic strokes within 30 days of the intervention.

RESULTS

A total of 239 and 302 patients underwent CAS at the CEA/CAS institutions and CAS-first institutions, respectively; ischemic stroke occurred in 12 (5.0%) and 7 patients (2.3%), respectively (p=0.09). No differences in major ischemic strokes (0.8% vs 1.3%; p=0.59), hemorrhagic strokes (0.4% vs 0.3%; p=0.87), or deaths (0.0% vs 0.7%; p=0.21) were observed. Myocardial infarction did not occur in either group. Propensity score analysis showed that ischemic stroke (odds ratio: 1.845, 95% confidence interval: 0.601-5.668, p=0.28) and hemorrhagic stroke (odds ratio: 1.000, 95% confidence interval: 0.0061-16.418, p=1.00) were not significantly associated with either institution group.

CONCLUSIONS

The CAS-specific treatment strategies for CAS can achieve the same level of outcomes as the treatment strategy based on risk factors. The CAS performed based on risk factors in CEA/CAS institutions and the treatment of more than 30 patients/year/institution in CAS-first institutions were associated with good clinical outcomes.

Safety of romiplostim administered immediately after cord-blood transplantation: a phase 1 trial

Graft failure and delayed hematopoietic recovery are the major limitations of cord-blood transplantation (CBT). Romiplostim, a thrombopoietin-receptor agonist, promotes megakaryopoiesis and multilineage hematopoiesis in aplastic anemia. The decreased number of hematopoietic stem cells in the early phase after CBT and aplastic anemia share certain characteristics. Therefore, we hypothesized that romiplostim administration immediately after CBT may promote multilineage hematopoietic recovery. We investigated the safety and preliminary efficacy of administering romiplostim a day after CBT. This phase 1 dose-escalation study included six adults with hematologic malignancies in remission. Romiplostim was administered subcutaneously within 7 days after single-unit CBT, initially at doses of 5 µg/kg or 10 µg/kg in three patients, then once a week for 14 weeks or until platelet recovery. The maximum dose was 20 µg/kg. The median number of romiplostim administrations was 6 (range, 3-15). Romiplostim-related adverse events included bone pain (3/6) and injection site reaction (1/6). Non-hematological grade ≥ 3 toxicities were observed in four patients; febrile neutropenia was the most common (4/6). All patients achieved neutrophil engraftment and the median time was 14 days (range, 12-32). Platelet counts ≥ 50 × 109 /L were recorded in all patients except for one who died on day 48; the median time was 34 days (range, 29-98). No relapse, thrombosis, or bone marrow fibrosis was observed during a median follow-up of 34 months. Romiplostim may be safely administered in the early phase of CBT. Further phase 2 trial is warranted for its efficacy evaluation. Trial registration number: UMIN000033799, August 18, 2018.

Retrospective Analysis of the Areas Responsible for Light Flash and Odor During Proton Beam Therapy and Photon Therapy

Background Abnormal sensations were frequently experienced by patients who received irradiation of the brain or head and neck region. We have previously suggested correlations with irradiation of the nasal cavity and retina. Purpose We performed a retrospective dose-volume histogram analysis focused on the brain and head and neck tumor to examine the relationship between these abnormal sensations and the details of irradiation. Methods Multivariate logistic regression models were applied for the presence or absence of light flash and odor. Gender, age, radiotherapy method (proton beam therapy vs. photon radiotherapy), dose of retina, optic nerve, chiasmatic gland, pituitary, nasal cavity, oral cavity, frontal lobe, parietal lobe, occipital lobe, temporal lobe, amygdala, and hippocampus were set as candidates of explanatory variables. Results Light flash and odor during radiotherapy have been suggested to be associated with younger age and retina and nasal cavity irradiation. Multivariate analyses including dose-volume histograms indicated that light flash was related to age, chiasmatic gland irradiation, and pituitary dose, and odor was related to age and nasal cavity irradiation. Conclusion Our results indicate that light flash during radiotherapy is caused by irradiation of the visual pathway and that odor is caused by irradiation of the nasal cavity or olfactory bulb.

Proton Beam Therapy versus Radiofrequency Ablation for Patients with Treatment-Naïve Single Hepatocellular Carcinoma: A Propensity Score Analysis

Introduction

Proton beam therapy (PBT) is known to be an effective locoregional treatment for hepatocellular carcinoma (HCC). However, few comparative studies in treatment-naïve cases have been reported. The aim of this study was to compare the survival outcomes of PBT with those of radiofrequency ablation (RFA) in patients with treatment-naïve solitary HCC.

Methods

Ninety-five consecutive patients with treatment-naïve HCC, a single nodule measuring ≤5 cm in diameter, and a Child-Pugh score of ≤8 who were treated with PBT at the University of Tsukuba Hospital between 2001 and 2013 were enrolled in the study. In addition, 836 patients with treatment-naïve HCC treated by RFA at the University of Tokyo Hospital during the same period were analyzed as controls. Recurrence-free survival (RFS) and overall survival (OS) were compared in 83 patient pairs after propensity score matching.

Results

The 1-year, 3-year, and 5-year RFS rates were 86.6%, 49.5%, and 35.5%, respectively, in the PBT group and 59.5%, 34.0%, and 20.9% in the RFA group (p = 0.058); the respective OS rates were 97.6%, 77.8%, and 57.1% in the PBT group and 95.1%, 81.7%, and 67.7% in the RFA group (p = 0.16). Regarding adverse effects, no grade 3 or higher adverse events were noted in the PBT; however, two grade 3 adverse events occurred within 30 days of RFA in the RFA group: one hemoperitoneum and one hemothorax.

Discussion

After propensity score matching, PBT showed no significant difference in RFS and OS compared to RFA. PBT can be an alternative for patients with solitary treatment-naïve HCC.

Development and validation of a prediction model for rehospitalization among people with schizophrenia discharged from acute inpatient care

Objective

Relapses and rehospitalization prevent the recovery of individuals with schizophrenia or related psychoses. We aimed to build a model to predict the risk of rehospitalization among people with schizophrenia or related psychoses, including those with multiple episodes.

Methods

This retrospective cohort study included individuals aged 18 years or older, with schizophrenia or related psychoses, and discharged between January 2014 and December 2018 from one of three Japanese psychiatric hospital acute inpatient care ward. We collected nine predictors at the time of recruitment, followed up with the participants for 12 months, and observed whether psychotic relapse had occurred. Next, we applied the Cox regression model and used an elastic net to avoid overfitting. Then, we examined discrimination using bootstrapping, Steyerberg's method, and "leave-one-hospital-out" cross-validation. We also constructed a bias-corrected calibration plot.

