Radiographic knee osteoarthritis severity has no impact on fall risk: the locomotive syndrome and health outcomes in the aizu cohort study (LOHAS): a cross-sectional study

BACKGROUND

To investigate factors that have an impact on the risk of falls and determine whether radiographic knee osteoarthritis (KOA) is a factor involved in falls independent of knee pain, psychological factors, and physical function.

METHODS

A cross-sectional analysis was conducted on 1083 subjects for the 2009 Locomotive Syndrome and Health Outcomes in the Aizu Cohort Study (LOHAS). A logistic regression analysis was performed to examine the relationship between radiographic KOA and fall history.

RESULTS

Fall history was significantly associated with the severity of knee pain. Compared to subjects with no knee pain, the odds ratio (OR) was 1.53 times higher in the subjects with mild knee pain (95% confidence interval [CI]: 1.04-2.25), 1.69 times higher in those with moderate knee pain (95%CI: 1.03-2.79), and 2.98 times higher in those with severe knee pain (95%CI: 1.67-5.30). In subjects with depression, the OR was 1.91 (95%CI: 1.25-2.92), and in those with decreased mobility, the OR was 1.70 (95%CI: 1.08-2.69). Age, gender, knee crepitus, BMI, OLST, and sleeping pill use were not significantly associated with fall risk. In a multivariate analysis, radiographic KOA severity was not significantly associated with fall risk (OR 0.81, 95%CI 0.44-1.50 in mild OA; OR 1.10, 95%CI 0.57-2.14 in severe OA).

CONCLUSION

Knee pain, decreased mobility, and depression, but not the radiographic KOA severity, were significantly associated with a fall risk. Regardless of the individual's radiographic KOA severity, the risk of falls may be reduced by treating his/her knee pain, mobility problems, and/or psychological factors.

Neutrophil extracellular trap formation and its implications in nonsteroidal anti-inflammatory drug-induced small intestinal injury

BACKGROUND AND AIM

Nonsteroidal anti-inflammatory drugs (NSAIDs) damage the small intestine via neutrophil infiltration driven by the mucosal invasion of enterobacteria. The antimicrobial function of neutrophils is partially dependent on neutrophil extracellular traps (NETs). Excessive NET formation has been associated with several inflammatory diseases. Here, we aimed to investigate the role of NETs in NSAID-induced small intestinal damage using human samples and an experimental mouse model.

METHODS

Human small intestine specimens were obtained from NSAID users during double-balloon enteroscopy. Wild-type, protein arginine deiminase 4 (PAD4) knockout, and antibiotic-treated mice were administered indomethacin to induce small intestinal injury. The expression of NET-associated proteins, including PAD4, citrullinated histone H3 (CitH3), cell-free DNA, and myeloperoxidase (MPO), was evaluated.

RESULTS

The double-positive stained area with CitH3 and MPO, which is specific for neutrophil-derived extracellular traps, was significantly high in the injured small intestinal mucosa of NSAID users. In a mouse model, small intestinal damage developed at 6 h after indomethacin administration, accompanied by increased mRNA levels of interleukin-1β and keratinocyte chemoattractant and elevated NET-associated protein levels of PAD4, CitH3, and MPO in small intestine and serum levels of cell-free DNA. Both genetic deletion and pharmacological inhibition of PAD4 attenuated this damage by reducing the mRNA expression of inflammatory cytokines and NET-associated proteins. Furthermore, mice pretreated with antibiotics showed resistance to indomethacin-induced small intestinal damage, with less NET formation.

CONCLUSION

These results suggest that NETs aggravate NSAID-induced small intestinal injury. Therefore, NET inhibition could be a potential treatment for NSAID-induced small intestinal injury.

Responses of Proton Pump Inhibitors and Potassium-Competitive Acid Blockers According to Outcomes of Symptom, Endoscopy, and Histology in Patients With Eosinophilic Esophagitis

GOALS

We aimed to examine the response rate to proton pump inhibitors (PPIs) and potassium-competitive acid blockers and the prevalence of topical corticosteroid (TCS) therapy as the second-line treatment for eosinophilic esophagitis (EoE).

BACKGROUND

Acid-suppressive drugs such as PPIs and potassium-competitive acid blockers are often used to treat EoE. Treatment response is based on outcomes including symptoms, endoscopy, and histology; however, the detailed response rate to PPI/P-CAB is unknown.

STUDY

In total, 236 patients with histologically confirmed EoE who received PPI/P-CAB as the first-line treatment were included. We assessed the symptoms, endoscopic reference score (EREFS), and histology [eosinophils per high-power field (eos/hpf)] 8 weeks after PPI/P-CAB administration. Complete normalization was defined as the disappearance of symptoms, EREFS score 0, or 0-1 eos/hpf, and response as disappearance or improvement of symptoms, EREFS score ≤2, or <15 eos/hpf. The prevalence of TCS therapy in each response group was assessed.

RESULTS

Complete normalization was achieved in 25%, 50%, 36%, and 8% of patients for symptoms, endoscopy, histology, and all 3 outcomes, respectively. The response rates were 81%, 87%, 87%, 75%, and 60% for symptoms, endoscopy, histology, and all 3 outcomes, respectively. TCS use was significantly lower (8%) in patients who achieved response of all 3 outcomes than in other groups and was dependent on the number of outcomes with nonresponse.

CONCLUSIONS

Complete normalization of symptoms, endoscopy, and histology using PPI/P-CAB is uncommon. Based on treatment efficacy by response/nonresponse, TCS was the secondary treatment in cases with an increase in the number of nonresponse outcomes.

Perioperative Cerebrovascular Accidents in Spine Surgery: A Retrospective Descriptive Study and A Systematic Review with Meta-Analysis

Introduction

Perioperative cerebrovascular accidents (CVAs) related to spine surgery, although rare, can lead to significant disabilities. More studies on spine surgeries are required to identify those at risk of perioperative CVAs. The characteristics and outcomes of patients that experienced CVAs during spine surgery were assessed through a retrospective descriptive study and meta-analysis.

Methods

Patients aged ≥18 years who underwent spine surgery under general anesthesia at a hospital between April 2011 and March 2023 were examined. Of the 2,391 initially identified patients, 2,346 were included after excluding 45 who underwent debridement for surgical site infections. Subsequently, a meta-analysis including the present retrospective descriptive study was conducted. Databases such as PubMed and Google Scholar were searched for original peer-reviewed articles written in English.

Results

Of the 2,346 patients, 4 (0.17%) (three men, one woman) exhibited perioperative CVAs associated with spine surgery. The CVAs were diverse in nature: one case of cerebral hemorrhage resulting from dural injury during posterior occipitocervical fusion, two cases of cerebral infarctions after lumbar laminectomy and anterior thoracic fusion due to anticoagulant discontinuation, and one case of posterior reversible encephalopathy syndrome following microscopic lumbar discectomy due to gestational hypertension. The subsequent meta-analysis included three studies (n=186,860). It showed several risk factors for perioperative CVAs, including cervical level (pooled odds ratio [OR]=1.33), hypertension (pooled OR=2.27), atrial fibrillation (pooled OR=8.78), history of heart disease (pooled OR=2.47), and diabetes (pooled OR=2.13).

Conclusions

It was speculated that the potential risk factors for the four perioperative CVA cases of spine surgery in this retrospective descriptive study were intraoperative dural injury, preoperative anticoagulant discontinuation, and gestational hypertension history. The meta-analysis revealed that cervical spine surgery, hypertension, atrial fibrillation, heart disease, and diabetes increased the CVA risk. This highlights the need for risk assessment, preoperative optimization, and postoperative care to reduce spine surgery-associated perioperative CVAs.

A reduction method for anterior opening displacement in thoracolumbarvertebral fractures with diffuse idiopathic skeletal hyperostosisusing the skull clamp-assisted position

Diffuse idiopathic skeletal hyperostosis (DISH) frequently occurs in the spine, resulting in unstable fractures. Treating thoracolumbar fractures in patients with DISH is often difficult because the anterior opening of the vertebral body is exacerbated by dislocation in the prone position, making reduction difficult. In this study, we introduced a novel skull clamp-assisted positioning (SAP) technique. The patient is placed in a supine position with a skull clamp used in cervical spine surgery before surgery to prevent the progression of dislocation and to restore the patient's position. Using this method, the mean difference in local kyphosis angle improved from -2.9 (±8.4)° preoperatively to 10.9 (±7.7)° postoperatively. Furthermore, posterior displacement decreased from a preoperative mean of 5.5 (±4.3) mm to 0.3 (±0.7) mm postoperatively. Complications such as neurological sequelae, implant fracture, and surgical site infection were not observed through one year of postoperative follow-up. SAP may decrease invasiveness and complications. Longer-term studies and larger sample sizes are needed to establish long-term efficacy and benefits.