Results

Data from a total of 805 individuals were analyzed. The significant predictors were the number of previous hospitalizations (HR 1.42, 95% CI 1.22-1.64) and the current length of stay in days (HR 1.31, 95% CI 1.04-1.64). In model development for relapse, Harrell's c-index was 0.59 (95% CI 0.55-0.63). The internal and internal-external validation for rehospitalization showed Harrell's c-index to be 0.64 (95% CI 0.59-0.69) and 0.66 (95% CI 0.57-0.74), respectively. The calibration plot was found to be adequate.

Conclusion

The model showed moderate discrimination of readmission after discharge. Carefully defining a research question by seeking needs among the population with chronic schizophrenia with multiple episodes may be key to building a useful model.

Comparison of postoperative analgesic effects of thoracic epidural analgesia and rectus sheath block in laparoscopic abdominal surgery: A randomized controlled noninferiority trial

INTRODUCTION

In the Enhanced Recovery After Surgery program, abdominal wall blocks are strongly recommended as postoperative multimodal analgesia for laparoscopic abdominal surgery. The purpose of this study was to compare the efficacy of single-shot rectus sheath block (RSB) with that of thoracic epidural analgesia (TEA) as a method of multimodal analgesia in patients receiving conventional laparoscopic abdominal surgery.

METHODS

A noninferiority comparison was performed. Patients scheduled for laparoscopic gastric or colorectal surgery were enrolled in this study. Patients were divided randomly into two groups: TEA and RSB. The primary endpoint was the numerical rating scale (NRS) score upon coughing as of 24 hours after surgery.

RESULTS

In total, 80 patients were randomly assigned to receive TEA (n = 42) or RSB (n = 38). Three patients were excluded from the TEA group after randomization. The NRS score on coughing as of 24 hours after surgery was significantly lower in the TEA group than in the RSB group (least square mean: 3.59 vs 6.39; 95% confidence interval for the difference: 1.87 to 3.74, P < .001). The NRS scores upon coughing and at rest were significantly lower in the TEA group than in the RSB group as of 4, 24 and 48 hours after surgery. Patient satisfaction with postoperative analgesia was significantly higher in the TEA group. Postoperative adverse events were not significantly different between groups.

CONCLUSION

This is the first report of comparing RSB with TEA in laparoscopic surgery. TEA may be recommended as a multimodal analgesia protocol for laparoscopic gastric and colorectal surgery.

Antigen-specific T cell balance reveals Why patients with atopic dermatitis fail to achieve immune tolerance

The number of regulatory T cells (Tregs) and how they behave in the pathogenesis of atopic dermatitis (AD) are still controversial. We identified and quantified Tregs, mite-specific Tregs, and mite-specific effector T cells (Teffs) in patients with AD and healthy controls (HCs). We collected peripheral blood and analyzed the cells using flow cytometry after stimulation with mite antigens. Mite-specific Tregs and mite-specific Teffs were recognized by the expression of CD137 and CD154, respectively. Patients with AD had more Tregs than HCs; however, when focusing on a single antigen, the ratio of mite-specific Tregs/Teffs was lower in patients with AD than in HCs. Furthermore, the mite-specific Teffs in patients with AD were more likely to produce proinflammatory cytokines interleukin (IL)-4 and IL-13. This Teff-dominant imbalance is thought to be the cause of development of atopic status in patients with AD without immune tolerance.

A genome-wide association study for allergen component sensitizations identifies allergen component-specific and allergen protein group-specific associations

Background

Allergic diseases are some of the most common diseases worldwide. Genome-wide association studies (GWASs) have been conducted to elucidate the genetic factors of allergic diseases. However, no GWASs for allergen component sensitization have been performed.

Objective

We sought to detect genetic variants associated with differences in immune responsiveness against allergen components.

Methods

The participants of the present study were recruited from the Tokyo Children's Health, Illness, and Development study, and allergen component-specific IgE level at age 9 years was measured by means of allergen microarray immunoassays. We performed GWASs for allergen component sensitization against each allergen (single allergen component sensitization, number of allergen components analyzed, n = 31), as well as against allergen protein families (allergen protein group sensitization, number of protein groups analyzed, n = 16).

Results

We performed GWAS on 564 participants of the Tokyo Children's Health, Illness, and Development study and found associations between Amb a 1 sensitization and the immunoglobulin heavy-chain variable gene on chromosome 14 and between Phl p 1 sensitization and the HLA class II region on chromosome 6 (P < 5.0 × 10-8). A GWAS-significant association was also observed between the HLA class II region and profilin sensitization (P < 5.0 × 10-8).

Conclusions

Our data provide the first demonstration of genetic risk for allergen component sensitization and show that this genetic risk is related to immune response genes including immunoglobulin heavy-chain variable gene and HLA.

Occupational Fall Risk Assessment Tool for older workers

BACKGROUND

No easy-to-use fall risk assessment tools have been devised to assess occupational fall risk in older workers.

AIMS

To develop an Occupational Fall Risk Assessment Tool (OFRAT) and report its predictive validity and reliability in older workers.

METHODS

The baseline fall risk assessment was completed by 1113 participants aged ≥60 years who worked ≥4 days/month in Saitama, Japan. Participants were followed up for falls during occupational activities for 1 year, and 30 participants were assessed twice for test-retest reliability. The following assessment measures were summed to form the OFRAT risk score: older age, male sex, history of falls, physical work participation, diabetes, use of medications increasing fall risk, reduced vision, poor hearing, executive dysfunction and slow stepping. The scores were then classified into four grades (0-2 points: very low, 3 points: low, 4 points: moderate and ≥5 points: high).

RESULTS

During follow-up, 112 participants fell 214 times during work. The negative binomial regression model showed that participants with higher grades had a higher incidence rate ratio [95% confidence interval] for falls than those with very low grades (low: 1.64 [1.08-2.47], moderate: 4.23 [2.82-6.34] and high: 6.12 [3.83-9.76]). The intraclass correlation coefficient for risk score was 0.86 [0.72-0.93], and the weighted kappa coefficient for grade assessment was 0.74 [0.52-0.95].

CONCLUSIONS

The OFRAT is a valid and reliable tool for estimating the occupational fall risk in older workers. It may assist occupational physicians implement strategies to prevent falls in this group.

Proton beam therapy for muscle-invasive bladder cancer: A systematic review and analysis with Proton-Net, a multicenter prospective patient registry database

To assess the safety and efficacy of proton beam therapy (PBT) for muscle-invasive bladder cancer (MIBC), we examined the outcomes of 36 patients with MIBC (cT2-4aN0M0) who were enrolled in the Proton-Net prospective registry study and received PBT with concurrent chemotherapy from May 2016 to June 2018. PBT was also compared with X-ray chemoradiotherapy in a systematic review (X-ray (photon) radiotherapy). The radiotherapy consisted of 40-41.4 Gy (relative biological effectiveness (RBE) delivered in 20-23 fractions to the pelvic cavity or the entire bladder using X-rays or proton beams, followed by a boost of 19.8-36.3 Gy (RBE) delivered in 10-14 fractions to all tumor sites in the bladder. Concurrently, radiotherapy was given with intra-arterial or systemic chemotherapy of cisplatin alone or in combination with methotrexate or gemcitabine. Overall survival (OS), progression-free survival (PFS) and local control (LC) rates were 90.8, 71.4 and 84.6%, respectively, after 3 years. Only one case (2.8%) experienced a treatment-related late adverse event of Grade 3 urinary tract obstruction, and no severe gastrointestinal adverse events occurred. According to the findings of the systematic review, the 3-year outcomes of XRT were 57-84.8% in OS, 39-78% in PFS and 51-68% in LC. The weighted mean frequency of adverse events of Grade 3 or higher in the gastrointestinal and genitourinary systems was 6.2 and 2.2%, respectively. More data from long-term follow-up will provide us with the appropriate use of PBT and validate its efficacy for MIBC.

A comparison of bias-adjusted generalized estimating equations for sparse binary data in small-sample longitudinal studies

Using a generalized estimating equation (GEE) can lead to a bias in regression coefficients for a small sample or sparse data. The bias-corrected GEE (BCGEE) and penalized GEE (PGEE) were proposed to resolve the small-sample bias. Moreover, the standard sandwich covariance estimator leads to a bias of standard error for small samples; several modified covariance estimators have been proposed to address this issue. We review the modified GEEs and modified covariance estimators, and evaluate their performance in sparse binary data from small-sample longitudinal studies. The simulation results showed that GEE and BCGEE often failed to achieve convergence, whereas the convergence proportion for PGEE was quite high. The bias for the regression coefficients was generally in the ascending order of PGEE < $$ < $$ BCGEE < $$ < $$ GEE. However, PGEE and BCGEE did not sufficiently remove the bias involving 20-30 subjects with unequal exposure levels with a 5% response rate. The coverage probability (CP) of the confidence interval for BCGEE was relatively poor compared with GEE and PGEE. The CP with the sandwich covariance estimator deteriorated regardless of the GEE methods under the small sample size and low response rate, whereas the CP with the modified covariance estimators-such as Morel's method-was relatively acceptable. PGEE will be the reasonable way for analyzing sparse binary data in small-sample studies. Instead of using the standard sandwich covariance estimator, one should always apply the modified covariance estimators for analyzing these data.

A Japanese registry study and systematic review of particle therapy for renal cell carcinoma

The feasibility and efficacy of particle beam therapy (PBT) using protons or carbon ions were compared with those of photon-based stereotactic body radiotherapy (SBRT) for primary renal cell carcinoma (RCC) via a systematic review and nationwide registry for PBT (Japanese Society for Radiation Oncology [JASTRO] particle therapy committee). Between July 2016 and May 2019, 20 patients with non-metastatic RCC who were treated at six Japanese institutes (using protons at three, using carbon ions at the other three) were registered in the nationwide database and followed up prospectively. The 20 patients comprised 15 men and had a median age of 67 (range: 57-88) years. The total radiation dose was 66-79.6 Gy (relative biological effectiveness [RBE]). Over a median follow up of 31 months, the 3-year rates of overall survival (OS) and local control (LC) were 100% and 94.4%, respectively. No grade ≥ 3 toxicities were observed. Based on a random effects model, a meta-analysis including the present results revealed 3-year OS rates after SBRT and PBT of 75.3% (95% CI: 57.3-86.6) and 94.3% (95% CI: 86.8-97.6), respectively (P = 0.005), but the difference in LC rates between the two methods was not observed (P = 0.63). PBT is expected to have similar if not better treatment results compared with SBRT for primary renal cancer. In particular, PBT was shown to be effective even for large RCC and could provide a therapeutic option when SBRT is not indicated.

Ventilator-induced diaphragmatic dysfunction in extremely preterm infants: a pilot ultrasound study

To investigate the development of diaphragmatic dysfunction in ventilated extremely preterm infants (EPI) using diaphragm ultrasound (DU). EPI of less than 28 weeks' gestational age who required mechanical ventilation within six hours of birth were included in this prospective, observational study. DU was performed once a day until four days of life. End-inspiratory and end-expiratory thicknesses of the diaphragm were measured, and the diaphragm thickening fraction was calculated. A total of 20 EPI were enrolled. After intubation, there was a progressive reduction in end-inspiratory thickness of the diaphragm from baseline to day 1 (P < 0.001), but not from day 1 to day 2 (P = 0.092), day 2 to day 3 (P = 1.0), or day 3 to day 4 (P = 1.0). There was also a significant reduction in the diaphragm thickening fraction from baseline to day 1 (P < 0.001), but not from day 1 to day 2 (P = 1.0), day 2 to day 3 (P = 1.0), or day 3 to day 4 (P = 1.0).    Conclusions: This study provides the first evidence of diaphragmatic dysfunction in ventilated EPI. We demonstrated a rapid progression of ventilator-induced diaphragmatic dysfunction, with a significant reduction in diaphragm thickness and thickening fraction within 24 h of ventilation. What is Known: • Over-assistance of the ventilator suppresses respiratory effort and induces diaphragm unloading, resulting in diaphragm atrophy or dysfunction. • Diaphragmatic dysfunction contributes to prolonged ventilator dependence and poor clinical outcomes. What is New: • Most extremely preterm infants develop diaphragmatic dysfunction after intubation within 24 hours. • Diaphragm thickness and contraction ability measured by ultrasound would be important indicators of worsening breathing or respiratory outcomes.

Multifocal Contact Lenses and 0.01% Atropine Eye Drops for Myopia Control Study: Research Protocol for a 1-Year, Randomized, Four-Arm, Clinical Trial in Schoolchildren

OBJECTIVES

Previous studies have shown that combined use of orthokeratology and 0.01% atropine (AT) eye drops can strongly prevent axial elongation in myopic children. However, the efficacy of combined use with multifocal contact lens (MFCL) and 0.01% AT remains unclear. The aim of this trial is to clarify the efficacy of MFCL+0.01% AT combination therapy for myopia control and safety.