Risk factors for progression of the severity of locomotive syndrome: A two-year longitudinal observational study

BACKGROUND

The risk factors for progression of severity of locomotive syndrome (LS) remain unclear.

METHODS

We conducted a longitudinal observational study of 1148 community-dwelling residents (median age, 68.0 years old; 548 males, 600 females) from 2016 to 2018. LS was assessed by the 25-question Geriatric Locomotive Function Scale (GLFS-25), and total scores of ≤6 points, 7-15 points, 16-23 points, and ≥24 points were diagnosed as non-LS, LS-1, LS-2, and LS-3, respectively. If the LS severity in 2018 was higher than in 2016, the case was defined as progression of LS severity; otherwise, it was defined as non-progressive LS. We compared the age, gender, body mass index, smoking status, alcohol consumption, living situation, car use, chronic musculoskeletal pain, comorbidities, metabolic syndrome, physical activity, and LS severity in 2016 between the progression and non-progression groups. Furthermore, a multivariate logistic regression analysis was performed to elucidate the risk factors for progression of LS severity.

RESULTS

Participants in the progression group had a significantly older age, a lower rate of car use, a higher rate of low back pain, a higher rate of hip pain, a higher rate of knee pain, a higher GLFS-25 total score, and a higher rate of LS-2 than those in the non-progression group. The multivariate logistic regression analysis revealed that older age, female gender, higher body mass index (≥25.0 kg/m2), presence of low back pain, and presence of hip pain were risk factors for the progression of LS within two years.

CONCLUSIONS

To prevent the progression of LS severity, related prophylaxis strategies should be implemented, especially for individuals with the above-mentioned characteristics. Further longitudinal studies with a longer observation period are necessary.

The Usefulness of Deep Tendon Reflexes in the Diagnosis of Lumbar Spine Diseases: A Narrative Review

The deep tendon reflex (DTR) is a more objective indicator than sensory and muscle assessments for lumbar spine disorders. Further, unlike sensory and muscle assessments that require patient cooperation, the DTR can be assessed even in patients with impaired consciousness or cognition. Therefore, DTR assessment with a hammer is an essential neurological test for lumbar spinal diseases. However, despite the usefulness of DTR assessment, few reports have described the significance of increased, diminished, or absent deep lower extremity reflexes in lumbar spine diseases. This review outlines the history of DTR of the lower limbs and describes the techniques, evaluation, and interpretation of DTR for the diagnosis of lumbar spine diseases. The patellar tendon reflex (PTR) was the first parameter of lower extremity DTR identified to have clinical usefulness, followed by the Achilles tendon reflex (ATR), pathological reflexes (Babinski reflex), and reflex enhancement (Jendrassik maneuver). They have now become an integral part of clinical examination. To determine whether an increase or decrease in DTR is pathological, it is necessary to determine left-right differences, differences between the upper and lower extremities, and the overall balance of the limb. There are several critical limitations and pitfalls in interpreting DTRs for lumbar spine diseases. Attention should be paid to examiner and patient factors that make the DTR assessment less objective. When there is a discrepancy between clinical and imaging findings and the level of the lumbosacral nerve root disorder is difficult to diagnose, the presence of a lumbosacral transitional vertebra, nerve root malformation, or furcal nerve should be considered. In addition, assessing the DTR after the gait loading test and standing extension loading test, which induce lumbosacral neuropathy, will help provide a rationale for the diagnosis.

Serum periostin levels correlate with severity of intervertebral disc degeneration

PURPOSE

Periostin, an extracellular matrix protein closely related to mechanical stress, inflammation, and ageing, has been implicated in intervertebral disc degeneration (IVDD) in basic research. However, it has not been examined in clinical cases. This study aimed to evaluate the association between IVDD severity and serum periostin concentration as well as to analyse potential associations between IVDD and clinical and demographic factors.

METHODS

This retrospective cohort study included 198 patients who underwent lumbar disc herniation and lumbar canal stenosis between January 2020 and December 2022. The severity of IVDD was evaluated using the Pfirrmann grading, whereas serum periostin levels were measured using ELISA kits. Clinical demographics, including age, sex, body mass index, comorbidities, psoas muscle index, and spinal disease, were also recorded.

RESULTS

This study demonstrated a significant correlation between high serum periostin levels and IVDD severity, as indicated by a high cumulative Pfirrmann score. Serum periostin levels were identified as an independent risk factor for IVDD in a multivariate regression model. Correlation analysis showed a correlation between periostin levels and Pfirrmann grade at each lumbar level (ρ = 0.458-0.550, p < 0.001) and a strong correlation with cumulative Pfirrmann score (ρ = 0.690, p < 0.001).

CONCLUSION

The higher the serum periostin level, the higher the cumulative Pfirrmann score. Multivariate analysis showed that serum periostin was an independent risk factor for IVDD. Periostin levels may be a clinically suitable and useful biomarker for diagnosing IVDD, estimating disease progression and activity, providing prognostic information, and evaluating treatment options.

Correlation between anxiety and decreased quality of life in patients with non-esophageal eosinophilic gastrointestinal diseases

Background and Aim

Mental status such as anxiety and depression in patients with non-esophageal eosinophilic gastrointestinal diseases (non-EoE EGIDs) has not been studied. The aim of this study was to evaluate whether patients with non-EoE EGIDs had mental disorders and decreased mental-health-related quality of life (QOL) similar to those in patients with disorders of gut-brain interaction (DGBI).

Methods

We enrolled patients with non-EoE EGIDs and DGBI visiting the Osaka Metropolitan University Hospital, and the measures listed below were compared between the groups. We collected data using the following questionnaires: hospital anxiety and depression scale, and short form (SF)-8 including mental component summary (MCS)-8.

Results

We evaluated 21 and 17 patients with non-EoE EGIDs and DGBI, respectively. The anxiety score was not significantly different between the groups. The proportion of patients with possible anxiety was not significantly different between the groups (19.0% vs 33.3%). These results show that patients with non-EoE EGIDs had anxiety that might be equivalent to that of patients with DGBI. The depression score and proportion of patients with possible depression in the non-EoE EGID group tended to be lower than those in the DGBI group. MCS-8 scores were not significantly different between the non-EoE EGID and DGBI groups, which might imply an equivalent decrease in mental-health-related QOL in both groups of patients. In patients with non-EoE EGIDs, the anxiety score had a significant inverse association with the MCS-8 score.

Conclusions

Patients with non-EoE EGIDs may have anxiety that correlates with decreased mental-health-related QOL.

Background factors of idiopathic peptic ulcers and optimal treatment methods: a multicenter retrospective Japanese study

This study investigated the trends in idiopathic peptic ulcers, examined the characteristics of refractory idiopathic peptic ulcer, and identified the optimal treatment. The characteristics of 309 patients with idiopathic peptic ulcer were examined. We allocated idiopathic peptic ulcers that did not heal after 8 weeks' treatment (6 weeks for duodenal ulcers) to the refractory group and those that healed within this period to the healed group. The typical risk factors for idiopathic peptic ulcer (atherosclerosis-related underlying disease or liver cirrhosis complications) were absent in 46.6% of patients. Absence of gastric mucosal atrophy (refractory group: 51.4%, healed group: 28.4%; p = 0.016), and gastric fundic gland polyps (refractory group: 17.6%, healed group: 5.9%; p = 0.045) were significantly more common in the refractory group compared to the healed group. A history of H. pylori eradication (refractory group: 85.3%, healed group: 66.0%; p = 0.016), previous H. pylori infection (i.e., gastric mucosal atrophy or history of H. pylori eradication) (refractory group: 48.5%, healed group: 80.0%; p = 0.001), and potassium-competitive acid blocker treatment (refractory group: 28.6%, healed group, 64.1%; p = 0.001) were significantly more frequent in the healed group compared to the refractory group. Thus, acid hypersecretion may be a major factor underlying the refractoriness of idiopathic peptic ulcer.

Assessment of Lumbar Spinal Stenosis as a Risk Factor for Development of Sleep Disorder: The Locomotive Syndrome and Health Outcome in Aizu Cohort Study (LOHAS)

Purpose

Insomnia has been reported to coexist with various musculoskeletal disorders. Although lumbar spinal stenosis (LSS) is the most frequently operated on spinal disease, the causal relationship between LSS and development of sleep disorders remains unclear due to lack of longitudinal studies. This study aimed to determine whether LSS was a risk factor for developing new sleep disorders, primarily insomnia, using a prospective cohort of community residents.

Patients and Methods

This study was a prospective cohort study. Participants aged ≥65 years from the "Locomotive Syndrome and Health Outcomes in Aizu Cohort Study (LOHAS)" conducted in 2008 formed our study population. LSS was diagnosed using the self-administered, self-reported history questionnaire, a validated diagnostic support tool for LSS. Sleep disorder was investigated using a questionnaire during the 2-year follow-up. The impact of LSS on sleep disorder onset was analyzed after adjusting for potential confounders, such as age, sex, obesity, hypertension, diabetes, depression, and smoking habits, using propensity score matching.