METHODS

This prospective study is a randomized, double-masked, placebo-controlled trial with four arms. A total of 240 children aged 6 to 12 years with myopia is recruited and randomly assigned to one of the four groups in a ratio of 1:1:1:1 as follows: group 1: MFCL+AT combination therapy, group 2: MFCL monotherapy, group 3: AT monotherapy, and group 4: placebo. The participants will continue the assigned treatment for 1 year. The primary and secondary outcomes are the comparisons of axial elongation and myopia progression in the four groups during the 1-year study period.

DISCUSSION

The present trial would determine whether the MFCL+AT combination therapy is more effective in slowing axial elongation and myopia progression in schoolchildren as compared with each monotherapy or placebo, and it also confirm acceptable safety of the combination therapy.

Effects of lymphopenia on survival in proton therapy with chemotherapy for non-small cell lung cancer

Lymphocytes play an important role in the cancer immune system. In the present study, we aimed to evaluate the associations of lymphopenia during proton beam therapy (PBT) and concurrent chemotherapy with clinical outcomes and to determine whether lung or bone is more influential on lymphopenia during PBT. Data from 41 patients with stage III non-small cell lung cancer (NSCLC) who received PBT of 74 GyE with concurrent chemotherapy between 2007 and 2017 were reviewed retrospectively. The correlation between dosimetry parameters obtained from dose-volume histograms of the bone and lung and lymphopenia during PBT were analyzed. Minimum absolute lymphocyte count (ALCmin) and maximum neutrophil/lymphocyte ratio (NLRmax) were used as indicators of lymphopenia. Bone V5-20 and lung V5-50 were significantly correlated with the ALCmin and NLRmax during PBT. Multivariable analysis showed that the NLRmax, but not the ALCmin, was associated with overall survival (OS), progression-free survival (PFS) and distant metastasis-free survival (DMFS). The 3-year rates of OS, PFS and DMFS of patients with a low (≤ 6.3) versus high (> 6.3) NLRmax were 73.9% vs 44.4% (P = 0.042), 26.1% vs 5.6% (P = 0.022) and 39.1% vs 5.6% (P < 0.001), respectively. Lung V20 was significantly associated with DMFS on multivariable analyses (hazard ratio: 1.094, P = 0.008), whereas bone V5 had no impact on survival outcomes. We concluded that the NLRmax was a better prognostic indicator than the ALCmin, and the lung dose had more influence than the bone dose on the main survival outcomes in stage III NSCLC patients treated with PBT combined with concurrent chemotherapy.

Randomized crossover trial of 2-week Garment electrocardiogram with dry textile electrode to reveal instances of post-ablation recurrence of atrial fibrillation underdiagnosed during 24-hour Holter monitoring

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia and often recurs despite catheter ablation. The recurrence of AF is often underdiagnosed by standard 24-hour electrocardiogram (ECG) because of its transient and silent nature. A garment-style ECG with a highly conductive textile electrode made of poly(3,4-ethylenedioxythiophene) poly(styrenesulfonate)(PEDOTPSS) and nanofiber (Garment ECG) has been developed that can provide longer-term continuous monitoring. This study investigated whether 2-week Garment ECG can reveal instances of AF recurrence in patients who are diagnosed as remaining in sinus rhythm by 24-hour Holter ECG.

METHODS

The open-label randomized crossover study enrolled 67 patients (63.1±10.6 years old, 53 men) who had undergone initial AF ablation. Three months after ablation, patients were randomly assigned to group 1 (n = 35), 2-week Garment ECG followed by 24-hour Holter ECG, or group 2 (n = 32), 24-hour Holter ECG followed by 2-week Garment ECG. The detection of AF recurrence was compared between the two devices.

RESULTS

The Garment ECG showed AF recurrence in 12 patients (18%) compared to 4 patients for the Holter ECG (6%, p = 0.008). The ECG acquisition rate was higher for Holter ECG than for Garment ECG (100.0% [interquartile range 100.0-100.0%] versus 82.4% [71.1-91.0%], p<0.001), but the Garment ECG provided longer total analysis time (11.0 days [9.0-12.2 days] for Garment; 1.0 day [1.0-1.0 day] for Holter, p<0.001).

CONCLUSIONS

Despite the lower ECG acquisition rate, the 2-week Garment ECG revealed instances of AF recurrence after ablation in patients who were underdiagnosed by 24-hour Holter ECG.

TRIAL REGISTRATION

Clinical Trial Registration: URL: https://jrct.niph.go.jp/en-latest-detail/jRCTs032180018 Unique Identifier: jRCTs032180018.

A Retrospective Study of Renal Growth Changes after Proton Beam Therapy for Pediatric Malignant Tumor

The purpose of this study was to analyze renal late effects after proton beam therapy (PBT) for pediatric malignant tumors. A retrospective study was performed in 11 patients under 8 years of age who received PBT between 2013 and 2018. The kidney was exposed in irradiation of the primary lesion in all cases. Kidney volume and contour were measured on CT or MRI. Dose volume was calculated with a treatment-planning system. The median follow-up was 24 months (range, 11-57 months). In irradiated kidneys and control contralateral kidneys, the median volume changes were -5.63 (-20.54 to 7.20) and 5.23 (-2.01 to 16.73) mL/year; and the median % volume changes at 1 year were -8.55% (-47.52 to 15.51%) and 9.53% (-2.13 to 38.78%), respectively. The median relative volume change for irradiated kidneys at 1 year was -16.42% (-52.21 to -4.53%) relative to control kidneys. Kidneys irradiated with doses of 10, 20, 30, 40, and 50 GyE had volume reductions of 0.16%, 0.90%, 1.24%, 2.34%, and 8.2% per irradiated volume, respectively. The larger the irradiated volume, the greater the kidney volume was lost. Volume reduction was much greater in patients aged 4-7 years than in those aged 2-3 years. The results suggest that kidneys exposed to PBT in treatment of pediatric malignant tumor show continuous atrophy in follow-up. The degree of atrophy is increased with a higher radiation dose, greater irradiated volume, and older age. However, with growth and maturation, the contralateral kidney becomes progressively larger and is less affected by radiation.

Predictors of psychological distress and sleep deprivation in caregivers of stroke survivors

BACKGROUND

Caregivers for stroke survivors (CSS) suffer from long hours of care, limited support, and financial difficulties, which often affect their mental health.

OBJECTIVES

This study sought to determine the factors affecting psychological distress and sleep duration among CSS.

METHODS

We analyzed cross-sectional data from the 2013 Comprehensive Survey of the Living Conditions for Stroke Survivors and CSS. Linked data from 841 pairs of stroke survivors and CSS were extracted. Kessler's Psychological Distress scale (K6) was used to evaluate psychological distress. CSS who slept less than 5 hours per day were classified as having short sleep duration. Factors predictive of psychological distress and short sleep duration were evaluated using multivariable logistic regression analysis with the forward selection method.

RESULTS

The mean (SD) age of the CSS was 65.4 (12.5) years. A total of 5.6% of these caregivers presented with serious psychological distress, and 12.0% were sleep deprived. Serious psychological distress was associated with not having someone to consult with, having subjective symptoms within a few days, and having short sleep duration, while having their own houses reduced the risk of serious psychological distress. Furthermore, short sleep duration was associated with stroke survivors in long-term care levels 4 or 5, not having someone to consult with, participation in sponge baths as part of nursing care activities, and having serious psychological distress.

CONCLUSIONS

This nationwide survey identified several risk factors for psychological stress and sleep deprivation among CSS and suggests the need for multidimensional approaches to reduce their distress.

Association of social participation (including inconsistent participation) with the progression of frailty among older adults: Community-based cohort study in Japan

AIM

This study examined the relationship between continuity of social participation and progression of frailty among community-dwelling older adults, by baseline frailty level.

METHODS

This study was part of a 3-year community-based cohort study among adults aged ≥65 years, living independently in a rural municipality in Japan. Mail surveys were carried out in 2016, 2018 and 2019. This study involved 2799 participants who responded to the question about social participation in every survey. Frailty was evaluated by Kihon Checklist total scores. Social participation was categorized into consistent non-participation, interrupted recent non-participation, interrupted recent participation and consistent participation. We assessed the relationship between social participation and change in frailty scores using general linear regression analysis, stratifying the participants into groups by their frailty level at baseline.

RESULTS

There was a smaller frailty score increase in the robust (β -0.61, 95% CI -0.99 to -0.22) and prefrail groups (β -0.73, 95% CI -1.18 to -0.27) for consistent participation than consistent non-participation. Interrupted recent participation showed significant suppression in the prefrail group (β -0.96, 95% CI -1.60 to -0.32). Social participation had no clear effect on progression in the frail group.

CONCLUSIONS

Consistent social participation might reduce the progression of frailty in robust and prefrail people. Inconsistent participation might also help to reduce progression in prefrail older adults. It is important for prefrail older adults to return to their social activities and continue to engage as long as possible, even if their participation was intermittent in the past. Geriatr Gerontol Int 2023; 23: 25-31.

Adherence, safety and potential effectiveness of a home-based Radio-Taiso exercise program in older adults with frailty: A pilot randomized controlled trial

AIM

Radio-Taiso, a traditional exercise program in Japan, may serve as a coping strategy for older adults with frailty during the COVID-19 pandemic. This phase II trial tested program adherence and safety and explored the potential effectiveness of a home-based Radio-Taiso.

METHODS

This assessor-blind parallel randomized controlled trial included community-dwelling Jolder Japanese adults with frailty and pre-frailty. Fifty-eight eligible participants were randomly allocated to intervention and control groups. Intervention participants performed 3-5-min sessions of Radio-Taiso one to four times per day for 12 weeks. Feasibility criteria were set at practice and retention rates of ≥75%. Safety was monitored by assessing all adverse events reported by participants during the intervention period, irrespective of causality. Potential effectiveness was exploratorily assessed using items that allow clinical interpretation of changes: mobility and health-related quality of life (HR-QoL), assessed using the modified short physical performance battery (SPPB) and the SF-36, respectively.

RESULTS

Both practice (83%) and retention rates (100%) met the predetermined feasibility criteria. Eleven adverse events were reported but were supposedly unrelated to the intervention. In the intention-to-treat analysis, there was no clinically significant difference in the change in SPPB score between groups (-0.4 points, 95% confidence interval [CI], -1.2, 0.3); however, the intervention group scored higher in the mental component of HR-QoL than did the control group (3.4 points, 95% CI: -1.1, 7.8).

CONCLUSIONS

The preliminary data indicate that a phase III trial is feasible, focusing on the mental aspect of HR-QoL as the primary outcome. Geriatr Gerontol Int 2023; 23: 32-37.

Levetiracetam versus fosphenytoin as a second-line treatment after diazepam for adult convulsive status epilepticus: a multicentre non-inferiority randomised control trial

OBJECTIVE

Status epilepticus (SE) is an emergency condition for which rapid and secured cessation is crucial. Although fosphenytoin (FPHT) is recommended as a second-line treatment, levetiracetam (LEV) reportedly has similar efficacy, but higher safety. Therefore, we herein compared LEV with FPHT in adult SE.

METHODS

We initiated a multicentre randomised control trial in emergency departments with adult patients with convulsive SE. Diazepam was initially administered, followed intravenously by FPHT at 22.5 mg/kg or LEV at 1000-3000 mg. The primary outcome was assigned as the seizure cessation rate within 30 min of the administration of the study drug.

RESULTS

A total of 176 adult patients with SE were enrolled (82 FPHT and 94 LEV), and 3 were excluded from the full analysis set. Seizure cessation rates within 30 min were 83.8% (67/80) in the FPHT group and 89.2% (83/93) in the LEV group. The difference in these rates was 5.5% (95% CI -4.7 to 15.7, p=0.29). The non-inferiority of LEV to FPHT was confirmed with p<0.001 by the Farrington-Manning test. No significant differences were observed in the seizure recurrence rate or intubation rate within 24 hours. Serious adverse events developed in three patients in the FPHT group and none in the LEV group (p=0.061).

CONCLUSION

The efficacy of LEV was similar to that of FPHT for adult SE following the administration of diazepam. LEV may be recommended as a second-line treatment for SE along with phenytoin/FPHT.

TRIAL REGISTRATION NUMBER

jRCTs031190160.