Results

Of the 489 participants who were followed up for two years, 38 (7.8%) had newly developed a sleep disorder in 2010. After adjusting for confounding factors, a comparison of 133 participants each in the control and LSS groups showed significantly higher frequency of new-onset sleep disorders (19 [14.3%] in the LSS group versus 6 [4.5%] in the control group).

Conclusion

LSS was found to be an independent risk factor for sleep disorders.

The impact of COVID-19 on Japanese patients with eosinophilic gastrointestinal disorders during the vaccination era

Background

Eosinophilic gastrointestinal disorders (EGIDs) are chronic allergic diseases categorized as eosinophilic esophagitis (EoE) and non-EoE EGIDs. Few studies regarding the association between EGIDs and coronavirus disease 2019 (COVID-19) have been reported. Although most Japanese individuals received the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine, the incidence of COVID-19 remained high in 2022. This study examines the incidence of COVID-19 in patients with EGIDs during the vaccination era.

Methods

Patients with EGIDs who visited our department between October and December 2022 were enrolled in the study. The incidence and severity of COVID-19 prior to October 1, 2022 were determined. Patients who reported having COVID-19 also reported their hospitalization history, intensive care unit admissions, and EGID flares. The number of SARS-CoV-2 vaccinations received and treatment for EGIDs were obtained from the patients' medical records.

Results

Of 111 patients with EGIDs (65 with EoE and 46 with non-EoE EGIDs) included in this study, 31 (28%) patients reported having COVID-19, including 14 (22%) with EoE and 17 (37%) with non-EoE EGIDs. Fifty-nine (84%) patients received two or more vaccinations, and 11 (16%) patients received no vaccinations. COVID-19 was mild in all but one patient who had moderate symptoms. COVID-19 was not associated with EGID flares. EGID treatments and an unvaccinated status were not associated with an increased risk of COVID-19.

Conclusion

COVID-19 was mild in patients with EGIDs and not associated with EGIDs flares during the vaccination era. There was a relatively high incidence of COVID-19 among patients with non-EoE EGIDs.

Impact of the COVID-19 Pandemic on the Lifestyle and Psychosocial Behavior of Patients with Inflammatory Bowel Diseases: A Narrative Review

The coronavirus disease (COVID-19) pandemic has had a considerable impact on the global healthcare system and potentially the clinical course of patients with inflammatory bowel disease (IBD). Although IBD is a chronic disease, its therapy (except steroid therapy) does not increase the risk of contracting or aggravating COVID-19. However, the clinical course of patients is significantly influenced by environmental factors. Social restrictions due to the pandemic or the fear of contracting the virus have influenced lifestyle and psychosocial behaviors that may worsen the clinical course of patients with IBD. This narrative literature review summarizes the current evidence on the impact of the COVID-19 pandemic on the lifestyle and psychosocial behaviors of patients with IBD. The COVID-19 pandemic negatively affected the lifestyle and psychosocial behaviors of patients with IBD. Furthermore, patients with IBD failed to maintain medication adherence, thus affecting the clinical course of their condition.

Management of Antithrombotic Drugs before Elective Spine Surgery: A Nationwide Web-Based Questionnaire Survey in Japan

Introduction

The number of patients on antithrombotic drugs for coronary heart disease or cerebrovascular disease has been increasing with the aging of society. We occasionally need to decide whether to continue or discontinue antithrombotic drugs before spine surgery. The purpose of this study is to understand the current perioperative management of antithrombotic drugs before elective spine surgery in Japan.

Methods

In 2021, members of the Japanese Society for Spine Surgery and Related Research (JSSR) were asked to complete a web-based questionnaire survey that included items concerning the respondents' surgical experience, their policy regarding discontinuation or continuation of antithrombotic drugs, their reasons for decisions concerning the management of antithrombotic drugs, and their experience of perioperative complications related to the continuation or discontinuation of these drugs.

Results

A total of 1,181 spine surgeons returned completed questionnaires, giving a response rate of 32.0%. JSSR board-certified spine surgeons comprised 75.1% of the respondents. Depending on the management policy regarding antithrombotic drugs for each comorbidity, approximately 73% of respondents discontinued these drugs before elective spine surgery, and about 80% also discontinued anticoagulants. Only 4%-5% of respondents reported continuing antiplatelet drugs, and 2.5% reported continuing anticoagulants. Among the respondents who discontinued antiplatelet drugs, 20.4% reported having encountered cerebral infarction and 3.7% reported encountering myocardial infarction; among those who discontinued anticoagulants, 13.6% reported encountering cerebral embolism and 5.4% reported encountering pulmonary embolism. However, among the respondents who continued antiplatelet drugs and those who continued anticoagulants, 26.3% and 27.2%, respectively, encountered an unexpected increase in intraoperative bleeding, and 10.3% and 8.7%, respectively, encountered postoperative spinal epidural hematoma requiring emergency surgery.

Conclusions

Our findings indicate that, in principle, >70% of JSSR members discontinue antithrombotic drugs before elective spine surgery. However, those with a discontinuation policy have encountered thrombotic complications, while those with a continuation policy have encountered hemorrhagic complications.

Potential influencing factor on health-related quality of life in Japanese with knee osteoarthritis: the Locomotive syndrome and Health outcome in Aizu cohort Study (LOHAS)

PURPOSE

Several studies have investigated the factors that influence health-related quality of life in patients with knee osteoarthritis (KOA). This study aimed to identify and investigate the degree of involvement of potential factors influencing health-related quality of life (HRQOL) in an aged population with or without KOA.

METHODS

This multi-centered study included 651 participants who underwent health checkups in rural areas of Japan in 2010. The association between three component summary score of short-form 12 (physical component summary; PCS, mental component summary; MCS, and role-social component summary; RCS) and covariates were investigated using multiple linear regression model and calculated the scaled estimated regression coefficient.

RESULTS

Decreasing mobility, severity of knee pain, high pain-related self-efficacy (PSE), older age, high functional self-efficacy (FSE), and female gender had significant effect on PCS (p < 0.05). However, radiographic KOA had no influence on PCS. Presence of depression and body mass index had a significant influence on the MCS (p < 0.05). Decreasing mobility, presence of depression, PSE and older age had significant influence on the RCS (p < 0.05).

CONCLUSION

Our study results showed that physical, mental, and role/social QOL were affected by different influencing factors. Physical QOL was strongly influenced by subjective pain, physical performance, and self-efficacy, whereas radiographic KOA had no such effect. Depressive mood is associated with both mental and role/social QOL. The role/social QOL was predominantly affected by physical function and pain-related self-efficacy. Taking measure to improving functional ability and mental status might be the key factor to improve HRQOL in patient with KOA.

LEVEL OF EVIDENCE

Level 3: Epidemiologic cross-sectional study (prognostic study).

A muscle-preserving, spinous process-splitting approach for ossification of the ligamentum flavum in the thoracic spine in professional athletes: a report of three cases

A muscle-preserving, spinous process-splitting approach may be a less invasive approach to conventional laminectomy in patients with thoracic ossification of the ligamentum flavum. Few reports have discussed the usefulness of this procedure for thoracic lesions in professional athletes who need highly active thoracic spinal function after surgery. The treatment of thoracic ossification of the ligamentum flavum using a spinous process-splitting approach in 3 professional athletes is presented. In all three cases the patients could return to play within 3 months after surgery without complications, and in two of the cases, there was no spinal deformity or local recurrence of ossification of the ligamentum flavum at the final follow-up at least 8 years after surgery. The spinous process-splitting approach could be a safe procedure for multi-level and all other forms of ossification of the ligamentum flavum and is less invasive to the paraspinal muscles, relieves back symptoms, and restores function for athletes.

Lumbar intradural space reduction during the Valsalva maneuver observed using cine MRI and MR myelography: a single-case experimental study

BACKGROUND

Previous studies have shown that the Valsalva maneuver (VM) causes spinal canal object movements. We hypothesized that this occurs because of cerebrospinal fluid (CSF) flow generated from intradural space reduction. Previous studies using myelograms reported lumbar CSF space changes during inspiration. However, no similar studies have been conducted using modern MRI. Therefore, this study analyzed intradural space reduction during the VM using cine magnetic resonance imaging (MRI).

METHODS

The participant was a 39-year-old, healthy, male volunteer. Cine MRI involved fast imaging employing steady-state acquisition cine sequence during three resting and VM sets for 60 s each. The axial plane was at the intervertebral disc and vertebral body levels between Th12 and S1 during cine MRI. This examination was performed on 3 separate days; hence, data from nine resting and VM sets were available. Additionally, two-dimensional myelography was performed during rest and the VM.