TMPRSS2 gene polymorphism common in East Asians confers decreased COVID-19 susceptibility

COVID-19 has a wide range of clinical presentations, and the susceptibility to SARS-CoV-2 infection and the mortality rate also vary by region and ethnicity. Here, we found that rs12329760 in the TMPRSS2 gene, a missense variant common in East Asian populations, contributes to protection against SARS-CoV-2 infection. TMPRSS2 is a protease responsible for SARS-CoV-2 entry and syncytium formation. rs12329760 (c.478G>A, p. V160M) was associated with a reduced risk of moderate symptoms. The enzymatic activity of Met160-TMPRSS2 was lower than that of Val160-TMPRSS2, and thus the viral entry and the syncytium formation of SARS-CoV-2 were impaired. Collectively, these results indicate that the genetic variation in TMPRSS2, which is common in East Asians, is one of the molecular determinants of COVID-19 susceptibility.

Psychotic relapse in people with schizophrenia within 12 months of discharge from acute inpatient care: protocol for development and validation of a prediction model based on a retrospective cohort study in three psychiatric hospitals in Japan

BACKGROUND

Schizophrenia is a severe mental illness characterized by recurrent psychoses that typically waxes and wanes through its prodromal, acute, and chronic phases. A large amount of research on individual prognostic factors for relapse in people with schizophrenia has been published, and a few logistic models exist to predict psychotic prognosis for people in the prodromal phase or after the first episode of psychosis. However, research on prediction models for people with schizophrenia, including those in the chronic phase and after multiple recurrences, is scarce. We aim to develop and validate a prediction model for this population.

METHODS

This is a retrospective cohort study to be undertaken in Japan. We will include participants aged 18 years or above, diagnosed with schizophrenia or related disorders, and discharged between January 2014 and December 2018 from one of the acute inpatient care wards of three geographically distinct psychiatric hospitals. We will collect pre-specified nine predictors at the time of recruitment, follow up the participants for 12 months after discharge, and observe whether our primary outcome of a relapse occurs. Relapse will be considered to have occurred in one of the following circumstances: (1) hospitalization; (2) psychiatrist's judgment that the person needs hospitalization; (3) increasing doses of antipsychotics; or (4) suicidal or homicidal ideation or behavior resulting from such ideation. We will develop a Cox regression model and avoid overfitting by penalizing coefficients using the elastic net. The model will be validated both internally and externally by bootstrapping and "leave-one-hospital-out" cross-validation, respectively. We will evaluate the model's performance in terms of discrimination and calibration. Decision curve analysis will be presented to aid decision-making. We will present a web application to visualize the model for ease of use in daily practice.

DISCUSSION

This will be the first prediction modeling study of relapse after discharge among people with both first and multiple episodes of schizophrenia using routinely collected data.

TRIAL REGISTRATION

This study was registered in the UMIN-CTR (UMIN000043345) on February 20, 2021.

Effectiveness of an online support program to help female cancer patients manage their health and illness: Protocol for a randomized controlled trial

Background

The aim of the trial is to evaluate the effectiveness of interventions provided by online support program apps, adopting health-related quality of life (HR-QOL) scores as indicators.

Methods

The design is as an open, randomized, parallel-group trial with longitudinal data collection. The subjects will be female cancer patients receiving treatment in a Japanese National Cancer Hospital. Patients assigned to the experimental group will use three apps: an app for them to monitor their own health (monitoring app), an app to assess their understanding of their diagnosis and treatment and their readiness to receive treatment (confirmation app), and an app to address mental health issues (writing app); patients assigned to the control group will use only the monitoring app. At baseline (before patients undergo cancer treatment) and three other times during the study, evaluation indicators will be obtained from three different standardized HR-QOL scales that are incorporated in the monitoring app. The study hypothesis is that at 6 months after patients’ baseline health monitoring, patients in the experimental group will have improved HR-QOL as compared with patients in the control group.

Conclusion

This study is based on self-regulation theory, so it is important that the online support program works in an efficient way with respect to patients finding and setting their own health-related goals and adapting their behaviors to achieve those goals. Verifying the effectiveness of the combination of the three apps will show that it is a scientifically valid approach to maintaining or improving the HR-QOL of cancer patients.

Effects of Image Processing Using Honeycomb-Removal and Image-Sharpening Algorithms on Visibility of 27-Gauge Endoscopic Vitrectomy

Endoscopic vitrectomy with small gauge probes has clinical potentials, but intraocular visibility is inherently limited by low resolution and dim illumination due to the reduced number of optic fibers. We investigated whether honeycomb-removal and image-sharpening algorithms, which enable real-time processing of live images with a delay of 0.004 s, can improve the visibility of 27-gauge endoscopic vitrectomy. A total of 33 images during endoscopic vitrectomy were prepared, consisting of 11 original images, 11 images after the honeycomb-removal process, and 11 images after both honeycomb-removal and image-sharpening procedures. They were randomly presented to 18 vitreous surgeons, who rated each image on a 10-point scale. The honeycomb-removal algorithm almost completely suppressed honeycomb artifacts without degrading the background image quality. The implementation of image-sharpening algorithms further improved endoscopic visibility by optimizing contrast and augmenting image clarity. The visibility score was significantly improved from 4.27 ± 1.78 for the original images to 4.72 ± 2.00 for the images after the honeycomb-removal process (p < 0.001, linear mixed effects model), and to 5.40 ± 2.10 for the images after both the honeycomb-removal and image-sharpening procedures (p < 0.001). When the visibility scores were analyzed separately for 10 surgeons who were familiar with endoscopic vitrectomy and 8 surgeons who were not, similar results were obtained. Image processing with honeycomb-removal and image-sharpening algorithms significantly improved the visibility of 27-gauge endoscopic vitrectomy.

Effects of intergenerational contact on social capital in community-dwelling adults aged 25–84 years: a non-randomized community-based intervention

Background

Accumulating social capital in urban areas is essential to improve community health. Previous studies suggested that intergenerational contact may be effective for enhancing social capital. However, no study has examined the effect of intergenerational contact on social capital through a population-based evaluation. This study aimed to investigate the effects of a community-based intervention to increase the frequency of intergenerational contact on social capital among adults aged 25–84 years.

Methods

This study used a non-randomized controlled trial design to conduct a community-based intervention (from March 2016 to March 2019). The study area was Tama ward, Kawasaki city, Kanagawa, Japan. The area comprises five districts; one district was assigned as the intervention group and the other four districts as the control group. We provided the intervention to residents in the intervention group. The intervention comprised three phases: Phase 1 was the preparation term (organizing the project committee); Phase 2 was the implementation term (trained volunteer staff members, conducted the intergenerational greeting campaign, and held intergenerational contact events); and Phase 3 was the transition term (surrendering the lead role of the project to the city hall field workers). In the control group, field workers provided public health services as usual. We conducted mail surveys in September 2016 and November 2018 to assess the effects of the intervention on social capital during Phase 2. Eligible participants were randomly selected from community-dwelling adults aged 25–84 years according to age (10,620 control group individuals and 4479 intervention group individuals). We evaluated social trust, norm of reciprocity, and social support as outcome variables.