RESULTS

Intradural space reduction was observed during the VM using cine MRI and myelography. The intradural space cross-sectional area during the VM (mean: 129.3 mm2; standard deviation [SD]: 27.4 mm2) was significantly lower than that during the resting period (mean: 169.8; SD: 24.8; Wilcoxon signed-rank test, P < 0.001). The reduction rate of the vertebral body level (mean: 26.7%; SD: 9.4%) was larger than that of the disc level (mean: 21.4%; SD: 9.5%; Wilcoxon rank sum test, P = 0.0014). Furthermore, the reduction was mainly observed on the ventral and bilateral intervertebral foramina sides at the vertebral body and intervertebral disc levels, respectively.

CONCLUSION

The intradural space was reduced during the VM, possibly because of venous dilatation. This phenomenon may be associated with CSF flow, intradural object movement, and nerve compression, potentially leading to back pain.

Risk factors for adverse events associated with endoscopic submucosal dissection for superficial pharyngeal cancer

BACKGROUND

Superficial pharyngeal cancer can be treated with curative intent while preserving function using minimally invasive peroral endoscopic resection techniques such as endoscopic submucosal dissection (ESD). However, severe adverse events occasionally occur, such as laryngeal edema requiring temporary tracheotomy and fistula formation. Therefore, we investigated the risk factors for adverse events associated with ESD for superficial pharyngeal cancer.

METHODS

This retrospective observational study was conducted at a single institution, and 63 patients who underwent ESD were enrolled. The primary outcome was the risk factors for adverse events associated with ESD. The secondary outcomes were adverse events associated with ESD and their frequency.

RESULTS

The overall adverse event rate was 15.9% (10/63). The incidence of laryngeal edema requiring prophylactic temporary tracheotomy was 11.1%, while laryngeal edema requiring emergency temporary tracheotomy, postoperative bleeding, aspiration pneumonia, fistula, abscess, and stricture formation occurred in 1.6% of patients, respectively. Logistic regression analyses showed that a history of radiotherapy for head and neck cancer was a risk factor for adverse events (odds ratio [OR], 16.67; 95% confidence interval [CI], 3.04-91.34; p = 0.001). After adjusting the model for differences in the baseline risk factors using the inverse probability of treatment weighting method, the adverse events were found to increase in association with a history of radiotherapy for head and neck cancer (OR, 39.66; 95% CI,5.85-268.72; p < 0.001).

CONCLUSION

History of radiotherapy for head and neck cancer is an independent risk factor for adverse events associated with ESD for superficial pharyngeal cancer. Among adverse events, laryngeal edema requiring prophylactic temporary tracheotomy was particularly high.

Relationship between dysphagia and motor function in community-dwelling older people

AIM

Dysphagia is a problem typically associated with aging. The aim was to investigate the relationship between dysphagia and motor function using a simple assessment method that can be performed in the community setting, and to promote the early detection and prevention of dysphagia.

METHODS

Data from the Locomotive Syndrome and Health Outcome in Aizu Cohort Study (LOHAS) were used. Those aged ≥65 years were included. Motor function was assessed using a grip strength test, single limb standing test (SLS), and timed up and go test (TUG). Swallowing function was assessed using the Japanese version of the 10-item Eating Assessment Tool (EAT-10). The association between motor function and swallowing function was analyzed.

RESULTS

In total, 1732 participants were included. In logistic regression modes in which grip strength, SLS, and TUG results were included separately, the odds ratio for dysphagia increased by 1.08 (P = 0.001) for each 1-kg decrease in grip strength, and increased by 1.15 (P < 0.001) for each 1-s increase in TUG time. No association was found for SLS. In the model in which grip strength and TUG were included simultaneously, the odds ratio for dysphagia increased by 1.06 (P = 0.01) in grip strength, and increased by 1.11 (P = 0.009) in TUG time.

CONCLUSION

Our results suggest that skeletal muscle strength and dynamic balance function are associated with dysphagia in community-dwelling older people. Geriatr Gerontol Int 2023; ••: ••-••.

Development of Machine Learning Model for Selecting the 1st Coil in the Treatment of Cerebral Aneurysms by Coil Embolization

To achieve good treatment outcomes in coil embolization for cerebral aneurysms, it is important to select an appropriate 1st coil for each aneurysm since it serves as a frame to support the subsequent coils to be deployed. However, its selection as appropriate size and length from a wide variety of lineups is not easy, especially for inexperienced neurosurgeons. We developed a machine learning model (MLM) to predict the optimal size and length of the 1st coil by learning information on patients and aneurysms that were previously treated with coil embolization successfully. The accuracy rates of the MLM for the test data were 86.3% and 83.4% in the prediction of size and length, respectively. In addition, the accuracy rates for the 30 cases showed good prediction by the MLM when compared with two different skilled neurosurgeons. Although the accuracy rate of the well-experienced neurosurgeon is similar to MLM, the inexperienced neurosurgeon showed a worse rate and can benefit from the method.Clinical Relevance- The developed MLM has the potential to assist in the selection of the 1st coil for aneurysms. A technically and cost efficient supply chain in the treatment of aneurysms may also be achieved by MLM application.

Prevalence of elderly eosinophilic esophagitis and their clinical characteristics

BACKGROUND AND AIMS

Eosinophilic esophagitis (EoE) is predominantly found in middle-aged men among adults. There are few reports about EoE in the elderly, despite an ageing population. The study aimed to define the prevalence and clinical characteristics of EoE amongst older adults.

METHODS

Elderly patients (defined as those ≥65 years) were compared to younger adults (18-64) in terms of clinical characteristics (age, gender, presenting symptoms, comorbidities), histological activity (eosinophil count), treatment modality and response to treatment. A pre- existing prospectively generated database of all EoE patients presenting to our department between February 2010 and December 2022 was interrogated. 309 patients who underwent endoscopy and esophageal biopsy and were found to have ≥15 eosinophils/HPF were defined as having EoE and were included for study. Statistical analyses were performed using Fisher's extract test or Mann-Whitney U test.

RESULTS

309 cases of EoE were recorded, mean age 45.7, range (21-88 years), of which20 patients were aged 65 years and over. Compared to younger patients, those aged ≥65 had more medical comorbidities (15 [75%] vs 111[38%], p = 0.002), and instead a non-significant trend toward less fibrosis (0.25 vs 0.46, p = 0.117). Although rate of cases required topical steroid (TCS) therapy was similar, none received repeated or maintenance TCS therapy in elderly.

CONCLUSION

In our cohort, only 20 patients (6%) were aged 65 years or older, suggesting that EoE is uncommon in the elderly. The clinical characteristics of EoE in the older age group were similar to the younger patients. Future studies with prospective data collection may determine if EoE disappears with age, or if the younger mean age is reflective of an increasing prevalence in recent years, that may be realized in the elderly EoE population in the future.

Relationship between lumbar facet joint osteoarthritis and comorbidities: A cross-sectional study in the Japanese community

BACKGROUND

Few epidemiological studies have evaluated associations between lumbar facet joint (LFJ) osteoarthritis (OA) and comorbidities. This study aimed to investigate the prevalence of LFJ OA in a Japanese community population and associations between LFJ OA and underlying diseases, including lower extremity OA.

METHODS

This epidemiological cross-sectional study evaluated LFJ OA in 225 Japanese community residents (81 males, 144 females; median age, 66 years) using magnetic resonance imaging (MRI). LFJ OA from L1-L2 to L5-S1 was evaluated using a 4-grade classification. Associations between LFJ OA and comorbidities were examined using multiple logistic regression analyses adjusting for age, sex, and body mass index.

RESULTS

Prevalences of LFJ OA were 28.6% at L1-L2, 36.4% at L2-L3, 48.0% at L3-L4, 57.3% at L4-L5, and 44.2% at L5-S1. Males were significantly more likely to have LFJ OA at several spinal levels (L1-L2 45.7% vs 18.9%, p < 0.001; L2-L3 46.9% vs 30.6%, p < 0.05; L4-L5 67.9% vs 51.4%, p < 0.05). LFJ OA was present in 50.0% of residents <50 years old, 68.4% at 50-59 years old, 86.3% at 60-69 years old, and 85.1% at ≥70 years old. Multiple logistic regression analysis showed no associations between LFJ OA and comorbidities.

CONCLUSIONS

The prevalence of LFJ OA as evaluated by MRI was >85% at ≥60 years old and highest at the L4-L5 spinal level. Males were significantly more likely to have LFJ OA at several spinal levels. Comorbidities were not associated with LFJ OA.