Results

In total, 2518 participants completed both surveys and were analyzed (control group: 1727; intervention group: 791). We found that social trust (coefficient = 0.065; 95% confidence interval [CI]: 0.006, 0.125) and norm of reciprocity (coefficient = 0.084; 95% CI: 0.020, 0.149) positively changed in the intervention group compared with the control group.

Conclusions

This community-based intervention may contribute to sustaining and improving social capital among community-dwelling adults.

Trial registration: UMIN000046769 (UMIN-CTR); first registered on January 28, 2022 (retrospectively registered).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14205-6.

Effects of a home-based Radio-Taiso exercise programme on health-related quality of life in older adults with frailty: protocol for an assessor-blind randomised controlled trial

INTRODUCTION

Few clinical trials have examined the effects of home-based exercise programmes on health-related quality of life (HR-QoL) in older adults with frailty. Radio-Taiso is the most famous exercise programme in Japan. A home-based Radio-Taiso exercise programme may serve as an accessible, scalable and sustainable care intervention for older adults with frailty. The primary aim of this trial is to test whether older adults with frailty who are prescribed our home-based Radio-Taiso exercise programme will receive greater benefits for HR-QoL compared with those who are not prescribed the exercise programme. Potential mechanisms underlying the effectiveness of the programme and the effects of the programme on daily lifestyle will also be investigated.

METHODS AND ANALYSIS

This assessor-blind randomised controlled trial will be conducted at the Tokyo Metropolitan Institute of Gerontology (TMIG) in Itabashi-ku, Tokyo, Japan. From April to May 2022, 226 older adults with prefrailty or frailty according to the revised Japanese version of the Cardiovascular Health Study criteria will be included from a large database. After a baseline assessment in June 2022, participants will be randomly assigned to the intervention (home-based Radio-Taiso exercise and nutrition programme) or control (nutrition programme) groups at a 1:1 ratio. After intervention completion, a follow-up assessment will be conducted in September 2022. The primary outcome is the change in the mental domain of HR-QoL assessed using SF-36. Secondary outcomes include physical and role/social domains and subscales of HR-QoL, frailty phenotype, physical fitness, posture, cognition, exercise self-efficacy, depressive symptoms, brain-derived neurotrophic factor, social network, habitual energy intake, physical activity and sleep conditions.

ETHICS AND DISSEMINATION

The Research Ethics Committee of TMIG has approved the research protocol. This trial will be conducted in accordance with the principles of the Declaration of Helsinki. The findings will be presented at international academic conferences and published in peer-reviewed international journals.

TRIAL REGISTRATION NUMBER

UMIN000047229.

Abnormal sensation during total body irradiation: a prospective observational study

Light flash and odor during radiotherapy are well-known phenomena. Two prospective observational studies have indicated that 55% of patients observed a light flash during irradiation of the retina and 27% of patients sensed an odor during radiotherapy for the nasal cavity. A prospective observational study was performed in all patients at our hospital who received total body irradiation (TBI) between January 2019 to October 2021. Light flash and odor during TBI were examined using the same method as that used in previous studies. A total of 32 patients received TBI during the study period. The patients had a median age of 41 (18-60) years, and included 20 males and 12 females. A survey checklist showed that 14 patients (44%) sensed light and 14 patients (44%) sensed odor during TBI,. The color of the light during irradiation was yellow in six cases, white in four cases, and blue in four cases. The intensity of the light was 2-5 (median 3, 1 is very weak, 5 is very strong) and the time over which the light flash was felt was 4-60 s (median 10 s). Two patients each sensed smells of plastic, ozone and bleach, and others sensed one smell each. The intensity of the odor was 1-4 (median 3, 1 is very weak, 5 is very strong) and the time over which the odor was sensed was 1-25 s (median 3 s). We conclude that light flashes and odors are each sensed by 44% of patients during TBI. Various types of light flashes and odors were reported in this study.

Blood Levels of Ammonia and Carnitine in Patients Treated with Valproic Acid: A Meta-analysis

Objective

Long-term valproic acid (VPA) administration is associated with adverse metabolic effects, including hyperammonemia and hypocarnitinemia. However, the pathogeneses of these adverse events remain unclear, and not enough reviews have been performed. The aim of this study was to conduct a meta-analysis of studies examining blood levels of ammonia and carnitine in patients treated with VPA.

Methods

We conducted database searches (PubMed, Web of Science) to identify studies examining blood levels of ammonia and carnitine in patients treated with VPA. A meta-analysis was performed to conduct pre- and post-VPA treatment comparisons, cross-sectional comparisons between groups with and without VPA use, and estimations of the standardized correlations between blood levels of ammonia, carnitine, and VPA.

Results

According to the cross-sectional comparisons, the blood ammonia level in the VPA group was significantly higher than that in the non-VPA group. Compared to that in the non-VPA group, the blood carnitine level in the VPA group was significantly lower. In the meta-analysis of correlation coefficients, the blood VPA level was moderately correlated with blood ammonia and blood free carnitine levels in the random effects model. Furthermore, the blood ammonia level was moderately correlated with the blood free carnitine level.

Conclusion

Although the correlation between ammonia and free carnitine levels in blood was significant, the moderate strength of the correlation does not allow clinicians to infer free carnitine levels from the results of ammonia levels. Clinicians should measure both blood ammonia and free carnitine levels, especially in patients receiving high dosages of VPA.

Light flash and odor during proton beam therapy for pediatric patients: a prospective observational study

Light flash and odor during radiation therapy are well-known phenomena, but the details are poorly understood, particularly in pediatric patients. Therefore, we conducted a prospective observational study of these events in pediatric patients (age ≤20 years old) who received radiotherapy at our center from January 2019 to November 2021. Light flash and odor were evaluated using a patient-reported checklist including the presence, strength, and duration of the phenomenon, and color of light or type of odor. 53 patients who received proton therapy (n=47) and photon radiotherapy (n=6) were enrolled in this study. The median age of the patients was 10, ranged from 5 to 20. The patients who was able to see the light flash was 4, and all of them received retina irradiation. This was equivalent to 57% of the patients who received radiotherapy to retina (n=7). The light was bright and colored mainly blue and purple, which seemed to be consistent with Cherenkov light. Odor was sensed by 9 (17%) patients, and seven patients of the 9 received nasal cavity irradiation. This was equivalent to 41% of the patients who received nasal cavity irradiation (n=17). Other 2 patients received proton therapy to brain tumor. The odors were mainly described as plastic, burnt and disinfectant, which may be caused by ozone generated during irradiation. These data suggest that pediatric patients with retinal and nasal cavity irradiation frequently sense light flashes or odor. So adequate care is necessary so that these patients are not worried about this phenomenon.