A Simplified Screening Tool for the One-Leg Standing Test to Determine the Severity of Locomotive Syndrome

This study determined the cut-off time for the one-leg standing test (OLST) to simply screen the severity of locomotive syndrome (LS). We conducted this cross-sectional study on 1860 community-dwelling residents (age, 70.5 ± 9.5 years old; males, n = 826; females, n = 1034) who underwent the OLST and completed the 25-question geriatric locomotive function scale (GLFS-25). Multivariate linear regression and multivariate logistic regression analyses were conducted to assess the relationship between the OLST and the GLFS-25 score and LS after adjusting for age, sex, and body mass index. A receiver operating characteristic (ROC) curve analysis was performed to calculate the optimal cut-off time of the OLST for determining LS severity. The multivariate linear regression and multivariate logistic regression analyses showed that the OLST was significantly associated with the GLFS-25 score and a diagnosis of LS. The optimal cut-off times of the OLST to screen LS-1, LS-2, and LS-3 were 42 s (sensitivity 65.8%, specificity 65.3%), 27 s (sensitivity 72.7%, specificity 72.5%), and 19 s (sensitivity 77.4%, specificity 76.8%), respectively. We developed a simplified screening tool for the OLST to determine LS severity.

Clinical characteristics of locomotive syndrome categorised by the 25-question Geriatric Locomotive Function Scale: a systematic review

OBJECTIVES

The purpose of this study was to compile the currently available evidence on the clinical characteristics of the locomotive syndrome (LS) categorised by the 25-question Geriatric Locomotive Function Scale (GLFS-25) and clarify its clinical usefulness for assessing mobility function.

DESIGN

Systematic review.

DATA SOURCES

The PubMed and Google Scholar were searched for the relevant studies on 20 March 2022.

ELIGIBILITY CRITERIA

We included relevant peer-reviewed articles, available in English language, on clinical LS characteristics categorised with the GLFS-25.

DATA EXTRACTION AND SYNTHESIS

Pooled ORs or mean differences (MDs) of the LS groups were calculated and compared with the non-LS groups for each clinical characteristic.

RESULTS

In total, 27 studies that involve 13 281 participants (LS, n=3385; non-LS, n=9896) were examined in this analysis. Older age (MD 4.71; 95% (CI) 3.97 to 5.44; p<0.00001), female gender (OR 1.54; 95% CI 1.38 to 1.71; p<0.00001), higher body mass index (MD 0.78; 95% CI 0.57 to 0.99; p<0.00001), osteoporosis (OR 1.68; 95% CI 1.32 to 2.13; p<0.0001), depression (OR 3.14; 95% CI 1.81 to 5.44; p<0.0001), lower lumbar lordosis angle (MD -7.91; 95% CI -10.08 to -5.74; p<0.00001), higher spinal inclination angle (MD 2.70; 95% CI 1.76 to 3.65; p<0.00001), lower grip strength (MD -4.04; 95% CI -5.25 to -2.83; p<0.00001), lower back muscle strength (MD -15.32; 95% CI -23.83 to -6.81; p=0.0004), lower maximum stride (MD -19.36; 95% CI -23.25 to -15.47; p<0.00001), higher timed up-and-go (MD 1.36; 95% CI 0.92 to 1.79; p<0.00001), lower one-leg standing time (MD -19.13; 95% CI -23.29 to -14.97; p<0.0001) and slower normal gait speed (MD -0.20; 95% CI -0.22 to -0.18; p<0.0001) were found to be associated with LS. No significant differences were noted in other clinical characteristics between the two groups.

CONCLUSIONS

GLFS-25 is clinically useful for assessing mobility function according to the evidence available on the clinical characteristics of LS categorised by the GLFS-25 questionnaire items until.

Upper gastrointestinal endoscopic findings in functional constipation and irritable bowel syndrome diagnosed using the Rome IV criteria: a cross-sectional survey during a medical check-up in Japan

BACKGROUND

The Rome IV criteria have been established as an international standard for diagnosing disorders of gut-brain interaction. In this study, we aimed to examine the upper gastrointestinal (GI) endoscopic findings and symptoms of subjects with functional constipation (FC) and irritable bowel syndrome (IBS) of individuals undergoing a medical check-up.

METHODS

A total of 13,729 subjects underwent a medical check-up at Osaka City University-affiliated clinic, MedCity21, between April 2018 and March 2019. Among the 5,840 subjects who underwent screening upper GI endoscopy and completed a questionnaire based on the Rome IV criteria, 5,402 subjects were consecutively enrolled after excluding subjects with a large amount of gastric residue (n = 6), those who had previously undergone partial or total gastrectomy (n = 40), or those with daily use of low-dose aspirin (n = 82), nonsteroidal anti-inflammatory drugs (n = 63), or acid secretion inhibitors (n = 308).

RESULTS

Robust Poisson regression analyses adjusted for age, sex, Helicobacter pylori infection status, alcohol intake, and smoking habits showed a significant association between FC and corpus erosion (adjusted prevalence ratio [aPR], 2.93; 95% confidence interval [CI], 1.51-5.67; p < 0.01) and red streaks (aPR, 3.83; 95% CI, 2.53-5.79; p < 0.01), whereas IBS was significantly associated with erosive gastritis (aPR, 8.46; 95% CI, 4.89-14.67; p < 0.01) and duodenitis (aPR, 7.28; 95% CI, 3.64-14.59; p < 0.01). Red streaks tended to be associated with IBS (aPR, 1.96; 95% CI, 1.00-3.83; p = 0.05). Subjects with IBS were the most to complain of both upper and lower GI symptoms and psychological symptoms, followed by those with FC and controls. IBS subjects with erosive gastritis or duodenitis had significantly more complaints of stomachache and feeling stressed than those without erosive gastritis or duodenitis (54.5% vs. 18.8%; p = 0.03 and 66.7% vs. 25.0%; p = 0.01).

CONCLUSIONS

Subjects with FC and IBS had a variety of upper GI and psychological symptoms. In the upper GI endoscopic findings, corpus erosion and red streaks were associated with FC, and erosive gastritis, duodenitis, and possibly red streaks were associated with IBS.

Esophageal mast cells may be associated with the perception of symptoms in patients with eosinophilic esophagitis

BACKGROUND

Eosinophilic esophagitis (EoE) is a type 2 helper T-cell (Th2)-mediated allergic disease that involves mast cells. This study aimed to clarify the relationship between perception of symptoms and mast cell levels in patients with EoE.

METHODS

We enrolled patients with asymptomatic esophageal eosinophilia (aEE) and those with symptomatic EoE. Immunofluorescence staining was performed on esophageal biopsy specimens to quantify mast cell-related molecules, such as tryptase, proteinase-activated receptor (PAR)-2, and vasoactive intestinal peptide receptor (VPAC)-1.

RESULTS

We evaluated 28 and 58 patients with aEE and EoE, respectively. There were no significant differences in clinical and endoscopic features and peak eosinophil counts between both groups. Mast cell tryptase-positive areas were significantly higher in EoE than in aEE (4.9 [3.5-6.2] vs. 2.0 [1.2-3.4] %, p < 0.01). The number of PAR-2-positive cells was significantly higher in EoE than in aEE (14 [8.8-20.0] vs. 4 [2.8-8.0] cells/high-power field [HPF], p < 0.01). The number of VPAC-1-positive cells was significantly higher in the EoE group than in the aEE group (13 [8.8-16.0] vs. 6 [3.0-9.3] cells/HPF, p < 0.01). A positive correlation was observed between the numbers of PAR-2-positive cells and VPAC-1-positive cells (r = 0.851, p < 0.01). Moreover, mast cell tryptase-positive areas positively correlated with the number of PAR-2- and VPAC-1-positive cells (r = 0.352, p < 0.01; r = 0.355, p < 0.01, respectively).

CONCLUSIONS

Esophageal mast cells and their receptors, PAR-2 and VPAC-1, may contribute to the perception of symptoms in patients with EoE.

Comparison of student self-assessment and teacher assessment of medical interview performance during bedside learning

Accurate and efficient self-assessment is a critical skill for medical students to develop as part of their professional development. Along with clinical training reform at Fukushima Medical University, rubric-based student self-assessment and teacher assessment of students' performance using our proposed assessment tool, which includes several aspects of clinical skills and abilities, was initiated to improve the clinical clerkship process. To investigate how students identified their weaknesses and strengths, we analyzed the results of 119 fourth-year medical students' self-assessment and corresponding teacher assessment. Our study revealed substantial consistency between student self-assessment and teacher assessment, despite some overestimation and underestimation in student self-assessments. Students who incorrectly assess themselves require a variety of feedback to increase their self-efficacy and self-confidence, as well as to identify their weaknesses.

The association of comorbidities with the 25-question geriatric locomotive function scale and the diagnosis of locomotive syndrome

BACKGROUND

No studies have provided statistical evidence of the relationship between comorbidities and locomotive syndrome (LS). We therefore investigated the association of comorbidities with the 25-question Geriatric Locomotive Function Scale (GLFS-25) and the diagnosis of LS in community-dwelling residents.

METHODS

This cross-sectional study was conducted on 2612 community-dwelling residents (≥40 years old) who attended a 'basic health checkup'. There were 432 participants with comorbidities (45 with cerebrovascular diseases, 133 with cardiovascular diseases, 83 with pulmonary diseases, 108 with renal diseases, and 63 with multiple diseases) and 2180 participants without comorbidities. Subjects with a GLFS-25 total score of ≤6 points, 7-15 points, 16-23 points, and ≥24 points were diagnosed with non-LS, LS-1, LS-2, and LS-3, respectively. The domain scores covered body pain (items 1-4), movement-related difficulty (items 5-7), usual care (items 8-11 and 14), social activities (items 12, 13, and 15-23), and cognition (items 24 and 25). A multivariate regression analysis and multivariate logistic regression analysis were performed to assess the association between the GLFS-25 scores and comorbidities and between the diagnosis of LS and comorbidities after adjusting for age, sex, body mass index, and smoking status.

RESULTS

A multivariate regression analysis showed that comorbidities were significantly related to the GLFS-25 total score and all domain scores. A multivariate logistic regression analysis revealed that comorbidities were significantly related to a diagnosis of LS-1 or more, LS-2 or more, and LS-3 or more.

CONCLUSIONS

Comorbidities were associated with increased GLFS-25 domain scores and total score and consequent diagnosis of LS. Therefore, attention should also be paid to the presence of comorbidities when diagnosing LS. Nevertheless, the causal relationship between comorbidities and the GLFS-25 remains unclear, and further studies are therefore required.

Factors affecting the quality of life in the chronic phase of thoracolumbar osteoporotic vertebral fracture managed conservatively with a brace

BACKGROUND CONTEXT

Although osteoporotic vertebral fractures (OVFs) are the most common type of osteoporotic fracture, few reports have closely investigated the factors contributing to the quality of life (QOL) in the chronic phase after thoracolumbar OVFs using detailed radiographic evaluation.

PURPOSE

This study aimed to identify factors associated with the QOL in the chronic phase after thoracolumbar OVF.

DESIGN

Post hoc analysis of a prospective randomized study.

PATIENT SAMPLE

Participants included 195 patients with fresh thoracolumbar OVF managed conservatively with a brace who were available for radiographic analysis 48 weeks after injury.

OUTCOME MEASURES

The degree of QOL impairment at 48 weeks after thoracolumbar OVF was assessed using the Japanese three-level version of the EuroQol five-dimensional questionnaire (EQ-5D) score.

METHODS

Univariate and multivariate regression analyses were used to evaluate the relationships between the QOL and radiographic factors.

RESULTS

The univariate analysis showed that age, analgesic use, T10/L5 Cobb angle on magnetic resonance imaging (MRI), subsequent vertebral fracture, and nonunion were significantly associated with the EQ-5D score at 48 weeks after thoracolumbar OVF. The multiple regression analysis showed that nonunion, analgesic use, subsequent vertebral fracture, and sacral slope on MRI were independently associated with the EQ-5D score at 48 weeks after thoracolumbar OVF. Receiver operating characteristic analysis for the deterioration of QOL showed that the cutoff value for sacral slope on MRI was 35 degrees.

CONCLUSIONS

This study demonstrated that nonunion, subsequent vertebral fracture, and lower sacral slope were independently associated with poorer QOL in the chronic phase of thoracolumbar OVF managed conservatively with a brace. Therefore, improving or preventing these factors in patients with thoracolumbar OVF in the chronic phase may improve the QOL of the affected patients.

Pretreatment serum monocyte chemoattractant protein-1 as a predictor of long-term outcome by ustekinumab in patients with Crohn's disease

BACKGROUND AND AIMS

Ustekinumab has been proven to be effective for treatment of patients with Crohn's disease; however, 30-40% of patients have been reported to lose clinical response within 2 years. We aimed to evaluate the efficacy of ustekinumab and identify predictors of short-term and long-term efficacy in Crohn's disease.

METHODS

Patients with Crohn's disease receiving their first ustekinumab infusion in our hospital between June 2017 and September 2020 were prospectively enrolled. Concentrations of serum cytokines and chemokines were measured using a multiplex bead array assay.

RESULTS

Fifty-nine Crohn's disease patients were enrolled in this study. Among 34 clinically active patients, 38.2% achieved a clinical response at week 8. None of the assayed factors were associated with short-term clinical response. Cumulative persistence rates of ustekinumab were 77.6% at 1 year and 58.9% at 2 years. Univariate Cox regression analysis revealed that Harvey-Bradshaw Index scores at baseline, concomitant immunomodulator treatment, and concentrations of interferon gamma-induced protein-10, monocyte chemoattractant protein-1 (MCP-1), and interleukin (IL)-1RA, IL-4, IL-6, and IL-8 were significantly associated with loss of efficacy. Multivariate Cox regression analysis found that biologic naïve status (hazard ratio [HR]: 0.1191, 95% confidence interval [CI]: 0.02458-0.5774) and MCP-1 concentrations (HR: 1.038, 95% CI: 1.015-1.062) were significantly and associated with loss of sustained efficacy for ustekinumab treatment.

CONCLUSIONS

Our findings suggest that pretreatment serum MCP-1 analysis, combined with a history of biologic use, could be a novel biomarker for predicting the long-term efficacy of ustekinumab in patients with Crohn's disease.

Lumbar spinal stenosis is a risk factor for the development of dementia: locomotive syndrome and health outcomes in the Aizu cohort study

PURPOSE

It remains unclear whether musculoskeletal diseases are risk factors for dementia development. This prospective cohort study of community-dwelling residents aimed to clarify the impact of lumbar spinal stenosis (LSS) on dementia development.

METHODS

We included participants aged ≥ 65 years from the Locomotive Syndrome and Health Outcomes in the Aizu cohort study. LSS was diagnosed using the validated LSS diagnostic support tool. Dementia development between 2008 and 2015 was investigated using official long-term care insurance certification data. We analysed the effects of LSS on dementia development after adjusting for potential confounders, like age, sex, diabetes, depressive symptoms, hip and knee joint osteoarthritis, daily activity, and smoking habit.

RESULTS

We included 1220 patients in the final analysis. The incidence of dementia was significantly higher in the LSS group [48 of 444 (10.8%)] than in the control group [34 of 776 (4.4%)]. Multivariable analysis using multiple imputations revealed that the confidence interval for the adjusted odds ratio of LSS for dementia development was 1.87 (95% confidence interval; 1.14-3.07).

CONCLUSION

We clarified that LSS is an independent risk factor for dementia development. Our findings suggest the importance of considering the risk of dementia in the decision-making process for the treatment of LSS.

Neutrophil-to-lymphocyte ratio may predict clinical relapse in ulcerative colitis patients with mucosal healing

Endoscopic mucosal healing (MH) is an important treatment goal for patients with ulcerative colitis (UC). The neutrophil-to-lymphocyte ratio (NLR) reflects systemic inflammation and has been reported to be a useful predictive marker for UC. This study aimed to evaluate the clinical utility of the NLR for predicting clinical relapse in UC patients with MH. We retrospectively enrolled patients with UC who underwent colonoscopy at the Osaka City University Hospital between January 2010 and December 2010, whose Mayo Endoscopic Subscore was 0 or 1. The correlation between the incidence of relapse and demographic factors, including the NLR, was analyzed. We included 129 patients in the present study. The median NLR at the time of endoscopy was 1.98, and differences in the high NLR group and the low NLR group were compared. During a median follow-up period of 46.4 months, 58 patients (45.0%) experienced relapse. The cumulative relapse-free rate was significantly higher in the low NLR group than in the high NLR group (P = 0.03, log-rank test). Multivariate analysis identified high NLR as an independent prognostic factor for clinical relapse (hazard ratio, 1.74; 95% confidence interval, 1.02-2.98; P = 0.04). NLR is a novel and useful predictor of clinical relapse in UC patients with MH, and it can potentially be a strong indicator to determine the appropriate treatment strategy and decision-making in clinical practice.

Bow hunter's syndrome: temporary obstruction of blood flow in the affected vertebral artery during posterior occipitocervical fusion. Illustrative case

BACKGROUND

Bow hunter's syndrome (BHS) is a rare condition characterized by mechanical impingement of a vertebral artery (VA) during neck rotation followed by vertebrobasilar insufficiency. Posterior fusion is a typical surgical method for BHS.

OBSERVATIONS

The case of a 70-year-old Japanese man who presented with presyncope that occurred during right cervical rotation is reported. Given the possibility of vertebrobasilar insufficiency, digital subtraction angiography and computed tomography angiography were performed and showed a hypoplastic right VA and severe stenosis of the left VA over the occiput (O)-C2 level. The blood flow of the left VA was interrupted by right cervical rotation, with resumption of blood flow on left cervical rotation. BHS was diagnosed, and posterior fusion at the O-C2 level was performed. Immediately after implant fixation, selective arteriography confirmed disruption of blood flow in the left VA. The rods were removed immediately; resumption of blood flow was confirmed; and the rods were refixed, anatomically bent with slight left cervical rotation. Then, sustained blood flow in the left VA was confirmed.