Statistical tests for two-stage adaptive seamless design using short- and long-term binary outcomes

The adaptive seamless design combining phases II and III into a single trial has been shown growing interest for improving the efficiency of drug development, becoming the most frequent adaptive design type. It typically consists of two stages, the trial objectives being often different in each stage. The primary objectives are to select optimal experimental treatment group(s) in the first stage and compare the efficacy between the selected treatment and control groups in the second stage. In this article, we focus on a two-stage adaptive seamless design, for which treatment selection is based on the short-term binary endpoint and treatment comparison is based on the long-term binary endpoint. We thus propose an exact conditional test as a final analysis, based on the bivariate binomial distribution and given the selected treatment with the most promising short-term endpoint response rate from an interim analysis. Additionally, the mid- p $$ p $$ approach is incorporated to improve conservativeness for an exact test. Simulation studies were conducted to compare the proposed methods with a method based on the combination test. The proposed exact method controlled for type I error rate at the nominal level, regardless of the number of initial treatments or the correlation between short- and long-term endpoints. In terms of the treatment comparison power, the proposed methods are more powerful than that based on the combination test in the scenarios, with only one treatment being effective.

Confirmatory efficacy testing for individual dose-placebo comparisons using serial gatekeeping procedure in dose-finding trials with multiple comparison procedures-modeling

Dose-finding trials play a key role in the entire drug development process to determine optimal doses for regulatory approval. We address confirmatory efficacy testing for individual dose-placebo comparisons in the context of a dose-finding trial designed with multiple comparison procedures-modeling (MCP-Mod). An extension of the MCP-Mod, called closed MCP-Mod, has been proposed to carry out the MCP-Mod in conjunction with pairwise dose-placebo comparisons; however, an issue associated with the misspecification of candidate dose-response models remains. We consider another way to combine the MCP-Mod and the individual dose-placebo comparisons using serial gatekeeping procedures with fixed sequence, Holm, Hochberg, and step-down Dunnett procedure. The method controls the family-wise error rate in the strong sense and is simple enough to be implemented by existing software. Simulation studies suggested that the serial gatekeeping procedure was comparable with the closed MCP-Mod in terms of statistical power to detect the efficacy of at least one dose, and both methods were capable of pursuing the efficacy claim rather than just establishing the dose-response signal with less than a 20% increase in sample size when assuming monotonic dose-response shapes. The serial gatekeeping procedure would have advantages in the simplicity of implementation and ease of interpretation. The dose-finding trials aiming to declare the dose-response signal, as well as the efficacy of individual doses, would be worth considering as an option to accelerate the drug development program in certain situations.

Conduction disorders after perimembranous ventricular septal defect closure: continuous versus interrupted suturing techniques

OBJECTIVES

The aim of this study was to investigate postoperative conduction disorder differences between continuous and interrupted suturing techniques for the closure of perimembranous outlet-type ventricular septal defects (VSDs) in both tetralogy of Fallot (ToF) and isolated VSD cases.

METHODS

Patients aged 4 years or younger who underwent VSD closure for ToF (n = 112) or isolated perimembranous outlet-type VSD (n = 73) from April 2010 to December 2018 at 3 centres were reviewed. Patients either received continuous suturing for ToF (C-ToF, n = 58) or isolated VSD (C-VSD, n = 50), or interrupted suturing for ToF (I-ToF, n = 54) or isolated VSD (I-VSD, n = 23). Cohorts did not differ in preoperative characteristics. Postoperative conduction disorder differences upon discharge and postoperative year 1 (POY1) were evaluated by electrocardiography.

RESULTS

The C-ToF group showed significantly shorter PQ intervals (124.0 vs 133.5 ms; P = 0.042 upon discharge, 125.3 vs 133.5 ms; P = 0.045 at POY1) and QRS durations (98.0 vs 106.2 ms; P = 0.031 upon discharge, 97.3 vs 102.5 ms; P = 0.040 at POY1) than the I-ToF group. Right bundle branch block incidence was significantly lower in the C-ToF versus I-ToF groups (56.8 vs 75.9; P = 0.045 upon discharge, 56.8 vs 75.9; P = 0.045 at POY1). Heart rates were significantly lower in the C-ToF versus I-ToF groups at POY1 (109.2 vs 119.3 bpm; P < 0.001). No parameters significantly differed between C-VSD and I-VSD groups. Multivariable analyses confirmed the group (C-ToF versus I-ToF) as a significant covariate in postoperative heart rate, PQ interval, QRS duration and right bundle branch block outcomes at POY1 (P = 0.013, 0.027, 0.013 and 0.014, respectively).

CONCLUSIONS

A continuous suturing technique for the closure of outlet-type VSD in ToF could reduce the incidence of postoperative right bundle branch block, shorten the PQ interval and lower heart rate.

SUBJECT COLLECTION

110, 138, 139.

Perceptual inference, accuracy, and precision in temporal reproduction in schizophrenia

Accumulating evidence suggests that deficits in perceptual inference account for symptoms of schizophrenia. One manifestation of perceptual inference is the central bias, i.e., the tendency to put emphasis on prior experiences over actual events in perceiving incoming sensory stimuli. Using an interval reproduction task, this study aimed to determine whether patients with schizophrenia show a stronger central bias than participants without schizophrenia. In the interval reproduction task, participants were shown a cross on a screen. The cross was replaced with a Gaussian patch for a predetermined time interval, and participants were required to reproduce the interval duration by pressing and releasing the space key. We manipulated the uncertainty of prior information using different interval distributions. We found no difference in the influence of prior information on interval reproduction between patients and controls. However, patients with SZ showed a stronger central bias than healthy participants in the intermediate interval range (approximately 450 ms to 900 ms). It is possible that the patients in SZ have non-uniform deficits associated with interval range or uncertainty of prior information in perceptual inference. Further, the severity of avolition and alogia was correlated with the strength of central bias in SZ. This study provides some insights into the mechanisms underlying the association between schizophrenic symptoms and perceptual inference.