LESSONS

Posterior fixation for BHS can induce VA occlusion due to minor changes in cervical spine alignment. Intraoperative selective arteriography is a necessary tool to identify occlusion of the affected VA.

Long-term rebleeding rate and predictive factors of rebleeding after capsule endoscopy in patients with obscure GI bleeding

BACKGROUND AND AIMS

The incidence of rebleeding in obscure GI bleeding (OGIB) remains unclear. This study used capsule endoscopy (CE) to determine the long-term rebleeding rate and predictive factors for rebleeding in patients with OGIB.

METHODS

This single-center, observational study enrolled consecutive patients with OGIB who underwent CE as the first small intestinal examination between March 2004 and December 2015 and were followed up through medical records or letters.

RESULTS

Three hundred eighty-nine patients were included in the analysis. Survival curve analysis showed that the overall cumulative rebleeding rate in OGIB during the 5 years was 41.7%. Multivariate analysis using the Cox proportional hazards model revealed that overt OGIB (hazard ratio [HR], 2.017; 95% confidence interval [CI], 1.299-3.131; P = .002), anticoagulants (HR, 1.930; 95% CI, 1.093-3.410; P = .023), positive balloon-assisted enteroscopy findings after CE (HR, 2.927; 95% CI, 1.791-4.783; P < .001), and iron supplements without therapeutic intervention (HR, 2.202; 95% CI, 1.386-3.498; P = .001) were associated with rebleeding, whereas a higher minimum hemoglobin level (HR, .902; 95% CI, .834-.975; P = .009) and therapeutic intervention (HR, .288; 95% CI, .145-.570; P < .001) significantly reduced the risk of rebleeding. Among the Charlson Comorbidity Index components, liver cirrhosis was an independent predictor associated with rebleeding in patients with OGIB (HR, 4.362; 95% CI, 2.622-7.259; P < .001) and in patients with negative CE findings (HR, 8.961; 95% CI, 4.424-18.150; P < .001).

CONCLUSIONS

Rebleeding is common during the long-term follow-up of patients with OGIB. Careful follow-up is required for patients with liver cirrhosis or previous massive bleeding.

Development of a Novel Diagnostic Support Tool for Degenerative Cervical Myelopathy Combining 10-s Grip and Release Test and Grip Strength: A Pilot Study

Early diagnosis of degenerative cervical myelopathy (DCM) is desirable, as delayed treatment can cause irreversible spinal cord injury and subsequent activity of daily living (ADL) impairment. We attempted to develop a straightforward and accurate diagnostic tool for DCM by combining the grip and release test (GRT) and grip strength. As a pilot study, we measured the GRT and grip strength of patients with DCM (n = 247) and a control group (n = 721). Receiver operating characteristic analysis was performed using the lower left and right. The Youden index was used to set cutoff values by sex and age group. The diagnostic performance of each test varied by sex and age, and a diagnostic support tool was created to determine any abnormal results in a test. The calculated M/F cutoff values for GRT were as follows: 40–59 years, 21/18; 60–69 years, 17/17; 70–79 years, 15/15; and 80–89 years, 11/12. The calculated M/F cutoff values for grip strength 32/20, 29/13, 21/15, and 19/10. When either GRT or grip strength was judged as positive, the overall sensitivity was 88.2%, specificity was 78.1%, positive likelihood ratio was 4.03, and the negative likelihood ratio was 0.15. This novel diagnostic support tool was superior to using GRT and grip strength alone in the early DCM diagnosis. Future research to obtain age- and sex-specific data is necessary to validate and further improve the tool.

Cauda equina movement during the Valsalva maneuver in two patients with Lumbar spinal canal stenosis

Lumbar spinal canal stenosis (LSS) is a common spinal disorder among older people. Some LSS patients say that their pain worsens when they lift heavy objects. The Valsalva maneuver is the optimal breathing pattern for producing maximal force. Herein, we present two cases of LSS where the movement of the cauda equina was observed during the Valsalva maneuver.

Relationship between lumbar disc degeneration on MRI and low back pain: A cross-sectional community study

Purpose:

Although an association has been suggested between disc degeneration (DD) and low back pain (LBP), some DD is thought to be an age-related change unrelated to symptoms. Age-inappropriate DD, however, may be associated with LBP. The purpose of this study was to investigate whether there is a difference in LBP and LBP-related quality of life between age-appropriate and age-inappropriate DD, as assessed by magnetic resonance imaging (MRI).

Participants and methods:

In this cross-sectional study, degenerative change in the lumbar intervertebral discs of 382 subjects (age range, 27-82 years) was evaluated by MRI. Degenerative Disc Disease (DDD) scores were assigned using the Schneiderman classification, as the sum of grades for all intervertebral levels (0-15). We classified subjects into three groups according to age and DDD score: Low DD (mild DD relative to age), Appropriate (age-appropriate DD), and High DD (severe DD relative to age). We compared the three groups in terms of LBP prevalence, LBP intensity, LBP-specific quality of life (QOL) according to the Roland-Morris Disability Questionnaire (RDQ), and the Short Form-36 Item Health Survey (SF-36).

Results:

Of 382 subjects, there were 35% in the Low DD group, 54% in the Appropriate group, and 11% in the High DD group. There were no significant differences among the groups in terms of prevalence of LBP, LBP intensity, RDQ score, or SF-36 score.

Conclusion:

No association was found between age-inappropriate DD (Low or High DD group) and age-appropriate DD (Appropriate group) in terms of prevalence of LBP, LBP intensity, RDQ, or SF-36.

Gastrointestinal IgG4 Deposition Is a New Histopathological Feature of Eosinophilic Gastroenteritis

BACKGROUND

The pathogenesis of eosinophilic esophagitis involves immunoglobulin G4 (IgG4) deposition. However, the relationship between IgG4 and eosinophilic gastroenteritis (EGE) is unclear.

AIMS

To investigate gastrointestinal deposition of IgG4 in EGE.

METHODS

Biopsies of the esophagus, stomach, and small intestine were evaluated in patients with and without EGE. Immunohistochemical staining for IgG4 was performed, and the proportions of the stained areas were compared. Sera from patients with EGE were assayed for food-specific IgG4, including egg white, wheat, rice, soy, and cow milk.

RESULTS

Seventeen patients were included in this study (EGE group, n = 10; control group, n = 7). Compared with the control group, the proportion of IgG4-stained area in the EGE group was approximately threefold higher (40.2% [32.3-49.5]) vs. 12.1% [4.0-21.9], p = 0.014) in the esophagus, fivefold higher in the stomach (17.3% [11.1-26.2] vs. 3.7% [1.5-5.2], p = 0.014), and sixfold higher in the small intestine (28.0% [15.0-33.2] vs. 4.5% [2.6-9.8], p = 0.019). There was no significant association between the proportion of IgG4-stained area and the number of infiltrating eosinophils. Serum egg white-specific IgG4 levels were correlated with the proportion of IgG4-stained areas in the small intestine (R = 0.7, p = 0.035).

CONCLUSIONS

IgG4 accumulated within the gastrointestinal mucosa in EGE. The positive correlation between serum egg white-specific IgG4 levels and the proportion of IgG4-stained areas in the small intestine suggests a role for IgG4 in the disease pathophysiology.

Perioperative functional imaging after extracranial carotid endarterectomy for the detection of cerebral hyperperfusion syndrome

INTRODUCTION

SyngoDynaPBVNeuro® is a tool to perform cerebral blood volume (CBV) measurements intraoperatively by functional imaging producing CT-like images. Aim of this prospective study was to analyze the clinical relevance and benefit of CBV measurement with regard to neurological complications like cerebral hyperfusion syndrome (CHS).

METHODS

Forty-five patients undergoing endarterectomy (CEA) of the internal carotid artery were included; functional imaging with CBV measurement was performed before and after CEA. To evaluate and analyze CBV, six regions of interest (ROI) were identified for all patients with an additional ROI in patients with symptomatic ICA stenosis and previous stroke. The primary endpoint of the study was a perioperative change in CBV measurements. Secondary outcomes were incidence of stroke, TIA, CHS, and perioperative morbidity and mortality.

RESULTS

Thirty-day stroke incidence and thirty-day mortality were 0%. Thirty-day morbidity was 6.7%. Two patients from the asymptomatic group suffered from transient neurological symptoms without signs of intracerebral infarction in CT or MR scan, meeting diagnostic criteria for CHS. In 83.3% of ROIs in these patients, an increase of blood volume was detected. Overall, 26.7% patients suffered from unilateral headache as expression of potential CHS. A total of 69.4% of ROIs in patients with postoperative unilateral headache showed an increase when comparing pre- and postoperative CBV measurements.

CONCLUSION

The results show that increased CBV measured by functional imaging is a possible surrogate marker of neurological complications like CHS after CEA. By using intraoperative CBV measurement, the risk of CHS can be estimated early and appropriate therapeutic measures can be applied.

Short bevacizumab infusion as an effective and safe treatment for colorectal cancer

Bevacizumab is a humanized monoclonal antibody that contains <10% murine protein. To prevent infusion-related hypersensitivity reactions (HSRs), the initial bevacizumab infusion is delivered for 90 min, the second for 60 min and subsequent doses for 30 min. Several previous studies have shown that short bevacizumab infusions are safe and do not result in severe HSRs in patients with colorectal, lung, ovarian and brain cancer. However, the efficacy of short bevacizumab infusions for colorectal cancer management remains unclear. Therefore, to investigate this issue, a prospective multicenter study was conducted using 23 patients enrolled between June 2017 and March 2019. The initial infusion of bevacizumab was for 30 min followed by a second infusion rate of 0.5 mg/kg/min (5 mg/kg over 10 min and 7.5 mg/kg over 15 min. The primary endpoint was progression-free survival (PFS). The overall response and disease control rates were 57 and 87%, respectively. The median PFS time was 306 days (interquartile range, 204-743 days). No HSRs were noted. Adverse events associated with bevacizumab included grade 4 small intestinal perforation and grade 3 stroke in 1 patient each. These results suggest that a short bevacizumab infusion regime comprising an initial infusion for 30 min followed by a second infusion at 0.5 mg/kg/min is safe and efficacious for the management of colorectal cancer.

Development of a simple screening tool based on the 5-question geriatric locomotive function scale for locomotive syndrome

BACKGROUND

The optimal cut-off values of the 5-question Geriatric Locomotive Function Scale (GLFS-5) as a screening tool to identify Locomotive Syndrome (LS) diagnosed with the 25-question Geriatric Locomotive Function Scale (GLFS-25) has yet to be fully investigated. This study aimed to construct a simple screening tool, based on the GLFS-5, for the detection of LS-1, LS-2, and LS-3 diagnosed with the GLFS-25.

METHODS

This research was approved by the institutional review board of Fukushima Medical University School of Medicine (No. 2907). A cross-sectional study of 1258 consecutive Japanese volunteers with a mean age of 76.0 ± 6.0 years who consecutively attended a basic health checkup was conducted. We excluded individuals of <65 years of age, individuals with comorbidities, and individuals who did not fully complete the GLFS-25. Subjects with a GLFS-25 total score of 0-6 points, 7-15 points, 16-23 points, and 24-100 points were diagnosed with non-LS, LS-1, LS-2, and LS-3, respectively. A conventional receiver-operating characteristic curve analysis was used to confirm the optimal cut-off values of the GLFS-5 total score and their sensitivity and specificity in the identification of LS-1, LS-2, and LS-3, with a preference for slightly higher sensitivity as the intended use of the tool is primarily for screening purposes.

RESULTS

The diagnoses of the 1258 subjects were as follows: non-LS (n = 559), LS-1 (n = 396), LS-2 (n = 134), and LS-3 (n = 169). The mean GLFS-5 was 3.3 ± 3.5 points. The optimal cut-off values of the GLFS-5 total score for discriminating LS-1, LS-2, and LS-3 (as a screening tool) were 2 points (sensitivity 91.7% and specificity 77.8%), 4 points (sensitivity 95.7% and specificity 81.7%), and 6 points (sensitivity 92.9% and specificity 90.0%), respectively.

CONCLUSIONS

This simple screening tool based on GLFS-5 could help physicians and surgeons to easily and practically predict the severity of LS.

Lustrous White Erosions Surrounded by an Erythematous Mucosa: A Novel Endoscopic Finding of Gastric Lesions in Patients with Wilson Disease

Wilson disease is an inherited copper metabolism disorder. We herein report a novel endoscopic finding in three men with Wilson disease. These patients underwent upper endoscopy due to gastrointestinal symptoms or during follow-up. In each case, endoscopy revealed lustrous white erosions surrounded by an erythematous mucosa in the greater curvature of the gastric body. A biopsy of the lesions showed orcein-positive tissue, indicating copper deposition, in the interstitial stroma and fundic glands of the mucosa. All patients had been receiving treatment with zinc acetate. These endoscopic findings might have been related to the cytotoxicity of the accumulated copper and zinc acetate.

Optimizing simulated interviews and feedback to maximize medical students' self-efficacy in real time

BACKGROUND

Self-efficacy is crucial in improving medical students' communication skills. This study aims to clarify where medical students' self-efficacy is greatest following an interview with a simulated patient and subsequent feedback.

METHODS

A total of 162 medical students (109 men, 53 women) in their fourth or fifth year at a university in Japan participated in this study. The degree of self-efficacy in medical interviewing was measured before and after a medical interview with a simulated patient, and after the subsequent feedback session.

RESULTS

ANOVA analysis revealed that self-efficacy for medical interviews was higher after both the interview and the feedback session than before the interview. Among all three time points, self-efficacy was highest after the feedback session.

CONCLUSIONS

Feedback following a simulated interview with a simulated patient is important to improve the self-efficacy of medical students when learning medical interviewing skills.

Pirfenidone prevents esophageal stricture by inhibiting nucleotide binding oligomerization domain like receptor protein 3 inflammasome activation

BACKGROUND AND AIM

Esophageal injury often results in a scar, leading to refractory strictures. The NLRP3 inflammasome activates caspase-1, causing the maturation of interleukin (IL)-1β. Here, we aimed to investigate the preventive effect of pirfenidone (PFD), an antifibrotic drug, on esophageal stricture after ulcer healing and studied its mechanism by focusing on the activation of the NLRP3 inflammasome.

METHODS

Esophageal ulcers were induced in rats via the local application of acetic acid in the serosa. PFD was intraperitoneally administered to the rats 3 days after ulcer induction. The effect of PFD on esophageal stricture after ulcer healing was assessed by esophagography on day 9. The protein levels of mature caspase-1 and IL-1β were assessed by western blotting.

RESULTS

The ulcers fully developed 3 days after induction and were almost scarred by day 9 with severe strictures. PFD promoted ulcer healing and attenuated fibrotic collagen in the submucosa by suppressing the increase in NLRP3, cleaved caspase-1, and mature IL-1β expression, improving stricture rate (PFD vs vehicle = 55% vs 81%). Exogenous IL-1β abolished the therapeutic effects of PFD on ulcer healing and stricture formation. Furthermore, NLRP3 and caspase-1 inhibitors mimicked the effects of PFD on ulcer healing and stricture formation, with suppression of the increase in cleaved caspase-1 and mature IL-1β proteins and expression of fibrosis-related molecules including transforming growth factor (TGF)-β1.

CONCLUSION

The NLRP3 inflammasome promotes esophageal stricture formation following ulcer healing, and PFD exerts potential prophylactic activity against strictures, possibly via the inhibition of the NLRP3/IL-1β/TGF-β1 axis.

The Relationship between Exercise-Induced Low Back Pain, the Fat Infiltration Rate of Paraspinal Muscles, and Lumbar Sagittal Balance

Introduction

Exercise-induced low back pain (EILBP) is induced during anterior trunk tilting when walking or prolonged standing. In some elderly with chronic LBP, the pain is induced by EILBP. The paraspinal muscles play an important role in supporting the spine; therefore, a dysfunction of back muscles and kyphotic alignment are considered to be associated with EILBP. However, few reports are showing the relationship between EILBP and degenerative muscle changes. This study aimed to clarify the relationship between EILBP, degenerative changes of paraspinal muscles, and spinal alignment in an epidemiological study.

Methods

A total of 324 subjects were included in the analysis. The presence of EILBP was determined through a medical interview and physical examination. The subjects underwent lumbar spine magnetic resonance image (MRI) and X-ray. The fat infiltration rate (FIR) of the multifidus, erector spinae, and psoas major were analyzed using MRI. For lumbar sagittal balance, L1 axis S1 distance (LASD) was measured using X-ray images. Multivariate logistic regression analysis was used to analyze the association between the presence of EILBP and FIR or LASD.

Results

The prevalence of EILBP was 21% and it increased with age. The subjects with EILBP had statistically higher FIR of the multifidus, erector spinae, and psoas major than those without EILBP. There was a significant association between the presence of EILBP and higher FIR of the erector spinae at L1-2 and L5-S1 (p<0.05). However, there were no significant associations between EILBP and LASD.

Conclusions

According to the results in this study, EILBP is not rare and the FIR of the erector spinae is associated with the presence of EILBP.